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CLINICS HELP VETERANS WITH BRAIN INJURIES --

Roadside bombs don't have to break

the skin to injure troops.

 

 

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Internal wounds

Clinics help veterans with brain injuries

By Joelle Farrell
Monitor staff

Roadside bombs don't have to break the skin to injure troops. The blast creates a wave of pressure that moves past a soldier's armor and through his body, the force shaking the brain. The pressure wave can travel hundreds of yards, depending on the force of the blast. A soldier may come home without a scratch but find he has trouble putting sentences together or controlling his anger.

"Each war has its own signature injury," said Dr. Tina Trudel, principal investigator of the Defense and Veterans Brain Injury Center at Virginia Neurocare, a civilian brain injury rehabilitation site. "Clearly that's where we're at with blast injuries."

Last month, the Manchester VA Medical Center started screening all combat veterans returning from Iraq and Afghanistan for traumatic brain injury, and Director Marc Levenson said he expects the Department of Veterans Affairs will have to reach out to private hospitals for help treating soldiers with the injury. Local rehabilitation centers like Crotched Mountain in Greenfield, which has treated brain injuries for 20 years, are eager to help.

"It's really what we focus on," said Donald Shumway, president of Crotched Mountain. "If there's expertise in the civilian sector, use that."

A blast can damage any part of the brain and therefore affect any function: movement, speech, personality. The most severe injuries leave veterans incapacitated, unable to speak, move, or even swallow. Even moderate injuries can cause permanent damage and seriously alter a person's life. Some soldiers don't recognize their family's faces. Others lose movement on one side of their body or can't control angry outbursts.

Since brain injuries can produce a wide array of symptoms, treatments also vary greatly, requiring treatment centers to have speech, physical and occupational therapists on hand. Recovering brain function can be a slow and arduous process that takes years, said Catherine Devaney, chief executive officer of HealthSouth Rehabilitation Hospital in Concord.

"People don't just wake up out of a coma," she said. "It's a long and difficult process. That initial care is extremely labor intensive; the patient may need two or three therapists just to get up."

Soldiers with more moderate injuries don't need to stay in a hospital, but they may have trouble returning to their lives in the community. Some struggle with simple tasks like shopping or cooking. Families may find it difficult to adjust to a soldier whose personality is markedly different following a brain injury, Trudel said.

"That's the organ that tells us how we are and how we come across in the world," she said. Brain injuries require a spectrum of physical and psychological treatment that is "much broader than what the VA was initially set up to address."

Earlier this month, the Department of Defense's Task Force on Mental Health issued an urgent warning that military health organizations may not have sufficient money or staff to deal with increasing numbers of combat veterans suffering from traumatic brain injuries and post-traumatic stress disorder. According to the task force's report, about a third of returning combat veterans suffer from one or both of the conditions.

"This is a big thing," Levenson said. "So far, we're really just scratching the surface."

Since the VA began testing veterans for traumatic brain injuries last month, 12 have shown symptoms and been referred for further treatment. But Levenson expects 8 percent of returning veterans may need some brain injury rehabilitation. So far, 1,000 returning veterans have enrolled at the VA, he said.

Multiple and extended deployments may put more troops at risk for brain injuries, Trudell said. A soldier who suffers a concussion from one blast may return to combat and have no obvious symptoms. But a second blast could re-injure the brain, causing a cumulative effect, she said.

Levenson said he has spoken to several private rehabilitation centers about the issue, including Northeast Rehabilitation Hospital in Salem and the Krempels Brain Injury Foundation in Portsmouth. HealthSouth has also contacted the VA to help.

"The head injury piece is a new disability for them to be dealing with in the short and the long term," Devaney said. "Even if it's mild, it's a life long issue."

A variety of symptoms

Local rehabilitation centers treat people who've been injured by strokes, crashes or falls. Crotched Mountain can treat brain injuries that require longer-term care and rehabilitation, although patients must be medically stable to receive treatment at the center, said Vice President Michael Redmond.

Crotched Mountain has been in communication with the Boston VA Medical Center for two years. Crotched Mountain has 31 beds for adults and treats 10 to 15 new brain injuries yearly, Redmond said. The staff includes 700 people onsite and an additional 200 who assist brain injured victims throughout the state, Redmond said.

A brain injury from a bomb can produce symptoms that resemble those of strokes and car crashes, but they have unique facets as well, said Dr. Rocco Chiappini, a physiatrist and director of the brain injury center at Crotched Mountain. If a blast causes an injury without puncturing the brain, the injury is more diffuse, and can resemble damage seen in shaken baby syndrome. Wiring in the brain is shorn and frayed when the brain is shaken, which can affect multiple movement and cognition centers in the brain, he said.

If shrapnel enters a soldier's brain, it can wipe out functioning in the area it hits, similar to stroke victims. Damage to the left side of the brain affects a person's ability to speak and understand language. A blast on the right side could damage a person's spatial orientation, making it difficult to see properly, he said.

But unlike stroke or accident victims, soldiers with brain injuries may also suffer from post-traumatic stress disorder, which can complicate treatment, Trudel said. It can be difficult for doctors to distinguish whether irritability or depression comes from stress disorder or brain injury. And if a soldier suffers from post-traumatic stress or anxiety, a blast may have damaged the centers of his brain that would help him cope with his emotions, Trudel said.

Preparing for more injuries

While the VA is bracing itself for increases in moderate brain injuries and the long-term care it may require, some in the state are also hoping that those with severe head injuries can receive treatment in the private sector in New Hampshire.

Staff Sgt. Jose Pequeno, a New Hampshire National Guard soldier seriously wounded in Iraq in March 2005, is receiving treatment in Florida because local veterans hospitals are not equipped to provide the care he needs. Pequeno, 32, a father of three and the police chief in Sugar Hill, suffered a sever head injury when insurgents attacked his humvee. He is no longer in a coma, but he hasn't been able to speak. His wife, Kelley Pequeno, said she hopes he can receive treatments closer to home once he's undergone surgery to replace part of his skull that was damaged in the blast.

Currently, veterans with the most severe head injuries are treated at veterans hospitals in Florida, Virginia, Michigan or California, Levenson said. The Boston VA Hospital can treat veterans with more moderate injuries, and the Manchester VA is limited to treating the least dramatic brain injuries, Levenson said.

But Sen. John Sununu has asked Secretary of Veterans Affairs James Nicholson to allow veterans with severe brain injuries to seek treatment at Crotched Mountain.

"New England servicemen and women who are critically injured in the line of duty, particularly with traumatic brain injuries, must often receive their care far away from home, family, and loved ones," Sununu said in a statement. "That's why I am asking Secretary Nicholson to provide guidance on how Crotched Mountain can take the necessary steps to become a civilian-partnered Defense and Veterans Brain Injury Center."

Veterans who've suffered severe head trauma usually require a lifetime of care, estimated to cost at least $3 million, said Steven Wade, Executive Director of the Brain Injury Association of New Hampshire.

The first year after a brain injury is when the most progress is usually made, doctors said. But with continued outpatient care, some have improved function even decades after their injury, Chiappini said. He recently saw a patient who'd been injured eight years earlier and was shocked to find that he was speaking more clearly than even a year earlier.

"It appears that the human brain has the ability to repair itself as long as you keep challenging it," he said.

As the wars in Iraq and Afghanistan continue, medical personnel are readying themselves for treatments that will continue long after the wars end.

"People are going to need a lifetime of care," Shumway said. "These veterans are going to need support for a very long time."

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Larry Scott  --