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A SHOCK WAVE OF BRAIN INJURIES -- "We can save
you.
But you might not be what you were."
(photo: Mohammed Adnan ASSOCIATED PRESS)
Story here...
http://www.statesman.com/
insight/content/editorial/stories/
insight/04/15/15iraqwounded.html
Story below:
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A shock wave of brain injuries
For the first time, the U.S. military is
treating more head injuries than chest or abdominal wounds, and it is
ill-equipped to do so.
By Ronald Glasser
SPECIAL TO THE WASHINGTON POST
This is the new physics of war. Three 155 mm shells, linked together and
combined with 100 pounds of Semtex plastic explosive, covered by
canisters of butane or barrels of gasoline, can upend a 70-ton tank,
destroy a Humvee or blow an engine block through the hood of a truck.
Those deadly ingredients form the signature weapon of the war in Iraq:
improvised explosive devices, known by anybody who watches the news as
IEDs.
Some of the impact of these roadside bombs is brutally clear: Troops are
maimed by projectiles, poisoned by clouds of bacteria-laced debris and
burned by post-blast flames. But the IEDs have added a new dimension to
battlefield injuries: injuries and even deaths among troops who have no
external signs of trauma but whose brains have been severely damaged.
Iraq has brought back one of the worst afflictions of World War I trench
warfare: shell shock. The brain of a soldier exposed to a roadside bomb
is shocked, truly.
About 1,800 U.S. troops, according to the Department of Veterans
Affairs, are suffering from traumatic brain injuries caused by
penetrating wounds. But neurologists worry that hundreds of thousands
more — at least 30 percent of the troops who have engaged in active
combat for four months or longer in Iraq and Afghanistan — are at risk
of potentially disabling neurological disorders from the blast waves of
IEDs and mortars, without suffering a scratch.
For the first time, the U.S. military is treating more head injuries
than chest or abdominal wounds, and it is ill-equipped to do so.
According to a July 2005 estimate from Walter Reed Army Medical Center,
two-thirds of all soldiers wounded in Iraq who don't immediately return
to duty have traumatic brain injuries.
Here's why IEDS carry such hidden danger. The detonation of any powerful
explosive generates a blast wave of high pressure that spreads out at
1,600 feet per second from the point of explosion and travels hundreds
of yards. The lethal blast wave is a two-part assault that rattles the
brain against the skull. The initial shock wave of very high pressure is
followed closely by a huge volume of displaced air flooding back into
the area, again under high pressure. No helmet or armor can defend
against such a massive wave front.
It is these sudden and extreme differences in pressures — routinely
1,000 times greater than atmospheric pressure — that lead to significant
neurological injury. Blast waves cause severe concussions, resulting in
loss of consciousness and obvious neurological deficits such as
blindness, deafness and mental retardation. Blast waves causing
traumatic brain injuries can leave a 19-year-old who could easily run a
six-minute mile unable to stand or even to think.
New kind of injuries
Blast-related brain injuries differ from other severe head traumas, and
the complexity of treating returning troops with "closed-head" injuries
is taxing an already overburdened military health care system. There is
not a neurosurgeon who works in a trauma unit anywhere in the United
States who doesn't know what to do when an ambulance brings in a biker
who has suffered a severe head injury in a highway accident. The
standard care involves using calcium channel blockers to protect damaged
nerve cells against further injury, intravenous diuretics to control
brain swelling and, if the swelling becomes too great, removal of the
top of the skull to allow the brain to swell without increasing
neurological damage.
All this works with the common types of severe head injuries, but it
does not work with brains damaged by shock waves. There is a growing
understanding within the neurosurgical community that blast injuries are
different from those caused by penetrating or skull-fracture trauma. It
is thought that shock waves damage the brain at a microscopic,
subcellular level. That's why surgeons who are quite capable of
reconstructing the skull of a motorcycle crash victim — something for
which they have been well-trained — struggle to come up with treatment
and rehabilitation techniques for the explosion-damaged brains of
troops.
Traumatic brain injuries from Iraq are different, said P. Steven Macedo,
a neurologist and former doctor at the Veterans Administration.
Concussions from motorcycle accidents injure the brain by stretching or
tearing it, he said. But in Iraq, something else is going on.
"When the sound wave moves through the brain, it seems to cause little
gas bubbles to form," Macedo said. "When they pop, it leaves a cavity.
So you are littering people's brains with these little holes."
Almost as daunting as treating traumatic brain injuries is the number of
such injuries coming out of Iraq. Macedo cited the estimates, gleaned at
seminars with VA doctors, that as many as one-third of all combat forces
are at risk of traumatic brain injuries. Military physicians have
learned that significant neurological injuries should be suspected in
any troops exposed to a blast, even if they were far from the explosion.
Indeed, soldiers walking away from IED blasts have discovered that they
often suffer memory loss, short attention spans, muddled reasoning,
headaches, confusion, anxiety, depression and irritability.
What's baffling is the Pentagon's failure to work with Congress to
provide a steady stream of funding for research on traumatic brain
injuries. Meanwhile, the high-profile firings of top commanders at
Walter Reed have shed light on the woefully inadequate treatment for
troops. In these circumstances, soldiers face a struggle to get the
long-term rehabilitation necessary for treatment of a traumatic brain
injury. At Walter Reed, Macedo said, doctors have chosen to medicate
most brain-injured patients, even though cognitive rehabilitation,
including brain teasers and memory exercises, seems to hold the most
promise for dealing with the disorder.
No way to live
Oddly enough, having so many military patients that they can't all be
adequately treated is, in terms of warfare, a gruesome kind of success.
These are the war's injured who once would have been the war's dead. And
it is the unexpected number of casualties who in a previous medical era
would have been fatalities that has sunk the outpatient clinics at
Walter Reed and left those in the VA system lost and adrift.
In Iraq and Afghanistan, the ratio of wounded service members to
fatalities is 16 to 1, if the definition of "wounded" is anyone
evacuated from a combat zone. During the Vietnam War, according to the
VA, the ratio was 2.6 to 1.
U.S. troops no longer die from the kind of injuries that killed
thousands in Vietnam. If you'd had an arm or leg blown off in Vietnam,
the chances were that you had also suffered a penetrating chest or
abdominal wound and would bleed to death waiting to be taken to the
nearest surgical hospital. But if the bleeding could be staunched and
you were still breathing when the medics got to you, the odds on
survival were in your favor.
It wasn't until October 1993, when a U.S. combat assault team rappelled
down from a helicopter into a 72-hour gunfight in the streets of
Mogadishu, Somalia, that the notion of military medicine changed from
basic life support to intensive care. In that siege situation, medics
had no choice but to care for a growing number of wounded on their own,
because evacuation was impossible. But without clear intensive-care
procedures, they ran out of medications and fluids to treat the most
severely injured.
In the civilian world, trauma medicine had progressed throughout the
1970s and '80s, well past the simple expedients of tourniquet, plasma
and keeping an airway open. Mogadishu forced the military to abandon the
last of its medical practices from Vietnam.
Pentagon officials increased the training period for a combat medic from
10 to 16 weeks. Medics today learn new intensive-care techniques, use
better-designed tourniquets and bandages, and administer the latest
nonopiate painkillers, which, unlike morphine and Demerol, do not slow
breathing. Iraq is the first war in which troops are very unlikely to
die if they're still alive when a medic arrives.
Another large part of the 16-to-1 wounded-to-fatality ratio has to do
with advances in body armor. Today's body armor is dramatically
effective in preventing fatal wounds of the chest and upper abdomen.
There is not a surgeon in Iraq or Afghanistan who hasn't been astonished
the first time a soldier with two missing limbs and a traumatic brain
injury is carried off a chopper and the surgeon removing the armor
cannot find a scratch from the chin to the groin.
But the unseen damage can be long-lasting. Most of the families of
wounded service members that I have interviewed months, if not years,
after the injury say the same thing: "Someone should have told us that
with these closed-head injuries, things would not really get all that
much better."
Now in its fifth year, the Iraq conflict is not a war of death for U.S.
troops nearly so much as it is a war of disabilities. The symbol of this
battle is not the cemetery but the orthopedic ward and the neurosurgical
unit.
The men and women inside those units have come home alive but missing
arms and legs, many unable to see or hear or remember who they were
before being hit by a roadside bomb.
Survival clearly represents as much of a revolution in military medicine
as does the dominance of the suicide bomber and the roadside bomb. But
now both the medical profession and the country are left to play a
terrible game of catch-up.
Ronald Glasser is a pediatric nephrologist and author of 'Wounded:
Vietnam to Iraq.' From 1968 to 1970, he was deployed at an Army hospital
in Japan, treating soldiers wounded in Vietnam.
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Larry Scott --
