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A multidisciplinary approach

December 1, 2006
by MICHAEL LEVIN-EPSTEIN
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As more soldiers suffer brain injuries, more are benefiting from coordinated care

State-of-the-art body armor and advances in frontline trauma care are enabling soldiers to survive attacks that would have been fatal just a decade ago. As a result, military caregivers have had to come up with new strategies for caring for the alarming number of troops who have served in Iraq and Afghanistan and suffered a traumatic brain injury (TBI).

From January 2003 to September 2006, 1,529 patients were treated for TBI at the eight sites run by the Defense and Veterans Brain Injury Center (DVBIC), according to Department of Defense (DOD) spokesman Chuck Dasey. DVBIC, a collaborative effort between DOD and the Department of Veterans Affairs established after the 1991 Gulf War, has clinical care and research programs at three military sites and four VA facilities, along with one civilian partner program.

In the Vietnam War, at least 75% of all soldiers who suffered a TBI died, according to Ronald Bellamy, former editor of the Textbook of Military Medicine, whose research is cited in a 2005 article on TBI in the New England Journal of Medicine. In the Iraq and Afghanistan conflicts, the article notes, Kevlar body armor and helmets have protected soldiers from bullets and shrapnel and improved overall survival rates. However, the article explains that “helmets cannot completely protect the face, head, and neck, nor do they prevent the kind of closed brain injuries often produced by blasts,” adding that “among surviving soldiers wounded in combat in Iraq and Afghanistan, TBI appears to account for a larger proportion of casualties than it has in other recent U.S. wars.”1

In fact, as many as 70% of the wounds suffered by U.S. forces in Iraq could result in brain injuries, according to Major General Kevin Kiley, commanding general of the North Atlantic Regional Medical Command, who was cited in a 2003 Boston Globe article. In the Vietnam War, only about 15% of all combat casualties involved brain injuries, says Bellamy.

In response to this new development, DVBIC has dramatically expanded operations at its four TBI centers in Minneapolis; Richmond, Virginia; Tampa; and Palo Alto, California, to provide specialized treatment for military personnel who have a TBI. These four regional facilities, called “polytrauma centers,” have significantly changed the way medical care is administered to soldiers with a TBI.

Barbara Sigford, MD, national program director of physical medicine and rehabilitation services for the VA, says TBI care is now delivered in a much more coordinated fashion. “Instead of just treating TBI,” she says, “the centers now are capable of treating soldiers for other conditions, including amputation, blindness, visual or auditory impairment, complex orthopedic injuries, and mental health concerns.” Today, she notes, “soldiers with TBI don't have to be transported to another facility for behavioral health issues, for example.” She adds that “the centers all have at their disposal a team of medical consultants who can address an array of acuities that you might not see in a standard setting.” For instance, the centers have infectious disease experts to care for TBI victims who might not have had ideal wound care on the battlefield.

The centers are developing state-of-the-art, interdisciplinary pain management strategies for TBI patients, as well. TBI patients often take much longer to recover than other injured soldiers and, therefore, have pain issues that must be managed over a much longer period, Dr. Sigford notes. Pharmacists assist with pain medication management, psychologists experienced in pain management suggest behavioral coping strategies, and therapists recommend alternative modalities for pain management. The polytrauma centers also devote considerable attention to educating providers and family members about pain management. In fact, the centers now have the capability to deal with a wide range of issues that can affect the families of TBI victims.

The centers also must care for a common complication of TBI: post-traumatic stress disorder (PTSD). Between 10 to 15% of soldiers develop PTSD after deployment to Iraq, and a comparable number have significant symptoms of PTSD, depression, or anxiety and may benefit from care, VA officials report. The VA has made training in PTSD mandatory for physicians and other key staff in primary care, rehabilitation, and mental health programs, Dr. Sigford notes.

Is the polytrauma centers’ coordinated approach working? Dr. Sigford says there is no question about it. Seventy-eight percent of those treated for TBI return home, and another 15% return to military facilities for additional treatments or evaluations. After soldiers return home, they will need continued follow-up for behavioral and neurologic issues, such as irritability and anger management, cognitive impairments, impulsivity and poor executive function, PTSD, movement disorders, seizure disorders, and headaches. Such care likely will involve more community-based behavioral health resources as more soldiers return home. Dr. Sigford explains that “Behavioral health services will continue to be needed in the management of these problems, especially as these young TBI victims continue through the developmental stages of life.”

Michael Levin-Epstein is a freelance writer.

Reference

  1. Okie S. Traumatic brain injury in the war zone. N Engl J Med 2005; 352:2043-7.
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