ENCINITAS, CALIF. — At a community hospital here, doctors and therapists are working to help Marines overcome what is often called the signature injury of the Iraq war: brain trauma with no visible wounds.
"It's the silent injury," said Jessica Martinez, an occupational therapist at Scripps Memorial Hospital Encinitas. "With every blast they suffer, their brain is rattling like a yolk in an egg."
Marine Lance Cpl. Brian Vargas was a high school football player. Now, even though he looks fit, he cannot toss the football with his buddies, let alone be part of pickup games with other off-duty Marines.
"I can't catch anything," he said. "I can't remember any plays."
Vargas, 20, was subjected to innumerable mortar and roadside bomb blasts while patrolling the insurgent stronghold of Hit in the Euphrates River Valley. In mid-January he was shot in the hand and cheek by a sniper and airlifted to Germany and then the United States for treatment.
He has the classic signs of post-concussive injury.
"My thinking has gone down," he said. "I can't remember what I did this morning. I have trouble putting memory and speaking together. I'm trying to learn to speak as clearly as possible."
Lance Cpl. Keene Sherburne, 20, who was injured when a bomb exploded under his Humvee in Fallouja, is frustrated at the slow pace of his recovery.
"I can't read," he said. "I used to love it, but now I hate it. I pick up a snowboard magazine, and I get so mad because I don't understand it."
For most of the Marines, who come here from nearby Camp Pendleton, the regimen is six hours a day, three days a week. Physical therapists work with them to restore their balance, hand-eye coordination and stamina. Counselors work on behavioral changes and anger management. Occupational and speech therapists work on language skills and on restoring their memories.
In one exercise, Marines listen to words being defined and then are asked to repeat the definitions. Sometimes their wartime experiences intrude.
Asked to define "cherry," Vargas could not remember, but he recalled something else: "That was the name of the street I was walking over when I got shot."
Experts say studies of civilians with mild to moderate brain injuries suggest that they can recover. But it remains unknown whether military personnel, whose injuries are coupled with the experiences of war, have similar chances.
For a decade, the Encinitas hospital has had a contract with Camp Pendleton to provide care for active-duty personnel and their family members. As the numbers of brain-injured Marines and sailors mounted, the contract was expanded last year to include those kinds of injuries.
The more severe cases in which the skull has been damaged are treated at acute-care hospitals, including the Department of Veterans Affairs center in Palo Alto. Often, brain injuries without outward wounds go undiagnosed. Symptoms can be slow to appear. Brain injuries such as those suffered by Vargas and Sherburne commonly do not show up on MRIs or CT scans.
There is also the complicating factor of Marine Corps culture.
"Marines are taught to be self-reliant, to not complain, to 'suck it up and do your job,' " said Dr. Michael Lobatz, director of the rehabilitation center at Scripps-Encinitas and a clinical assistant professor at the UC San Diego medical school. "As a result, Marines are often delayed in getting recognition for their symptoms."
At Camp Pendleton, Marines are examined for possible concussion injuries when they return from Iraq and again 90 days later. Those showing signs of injury are referred for further examination at the base hospital's concussion clinic.
Navy doctors and corpsmen, as part of their pre-deployment training, now receive additional instruction in how to spot and treat brain injuries.
A study by the Defense and Veterans Brain Injury Center at Walter Reed Army Medical Center in Washington, D.C., suggests that "closed-brain" injuries -- those without visible wounds -- outnumber penetrating brain injuries by 7 to 1. Navy Capt. Edward Hessel, the top doctor with the 1st Marine Division, said he thinks the number may be far greater.
Maj. Gen. John M. Paxton Jr., commanding general of the 1st Marine Division, said Marine leaders became concerned when they noticed that some Marines returning from Iraq were "struggling emotionally."
"It's like football or boxing injuries. You never know the cumulative effect," he said.
The surgeon general of the Army ordered a report done on traumatic brain injuries and possible treatment plans. The report is due May 1. Two battalions from Camp Pendleton have been selected for another study on brain injury assessment and treatment in Iraq.
One preliminary study at Walter Reed suggests that patients with mild traumatic brain injury are at greater risk of developing post-traumatic stress disorder than patients who have suffered even greater brain injuries through direct wounds.