Struggling to find brain injuries

[thedrifter]

June 19, 2006
Struggling to find brain injuries
Doctors grapple for benchmarks that denote concussions — an increasingly frequent injury

By Gregg Zoroya
USA Today

After a land mine exploded under his armored vehicle last October in Barwana, Iraq, Sgt. Devon Bradley remembers a deafening noise and a flash. Then nothing.

Seconds later, when he came to, Bradley grabbed his weapon and went back into the fight. He led his team for the next two months in efforts to clear insurgents from Barwana.

“We’re hard dogs, and I kept pushing to be with my Marines,” said Bradley, 29, who was on his third combat tour.


But something was wrong. In the weeks that followed the blast, he began forgetting what other Marines had just told him. He struggled to handle more than one task at once. Taste and smell disappeared. Worst of all, so did the name of his soon-to-be-born daughter, Addison. Bradley said he had to dig through letters from home to remember it.

He was eventually flown to a battlefield hospital where he was diagnosed with a concussion — his second in the Iraq war and the third of his life. Bradley learned that what he thought was post-nasal drip was actually leaking spinal fluid.

By January, he was back at Camp Pendleton, Calif. Doctors told him his brain may never fully recover, and his career in the Marine Corps is in doubt.

After more than three years of war in Iraq, where bombs are the biggest threat to U.S. troops, military doctors are seeing a growing number of brain injuries among soldiers and Marines caught too close to a blast. The vast majority are mild concussions that cannot be detected even with a CT scan or MRI.

In danger of permanent damage

Mild brain injuries can heal in days or even months. Additional concussions can cause permanent damage. “This is a real issue, and people are ... taking it very seriously,” said Deborah Warden, director of the Defense and Veterans Brain Injury Center, a research arm of the Department of Veterans Affairs and the Pentagon.

The ramifications are broad. How do field surgeons and medics diagnose a wound they can’t see? What can be done when soldiers and Marines try to shake off the blast effects, unaware of the concussion, and keep fighting? Should the Pentagon keep tabs on how many concussions each service member suffers? And if so, how many concussions is too many before someone is kept from combat?

“We’re not at the Star Trek point where we can run a phaser over everybody and determine their exact problem. Closed-head injuries are very hard to assess,” said Michael Kilpatrick, deputy director of deployment health support for the Pentagon.

The number of concussions keeps rising. Almost 30 percent of the patients admitted to Walter Reed Army Medical Center in Washington, D.C., have brain injuries.

Doctors fear that thousands of others go undiagnosed. A two-question survey developed by the Brain Injury Center shows that about 10 percent of troops returning from Iraq and Afghanistan suffered a concussion during their combat tour.

About half still had symptoms that could be related to a concussion, including slowed thinking, headaches, memory loss, sleep disturbance, attention and concentration deficits and irritability, said Air Force Lt. Col. Michael Jaffee, a neurologist with the center. More than 500,000 soldiers and Marines have served in combat since Sept. 11, 2001, many more than once.

During the screening, troops are first asked whether they were hurt in a blast, fall or vehicle accident. Then, they are asked whether they felt dazed, were confused or saw “stars” afterward; do not recall what happened; or lost consciousness. If any of those symptoms occurred, the service member probably suffered a concussion, Warden said.

The screening offers a way to document brain injuries. But the ability to count the injuries also has prompted disagreement about what to do with the information.

Warden urges that all returning troops be screened to build a concussion database. But today the screenings — which began about two years ago — are done at only a few military installations, including Pendleton and the Army’s Fort Carson in Colorado, Fort Bragg in North Carolina and Fort Irwin in California.

Kilpatrick, the Pentagon official, questions the screening’s accuracy. “Multiple head injuries can lead to permanent brain damage,” he said. “But we don’t have any criteria today that if you get X number of concussions, that you can’t serve anymore.”

Jaffee said settling on one number that applies to every service member is impossible because of the variables, among them the size of the blast and the severity of the concussion. That’s why concussion histories and better battlefield diagnoses are needed, he said.

Developing diagnostics

The military is developing tests that examine short-term memory, reaction time and attention deficit, key indicators of concussion. The tests are similar to those used on athletes with head injuries. The Brain Injury Center is also creating a short exam Kilpatrick said could soon be used in war zones.

Computerized testing programs, used to monitor combat troops at Fort Bragg, are being tested for the battlefield. In April, the military approved a battlefield study by Air Force neurologist Maj. Gerald Grant for developing an online test for troops in Iraq.

In preliminary field tests, about 60 soldiers and Marines exposed to blasts were examined. In one case, a 25-year-old man caught near a roadside bomb struggled to process information and quickly answer questions. Two weeks later, before returning to combat, he continued to score below average or worse in both areas.

A second man, age 37, took the exam 15 hours after a rocket exploded on the other side of the wall from where he was standing guard. He showed attention-deficit problems and scored poorly in short-term memory.

“We need a field test to be able to practically assess the safety of sending people back to duty,” Grant said.

Bradley, the Marine sergeant, said he suffered his first concussion in high school. His second concussion came during a rocket-propelled grenade attack in Iraq. After his third brain injury, doctors told him a fourth could kill him.

He and his wife, Megan, have three young daughters and say they face an uncertain future leaving the military. Bradley still experiences dizzy spells, bad headaches and back problems.

“Most of them are pretty much every day,” he said. “I have one right now.”

Ellie

[thedrifter]

June 19, 2006
Concussions go undiagnosed in thousands of troops, doctors say

By Gregg Zoroya
USA Today

Thousands of troops in Iraq and Afghanistan may risk permanent brain damage by returning to combat with relatively minor but undiagnosed concussions, often caused by bomb blasts, military researchers say.

Doctors say they are only now understanding the scope of the problem.

The injuries frequently go undiagnosed because troops may not know they suffered a concussion, doctors say. Medics and field doctors often aren’t aware of what happened during fighting.

“This blast group is going to be potentially huge,” said Angela Drake, a neuropsychologist with the Defense and Veterans Brain Injury Center, a research arm of the Department of Veterans Affairs and the Pentagon. “We’re looking at thousands of potential patients.”


But the Pentagon has refused to release precise data on how many soldiers have suffered brain injuries in Iraq and Afghanistan, saying that disclosing the information would put the lives of those fighting at risk.

The data come from screenings of 1,587 soldiers at Fort Bragg, N.C., and 9,000 at Fort Carson, Colo. Army Medical Command spokesman Jaime Cavazos said June 7 that the results of the tests represent “information the enemy could use to potentially make soldiers more vulnerable to harm.” He declined to elaborate.

However, the Naval Medical Center San Diego, which has been screening Marines from nearby Camp Pendleton for two years — and, more recently, soldiers from the Army’s Fort Irwin — released separate data the week of June 5.

Those data show that 10 percent of 7,909 leathernecks with the 1st Marine Division suffered brain injuries.

Researchers tried to follow up with 500 Marines who suffered concussions. They reached 161 of them and found that 83 percent were still suffering symptoms on average 10 months after the injury.

From Fort Irwin, 1,490 soldiers were screened, and almost 12 percent suffered concussions during their combat tours.

Military doctors describe brain injuries as a signature wound of these wars. That’s because advances in body armor save soldiers who might have died in previous conflicts, but roadside bombs can cause brain damage. U.S. troops in Iraq are exposed to hundreds of bombings each month.

“Repeated concussions can be quite serious and even lethal,” said Air Force Maj. Gerald Grant, a neurosurgeon who treated troops in Iraq.

Ellie

[thedrifter]

June 19, 2006
War’s healing power
Battlefield-born medical breakthroughs may save lives beyond the front lines

By Gregg Zoroya
USA Today

DULUIYAH, Iraq — Even with 10 milligrams of morphine, Army Sgt. Robert Mundo lay in agony after a sniper’s bullet pierced his thigh and blasted through his groin.

Mundo gripped the hand of another GI as medic Staff Sgt. Bridgett Joseph surveyed the bloody damage. Then, Joseph reached into her bag for a bandage no other war has seen.

Made with an extract from shrimp cells, the HemCon bandage creates a tight bond that stopped the bleeding almost instantly. Seconds later, Mundo, 24 — a widower from Colorado Springs, Colo., and the father of two young girls — was airlifted to the Air Force Theater Hospital in Balad, 10 miles away. He got there in five minutes.


New ways of healing are as much a product of war as are new ways of killing. To save lives on the battlefield, medical innovations are born in days rather than in years, military and civilian doctors say. And as with wars past, the new ways of treating the injured and sick in Iraq and Afghanistan — service members such as Mundo — could have benefits beyond the battlefield.

Civilian emergency care experts such as Thomas Judge say medical technicians in the U.S. are beginning to use the HemCon bandage and new battlefield-inspired tourniquets to treat trauma patients. A portable heart-lung machine developed in Germany and not yet approved for use by U.S. doctors is helping wounded soldiers breathe. Not much larger than a laptop computer, it connects to blood vessels in the groin to filter out poisonous carbon dioxide while filtering in oxygen. Military doctors in Balad also are using an expensive clotting drug, licensed for use in hemophiliacs, to help stem massive hemorrhaging in troops torn apart by roadside bombs.

Not all advances come easily. Civilian doctors complain that the military sometimes fails to share information on the success of a new drug or technology. Military doctors disagree over the effectiveness of some new products. The Army, for instance, favors the HemCon bandage even though Navy and Marine doctors question whether it works as well as a cheaper bandage developed by the Navy.

Some innovations, such as the HemCon, result from government-sponsored research. Others come from the ingenuity of battlefield doctors who seek new ways to use existing medicines, or try untested technology when all else fails.

“The military has to try things that nobody has tried before,” said Judge, immediate past president of the Association of Air Medical Services, an air ambulance trade group. “Some of the greatest advancements of medicine only come about from war.”

Controlled chaos

When Mundo arrived at Balad at 11:45 a.m. March 5, a rickshaw-like gurney carried him from the helipad into the controlled chaos of the Air Force Theater Hospital emergency room. Nurses, medical technicians and doctors — some of them with 9mm pistols slung from shoulder holsters — swarmed over each patient wheeled inside. (Medical staff are under orders to carry weapons, even during surgery.)

As patients arrive, doctors and nurses poke, prod and inspect; they cut away clothing, shout out blood pressure readings, insert oxygen tubes and wheel up portable X-ray machines. Helicopter medics, helmets under their arms, squeeze into the scrum to recite how each soldier fell on the battlefield.

Bloody linens and body fluids collect on the floor. The clatter of arriving or departing helicopters, beating against the hospital tents, muffles conversation.

“You got kids?” Air Force Lt. Col. Jay Bishoff, a urologist, asked Mundo.

“I have kids,” Mundo answered apprehensively. “But if I get home, I may want more.”

“Well,” Bishoff replied, “you’ll be able to have a lot more.”

About 20 minutes after entering the ER, Mundo was wheeled into one of three operating rooms. There, Bishoff began knitting the soldier back together.

“We’ll rebuild everything,” Bishoff said through his surgical mask. “We’re going to reconstruct it. Save it.”

Simple, effective design

The Air Force hospital in Balad is one of the two largest military hospitals in Iraq — the other is an Army facility in Baghdad.

The 300 staff members at Balad treat about 9,000 patients a year: Americans, coalition troops, Iraqis, even captured insurgents. The caseload rivals any major trauma center in the U.S., said Air Force Col. Tyler Putnam, chief of intensive care.

Its 37,000 square feet lie under a series of tents, and surgeons are particularly proud of the hospital’s simple design. Combat casualties pass from emergency room to CT scan and into surgery.

“It’s this 100 yards from the ER doors to the operating room. It’s just a straight shot. There are no corners, no turns — you just go straight down the hallway,” said Air Force Lt. Col. Jeffrey Bailey, 49, of St. Louis, the chief of trauma at Balad.

Because a major airbase sits within the Balad installation, almost all sick and wounded Americans from across Iraq flow through the hospital on their way home.

American casualties at Balad fall into two categories. Those with mild ailments — kidney stones, for example — are treated and recuperate at the base, then return to their units.

The severely wounded undergo surgery, then are quickly placed aboard aircraft for flights to the Army’s Landstuhl Regional Medical Center in Germany. Mundo would join this river of casualties soon.

After Mundo underwent almost two hours of surgery, his battalion and company commanders and other soldiers visited to wish him well. They joked about his bravely “taking one for the team.” A Purple Heart and a Combat Infantryman Badge were pinned to his pillow.

Bishoff, 44, of San Antonio, said it was the 16th groin injury he has repaired since arriving in Iraq more than a month ago.

“Every time I do it, I get better, I get faster, I learn more,” he said. “In prior wars, he would have likely lost both of his testicles.”

Doctors have learned about the extent of damage caused by high-velocity bullets and bomb blasts. They have taught themselves how to better identify dead tissue and reconnect what can be saved.

Applying the lessons

The lessons from treating complex battle wounds can form the basis for seminars and published papers to educate doctors at home.

Almost every war has given rise to medical achievements. After yellow fever killed soldiers during the Spanish-American War, military doctors were the first to prove that mosquitoes carried the disease. Among those doctors: Maj. Walter Reed, namesake of the Army hospital in Washington, D.C.

Large-scale blood transfusions began during World War I. And medical evacuations by helicopter originated during the Korean War and became common in Vietnam.

Today, the Pentagon is asking civilian researchers to develop dehydrated blood products that can be stored up to two years, a portable battlefield device that stops internal bleeding with ultrasound, a nonaddictive painkiller as powerful as morphine, and prosthetics that respond to brain waves.

“Many, if not all, of these will have civilian uses,” said Brett Giroir, a deputy director at the Defense Advanced Research Projects Agency, which does research and development for the Pentagon.

Even more important, doctors say, are greater advances in trauma care, the long-term process of saving, healing and rehabilitating the wounded and injured.

Traumatic injuries remain the No. 1 killer of Americans under age 45. The speed and efficiency of trauma care, improved upon recently by civilian medicine, are being pushed even further in Iraq and Afghanistan.

“Things come from civilian medicine, and then we take it into the cauldron of the war and focus it, test it and evaluate it, and then use it many, many, many more times than the civilians have. And then whatever spits out in the end is better,” said Army Col. John Holcomb, commander of the U.S. Army Institute of Surgical Research.

At the Balad hospital, Air Force Maj. Paul “Chip” Gleason, 35, of Springboro, Ohio, heads orthopedic surgery. Advances in body armor protect the abdomen and upper chest of soldiers. But the legs, arms, face and lower abdomen remain vulnerable to bullets and explosions. Orthopedic surgeons stay busy. In surgery, Gleason uses a small digital camera to record images for future lessons. A key task is recognizing and removing dying tissue eviscerated by bullets or shrapnel. Dead tissue can cause infection.

Because of endless opportunities to examine torn flesh, “I’ve noticed a steady progression in my ability to judge what’s viable, what’s living and what’s been too damaged,” Gleason said.

Back in the U.S., experts such as Andrew Pollak, an associate professor of orthopedics at the University of Maryland School of Medicine, said the knowledge gained in Iraq will prove priceless.

“If you see these injuries in numbers of one and two, you never gain any experience,” Pollak said. “When you do a high volume ellipsis, you can teach people what works and what didn’t work.”

Air Force Lt. Col. David Powers, 42, of Louisville, Ky., is a facial surgeon at Balad. He already has helped publish a guide based on his experience treating the wounded. One lesson: Hold off on surgery until three-dimensional models of the face can help guide doctors on what lies beneath the damage.

A medical journey

From the moment the sniper shot Mundo in a market in Ad Duluiyah, his world changed rapidly. After the five-minute helicopter ride to Balad and almost two hours in surgery, he was recuperating.

By 5 a.m. the next day, he was strapped to a litter and loaded onto a C-17 aircraft headed for Germany.

The Air Force’s system of using specially configured aircraft to move thousands of casualties from war zones almost daily is another crucial innovation. The technology didn’t exist during Vietnam, the last war in which large numbers of casualties were routinely evacuated to the U.S. In those days, doctors typically waited up to six weeks for patients to become stable enough to complete the trip home, said Dale Smith, a professor of medical history at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Now, because of new treatment methods and technology on the aircraft, the most critically injured patients can make the trip in a few days.

“They’ve really thought about this very carefully — no wasted moments, no wasted movements,” Judge said of the military. “It’s very, very focused.”

He and others say the long-distance air evacuation process — with its speed and flying care centers — would prove invaluable should a terrorist attack or natural disaster overwhelm local medical facilities, as happened with Hurricane Katrina last year. After Katrina, hundreds of patients from flooded hospitals were moved to other cities by Air Force medical crews. The White House investigation into the hurricane recommended that disaster response plans better integrate military air evacuations.

Rather than try to recreate in Iraq or Afghanistan sophisticated hospitals such as Landstuhl, the military has built smaller field hospitals where patients are treated and stabilized. Doctors in Iraq now leave many wounds open and vacuum-sealed with plastic. That also was not possible in Vietnam.

“Now, the sickest of sick patients can get on that airplane,” said Air Force Maj. Timothy Woods, a general surgeon at Landstuhl.

A hospital in the sky

On a recent C-17 medical evacuation flight from Balad to Landstuhl, 32 patients rested comfortably, many of them in litters stacked three high on aluminum racks. Among them: burn patients, an amputee, soldiers with broken bones and shoulder and back injuries, one with a blood disorder, two psychiatric cases, and a service member stricken with lung cancer. Two in critical condition were hooked to ventilators.

Like flight attendants, the nurses, medical technicians and doctors circulated throughout the plane, offering water, oxygen and medication to relieve the pain. They also kept a close eye on monitors.

“The civilians are always amazed at how we do this,” said Air Force Reserve Maj. Ken Winslow, 49, a flight nurse from Issaquah, Wash.

About 65 hours after he was shot — and after a stop in Germany — Mundo arrived at Andrews Air Force Base, Md. From there, he headed to Walter Reed.

“It was great because I didn’t really feel like I needed to be that far away from home. I wanted to get here to Walter Reed and start doing my rehab,” he said.

Within eight days of his return, Mundo had been reunited with his daughters — JoLyne, 3, and Shania, 1 — and flew home to Colorado. The two girls had lost their mother, Rachel, to lupus in November, just days before their father shipped out for Iraq. In his absence, Mundo’s sister-in-law, Jessie Mundo, cared for them.

The children were thrilled to see him and curious about his wound.

“I didn’t want to tell them about the sniper or anything,” Mundo said.

“As far as they know, it was just a nice little doctor’s shot.”

Paul Overberg, Robert Davis, and Liz Szabo contributed to this report from McLean, Va.

Ellie

[Ironrider]

Don't know if this is going to help. A few years back, I was on my bike and hit by Ford pickup...yeah I still hate Fords. I didn't suffer any head injuries, however the concussion was a real doozy. I'm having alot of long term memory loss, of everything prior to the accident. Things are really patchy, and I've found I'm having a real hard time remembering peoples names. My doctor told me this is 'normal' in a major concussion.