ARTICLE IN BRIEF
Two military neurologists describe their lives and the state of neurology care in Afghanistan.
Nearly a year after the US Defense Department instituted a strict new policy for diagnosing and treating traumatic brain injuries, the two neurologists practicing at Bagram Air Base in Afghanistan say that military personnel are now receiving concussion care that rivals that given civilians in the US.
“We have a clear system for comprehensive care of concussion in theatre; it sometimes exceeds what we have at home,” said Colonel Beverly R. Scott, MD, a specialist in neuro-ophthalmology. “We currently have a five-member team with a neurologist, a psychologist, a family medicine practitioner, an occupational therapist, and an occupational therapy technician, further supported by psychiatrists and other specialists as needed. It's a highly coordinated program that's remarkably effective.”
No military neurologists served at Bagram until two years ago, but both who work there now took time out of their seven-day-a-week schedule to speak with Neurology Today. The first tour of duty in an active war zone for each, they expressed pride in not just the level of care provided on the base, but in the diagnostic and treatment algorithms being propagated all the way to the front lines.
“Instituting rest in a combat environment is a difficult thing,” said Major Jason S. Hawley, MD, who serves with Dr. Scott as theater neurologist at Bagram's 50-bed military hospital, the Heathe N. Craig Joint Theater Hospital, located in the Parwan province of Afghanistan. “That's where the military and DOD [Department of Defense] have really stepped up to institute some pretty clear guidelines about how concussions are managed. If there's a suspicion of concussion, the soldier is given at least 24 hours in quarters. He's re-evaluated on a daily basis until he's symptom-free.”
DIRECTIVES FOR CARE
Following earlier criticism that the military was failing to properly diagnose and treat mild traumatic brain injury (TBI) in both Afghanistan and Iraq, the Defense Department issued a directive in July of last year requiring that troops within 50 meters of an explosion be confined to rest for 24 hours and examined by a trained medic or primary care provider for signs and symptoms of a concussion. In a single month, the number of diagnosed concussions among service members in Afghanistan jumped nearly six-fold, from 62 in June to 370 in July, according to the US Central Command.
In addition, the directive requires that any service member who experiences three concussions, or has a complicated clinical course following fewer concussive episodes, be evaluated directly by a neurologist and the specialty care team.
In October, Dr. Scott deployed from Madigan Army Medical Center at Fort Lewis, WA, where she was chief of neurology, to serve a six-month tour as Theatre Neurology Consultant in Afghanistan — essentially the head military neurologist in the war-torn nation. Dr. Scott has traveled widely to military bases across the country, where she has evaluated current clinical practices and provided education and training on concussion care. But her primary office has been at Bagram, initially as the sole neurologist on the base, home to over 20,000 troops and civilians.
In December, she was joined there by Dr. Hawley, who came from Walter Reed Army Medical Center in Washington, DC, where he was a staff neurologist and movement disorder specialist. He is now serving a six-month tour at Bagram and provides the predominant neurologic care for the region, while Dr. Scott transitions to a full-time theater consultant role.
CONDITIONS ON THE BASE
Despite the size of the base, Dr. Hawley said, there is no doubting it's in Afghanistan, between the sound of occasional mortar and rocket attacks, the 360-degree view of snowcapped Himalayan peaks, and the feel of the M9 pistol he is required to carry at all times.
“My office is right next to the emergency room,” he said. “We see a lot of the traumas that come in and out of the emergency room. If there's a thing that makes you realize you're in a war, it's seeing those casualties.”
Another difference between Bagram and working stateside is the round-the-clock work schedule.
“We kind of just work all the time,” Dr. Hawley said. “When you're in a deployed environment, there are no weekends, no days off. You become pretty close to the people you work with. Being in a combat situation, you develop a very strong sense of teamwork. I don't think I'll ever again work in a hospital that has such a connection between the emergency room, the surgeons, and the specialists. It's a connection you really don't get elsewhere.”
Being free of time restrictions permits them to offer exceptional clinical care, Dr. Scott said. “I've learned more than ever the importance of listening and gently exploring patients' concerns well beyond basic clinical history and their initial reported symptoms,” she said. “We take the time needed to provide optimal clinical care.”
Military neurologists had been seeking for some time to work in the Afghan theatre, Dr. Hawley said. “Prior to two years ago, the most forward [in the field] neurologist was in Germany, at Ramstein Air Base. We felt like we could bring some of the more specialized care farther forward, and teach other physicians and medics how to treat them on the field.”
One of the chief surprises for him upon arriving was the sheer austerity. “This is an incredibly poor country,” Dr. Hawley said. “You can see it in the faces of the people.” For half a day each week, he provides neurologic care on the base to Afghan civilians who travel as far as 100 miles for treatment.
“People just line up in front of the door of the clinic,” he said. With the aid of a translator, usually an Afghan medical student from Kabul, he takes all comers. “It's very tough,” he said. “A lot of what I've seen is older individuals who've had a stroke. Two weeks ago I saw a teenage girl who had Landau-Kleffner syndrome. A man I saw with Parkinson disease certainly would have benefited from being on levadopa, but whether he would be able to afford it and have access to it is a question.”
In contrast to patients in the US, however, “in Afghanistan, they're not going to question us about a diagnosis. If they leave with a medication, they think that will help. It's a strange dynamic I've had to get used to. As I try to explain what a migraine is or what Parkinson disease is, the individuals have total trust that I know what the problem is, and they'll do whatever I say.”
THE BIGGER PICTURE
In seeking to deliver the best possible concussion care, Dr. a emphasized that concussions in the deployed environment do not occur in isolation.
“In the worst case,” she said, “it occurs in the setting of a battle, a blast, a vehicle rollover, commonly associated with an acute stress reaction and risk for other injuries.”
“Even in non-battle-related causes, there is the potential for underlying operational stress,” Dr. Scott continued. “That was a very notable revelation that became clear to me as I evaluated a number of these service members following concussion. Each patient brings his own pre-morbid and co-morbid medical conditions, such as migraines, suboptimal sleep, possible underlying mood disorders, even their own personal experiences, expectations and resilience, which often may impact their symptomology and recovery.”
Dr. Hawley echoed the view that neurologists treating military personnel must consider the context in which a concussion occurs. “Add the aspect that he might have been almost killed or maimed, and that he might have a broken leg or a burn, and you can understand why having a team approach to treatment is so important,” he said.
“If we can address those psychological issues, the pain issues, the headache issues and do it all at the same time and very early on, we believe we can have really good outcomes,” Dr. Hawley continued. “We validate their injury, give them time to rest, and give them that educational piece. Whereas if it's a big mystery and a lot of the symptoms aren't validated, their recovery could be longer.”
For him and Dr. Scott, part of the bigger picture is the families they have temporarily left behind in the United States. Both are married with three children, all of them under age 18.
“I skype with my kids and husband most days,” Dr. Scott said. “It's sometimes a challenge with the time change — we have a 12-and-a-half-hour time difference. But I feel very connected and involved in their lives. I've successfully continued to parent over the Internet while my husband holds down the fort.”
Despite the hardships, both she and Dr. Hawley expressed great satisfaction about their time served in Afghanistan.
“I can't say enough about how rewarding the experience has been,” she said. “I'm typically not someone who wants to be in the public eye, but we have a very good-news story to share about the excellent neurology care we're providing for our deployed service members, often facilitating their full recovery following acute concussion.”