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Brain Injuries Remain Undiagnosed in Thousands of Soldiers - Part Two

T. Christian Miller | , Npr | , ProPublica | , Daniel Zwerdling | 6/10/2010, 12:49 p.m.

Part Two of Two

But leaders' zeal to improve care quickly encountered a host of obstacles. There was no agreement within the military on how to diagnose concussions, or even a standardized way to code such incidents on soldiers' medical records. Good intentions banged up against the military's gung ho culture. To remain with comrades, soldiers often shake off blasts and ignore symptoms.

Commanders sometimes ignore them, too, under pressure to keep soldiers in the field. Medics, overwhelmed with treating life-threatening injuries, may lack the time or training to recognize a concussion. The NPR and ProPublica investigation, however, indicates that the military did little to overcome those battlefield hurdles.

They waited for soldiers to seek medical attention, rather than actively seeking to evaluate those in blasts. The military also has repeatedly bungled efforts to improve documentation of brain injuries, the investigation found. Several senior medical officers said soldiers' paper records were often lost or destroyed, especially early in the wars. Some were archived in storage containers, then abandoned as medical units rotated out of the war zones.

Lt. Col. Mike Russell, the Army's senior neuropsychologist, said fellow medical officers told him stories of burning soldiers' records rather than leaving them in Iraq where anyone might find them.

"The reality is that for the first several years in Iraq everything was burned. If you were trying to dispose of something, you took it out and you put it in a burn pan and you burned it," said Russell, who served two tours in Iraq. "That's how things were done."

To improve recordkeeping, medics began using pricey handheld devices to track injuries electronically. But they often broke or were unable to connect with the military's stateside databases because of a lack of adequate Internet bandwidth, said Nevin, the Army epidemiologist.

"These systems simply were not designed for war the way we fight it," he said.

In 2007, Nevin began to warn higher-ups that information was being lost. His concerns were ignored, he said. While communications have improved in Iraq, Afghanistan remains a concern.

That same year, clinicians interviewed soldiers about whether they had suffered concussions for an unpublished Army analysis, which was reviewed by NPR and ProPublica. They found that the military files showed no record of concussions in more than 75 percent of soldiers who reported such injuries to the clinicians.

Nevin said that without documentation of wounds, soldiers could have trouble obtaining treatment, even when they report they can't think, or read, or comprehend instructions normally anymore.

Doctors might say, "there's no evidence you were in a blast," Nevin said. "I don't see it in your medical records. So stop complaining."

Problems documenting brain injuries continue. Russell said that during a tour of Iraq last year, he examined five soldiers the day after they were injured in a January 2009 rocket attack. The medical staff had noted shrapnel injuries, but Russell said they failed to diagnose the soldiers' concussions.
The symptoms were "classic," Russell said.

The soldiers had "dazed" expressions, and were slow to respond to questions.

"I found out several of them had significant gaps in their memory," Russell said. "It wasn't clear how long they were unconscious for, but the last thing they remember is they were playing video games. The next thing they remember, they are outside the trailer."

Another doctor told NPR and ProPublica of finding soldiers with undocumented mild traumatic brain injuries in Afghanistan as recently as February 2010.

"It's still happening, there's no doubt," said the military doctor, who did not want to be named for fear of retribution.

Screened Out
After the Walter Reed scandal, the military instituted a series of screens to better identify service members with brain injuries. Soldiers take an exam before deploying to a war zone, another after a possible concussion in theater, and a third after returning home. But each of these screens has proved to have critical flaws.

The military uses an exam called the Automated Neuropsychological Assessment Metrics, or ANAM, to establish a baseline for soldiers' cognitive abilities. The ANAM is composed of 29 separate tests that measure reaction times and reasoning capabilities. But the military, looking to streamline the process, decided to use only six of those tests.

Doubts immediately arose about the exam, which had never been scientifically validated. Schoomaker, the Army surgeon general, recently told Congress that the ANAM was "fraught with problems" and that "as a screening tool," it was "basically a coin flip."

Military clinicians have administered the exam to more than 580,000 soldiers, costing the military millions of dollars per year, but have accessed the results for diagnostic purposes only about 1,500 times.

Rep. Bill Pascrell Jr., D-N.J., who has led efforts to improve the treatment and study of brain injuries, accused the military of ignoring the Congressional directive.

"We are not doing service to our bravest," Pascrell said. "There needs to be a sense of urgency on this issue. We are not doing justice."
Once in theater, soldiers are supposed to take the Military Acute Concussion Evaluation [7], or MACE, to check for cognitive problems after blasts or other blows to the head.

But in interviews, soldiers said they frequently gamed the test, memorizing answers beforehand or getting tips from the medics who administer it.
Just last summer, Sgt. Victor Medina was leading a convoy in southern Iraq when a roadside bomb exploded. He was knocked unconscious for 20 minutes.

Afterwards, Medina had trouble following what other soldiers were saying. He began slurring his words. But he said the medic helped him to pass his MACE test, repeating questions until he answered them correctly.

"I wanted to be back with my soldiers," he said. "I didn't argue about it.".

Senior military officials said problems with the MACE were common knowledge.

"There's considerable evidence that people were being coached or just practicing," said Russell, the senior neuropsychologist. "They don't want to be sidelined for a concussion. They don't want to be taken out of play."

If cases of brain trauma get past the battlefield screen, a third test -- the post-deployment health assessment [8], or PDHA -- is supposed to catch them when soldiers return home. But a recent study, as yet unpublished, shows this safety net may be failing, too.

When soldiers at Fort Carson, Colo., were given a more thorough exam bolstered by clinical interviews, researchers found that as many as 40 percent of them had mild traumatic brain injuries that the PDHA had missed. In a 2007 e-mail, a senior military official bluntly acknowledged the shortcomings of PDHA exams, describing them as "coarse, high-level screening tools that are often applied in a suboptimal assembly line manner with little privacy" and "huge time constraints."

Col. Heidi Terrio, who carried out the Fort Carson study, said the military's screens must be improved.

"It's our belief that we need to document everyone who sustained a concussion," she said. "It's for the benefit of the Army and the benefit of the family and the soldier to get treatment right away."

Gen. Peter Chiarelli, the Army's second in command, acknowledged that the military has not made the progress it promised in diagnosing brain injuries.

"I have frustration about where we are on this particular problem," Chiarelli said.

Fundamentally, he said, soldiers, military officers and the public needed to take concussions seriously.
"We've got to change the culture of the Army. We've got to change the culture of society," he said, adding later, "We don't want to recognize things we can't see."

Skeptics
The shift Chiarelli envisions may be impossible without buy-in from senior military medical officials, some of whom are skeptical about the long-term harm caused by mild traumatic brain injuries.

One of Schoomaker's chief scientific advisors, retired Army psychiatrist Charles Hoge, has been openly critical of those who are predisposed to attribute symptoms like memory loss and concentration problems to mild traumatic brain injury.

In 2009, he wrote a opinion piece in the New England Journal of Medicine that said the "illusory demands of mild TBI" might wind up hobbling the military with high costs for unnecessary treatment. Recently, Hoge questioned the importance of even identifying mild traumatic brain injury accurately.
"What's the harm in missing the diagnosis of mTBI?" he wrote to a colleague in an April 2010 e-mail obtained by NPR and ProPublica. He said doctors could treat patients' symptoms regardless of their underlying cause.

In an interview, Hoge said, "I've been concerned about the potential for misdiagnosis, that symptoms are being attributed to mild traumatic brain injury when in fact they're caused by other" conditions. He noted that a study he conducted, published in the New England Journal of Medicine, "found that PTSD really was the driver of symptoms. That doesn't mean that mTBI isn't important. It is important. It's very important."
Other experts called Hoge's posture toward mild TBI troubling.

To be sure, brain injuries and PTSD sometimes share common symptoms and co-exist in soldiers, brought on by the same terrifying events. But treatments for the conditions differ, they said. A typical PTSD program, for instance, doesn't provide cognitive rehabilitation therapy or treat balance issues. Sleep medication given to someone with nightmares associated with PTSD might leave a brain-injured patient overly sedated, without having a therapeutic effect.

"I'm always concerned about people trivializing and minimizing concussion," said James Kelly, a leading researcher who now heads a cutting-edge Pentagon treatment center for traumatic brain injury. "You still have to get the diagnosis right. It does matter. If we lump everything together, we're going to miss the opportunity to treat people properly."

At her family farm outside Hanover, Pa., Michelle Dyarman has a large box overflowing with medical charts, letters and manila envelopes. They are the record of her fight over the past five years to get diagnosis and treatment for her traumatic brain injury. After her last roadside blast in Baghdad, which killed two colleagues, Dyarman wound up at Walter Reed for treatment of post-traumatic stress.

Over the course of two and a half years, she received drugs for depression and nightmares. She got physical therapy for injuries to her back and neck. A rehabilitation specialist gave her a computer program to help improve her memory. But it wasn't until she began talking with fellow patients that she heard the term mild traumatic brain injury.

As she began to research her symptoms, she asked a neurologist whether the blasts might have damaged her brain. Records show the neurologist dismissed the notion that Dyarman's "minor head concussions" were the source of her troubles, and said her symptoms were "likely substantially attributable" to PTSD and migraine headaches.

"It was disappointing," she said. "It felt like nobody cared."

When she was later given a diagnosis of traumatic brain injury by Veterans Affairs doctors, she said she felt vindicated, yet cheated all at once.

"I always put the military first, even before my family and friends. Now looking back, I wonder if I did the right thing," she said. "I served my country. Now what's my country doing for me?"