Soldiers Face Neglect, Frustration At Army’s Top Medical Facility

By Dana Priest and Anne Hull
Washington Post Staff Writers
Sunday, February 18, 2007; A01

the door of Army Spec. Jeremy Duncan’s room, part of the wall is torn
and hangs in the air, weighted down with black mold. When the wounded
combat engineer stands in his shower and looks up, he can see the
bathtub on the floor above through a rotted hole. The entire building,
constructed between the world wars, often smells like greasy carry-out.
Signs of neglect are everywhere: mouse droppings, belly-up cockroaches,
stained carpets, cheap mattresses.

This is the world of Building
18, not the kind of place where Duncan expected to recover when he was
evacuated to Walter Reed Army Medical Center from Iraq
last February with a broken neck and a shredded left ear, nearly dead
from blood loss. But the old lodge, just outside the gates of the
hospital and five miles up the road from the White House, has housed
hundreds of maimed soldiers recuperating from injuries suffered in the
wars in Iraq and Afghanistan.

common perception of Walter Reed is of a surgical hospital that shines
as the crown jewel of military medicine. But 5 1/2 years of sustained
combat have transformed the venerable 113-acre institution into
something else entirely — a holding ground for physically and
psychologically damaged outpatients. Almost 700 of them — the majority
soldiers, with some Marines — have been released from hospital beds
but still need treatment or are awaiting bureaucratic decisions before
being discharged or returned to active duty.

They suffer from
brain injuries, severed arms and legs, organ and back damage, and
various degrees of post-traumatic stress. Their legions have grown so
exponentially — they outnumber hospital patients at Walter Reed 17 to
1 — that they take up every available bed on post and spill into
dozens of nearby hotels and apartments leased by the Army. The average
stay is 10 months, but some have been stuck there for as long as two

Not all of the quarters are as bleak as Duncan’s, but the
despair of Building 18 symbolizes a larger problem in Walter Reed’s
treatment of the wounded, according to dozens of soldiers, family
members, veterans aid groups, and current and former Walter Reed staff
members interviewed by two Washington Post reporters, who spent more
than four months visiting the outpatient world without the knowledge or
permission of Walter Reed officials. Many agreed to be quoted by name;
others said they feared Army retribution if they complained publicly.

the hospital is a place of scrubbed-down order and daily miracles, with
medical advances saving more soldiers than ever, the outpatients in the
Other Walter Reed encounter a messy bureaucratic battlefield nearly as
chaotic as the real battlefields they faced overseas.

On the
worst days, soldiers say they feel like they are living a chapter of
“Catch-22.” The wounded manage other wounded. Soldiers dealing with
psychological disorders of their own have been put in charge of others
at risk of suicide.

Disengaged clerks, unqualified platoon
sergeants and overworked case managers fumble with simple needs:
feeding soldiers’ families who are close to poverty, replacing a
uniform ripped off by medics in the desert sand or helping a
brain-damaged soldier remember his next appointment.

“We’ve done
our duty. We fought the war. We came home wounded. Fine. But whoever
the people are back here who are supposed to give us the easy
transition should be doing it,” said Marine Sgt. Ryan Groves, 26, an
amputee who lived at Walter Reed for 16 months. “We don’t know what to
do. The people who are supposed to know don’t have the answers. It’s a
nonstop process of stalling.”

Soldiers, family members,
volunteers and caregivers who have tried to fix the system say each
mishap seems trivial by itself, but the cumulative effect wears down
the spirits of the wounded and can stall their recovery.

creates resentment and disenfranchisement,” said Joe Wilson, a clinical
social worker at Walter Reed. “These soldiers will withdraw and stay in
their rooms. They will actively avoid the very treatment and services
that are meant to be helpful.”

Danny Soto, a national service
officer for Disabled American Veterans who helps dozens of wounded
service members each week at Walter Reed, said soldiers “get awesome
medical care and their lives are being saved,” but, “Then they get into
the administrative part of it and they are like, ‘You saved me for
what?’ The soldiers feel like they are not getting proper respect. This
leads to anger.”

This world is invisible to outsiders. Walter
Reed occasionally showcases the heroism of these wounded soldiers and
emphasizes that all is well under the circumstances. President Bush,
former defense secretary Donald H. Rumsfeld and members of Congress
have promised the best care during their regular visits to the
hospital’s spit-polished amputee unit, Ward 57.

“We owe them all
we can give them,” Bush said during his last visit, a few days before
Christmas. “Not only for when they’re in harm’s way, but when they come
home to help them adjust if they have wounds, or help them adjust after
their time in service.”

Along with the government promises, the
American public, determined not to repeat the divisive Vietnam
experience, has embraced the soldiers even as the war grows more
controversial at home. Walter Reed is awash in the generosity of
volunteers, businesses and celebrities who donate money, plane tickets,
telephone cards and steak dinners.

Yet at a deeper level, the
soldiers say they feel alone and frustrated. Seventy-five percent of
the troops polled by Walter Reed last March said their experience was
“stressful.” Suicide attempts and unintentional overdoses from
prescription drugs and alcohol, which is sold on post, are part of the
narrative here.

Vera Heron spent 15 frustrating months living on
post to help care for her son. “It just absolutely took forever to get
anything done,” Heron said. “They do the paperwork, they lose the
paperwork. Then they have to redo the paperwork. You are talking about
guys and girls whose lives are disrupted for the rest of their lives,
and they don’t put any priority on it.”

Family members who speak
only Spanish have had to rely on Salvadoran housekeepers, a Cuban bus
driver, the Panamanian bartender and a Mexican floor cleaner for help.
Walter Reed maintains a list of bilingual staffers, but they are rarely
called on, according to soldiers and families and Walter Reed staff

Evis Morales’s severely wounded son was transferred to
the National Naval Medical Center in Bethesda for surgery shortly after
she arrived at Walter Reed. She had checked into her government-paid
room on post, but she slept in the lobby of the Bethesda hospital for
two weeks because no one told her there is a free shuttle between the
two facilities. “They just let me off the bus and said ‘Bye-bye,’ ”
recalled Morales, a Puerto Rico resident.

Morales found help
after she ran out of money, when she called a hotline number and a
Spanish-speaking operator happened to answer.

“If they can have
Spanish-speaking recruits to convince my son to go into the Army, why
can’t they have Spanish-speaking translators when he’s injured?”
Morales asked. “It’s so confusing, so disorienting.”

wives, mothers, social workers and the heads of volunteer organizations
have complained repeatedly to the military command about what one
called “The Handbook No One Gets” that would explain life as an
outpatient. Most soldiers polled in the March survey said they got
their information from friends. Only 12 percent said any Army
literature had been helpful.

“They’ve been behind from Day One,”
said Rep. Thomas M. Davis III (R-Va.), who headed the House Government
Reform Committee, which investigated problems at Walter Reed and other
Army facilities. “Even the stuff they’ve fixed has only been patched.”

the public, Davis said, “there’s vast appreciation for soldiers, but
there’s a lack of focus on what happens to them” when they return.
“It’s awful.”

Maj. Gen. George W. Weightman, commander at Walter
Reed, said in an interview last week that a major reason outpatients
stay so long, a change from the days when injured soldiers were
discharged as quickly as possible, is that the Army wants to be able to
hang on to as many soldiers as it can, “because this is the first time
this country has fought a war for so long with an all-volunteer force
since the Revolution.”

Acknowledging the problems with outpatient
care, Weightman said Walter Reed has taken steps over the past year to
improve conditions for the outpatient army, which at its peak in summer
2005 numbered nearly 900, not to mention the hundreds of family members
who come to care for them. One platoon sergeant used to be in charge of
125 patients; now each one manages 30. Platoon sergeants with
psychological problems are more carefully screened. And officials have
increased the numbers of case managers and patient advocates to help
with the complex disability benefit process, which Weightman called
“one of the biggest sources of delay.”

And to help steer the
wounded and their families through the complicated bureaucracy,
Weightman said, Walter Reed has recently begun holding twice-weekly
informational meetings. “We felt we were pushing information out
before, but the reality is, it was overwhelming,” he said. “Is it
fail-proof? No. But we’ve put more resources on it.”

He said a 21,500-troop increase in Iraq has Walter Reed bracing for “potentially a lot more” casualties.

Bureaucratic Battles

best known of the Army’s medical centers, Walter Reed opened in 1909
with 10 patients. It has treated the wounded from every war since, and
nearly one of every four service members injured in Iraq and

The outpatients are assigned to one of five
buildings attached to the post, including Building 18, just across from
the front gates on Georgia Avenue. To accommodate the overflow, some
are sent to nearby hotels and apartments. Living conditions range from
the disrepair of Building 18 to the relative elegance of Mologne House,
a hotel that opened on the post in 1998, when the typical guest was a
visiting family member or a retiree on vacation.

The Pentagon has
announced plans to close Walter Reed by 2011, but that hasn’t stopped
the flow of casualties. Three times a week, school buses painted white
and fitted with stretchers and blackened windows stream down Georgia
Avenue. Sirens blaring, they deliver soldiers groggy from a pain-relief
cocktail at the end of their long trip from Iraq via Landstuhl Regional
Medical Center in Germany and Andrews Air Force Base.

Sgt. John Daniel Shannon, 43, came in on one of those buses in November
2004 and spent several weeks on the fifth floor of Walter Reed’s
hospital. His eye and skull were shattered by an AK-47 round. His
odyssey in the Other Walter Reed has lasted more than two years, but it
began when someone handed him a map of the grounds and told him to find
his room across post.

A reconnaissance and land-navigation
expert, Shannon was so disoriented that he couldn’t even find north.
Holding the map, he stumbled around outside the hospital, sliding
against walls and trying to keep himself upright, he said. He asked
anyone he found for directions.

Shannon had led the 2nd Infantry
Division’s Ghost Recon Platoon until he was felled in a gun battle in
Ramadi. He liked the solitary work of a sniper; “Lone Wolf” was his
call name. But he did not expect to be left alone by the Army after
such serious surgery and a diagnosis of post-traumatic stress disorder.
He had appointments during his first two weeks as an outpatient, then

“I thought, ‘Shouldn’t they contact me?’ ” he said. “I
didn’t understand the paperwork. I’d start calling phone numbers,
asking if I had appointments. I finally ran across someone who said:
‘I’m your case manager. Where have you been?’

“Well, I’ve been here! Jeez Louise, people, I’m your hospital patient!”

Shannon, many soldiers with impaired memory from brain injuries sat for
weeks with no appointments and no help from the staff to arrange them.
Many disappeared even longer. Some simply left for home.

outpatient, a 57-year-old staff sergeant who had a heart attack in
Afghanistan, was given 200 rooms to supervise at the end of 2005. He
quickly discovered that some outpatients had left the post months
earlier and would check in by phone. “We called them ‘call-in
patients,’ ” said Staff Sgt. Mike McCauley, whose dormant PTSD from
Vietnam was triggered by what he saw on the job: so many young and
wounded, and three bodies being carried from the hospital.

beyond the hospital bed is a frustrating mountain of paperwork. The
typical soldier is required to file 22 documents with eight different
commands — most of them off-post — to enter and exit the medical
processing world, according to government investigators. Sixteen
different information systems are used to process the forms, but few of
them can communicate with one another. The Army’s three personnel
databases cannot read each other’s files and can’t interact with the
separate pay system or the medical recordkeeping databases.

disappearance of necessary forms and records is the most common reason
soldiers languish at Walter Reed longer than they should, according to
soldiers, family members and staffers. Sometimes the Army has no record
that a soldier even served in Iraq. A combat medic who did three tours
had to bring in letters and photos of herself in Iraq to show she that
had been there, after a clerk couldn’t find a record of her service.

who wears an eye patch and a visible skull implant, said he had to
prove he had served in Iraq when he tried to get a free uniform to
replace the bloody one left behind on a medic’s stretcher. When he
finally tracked down the supply clerk, he discovered the problem: His
name was mistakenly left off the “GWOT list” — the list of “Global War
on Terrorism” patients with priority funding from the Defense

He brought his Purple Heart to the clerk to prove he was in Iraq.

paperwork for new uniforms has forced some soldiers to attend their own
Purple Heart ceremonies and the official birthday party for the Army in
gym clothes, only to be chewed out by superiors.

The Army has
tried to re-create the organization of a typical military unit at
Walter Reed. Soldiers are assigned to one of two companies while they
are outpatients — the Medical Holding Company (Medhold) for
active-duty soldiers and the Medical Holdover Company for Reserve and
National Guard soldiers. The companies are broken into platoons that
are led by platoon sergeants, the Army equivalent of a parent.

normal circumstances, good sergeants know everything about the soldiers
under their charge: vices and talents, moods and bad habits, even
family stresses.

At Walter Reed, however, outpatients have been
drafted to serve as platoon sergeants and have struggled with their
responsibilities. Sgt. David Thomas, a 42-year-old amputee with the
Tennessee National Guard, said his platoon sergeant couldn’t remember
his name. “We wondered if he had mental problems,” Thomas said.
“Sometimes I’d wear my leg, other times I’d take my wheelchair. He
would think I was a different person. We thought, ‘My God, has this man
lost it?’ ”

Civilian care coordinators and case managers are
supposed to track injured soldiers and help them with appointments, but
government investigators and soldiers complain that they are poorly
trained and often do not understand the system.

One amputee, a
senior enlisted man who asked not to be identified because he is back
on active duty, said he received orders to report to a base in Germany
as he sat drooling in his wheelchair in a haze of medication. “I went
to Medhold many times in my wheelchair to fix it, but no one there
could help me,” he said.

Finally, his wife met an aide to
then-Deputy Defense Secretary Paul D. Wolfowitz, who got the erroneous
paperwork corrected with one phone call. When the aide called with the
news, he told the soldier, “They don’t even know you exist.”

“They didn’t know who I was or where I was,” the soldier said. “And I was in contact with my platoon sergeant every day.”

lack of accountability weighed on Shannon. He hated the isolation of
the younger troops. The Army’s failure to account for them each day
wore on him. When a 19-year-old soldier down the hall died, Shannon
knew he had to take action.

The soldier, Cpl. Jeremy Harper,
returned from Iraq with PTSD after seeing three buddies die. He kept
his room dark, refused his combat medals and always seemed heavily
medicated, said people who knew him. According to his mother, Harper
was drunkenly wandering the lobby of the Mologne House on New Year’s
Eve 2004, looking for a ride home to West Virginia. The next morning he
was found dead in his room. An autopsy showed alcohol poisoning, she

“I can’t understand how they could have let kids under the
age of 21 have liquor,” said Victoria Harper, crying. “He was supposed
to be right there at Walter Reed hospital. . . . I feel that they
didn’t take care of him or watch him as close as they should have.”

The Army posthumously awarded Harper a Bronze Star for his actions in Iraq.

viewed Harper’s death as symptomatic of a larger tragedy — the Army
had broken its covenant with its troops. “Somebody didn’t take care of
him,” he would later say. “It makes me want to cry. ”

Shannon and
another soldier decided to keep tabs on the brain injury ward. “I’m a
staff sergeant in the U.S. Army, and I take care of people,” he said.
The two soldiers walked the ward every day with a list of names. If a
name dropped off the large white board at the nurses’ station, Shannon
would hound the nurses to check their files and figure out where the
soldier had gone.

Sometimes the patients had been transferred to
another hospital. If they had been released to one of the residences on
post, Shannon and his buddy would pester the front desk managers to
make sure the new charges were indeed there. “But two out of 10, when I
asked where they were, they’d just say, ‘They’re gone,’ ” Shannon said.

after Weightman and his commanders instituted new measures to keep
better track of soldiers, two young men left post one night in November
and died in a high-speed car crash in Virginia. The driver was supposed
to be restricted to Walter Reed because he had tested positive for
illegal drugs, Weightman said.

Part of the tension at Walter Reed
comes from a setting that is both military and medical. Marine Sgt.
Ryan Groves, the squad leader who lost one leg and the use of his other
in a grenade attack, said his recovery was made more difficult by a
Marine liaison officer who had never seen combat but dogged him about
having his mother in his room on post. The rules allowed her to be
there, but the officer said she was taking up valuable bed space.

you join the Marine Corps, they tell you, you can forget about your
mama. ‘You have no mama. We are your mama,’ ” Groves said. “That
training works in combat. It doesn’t work when you are wounded.”

Frustration at Every Turn

frustrations of an outpatient’s day begin before dawn. On a dark,
rain-soaked morning this winter, Sgt. Archie Benware, 53, hobbled over
to his National Guard platoon office at Walter Reed. Benware had done
two tours in Iraq. His head had been crushed between two 2,100-pound
concrete barriers in Ramadi, and now it was dented like a tin can. His
legs were stiff from knee surgery. But here he was, trying to take care
of business.

At the platoon office, he scanned the white board on
the wall. Six soldiers were listed as AWOL. The platoon sergeant was
nowhere to be found, leaving several soldiers stranded with their

Benware walked around the corner to arrange a dental
appointment — his teeth were knocked out in the accident. He was told
by a case manager that another case worker, not his doctor, would have
to approve the procedure.

“Goddamn it, that’s unbelievable!”
snapped his wife, Barb, who accompanied him because he can no longer
remember all of his appointments.

Not as unbelievable as the time he received a manila envelope containing the gynecological report of a young female soldier.

came 7 a.m. formation, one way Walter Reed tries to keep track of
hundreds of wounded. Formation is also held to maintain some
discipline. Soldiers limp to the old Red Cross building in rain, ice
and snow. Army regulations say they can’t use umbrellas, even here. A
triple amputee has mastered the art of putting on his uniform by
himself and rolling in just in time. Others are so gorked out on pills
that they seem on the verge of nodding off.

“Fall in!” a platoon sergeant shouted at Friday formation. The noisy room of soldiers turned silent.

Army chaplain opened with a verse from the Bible. “Why are we here?”
she asked. She talked about heroes and service to country. “We were
injured in many ways.”

Someone announced free tickets to hockey
games, a Ravens game, a movie screening, a dinner at McCormick and
Schmick’s, all compliments of local businesses.

Every formation
includes a safety briefing. Usually it is a warning about mixing
alcohol with meds, or driving too fast, or domestic abuse. “Do not beat
your spouse or children. Do not let your spouse or children beat you,”
a sergeant said, to laughter. This morning’s briefing included a
warning about black ice, a particular menace to the amputees.

Dress warm, the sergeant said. “I see some guys rolling around in their wheelchairs in 30 degrees in T-shirts.”

hate formation for its petty condescension. They gutted out a year in
the desert, and now they are being treated like children.

trying to think outside the box here, maybe moving formation to Wagner
Gym,” the commander said, addressing concerns that formation was too
far from soldiers’ quarters in the cold weather. “But guess what? Those
are nice wood floors. They have to be covered by a tarp. There’s a tarp
that’s got to be rolled out over the wooden floors. Then it has to be
cleaned, with 400 soldiers stepping all over it. Then it’s got to be
rolled up.”

“Now, who thinks Wagner Gym is a good idea?”

this strange world to family members is not easy. At an orientation for
new arrivals, a staff sergeant walked them through the idiosyncrasies
of Army financing. He said one relative could receive a 15-day advance
on the $64 per diem either in cash or as an electronic transfer: “I
highly recommend that you take the cash,” he said. “There’s no
guarantee the transfer will get to your bank.” The audience yawned.

he went on, relatives can collect only 80 percent of this advance,
which comes to $51.20 a day. “The cashier has no change, so we drop to
$50. We give you the rest” — the $1.20 a day — “when you leave.”

crowd was anxious, exhausted. A child crawled on the floor. The
sergeant plowed on. “You need to figure out how long your loved one is
going to be an inpatient,” he said, something even the doctors can’t
accurately predict from day to day. “Because if you sign up for the
lodging advance,” which is $150 a day, “and they get out the next day,
you owe the government the advance back of $150 a day.”

A case
manager took the floor to remind everyone that soldiers are required to
be in uniform most of the time, though some of the wounded are amputees
or their legs are pinned together by bulky braces. “We have break-away
clothing with Velcro!” she announced with a smile. “Welcome to Walter

A Bleak Life in Building 18

“Building 18! There
is a rodent infestation issue!” bellowed the commander to his troops
one morning at formation. “It doesn’t help when you live like a rodent!
I can’t believe people live like that! I was appalled by some of your

Life in Building 18 is the bleakest homecoming for men
and women whose government promised them good care in return for their

One case manager was so disgusted, she bought roach
bombs for the rooms. Mouse traps are handed out. It doesn’t help that
soldiers there subsist on carry-out food because the hospital cafeteria
is such a hike on cold nights. They make do with microwaves and hot

Army officials say they “started an aggressive campaign
to deal with the mice infestation” last October and that the problem is
now at a “manageable level.” They also say they will “review all
outstanding work orders” in the next 30 days.

Soldiers discharged
from the psychiatric ward are often assigned to Building 18. Buses and
ambulances blare all night. While injured soldiers pull guard duty in
the foyer, a broken garage door allows unmonitored entry from the rear.
Struggling with schizophrenia, PTSD, paranoid delusional disorder and
traumatic brain injury, soldiers feel especially vulnerable in that
setting, just outside the post gates, on a street where drug dealers
work the corner at night.

“I’ve been close to mortars. I’ve held
my own pretty good,” said Spec. George Romero, 25, who came back from
Iraq with a psychological disorder. “But here . . . I think it has
affected my ability to get over it . . . dealing with potential threats
every day.”

After Spec. Jeremy Duncan, 30, got out of the
hospital and was assigned to Building 18, he had to navigate across the
traffic of Georgia Avenue for appointments. Even after knee surgery, he
had to limp back and forth on crutches and in pain. Over time, black
mold invaded his room.

But Duncan would rather suffer with the
mold than move to another room and share his convalescence in tight
quarters with a wounded stranger. “I have mold on the walls, a hole in
the shower ceiling, but . . . I don’t want someone waking me up coming

Wilson, the clinical social worker at Walter Reed, was part
of a staff team that recognized Building 18’s toll on the wounded. He
mapped out a plan and, in September, was given a $30,000 grant from the
Commander’s Initiative Account for improvements. He ordered some
equipment, including a pool table and air hockey table, which have not
yet arrived. A Psychiatry Department functionary held up the rest of
the money because she feared that buying a lot of recreational
equipment close to Christmas would trigger an audit, Wilson said.

January, Wilson was told that the funds were no longer available and
that he would have to submit a new request. “It’s absurd,” he said.
“Seven months of work down the drain. I have nothing to show for this
project. It’s a great example of what we’re up against.”

A pool table and two flat-screen TVs were eventually donated from elsewhere.

Wilson had had enough. Three weeks ago he turned in his resignation.
“It’s too difficult to get anything done with this broken-down
bureaucracy,” he said.

At town hall meetings, the soldiers of
Building 18 keep pushing commanders to improve conditions. But some
things have gotten worse. In December, a contracting dispute held up
building repairs.

“I hate it,” said Romero, who stays in his room
all day. “There are cockroaches. The elevator doesn’t work. The garage
door doesn’t work. Sometimes there’s no heat, no water. . . . I told my
platoon sergeant I want to leave. I told the town hall meeting. I
talked to the doctors and medical staff. They just said you kind of got
to get used to the outside world. . . . My platoon sergeant said, ‘Suck
it up!’ ”

Staff researcher Julie Tate contributed to this report.

Soldiers Face Neglect, Frustration At Army’s Top Medical Facility –


  1. John McClain says:

    How do I get in touch with disabled vets in my area, Oklahoma City, tried going through the State of Oklahoma employment center for disabled vets, they gave me some one who could hardly speak english, this person was over finding work for our Vets! Why is there not a Vet going this job?

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