With a rise in the number of returning Gulf War veterans with traumatic brain injury (TBI), there will be a greater need for experts in neurology and rehabilitation. That's the assessment of experts on the frontlines of care for returning veterans at military and Veterans Affairs facilities around the country.
A television special by ABC News anchor Bob Woodruff, 45, documenting his dramatic recovery from a traumatic brain injury (TBI) in Iraq, has opened a debate about the US military's estimates of brain injuries among veterans and whether injured soldiers are receiving adequate follow-up once they return home from acute-care facilities.
The newsman was severely injured in a roadside bomb blast in early 2006 and he was treated at the National Naval Medical Center in Bethesda, MD, and at Mount Sinai Medical Center in New York City. Woodruff, who nearly died from his injury, spent 36 days in a medically induced coma to assist in his recovery from surgery; a portion of his skull was removed to reduce the damage from brain swelling.
The special report, “To Iraq and Back,” which aired Feb. 27, provided a graphic course in neurosurgery and neurorehabilitation for TBI, but the reporter was quick to point out that his recovery was “an exception,” and that most military personnel with brain injuries do not fare as well.
In addition to interviews with injured GIs and their families, representative of veterans' organizations, and military health officials, Woodruff examined whether the military has underestimated the number of TBIs and is providing, in some cases, substandard care to brain-injured GIs, especially those living in rural areas.
The Department of Defense has reported about 23,000 combat injuries from the fighting, and there has been a 30 percent incidence of brain injuries treated at Walter Reed Army Medical Center — twice the rate of prior military operations, including Vietnam, Korea, and World War II.
After being stabilized, most combatants with TBI are treated at Walter Reed or the National Naval Medical Center. According to the Defense and Veteran's Brain Injury Center, about half of these have been milder brain injuries, which cause temporary disability and impairment, the equivalent of a concussion. More than 85 percent of TBIs treated at military hospitals have been closed-head injuries from explosions rather than penetrating head wounds.
An August 2006 Department of Defense analysis found that 184,524 Iraq veterans had sought care from Veterans Affairs (VA) medical centers and clinics, including 1,304 for suspected TBIs. However, Woodruff and others believe the number to be much higher, especially “occult” injuries that may not be immediately apparent and may not cause debilitating symptoms for years after an injury.
According to an internal Department of Defense document obtained by Woodruff, at least 10 percent of Iraq and Afghanistan veterans may have had a brain injury. “That could mean that of the 1.5 million who have served or are now serving in Iraq and Afghanistan, more than 150,000 people could have a brain injury that may be undiagnosed and unrecognized by the casualty numbers from the Department of Defense,” he said in his television report.
‘A DIFFERENT WAR’
When questioned about current TBI estimates, VA Secretary Jim Nicholson said that the public “is probably surprised to know that 200,000 [veterans] come to the VA for some kind of medical treatment [each year], and not all of these are serious injuries.” Many also visit VA centers “for dental problems,” he noted.
Steve Scott, MD, director of the physical medicine and rehabilitation program at the VA's polytrauma center in Tampa, FL, told Woodruff that the entire VA medical system has been affected by the high number of TBI in returning combatants.
“When they started coming back with so many traumatic brain injuries, that was when we knew we were in a different war,” he said.
Dr. Scott noted that the VA is trying to coordinate and ensure a continuum of care for brain-injured veterans, but he admitted that they are unlikely to receive the same level of care once they leave one of the four VA polytrauma centers.
“We've seen a lot more cases here, so we have the experience,” he said. “Smaller facilities nearer to veterans' communities cannot be expected to have the same level of experience,” Dr. Scott noted. “They're not completely prepared.”
The VA established four “polytrauma” centers in 2005 to handle the treatment and rehabilitation of veterans with multiple injuries, and about 60 percent of patients at the centers have suffered some degree of TBI, according to the VA.
Barbara Sigford, MD, director of VA's polytrauma center in Minneapolis, MN, told Neurology Today in a telephone interview that changes are underway to help meet the needs of veterans with TBI.
She noted that an independent panel will soon review the VA's TBI treatment and rehabilitation program and make recommendations for improvement.
While the polytrauma centers offer the highest level of TBI expertise, a second tier of “network sites” was established in April 2005 to manage TBI patients “at a lower level of acuity and closer to home,” she said.
In the months ahead a third level of between 50 to 100 “polytrauma support teams” will also be in place at VA facilities around the country. “This will bring care one step closer to home.”
She said the VA will also be assigning an individual contact person at the network sites for every veteran with a neurological condition. Although these will not be case managers, per se, they will be able to assess health complaints and triage veterans to an appropriate facility if treatment is necessary.
“They'll serve as a contact person and patient advocate,” she said. “Right now there are too many people involved in each veteran's case — between the DOD, the VA, and the Army's Wounded Warrior Program, there are multiple case managers. Our goal is to have everyone in the polytrauma system assigned to just one contact person who can coordinate care for the veteran.”
But perhaps the most major change will occur in April, when the VA will initiate mandatory screening of all veterans for less overt brain injuries, according to Dr. Sigford. Starting April 1, all combat veterans who have served in the Gulf since the 9/11 attack on the World Trade Center will be screened, she told Neurology Today.
“The screening can be done by any VA provider, and will be mandatory for these veterans on their next scheduled appointment. It would be ideal if they came in on their own instead of waiting. The [Woodruff] special on TV might just be the right trigger that gets them to say, ‘maybe that's why I'm having this trouble.’”
According to Rolland S. Parker, PhD, adjunct professor of clinical neurology at New York University School of Medicine and president of the New York Academy of Traumatic Brain Injury, a multi-disciplinary professional association, the military's medical infrastructure today has to cope with a vastly different population than in the past.
“For many years, up until this second Iraq operation, much of the concern of the VA has been the chronic illnesses of elderly veterans,” he told Neurology Today in a telephone interview. “Now suddenly there's this huge influx of younger and highly injured patients. What was the model of care for patients even five years ago is no longer applicable.”
Previous battlefield conditions were different, he noted, and the nature of the trauma is new — there is little data on treating blast injuries, especially multiple exposures.
“With the number of victims …the Armed Forces and the VA just can't do it themselves; they just don't have enough trained medical personnel or facilities set up to deal with so many casualties. They're going to need outside experts in neurology, rehabilitation, and neuropsychology with experience in TBI.”
Has the VA's TBI infrastructure been substantially re-tooled or are changes it is making enough to meet the challenge?
“That's the big question,” noted Dr. Parker, a neuropsychologist who has worked with patients who survived the World Trade Center attack and other military conflicts. “It will be difficult to keep pace with the large number of GIs returning from Iraq with polytrauma. Treatment of these injuries requires a changed rehabilitation paradigm. And the current system needs to be greatly augmented, with innovative procedures for the current group of combat injuries,” he said.
WALTER REED HOSPITAL REELING FROM INVESTIGATIONS INTO CARE FOR TBI AND OTHER INJURIES OF RETURNING VETS
March blew in like a lion for the military's medical high command, as ABC News anchor Bob Woodruff's television special dovetailed with investigative reports by the Washington Post that found injured Iraq and Afghanistan veterans housed in squalid outpatient quarters while receiving allegedly suboptimal care at Walter Reed Army Medical Center.
The news reports sparked a storm of criticism against Walter Reed, its leadership, and the Bush Administration.
Army Secretary Francis J. Harvey, the service's ranking civilian official, abruptly stepped down March 1 as the controversy began gaining momentum. Walter Reed's commander, Maj. Gen. George W. Weightman, was also dismissed.
Their resignations came just hours after President Bush ordered a comprehensive review of the allegations at Walter Reed and other possible shortcomings in the care provided veterans at all military and VA hospitals.
A series of congressional investigative hearings were scheduled, starting March 5, to review the status of veteran medical treatment. After hearing dramatic and at times tearful testimony from veterans with TBI and other injuries, and their families, Maj. Gen. George W. Weightman took personal responsibility for the problems at Walter Reed. “I failed,” he said. “We can't fail one of these soldiers or their families, not one. And we did.”
On Mar. 7, President Bush announced the formation of a special commission to review of the entire system of medical care and treatment for wounded veterans from Iraq and Afghanistan. He also directed the VA Secretary to lead a task force to investigate and respond to any immediate veterans' needs.
“I'm concerned that there may be flaws in the system,” the president said in announcing the new commission, which will be headed by Sen. Robert Dole (R-KS), himself an injured veteran, and Donna Shalala, former Secretary of Health and Human Services. “I'm confident that this commission will bring forth the truth.”
ARTICLE IN BRIEF
The government is launching a national investigation into care for returning vets with traumatic brain injury in response to news reports that the military has underestimated the incidence of TBI and is providing, in some cases, substandard care to brain-injured GIs, especially those living in rural areas.