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Tuesday, August 26, 2008

New York Times Reports on the Unique Characteristics of Combat TBI

Lizette Alvarez of the New York Times writes of the special blast category that is combat-related traumatic brain injury (TBI). The entire piece is well worth a read, but I'd like to share a few of the more statistics-heavy grafs:

As many as 300,000, or 20 percent, of combat veterans who regularly worked outside the wire, away from bases, have suffered at least one concussion, according to the latest Pentagon estimates. About half the soldiers get better within hours, days or several months and require little if any medical assistance. But tens of thousands of others have longer-term problems that can include, to varying degrees, persistent memory loss, headaches, mood swings, dizziness, hearing problems and light sensitivity. ...

Little is known medically by doctors or scientists about what happens to a brain as a result of a powerful bomb blast, as opposed to car crashes on a highway, blows to the head on a football field or a bullet wound. These are the first wars in which soldiers, protected by strong armor and rapid medical care, routinely survive explosions at close range and then return to combat.

The bomb blasts, which throw off energy waves — atmospheric overpressures and underpressures — that are absorbed by the body, add a little-studied dimension to the trauma. Scientists are only now beginning to study the extent of the damage.

In educational interest, article(s) quoted from extensively.


That soldiers are sometimes exposed to multiple blasts during a deployment, or can suffer from a vast combination of wounds, including shrapnel, burns, blows to the head, blast waves, lost limbs or internal injuries, can exacerbate brain trauma in ways unseen among civilians. “It is the black box of injuries,” said Dr. Alisa D. Gean, the chief of neuroradiology at San Francisco General Hospital and a traumatic brain injury expert who spent time treating soldiers at Landstuhl Regional Medical Center in Germany. “We’re at the tip of the iceberg of understanding it. It is one of the most complicated injuries to one of the most complicated parts of the body.

These mild concussions, which do not necessarily lead to loss of consciousness, are easy to dismiss, simple to misdiagnose and difficult to detect. The injured soldiers can walk and talk. Their heads usually show no obvious signs of trauma. CT scans cannot see the injuries. And the symptoms often mirror those found in post-traumatic stress disorder, making it hard to distinguish between them. In fact, the two ailments often go hand in hand. ...

It was not until 2006, three years into the Iraq war, that the Departments of Defense and Veterans Affairs began to pay close attention to mild traumatic brain injuries. The Pentagon last year opened the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, a clearinghouse for treatment, training, prevention, research and education. This year it is spending a record $300 million on research for traumatic brain injury and post-traumatic stress disorder.

“We are more attuned to brain injuries now,” said Lt. Col. Michael Jaffee, the director of the Defense and Veterans Brain Injury Center. “There has not been as aggressive an effort before.”

That effort begins with screening. As of May, service members who deploy longer than 30 days will undergo neurocognitive testing before leaving, to establish a baseline for changes that may occur later, and again upon returning. At the same time, soldiers in battle who lose consciousness or feel dazed after a blast or other event must be screened by a medical provider and are either approved for duty in the field, told to rest for several days on base or sent to Landstuhl for further evaluation.

Last year, Veterans Affairs started screening all Iraq and Afghanistan war veterans who come in for clinical help. So far, 33,000 of 227,015, about 15 percent, have screened positive for mild brain injury since April 2007.

It is unclear how many service members, particularly those who fought earlier in the war, remain unscreened and whose injuries go undiagnosed.

“No doubt that there are significant numbers out there,” said Dr. Barbara Sigford, director of physical medicine and rehabilitation for the Department of Veterans Affairs. ... Post-traumatic stress disorder and traumatic brain injury are closely tied, although the precise relationship between the two is unknown.

This connection was most recently established in a study in The New England Journal of Medicine in January by Col. Charles W. Hoge, an Army psychiatrist who is leading efforts to identify mental health problems among combat troops. His survey of 2,500 Army infantry soldiers found that more than 40 percent of those who reported loss of consciousness also met the criteria for post-traumatic stress disorder. That was a much higher percentage than those who had suffered other injuries, like Humvee accidents or falls.

Dr. Hoge cautioned, though, that some symptoms — anger, headaches, depression, sleeplessness, mood swings — may stem solely from combat stress, a psychiatric disorder, and not traumatic brain injury. Combat, he emphasized, often goes hand in hand with traumatic experiences, including a near loss of life or the death or injury of others.

For years most troops with mild concussions stayed on the job, immersing themselves in combat again and re-exposing themselves to additional blasts with little or no time to rest and recover. This pattern only heightened the risk of brain injury and post-traumatic stress disorder, doctors say.

Civilians with brain injury, on the other hand, are given time to recuperate for long periods in a safe environment, which may explain why they respond differently to stress.

Well worth a full reading.

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