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BATTLEFIELD BRAIN INJURIES DEFY EASY DETECTION --

Mark Palmquist first noticed his memory problems

while reciting nursery rhymes with his son.

 

 

Story here... http://pressherald.mainetoday.com/
news/state/070513brains.html

Story below:

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Battlefield brain injuries defy easy detection

By BART JANSEN, Washington D.C. Correspondent Maine

Mark Palmquist first noticed his memory problems while reciting nursery rhymes with his son. The former Marine sergeant couldn't remember where Jack and Jill were heading, or what they'd do once they got there.

Years after he left the Marines -- and a decade after his helicopter was shot down in Panama -- testing revealed the hidden effects of Palmquist's head injury. Difficulty with math. Memory loss.

"It's very frustrating," said Palmquist, 40, of Augusta. "I can't remember nursery rhymes to save my life."

Doctors made the diagnosis: traumatic brain injury, a debilitating ailment that can lurk unrecognized for years. TBI is cropping up more frequently in soldiers fighting in Iraq and Afghanistan, where the concussive force of roadside explosions can harm soldiers' brains even when they're wearing helmets and body armor.

Because it is often difficult to detect, soldiers can go a decade without realizing something is seriously wrong.

"Traumatic brain injury is one of the signature injuries of this conflict," Veterans Affairs Secretary Jim Nicholson said. "Many of them would not have survived in other wars. They're coming back to us, though, with these serious brain injuries."

Thousands of troops have been diagnosed, but officials warn that the total could be many times higher.

The expanding problem has prompted the Pentagon to do better at tracking soldiers who have been nearby when bombs explode. Congress is poised to add millions for treatment in a pending emergency spending bill.

"Closed-brain injury and mild traumatic brain injury are often missed, especially if the service member has an external injury such as a burn or other life-threatening condition that requires immediate medical attention," said Rep. Mike Michaud, D-Maine, chairman of the Veterans Affairs health subcommittee.

Doctors, patients and their advocates are groping for better ways to diagnose and treat the injuries. But as Palmquist's experience shows, the damage can elude detection until a soldier leaves the service, and it can require a variety of treatments.

Damage to different parts of the brain causes different problems, from immobility to memory loss to depression. Even after diagnosis, medication and physical therapy vary.

Defense Secretary Robert Gates said the Pentagon is going to screen every returning service member for exposure to blasts or accidents that might have resulted in traumatic brain injury, but he noted that there is no clear diagnostic standard in either military or civilian medicine.

The number of diagnoses is growing as the number of combat injuries increases -- and because tracking is improving.

A recent Army study found that 18 percent of troops who have been to Iraq likely suffered at least some brain damage from the blasts of improvised explosive devices. The military formally diagnosed 2,121 cases of traumatic brain injury from October 2001 through January 2007, according to the Defense and Veterans Brain Injury Center. But these injuries account for only a fraction of the 25,320 wounded in Iraq and Afghanistan through March 26, and from October 2001 through November 2006, 229,015 U.S. military veterans have sought health care of some kind.

Lt. Gen. Steven Blum, who commands the National Guard, has warned that seven of 10 soldiers injured in Iraq are hurt by IEDs, and that could lead to traumatic brain injury down the road.

"If they don't kill them, they may look absolutely perfect and whole, but they may have soft-tissue brain damage that is tough to detect unless you really knew that person extremely well and knew how they would think and react," Blum told Congress last month.

The injuries often lack bullet or shrapnel wounds. The force of the explosion itself -- or that of being knocked against a truck or building by a blast -- can jar the brain inside the skull.

"There is a great deal of force with it," said Dr. Bruce Sigsby, a Rockport neurologist who has treated a few soldiers with brain injuries. "Because of the helmet and other body armor, you may not have a laceration. Yet you still have injured the brain. It's basically hitting up against the skull."

Another difficulty in diagnosing the injuries is that many of the symptoms overlap or sound like post-traumatic stress syndrome or other ailments. And soldiers are often reluctant to volunteer information about head injuries.

"It may get passed off as the soldier being burned out or a troublemaker," Sigsby said.

Symptoms include pain, weakness, seizures, dizziness, fatigue, gaps in attention and memory loss. Emotional issues include depression, anxiety and irritability.

DIFFICULT TO TREAT

The case of Army Spec. Evan Mettie, who was injured in Iraq by a suicide bomber on Jan. 1, 2006, shows how difficult it is to treat traumatic brain injury.

Doctors in Balad, Iraq, removed shrapnel from Mettie's brain, and he soon arrived at Bethesda Naval Hospital, where he spent 86 days in the intensive-care unit.

Since then, Mettie, of Selah, Wash., has spent time at various Veterans Affairs and skilled-nursing facilities, where his progress has been mixed, his mother said.

While he was still in a coma, his therapy began in the form of rubbing his arm against something rough several times a day to determine his reaction. Later, he could move his arms and toes, giving him a means to occasionally respond to yes-or-no questions.

He'd smile sometimes.

"He understands. He's hearing what we're saying," Denise Mettie said. "We're trying to find a consistent yes-no response so that he can communicate to us what he needs."

Meanwhile, doctors have experimented with medications. Ritalin, which is typically used to treat hyperactivity, can stimulate the brain, and Ambien, a sleeping pill, actually can rouse a person from a coma.

But trauma centers, such as one in Palo Alto, Calif., where the Metties have stayed since November, are reluctant to treat him for longer than a few months. And Mettie's results were inconsistent enough that doctors started withdrawing drugs and backing off therapies on Feb. 1, Denise Mettie said.

"At that point, we saw a regression," she said. "He's just regressed so that he's back to just about where he was when we came in."

Mettie, 23, recently transferred into an intense six-week program at a New Jersey facility to investigate which therapies work best.

Then he probably will head to another skilled-nursing facility, until his parents are able to renovate their home in Washington to accommodate him and his wheelchair.

Denise Mettie, who has testified before Congress on the issue, suggested that the Pentagon and the Department of Veterans Affairs create a single center to screen all patients with traumatic brain injury, using the best technology. Palo Alto offers rehabilitation, but the center also serves older vets who have suffered strokes or need knee replacements.

"Everybody who's been in a TBI setting knows how overwhelming it is and how much work they need, and (Palo Alto) just doesn't have the therapists and the staff to go around to cover everything," she said.

The national spotlight focused on traumatic brain injury when ABC News anchor Bob Woodruff talked about his case. He had been riding in an Iraqi army tank on Jan. 29, 2006, when a bomb exploded.

Woodruff was comatose for 36 days and emerged unable to recall the names of his 6-year-old twin daughters. His room was two doors down from Mettie's, Denise Mettie said.

After a year of treatment, Woodruff described his recovery in a prime-time special in February. He still searches for words and occasionally becomes confused.

"If it had not been for Bob coming out with his story, we would still be back where we were," Denise Mettie said.

CONGRESS TAKES NOTICE

The subject is beginning to command more attention on Capitol Hill.

At an April 12 hearing of the Veterans Affairs and Armed Services committees, Sen. Susan Collins, R-Maine, noted her discussions with Sigsby, the Rockport neurologist, about misdiagnosed injuries.

"He believes our armed forces need to do a far better job screening our soldiers, Marines, and sailors in Iraq and Afghanistan when they come back stateside as a post-deployment medical examination," Collins said.

David Chu, the Defense Department's undersecretary for personnel, said the Pentagon now tracks all soldiers with concussions to determine whether to flag them for potential brain injuries.

The military also is revising its post-deployment health assessment, and the Department of Veterans Affairs is evaluating every veteran.

In August 2006, the Pentagon started to more carefully track service members exposed to battlefield explosions as long as they are in uniform. But patients, their families and advocates say that symptoms might not appear until long after a soldier returns home, as was the case with Palmquist.

"TBI is often an invisible wound, but battlefield tracking would shine a light on possible exposures earlier so we can get people the help they need sooner," said Sen. Patty Murray, D-Wash., a member of both the Veterans Affairs and Appropriations committees.

V.A. Secretary Nicholson announced in February that starting this spring, all 155 Veterans Affairs medical centers would offer Iraq and Afghanistan veterans screening for traumatic brain injury, because some soldiers with such injuries might not be aware of it.

An Army task force studying traumatic brain injury is scheduled to submit recommendations for improving care by May 17.

Lawmakers are starting to urge that greater attention -- and funding -- be paid to the subject. The $95 billion emergency spending bill pending in Congress includes $50 million for trauma centers, $100 million for mental-health care and $870 million to fix problems unearthed at veterans facilities across the country.

Michaud praised the Veterans Administration for bolstering its trauma centers and tracking patients better, but he warned that the agency must develop a robust program to diagnose the injuries.

"TBI does not go away, and we will need to provide care for these individuals throughout their lifetime," Michaud said.

Collins joined Sen. Hillary Clinton, D-N.Y., in proposing $3.75 million for the defense secretary to create a computer-based system to measure cognitive function before and after deployment. The proposal also would provide training for relatives forced to care for soldiers suffering from traumatic brain injury, with the Department of Veterans Affairs reimbursing them for the care.

"I just think that we have so much to learn about diagnosing and treating traumatic brain injury," Collins said. "It can have terrible and lasting impacts."

A DIFFICULT LABEL

That was the case for Palmquist, who doesn't remember much about his injury during the fighting in Panama in late 1989. He was riding in a Huey helicopter when a rocket-propelled grenade downed the aircraft.

"I just remember waking up and having a corpsman working on me," Palmquist said. "The residual effects were not actually seen on my exit. I wasn't diagnosed as I left."

He returned to full duty after healing from more obvious injuries to his back and head.

"Marines are Marines. They go back to duty," Palmquist said. "We don't like to be labeled sick-bay commandos."

A decade later, a counselor in vocational rehabilitation found that Palmquist wasn't doing as well with college classes as he had before the injury. His writing wasn't up to snuff, and he had trouble remembering his phone number and balancing a checkbook.

He was able to earn a bachelor's degree in political science and a master's degree in public administration from Northern Michigan University. The school offered veterans help in the form of reading assistance and extra time to take tests, which Palmquist said he declined.

"I didn't want to have special treatment because I didn't like being labeled," he said.

Palmquist, who is now a patient advocate at Togus Veterans Affairs Medical Center, swims and has healthy eating habits. Some of his strategies for coping with his injury include jotting down reminders in a notebook.

Singing "Jingle Bells," for instance, means jotting down the lyrics.

Palmquist's 8-year-old son, Jordan, helps remember what to get at the grocery store as they walk up and down the aisles.

"He'll say, 'We need to get this. We forgot this,'" Palmquist said.

The national spotlight focused on traumatic brain injury when ABC News anchor Bob Woodruff talked about his case. He had been riding in an Iraqi army tank ... when a bomb exploded ... was comatose for 36 days and emerged unable to recall the names of his 6-year-old twin daughters.

 

BRAIN INJURY STATISTICS

EACH YEAR, approximately 1.4 million people in the United States suffer a traumatic brain injury. Of those, 1.1 million are treated and released from a hospital emergency room and 235,000 are hospitalized. About 50,000 die.

ABOUT 75 PERCENT of traumatic brain injuries reported in 2003 were relatively mild, such as concussions. Repeated mild traumatic brain injuries -- even over a period of years -- can cause cognitive deficits. Repeated mild brain injuries over a short period can be fatal.

AN ESTIMATED 55.3 million people in the United States are suffering from the results of a taumatic brain injury and need help in daily living.

LEADING CAUSES
FALLS: 28 percent

TRAFFIC ACCIDENTS: 20 percent

COLLISIONS: With stationary or moving objects -- 19 percent

ASSAULTS: 11 percent

UNKNOWN: 9 percent

OTHER: 7 percent

NON-MOTORIZED CYCLES: 3 percent

HIGH-RISK GROUPS

MALES: Are at twice the risk of females.

CHILDREN: Up to age 4, teens age 15-19.

ELDERLY: Those 75 or older have the highest rate of hospitalization and death from traumatic brain injuries.Data from 2004unless noted.

Source: Centers for Disease Control and Prevention

 

Washington D.C. Correspondent Bart Jansen can be contacted at (202) 488-1119 or at:
bjansen@pressherald.com

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Larry Scott  --