War’s ‘signature’ wound

War’s ‘signature’ wound
Traumatic brain injuries common, but hard to spot
By Kelly Kennedy - kellykennedy@militarytimes.com
Posted : August 13, 2007

Sitting in a fast-food restaurant near Fort Belvoir, Va., Army Master Sgt. Jose Santiago, his knee bouncing up and down, asked to switch to another table.

“Since I got back, I don’t like to be around dirty things,” he said, wiping a wet spot from the new table with a napkin.

He then settled in for a five-hour conversation that looped back over things he had already covered, stalled when he couldn’t remember a word he wanted to use and stopped when he tried to talk about how the first day of the Iraq war damaged his family.

“Did I already tell you that?” he asked, dozens of times, wincing when he feared he had.

Santiago, a chemical, biological, radiological and nuclear operations specialist, made E-7 in nine years, was picked for a special team assigned to look for weapons of mass destruction in Iraq, and spent most of his school years in classes for gifted kids.

“I was a fast-tracker,” he said.

Now, he leaves for medical appointments three hours early — even if he knows the office is only 45 minutes away — because he gets lost easily. An alarm reminds him to take his eight medications. Worse, he forgets he already swallowed his pain or anti-depression pills, and gulps down another handful.

“I almost OD’ed twice,” he said.

At home, his three teenage daughters don’t talk at breakfast because the noise is too distracting for their dad. They know the annual trips to the amusement park are over, as are barbecues, parties and Sunday afternoons at the movies. He stutters when frustrated, has little impulse control and angers easily.

“I just thought I got stupid all of a sudden,” he said, laughing ruefully as he sipped a Coke. “My buddies kept saying, ‘What the hell’s wrong with Joe?’”

What’s wrong with Joe is this: At dawn on March 20, 2003, as U.S. troops awaited word to cross the Kuwaiti border and invade Iraq, Santiago fell off a berm as he scanned the enemy territory ahead through binoculars.

“It was still a little dark,” he said. “I lost my footing, fell 15 to 20 feet and landed on the crown of my head.”

Rather than see a doctor about his headaches and tunnel vision or the numbness in his arm, he dusted off the sand and drove on.
The ‘signature’ war injury

It was three more years before doctors realized Santiago had what experts call the Iraq war’s “signature” wound: a traumatic brain injury.

Since the war in Afghanistan began in 2001, about 2,100 troops have been formally diagnosed with TBIs. But officials estimate up to 150,000 troops may have suffered concussions — mild TBIs — from roadside bomb attacks.

According to the Defense and Veterans Brain Injury Center, a research and treatment agency run by the Pentagon and Veterans Affairs Department, 64 percent of injured troops have suffered brain injuries.

“On today’s battlefield,” the DVBIC Web site says, “TBI is one of the most frequent causes of death and disability.”

Santiago’s “mild” TBI killed his Army career, drove his wife to the edge of divorce and forces him to rely on special assistance to get through each day.

“I’ll never be the same,” he said.

And because he had a closed-head injury and seems normal enough to people who didn’t know him before, he said military doctors accused him of faking his symptoms to try to bilk the Army for tax-free, combat-related disability pay.

His family got no counseling, he said, and the medical evaluation board to determine his disability retirement pay began this spring — four years after his injury.

As with many other military medical issues emerging in recent years, no one planned for so many TBIs. Six years after the war in Afghanistan began, the military has just established standardized treatment for TBI symptoms; begun to reorganize the Defense and Veterans Brain Injury Center’s administrative, research and budget functions; and launched front line education programs.

“We’re actually pretty good at treating moderate to severe head injuries and have improved since the war began,” said Col. Jonathan Jaffin, commander of Army Medical Research and Materiel Command.

But because mild head injuries are not obvious, they haven’t inspired a lot of money for research.

However, the wars are changing the priority level of TBIs.

“We’re getting money � visibility � answers to questions that have troubled us — and patients — for years,” Jaffin said.
Difficult to diagnose

A head injury is any change in consciousness. Black out for even a few seconds, it’s a head injury. Conk your head on a beam and get dizzy, it’s a head injury. Get whiplashed by an explosion, it’s a head injury.

When the injuries are moderate to severe, they’re fairly easy to diagnose. They may come with a cracked skull, and bleeding of the brain will show up on an MRI or CT scan. Moderate to severe head injuries knock people out longer and may cause amnesia.

Mild brain injuries are “more subtle,” Jaffin said.

Even the term “mild” is confusing. Most people with mild brain injuries — 70 percent, according to Jaffin — have no symptoms by the time they’re screened by a doctor who knows what to look for. Because their injuries don’t show on electronic scans, they have to be diagnosed based on a medical exam, he said.

And that’s tricky, too, because several symptoms are similar to those of post-traumatic stress disorder: depression, anger, sleep problems, a sensitivity to noise.

So doctors must pay attention to the timing of the symptoms and the experiences of the service member — did the angry outbursts begin after his Humvee was hit by a roadside bomb?

Some symptoms do point to mild TBI: stuttering, seizures, headaches, obsessive-compulsive disorder, tunnel vision and numbness in some areas of the body. There are also cognitive disabilities: problems with math, short-term memory loss, slowed reactions and other problems.

On July 18 at Camp Pendleton, Calif., Marine Cpl. Trent Thomas was convicted of conspiracy to commit murder and kidnapping in the death of an Iraqi civilian and now faces a life sentence.

His attorneys tried to show that exposure to multiple explosive blasts caused traumatic brain injury that may have impaired Thomas’ judgment. The Marine was on his third combat tour in Iraq and had been exposed to more than 25 bomb blasts, said Maria Mouritidis, head of the traumatic stress and brain injury program at the National Naval Medical Center in Bethesda, Md.

Thomas “would have difficulty with decision-making, problem-solving and especially coming up with different solutions in a high-pressure atmosphere,” she said. “The evidence suggests that he would be very susceptible to influence and have difficulty seeing other options.”

Often, the initial evaluation of a traumatic brain injury is done by a service member’s primary-care physician. “That’s going to miss people,” Jaffin said. “We have to educate providers.”

In Santiago’s case, a 2003 X-ray showed a Chiari malformation —the base of the rear of the skull was smaller than normal. That can push the cerebellum and brainstem toward the spine, blocking the fluid that surrounds and protects the brain from flowing through the spine.

But doctors in his initial medical exams “didn’t even look at the right rear orbital lobe,” he said.

The damage there wasn’t found until late 2006, when he was diagnosed with TBI because he’d been having vision problems.

Santiago had no symptoms before he fell in 2003. But Col. Joel Fishbain, acting deputy commander for clinical services at Walter Reed Army Medical Center in Washington, responded to a congressional inquiry with a letter dated May 7, 2007, that said Santiago’s problems were due to a condition that had existed before he entered service, though Fishbain allowed that Santiago’s mild brain injury could be a contributing factor in the condition’s manifestation.

Fishbain also said Santiago was a hypochondriac, faking his cognitive difficulties. “It is felt that his traumatic brain injury is not playing a major role in his current symptoms,” he wrote.

He also said Santiago hadn’t been to the TBI clinic since late 2006, implying that he refused treatment. But Fishbain didn’t mention that the military had referred Santiago to a VA clinic.

“They really don’t want to say ... that all those other problems are related to the fall,” Santiago said. “I had never heard of TBI.”
No reason for faking

Santiago denied seeking a high disability rating. He said he wanted to stay in uniform; he had 18� years in and wanted his retirement.

“I didn’t want to take chances with a medical board,” he said. “I had talked to too many guys who were getting screwed.”

He began researching the issue himself, taking meticulous notes because he often couldn’t recall what he’d learned the day before.

Santiago believes his Chiari malformation is acquired because it didn’t show up in X-rays after a car accident a few years ago.

Ronald Glasser, a former Army doctor who has studied brain injuries since Vietnam, said that shouldn’t matter; the malformation put Santiago at higher risk for a brain injury, and he should be compensated for it.

“Short-term memory loss does not come from Chiari,” Glasser said. “He’s damaged.”

Santiago is not the only service member who has been treated as if he were making up symptoms.

Annette McLeod, wife of Spc. Wendell McLeod Jr., told Congress on March 5 that rather than acknowledge her husband’s cognitive disabilities after a brain injury, the Pentagon found out he had taken Title 1 math in grade school and used that to label him as already “intellectually slow.”

The military TBI clinic said McLeod “didn’t try hard enough,” his wife said. “I know what Dell is capable of, and I knew that there was something wrong.” VA later diagnosed McLeod with a TBI.

Jeannette Mayer said her husband, DeWayne, was evaluated for TBI at a private clinic because the Army ignored her plea for help. He had been in five IED explosions, including one that rolled his Humvee. Rather than evaluate him for a TBI, she said, the Army began a medical evaluation board for PTSD, a neck injury and hearing loss, without considering why he still has headaches and short-term memory loss.

Michele Paulson’s husband, a first sergeant who asked that his name not be used, was knocked out by an IED, and pieces of shrapnel forced their way into his temple. He was not scanned for a brain injury, said Paulson, who now works as a TBI technician.

He suffered short-term memory loss, angry outbursts, dizziness and vision problems. But he was not counseled or treated for the TBI, and was sent back to work before he felt ready. He still suffers short-term memory loss.
The big picture

David Cifu, who oversees the Traumatic Brain Injury program at the VA medical center in Richmond, Va., said treating TBI patients as if they’re making up their injuries is about the worst way to take care of them.

The longer diagnosis and treatment are delayed, the harder such care can be. “Sometimes the layers are so significant we can’t peel them away,” Cifu said.

The Defense Department is working to better educate doctors about that issue, Jaffin said.

The Army announced in mid-July the launch of a “chain teaching” awareness program to “educate more than 1 million � soldiers within 90 days about post-traumatic stress disorder and traumatic brain injuries.”

Barbara Sigford, director of the VA Physical Medicine and Rehabilitation Service, said VA also has begun “looking at the big picture.” When treating a veteran with a missing limb, for example, health professionals note how a TBI may make walking with a prosthetic device more difficult.

Jaffin said he and other TBI specialists have met with top Pentagon health officials to discuss what else should be done. Some actions are in motion, such as putting out word on how to care for the top 22 TBI symptoms, and sending pamphlets to Iraq and Afghanistan so units as well as medical personnel understand the issues better.

Such care should expand to families, he added, noting spouses can serve as early warning alarms for behavioral changes.

“The doctor may not detect it in someone he’s meeting for the first time,” Jaffin said. “That’s something we need to teach people. ... That’s really important.”
Cloudy future

“My wife has been taking it hard,” Santiago said at the fast-food restaurant. “We get into a lot of arguments.”

After a particularly bad fight, he said, his wife of 17 years had gotten a restraining order.

“I’m married to two different people now — the one I fell in love with, and the one who came back from the war,” Stacy Santiago said a few days later.

She said the house has to be spotless because of Jose’s new obsessive-compulsive disorder.

“You want to really freak him out? Leave a fork in the sink,” she said, chuckling. “His memory is shot. He’ll call, and call back 10 minutes later and ask the same question.”

Santiago initially went to the Traumatic Brain Injury Clinic at Walter Reed, but when his neurophysiologist accused him of not trying hard enough on cognitive tests, he asked for another doctor. That’s when he was sent to VA.

VA diagnosed him with PTSD, OCD and cognitive problems. He began seeing a speech pathologist to help with his stuttering and attended group therapy.

He still has shaky days, but feels better now that the gadgets VA gave him — personal digital assistant, global positioning system and beeper — help him keep his life under control. And the VA counseling he is getting also helps.

He and Stacy are on good terms now, but she said it’s still difficult — enough so that she wonders how long she can last.

“There are days when I go, ‘Give me the divorce papers.’ And there are days when I say, ‘Wow, this is a good day.’”

That it took over three years to reach a place where good days are possible still makes her angry.

“They told him it was all in his head,” she said.

“Ask the people he lives with.”

Ellie