At will and sometimes against his will, Sam Brown can return in his mind to that hour in the Kandahar desert when he knelt at the edge of a blast crater and raised his flaming arms to the Afghanistan sky. He’d already run through the macabre slapstick routine of a man on fire, trying to put himself out by rolling on the ground. He’d resorted to pelting his face with fistfuls of sand. That failing, he’d run in helpless circles. Finally he’d dropped to his knees, lifted his arms, and screamed Jesus, save me. Each scream drew fire deeper into his lungs. Behind him his Humvee was a twisted inferno. Bullets whizzed around him. His men were scattering, taking cover, moving dreamily in clouds of so-called moondust, that weird powdery talc, which hung in the air and gave the soldiers the appearance of snowmen. It was going on dusk, and in the fading light the enemy gunfire blazed behind the walls of the village.
Only the day before, Brown’s brother, Daniel, had told him, in a phone call, You’re invincible, they can’t kill you. Best he could remember, he’d always felt invincible. Pretty much right up to the instant they rolled over the IED, he had remained the same man he’d been at West Point. That is, he was a man whose life still had meaning. Every action had been meant to hone him for the glory of battle. Even as varsity stroke, in command of a shell on the rowing team, out on the water every morning at dawn, the sun dripping off his oars, his arms burning as he counted off the strokes, welcoming the pain into his body, bronzed, sculpted, almost too good-looking, he sought hard perfection in himself and those around him.
A diligent cadet who would spend the whole of an afternoon in the library reading about ancient Greek wars in Herodotus, immersed in the virtual reality of history, yearning for his own chance to test his mettle—but that was before eight brain-dead weeks of providing security for the construction of a new FOB in the middle of nowhere, watching bulldozers push sand, anxious for anything to break up the tedium, anything. When he was told his platoon would have to help provide security for a convoy coming through his sector on its way to a hydroelectric dam out in Helmand—delivering turbines, on a hearts-and-minds mission—he was all for the diversion, almost ecstatic when the call came from First Platoon reporting they’d been ambushed and needed backup. Brown had responded immediately. He was on the radio to his lead vehicle when he saw the bright flash. His body went inert as the Humvee lifted into the air. How he escaped from the wreck he couldn’t recall.
Kneeling there, on fire, he’d resigned himself to death. All he’d wanted to know was how long? How long would he have to burn? How many more torturous fractions of a second would he have to remain alive?
His gunner, Jensen, had come to his rescue, extinguishing the fire with sand, helping him to his feet. Running for cover, Brown had kept his arms held out in front of him, as if he were carrying an infant that he did not know what to do with. The sleeves of his uniform were burned off, with patches of the desert camo fused to his skin, and the visible bits of his own flesh either meat-raw or charred black. It felt as though his gloves—made of thick leather and fire-retardant Nomex—were somehow cooking his hands.
Crouching behind a wall, he turned to the private beside him and said, "Take my gloves off."
The private hesitated, but then took hold of the glove and started pulling. "Sir," he said, "it’s not coming off."
"Take the glove off," First Lieutenant Brown said.
The soldier grimaced but put his strength into it, and the glove came off, and with it, Brown’s flesh. They all looked at the glove on the ground and then at his hand. Or tried not to look.
Brown extended the other hand. "This one."
It was dark before vehicles from the other platoon managed to reach them. In the back of a Humvee, Brown watched the hot .50-cal brass shells raining down from the turret. After a few moments, he could hear the battle fading behind, and then they were out bumping across the poppy fields. At one point, Brown caught a glimpse of himself in the side mirror. His hair was ash. His nostrils were black. His face was unrecognizable.
Before the Humvee reached the appointed helicopter landing zone, whatever Brown had been running on was gone. After helping him out of the Humvee and onto a stretcher, Brown’s men had wrapped gauze around his eyes to protect them from the flying dust the helicopter would kick up, and when they saw that he was having difficulty breathing, they began to sedate him in preparation to intubate. His arms were too badly burned, so they had to run the IV through his sternum. By the time they heard the Black Hawk and saw its search beam twitching over the poppy fields, the giant blades shredding the dark, the morphine had begun to find its way.
Hunter Hoffman hadn’t set out to help burn patients. As a cognitive psychologist—who had gotten his start back in the ’80s conducting experiments at Princeton to test the mind’s ability to discern between real and false memories—he had begun experimenting with virtual reality as a treatment for arachnophobes. Using a VR game he’d designed called SpiderWorld (see box), he had helped a number of individuals so crippled by fear that they had to seal up their windows to sleep. Outfitted with virtual-reality goggles, the patient began at the far end of a virtual kitchen, opposite the counter, upon which was a small, barely visible spider. Once the fight-or-flight response had subsided, the patient could inch closer until he could stand being close enough to see the spider’s reflection in the toaster’s chrome finish. Hoffman had created a world that people could enter, reemerging with their nightmares erased. It was an artificial world with the power to transform meaning itself in the so-often-insufferable sphere known as the real.
One day in 1994, a colleague of Hoffman’s told him he’d been observing patients at a burn center using hypnosis to control pain. His colleague wasn’t exactly sure how the treatment worked, but he thought it had something to do with distraction.
"Distraction?" Hoffman said. "I’ll show you distraction," and he showed his friend SpiderWorld.
Not long after, Hoffman went to meet the hypnotist himself, who agreed VR sounded like a pretty good idea. On the very first
burn patient they tried, SpiderWorld worked. He simply forgot to think about his pain. Still, stoves and toasters didn’t seem right, considering—kind of cruel, really. So Hoffman hired a world builder to make something else, something colder, fireproof.
Later, after Hoffman became director of the Virtual Reality Analgesia Research Center at the University of Washington Human Interface Technology Laboratory, or HITLab, he had some remarkable success. Using $35,000 goggles—the sort of hardware ordinarily used for training fighter pilots—researchers obtained drops in pain ratings by 30 to 50 percent.
If distraction was the key, why not just use over-the-counter video games for a fraction of the cost? To answer that question, Hoffman had run a control experiment. In his first case study, he had a teenager with a severe flash burn play Nintendo Mario Kart while having five staples removed from a skin graft. The data showed that in terms of reducing pain, anxiety about pain, and time spent thinking about pain, playing Nintendo Mario Kart compared poorly to SpiderWorld. The reason VR was so much more effective than a regular video game came down to a quality called "presence"—that sense of being immersed inside an artificial world.
In 2006, Hoffman presented his findings at a DoD conference on combat-casualty care. The most prominent image Hoffman had played on the screen had been a giant digital snowman, somewhat menacing in mien. Yet it was hard for all the high brass in the room to ignore the two 3-D brain scans comparing activity in the region of the mind known as the pain matrix. In the scan of a patient who had received only conventional opioids during wound care, the matrix was lit up like a cortical pool of lava. The other brain—the brain on VR—was a cooling star. "According to our results," Hoffman said, "VR not only reduces pain perception; it changes the way the brain processes pain signals." A day or so after the conference, he got a call from Colonel John Holcomb, commander of the army’s Institute of Surgical Research, or ISR, at Brooke Army Medical Center in San Antonio.
ISR was a unit born during World War II, in part out of the need to find better ways to treat thermal injuries, in anticipation of the waves of atomic-burn casualties that many reasonable, if gloomy, individuals regarded as inevitable. Ironically, sixty years later, those new techniques were being used more than ever, in response not to the most sophisticated weapons on earth but to the most crudely effective. An approximate 70 percent of injuries and deaths of U.S. troops this decade have involved an IED.
"Hoffman, we need VR," Colonel Holcomb said when he called. "Make it happen. Get it over here."
When a man’s body explodes in flame, the most visible devastation—the charring, the suppuration, the phantasmagoric melting—takes place on the surface, but the worst damage, the most dangerous and permanent damage, takes place invisibly, under the skin. In the crucible of fire, the body undergoes such a rapid metamorphosis that Major Christopher Maani, chief of anesthesiology at ISR’s burn center, likes to compare the physical changes to a kind of satanic fast-forward pregnancy.
"With pregnancy, you have nine months to see how that change is going to happen. You’ve got swelling, you’ve got stretching, you’ve got hormonal changes. With a burn victim, that evolution is so quick. You go from being perfectly where you were five minutes ago, to five minutes after the injury you’ve got leaking capillary membranes, you’ve got burn shock, your heart is acting differently, your kidneys are acting differently, your airways are starting to swell. Your mucosae are taking on fluid, so sometimes you get even total body swelling, or anasarca." In anasarca, the body balloons until it looks as if it’s going to explode.
A burn trauma is among the most significant stresses that the human body can survive. It’s far more complex and devastating than a gunshot
wound or a stab or a blunt-force injury. "All of them are bad," Maani said, "all of them carry their own risks and complications, and each can be a nightmare to deal with, but with burn injuries you often have all those things rolled into one." And that was the condition in which Lieutenant Sam Brown arrived—less than a week after hitting the IED in Afghanistan, with a brief layover in Germany—in San Antonio in the early evening of September 9, 2008.
Fortunately for Sam Brown, in the previous decade or so, with a steady stream of wounded veterans returning from the battlefields of Afghanistan and Iraq, doctors had come up with much better techniques for saving the lives of severe-burn victims. There had been huge leaps in antibiotic therapy, and specific resuscitation formulas tailored to the unique physiology of each patient. Now, rather than waiting, doctors rushed patients into the OR to begin the excision of dead and burned flesh and to begin performing the first skin harvests and grafts. Together, such changes had significantly improved final outcomes.
What had hardly improved at all, however, was the management of pain. Modern science had mapped the brain well enough that neurologists could now trace pain to its source in the pain matrix, and they knew that pain had been an evolutionary friend, a physiological adaptation. But pain experts were gradually starting to understand that it was just as often a pathological adaptation. Not a symptom of something else, but a disease in and of itself. Pain had a tendency to go berserk and send a lot of maladaptive signals, like telling an amputee that his nonexistent foot itched. Yet for all they’d learned, when it came to treating pain, little had changed since the invention of morphine in 1804.
Opiates usually helped, but they had plenty of bad side effects: nausea; acute constipation; they threw off your sleep cycle; some patients didn’t respond to them at all for whatever reason; addiction was pretty much par for the course, and as a practical matter for the military, rehab was costly, not to mention possibly fatal: Administer too big a dose and a patient could stop breathing or choke to death on his own vomit. Also, it wasn’t very easy to debrief somebody who was stoned out of his mind.
When Brown first came to in San Antonio, he began babbling about Mexico, and terrorists, and an exploding school bus, and an orgy on a battleship. For the previous two weeks, he’d received a continuous infusion of a powerful analgesic called ketamine—as in Special K, the same drug kids use at raves. As a sympathomimetic, ketamine was kind of a wonder drug for trauma and burn victims, Maani explained. The military loved it. Of course, there had been some concerns that it might contribute to post-traumatic stress disorder, since it did sometimes induce psychotic reactions: It was, after all, molecular kissing cousins with PCP.
While Brown’s body lay unconscious in Germany and then in San Antonio, his mind had romped and roamed. He’d awakened aboard a naval warship in an empty cabin painted battleship gray. Visitors had entered, not doctors and nurses but a gang of sailor boys and their girls. They’d held a drunken orgy, and one of the sailors had decided to torch Brown with a lighter and a canister of aerosol for fun. The ship had delivered him to a weird hospital in Mexico resembling a mosque. He’d been the only patient. Lurking around the grounds were mysterious Middle Eastern men armed with rifles. One day, while Brown was out walking the mazelike halls, these terrorists snuck into his room and handcuffed dead American soldiers to his hospital bed. To sleep, Brown had lain down among them.
These hallucinations hadn’t been like ordinary dreams. Dream time accelerated, skipped, blurred. Brown’s hallucinations had played out in real time. He remembered the tedium of his days at sea, counting off the minutes and hours. He recalled trying and failing to get comfortable beside those corpses handcuffed to his hospital bed. "It was," he said, "nothing short of reality." If he’d known it, the word he might have used to describe what his hallucinations had that a dream lacked was presence.
His doctors were surprised that he was able to recall it all with such horrible precision. Perhaps, despite the massive amounts of analgesia, the whole trip was some kind of unconscious interpretation of the surgical grafts they’d performed on him while he’d been sedated. As if the pain had somehow snuck in and managed to build an entire virtual world in his mind, complete with invented cities, mosques, and torturers. Wide-awake now to his new dawning reality—once conscious, the first surgical consent he gave was to have his left index finger amputated—Brown had to wonder if this world was preferable to the psychedelic one he had just escaped.
Morphine barely touched the worst levels of pain, such as the excruciating daily cleaning and debridement of open wounds. The first morning after Brown had regained consciousness, two nurses came to change his bandages. As gentle as they tried to be, the scabs still ripped, and the open air on his bared nerve endings made him writhe in agony. After an hour, which was how long it took just to take the bandages off, one of the nurses put two more milligrams of Dilaudid into his IV before wheeling him into the shower room. The nurses lathered him with soap and began to scrub and scour his skin. Even with the Dilaudid, they may as well have strapped him to a metal gurney, doused him with gasoline, and set him back on fire.
Every day he had to undergo the showers. He begged them not to do it, and his whole day was built around dreading it. Pain was ultimately a subjective experience, and the anxiety that built up to the daily torture of wound care, the anticipation, the fear of knowing what was coming, of being set on fire by your memory over and over again every day, often triggered a cycle of escalating pain that led inexorably toward PTSD.
After a few months, when the scar tissue from his grafts began to grow out of control, Brown discovered a new kind of torture even more agonizing even than the showers.
Scar tissue, of course, was meant to knit things back together. But his had gone into overdrive. It was a hypertrophic, aggressive scarring pattern, and it had something to do with his collagen tendrils not being properly "organized." The worst was how it had thickened on his back and shoulders, where his own skin had been harvested and the first grafts had been made while he was off in his ketamine dreams. His scars looked like some kind of mutant armor. In physical therapy, in hopes of restoring his range of motion, they had to stretch those contractures out. It was like stretching—and ripping—a plastic milk jug. On a scale of 1 to 10 the pain was easily a 9. His pain was always being quantified, appointed a numerical grade. On many days it was a 10. Why had nobody yet realized that—just to be fair—they really needed a new scale that went from 1 to 50? At least.
First Lieutenant Amy Larsen and Sam Brown: He was a burn patient, she was his dietician. "How about some lieutenant time?" he asked.
It was once he was off the ICU, in the step-down unit, that Maani came in one day and asked if Sam would be interested in taking part in a research trial. He consented, along with eleven other soldiers in the burn unit. He probably would have consented to just about anything now if it promised relief. Soon thereafter, doctors wheeled an apparatus into his room, a robotic-arm-type thing with what looked like a welder’s mask affid to one end. This was the delivery system for a state-of-the-art virtual-reality game, they explained. It was called SnowWorld.
When they first lowered the goggles over his eyes, Brown was not all that impressed. He found himself floating through a kind of glacial canyon, but the overall vibe was pretty kiddie. Snowflakes wheeled gently from a digital sky. Snowmen and penguins lined up on ledges along the fjord. The soundtrack was kind of lame, too. Kind of an upbeat chirpy world music, a catchy-against-your-will kind of thing that he’d never heard before. If you’ll be my bodyguard, I can be your loo-ong lost pal, the lyrics went.
But there was no question Sam felt very much inside this Disneyesque world on ice, and it was a hell of a lot better than being present while they yanked and pulled at his petrified shoulders. So he tried to get into the game. A few milligrams of Dilaudid didn’t hurt.
The action of the mouse allowed him to fire off snowballs as fast as he could click. He had, more or less, a snowball M16. When one of the snowmen lobbed a big misshapen snowball at him, magically unholstering it from its hip with its stick arm, he took it out with three controlled head shots. The first shot turned the snowman to ice, freezing it with its arm served back, mid-lob. A third sent an explosion of ice shrapnel raining down into the canyon. Eerily, its disembodied face, the charcoal eyes and carrot nose and button teeth, lingered in the air for a few seconds afterward.
I can call you Betty, and Betty when you call me...
He passed under a low overhang, a kind of narrow passage in the bluish opalescent icy wall, strafed a couple of igloos, and then turned his attention to a squad of penguins flapping their wings further up the escarpment.
After a few circuits, he realized that each time he went through the cavern by the waterfall and then came back out, all the snowmen and penguins he’d killed were resurrected. It was a game that could not be won. So to make it more interesting, he began to test how to ricochet snowballs off the canyon wall and make carom shots. He started thinking trajectory. He thought ballistics, correcting his maximum ordinates before laying down wave after wave of penguin annihilation.
When he stopped shooting, he could hear the trickle of the river moving underneath him, and he took a moment to notice that he was suspended in air, floating along, out of his body. Everything moved in slow motion, just a few frames slower than reality, which was relaxing. As he passed beside the waterfall, he felt a tug of pain from the outside world but then directed his attention to the flying fish leaping below. He fired off a few shots, and his snowballs splashed up with blue steam.
Don’t wanna end up a cartoon in a cartoon graveyard, bone digger, bone digger.
Sam found out quickly that the woolly mammoths wading below were indestructible. Shoot them and they only trumpeted angrily, so he didn’t bother wasting any more rounds. Sometimes the snowfall waned, the sky turned blue, and then the snow started again. Between Paul Simon, the indoor waterfall, and the sedated peripatetic tempo, the whole place kind of had the feel of a suburban mall. Except, of course, here you could machine-gun everything in sight guilt-free.
The truth was, he was rather enjoying it. It wasn’t like he could feel a cold breeze blowing through his hair or any bullshit like that, but being down in that digital wintry realm, it did have a certain effect, enough that he found himself drifting back to the last time he’d gone skiing with Daniel, his brother, at the same resort in Colorado where his family had always gone on Christmas break, this last trip being during his final year at West Point. He and Daniel had gone skiing backcountry, off the trails, well beyond where the tourists went, so they had it all to themselves. They had found a bowl that was pure and untouched, the powder so deep they’d just floated down the whole way, the best skiing of his life. He also remembered the crazy stunt his brother had pulled that Christmas, cracking everyone up, when he’d gone on a black-diamond run almost naked, busting down the mountain in nothing but a pair of bor shorts and red-and-white-striped elf tights, the pom-pom on his red Santa hat flipping back and forth. It was only as he got closer, almost to the bottom, that you could see the rubber skull mask, and when he skidded to a stop, his laughter was muted by the mask, the steam of his breath huffing out the rubber eyeholes.
Before Sam knew it, the game was over. His therapists were taking off the goggles. "We’re already done?" He still had a whole village of igloos left to liquidate.
When they went through the list of questions, Sam was surprised to hear himself say that his observed pain had only been a 6. The therapists were pleased, and maybe a bit surprised as well, to tell him that they had gotten more range of motion than previously.
"Really?" But it was true, Sam had only been vaguely aware of the pain, mostly when it had caused him to muff a shot. The game play was like a white noise that canceled out the pain—as great a relief as he’d gotten so far during therapy, better even than morphine.
Later on, Hunter Hoffman came in to explain how it worked. Sam immediately liked Hoffman, who must have been about 50 but had the wispy blond hair and boyish energetic demeanor of a surfer on some kind of mission impossible. He liked hearing Hoffman break apart the mechanics of how his mind and his pain operated. How giving pain attention meant giving pain meaning, and how meaning amplified the experience of pain. How his conscious attention was like a spotlight. "Usually," Hoffman said, "it is focused on the pain during your wound care, but we’re luring that spotlight into the virtual world."
Virtual Iraq
M4 rifle in hand, vets suffering from PTSD patrol a generic Middle Eastern street. The unseen therapist introduces sensory triggers—the shock wave of an IED, the Muslim call to prayer, spices pumped in by a scent machine.
Spiderworld
Arachnophobes endure increasingly intimate encounters with digital spiders until theyre brave enough to touch both a virtual spider and, with their actual fingers, a lifelike replica of a Goliath bird-eating tarantula.
Dirty Bathroom
Germaphobes explore a series of increasingly befouled bathroom stalls, touching every nasty surface. The final test: flush a clogged toilet and resist the urge to flee as feces and urine flood the floor.
Chez Fortune
Gambling addicts enter a dim bar equipped with blinking slot machines. Music blares, and cigarette smoke clouds the room. Ask the bartender which machine to play and hell tell you, They all pay eventually.
Sam thought about one of the questions they had asked when he’d finished: "While experiencing the virtual world, to what extent did you feel like you WENT INSIDE the computer-generated world?"
0 = I did not feel like I went inside at all
1–4 = mild sense of going inside
5–6 = moderate sense of going inside
7–9 = strong sense of going inside
10 = I went completely inside the virtual world
He had answered "moderate" for that one. But everything was relative. When it came to being inside virtual worlds, he was a veteran. He knew a thing or two about immersion. SnowWorld did not even compare to KetamineWorld. KetamineWorld was a solid 10 for presence. Still, he fid Hoffman with his brown eyes and said, "I think you guys are onto something."
In the following weeks, he was surprised how often he found himself wanting the balm of that snowy fireproof wonderland. The fact of the matter was, his doctors had let him visit it only the one time—not as a patient but as a research subject. They would need to test the game on a larger sample of patients before prescribing it as therapy. For now, Brown would have to depend on drugs alone. After two more months, he was stable enough to arrange a visit home to Virginia at Christmas. If he wanted snow, he stood a better chance of seeing it there than he would in Texas.
Since he had microstomia—meaning his mouth was frizzled down to the size of a nickel—he couldn’t eat real food yet and had to drink this geriatric stuff called Boost Plus. He was going to need five pints a day just to get him through Christmas. So his case adviser paged a dietician to make the arrangements, and when she came into the room, Sam could see she was nervous as hell. Cute, but nervous as hell. She tried to cover it up by being extra perky, the way nurses sometimes did. She was new—her name was Amy—and probably wasn’t used to being around burn victims yet. Sam could only imagine what he must have looked like to her, sitting there in jeans and sneakers and an antimicrobial T-shirt spotted with blood from his seepy wounds.
A week later, at his parents’, he was watching some lousy Christmas special on TV, having a beer (with a straw), when the phone rang. To his surprise, it was the dietician. She sounded less chirpy, more stuffy and uptight: "Hi, it’s Lieutenant Larsen. How are you doing, Lieutenant Brown?"
"Hey Amy," he said, "how’s it going?" He tried to chat her up, but she was all business. As soon as she knew the Boost Plus had arrived safely, she hung up.
When he returned to Texas, he was living in an apartment near BAMC, existing in a state of limbo, no longer a full-time patient but not yet repatriated into the world of the healed. The pain he experienced during daily physical-therapy sessions had not so much diminished as become familiar, habitual. So had the drugs, which worried him. There was this quote he’d scratched on a Post-it that he carried around with him: "He who makes a beast of himself gets rid of the pain of being a man." He’d heard it in a song by Avenged Sevenfold, then later Googled it. The quote was Samuel Johnson’s. He didn’t know what metalcore sentiment Johnson had had in mind, but for him, it described every burn victim’s fear: that he will wander the earth as a monster, alone, unloved, unplugged from his soul in a haze of drugs.
Then, in February, he had to go back in for an eye-release surgery (his left cheek was contracting and pulling the eyelid down), and on his way to getting discharged, he ran into Amy Larsen. Just for the heck of it—maybe just to be testy—he asked if she wanted to go to the rodeo with him.
"You know," he said in his softest drawl. "How about some lieutenant time?" He was surprised when she said yes.
It turned out the rodeo was on Valentine’s Day. She’d never gone to one, but Sam’s old man had actually done rodeo, so he talked her through it a bit, though the point was fairly obvious: Hold on to the bull until it gored you or threw you to the ground. People stared at them, but he didn’t care. Just being around Amy, having her touch his arm, where the skin was seamed, meshlike and web-textured, gave him a sense of comfort—a reassuring presence—that he had not felt in a long time.
The following weekend, a family friend was getting married in Houston, and she agreed to be his date. Somewhere in the midst of all those hours alone in her car to Houston and back, Amy told Sam about the first time she had seen him in the hospital, before he’d even been conscious. He had been bandaged from head to toe, hooked up to a ventilator and feeding tubes, in deep sedation, off floating across a sea of ketamine. But when she heard that he was awake and extubated, she just felt this bizarre need to go talk to him. It was kind of crazy. She didn’t even know him. She didn’t know what he looked like under all the bandages. But when she got to his room, there was already a crowd, a circle of doctors and family members wearing the yellow isolation gowns, blue caps, and blue masks, and a chaplain leading everyone in prayer. Right away she turned and walked out.
It was not until the end of November—two months later—that she got the page from Sam’s case adviser about the Boost Plus. She confessed how nervous she had been, but not on account of his appearance. His face was rippled, like wax that had been blown by a gust of wind just before cooling, and the sides of his nostrils were fused to his face; but the brown eyes that looked out from underneath the hardened mask of melted flesh weren’t the eyes of any monster. She’d seen photographs of him from before: rock climbing, in a tank top with his crew team, looking gorgeous and smug as hell. If they’d met a year earlier, she’s not sure she’d have fallen for him. In this respect, the fire had changed him for the better. By the time she met Sam Brown, he’d had the ego burned off.
By March, Sam was able to go jogging again. So he and Amy started running together, talking, and finally one day, while they were stretching, Sam stopped and said, Look, if we’re going to keep hanging out like this, does that mean we’re dating? And Amy said yes, she thought it did, and then he said that he was of the opinion, given how short life was, even if they were both still in their twenties, that if he was going to date somebody, he felt it ought to be with marriage as an ultimate goal. Did she think she agreed with that? Amy said that yes, she thought she did. And so they continued jogging and dating until the end of April, when Sam proposed.
A month later, they ordered a cheesecake and flowers and got married in a friend’s backyard. Sam’s brother, Daniel, was best man. A few weeks later, they had another reason to celebrate: Sam received word he’d been promoted to captain. He and Amy didn’t go on a honeymoon right away, because Sam was scheduled for surgery to cut the scar tissue away from around his mouth. The result was he got back the semblance of an upper lip. That was followed by another surgery where microscopic holes were poked all over the skin on his face and neck to try and break down the scar tissue that was threatening to swallow up his features. But the scar tissue just continued to grow thicker. While he was suffering through his post-op recovery, Maani contacted him to say that if he was still interested, he could come back in for another dose of SnowWorld. He needed to demonstrate it for a few visiting officials. Sam leapt at the chance. He didn’t care if he had an audience.
But once he donned the goggles, the experience fell short of what he remembered. It still did an okay job, but now, somehow, the distractions—the music, the demonically happy snowmen, the exploding penguins—felt more like sensory overload. That, but also, he wasn’t a patient in this hospital anymore, nor was he caught in that lonely gray limbo of an apartment. He had a real home now, where Amy and a little peace and quiet were waiting.
The next Easter, in 2010, Sam and Amy finally managed to take a proper honeymoon, to Hawaii. One afternoon, swimming in the hotel pool, Sam was in one of those rare moments where, without medication, he felt no pain, felt like his old self, and he didn’t harbor a doubt in his mind as to why the most beautiful girl at the hotel was sunning herself on a towel, waiting for him and only him. She made the world around them bloom into something that not even the best VR architect could ever have conceived. There was no beating this actual water, this actual sun, this actual wife. Then this actual kid, this 4-year-old shit who’d been porpoising around, came up for air right in front of Sam, and you could see the kid thought he’d come face to face with the Creature from the Black Lagoon. Maybe if it had been another time, Sam would have let it go, but this time, jerked so abruptly out of his bliss, he snapped: "You know, if you don’t wear sunscreen like your mother tells you, you’ll end up looking like me!"
Soon after they got home, Sam had to go back into the hospital to have tissue expanders surgically implanted. That was in May. A tissue expander was basically an inflatable silicone balloon that went just under the skin and was gradually pumped full of saline over several months. The tension caused the cells to grow more skin, which the surgeon could then harvest and graft onto his face. It was somewhat like getting a breast implant, except the bags were rectangular shaped, and Sam was getting four: two under the soft skin on both hips and two on his upper chest, below each shoulder. It was slow torture, every bit as excruciating as it looked, and lasted right up until the final procedure—the first step of which was to remove most of his face.
A week after surgery, the graft was going south. There were dark areas, gray patches. They waited another week just to see, but when they took off the bandages, the graft had turned black. The scarring from that surgery too now began to grow with a vengeance, thick and red, hard as exoskeleton. Soon he could not move his face at all. This made it easier for him to conceal his emotions and harder for Amy to see, in the following weeks, that he was slipping away.
He no longer accepted that this was his reality. He couldn’t. He even wondered sometimes, fleetingly, whether Amy was a dream, perhaps generated from the same place in his mind that, under the influence of ketamine, had built those minarets and mazes and phantom ships. The last time, ironically, that he could have known, really known, without a trace of doubt, where he was, was in Afghanistan, after his gunner, Jensen, had rescued him but before the morphine, when he was curled in the back of a Humvee, headed to the helicopter landing zone. In dust kicked up by other vehicles, the driver had gotten lost, and Sam had still somehow mustered enough clarity of mind and enough strength, or at least enough adrenaline, to rouse himself from the backseat, radio for coordinates, and tell the driver where to go: due south three and a half kilometers. He leaned forward to jab at the GPS with his finger. "Look, we are right here." He was just as stunned as the driver to see his own flesh smeared on the glowing screen. Outside, through the armored windshield, the last gray specks of daylight glimmered in the dust rising from the poppy fields. That was the last time Sam could have said for sure that any map in his life could correlate to one and only one world, virtual or otherwise.
He became a recluse, hardly ever leaving the house. What was interesting was that he no longer really feared pain. Not physical pain. He had chosen to be strict with himself about getting by now on lower doses of drugs. He had learned to escape into his own mind, where there was a quiet chamber awaiting him, a peaceful void without a soundtrack or flying snowballs, but also without Amy or anyone, where the pain only came through like a distant muted voice that he could choose to ignore.
Then, one evening, he and Amy sat down and watched a movie together called, of all things, Fireproof. The movie was about this firefighter and a nurse whose marriage is about to dissolve. The firefighter, played by Kirk Cameron, gets injured while saving a girl from a house fire. He’s brought to the hospital where his wife works and where she’s been flirting with a doctor who doesn’t know that she is married to the firefighter (since things had already gotten really bad, bad enough that she no longer wore her wedding band). By the time the credits rolled, Amy was sobbing.
Sam found himself suddenly panicked at the thought of losing her, the one person who had made his life bearable. If he was going to win out over self-pity, if he was going to save his marriage, he’d have to recommit to the only world that mattered. The others were all cheap phantoms. Mazes of smoke and ash. Because this world, the one with meaning, the one where he was a lucky bastard just to be alive, this world that had the deepest and most unforgiving kinds of pain that you could not even fucking believe—well, he, for one, would not have rid himself of it for anything.
Last July, Maani and Hoffman published the results of the study in which Sam Brown had participated. Echoing the civilian studies, soldiers reported significant drops in pain while immersed in SnowWorld. Time spent thinking about pain, which is an inextricable contributor to actual pain, dropped from 76 percent without SnowWorld to 22 percent with SnowWorld. Amazingly, some of the biggest drops were for the most severe levels of pain, which went against every previous expectation. Since then, SnowWorld has received a good deal of enthusiasm from several well-lit corners of the Pentagon. At least one four-star general, after seeing the results from the ISR study, has gone so far as to say that he foresees a day coming soon when VR pain distraction might become standard care. There is nearly equal excitement about Hoffman’s other applications, including one called IraqWorld, a virtual-reality exposure therapy he built to treat soldiers with PTSD.
Hoffman knows that more studies need to be done before VR becomes a regular part of a medic’s field kit. To that end, he and his colleagues at HITLab are now using $7.5 million in NIH grants to further investigate how VR affects the mind and how better to apply it in clinical situations. One part of the study is looking at using small doses of ketamine to enhance the sense of presence. But he is confident that eventually, as the technology becomes more sophisticated, VR will be exponentially more effective. Soon, he predicts, VR worlds will be customized, personally tailored, and as in social networks or Second Life, they’ll allow patients to bring along other people—a vet’s mother, girlfriend, buddies. Hoffman imagines programs that will tap into a patient’s happy memories—of a ski vacation or a honeymoon or a morning rowing on a river, sunlight dripping from the oars.
Hoffman can also see battlefield applications. Customized VR worlds will be pre-programmed right into the soldier’s eye gear. He’s already experimenting with piezoelectric crystals to that end. It doesn’t seem like much of a stretch to imagine a near future in which combat patients could simultaneously distract themselves from their own pain while inflicting it on a virtual and remote enemy. A soldier could put his mind inside a drone instead of watching as a medic changed his bandages. In such a future of techno-utopian warfare, at least for those combatants equipped to fight outside the pain matrix, victory will indeed belong to those who have rid themselves of the inconvenience of being men and who, for all we know, may as well bleed snow.
By last winter, Sam had started jogging with Amy again, and the cold air felt wonderful in his lungs. He had already begun having laser therapy on his face and was seeing some results. The scar tissue was starting to settle, to calm, and he felt reasonably optimistic that before long it would soften and become more pliable as it gradually had on his arms. A few days after Christmas, Amy told him she was pregnant. They went into their bedroom and lay down together and called his brother, Daniel, a navy corpsman serving as a medic with the Marines at Camp Pendleton. Daniel had just returned from Afghanistan. He wasn’t sure when he was headed back, probably soon. Sam told him that his son’s name was going to be Roman Alexander.
"Really? I’m going to be an uncle?" Sam could almost hear in his brother’s voice an innocence that he remembered from before either of them had seen war.
On that last ski trip in Colorado, when the two of them had gone off the trails, they had taken the chairlift to the very end and then hiked through the woods, carrying their skis, coming out above the treeline, out of breath, above that pristine untouched bowl. It curved out below them, empty and unblemished. They had it all to themselves.
It was Sam’s last semester at West Point, and he knew he might be deployed the following year. But there was a chance Daniel, already on active duty, could beat him over there.
In a moment, they would hammer it to the bottom, racing each other all the way. Just before he lowered his goggles and pushed off, Sam took one last look down. The sky was blue and white, and his shoulders felt loose and ready to fly. The bowl held the promise of everything and nothing. When he raised his face to the snow falling softly across the treeless ridge, he felt the cold against his skin, and it felt like nothing so much as glory.
Jay Kirk is the author of ‘Kingdom Under Glass’, just out in paperback.
