The roadside blast nearly destroyed the right hemisphere of the US soldier's brain as she rode in a convoy to Baghdad International Airport, yet several months later she was able to walk unaided from a special Veterans Administration traumatic brain injury rehabilitation unit and return home.
The remarkable recovery of 27-year-old Staff Sgt. Jessica Clements is due in part to her own determination, a quick-thinking field neurosurgeon in Iraq, and a team of traumatic brain injury (TBI) rehabilitation professionals at the Department of Veterans Affairs (VA) Medical Center Traumatic Brain Injury Unit in Minneapolis, MN, one of four VA sites of the Defense and Veterans Injury Center.
Sgt. Clements was injured in early May 2004. A neurosurgeon with the 31st Combat Support Hospital, outside of Baghdad, performed an emergency craniotomy on the comatose and unresponsive patient and inserted an intracranial pressure monitor to gauge any swelling. He then “packed” the excised piece of skull into the patient's stomach wall to keep the bone safe and viable during evacuation and used a soft covering of skin over the opening. This allowed continued pressure monitoring and easier emergency access to treat subsequent bleeding from broken blood vessels or spasms.
The skull fragment remained in place for three months until surgeons at Walter Reed Army Medical Center reattached it. In the interim, she underwent intensive rehabilitation at the VA's TBI Unit in Minneapolis, one of four units that specialize in such treatment. The others are located at VA centers in Tampa, FL, Palo Alto, CA, and Richmond, VA.
Sgt. Clements is now living at home with her family in Minneapolis where she is in the care of a VA neurologist.
COORDINATED SYSTEM OF CARE
Over the last year, the Minneapolis TBI Unit has provided rehabilitation services for 19 members of the armed forces wounded in Iraq or in operations in Afghanistan, including six injuries among personnel injured in stateside training exercises prior to being deployed. About 400 patients have received care at all four rehabilitation units and associated military treatment facilities.
“We provide a coordinated system of care for traumatic brain injuries for injured active duty combatants who have been treated at major military medical hospitals,” explained Barbara Sigford, MD, the VA's National Program Director for Physical and Medical Rehabilitation. “Our four centers have dedicated brain injury units offering a high level of neurological rehabilitation, and we partner with other medical facilities to provide a continuum of care after the patient completes inpatient treatment. We have our network [of VA hospitals] or collaborations with other sites for outpatient care when our nearest facility is too distant.”
Teams are made up of a physiatrist and a rehabilitation physician as team leader, with a case manager to ensure a smooth transition into and out of the system, said Dr. Sigford.
Other team members include rehabilitation and speech therapists, together with a neurological clinical specialist – a physical or occupational therapist with special training in neurological rehabilitation – and a psychologist who provides counseling and neuropsychological consultation with neurologists and neurosurgeons – all within the VA system.
Speech pathologist Don MacLennan and psychologist Rose Collins, together with neurological clinical specialist Michelle Peterson and occupational therapist Debra Boydeitch, round out the team at the Minneapolis TBI unit.
Because many soldiers injured in Iraq suffer vision problems as a result of central nervous system damage or other injuries, a neuro-ophthalmologist is often called in as well. Although the teams do not include a neurologist, staff neurologists are always available for consultation, said Dr. Sigford.
US military hospitals in Europe are the first destination for serious casualties evacuated from Iraq, usually Landstuhl Regional Medical Center, in Landstuhl, Germany. After their condition stabilizes they are transferred to Walter Reed Army Medical Center or the National Naval Medical Center (Bethesda Naval Medical Center), and occasionally the Naval Medical Center in San Diego.
“These injuries can be very debilitating with severe cognitive defects, especially when patients suffer hemiplegia or hemiparesis,” said Dr. Sigford. “Some patients later require follow-up surgery, especially for skull injuries. There are problems with physical mobility, even just getting out of bed, and awareness of the nature of their injury. It's very different from [civilian] patients with brain injuries, in part because combat injuries tend to be more complex.”
‘AN AMAZING RECOVERY’
Team member and neurological clinical specialist Ms. Peterson specializes in traumatic brain injuries and specific mechanisms of injury, including those in patients with concurrent blindness or amputation.
She and other team members outlined the process of care and recovery of Sgt. Clements, who had also suffered a major injury to the buttocks and was weak, out of condition, and in considerable pain. Like many patients Sgt. Clements had episodes of dizziness and nausea, but she showed gradual improvement in physical as well as cognitive functioning as rehabilitation proceeded.
“We started with simple tasks,” explained Ms. Peterson. “Activities of daily living like brushing teeth, combing hair, and getting dressed. Then we gradually progressed to higher-level activities such as preparing simple meals and managing a daily schedule. A notebook was kept to help remind her of daily appointments and to compensate for any memory loss problems.”
Sgt. Clements became actively involved in both physical and psychological therapy, including group sessions, recreational, and occupational therapy, she continued. “By recreational therapy we don't mean simple diversions either – we actually get them out into the community so they can do things like operate an elevator, for instance.”
Speech pathologist Mr. MacLennan, who helped test Sgt. Clements' verbal and cognitive functioning several times during rehabilitation, said she started out with severe cognitive difficulties, including attention, sensory, memory, and reasoning problems. But testing showed steady progress as the rehabilitation team's therapeutic efforts began to pay off. Brain injury recovery typically takes one to two years, if full recovery is possible, Mr. MacLennan said.
“Several weeks later there was improved right hemisphere function, even though the patient was missing much of [that region],” he said. “Testing showed improved discourse comprehension, including the ability to recognize differences in inferred statements and facial affect. It was an amazing recovery.”
According to Dr. Sigford, the case illustrates the progression of care that her TBI unit provides that she believes is critical for successful rehabilitation. The team addresses as many issues as possible with the goal of “moving patients out into the community and then home,” she emphasized. “That's the package.”
The Walter Reed Center is involved in several studies to find possible therapies that might help relieve some of the post-concussive sequelae of TBIs, including treatment with the selective serotonin reuptake inhibitors sertraline (Zoloft) after a concussion and citalopram (Celexa) for anxiety. Another study that is in the final stages of approval will examine use of methylphenidate in TBI cases to see if it might improve concentration and speed of mental processing, because conditions are similar to those seen in attention deficit hyperactivity disorder.
A Different War
The fighting in Iraq and Afghanistan has resulted in a large increase in blast-related traumatic brain injuries – more so than in prior US battle engagements, according to data collected at Walter Reed in early 2004. In the study of 155 wounded soldiers, 60 percent had some degree of TBI, according to Deborah L. Warden, MD, National Director of Walter Reed's Defense and Veterans Brain Injury Center, who is also Associate Professor of Neurology and Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, MD. This compares with 20 to 40 percent among Vietnam and World War II vets.
Dr. Warden said the shift in the type of battle injuries is attributed primarily to the bombs, mines, and rocket-propelled grenades responsible for so many Iraq casualties, together with the advent of special body armor that protects the torso while leaving the limbs and head at higher risk. Ongoing studies evaluate the best protective gear, including helmets, for these type of injuries.
Dr. Warden said: “In an explosion there are primary injuries from the blast air wall and gasses released, secondary injuries from bits and fragments of shrapnel striking the head, and tertiary injuries from being thrown to the ground or against something solid like a wall.”
More soldiers are surviving blast injuries, in part because of better armor, but also because of improved diagnostic equipment and better trained field medics, as well as medical and surgical staff at military hospitals, she noted.
BETTER TRAINING IN THE FIELD
“There are more TBIs than we've previously seen because there have been so many roadside bombs in Iraq. As a society we need [medical] professionals more attuned to the effects of concussion injuries: temporary difficulty in cognition, dizziness, mood changes, and difficulty sleeping. More severe brain injuries are identified early because they typically require surgery, either craniotomy or craniectomy, and it is pretty evident that there is brain injury. But others injuries are less evident, resulting in a brief loss of consciousness.”
Medics at Naval Medical Center in Sand Diego are being trained in better screening for TBIs on the battlefield, said Dr. Warden. “Our group works training medics who are part of the Marine Independent Corpsmen stationed at Camp Pendleton in California. It's an ongoing effort.”
One interesting contribution to improved battlefield medic training are the AAN return-to-play guidelines for head injuries in sports, which are considered for use as a possible “return-to-battlefield” guide for medics to follow. (The guidelines, Management of Concussion in Sports, are available on the AAN Web site at www.aan.com/professionals/practice/guideline/index.cfm.)
Under the guidelines, if a player does not lose consciousness and dizziness or vision problems disappear after a 15-minute “time-out” period, they can return to the game. An episode of unconsciousness requires a weeklong hiatus, as does dizziness or vision problems lasting more than 15 minutes. Other TBI symptoms range from simple headache to concentration and/or memory difficulty, irritability, anxiety, depression, fatigue, and sensitivity to light or noise.
“The AAN guidelines were certainly helpful in Afghanistan, and they're using them in the field,” she said. “Not everywhere, and not regularly, but in some places.”
Dr. Warden said she feels strongly that the guides should be disseminated to all care providers treating combat veterans and others. “We keep copies in a drawer and give them away to people,” she said.
ARTICLE IN BRIEF
✓ The fighting in Iraq and Afghanistan has resulted in a large increase in blast-related traumatic brain injuries. The story examines changes in care at the point of injury and the follow-up rehabilitation programs.