Brain Injuries Remain Undiagnosed in Thousands of Soldiers - Part One

T. Christian Miller | 6/8/2010, 12:29 p.m.

Part One of Two

The military medical system is failing to diagnose brain injuries in troops who served in Iraq and Afghanistan, many of whom receive little or no treatment for lingering health problems, an investigation by ProPublica and NPR has found.

So-called mild traumatic brain injury has been called one of the wars' signature wounds. Shock waves from roadside bombs can ripple through soldiers' brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.

Officially, military figures say about 115,000 troops have suffered mild traumatic brain injuries since the wars began. But top Army officials acknowledged in interviews that those statistics likely understate the true toll. Tens of thousands of troops with such wounds have gone uncounted, according to unpublished military research obtained by ProPublica and NPR.

"When someone's missing a limb, you can see that," said Sgt. William Fraas, a Bronze Star recipient who survived several roadside blasts in Iraq. He can no longer drive, or remember simple lists of jobs to do around the house. "When someone has a brain injury, you can't see it, but it's still serious."
In 2007, under enormous public pressure, military leaders pledged to fix problems in diagnosing and treating brain injuries. Yet despite the hundreds of millions of dollars pumped into the effort since then, critical parts of this promise remain unfulfilled.

Over four months, we examined government records, previously undisclosed studies, and private correspondence between senior medical officials. We conducted interviews with scores of soldiers, experts and military leaders.

Among our findings:
From the battlefield to the home front, the military's doctors and screening systems routinely miss brain trauma in soldiers. One of its tests fails to catch as many as 40 percent of concussions, a recent unpublished study concluded. A second exam, on which the Pentagon has spent millions, yields results that top medical officials call about as reliable as a coin flip.

Even when military doctors diagnose head injuries, that information often doesn't make it into soldiers' permanent medical files. Handheld medical devices designed to transmit data have failed in the austere terrain of the war zones. Paper records from Iraq and Afghanistan have been lost, burned or abandoned in warehouses, officials say, when no one knew where to ship them.

Without diagnosis and official documentation, soldiers with head wounds have had to battle for appropriate treatment. Some received psychotropic drugs instead of rehabilitative therapy that could help retrain their brains. Others say they have received no treatment at all, or have been branded as malingerers.

In the civilian world, there is growing consensus about the danger of ignoring head trauma: Athletes and car accident victims are routinely tested for brain injuries and are restricted from activities that could result in further blows to the head.

But the military continues to overlook similarly wounded soldiers, a reflection of ambivalence about these wounds at the highest levels, our reporting shows. Some senior Army medical officers remain skeptical that mild traumatic brain injuries are responsible for soldiers' troubles with memory, concentration and mental focus.

Civilian research shows that an estimated 5 percent to 15 percent of people with mild traumatic brain injury have persistent difficulty with such cognitive problems.

"It's obvious that we are significantly underestimating and underreporting the true burden of traumatic brain injury," said Maj. Remington Nevin, an Army epidemiologist who served in Afghanistan and has worked to improve documentation of TBIs and other brain injuries.

"This is an issue which is causing real harm. And the senior levels of leadership that should be responsible for this issue either don't care, can't understand the problem due to lack of experience, or are so disengaged that they haven't fixed it."

When Lt. Gen. Eric Schoomaker, the Army's most senior medical officer, learned that NPR and ProPublica were asking questions about the military's handling of traumatic brain injuries, he initially instructed local medical commanders not to speak to us.

"We have some obvious vulnerabilities here as we have worked to better understand the nature of our soldiers' injuries and to manage them in a standardized fashion," he wrote in an e-mail sent to bases across the country. "I do not want any more interviews at a local level."

When confronted with the findings later, however, he acknowledged shortcomings in the military's diagnosing and documenting of head traumas.
"We still have a big problem and I readily admit it," said Schoomaker, the Army's surgeon general. "That is a black hole of information that we need to have closed."

Brig. Gen. Loree Sutton, who oversees brain injury issues for the Pentagon, said the military had made great strides in improving attitudes towards the detection and treatment of traumatic brain injury. The military is considering implementing a new policy to mandate the temporary removal from the battlefield of soldiers exposed to nearby blasts. Later this year, the Pentagon expects to open a cutting-edge center for brain and psychological injuries, which will treat about 500 soldiers annually.

"This journey of cultural transformation, it is a journey not for the faint of heart," Sutton said. "At the end of our journeys, at the end of our travels, what we must ensure is, we must ensure that we have consistent standards of excellence across the board. Are we there yet? Of course we're not there yet."

Soldiers like Michelle Dyarman wonder what's taking so long. Dyarman, a former major in the Army reserves, was involved in two roadside bomb attacks and a Humvee accident in Iraq in 2005. Today, the former dean's list student struggles to read a newspaper article. She has pounding headaches. She has trouble remembering the address of the farmhouse where she grew up in the hills of central Pennsylvania.

For years, Dyarman fought with Army doctors who did not believe that she was suffering lasting effects from the blows to her head. Instead, they diagnosed her with an array of maladies from a headache syndrome to a mood disorder.

"One of the first things you learn as a soldier is that you never leave a man behind," said Dyarman, 45. "I was left behind."

In 2008, after Dyarman retired from the Army, Veterans Affairs doctors linked her cognitive problems to her head traumas.
Dyarman has returned to her civilian job inspecting radiological devices for the state, but colleagues say she turns in reports with lots of blanks; they cover for her.

Dyarman's 67-year-old father, John, looks after her at home, balancing her checkbook, reminding her to turn the oven on before cooking. The joyful, bright child he raised, the first in the family to attend college, is gone, forever gone.

"It hurts me, too," he said, growing upset as he spoke. "That's my daughter sitting there, all screwed up. She's not the kid she was."

Walkie Talkies

Better armor and battlefield medicine mean troops survive explosions that would have killed an earlier generation. But blast waves from roadside bombs, insurgents' most common weapon, can still damage the brain.

The shock waves can pass through helmets, skulls and through the brain, damaging its cells and circuits in ways that are still not fully understood. Secondary trauma can follow, such as sending a soldier tumbling inside a vehicle or hurling into a wall, shaking the brain against the skull.
Not all brain injuries are alike. Doctors classify them as moderate or severe if patients are knocked unconscious for more than 30 minutes. The signs of trauma are obvious in these cases and medical scanning devices, like MRIs, can detect internal damage.

But the most common head injuries in Iraq and Afghanistan are so-called mild traumatic brain injuries. These are harder to detect. Scanning devices available on the battlefield typically don't show any damage. Recent studies suggest that breakdowns occur at the cellular level, with cell walls deteriorating and impeding normal chemical reactions.

Doctors debate how best to categorize and describe such injuries. Some say the term mild traumatic brain injury best describes what happens to the brain. Others prefer to use concussion, insisting the word carries less stigma than brain injury.
Whatever the description, most soldiers recover fully within weeks, military studies show. Headaches fade, mental fogs clear and they are back on the battlefield.

For a minority, however, mental and physical problems can persist for months or years. Nobody is sure how many soldiers who suffer mild traumatic brain injury will have long-term repercussions. Researchers call the 5 percent to 15 percent of civilians who endure persistent symptoms the "miserable minority."

A study published last year in the Journal of Head Trauma Rehabilitation found that, of the 900 soldiers in one battle-hardened Army brigade who suffered brain injuries, most of them mild, almost 40 percent reported having at least one symptom weeks or months later. The long-term effects of mild traumatic brain injuries can be devastating, belying their name. Soldiers can endure a range of symptoms, from headaches, dizziness and vertigo to problems with memory and reasoning. Soldiers in the field may react more slowly.

Once they go home, some commanders who led units across battlefields can no longer drive a car down the street. They can't understand a paragraph they have just read, or comprehend their children's homework. Fundamentally, they tell spouses and loved ones, they no longer think straight.
Such soldiers are sometimes called "walkie talkies" -- unlike comrades with missing limbs or severe head wounds, they can walk and talk. But the cognitive impairments they face can be severe.

"These are people who go on to live" with "a lifelong chronic disability," said Keith Cicerone, a leading researcher in the field. "It is going to be terrifically disruptive to their functioning."

An increasing number of brain-injury specialists say the best way to treat patients with lasting symptoms is to get them into cognitive rehabilitation therapy as soon as possible. That was the consensus recommendation of 50 civilian and military experts gathered by the Pentagon in 2009 to discuss how to treat soldiers.

Such therapy can retrain the brain to compensate for deficits in memory, decision-making and multitasking.
A soldier whose injuries are not diagnosed or documented misses out on the chance to get this level of care -- and the hope for recovery it offers, say veterans advocates, soldiers and their families.

"Talk is cheap. It is easy to say we honor our servicemen," said Cicerone, who has helped the military develop recommendations for appropriate treatments for soldiers with brain injuries. "I don't think the services that we are giving to those servicemen honors those servicemen."

Missing Records

The military's handling of traumatic brain injuries has drawn heated criticism before.
ABC News reporter Bob Woodruff chronicled the difficulties soldiers faced in getting treatment for head traumas after recovering from one himself, suffered in a 2006 roadside bombing in Iraq. The following year, a Washington Post series about substandard conditions at Walter Reed Army Medical Hospital described the plight of several soldiers with brain injuries.

Members of Congress responded by dedicating more than $1.7 billion to research and treatment of traumatic brain injury and post-traumatic stress, a psychological disorder common among soldiers returning from war. They passed a law requiring the military to test soldiers' cognitive functions before and after deployment so brain injuries wouldn't go undetected.

End of Part One