The physical therapists on the fifth floor of Walter Reed Army Medical Center have a bulletin board they call their Wall of Heroes. It is crammed with photos of young soldiers in their care -- soldiers wounded in the war in Iraq.
The images of the amputees and burn victims stand out, a tragic irony of an important advance in military protective gear.
The new armored vests that soldiers are wearing in this war protect the human torso and have saved countless lives, but often at a terrible price. One day last week, all but 20 of the 250 beds at the center were taken up with casualties of the war. Fifty of them have lost limbs, often more than one. Dozens more suffer burns and shrapnel wounds that begin where their armored vests ended.
On average, they are 23 years old.
Many would have died except for their Kevlar vests, which stopped rounds from a Kalashnikov rifle, a 9-millimeter handgun or fragments from a grenade. There have been more wounded -- and over a longer period -- than the hospital expected.
"We didn't start [the bulletin board] when the war began because we didn't have any idea," said Maj. Mary Hannah, a physical therapist. "Even the most experienced people here -- it is beyond their imagining. These are our babies. And they just keep coming, coming, coming."
As the U.S.-led coalition forces battle an increasingly fierce insurgency in Iraq, the military's medical system is waging its own war -- and Walter Reed, its premier medical center, is in the thick of it.
The world-renowned teaching and research hospital, which opened in 1909, has treated presidents and senators. Since World War I, Walter Reed has been a crucial, and often a long-term, stop for the most seriously wounded in war. Last week, more than a dozen survivors of the Chinook helicopter shot down by insurgents in Iraq Nov. 2 were carried in on stretchers. They entered a hospital transformed over the last seven months by the first big wave of combat casualties since the Vietnam War.
Since April, when the first casualties began arriving, more than 1,875 have been treated at Walter Reed, an average of about 10 a day, 300 a month. On any given day during that time, the hospital has had about 50 inpatients and 180 outpatients from the war.
The number of amputees and burn patients is still small compared with that during height of the Vietnam War, in which far more soldiers fought for far longer. But in the 1991 Persian Gulf War, just 10 amputees were treated at Walter Reed compared with the 50 in this war.
"The number is big to me now, bigger than anything I've seen since Vietnam," said Jim Mayer, 57, who lost both legs in that war and now volunteers at the hospital several days a week helping amputees. "When we see each other here, me and the other volunteers, our line to each other is, 'They just keep coming and coming.' "
In Ward 57, orthopedic surgeons work day and night. In the physical therapy rooms, young men missing limbs lie side by side and head to toe on mats, lifting weights. Hospital staffers come in on their days off, bringing pizza to the wounded soldiers, taking those who are well enough out to the movies. One physical therapist took a recovering "green card" soldier to the Immigration and Naturalization Service to pick up his U.S. citizenship papers.
A half hour away, at Andrews Air Force Base, the tennis court and gymnasium of the fitness center have become a medical staging facility for those evacuated from the war zone. More than 7,500 have come through since April.
In addition to the nearly 1,900 who have gone on to Walter Reed, 1,500 have been sent to the National Naval Medical Center in Bethesda, Md., which treats the injured from the Navy and Marines. Several thousand less seriously wounded soldiers have been sent directly to some of the military's dozens of smaller hospitals and clinics around the country.
After reports surfaced last month that the level of care being given at one of those smaller facilities was substandard, the Army took steps to improve services there and began an evaluation of the care at other regional hospitals.
The grounds at Walter Reed are crammed with recuperating soldiers and their families. There are so many spouses, parents and children that the more than 600 rooms in guest houses on the hospital grounds are not enough to hold them. Some are doubling up in single rooms. Hundreds are staying, at Pentagon expense, in hotels nearby. Hospital officials plan to lease space at a military housing complex four miles away to handle the overflow.
At least one mother has finagled a bed down the hall from her son's hospital room.
"I have to," says Joyce Gray, mother of Roy, an Army corporal whose leg was torn open by a mortar round as he was climbing into his truck. "My son has nightmares."
The hospital's other clients -- mostly military retirees who live in the Washington area -- are increasingly being asked to seek treatment elsewhere. And the hospital is restricting referrals to Army patients rather than accepting any from other branches of the military.
The ranks of nurses and physical and occupational therapists have been bolstered with reservists and private contractors from around the country, while doctors and nurses from the pediatrics and psychiatric departments have been pulled into the busiest wards.
"I don't think this is going to go away," said Army Major Gen. Kevin C. Kiley, an obstetrician and gynecologist by training who is commander of the hospital. "Our people are pedaling as hard and fast as they can. We can do this for a long time. But at some point, if there's no letup, the casualty demand will have to start affecting what Walter Reed is."
Even so, the 113-acre Walter Reed complex has a deep reservoir of medical professionals and resources -- 600 doctors on staff and 200 more in training. Of the $90 million spent to date at military hospitals on the Eastern seaboard in support of the war in Iraq, $50 million has been spent at Walter Reed.
Pfc. Jessica Lynch was treated at Walter Reed after her unit, the 507th Maintenance Company, took a wrong turn in southern Iraq and was ambushed. She left months ago.
But a fellow soldier from the 507th, Staff Sgt. Tarik Jackson, 28, is still there. The mechanic was shot four times -- in his thigh, finger, hip and upper arm -- and may be in treatment until well into next year.
In 2002, after the U.S. went to war in Afghanistan, Congress allocated $13 million to Walter Reed to establish what the hospital calls the Amputee Center of Excellence. The unit was up and running just in time. These days, its prosthetics lab is busy scanning stumps of limbs using digital laser technology, then using computerized machines to fashion sockets to fit over them.
Outside the lab on a recent day, three soldiers missing legs waited their turn to be fitted for prostheses. Inside, Pfc. Tristan Wyatt, 21, tried on his titanium and graphite leg for the first time. A rocket had severed his limb and those of the two soldiers standing next to him in Fallouja on Aug. 25. They have also been treated at Walter Reed.
"The rocket went through my leg like a knife through butter," Wyatt said. "It was a terrible scene with the three of us. There was just blood and muscle everywhere."
But Wyatt said the sheer numbers of patients like him at Walter Reed, many of them already learning to walk proficiently on their new prostheses, is heartening.
"It's hard to see your comrades hurt, but there are a lot of people here farther down the line with the same injuries," Wyatt said. "It definitely gives you hope."
Wyatt was wearing the new body armor when he was hit. Shrapnel hit his legs and arms but not his torso. The Kevlar armor, composed of a multiple-layer mesh of woven fabrics that "catches" projectiles, is stronger than the kind worn by police officers. Attachments protect the neck and groin. Two plates slip into the vest to cover vital organs.
It weighs 16 pounds, a third lighter than the previous, 20-year-old design that offered protection against shrapnel but couldn't stop bullets.
The military began developing the new vests after the battle in Somalia, when some U.S. soldiers were wounded or died after removing part of their too-heavy armor. The new gear got its first major battlefield tryout during Operation Anaconda in Afghanistan in 2001.
"We've seen a number of patients that, in our minds, in 'Nam they would not have lived," Mayer, the veteran who volunteers at Walter Reed, said. "One comes to my mind. You see how his wounds stop like a sunburn line right where the body armor started. As soon as you see him, you know that it was the body armor that saved his life."
But while advances such as the body armor -- combined with faster, more efficient battlefield medical care and even better bandages -- are saving lives and getting high marks within the military and the medical profession, they cannot keep soldiers from being injured or killed.
The seriously wounded are generally treated first at medical facilities set up in Iraq. Last spring, 200 doctors from Walter Reed alone were assigned to such facilities. About half of them are still there.
Patients are then flown to a U.S. military hospital in Landstuhl, Germany, and, when they are able to be moved, to Walter Reed or a few other top military trauma centers.
Burn victims, for example, are often sent to Brook Army Medical Center in San Antonio, known for its advanced burn unit. As of late October, a total of 605 soldiers from the war had been treated at Brook, dozens with life-threatening burns. Today, five soldiers are still being treated there for burns; 40 are outpatients.
"We are constantly checking how many burn beds we have, checking on supplies," hospital spokeswoman Nelia Schrum said. "They are complicated injuries that require lengthy therapy and treatment."
As soon as possible, the Army tries to move patients to smaller hospitals close to their home bases and families.
It was at one of those facilities, at Ft. Stewart in Hinesville, Ga., that the quality of treatment was deemed to be substandard.
Reserve and National Guard soldiers recuperating from wounds or illnesses contracted in Iraq were housed in barracks without air conditioning or private bathrooms and often forced to endure long waits for surgery and other treatment, said Brig. Gen. Richard L. Ursone, assistant Army surgeon general for force protection.
Ursone evaluated problems there this month after news reports about the poor conditions. Hospital officials, anticipating the surge of patients, had added rooms and surgery facilities but had not yet hired staff, Ursone said.
Late last month, Acting Army Secretary Les Brownlee traveled to Ft. Stewart to see the problems for himself. Days later, sick reservists living in the substandard barracks were moved to better accommodations, some at other military bases. New case managers were dispatched to Ft. Stewart's Winn Army Community Hospital to help move reservists through the system.
Meanwhile, Army officials are reviewing care at the 28 other Army hospitals around the country to ensure that patients are receiving adequate medical attention.
The staff at Walter Reed, with responsibility for the majority of the seriously wounded, has tried to address potential problems before they arise.
When they had trouble getting timely information from their counterparts in Germany on the number and type of casualties being flown to Walter Reed, it sent over its own nurse to report back.
Meanwhile, doctors have been known to schedule the multiple surgeries of patients who have become friends on staggered schedules so the patient who is in better shape on a given day can console the other.
"The whole hospital is on a war footing and emotionally involved," said Kiley, the commanding officer. "The broader challenge is how do you keep the battle tempo up for a long period of time."
As casualties continue to mount in Iraq, the bulletin board at Walter Reed's physical therapy unit long ago ran out of room. "This is like 1%" of the Iraq casualties who passed through the hospital, said Hannah, one of the physical therapists. "If we had a picture of everyone, it would take up a whole wall."