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TBI:2 5/27/08 12:35 PM Page 14 caused people to come around to acknowledge the psychological aspects of TBI," said Gean, who has worked with wounded soldiers at the U.S. Army's Regional Medical Center in Landstuhl, Germany. "It is a complicated injury to the most complicated part of the body." She credits ABC News reporter Bob Woodruff for helping to bring the subject before the public. Woodruff was seriously wounded in the head by a roadside bomb in Iraq and his struggle to return to work was covered extensively by his news organization. Woodruff has since done a number of reports on soldiers suffering from TBI. Gean said there are many similarities between civilian TBIs and those inflicted in combat. As a neuroradiologist who images brains, her major experience is with penetrating TBI, of which the wars in Iraq and Afghanistan have produced many cases. "Penetrating injuries are penetrating injuries. They are seen everyday in gang warfare," she said, although in Iran and Afghanistan the projectiles may be "nuts, bolts and pieces of car fenders" rather than bullets. But there are also major differences. "Combat trauma is trauma on steroids," said Gean. "It is truly polytraumatic." When she talked about seeing soldiers with burns, open wounds, multiple amputa- "Vets don't tell the truth. They say, 'I'm fine, I can go back into battle.' The result, however, is that TBI victims may be exposed to further damage before they can heal." TBI AND THE CHANGING FACE OF WAR Some 30 miles north of Baghdad is the site of the world's most advanced treatment center for traumatic brain injuries (TBI). One stands a much better chance of recovering from TBI at the Air Force Theater Hospital at the Balad Air Base than back home in the U.S. Behind the reason for the existence of the center and its location lies the story of fundamental change in the nature of warfare in the 21st century. No longer do wars consist of two armies facing off in battle. Instead, today's conflicts are more likely to be asymmetrical: a brief conflict decided by massive airpower against a foe with none, leading to an occupation force and a shadowy insurgency. The latter, lacking modern weapons and air power, arm themselves with such weapons as improvised explosive devices (IED), rudimentary and fairly easy to conceal. In places like Iraq and Afghanistan, brain injuries caused by IEDs are the leading cause of injury for occupation troops. The high-tech operating theater at Balad is described by author Paul Mason in his new book Head Cases. He describes the Balad facility – 35,000 square feet of tents and retrofitted shipping containers – as "the brain injury capital" and "the most aggressive medical system" in the world. "A hundred years ago, a horse's kick to the head would have done you in," Mason writes. "In Iraq you can take a golf-ball-size missile through the skull and survive." The book is about the mysterious and often horrendous physical and behavioral consequences of such survival. U.S. armed forces are currently being shifted from one capable of fighting conventional wars to one designed more for occupation and combating insurgencies. Given this, the treatment of TBIs is likely to be a growth industry in the future. —c.h. and c.b. 14 REGISTERED NURSE tions and TBI at Landstuhl, she stopped at one point as she remembered a mutilated 20-year-old and said quietly, "I will never forget those injuries." A penetrating injury that causes brain damage is extremely difficult to treat, but non-penetrating TBI may be just as tricky, in part because it can both be subtle and stubborn, and in part because military culture resists admitting to problems. A Pentagon study found that 60 percent of soldiers who suffered from the symptoms of TBI refused to seek help because they felt their unit leaders would treat them differently. Some 55 percent refused help because they thought they would be seen as weak, or would lose the trust of their fellow soldiers. A number feared that reporting the symptoms of TBI could prevent them from getting jobs as police and firemen once they left the military. "Vets don't tell the truth," said Hovda. "They say, 'I'm fine, I can go back into battle." The result, however, is that TBI victims may be exposed to further damage before they can heal. MTBI is a biochemical event that creates a crisis for the brain, said Hovda. During this crisis, "the brain is vulnerable to another incident. A second incident during this phase is likely to have more severe repercussions." The Center for the Study of Retired Athletes found that three or more concussions meant that athletes were three times as likely to have "significant memory problems," and five times as likely to suffer from depression or develop an Alzheimer's-like syndrome called Chronic Traumatic Encephalopathy. Whether it is sports or war, the more one is exposed to trauma, the worse the damage. Multiple tours and longer deployments mean soldiers are exposed to more explosions. "The multiple nature of it is unprecedented. People just get blasted, and blasted, and blasted," said Maj. Connie Johnmeyer of the 332ed Medical Group, a unit that deals with psychological problems, in Stars and Stripes magazine. But with a major shortage of troops, the pressure is to get lightly wounded soldiers back into battle. Out of the 1.6 million who served in both wars, some 525,000 troops have had more than two combat tours, 70,000 have served three, and 20,000 have done five or more. When soldiers are first wounded, said Gean, "The acute care [at Landstuhl and Walter Reed] is truly world class," far better than most people could get in the U.S., barring a few trauma centers. But she thinks that the TBI problem is larger than we think and she worries about what happens after patients leave. The worry is well placed. Soldiers return to find that there are few psychological resources for them, and virtually no individual therapy. "There are two things going on regarding vets," said retired Col. Will Wilson, chair of the American Psychological Association's military psychology division in National Psychologist. "One, there are not enough care providers available, and two, there are not enough people focusing on the problem outside of the military." The Department of Defense's Task Force on Mental Health concluded that "The psychological health needs of service members, W W W. C A L N U R S E S . O R G M AY 2 0 0 8