Traumatic Brain Injuries Sustained in the Afghanistan and Iraq Wars*

C L I N I CA L CA R E Traumatic Brain Injuries Sustained in the Afghanistan and Iraq Wars* Elisabeth Moy Martin, MA, RN-BC Wei C. Lu, MS, BSN Katherine Helmick, MS, CNRN, CRNP Louis French, PsyD Deborah L. Warden, MD Overview: When traumatic brain injury (TBI) occurs simultaneously with more obviously life-threatening wounds, it may go unrecognized. Civilians and military personnel working in or near combat zones are at risk for this injury. Blast-related and closed-head injuries, rather than penetrating injuries, constitute the majority of TBIs in this population. The authors describe the experiences of the Defense and Veterans Brain Injury Center team at Walter Reed Army Medical Center in Washington, DC, and present a composite case to illustrate the nurse s role in the assessment and care of the TBI patient. T raumatic brain injury (TBI) has been called the signature wound of U.S. troops serving in the wars in Afghanistan and Iraq, which have been ongoing since October 2001 and March 2003, respectively. TBI is called that because it appears to account for a larger proportion of casualties than it has in other recent U.S. wars. 1 The use of more protective equipment such as body armor and advances in battlefield care such as the establishment of combat surgical hospitals have reduced the incidences of penetrating head injuries and death. But closed-head TBIs, many resulting from explosions, continue to occur. Some experts, including one of us (DLW), have estimated the incidence of TBI among wounded soldiers to be as high as 22%.1 (Editor s note: In recent testimony before the U.S. House of Representatives, Matthew S. Goldberg, deputy assistant director for national security, stated that among all wounded troops, the incidence of TBI is about 8%.2) In particular, mild TBI, including concussion, has not been Reprinted with permission from AJN, Am J Nurs. 2008; 108(4):40 47. Copyright Lippincott Williams & Wilkins. 94 Journal of Trauma Nursing Volume 15, Number 3 well documented. In combat zones, TBI often occurs simultaneously with more obviously life-threatening injuries; therefore, cases may go unrecognized. And when TBI occurs with no outward signs of trauma, service members might not seek medical treatment. Who is at risk? As of December 2006, more than 1 million active-duty military personnel and more than 400,000 reservists (including those in the National Guard) had served since the beginning of the conflicts2 in Iraq and Afghanistan; those figures have continued to rise. In addition, many American civilians work as contract employees, providing security, construction, and food services in or near combat zones. They are also at risk for injury, including TBI. After fulfilling their military obligations or civilian contracts, many of these individuals seek health care within their home communities, presenting at outpatient clinics or EDs. Common complaints include severe headaches, difficulty sleeping, and mood swings, symptoms that may or may not be related to concussion. The Centers for Disease Control and Prevention has estimated that 5.3 million Americans are currently living with TBI-related disabilities.3 It s important that all nurses know how to use TBI screening and assessment tools effectively and implement the appropriate evidence-based interventions. BLAST-RELATED TBI Explosions and TBI When an explosion occurs, ambient pressure rises suddenly and sharply above normal, resulting in a blast wave. This has been described as having two components a shock wave of high pressure, followed closely by a blast wind, or air in motion that move rapidly outward from the point of explosion.4 As the initial overpressure wave dissipates, ambient pressure plummets, causing a pressure wave that is lower than the ambient pressure and a reverse blast wind.5 *Because these injuries can go unrecognized, nurses stateside need to know how to recognize possible cases and how to help. July September 2008

Patients rarely volunteer information on unhealthy behaviors unless they re asked. Although the pathophysiology of blast-related TBI is complex and not fully understood, it s thought that these rapid pressure changes create shear and stress forces that lead to trauma such as concussion, subdural hematoma, and diffuse axonal injury. 4,5 Some experts also believe that these pressure changes cause gaseous embolisms to form in the brain, leading to infarction. 4,5 The blast waves can move objects and people, causing penetrating injuries or blunt trauma. 4 The effects of an explosion are likely to be intensified if it occurs in a confined space, such as a vehicle, as the blast wave reflects and reverberates against nearby objects instead of dissipating. Blast injuries are categorized into four types. Primary blast injuries (described above) are caused by the blast wave. Secondary blast injuries (penetrating injuries) are caused by falling or windblown debris. Tertiary blast injuries (impact injuries) are caused by being thrown to the ground or against a stationary object. And quaternary blast injuries, such as burns, are caused by gases or heat released by the explosion. 4 (Editor s note: Among troops in Afghanistan, the Army has recently begun testing helmets with sensors that measure the energy from a blast wave and other events that could cause head trauma. It s hoped that such data will eventually help in diagnosing TBI.) Screening and assessment at the DVBIC Most military personnel who are injured in Afghanistan or Iraq are medically evacuated to Landstuhl Regional Medical Center, a U.S. Army hospital in Germany. Once their condition has stabilized, they re sent to a military hospital or treatment center in the United States for further evaluation and treatment. Most of the patients at Walter Reed Army Medical Center are inpatients. The DVBIC s TBI team there consists of nurses with master s degrees in psychiatric or neuroscience nursing, physicians, neuropsychologists, physician s assistants, and care coordinators (four of us EMM, KH, LF, and DLW have been TBI team members). The team screens patients suspected of having a TBI (either combat related or not) and reviews their medical records; this includes all wounded service members who have been injured in an explosion, a fall, or a motor vehicle accident (including helicopter crashes) or who have sustained a gunshot wound to the head, neck, or face. Anyone who was dazed or confused, saw stars, or lost consciousness, even momentarily, is evaluated for a TBI. In 1993 the American Congress of Rehabilitation Medicine (ACRM) published its definition of mild TBI. 6 With minor changes, the DVBIC incorporates part of this as a case definition of TBI: a traumatically induced physiologic disruption of brain function, as indicated by at least one of the following: any period of loss of consciousness any loss of memory of events immediately before or after the accident any alteration in mental state at the time of the accident focal neurologic deficit(s) that may or may not be transient Medics in the field currently screen troops for TBI using the Military Acute Concussion Evaluation (www.dvbic. org/pdfs/dvbic_documentation_sheet.pdf), which establishes how, where, and when the patient was injured and whether a loss of consciousness occurred. A similar tool, the 3 Question DVBIC TBI Screening Tool (www.dvbic. org/pdfs/3-question-screening-tool.pdf), as also been used stateside with troops who had not previously been assessed for TBI by medical personnel. We begin with the information culled by these tools and proceed from there. Because the ACRM s definition covered only mild TBI, the DVBIC created a severity classification system for use in confirmed cases of TBI. A case is classified as mild, moderate, or severe according to three factors: the duration of the loss of consciousness, the duration of posttraumatic amnesia, and the score on the Glasgow Coma Scale. (See Table 1, at right.) Specific queries about loss of consciousness and posttraumatic amnesia help in determining the severity of the brain injury. For example, the patient might be asked, What s the last thing you can remember clearly before the event? Do you remember hearing an explosion or seeing or smelling smoke? Did you feel dazed or confused during the event? Did you lose consciousness? Were you told by others that they couldn t wake you? What s the first memory you have after the event? Posttraumatic amnesia refers to the loss of memory of events immediately after the trauma, and sometimes during the trauma; its duration varies greatly, from seconds to days or longer. Duration is measured from the point at which memory was lost (usually upon the triggering event) to the point at which the person can again recall events clearly and chronologically. Once a patient is determined to have suffered brain injury, she or he is assessed at the bedside for common postconcussive symptoms using the Post Mild TBI Symptom Checklist, a 22-item questionnaire. 7 Symptoms can include headache, dizziness, irritability, mood changes, fatigue, sleep difficulties, memory impairment, and disordered thinking. While most people with mild July September 2008 Journal of Trauma Nursing Volume 15, Number 3 95

TABLE 1 Determining the Severity of a Traumatic Brain Injury (TBI) Glasgow Coma Loss of consciousness Posttraumatic amnesia Severity Scale (total score) (duration) (duration) mild 13 15 1 hr. 24 hrs. moderate 9 12 1 24 hrs. 24 hrs. to 7 days severe 3 8 24 hrs. 7 days or more Helmick et al. Mild traumatic brain injury in wartime. Federal Practitioner Oct. 2007; 58-65. Copyright 2007 Quadrant HealthCom Inc. All rights reserved. Reprinted with permission. TBI return to full functioning over time, transient consequences such as reduced reaction time and persistent postconcussive symptoms should be expected. 8 Many combat veterans also suffer from acute stress disorder (ASD) or posttraumatic stress disorder (PTSD); symptoms of both include nightmares, avoidance of thoughts or activities associated with the trauma, reexperiencing the trauma as if it were happening now (flashbacks), increased irritability, increased startle response, and hypervigilance. Some of these symptoms (such as irritability and sleep difficulties) are also common in TBI. Whether and how TBI and ASD or PTSD are associated is unclear. Symptom frequency and severity are assessed using the Posttraumatic Stress Disorder Checklist Civilian Version, a 17-item questionnaire. 9 If warranted, more comprehensive cognitive or neuropsychological testing and monitoring are scheduled. (For a relevant article, see PTSD in the World War II Combat Veteran, November 2003.) Few descriptions of the clinical characteristics of patients with blast-related TBI can be found in the literature. Since October 2001, more than 700 patients have been evaluated for TBI and post-tbi sequelae by DVBIC personnel at Walter Reed Army Medical Center. In 2005 DLW and colleagues reported on characteristics of the first 433 patients diagnosed with TBI there between January 2003 and April 2005. 10, 11 Initial data indicated that 88% were closed-head TBIs (the rest were penetrating) and 68% were blast related. Twenty-five percent of patients had a skull fracture, 19% had a subdural hematoma, and 2% had an epidural hematoma. Nineteen percent had a limb amputation (lower-limb amputations were more common than upper-limb amputations). Of all service members, enlisted army personnel (of whom 95% are male) were found to incur TBI most often. Headache, memory deficits, irritability, attention deficits, and sleep difficulties were the most common symptoms. According to the researchers unpublished data, 51% of the closedhead TBIs were categorized as mild. Long-term follow-up of these patients will help to determine which symptoms, if any, are likely to become chronic. Treatment at the DVBIC Once a patient has been diagnosed and her or his symptoms have been characterized, the team devises a treatment plan, which includes symptom management, rest and return-to-duty guidelines, institution of specialized therapies when indicated, and patient and family education. We provide patients and families with written materials, review common post-tbi symptoms with them, and counsel patients to resume their normal activities gradually. (Early education may have protective value: one study of people with mild TBI found that those who received a booklet on post-tbi coping strategies within a week of injury had fewer symptoms three months later than those who did not. 12 ) If the patient has attention or memory deficits, we might suggest reading, starting with periods of 10 minutes twice a day and gradually increasing the duration of each session by a few minutes. Some people with TBI find that strenuous exercise triggers or worsens headaches; in such cases we might advise a moderate workout with small daily increases in intensity. When symptom management includes pharmacologic intervention, we review the medication with the patient and family. We explain that post-tbi symptoms are common and tend to resolve over time. 96 Journal of Trauma Nursing Volume 15, Number 3 July September 2008

Post-TBI symptoms can interfere with personal relationships, as well as with the patient s daily routine. Post-TBI symptoms can interfere with personal relationships, as well as with the patient s daily routine. We try to identify associations between symptoms: for example, disrupted sleep can result in daytime fatigue, leading to worsened headache pain and increased irritability, making arguments with loved ones more likely. Interventions suggested to such a patient might include minimizing ambient noise and practicing deep breathing at bedtime. Patients who are able to are encouraged to participate in a weekly support group for survivors of TBI; family members can join weekly support groups as well. (See About the Defense and Veterans Brain Injury Center, page 45.) Patients with TBI who lost consciousness for more than one hour or suffered posttraumatic amnesia for more than 24 hours symptoms indicative of moderateto-severe TBI or who have penetrating brain injuries are usually referred to a Veterans Health Administration hospital or rehabilitation facility near their home or family for further evaluation and treatment. Clinical follow-up by telephone with reassessment of symptoms and progress occurs at six and 12 months after discharge. A CASE SCENARIO John Mills, a 22-year-old junior enlisted soldier on duty in Iraq, sustained blast injuries when his vehicle ran over an explosive device. (This case, a composite based on our experiences, depicts injuries we have often seen.) Mr. Mills lost consciousness for several seconds and later recalled the event in bits and pieces. He described the explosion as a massive vibration that caused a sucking and sinking feeling, as if my brain was being split in two. He believed he was tossed into the air: It felt like my soul had jumped out of my body and was watching things happen in slow motion. He recalled trying to crawl from the vehicle, smelling something burning, and seeing his left arm hanging at his side at a strange angle. Members of his squad provided immediate first aid and called for a medical evacuation team. He drifted in and out of consciousness for about 45 minutes before being sedated for air transport to a U.S. Army hospital in Europe. This period of decreased consciousness following a brief loss of consciousness met the criteria for mild TBI. Mr. Mills s injuries included immediate below-theknee amputation of his right leg, left ulnar fracture, retinal detachment in his left eye, tympanic membrane rupture in his left ear, and burns over much of his left thigh and the left side of his face and head. He had small pieces of shrapnel embedded in his skin in exposed areas, including his face. He also developed pancreatitis and Acinetobacter bacteremia. Three days later Mr. Mills s condition had stabilized enough to permit discharge to a U.S. Army hospital stateside with a physical rehabilitation clinic. After 10 weeks, when his other wounds had healed sufficiently and his condition had further stabilized, a more comprehensive, multidisciplinary evaluation for TBI was performed; prosthesis fitting and training were also initiated. In his initial assessment interview, he reported symptoms of cognitive slowing, saying that he didn t feel as sharp as usual. He also reported short-term-memory problems (he sometimes forgot appointments or visitors) and difficulty falling asleep at night. Nurses reviewed Mr. Mills s sleep cycle with him and explained that it s common for people to have trouble sleeping after a TBI. They suggested that he limit caffeine and use relaxation techniques (such as meditation) before bedtime. To address his memory and attention difficulties, the nurses encouraged him to establish a routine schedule, write down his appointments, and keep a calendar. They also suggested reducing background noise (such as that from a television or radio) during conversations to minimize distraction. They explained what he might expect as he recovered, monitored his progress, and offered reassurance and support. Mr. Mills s mood and outlook were generally optimistic. At the time of discharge from the hospital, no further immediate nursing interventions were required. He told the nurses that once his medical discharge from the military was final, he hoped to resume his college studies. If he reports continuing cognitive difficulties at his six-month follow-up assessment, compensatory strategies will be reviewed with him. Further neuropsychological testing might be warranted. If he reports recurring headaches or mood swings, weekly monitoring by telephone may be helpful. 13,14 COORDINATING CARE It s imperative that nurses understand the immediate and longer-term effects of an explosion on the human brain. Closely working with affected patients and accurately diagnosing TBI and documenting its history and symptoms will help to improve the care of survivors. Unfortunately, little is known yet about the longer-term effects, and both follow-up and additional research are essential. First, screening for concussion should be part of care for all patients with multiple injuries. In part because mild TBI has been underrecognized in such patients, military medics and corpsmen are now being trained to evaluate for it on the battlefield, using new assessment July September 2008 Journal of Trauma Nursing Volume 15, Number 3 97

About the Defense and Veterans Brain Injury Center The Defense and Veterans Brain Injury Center (DVBIC; www.dvbic.org) is a collaboration involving eight traumatic brain injury (TBI) programs seven at Department of Defense or Department of Veterans Affairs hospitals and one at a civilian facility. The DVBIC s mission is to offer active-duty service members with TBI, their dependents, and veterans with TBI state-of-the-art health care and opportunities to participate in innovative clinical research initiatives and educational programs. Last November the DVBIC became part of the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury. This new center is part of an effort, spearheaded by the Department of Defense, to create a national collaborative network of psychological health and TBI programs. Temporarily based in Rosslyn, Virginia, it s expected to become fully operational by October 2009. Other resources: Brain Injury Association of America (800) 444-6443 www.biausa.org Department of Defense Military OneSource (800) 342-9647 www.militaryonesource.com (The Department of Defense Military Severely Injured Center, now part of Military OneSource, can be reached at [888] 774-1361.) U.S. Army Wounded Warrior Program (800) 237-1366 or (800) 833-6622 https://www.aw2.army.mil tools developed by the DVBIC. These are based on current, standardized concussion assessment guidelines, which were originally developed for use with athletes. 15 One, the aforementioned 3 Question DVBIC TBI Screening Tool, has shown promising results in a study with 596 soldiers who had recently returned from tours of duty in Iraq or Afghanistan. 16 The use of standardized tools will help to generate evidence-based guidelines on screening for and assessing TBI. Further research may yield effective, efficient interventions that can assist patients with symptom management and self-care. It s now known that psychiatric sequelae can also occur after TBI, with major depressive disorder being the most common in both civilian and military populations. 17,18 Other psychiatric diagnoses associated with TBI include generalized anxiety disorder, PTSD, bipolar disorder, and personality changes. 17,18 For example, Hoge and colleagues assessed the mental health of four groups of U.S. troops before deployment to Iraq or after deployment to Iraq or Afghanistan (the study did not include soldiers who were severely wounded and did not investigate TBI). 19 The Hoge group found significantly higher incidences of major depression, generalized anxiety, and PTSD in troops assessed after deployment to Iraq than in those assessed before deployment to Iraq or after deployment to Afghanistan (however, fewer than a third of the troops who served in Afghanistan reported being in a firefight, compared to between 71% and 86% of those who served in Iraq). They also found that only 23% to 40% of those who acknowledged having enough symptoms to meet the criteria for major depressive disorder, generalized anxiety disorder, ASD, or PTSD actually sought mental health care. One of the main barriers to care was concern about being stigmatized for seeking treatment. Similar concerns about stigmatization might prevent service members with TBI from seeking assistance. There is some evidence of an association between TBI and substance abuse, 20 but whether TBI makes substance abuse more likely is unclear; at least one review found that it did not. 17 That said, at the DVBIC we have found that patients with TBI sometimes self-medicate with alcohol or drugs in an attempt to manage distressing symptoms, which can create additional problems such as dependency or addiction. This can complicate the longer-term effects of TBI, worsening cognitive difficulties and emotional lability and interfering with sleep. It s important to provide support for patients who have mental health or substance abuse concerns in a manner and setting in which they ll feel comfortable accessing it; for example, a peer support group for service members might meet at a local diner, away from the military base. Because nurses often perform initial screenings and assessments of patients in the community, they need to know when to suspect and how to recognize TBI. This is also pertinent to understanding the effects of TBI and planning nursing interventions. Early intervention is best. The essential components of care are symptom monitoring and management; referrals for counseling or peer support and pharmacologic treatment, as appropriate; and periodic follow-up after discharge. Care coordination is particularly important, especially for patients with TBI who have cognitive difficulties, emotional lability, or both. Nurses need to understand the immediate and longer-term effects of an explosion on the human brain. 98 Journal of Trauma Nursing Volume 15, Number 3 July September 2008

Nurses should be prepared to intervene to prevent the development of unhealthy behaviors, such as substance abuse or social isolation. In our experience patients rarely volunteer information on unhealthy behaviors unless they re asked. The nurse might ask first whether the patient currently drinks alcoholic beverages. If the answer is yes, the nurse can ask, How often do you drink alcohol? and Do you have any concerns about the amount you re drinking? When possible, it s important to talk with the patient s spouse or partner, as well; sometimes that person will view the patient s behavior quite differently. Currently the number of U.S. troops in Iraq stands at about 190,000 21 and is expected to rise further. (Editor s note: Another 26,000 are deployed in Afghanistan. 22 ) Several thousand U.S. civilian and contract employees also continue to work in these countries. 23 They will eventually return home to their communities, where they may need to be evaluated and receive follow-up care. When a patient has a history of working in or near a combat zone and complains of symptoms congruent with TBI, it s essential to consider that injury a possibility. Elisabeth Moy Martin is a clinical research nurse, Wei C. Lu is a clinical research coordinator, Katherine Helmick is the deputy director of Clinical and Education Affairs, and Louis French is the clinical director, all at the Defense and Veterans Brain Injury Center (DVBIC) at Walter Reed Army Medical Center in Washington, DC. Deborah L. Warden, the national director of the DVBIC from 2001 through 2007, was also based at Walter Reed. The original manuscript submitted for publication was reviewed and approved by officials at the Walter Reed Army Medical Center and the U.S. Military Operational Security. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the U.S. government. The authors have no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity. Contact author: Elisabeth Moy Martin, lisamoymartin@yahoo.com. REFERENCES 1. Okie S. Traumatic brain injury in the war zone. N Engl J Med 2005; 352(20):2043 7. 2. Goldberg MS. CBO testimony. Statement of Matthew S. Goldberg, Deputy Assistant Director for National Security: Projecting the costs to care for veterans of U.S. military operations in Iraq and Afghanistan. Washington, D.C.: Congressional Budget Office 2007. 3. National Center for Injury Prevention and Control. Centers for Disease Control and Prevention. Traumatic brain injury. 2007. http://www.cdc. gov/ncipc/factsheets/tbi.htm. 4. DePalma RG, et al. Blast injuries. N Engl J Med 2005;352(13):1335 42. 5. Taber KH, et al. Blast-related traumatic brain injury: what is known? J Neuropsychiatry Clin Neurosci 2006;18(2):141 5. 6. Kay T, et al. Definition of mild traumatic brain injury. J Head Trauma Rehabil 1993;8(3):86 7. 7. Cicerone KD, Kalmar K. Persistent post-concussive syndrome: structure of subjective complaints after mild traumatic brain injury. J Head Trauma Rehabil 1995;10(3):1 18. 8. Warden DL, et al. Persistent prolongation of simple reaction time in sports concussion. Neurology 2001;57(3):524 6. 9. Weathers FW, et al. The PTSD Checklist Civilian Version (PCL C) for DSM-IV. Boston: National Center for PTSD, Behavioral Science Division. VA Boston Healthcare System; 1994. 10. Warden DL, et al. War neurotrauma: the Defense and Veterans Brain Injury Center (DVBIC) experience at Walter Reed Army Medical Center (WRAMC). J Neurotrauma 2005;22(10):1178. 11. Warden D. Military TBI during the Iraq and Afghanistan wars. J Head Trauma Rehabil 2006;21(5):398 402. 12. Ponsford J, et al. Impact of early intervention on outcome following mild head injury in adults. J Neurol Neurosurg Psychiatry 2002;73(3):330 2. 13. Martin EM, et al. Telephonic nursing in traumatic brain injury. Am J Nurs 2003;103(10):75 81. 14. Martin EM, Coyle MK. Nursing protocol for telephonic supervision of clients. Rehabil Nurs 2006;31(2):54 7, 62. 15. McCrea M, et al. Standardized Assessment of Concussion (SAC): manual for administration, scoring and interpretation. 2nd ed. Waukesha, WI: CNS, Inc.; 2000. 16. Schwab KA, et al. Screening for traumatic brain injury in troops returning from deployment in Afghanistan and Iraq: initial investigation of the usefulness of a short screening tool for traumatic brain injury. J Head Trauma Rehabil 2007;22(6):377 89. 17. Gordon WA, et al. Traumatic brain injury rehabilitation: state of the science. Am J Phys Med Rehabil 2006;85(4):343 82. 18. Salazar AM, et al. Cognitive rehabilitation for traumatic brain injury: a randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group. JAMA 2000;283(23):3075-81. 19. Hoge CW, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351(1): 13 22. 20. Walker R, et al. Screening substance abuse treatment clients for traumatic brain injury: prevalence and characteristics. J Head Trauma Rehabil 2007;22(6):360 7. 21. Sunshine RA. CBO testimony. Statement of Robert A. Sunshine, Assistant Director for Budget Analysis: Estimated costs of U.S. operations in Iraq and Afghanistan and of other activities related to the war on terrorism. Washington, D.C.: Congressional Budget Office 2007. 22. Associated Press. US official: military leaders believe al-qaida stepping up activities in Afghanistan. International Herald Tribune, Asia-Pacific 2007 Dec 3. http://www.iht.com/articles/ap/2007/12/03/asia/as-gen- Afghanistan-Gates.php. 23. Snyder V. Statement of subcommittee chairman Vic Snyder. Oversight and Investigations Subcommittee hearing on Benefits and Medical Care for Federal Civilian and U.S. Contract Employees Deployed to Iraq and Afghanistan. Washington, D.C.: U.S. House of Representatives 2007. July September 2008 Journal of Trauma Nursing Volume 15, Number 3 99