SAN DIEGO — Four years ago this week, Marines from Camp Pendleton were the first conventional troops to surge into Iraq at the start of the U.S.-led assault. They were greeted by Navy SEALs from Coronado who had slipped across the border to gather intelligence days earlier.
By any measure, the San Diego region has played a prominent role at each step of the war: troops on the ground, troops killed, joyous returns, mournful funerals, medals awarded for bravery, courts-martial for alleged abuse of Iraqi civilians.
Even President Bush's politically controversial "Mission Accomplished" carrier landing took place off the San Diego coast.
Now, with public focus on how the wounded are being cared for in the wake of the scandal about shoddy outpatient care at Walter Reed Army Medical Center in Washington, D.C., San Diego is once again on the front lines.
Officials at the Naval Medical Center San Diego and Veterans Affairs Medical Center in La Jolla expect visits from the commission assigned by Bush to examine medical care for veterans. Numbers alone would seem to dictate them.
"We're right in the middle of the hot zone," said Gary J. Rossio, chief executive of the VA medical center in La Jolla.
Each year, 24,000 military personnel leave active duty in San Diego County.
The VA medical center in La Jolla has seen a near 50% increase in patients in nine years. The VA center, next to UC San Diego, is treating 4,500 Iraq war veterans, most as outpatients, with nearly 100 new veterans a month registering for care.
The Navy medical center, on the edge of Balboa Park, sees more patients -- active-duty, retirees and their family members -- than Walter Reed and the National Naval Medical Center in Bethesda, Md., combined.
With an upgrade in facilities and personnel, wounded troops since July can be airlifted directly to San Diego from the military hospital in Landstuhl, Germany, rather than spend months away from their families at Reed, Bethesda or Brooke Army Medical Center in San Antonio.
Officials at the VA and Navy centers concede that they have had to scramble to accommodate a larger number of wounded personnel than anyone anticipated 48 months ago when the Marines crossed the so-called Line of Departure into Iraq. The injuries have been more severe, with more amputations and more traumatic brain injuries.
Both centers also have had to increase counseling for patients with post-traumatic stress disorder. Some Vietnam veterans are suffering PTSD after watching TV news accounts of Iraq.
"It really is a wave," said psychologist Jeffrey Matloff of the VA medical center in La Jolla, who added, "I don't think we've seen the big wave. That we'll see in coming years."
The VA is adding case managers so that veterans do not slip through the cavernous cracks in the Department of Defense, Department of Veterans Affairs and private healthcare systems.
Bush has ordered that the Defense Department and Veterans Affairs computer systems be made compatible nationwide. Progress has been slow. Many veterans still have to carry their medical records in folders.
The Naval Medical Center is working to improve its services for troops suffering brain injuries so they do not have to travel to the VA hospital in Palo Alto, which specializes in brain injuries. The goal is to get to the point where only the most severely brain-injured will need to go to Palo Alto.
"I transferred three to Palo Alto from Camp Pendleton last week and two this week," said Kris Meyer, a combat-veteran case manager for the VA.
In July, the Naval Medical Center San Diego hopes to open a 23,000-square-foot space with exercise and therapy rooms, a climbing wall, prosthetics lab and diagnostic facilities tailored to the severely wounded from Iraq and Afghanistan. Fifty new employees are being added.
"We anticipate this will be part of our mission for a long time," said Navy Capt. David Tam, the center's deputy commander.
Both centers have faced problems with an increasing patient load and a finite budget.
At the VA medical center in La Jolla, the top complaint of patients is difficulty getting timely appointments. Last fall, the Naval Medical Center announced that, temporarily, nonemergency appointments would have to be delayed or outsourced until more doctors could be hired.
Retired Marine Lt. Col. Tom Richards, chairman of the San Diego Veterans Council, believes that the quality of medicine at both facilities is high but that quantity lags.
"They need more -- more doctors, more nurses, more everything," he said. "Washington has never followed through on its promises about medical care for veterans."
Last week, in the wake of the Walter Reed scandal, a bipartisan group of Congress members introduced HR 1538 to bolster medical care for veterans. Among the sponsors were Reps. Duncan Hunter (R-El Cajon), the ranking Republican on the Armed Services Committee; and Bob Filner (D-Chula Vista), chairman of the Veterans' Affairs Committee. The first hearing for the bill is set for Tuesday, the fourth anniversary of the opening of the assault on Baghdad.