© David L. Goldin, J.D., M.B.A.
The horror of traumatic brain injuries being suffered by our troops in Iraq and Afghanistan is becoming increasingly evident. The most damaging weapon of this war, the improvised explosive device (IED), is leaving a signature wound on our heroic troops: traumatic brain injury. Even when not knocked out by the blast, the forces unleashed by the explosion can leave permanent scars on the brain without visible wounds. Our returning soldiers may not even know they have been injured but can not account for the changes in their cognition, behavior and personality. They may find themselves confused, irritable, restless, unmotivated, angry, unable to focus their attention, disorganized, lacking former judgment, slow in thinking, with memory deficits, depressed, and feeling "like a different person," and yet not realize that this is caused by a traumatic brain injury.
There have been estimates that between 10 and 20% of soldiers returning from their deployments in Iraq and Afghanistan may have suffered a "mild" TBI. (Please see my article, What is "Mild" Brain Injury.) This means that thousands may be at risk for TBI’s lingering effects. As stated by Lieutenant Colonel Gary Southwell, Ph.D., an army neuropsychologist at Landstuhl Regional Medical Center in Germany: "It is certainly becoming an increasing concern about this war, as we realize that people may have been exposed to conditions in which they might have received a TBI without really being aware of it."
Traumatic brain injuries caused by IEDs, mortars, vehicle accidents, grenades, bullets, mines, falls and more, have also been described as the "hallmark" injury faced by veterans returning from Iraq and Afghanistan. When hit by the explosion of an IED, the force of the blast instantly overcomes the victim. The same explosion that is powerful enough to upend a 25-ton armored vehicle, also shakes the brain and can cause permanent damage. While it is the stated goal of the military to enable these wounded troops to maximize their physical and cognitive functions so they can move on with their lives, this goal requires resources and implementation not presently available for our veterans.
Nor is this a new problem although the circumstances of the war in Iraq and Afghanistan no doubt have greatly increased the prevalence of TBI. Described as the "secret epidemic" because it is unknown how many people live with brain injuries, statistics coming from modern war veterans raise questions from the past. How many veterans of Vietnam and other wars have returned with minor or severe brain injuries that went undiagnosed? How many of those unable to cope with return to civilian life, or haunted by excessive drug use, are victims of undiagnosed TBI. A July 2006 assessment from the VA Inspector General emphasizes that better coordination of care is needed to allow veterans to make a smoother transition between defense department care (for active military) and VA care (for veterans).
As with those unfortunate survivors who experience long term effects from mild traumatic brain injury in civilian life, our returning soldiers may be faced with the same deficits which for some will be permanent. These deficits include cognitive, emotional and physical limitations, a change in personality, and the inability to effectively take care of themselves or their loved ones. It is important for all of us to lend assistance and support to our returning troops to enable their recovery to the extent possible. This assistance is particularly critical for veterans who are no longer part of the active military and therefore do not have the medical care and attention provided to those on active duty.
Further, as recently reported (see lead column on the front page of the San Diego Union of July 24, 2007), a lawsuit has been filed against the U.S. Department of Veterans Affairs in federal court in San Francisco for, among other things, the alleged failure to provide services for post traumatic stress disorder (PTSD) to hundreds of thousands of veterans. (The lawsuit seeks to represent between 320,000 and 800,000 veterans of the Iraq war who are alleged to be at risk for PTSD.) The lawsuit accuses the VA of deliberately cheating some veterans by misclassifying PTSD claims as pre-existing personality disorders to avoid paying benefits. Because of the "invisible" nature of "mild" traumatic brain injury (please see my article, "Mild" Brain Injury Litigation: Making the Invisible Visible), the danger of mischaracterization is just as great for TBI as it is for PTSD.
Legislation is pending in the United States Congress to fund treatment for returning military. In July, 2007, the Senate voted unanimously to add the Dignified Treatment of Wounded Warriors Act through the National Defense Authorization Act for Fiscal Year 2008, including TBI provisions in the Veterans Traumatic Brain Injury and Health Programs Improvement Act of 2007. The proposed legislation takes steps to ensure that service members have access to non-governmental facilities when necessary to meet the goals of individualized TBI rehabilitation and community reintegration plans. The bill also instructs new TBI research programs within the Department of Veterans Affairs to be pursued through collaboration with existing TBI research programs receiving grants from the National Institute of Disability and Rehabilitation Research of the Department of Education.
Another piece of proposed legislation, Senate Bill 1606, contains several important provisions relating to care for returning service members with TBI. The bill would create an overlap of Department of Defense and Department of Veteran Affairs benefits for a period of three years to enable wounded warriors to benefit from the strengths of both systems, allowing increased access to TRICARE, which in turn could potentially facilitate enhanced access to civilian TBI care providers. A provision in the bill would require the Department of Defense to adopt a pre--and post-cognitive assessment tool to help diagnose TBI and PTSD (posttraumatic stress disorder) in returning service members.
The House Veterans Affairs committee, chaired by Bob Filner (D-CA), is also meeting in July, 2007, to discuss ways to provide treatment for traumatic brain injury. The urgency of the meeting is highlighted by the statistic that among veterans and service members from Iraq and Afghanistan treated at Walter Reed for injuries of any type, approximately 65% have TBI as a primary diagnosis or simultaneous injury. Participants at the meeting include medical doctors, neuropsychologists, researchers and family members.
The veterans of the war in Iraq and Afghanistan are entitled to the same types of resources which in the appropriate case can be made available through civil litigation to civilians suffering traumatic brain injury as a result of the fault of another. These resources should include a multi-disciplinary approach to rehabilitation which may involve the fields of neurology, neuropsychology, psychiatry, behavioral medicine, orthopaedics, family medicine, pediatrics, physical medicine and rehabilitation, physiatry, vocational rehabilitation, speech and hearing therapy, physical therapy, occupational therapy, education therapy, social work, case management and life care planning.
The goal of maximizing the recovery of our returning troops from traumatic brain injury should be a priority for us all. Without appropriate treatment there is a real danger soldiers coming home from Iraq and Afghanistan with traumatic brain injuries will someday end up holding signs on street corners, begging for money and food, sleeping on sidewalks and under bridges, and otherwise dropping out of society. Because of the changing nature of warfare from Vietnam to now, troops made homeless by the effects of traumatic brain injuries suffered in the war in Iraq and Afghanistan may ultimately dwarf in number those similarly affected from the Vietnam era.
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