Grunt: The Curious Science of Humans at War

4. BELOW THE BELT The Cruelest Shot of All

THE AMPUTEES WEAR SHORTS. I see them crossing the Walter Reed lobby, chatting with the security guy, standing in line at this or that café. It’s not shorts weather. It’s December 4, in Maryland. Christmas music ever in the background—jingle bells, holly jolly, Frank Sinatra agitating for snow. While it is true that a prosthetic leg is immune to the cold, this baring of limbs is about something else, I think. It’s an avowal of normalcy, of moving through the world with your hardware on show, no self-consciousness, no big deal. The era of the sad, stiff flesh-tone appendage is over.

Between a man’s carbon-fiber, vertical shock-absorbing, microprocessor-controlled prosthetics, it’s another matter. You don’t hear much about the injuries collectively known as urotrauma, or the techniques used to deal with them. Partly it’s the numbers: 300 genito-urological patients for 18,000 limb amputees. It’s not that insurgents don’t make big enough bombs. It’s that bombs that big create corpses, not patients. Advances in combat casualty care, swifter medevacs, and field hospitals closer to the action have meant that more men are surviving who need genital reconstruction. The work remains relatively low-profile, though, because genitals themselves are low-profile.

The clocks on the lobby wall say it’s 9:00 a.m. here in Bethesda (and 6:00 a.m. in Los Angeles, and midnight in Guam). I’ve been passing time in a café before heading up to Urology. A Navy officer practices his Spanish on a woman refilling the condiments caddy. “Thank God it’s viernes!” A stooped veteran looks at CNN—an Emirates airliner blown sideways during takeoff. “I’ve done that before,” he says to no one specific. Walter Reed is officially categorized as a national military medical center, but it has more the feel of a small indoor town. The larger corridors have been given names: Liberty Lane, Heroes Way, a Main Street with a post office and some fast food outlets. A poster board propped on an easel outside Dunkin’ Donuts announces that Colin Powell is doing a book signing at 11:00 a.m.

While General Powell is putting a Sharpie to the pages of It Worked for Me, while Guam sleeps, Gavin Kent White will be having his urethra rebuilt. Captain White, a 2011 graduate of West Point, stepped on an IED in Afghanistan. It Didn’t Work as Well for Him.

THEY ARE buried in twos and threes: one IED to kill the people in the vehicle, the others to kill the people who come to help. White saw the first blast from his lookout in the command and control vehicle on a route clearance mission on a heavily booby-trapped stretch of road in Kandahar Province. He was leading a platoon of combat engineers—specialists in construction and demolition: roads, walls, bunkers, bridges. A Humvee carrying Afghan National Army soldiers, partners of the US and NATO in the conflict, had ignored White’s warning not to drive on ahead. Three were killed, three wounded. The vehicle landed on its side, blocking the road, and it fell to the engineers to move it. White’s footstep on a buried pressure plate set off the second explosion—a twenty-pound “victim-operated” IED. I asked him what he remembers.

White lies in a hospital bed, propped against pillows but on top of the bedclothes, on the fourth floor of Walter Reed. The view is impressive, but after four months, you imagine he’s fairly well through with it. It began, he says, with intense red-orange in his field of vision and a feeling of lifting into the air. “I sat up, took out my tourniquet, and put it on my right leg, which I saw was missing.” The full length of White’s other leg remains, but the calf was blown off. He was unaware of this at the time. Because his boot and the front of his pant leg were intact, he assumed the leg was, too.

You sometimes hear that the first words of a man in White’s situation go essentially like this: Is my junk okay? White’s first concern was his soldiers: Was anyone bleeding to death? “I started calling out, ‘Who’s hit? Who’s hit?’” White was their commander, but any soldier’s first thoughts, post-explosion, are likely to be of fellow soldiers. Walter Reed surgeon Rob Dean, a colonel who served in Iraq, confirmed this. “The first thing they ask is, ‘Where’s my buddy? Is he okay?’ ” Which could, I supposed aloud, be a reference to one’s penis. “No,” Dean said. “Because the second thing they say is, ‘Is my penis there?’”

Despite the assurances of the medic (“Everyone’s fine, sir; it’s just you”), despite the fact that one leg was maimed and the other was elsewhere, White kept trying to get up to check on his soldiers. Appraise the situation. Be the commander. The medic had to strap him down. For better or worse, this kept him from taking more detailed stock of his injuries. In the immediate aftermath, he had seen that the tip of his penis was “flowered out” but was unsure how deep the damage went. (The verb to flower has found an incongruous home in descriptions of IED injuries. In the typical underfoot blast, leg muscle is blown out away from bone, and into that open bloom shoots a dense, fast-moving cloud of bacteria-laden dirt. The blossom then closes over the soil, making the wound hard to clean and prone to stubborn infection.)

White would have thirty-nine minutes to think about it. That’s how long the medevac helicopter took to arrive. “At one point I was like, ‘If my dick is gone, just leave me here.’ I was half-serious. I don’t have any kids yet. I didn’t want to have to go back without anything to do that with.” His men tried to reassure him. “They were like, ‘Your dick is fine, sir.’” I’m guessing that that’s White and his soldiers right there, in those five words: The formality and respect of “sir” with the easy slang of “your dick.”

“I was like, ‘Bullshit, I saw it. I just want to know, Is it fixable?’”

It’s fixable. Some urethral scarring and tightening has slowed urination and created some erectile torque, but surgery this week should remedy both, as well as some minor cosmetic damage.

Though the pain was heavy enough that White asked a medic for a second dose of fentanyl (“I can’t, sir; you’ll die”), he has little to say about it. “Honestly, I was more focused on my soldiers.” Though they were physically unharmed, a kind of psychic unraveling occurs when a leader falls. White could see how shaken they were, and tried to joke around with them: “Guess my running career is over, heh. Never really was any good at it.”

It’s hard for me to imagine: worrying about the emotional state of other people when you yourself have just lost part of both legs and possibly some of your genitalia and on top of that your pelvis is broken. White told me his platoon sergeant said to him recently, “Maybe it happened to you because you’re the kind of person who’s tough enough to handle it.” I think White is plenty tough, but I don’t think we’re talking about toughness here. This is some kind of blinding selflessness, the sort of instinct that sends parents running into burning buildings. The bonding of combat, the uncalculating instinct of duty to one’s charges and fellow fighters, these are things that I, as an outsider, can never really understand.

I emailed White the night after we met. It began as a thank-you, but came around to a sort of grasping fan letter. My world is full of people, and that includes me, who never have to put their lives and bodies on the line for other human beings or for things they believe in. Hero has always been a movie word, a swelling orchestral soundtrack word. A Walter Reed hallway word. Now it has something under it.

SURGERY PATIENTS are announced like guests at a ball. An orderly wheels them in and recites from the paperwork: name, age, procedure, body part. To be sure the surgeons are in the right room, with the right patient and the right piece. In White’s case, you might otherwise wonder. A nurse is swabbing the surgical site, applying the standard antiseptic man-tan, but she’s at his face, not his groin. Major Molly Williams, the almost comically pregnant assisting-surgeon, explains that a replacement stretch of urethra will be built from a strip of tissue harvested from the inside of White’s cheek. Mouth tissue makes an excellent urethral stand-in. For one thing, it’s hairless. Urine contains minerals that, were there hair growing in your urethra, would build up on the strands. The stony deposits are troublemakers, obstructing flow or breaking free and getting peed out in a blaze of pain.

The surgeon, James Jezior, has been over at the scrub sink going at his nails. He joins us now, hands front, drying. He has blue eyes and fine sandy hair and a mischievous wit. I would use the adjective boyish, but on paper he is very much not a boy. He’s a chief (of the Walter Reed urology department), a director (of reconstructive urology), and a colonel.

“Also,” says Jezior, “the mouth is tolerant of pee.” He means that the mouth is built for moisture. It’s possible to create a urethra from hairless skin on the underside of the forearm or behind the ear, but the frequent wetting from urine can degrade it. A kind of internal diaper rash may ensue. Inflammation eats away at the tissue, tunneling an alternate path for the waste, called a fistula. Now you are dribbling tinkle from a raw hole in your skin. Just what you need.

White’s face has been draped with a blue sterile cloth with a single opening, reminiscent of an Afghan burqa. In this case, the opening is positioned over the mouth, not the eyes, as though the patient belonged to some esoteric spin-off sect. Retractors square White’s mouth, pulling it wide to either side, the way kids will do with their fingers to frame a stuck-out tongue. Jezior outlines the graft with a surgical marker and uses an electrocauterizing tool to cut it free. A vaguely familiar aroma, somewhere between brazier and burning hair, hits the air. Jezior is indifferent to it but reveals that the prostate, when cut open, releases a distinctive scent that’s kind of nice.

Using long-handled forceps, Jezior passes the dangling tissue to Molly. They look like a couple sharing a Chinese entrée. Molly drapes the graft over one gloved thumb and, with her other hand, snips away bits of fat and tissue to make it thinner. It takes time for new blood vessels to grow in and service a graft. For the first couple of days, the cells of the graft are nourished by a broth of serum. If the graft is too thick, only the cells on the surface will thrive, and those on the interior will die. For this reason, larger skin grafts, like the ones on the back of White’s remaining leg, are run through a mesher. The holes of the mesh create more surface area for the business interactions of cellular life: nutrients in, waste out.

If replacing part of the urethra doesn’t resolve the problem, another option would be perineal urethrostomy. Here the surgeon would excise the damaged portion and thread the shortened urethra through an opening in the perineum—the no-man’s-land between scrotum and rectum. “Then they have to sit to urinate, like ladies do,” says Molly.

How big of a deal is that? Jezior makes the point that someone whose reproductive organs have been damaged by an IED has typically also lost one or more limbs. Having to sit down to urinate probably doesn’t rank high on the worry list.

Molly tilts her head to face me. “It’s huge.” Depending, to some extent, on culture. Some years back, she attended a session on perineal urethrostomy at an international urology conference. The Italian surgeons were aghast. “You can’t tell an Italian man he’s going to have to pee sitting down.”

Molly was one of two female urologists at the meeting. She notices the disparity, but it doesn’t faze her. On the upside, she never waits for a toilet during session breaks. “I’ve been the only one in the women’s room at some of these urology conventions.”

“Same here,” deadpans Jezior.

The piece of cheek is ready to begin its new career. A nurse pulls a sterile drape from White’s hips and begins rubbing his skin with the antiseptic wand. Such is the vigor of the youthful male that even under general anesthesia, even when it’s a ChloraPrep sponge bestowing the caress, the penis responds. It is a less robust response than normal, perhaps, because Jezior has prescribed something to temporarily blunt erections. Surgical incisions are sewn up while the organ is flaccid; erections stretch the incision. They hurt. However, erections bring more blood into the penis, which speeds healing, and they also help prevent scarring. The latter is important because scarring—especially in erectile tissue—can make erections crooked and uncomfortable. For this reason, sexual activity is sometimes encouraged postoperatively as a kind of physical therapy for the penis. Walter Reed nurse manager Christine DesLauriers, whom we’ll shortly meet, convinced the intensive care unit staff to establish a daily “intimate hour,” during which no medical staff would visit the patient’s room, just spouses and partners.

Jezior opens the organ to access the urethra. As he works, he rests the heel of one hand on White’s scrotum, using it like a tiny beanbag chair. Molly’s style is more formal; she holds her instruments like a knife and fork, wrists raised. The rectangular graft is stitched in place but left flat. Urine is temporarily diverted through an opening made in the skin below the graft. In a follow-up operation, once a new blood supply grows in and it’s clear the graft has taken, Jezior will go back in and hook up the waterworks. He’ll roll the graft into a tube and connect it to the original urethra, and that, one hopes, will be that.

When it’s over, Jezior snaps off his gloves and walks directly to a phone on a desk in the corner of the operating room and punches an extension. White’s mother is waiting in his hospital room. “He’s awake, and everything went well.”

FOR THE third time today, I’ve lost Dr. Jezior. I’ll bend down to slip on some surgical shoe covers or step away to use a drinking fountain, and when I turn back he’s gone: pulled away by a nurse, an administrator, a patient’s wife. He never says no, although he has every reason to. Chronically over-busy, he moves through the halls at a slight forward cant, as if arriving a second sooner might give him a jump on the enduring backlog of things that need doing. The stack of reading material in his office bathroom, all of it urological, threatens to collapse the sink.

Like a lost child in a mall, I know to stay put and eventually he’ll come for me. I browse some information on “Boxes and Storage,” one of the many themed bulletin boards that line the corridors of Walter Reed. “Mature Indian wheat moth larvae pupating in corrugated cardboard,” says a photo caption. It’s the most unsettling image I’ve seen all day, but not for long. Jezior and I are headed to his office so he can show me photographs of some of his patients in Iraq. Not to unsettle me, but to give me a broader sense of what bullets and bombs, and then surgeons, can do.

Jezior narrates with simple anatomical vocabulary, but I can’t always parse what I’m seeing in a way that matches the words. I can’t even see person in some of these images. I see butcher shop. Bandages protect the psyche, too; some of these soldiers never saw what I’m seeing. Jezior had a patient who didn’t see the injuries to his penis for three weeks. He clicks ahead to a slide from this man’s arrival at the hospital, a close-up of the weapon-target interaction, as they say in ballistics circles. How do you prepare a patient like this for the unveiling? “We used to try to sound optimistic,” Jezior says. “But when this guy finally saw it, he was like, ‘Oh, my God.’ It was another devastation, a second loss.” Now they’re blunter. “I’ll say, ‘It’s a severe injury. You’ll have to see it.’” If there’s going to be a surprise, let it be a positive one.

What can be done for these men? A lot. The art of phalloplasty—crafting a working penis from other parts of a patient’s body—has come a long way (thanks in no small part to the transgender community). To build a penis, Jezior begins with an arm. A rectangular flap of skin on the underside of the forearm is planed into two thinner layers. The inner one is rolled to form a urethra; the outer becomes the shaft. This tube within a tube is left in place, nourished by the arm’s blood supply. When what remains of the original organ heals, the new model is detached from the arm and reattached farther south.

Erectile tissue is the challenge. While spongiform erectile tissue exists in other parts of the male anatomy—along the urethra and in the sinus cavity (congestion being an erection of the nasal turbinates)—there isn’t much of it, and no one has tried to transplant it. And while there are eye banks and sperm banks and brain banks, no one is banking noses. So in place of the corpora cavernosa—the two parallel cylinders of erectile tissue—surgeons install a pair of inflatable silicone implants. (To get erect, the patient—or his friend—squeezes a little silicone bulb implanted in the scrotum that pumps saline from a receptacle in the bladder.) Hook up the tubes and let the nerves regrow, and in time orgasm and ejaculation are back on track.

Jezior continues with his slides. “This is a brigade commander. A sniper shot him across the top of the groin. Took out the middle part of his penis.” Losing the whole penis—and surviving the blast—is rare. Among Grade 3 and higher (the worst) cases of Dismounted Complex Blast Injury, 20 percent suffer damage to the penis, but only 4 percent lose everything.

You have to wonder: Was the sniper off his game, or was the shot intentional? Are there some who aim for the crotch? Jezior thinks that there are. He’s heard stories from World War II. Dale C. Smith, a professor of military medicine and history at the nearby Uniformed Services University of the Health Sciences (USUHS), has also heard those stories, but knows of no evidence to back them up. Smith points out that the secondary goal of a sniper is to sow fear. In that sense, the crotch is an effective shot. However, Smith said in an email, it is also a risky shot, in that a sniper is looking for a “high percentage return” on the tactical effort and risk of getting into position. The pelvis is not considered a “kill shot.”

Another gunshot case follows, this one through the scrotum and rectum. “This is half his anus here. Here’s his scrotum up here. This is the insides of the testes. ” The horrid Cubism of modern warfare. The reconstruction in this case was done by Rob Dean, Walter Reed’s director of andrology. The andrologist’s beat is reproduction, not excretion: testes and scrotums, hormones and fertility. Dean is joining Jezior and me in a few minutes for lunch, in a sandwich place downstairs. The two served four months together in Iraq.

Jezior closes the photo file and leads me out through the urology waiting area, toward the stairs. “Patient Jackson?” calls a receptionist. As though “patient” were the man’s rank. I guess in a sense it is. He may be a major or a colonel and the man across from him may be a private, but here everyone’s a patient. In a culture defined by rank and hierarchy, Walter Reed can seem—to an outsider, anyway—endearingly egalitarian.

Dean is already in the line to order sandwiches. He, too, is extremely busy, which, in the grand and ghastly scheme of war, is a good thing. It means more men are surviving bigger explosions. If funding and research lag behind, it’s partly because of the general cultural discomfort that surrounds all things sexual—including the poor organs themselves. On a much simpler level, Jezior says, it’s a case of out of sight, out of mind. “When some celebrity comes to Walter Reed and visits you in your room…”

Dean jumps in. They finish each other’s thoughts like an old married couple. “…Right, the President doesn’t pull down the sheet and go…”

“…‘That’s terrible, look at that. His penis is gone. Let’s get some money flowing for that.’”

Walter Reed Medical Center pays for phalloplasty, although there was initially some resistance. (The implants alone cost about $10,000.) Erections were thought of as “icing on the cake,” Dean says. “They’d say, ‘Oh, people don’t really need that.’ I’m like, ‘Well, the guy with the amputated legs doesn’t need prostheses. Put him in a wheelchair!’ And they’d go, ‘Oh, no! It’s important that they walk!’ I’d say, ‘Okay, well, most people think it’s important to have sex.’ Can I get a Caprese sandwich and a Coke Zero?”

Dean has expressive hands and eyes and prominent arching eyebrows, and when he talks and laughs, the whole lot of them join the fun. In this business, humor and candor are a therapy on their own. Dean has been known to put a ruler to a discouraged patient’s penis and hoot, “You’ve got six inches! How much more do you need?”

Don’t be fooled by the jolly tone. Dean is a bulldog for his patients. He was a force behind the push to get the VA to cover in vitro fertilization for soldiers whose injuries left them sterile. He gives talks to USUHS students about sexual health issues among injured service members and answers questions at veterans support groups. He helped colleague Christine DesLauriers found the Walter Reed Sexual Health and Intimacy Workgroup: a dozen-plus local medical providers and social workers who gather periodically to plot strategy and share resources. For instance: Sex and Intimacy for Wounded Veterans, a book by DC-area occupational therapists Kathryn Ellis and Caitlin Dennison. These two do not flinch. Here are sexual positioning tips for triple amputees. Ways to modify a vibrator for a patient who’s lost both arms below the elbow. I second the sentiments of the title page endorsement (if not the precise phrasing): “We should put a copy of this manual in the hands of every patient, spouse, and medical provider…”

Especially the medical providers. “It’s amazing,” says DesLauriers, “how many of them are frightened to bring it up.” She told me about a Marine she’d worked with who said to her, “Christine, I’ve had thirty-six surgeries on my penis, I’ve had my shaft completely reconstructed, and not one damn person told me how I’m going to go home and use the thing on my wife.”

Few talk to the wives, either. “It’s depressing watching some of them interact,” says Jezior. “In your mind you’re going, ‘She’s going to leave him.’” When I asked DesLauriers what the divorce rate is, she said, “Divorce rate? How about suicide rate. And what a shame to lose them after they’ve made it back. We keep them alive, but we don’t teach them how to live.” Walter Reed has no full-time sex educators or sex therapists on its payroll. The Internal Medicine Clinic offers appointments in “sexual health and intimacy,” but only one nurse is set up to handle them.

“It’s not,” Jezior says when the topic comes up, “as well situated as we’d like it to be…”

Dean cuts through it. “There’s nothing. There’s a vacuum.”

DesLauriers’ workgroup has spent seven years meeting with military boards, trying to get Defense Department funding for an on-staff sex therapist at Walter Reed. She gets lots of support, almost entirely verbal. The problem isn’t just budget cuts. “The problem is getting the US government to embrace sex.” She told me about a meeting several years ago with an admiral who headed up Walter Reed. “He said, ‘I don’t understand what we are teaching someone who doesn’t have a penis. What exactly are you going to help that person with?’”

There are so many things DesLauriers could have said to the admiral. She could have said, “Strap-ons, sir? Thigh riders?” She could have quoted from Ellis and Dennison’s book. “‘Incorporation of a residual limb in creative ways, such as stimulating a female partner’s clitoris,’ sir?” “‘Exploration of other areas that could provide more pleasure (e.g., nipples, neck, ears, prostate, rectum),’ sir?” She went with something more basic: “I said, ‘Sir, if I can be very candid with you. Does he have a tongue, and can he be taught?’”

“The other thing to keep in mind,” Jezior says, “is that in the early stages after a major injury, there’s a lot going on that makes sexual intimacy not necessarily the priority…”

Dean, nodding: “Like, Can I brush my own teeth now?”

“And they’re heavily medicated to get them through this period.” Narcotics, nerve stabilizers, antidepressants. “So if they’re not getting a good erection, you say, ‘Let’s get you through this, get you off the pain meds, and then see how you’re doing.’”

Or, if you’re Christine DesLauriers, you say, “Can you handle a bit of pain? Cut back on the meds for four hours, have sex, go back on the meds.” Catheter in the way? Fold it back and put on a condom. “Absolutely you can have sex with an indwelling catheter!”

Aside from Christine DesLauriers, are there other promising developments? What’s on the urotrauma horizon? What about penis transplants? I’m only half-serious, but Jezior starts talking about experimental work going on at Johns Hopkins.

“Wait, they’re going to transplant a penis?” Some extraneous decibels on that. A couple look up from their paninis.

Jezior says, “Yeah”—the kind of yeah you give someone who’s asked if you want your receipt, or fries with that, like it’s nothing. He adds that one of the patients in the photographs we were looking at is a candidate. Though it won’t happen for at least six months. “They’re doing some cadaver work right now.”

“Really.”