Pulse
Invisible Wounds
Military and veterans hospitals are seeing an increase in the number of soldiers with traumatic brain injuries.
Some time on the afternoon of Nov. 8, the truck in which Lance Cpl. Scott Kruchten was riding during a patrol just outside of Baghdad struck a bomb. “It destroyed the Humvee down to two front tires and an engine,” Kruchten says. “Only two of us made it out to a hospital. Three were killed.” Kruchten, a U.S. Marine reservist from Madison, Wisconsin, doesn’t remember being blown out of the vehicle by what turned out to be a 250-pound bomb. In fact, he doesn’t remember anything until the morning of Nov. 17, when he began trying to piece together his story as doctors were piecing together his broken leg and rib, and a chipped shoulder.
At first, those injuries had appeared to be all that was wrong with Kruchten. But at some point during his initial treatment, his speech began to slur and his right arm stopped functioning. “That is when they determined that there was a bigger issue and they needed to get me to a hospital,” Kruchten says. Although he had been wearing one of the military’s new Kevlar helmets, the impact that had sent him headfirst through the roof or side of the vehicle had done more damage than was obvious. Kruchten was bleeding inside his skull. For Kruchten, a diagnosis of a brain injury set in motion a series of events that the broken bones hadn’t. Within a month of being wounded, he found himself in the traumatic brain injury (TBI) program at the Minneapolis Veterans Affairs (VA) Medical Center.
Upsurge in Cases
Minneapolis VA doctors have been seeing more TBI patients since the start of the Iraq war in April 2003, according to Barbara Sigford, M.D., medical director for the Minneapolis TBI program. “The Minneapolis VA has been a prime receiving site for active-duty soldiers who have sustained traumatic brain injuries for about 12 years,” Sigford says. So when the conflict in Iraq started, she knew the hospital was going to see an influx of referrals. The Minneapolis facility is one of four VA hospitals with TBI programs; the others are located in Tampa, Florida; Richmond, Virginia; and Palo Alto, California.
Increased incidence of TBI among soldiers appears to be a trend. A 2003 study by the Defense and Veterans Brain Injury Center, a 12-year-old joint effort of the departments of Defense and Veterans Affairs, found that as many as two-thirds of injured U.S. soldiers sent from Iraq to Walter Reed Army Medical Center in Washington, D.C., had sustained a brain injury. Although there’s scant data to verify past rates, military experts had thought it was about 20 percent.
Why the increase in brain injuries? Some say it’s proof positive that better armor (for example, Kevlar helmets that deflect bullets and body armor that protects the torso), more sophisticated diagnostic tools, and better triage are saving the lives of soldiers who in the past would have been killed. But the increase is also said to reflect the nature of this war, with improvised explosive devices (IEDs), rocket-propelled grenades, and land mines being the weapons of choice. In other words, blasts not bullets are doing bulk of the damage. “It’s safe to say that we’re going to see higher numbers because of changing technology and the type of warfare but also because of advances in medicine and mobile medicine. More of these people are being saved,” says Sharon Rolenc, public awareness director for the Brain Injury Association of Minnesota.
The Hard Work of Rehabilitation
Of the 21 patients who have received care through the Minneapolis VA’s TBI program, all have sustained serious injuries requiring inpatient treatment, usually in an intensive care unit, at another hospital such as Walter Reed or the National Naval Medical Center in Bethesda, Maryland. By the time patients enter the TBI program, they don’t need ongoing, active care by neurosurgeons or other medical specialists, according to Larisa Kusar, M.D., staff physician with the TBI program. “They’re at a point where we can focus more on the rehab.”
And they do need to focus because TBI patients have their work cut out for them. While in the program, patients work intensely with a team of specialists composed of physical, occupational, speech, and recreational therapists, psychologists, physicians, and social workers. And they generally stay six weeks.
The most severely injured might start by learning such basic skills as getting in and out of bed or even turning themselves. They might need to relearn how to do grooming and hygiene tasks such as brushing their teeth. Some may need to work on oral motor control in order to feed themselves. Gradually, they progress to more complicated activities such as learning to use organizers to keep track of appointments, use memory devices, and solve problems.
The goal is both to help patients heal and to develop compensatory skills, which Sigford says are particularly important early on while the brain is recovering. A very basic example of how this works is that patients may need checklists of things to do to get ready for the day such as brushing their teeth, combing their hair, and putting on deodorant. But as they continue to recover, those things become internalized and they no longer need the list or the reminders. “It’s expected that the brain is undergoing recovery and reorganization so that a person is able to once again do those things without all those cues,” Sigford says.
Medications are prescribed to treat issues, such as inability to focus and low arousal levels, that might impede the rehabilitation and recovery process, according to Kusar. The most commonly used drug is Ritalin. But antidepressants, antibiotics, pain medications, sleep medications, and mood stabilizers are prescribed as well.
One of the hardest things about working with patients with brain injuries, according to Kusar, is that many of them aren’t aware of their deficits. “If there is physical evidence that they’re injured, that they have part of their skull removed, they’re able to focus on those concrete reminders,” she says. But there might not be awareness about cognitive deficits until the patient goes home and tries to go to work or back to school.
“The flip side,” Sigford says, “is that some patients are very aware that they’re not the same and are very distressed by it.”
A Latent Issue
Interestingly, TBI patients not seen in the VA programs may present some of the toughest challenges for health care providers. Sigford calls these the “complicated mild” cases. Unaware that they have been hurt, soldiers will return to their jobs, families, or school without awareness of their deficiencies or the skills needed to compensate for them. They may have trouble learning, relating to family, and controlling their emotions.
Some of the consequences of going without a diagnosis and proper care can be severe, according to Rolenc. “They are left with a lot of unanswered questions about what is wrong in their lives. Feelings of depression and self-doubt set in. … They might self-medicate as a way to solve unresolved problems, and get involved with alcoholism, substance abuse,” she says.
Both Rolenc and Sigford want primary care physicians to be aware that people who have served in Iraq may have hidden brain injuries. “If the person that they’re seeing has been near a blast, not necessarily even injured by the blast but in close proximity to the blast, it probably is a good idea to screen them for possible brain injury,” says Rolenc.
With injuries that appear to be mild, Scott Kruchten will stay in the TBI program just two weeks instead of six. Yet, he is taking his rehab seriously with the hope that he won’t have problems down the road. “I’m stimulating myself as far as brain function, hand-eye coordination, and fine-motor [skills],” he says. “I’ve got a puzzle set up in my room that I’m working on, magazine articles that I’m reading. I’m keeping myself really busy.
“Everything I’m doing is basically saving myself from possible [problems] that could come up in the near future,” he says. For although he knows he is luckier than most of the 20 other Iraq veterans admitted to the brain injury program at the Minneapolis VA, Kruchten knows that brain injuries can fool a person. After all, his brain injury fooled doctors once before. —Carmen Peota