BETHESDA, Md. -- Travis Mills sits in his hospital bed, holding his baby daughter, Chloe. His wife, Kelsey, stands nearby. He flashes the same grin that appears in photos from his deployment in Afghanistan, snapshots that are taped to the walls around his bed.
The full-blown smile is hard-wired into his identity. No matter how awful things get, his friends and loved ones can count on him to crack jokes, make a silly face and keep everyone loose. This was his attitude before the "point of injury" -- the Army's clinical term for the explosion that ripped apart all four of his limbs -- and it remains his attitude after.
"Just starting the day in a little place called Paradise," Travis tells visitors, including his wife's family from Frisco, Texas, in his room at Walter Reed National Military Medical Center outside Washington, D.C.
The story of Staff Sgt. Travis Mills, 25, a seven-year Army veteran on his third combat deployment to Afghanistan with the legendary 82nd Airborne Division, is one of courage, even humor, in the face of horrific injury.
But it is also a story of advances in medical knowledge, training and equipment that are saving more gravely wounded soldiers who likely would have died in previous wars.
From the moment a bomb exploded underneath him, Travis embarked on a seven-day, 7,000-mile odyssey that took him from a remote village in southern Afghanistan to a Level 1 trauma center in Germany and, finally, to Walter Reed, a long-term medical and rehabilitation facility. He was treated by trauma nurses on an airplane configured as an intensive care unit, and by surgeons operating in hospitals close to the battlefield -- a chain of care that began when a medic knelt next to him.
Travis' deployment was part of a revamped strategy to put more foot patrols in remote areas where the insurgents were active. But the presence of more foot soldiers has meant an increased risk of severe injuries from buried explosives.
Travis is one of only four quadruple amputees of the wars in Afghanistan and Iraq, according to Defense Department data. There are also 40 triple amputees from the two wars.
In the last three years, the number of amputees in combat -- and the number of those who have lost more than one limb -- has spiked, a trend that alarms medical officials.
In 2009, U.S. forces in Afghanistan recorded 62 cases of combat amputation, of which 24 percent involved the loss of more than one leg or arm, according to military data. The next year, more than one-third of the 198 combat amputees lost more than one limb. In 2011, almost half of the 240 combat amputees lost more than one limb. Through May of this year, 60 percent of the 43 combat amputees lost multiple limbs.
Though combat injuries are more severe, fatality rates are falling dramatically. In World War II, the survival rate for wounded soldiers was 69 percent. Since 2001, that survival rate has climbed to an average of 91 percent and reaches the high 90s for those who make it to a hospital.
Just a few feet inside his hospital room hangs a poster-size photo of Travis with his soldiers. Travis stands front and center, gripping his M-4 rifle.
At 6-foot-3, 240 pounds, tanned and broad-shouldered, the man in the poster looks like he could play linebacker for any college football team, if not the NFL. In fact, he's wearing an orange ball cap of his Vassar, Mich., high school football team.
Travis played football, basketball and baseball, said his father, Dennis Mills, 55. In football, "he never came off the field," his dad said, "and liked it that way."
Staff Sgt. Josh Buck met Travis on their first deployment in Afghanistan, which lasted 15 months and ended in April 2008. Josh, a medic, was assigned to his battalion commander's personal security detail, which included Travis.
"Right away, he was a big, likable guy. We ate every meal together," Josh said. "We got along real well -- until he started dating my sister, and then I didn't talk to him for a week."
During that first deployment, Travis first noticed Kelsey Buck on her brother's MySpace page. The two chatted and became close. On their first date, he took her to Cancun, Mexico, a "shock and awe" strategy that succeeded. They married just a few months later in June 2008.
In August 2009, Josh and Travis deployed again to Afghanistan. Their third deployment together started in February 2012. Josh was not in the same unit as Travis, but he ran a battalion aid station in the Kandahar Province, where Travis was assigned.
The 82nd Airborne Division is rapid-deployment, light infantry -- old-fashioned grunts. They like to say that they use "LPCs" to get from Point A to Point B, an ironic term for Leather Personnel Carrier, or boots.
The April 10 mission started as a routine foot patrol. The only thing unusual was the time of day, the middle of the afternoon: Just before chow, Travis grumbled.
Travis, a weapons squad leader, headed out with two dozen soldiers and an explosive ordnance disposal team. They approached an abandoned Afghanistan National Army security post, which consisted of two portable buildings. They suspected the buildings were being used by Taliban forces to make explosives. The soldiers stopped near the buildings to establish a security perimeter.
Travis' gun team started to set up their two M240B machine guns on a dirt barrier in a nearby field. Travis carried a backpack with 80 pounds of ammunition. He dropped the pack to the ground.
An explosion swallowed him.
Travis regained consciousness a few seconds later, flat on his back, the smoke and dust swirling around him. He took one look at his mangled left hand and cursed. He glanced down below his knees and saw nothing. His right shoulder felt on fire.
The bomb, a low-metallic, homemade device, was built to avoid minesweeper detection. It was filled with rocks that shattered into thousands of tissue-shredding shards. Two other soldiers were hit by shrapnel, though not as badly as Travis.
"Help my soldiers," Travis yelled several times at a medic.
"Sir," the medic said. "With all due respect, shut up." It takes only three to four minutes for a soldier with a hemorrhaging wound to bleed to death. The medic slipped four tourniquets onto Travis' arms and legs. He secured them with Velcro straps and tightened them with the attached rod.
He gave Travis a "fentanyl lollipop," a stick with a lozenge to suck that contained the pain medication.
Travis had already lost a lot of blood. A second medic, Sgt. Alexander Voyce, administered a fluid called Hextend, which temporarily replaces the lost blood. Because of the damage to Travis' arms and legs, an intravenous transfusion wasn't an option, Voyce said. The medic had to use a spring-loaded device to insert a needle into Travis' sternum.
Then Voyce helped the first medic pack the bleeding artery under Mills' right shoulder with combat gauze and pressure bandages.
Improvements in body armor are contributing to higher survival rates, doctors say. Travis was wearing chest, back and side protection.
But the swift actions by the medics saved his life -- a result of experience gained on battlefields over a decade of war.
Rapid loss of blood in arms or legs is the No. 1 preventable cause of death on the battlefield. Any medic will tell you that no soldier should die from a severe open wound to an extremity because it's so easy to take care of.
But 20 years ago, at the time of the Persian Gulf War, the tourniquet would not have been the first option, or even the second, said Maj. Patrick O'Neil, deputy director for the Center for Pre-deployment Medicine in San Antonio.
"In the way we were trained before, the tourniquet was the last thing we put on," said O'Neil. "We'd put pressure bandages on," or manually apply pressure to blood vessels to slow hemorrhaging, he said.
In 2001, special operations teams began to use tourniquets. But tourniquets didn't become standard practice until about six years later, about the time of the surge of U.S. troops in Iraq.
Another major change in military medicine concerns transfusions to replace blood loss. Medics need to quickly replace loss of blood or else the body's vital organs will shut down. It's impractical to carry blood into the battlefield, because it requires refrigeration and blood types vary from soldier to soldier. So other fluids are used until casualties can get to a hospital for a blood transfusion.
Medics once used saline. The problem is that saline doesn't stay inside the blood vessels -- it leaks out. Hextend is now used because it provides a better result with less fluid.
The biggest factor in the survival of injured soldiers is a new training doctrine started in 2007. All troops in a war zone are given first-aid training and carry a 1-pound medical kit, including a tourniquet that can be applied with one hand.
The idea is to make it easier for soldiers to perform first aid on themselves or their battle buddies. "This has been one of the greatest breakthroughs in battlefield medicine," O'Neil said.
In Afghanistan, a half-hour after Travis was evacuated on a Black Hawk helicopter, Josh got a call from a friend informing him of his brother-in-law's condition. Josh slammed his fist into a wall. He got permission to meet Travis at the combat support hospital in Kandahar, a 15-minute helicopter ride away.
Josh, 25, had to wait to call his younger sister, Kelsey, until the Army's official next-of-kin notification. Kelsey, 23, was staying at her parents' house in Frisco, 20 miles north of Dallas, waiting out Travis' deployment with their newborn baby.
Josh waited for Travis to come out of surgery. "I didn't know if he was going to be alive or dead," Josh said. "All I could think about was my sister not having a husband and his baby daughter not having a dad." Over the next week, Josh would become a lifeline to Kelsey and other loved ones waiting for news about Travis.
He accompanied Travis from the hospital in Kandahar to another medical facility in northern Afghanistan and then to a U.S. military hospital in Germany, a frequent stop for troops seriously injured in Afghanistan before they return to the U.S.
Even as a medic, Josh was shocked at the sight of Travis. "He's a big guy," Josh said. "All of a sudden he doesn't take up the whole bed anymore."
The explosion apparently hit Travis on his right side. He lost parts of both legs, but he had lost more of his right leg than his left. At the moment, he still had his left arm, though his left hand was severely injured. But only a small portion of his right arm remained below his shoulder.
Travis had somehow escaped serious injury to his internal organs, his chest, lower abdomen and groin. He had only pepper-size fragments in his face. "It's amazing, you couldn't duplicate it," Josh said. "If you have a hundred guys go through the same thing, most would die ..."
Travis was unconscious with a breathing tube in his throat. Josh sat next to him for hours. "Travis, we all love you and we're going to be here for you," Josh told Travis.
Later that night, the 82nd Airborne Division commander, Maj. Gen. James Huggins, stopped by to bestow a medal on Travis -- the Purple Heart.
The next morning, Travis and Josh flew to the military hospital at Bagram Air Base outside Kabul, a stop for injured troops leaving Afghanistan. Aides took Travis into surgery. When he came out, Josh noticed that Travis' left arm was amputated at the forearm. "It was necrosis -- dying tissue," Josh said. "To keep it from spreading, they had to remove it."
But now, Travis was a quadruple amputee.
Josh dreaded calling Kelsey to tell her that her athletic husband now had no arms or legs. "That was a tough call," he said, "a tougher call than the initial one."
Still reeling from the news of Travis' injury, Kelsey tried to sound upbeat and resolute: "If he wakes up, tell him I still love him."
After 24 hours in Bagram, Travis and Josh flew on a C-17 jet to Landstuhl Regional Medical Center in Germany, arriving on April 12. The C-17 was staffed by an intensive care physician, a nurse with critical care training and a respiratory technician.
These critical care air transport teams, which weren't available in previous wars, are an effort to treat seriously injured soldiers during long flights. This enables the most seriously wounded to get from the battlefield to an advanced care facility much faster, said Dr. John Oh, the trauma director at Landstuhl.
Communication to track battlefield medicine has also improved. In 2005, the Defense Department launched a database for sharing best practices about combat trauma care, Oh said.
Travis arrived at the hospital in stable condition, his blood pressure and heart rate steady, said Dr. Ron Kembro, a Landstuhl trauma surgeon. He had his breathing tube removed, and as Josh called his name, he woke up.
"To be able to see him go from this lifeless body on the bed to moving around trying to say his name, I was like, 'Yes! You're going to make it, dude,' " Josh said. "I was literally dancing in the hallways."
Travis was the first quadruple amputee that Kembro had treated. "I would say that it was unusual in that he survived," Kembro said. "We get a lot of triple amputees or two-limb amputees. Having a quadruple amputee is rare."
Doctors at Landstuhl focused on cleaning his wounds. "We literally wash these wounds out with liters and liters of water to help clean out debris and bacteria and things that can grow in these massive soft-tissue wounds," Kembro said.
Later that first day, Travis asked Josh, "How are my soldiers?"
"They're great, man," Josh said. "They're alive. They're happy you're alive."
Then Travis asked another question. "Am I paralyzed?"
"It's OK," Travis said. "You don't need to lie to me."
"Listen, Travis, you're not paralyzed," Josh said, finally. "But your arms and legs are gone."
Travis shook his head and closed his eyes.
Soon after, Kelsey was able to talk briefly with her husband after he came out of surgery. On Facebook, she wrote: "I was just able to talk to Travis!!!!! words can not express how filled with joy my heart is right now I was able to tell him I love him and that everything is going to be okay and he whispered 'hey babe what's up i love you.' "
A week after he was injured, Travis was flown to Walter Reed.
Kelsey flew in from Dallas with their baby daughter, Chloe, who was born in September. Her parents, Tammy and Craig Buck, joined her, and Dennis and Cheri Mills arrived from Michigan. They took turns at his bedside so Travis was never alone.
Mostly he slept, but his waking hours were rough. Travis suffered from phantom limb pain, which often afflicts amputees. He said it felt like someone was aiming a blowtorch at his missing feet.
"It's very common to complain of a stabbing or burning on the limb that's missing," said Dr. Benjamin Potter, chief orthopedic surgeon for amputee care at Walter Reed.
On her Facebook page, Kelsey wrote: "No one should ever ever ever have to suffer through this type of pain!!!!! It is not fair! It is so not fair, I would never in a million years wish this pain, loss and heartache on anyone."
Phantom limb pain is caused by an amputated nerve ending that is misfiring, said Potter, and the brain "interprets these signals as pain."
The medical staff tried to control his pain with medication and electrical stimulation. Nothing worked. The medications helped Travis sleep, but upon waking, the pain was as strong as ever. Finally, doctors put Travis into a medically induced coma for five days. They used ketamine, a drug that acts as a reset button for the brain and nervous system.
"(Ketamine) makes you forget," Potter said. "It is able to reset the pain clock whenever this type of pain gets out of control. It seems to be very useful in the type of pain where the nerves have gone haywire," he said.
"Most patients don't require the ketamine procedure," Potter said. "So he was one of the worst."
The treatment worked. With his pain under control, Travis could even start a rehabilitation program, including being fitted for prosthetic limbs. After all he'd gone through, including more than a dozen surgeries to clean and repair his injuries, he couldn't wait to use his new arms and legs. His doctors sounded optimistic.
"My goals for him are to be functional and independent in his daily life, to have as little pain as possible and to achieve what he wants to achieve," Potter said. "And that's something that he and Kelsey will work out over time."
Since his injury, Travis and his family have received an outpouring of support from his hometown in Michigan and from Frisco, where Kelsey's family moved from Maine in 1999. There are more than 18,000 friends on his Facebook page: "Support For Travis Mills and Family."
Travis is grateful for all the support, but he must rely on his own determination. He's been telling people that he has one major goal in mind.
He wants to be at Fort Bragg in North Carolina, standing on his prosthetic legs to greet his soldiers when they return home from Afghanistan later this year.
"And if I can get my right arm up to salute," he said, "I will salute."
By DAVID TARRANT
The Dallas Morning News