National Guard February 2012 : Page 26

A Heads-Up on TBI The ‘signature wound’ of the wars in Iraq and Afghanistan, traumatic brain injury, is also one of the most misunderstood By William Matthews ere’s Dr. Kenneth Lee’s prescription for mild traumatic brain injury (tBI): “read a lot of books. Get your brain working. Get back to normal.” that’s not just something the Wisconsin national Guard colonel tells his patients, it’s the remedy he administered to himself. And for the most part, he says, it has worked. In 2004, a car packed with ex-plosives roared toward Lee, who had volunteered to guard the rear of a con-voy stopped on the highway outside Baghdad International Airport. the explosion blew Lee under a humvee and knocked him unconscious. seven years later, Lee says he still suffers from nightmares, flashbacks and constant headaches. he deals with it using “mind over matter” and some over-the-counter painkillers, he says. he avoids heavy-duty drugs—“no narcotics, no psychotropic drugs”—although some doctors have urged him to take them. Lee says he won’t because he has to remain mentally sharp to care for his patients. he’s chief of the spinal-cord injury division at the Department of Veterans Affairs (VA) hospital in Mil-waukee. he’s also state surgeon for the Wisconsin national Guard. And he’s one of the thousands of Guard troops struggling with tBI, the so called “signature injury” of the wars in Iraq and Afghanistan. Powerful roadside bombs, rocket-26 H | National Guard

A Heads-Up On TBI

William Matthews

HERE’S DR. KENNETH Lee’s prescription for mild traumatic brain injury (TBI): “Read a lot of books.<br /> <br /> Get your brain working. Get back to normal.”<br /> <br /> That’s not just something the Wisconsin National Guard colonel tells his patients, it’s the remedy he administered to himself. And for the most part, he says, it has worked.<br /> <br /> In 2004, a car packed with explosives roared toward Lee, who had volunteered to guard the rear of a convoy stopped on the highway outside Baghdad International Airport. The explosion blew Lee under a Humvee and knocked him unconscious.<br /> Seven years later, Lee says he still suffers from nightmares, flashbacks and constant headaches.<br /> <br /> He deals with it using “mind over matter” and some over-the counter painkillers, he says. He avoids heavy-duty drugs—“no narcotics, no psychotropic drugs”—although some doctors have urged him to take them.<br /> <br /> Lee says he won’t because he has to remain mentally sharp to care for his patients. He’s chief of the spinal-cord injury division at the Department of<br /> Veterans Affairs (VA) hospital in Milwaukee. <br /> <br /> He’s also state surgeon for the Wisconsin National Guard. And he’s one of the thousands of Guard troops struggling with TBI, the so called “signature injury” of the wars in Iraq and Afghanistan. <br /> <br /> Powerful roadside bombs, rocket- Propelled grenades, land mines and blasts from other explosives have inflicted brain injuries on an estimated 320,000 U.S. soldiers who have fought in Iraq and Afghanistan.<br /> <br /> That number comes from the research institute, Rand, which concluded that about 20 percent of those who have fought in the wars “experienced a possible traumatic brain injury while deployed.”<br /> <br /> “I think that’s a low estimate,” says Dr. Chrisanne Gordon, director of rehabilitation services at Memorial Hospital of Union County, Ohio.She contends that “one in four” have received a TBI.<br /> <br /> For most—60 to 80 percent—the injury is classified as “mild TBI.” But even that can be a life-changing injury, Gordon says.<br /> <br /> In 2008, saddened by the death of a friend’s nephew in Iraq, Gordon volunteered to work with the VA in Ohio.She was assigned to conduct screening tests for traumatic brain injuries.<br /> <br /> Stunned by the number of cases she saw and the problems they cause, Gordon expanded her work to the Ohio National Guard, and later established the Resurrecting Lives Foundation to raise money for TBI research, treatment and advocacy.<br /> <br /> She calls war-related brain injuries “a growing epidemic.”<br /> <br /> The Defense Department reports numbers that are substantially lower than Rand’s. The Armed Forces Health Surveillance Center says that between 2000 and mid-2011, 220,430 service members suffered TBI.<br /> <br /> During that period, 21,500 Army Guard soldiers and 2,460 Air Guard troops sustained such injuries, according to the Health Surveillance Center.Those numbers include all traumatic brain injuries, not just those suffered in Iraq and Afghanistan.<br /> <br /> Brain injuries can result from blows to the head, auto accidents, falls and other mishaps. But most of the TBIs from Iraq and Afghanistan are blast injuries.<br /> <br /> The military often equates mild TBI caused by munitions blasts with ordinary concussions caused by a blow to the head, but Gordon says the TBI Suffered in Afghanistan and Iraq are usually worse.<br /> <br /> “This is a very different injury,” she says. “A blast injury is so much more severe.”<br /> <br /> Second Lt. Joshua Witt, the Kentucky National Guard’s safety and occupational health manager, says, “IEDs unleash an effect called blast overpressure, sometimes referred to as a shock wave. … [The waves] can travel about 1,000 feet per second and hit with a pressure of 100 pounds per square inch.”<br /> <br /> The impact can be devastating.<br /> <br /> “The brain has nerve tracks that connect the cells together,” Gordon explains.<br /> <br /> In an explosion, a blast wave passes through the skull and through the brain “and rips those fibers connecting the cells.” One blast is bad enough, but many troops are exposed to multiple blasts, which can cause repeated “bleeding, ripping and tearing” of the connecting fibers, leaving the brain permanently damaged.<br /> <br /> Yet, in many cases, there is no outward sign of injury, according to the military’s Defense and Veterans Brain Injury Center. And standard medical tests such as CT scans and MRI images often do not detect the damage.<br /> <br /> Immediate symptoms of mild TBI may include losing consciousness for a short time, being dazed and confused, and not remembering the injury, according to the Brain Injury Center.<br /> <br /> Longer-lasting symptoms include headaches, dizziness, fatigue, memory problems, irritability, balance problems, vision changes and difficulty sleeping.<br /> <br /> Most who suffer mild TBI “will recover to normal with possibly some minor residual” problems, says Lee.<br /> <br /> Those who suffer moderate and severe TBI are likely to have some degree of permanent brain damage, he says.<br /> <br /> The U.S. Institute of Medicine says that moderate and severe TBI may result in “conditions that include Alzheimer’s-like dementia, aggression, memory loss, depression and symptoms similar to those of Parkinson’s disease.”<br /> <br /> But even mild TBI can cause longlasting problems.<br /> <br /> Sgt. Cody Stagner, a military police team leader, was escorting soldiers from Baghdad International Airport to a base in Baghdad in 2005 when a civilian vehicle passing his Humvee convoy “swerved over to hit us and detonated.”<br /> <br /> A powerful blast and fireball erupted “about five feet from my door,” the Kentucky Army Guardsman recalls.<br /> <br /> Stagner was badly burned and his gunner was seriously hurt. They were helicoptered to an Army hospital in Baghdad.<br /> <br /> “I didn’t know I had TBI initially,” he says.<br /> <br /> He was transferred to Camp Anaconda at Balad Air Base to recover and Told to “stay out of the sun because of my burns,” Stagner says.<br /> <br /> After six weeks, Stagner returned to regular duty. He suffered from frequent headaches and experienced heightened anxiety, especially when it was time to escort another convoy.<br /> <br /> “I was really anxious about being out on the road,” Stagner says.<br /> <br /> He soldiered on for six more months, until his tour was over.<br /> <br /> “When I got back from Iraq, it was like a relief switch,” he says.<br /> <br /> His anxiety subsided, but he noticed problems with his memory. He frequently forgot where he had put things and found it hard to concentrate on his college courses.<br /> <br /> He was noticeably slower “as far as getting my thoughts in order,” and it was difficult “getting back into the things that I used to be able to do.”<br /> <br /> He mentioned his problems to a friend who was a VA hospital nurse.She said his condition sounded like TBI.<br /> <br /> Tests at the VA hospital confirmed it.<br /> <br /> “They say my brain operates at the capacity of someone twice my age. I react twice as slowly as someone my age. It’s a processing issue,” Stagner says.<br /> <br /> To compensate for memory problems, Stagner says he writes a lot of notes to himself and keeps reminders such as grocery lists on his smart phone. Since returning home, he has earned a business degree and landed a job as the Kentucky Guard’s medical outreach coordinator.<br /> <br /> Most troops who suffer mild TBI will recover in six to 24 months, says Gordon.<br /> <br /> “But the sooner you get a diagnosis and begin treatment, the better off you are,” she says.<br /> <br /> Unfortunately, prompt diagnosis And treatment for troops in combat has not been the rule.<br /> <br /> In 2010, a joint mental health advisory team appointed by the Army surgeon general surveyed 911 soldiers and Marines in Afghanistan and reported that more than half who were exposed to blasts or suffered head injuries, including some who were knocked unconscious, were not screened for TBI.<br /> <br /> Since then, the Pentagon has established mandatory procedures for screening troops and managing those who suffer from TBI.<br /> <br /> Even so, a lot of Guard troops still “come back not screened and are not getting treatment,” says Pete Duffy, the NGAUS deputy legislative director.<br /> <br /> TBI experts cite multiple reasons for inconsistent screening and treatment , Starting with the fact that mild TBI usually presents no outward sign of injury, making it difficult to diagnose.<br /> <br /> In addition, troops often are reluctant to report the symptoms of brain injuries.<br /> <br /> “A lot of people won’t bring these things up. They don’t want to admit that they have a problem,” says Lee.<br /> <br /> Some troops decline to report TBI symptoms because they don’t want to be separated from their units and medically evacuated, according to the Defense and Veterans Brain Injury Center.<br /> <br /> In some cases, symptoms simply don’t show up immediately. TBI “may not be identified as problematic until the service member returns home from the deployment,” the Brain Injury Center reports.<br /> <br /> Guard troops confront additional factors that may make it difficult to get TBI treatment, Duffy says. Distance from VA treatment centers is a problem for many.<br /> <br /> “The VA has some good TBI experts,” Duffy says, but they’re mostly at VA medical centers in big cities.The Guard draws heavily from rural areas, so getting VA treatment may require traveling hundreds of miles.<br /> <br /> “You have to take time off from work, you have to tell your employer that you’ve got a problem,” he says.<br /> <br /> Instead, many Guardsmen decide to skip treatment.<br /> <br /> Although VA is required to provide mental health care through local civilian medical centers, the agency has resisted doing so, both Duffy and Gordon say.<br /> <br /> And if brain injuries are not diagnosed before Guardsmen leave active duty, it may be difficult to convince VA that the injury is service-related and eligible for treatment, Duffy says.<br /> <br /> In essence “you have to fight the VA to prove that you’re abnormal,” says Gordon, who says only 36 percent of those who are eligible for VA treatment are getting it.<br /> <br /> But failure to get treatment for TBI can be dangerous.<br /> <br /> “There’s nothing like a damaged brain to make a person want to selfmedicate,” Gordon says.<br /> <br /> Amphetamines, cocaine and caffeine are drugs commonly abused by TBI victims, she says. As many as 90 percent of untreated TBI sufferers abuse alcohol.<br /> <br /> Sometimes the first indication that a combat veteran has a TBI problem “is when they are picked up for a legal issue,” which is often drunk driving, she says.<br /> <br /> Courts in some states have begun to recognize that TBI can cause serious behavioral changes in troops who would ordinarily never have legal run-ins.<br /> <br /> States, including Florida, Idaho and Pennsylvania have established special “veterans courts” to handle veterans’ offenses such as drunk driving, drug possession and disorderly conduct that are linked to TBI.<br /> <br /> Ideally, says Gordon, those who suffer a TBI should be removed from combat to avoid repeated injuries which compound the original one.<br /> <br /> “We really need to bring the brain To rest,” perform tests that pinpoint each individual’s particular brain problems and begin treatments tailored to repair those problems, she says.<br /> <br /> But in the midst of war, that often doesn’t happen.<br /> <br /> “When I was in Germany in the hospital, I clearly thought my roommate had TBI, but he was being sent back to his unit,” Lee recalls.<br /> <br /> Later, while recovering at Walter Reed Army Medical Center in Washington,D. C., Lee urged senior Army medical officers to increase screening for TBI, especially for patients who were injured enough to be evacuated.<br /> <br /> “I’m not saying my input changed the process,” Lee says, but screening requirements have been increased so that today many more troops now are supposed to be screened.<br /> <br /> The Defense and Veterans Traumatic Brain Injury Center agrees that “early intervention is important to speed recovery and maximize functional outcome.”<br /> <br /> Experts there say rehabilitation should begin as soon as injured troops are medically stable.<br /> <br /> Individuals with mild TBI can usually be treated as outpatients. Those with more serious brain injuries may need inpatient care at military hospitals or VA polytrauma centers.<br /> <br /> Recovery may require physical and speech therapy to relearn walking and talking, cognitive therapy to improve memory and problem solving skills, and occupational therapy to relearn daily living and job-related skills.<br /> <br /> “The VA actually was a lot of help,” says Stagner.<br /> <br /> “There has been a major leap forward” in acknowledging the seriousness of traumatic brain injuries, Gordon says. “But the system is still a long way from where it needs to be.”<br /> <br /> In 2012, there will be 40,000 troops coming back from Afghanistan.That means 10,000 more with TBI, she says.<br /> <br /> William Matthews is a Springfield, Va.- based freelance writer who specializes in military matters. He can be contacted via magazine@ngaus.org.<br /> <br /> At a Glance<br /> <br /> TBI Symptoms<br /> <br /> Immediately After Injury: <br /> <br /> Being dazed, confused, “seeing stars” <br /> <br /> Not remembering the injury <br /> <br /> Losing consciousness<br /> <br /> Later On: <br /> <br /> Persistent headaches or neck pain <br /> <br /> Sensitivity to light and noise <br /> <br /> Loss of balance <br /> <br /> Changes in sleep patterns.<br /> <br /> Constantly feeling tired, lacking energy <br /> <br /> Ringing in ears.<br /> <br /> Diminished sense of smell and taste <br /> <br /> Slowness in thinking, acting, speaking or reading <br /> <br /> Sudden mood changes for no reason <br /> <br /> Chronic anxiety, depression, apathy <br /> <br /> Short-term memory loss <br /> <br /> Getting lost or confused easily <br /> <br /> Inability to pay attention or concentrate <br /> <br /> Difficulty organizing daily tasks and making decisions <br /> <br /> Difficulty managing relationships <br /> <br /> Source: Vermont Office of Veterans Affairs<br /> <br /> Three Degrees of TBI<br /> <br /> Mild TBI is difficult to diagnose on the battlefield. It may involve brief loss of consciousness, but it may not. Confusion, headache, ringing ears may indicate TBI, but they may not.<br /> <br /> Moderate TBI is easier to spot. It involves loss of consciousness and clearly observable mental deficiencies, such as confusion that lasts for days to a week. Most service members identified with moderate TBI are evaluated at theater-level medical facilities, and evacuated back to the United States for further evaluation and care.<br /> <br /> Severe TBI is clearer still. Symptoms may be loss of consciousness for more than six hours, bleeding in the skull and brain injuries that are visible on MRI and CT scans, spinal fluid leaking from ears and nose, numbness, paralysis and seizures.<br /> <br /> Source: Army, Mayo Clinic

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