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Delayed TBI diagnoses inspire a mission

LANDSTUHL, Germany — It took nearly three years for the Army to understand the damage to Army Sgt. Chad Joiner’s brain after a roadside explosion left him unconscious in a Humvee on June 28, 2005.

He finished his tour and returned home, struggled with headaches and memory loss, went back to Iraq and survived another bombing in February that aggravated his symptoms.

Only after arriving here at the Army’s Landstuhl Regional Medical Center with an ankle injury in February did a new and aggressive screening program finally identify Joiner’s brain injury and lead to treatment.

“I’m just in shock that somebody is figuring out what’s wrong with me,” said Joiner, 26, adding that his gratitude for the treatment outweighs any bitterness over the delay in diagnosing his injury.

The Pentagon debated for years whether to systematically screen troops for brain injuries such as Joiner’s. A recent study by Rand Corp., a research group, said such injuries could have affected 320,000 Iraq and Afghanistan war veterans. Uncertain how aggressively to identify a wound that is still largely a mystery, the Pentagon initially resisted calls to screen all service members coming off the battlefield. Under pressure from Congress, the Pentagon in March ordered all military branches to screen for traumatic brain injury.

By then, doctors at this key Army hospital — through which all war casualties pass on their way home — already had begun to check each of the wounded for a brain injury in an effort that could set new standards for whether such troops ever return to duty.

“One of the things we’ve learned here at Landstuhl is you have to be actively looking for this to find it,” said Col. Stephen Flaherty, who oversees the TBI screening process here.

If there is the slightest indication that a service member is suffering TBI, he or she is almost certain to be kept from returning to combat. During the past six months, only two out of several hundred troops diagnosed with mild TBI have been allowed to return to the war, doctors here said.

The aggressive monitoring developed in Landstuhl could produce valuable information about how best to spot and treat brain injuries, the doctors said.

“If I have a hint of a whiff of a suspicion — no matter how vehemently you want to go back downrange [to Iraq] — that you will be compromised, then I’ve got to be the black hat and say, ‘No, you’re not going back,’” said Maj. Shawna Scully, a neurologist who directs TBI recovery. “I’m sure there are some commanders downrange who are furious with me because I didn’t take X soldier and send them back.”

Before the aggressive screening for brain injuries here, doctors at only a few military sites — most notably, Fort Carson, Colo. — and Department of Veterans Affairs hospitals screened for TBI.

However, a debate is growing within military medicine about mild TBI and aggressive screening efforts.

Army Col. Charles Hoge, a psychiatrist and epidemiologist who has conducted landmark research on post-traumatic stress disorder, published a controversial study in the New England Journal of Medicine this year, arguing that the screening can lead to misdiagnosis. He argued that any lingering symptoms are often the result of PTSD.

Landstuhl screening began on a limited basis in 2006, and it was expanded during the past year.

New arrivals now are asked about ways they were hurt and symptoms such as headaches, nausea, dizziness, light sensitivity and balance problems. Short-term memory and problem-solving skills are tested. They can receive a neuropsychological exam, an MRI and hearing and eyesight evaluations.

Doctors at Landstuhl have identified 2,391 brain-injured troops since 2006, most of them hurt by a blast. Such casualties make up 15 percent of all who arrived at the hospital.

‘We may seem normal’

Army Spc. Kyle Thompson, 19, and Pfc. Chad Williams, 21, slowly make their way to a lunch of tuna sandwiches in the hospital’s Subway restaurant. They are two of what Scully calls her “ghosts.”

“They’re the ones who are walking, talking. They look fine. But you spend a little bit of extra time with them and you realize that something isn’t right,” she said. “They’re the ones who are easy to miss.”

Twelve days after being flattened by the shock wave of a 2,000-pound bomb, neither soldier has a scratch, at least on the outside.

But Thompson, who earned a Ranger tab at 18 and could do 22 chin-ups at a time, walks stiffly. He leans against walls or counters to keep his balance.

Williams wears protective sunglasses because lights have hurt his eyes since the blast. The explosion also left him cross-eyed.

The two were among 18 soldiers wounded (another was killed) when a suicide-truck bomber detonated explosives June 8 at the gate of a patrol base in Kirkuk, Iraq.

They were 50 to 60 feet from the blast: Thompson was walking across the compound; Williams was packing gear in his room. Thompson was left unconscious. Williams was thrown across the room and struck by a heavy door, causing him to black out briefly.

They eventually were identified as brain-injury patients and sent to Landstuhl.

“We may seem normal,” Thompson said, “but we get headaches that are crazy. Neither of us can get a wink of sleep unless we’re heavily medicated. First couple of days after the incident, I couldn’t walk. I didn’t have the ability to stand up on my own without help.”

The two said they are frustrated to be casualties of some strange invisible wound and feel betrayed by their mental faculties.

“I would have much rather gotten shot,” Williams said. “Cuts and scars heal. But if you get knocked around in the head too many times, you could end up disabled. That’s not what I want.”

Here at Landstuhl, Scully emphasizes allowing the brain to begin healing by easing headaches, re-establishing sleep patterns and reducing anxiety through knowledge about the injury.

“I felt lost until we got here,” Williams said.

At Landstuhl, “everything was explained to us.”

“When these folks come to me, there is one thought on their mind. And that is, ‘What the heck is going on?’” Scully said. “When your brain is hit that hard, you can’t depend on you anymore. That has them upset. That has them scared. And that has them wondering, ‘Where do I go from here?’”

Returning to battle

“I don’t want to do anything else but be a soldier for as long as I can be,” Joiner said.

After surviving two bomb blasts, his future is unclear. While the military has made advances in preventing and treating brain injury, there is no policy on how many brain injuries is too many to continue serving. When service members appear to score well on problem-solving and short-term memory tests, they are deemed fit for combat.

“I think one [injury] is too many,” Scully said. “Am I in a place to make that policy? No.”

This has been an area of intense discussion, military medical officials said. Many compare the injury to sports concussions.

“Making a decision on whether that soldier should take a knee and step out of the battle so that they can recover — not unlike what a sports figure would be doing on a sports field — is our most important goal,” Army Surgeon General Lt. Gen. Eric Schoomaker said in a February press briefing.

Sideline physicians usually allow football players to resume play once symptoms abate, perhaps within days, said Julian Bailes, a neurosurgeon and sports medicine specialist who advises the Army on brain injuries.

He added that there are, however, growing concerns in football that multiple concussions leave permanent brain damage.

Boxing commissions generally require automatic suspension of a fighter for six weeks to six months depending on the severity of a knockout, said Margaret Goodman, neurologist and former ringside physician.

“Punches to the head are like interest,” she said. “You may not see anything right away. But if you let it accrue, eventually it adds up.”

The Rand Corp. study estimates the health care costs of traumatic brain injuries range from $30,000 per year for mild cases to $300,000 for moderate to severe wounds. Physicians working with this new generation of veterans worry that injury limits need to be set.

“A question has to be raised about whether or not that person should be in a combat position and exposed again,” said Harriet Zeiner, a VA neuropsychologist who works with brain-injured veterans in Palo Alto, Calif. “Each successive injury means a slower rate of recovery and a greater overall loss.”

“We do have concerns,” said Pamela Harman, a speech-language pathologist who works with Iraq and Afghanistan veterans with TBI identified through VA screening efforts at hospital in Washington, D.C. “We have had soldiers come back with 40 self-reported exposures [to blasts].”

Finding help

Joiner said he has been near seven blasts during three tours of combat. Two caused him particular trouble: the first in 2005, which left him unconscious, and the second last February.

He walked away from that second roadside explosion. The next morning, “my speech was slow, and I couldn’t concentrate,” he said. “It hurt to read. I was writing very slow. And I was just thinking to myself, ’Here I go again.’”

Though diagnosed with TBI by a battlefield medic, Joiner didn’t mention his re-emerging symptoms and eventually was returned to combat.

“I didn’t bring up to anyone about me feeling like I was slower mentally or [had] trouble concentrating,” he said. “I had felt it before and dealt with it before. I didn’t think much of it.”

Days later in February, however, when he tore ligaments in his ankle stumbling over a curb and was sent to Landstuhl, hospital screeners caught the brain injury. Joiner said he marveled at Scully’s immediate grasp of his symptoms.

“I never had anyone start taking an interest like this,” he said.

However, Scully had no answers on whether his damage is permanent.

“I can’t make up for the fact that a lot of these guys never got the care they needed,” Scully said. “But when they come to me, I can take care of them now.”