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Clif Cleaveland, MD
21 May 2009
Many men and women of our armed forces who have served in Iraq and Afghanistan have sustained head injuries. An estimated 20 per cent or 300,000 of the 1.6 million veterans of service in these wars have suffered varying degrees of brain trauma. At least one thousand of our veterans are disabled by moderate to severe, nervous system injury.
Road-side bombs, rocket-propelled grenades, and suicide-bombers have been weapons of choice for our adversaries. These weapons account for the unusually high incidence of brain injuries. Wounds may be due to penetration by projectiles or shrapnel. More commonly injury occurs when the force of an explosion hurls the victim against a fixed barrier or when a wave of high pressure—a “blast-wave”—expands outward from the site of an explosion to damage brain and other soft tissue of its victims. Blast-wave injuries may be especially severe for personnel in confined spaces such as the interior of armored vehicles.
The plight of Army Sergeant Daniel Tallouzi illustrates the terrible consequences of penetrating brain injuries. He died on February 28th of this year, seventeen months after a piece of shrapnel pierced his brain in Afghanistan. His story was detailed in the New York Times earlier this year. The wound left him in a chronic vegetative state, totally helpless and unable to respond to his environment. Limitations in the Veterans Administration (V.A.) hospital to which he was assigned led to his transfer to a private rehabilitation unit at government expense. His mother, a single parent, gave up her job to assist in essential bedside care each day until he died. Media accounts describe a V.A. health system that was initially overwhelmed by severe brain and spinal cord injuries.
Far more common are mild, non-penetrating brain injuries. Most of these are concussions of varying severity. A concussion is, in effect, a bruise of the brain. Localized bleeding, swelling, and possible interference with normal brain activity occur. I have read of soldiers who have sustained multiple concussions during their assignments in Iraq. In the specific cases of blast-wave injuries there may be few, if any, outward signs of trauma. Most require no treatment in the field. The victim may have an interval of unconsciousness followed by a period of amnesia for recent events. Injury is classified as mild if unconsciousness lasts no longer than 30 minutes and amnesia persists less than 24 hours.
Sufferers of mild brain injury may report a variety of subsequent symptoms: difficulty concentrating, disordered sleep patterns, disturbances in vision or hearing, recurrent headaches, and episodes of confusion. They may have problems completing a task. Such symptoms may not be apparent immediately after the injury. Symptoms may not be fully appreciated until personnel are transferred to quieter, non-combat zones.
In April 2007, V.A. outpatient clinics began to screen all veterans of Iraq and Afghanistan who seek treatment for any complaint for evidence of mild traumatic brain injury. Veterans with positive screening examinations are evaluated by neurologists. If a brain injury is confirmed, the patient is referred for treatment and appropriate rehabilitation. A report in the April 16th New England Journal of Medicine by Hoge, Goldberg, and Castro discusses the difficulty in assessing such injuries.
Problems arise from the lack of clear-cut diagnostic criteria for mild brain injury. Similar symptoms may be seen in post-traumatic stress disorder, which also includes recurrent flashbacks to horrible experiences. Veterans might suffer from both disorders. The long term outcome for mild, traumatic injuries is unclear. Will victims experience gradual worsening of symptoms or will the symptoms gradually diminish? Will victims, similar to prize-fighters, show an earlier onset of dementia? How can disability pensions be computed? At this point, no one knows.
Memorial Day reminds us each year of debts that we can never repay to the men and women who protect us. This year I suggest special prayers and thoughts for the victims of service-related head injuries.
Contact Clif Cleaveland at firstname.lastname@example.org.