Traumatic brain injury (TBI) has been called the “signature injury” of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF; the latter of which has been replaced by Operation New Dawn). The Department of Defense (DoD) estimates that more than 200,000 service members sustained a TBI between 2000 and 2010; the majority of cases were deemed mild.
But despite the name, even mild TBI can impair a soldier’s or veteran’s functioning, requiring symptom management to enable him or her to continue daily activities. And while the DoD and the Veterans Administration (VA) have a vast network of care facilities and resources at their disposal, there is still a reasonable chance that a veteran will present to a private practice with unresolved symptoms. Will the clinician understand the true nature of the problem?
“A large percentage of veterans are out there seeking care in a private practice or an HMO or wherever they choose, and that’s the group I worry about,” says Clinician Reviews editorial board member Cathy M. St. Pierre, PhD, APRN, FNP-BC, FAANP, Associate Chief of Nursing Research and member of the TBI/Polytrauma Team at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Massachusetts. “They are the ones who are not necessarily going to get screened for TBI. If they’re not identified, they can’t be evaluated and treated.”
THE NATURE OF THE INJURY
The most common cause of TBI in a combat zone is a blast injury. Troops in a Humvee may hit an improvised explosive device (IED), which detonates and overturns or destroys the vehicle; those who aren’t more severely injured or even killed may at least strike their heads. Sometimes, troops on the ground are knocked down by the wave of compressed gas released in the aftermath of a detonation. Being struck by shrapnel, mortar, bullets, and grenades can also inflict a TBI.
“We actually had a soldier who was diving to protect himself and hit his head on a sandbag full of rocks,” says MAJ Melissa L. Mitravich, FNP-BC, Primary Care Manager of the Warrior Transition Unit at Fort Belvoir Community Hospital in Virginia. “Not that sandbags are supposed to be full of rocks, but this one was, and he sustained a TBI that way.”
When a soldier is injured in theater, he or she usually receives a quick evaluation and/or treatment, then is transferred to Landstuhl Regional Medical Center in Germany to be stabilized before being transported back to the US. At a large-scale facility such as Fort Belvoir Community Hospital, technology is available that aids in the diagnosis of TBI.
“We have the capability to do the color-graphic MRI, which actually shows the brain shear and helps to distinguish between mild, moderate, and severe TBI,” Mitravich says. “But usually, the diagnosis of TBI, regardless of what stage it is, is based on self-reported or visualized injury.”
Mild TBI is not always easily identified. “Many people with mild TBI show no external signs,” says St. Pierre. “The majority of them are dealing with symptoms that are more subtle.”
Typical symptoms include short-term memory loss, speech impairment, blurred vision, hearing problems, headache, balance issues, incoordination, nightmares, irritability, and insomnia. Many of these overlap with posttraumatic stress disorder (PTSD), so clinicians may have to delve deeper to determine whether it’s a case of one, the other, or both.
“We have gotten cases that range from a soldier who has sustained just a headache with maybe a slight loss of memory,” Mitravich says, “to a solider with complete memory loss and/or the inability to even walk correctly due to severe balance issues.”
The military’s goal is to return the soldier to duty; if that is not possible, the focus shifts to finding the solider another job or preparing him/her to return to civilian life. “We want to make sure, depending on what their job skill is, can they perform it?” Mitravich explains. “If a pilot is having vision issues, that’s a huge problem—he or she is most likely not going to be able to return to duty.”
In the VA health care system, which has a universal screening policy for TBI, veterans are asked four questions to determine whether there is potential for TBI. Veterans who are identified as “at risk” are offered a referral for more in-depth evaluation. At the Bedford VA, St. Pierre performs those evaluations, which utilize a structured interview format.
“Even though they were in harm’s way and many of them were exposed [to a blast injury], it obviously depends on how close they were,” she says. “So they actually have to figure out how far, in feet, they were from a particular blast, and tell me.”
Once a soldier or veteran has been identified as having TBI, he or she can be referred for specific treatment. Symptom management is the focus, so depending on the patient’s presentation, referrals might be made to physical or occupational therapy, cognitive therapy, speech therapy, audiology, or optometry, among others.
TBI IN THE CIVILIAN WORLD
The DoD conducts both pre- and post-deployment evaluations of service members that include neurocognitive testing. Yet almost 95% of the veterans St. Pierre sees at the Bedford VA, for example, indicate they are experiencing their first TBI-specific evaluation. Why the disconnect?
The truth is, soldiers may hesitate to disclose their TBI symptoms. For those on the verge of demobilization, they don’t want anything to delay their return to their homes and families. For others who have seen comrades lose limbs or lose their lives, their own symptoms may seem far less significant.
Another issue may be misperceptions about TBI, on the part of both patients and providers. Mitravich emphasizes that TBI is not synonymous with loss of consciousness. “Anybody who has ‘had their bell rung’ or ‘seen stars’ has probably sustained a TBI, and the symptomatology is going to vary for each patient,” she says. “You have to make sure you know what the mechanics of the injury were in order to know what to look for.”
Just as clinicians in the VA may identify patients with TBI who slipped under the military’s radar, the same might be true for clinicians in private practice. Some veterans seek care outside the VA, but their provider may or may not know their history.
“Veterans are going in and seeing providers for a variety of medical and psychological issues, but often two and two is not being put together: Could this be related to a TBI?” says St. Pierre.
The first question to ask is whether the patient is a veteran. Second, did he or she serve in Iraq or Afghanistan? And third, did he or she experience a blast or trauma in which consciousness was lost or he/she became dazed and confused?
“Those are simple questions,” St. Pierre says, “but a ‘yes’ to any of them—or to all three—would be an indicator that [patients] probably need further evaluation.”
St. Pierre encourages colleagues to send identified patients to the nearest VA facility—not out of a desire to “poach” patients. “When it comes to specialty problems like this, I think you want to go to the best,” she explains, “and the ones who are doing the most research and have the most up-to-date management and treatment of these problems are the VA and the DoD.”
Veterans who access services for TBI (and/or PTSD) through the VA often continue to receive their primary care in private practice. Since full recovery from TBI can take up to five years, depending on the severity of the injury (although a majority of patients with symptoms of TBI return to baseline within one year), non-VA clinicians need to understand the nature of their patient’s condition and be aware of how it may complicate the rest of their care.
“If they’re having acute problems with PTSD or TBI, it’s difficult to get a fair evaluation of what exactly is going on,” St. Pierre says, “because you have these outliers that are absolutely impacting on their daily lives.”
Symptoms of TBI and PTSD can overlap and can also exacerbate or instigate additional problems. Insomnia, for example, could make anyone irritable; addressing one problem could improve both symptoms. Also, returning to civilian life is a stressful experience for soldiers and veterans, so it’s important to recognize that the transition can impact a patient’s progress. Some may decline referrals for further evaluation at one time, but may decide later that the problem needs to be addressed.
Whether it’s an initial assessment or an ongoing status check, clinicians who care for veterans need to keep the lines of communication open and watch for cues from patients who might be experiencing TBI or PTSD. “It’s truly that listening portion of our jobs that you really have to do,” says Mitravich. “You ask one question 10 different ways to see if you can get the same answer. Every once in a while you get that one patient who just doesn’t tell the same story, and you have to look at the underlying motive of what’s going on with him or her.”
Clinicians within the VA and DoD systems work in teams that include behavioral health specialists and social workers. Being able to share concerns and rely on others’ expertise to complement their own is key when it comes to complicated diagnoses such as TBI and PTSD.
“I’m not a psychologist, I’m not a social worker, so I really have to listen to what these soldiers say about what they were involved with overseas,” Mitravich says. “I’ve got my perception, and then I talk to the social worker and say, ‘What do you think?’ and we will keep talking, since we have different perspectives of what we’re seeing and hearing.”
Soldiers are trained to stand firm in the face of danger and to protect at all costs. “They see themselves as strong, and if they start having symptoms of behavioral or cognitive issues, they feel like somehow that’s their fault,” St. Pierre says. “Sometimes, it’s a matter of helping them understand that this is related to a diagnosis, and they can maybe get better. They don’t have to take care of all this on their own, and it’s not that they’re not strong or not a good soldier.”
For a list of Web-based resources where clinicians can learn more about TBI and PTSD, or to which they can direct veteran patients who need additional assistance with any aspect of transitioning home, please visit www.clinicianreviews.com.