# A growing toll on battlefield brains



## 3rd Herd (28 Jul 2007)

http://www.thestar.com/News/article/240721
The Usual Disclaimer and move if needed:
WAR WOUNDS
TheStar.com - News - A growing toll on battlefield brains
A growing toll on battlefield brains
From Afghanistan to Iraq, bomb blasts are causing the U.S., British and Canadian troops who survive them a staggering number of brain injuries. Military doctors warn we've only justed started to suffer the effects

Jul 28, 2007 04:30 AM 
Olivia Ward 
FOREIGN AFFAIRS WRITER

On a dusty road near Kandahar, a Canadian soldier crawls from his bomb-battered vehicle as his bleeding colleagues are carried away on stretchers. Dizzy, his ears ringing, he dusts himself off and shakes his head in amazement that he has escaped injury.

Or has he?

"Everyone knows that traumatic brain injury is the leading cause of death and disability in both civilian and military trauma," says Canadian military trauma surgeon Homer Tien. "It takes a huge toll."

Since the days of World War II and Vietnam, protective body armour and medical treatment received by Western troops have brought a quantum leap in survival rates of wounded soldiers.

But researchers have found that even those who walk away from an explosion may be suffering from traumatic brain injury, which has been tagged "a silent epidemic" in the United States.

Military doctors have found that mild or serious brain injury is afflicting substantial numbers of soldiers who survive the ever more powerful bombs, or "improvised explosive devices," planted by militants in Afghanistan and Iraq .

This week, a presidential panel charged that the military health care system was no longer able to meet the demands of the contemporary battlefield — including the mounting number of traumatic brain injuries.

It recommended sweeping changes to upgrade treatment and benefits of affected veterans.

So concerned is the U.S. Congress that it has authorized $450 million for care and research into head injuries, whose treatment may cost millions more over the next few decades.

Up to January 2007, more than 2,000 brain injuries were recorded by the U.S. military. But doctors treating veterans from Iraq and Afghanistan say figures are several times higher. 

Canada, which is just beginning to focus on the seriousness of the problem, is no exception.

In Afghanistan, among Canadians killed between February and July 2006, brain injury and bleeding were leading causes of death, according to a study by Tien and two Canadian forces colleagues.

But those who die, or suffer severe head injury, are easier to classify as brain-damaged than soldiers who walk away from the blasts.

"People who have experienced a mild head injury might not know at first, because of medical or tactical considerations," says Col. Jonathan Jaffin, acting commander for U.S. Army Medical Research and Materiel Command. "It is important for commanders to be aware of (those injuries) because it can have great bearing on a soldier's readiness to go back to active duty."

According to Walter Reed Army Medical Center in Washington D.C., which routinely evaluates combat casualties for brain injury, 59 per cent of those exposed to a blast are diagnosed with traumatic brain injury – 56 per cent moderate to severe, and 44 per cent mild.

As the bombs used to attack the troops in Iraq and Afghanistan pack bigger explosive punches, those numbers could escalate.

"A blast creates a sudden increase in air pressure by heating and accelerating air molecules, and immediately thereafter, a sudden decrease in pressure that produces intense wind," writes American physician Susan Okie in the New England Journal of Medicine.

Rapid pressure shifts can injure the brain, without any visible head wound. They can also cause fatal or damaging brain swelling, or drive fragments of metal through the skull. Specialists in battlefield medicine say it's the "invisible" or closed head injuries that are the most difficult to treat.

Brain swelling that results from car crash or sports injuries responds well to medication and surgical techniques. But the damage caused by explosions is a special challenge.

"When the sound wave moves through the brain it seems to cause little gas bubbles to form," neurologist P. Stephen Macedo told the Washington Post. "When they pop, it leaves a cavity. So you are littering people's brains with these little holes." 

And, says Sunil Ram, an Ontario-based international security and defence analyst, "everyone in the blast zone is a potential casualty. When you look at Canadian casualties in Afghanistan, more than half of those who die are killed by IEDs. But depending on the munition and the environment, the blast wave is catching everyone within a 200- to 500-metre range."

Advanced body armour saves lives by protecting soldiers' bodies, says Dr. Ronald Glasser, author of Wounded: Vietnam to Iraq, in an essay in the Washington Post.

But he says, "neurologists worry ... at least 30 per cent of the troops who've engaged in active combat for four months or longer in Iraq and Afghanistan ... risk potentially disabling neurological disorders from the blast waves of IEDs and mortars, all without suffering a scratch."

Those who are worst hit may lose consciousness, or suffer seizures and convulsions. Moderately affected troops may experience vomiting, numbness in the arms and legs, and nausea.

But mild brain injuries can cause memory loss, sleep disturbances, confusion, dizziness and blurred vision – symptoms that zealous soldiers or their superiors might shrug off as unimportant. They may also be classified as psychological. 

"Events that cause head injury are the same ones that cause post-traumatic stress disorder. And some people have components of both," says Jaffin.

Most mild brain injuries get better without treatment, he adds. But as with sports injuries, those who go back to their activities too soon risk more serious problems.

Victims of worse brain injuries need careful long-term care, which is costly and requires close monitoring and treatment of blast victims. In moderate as well as severe cases, the brain's attempts to heal itself can cause epilepsy, as it "miswires" neural circuits. In other cases, victims suffer personality changes that make them unable to lead a normal life.

Glasser, who treated soldiers wounded in Vietnam, contends that the real toll of war now goes far beyond the death count. 

"The real risk to our troops is no longer the numbers of dead but the numbers ending up on orthopedic wards and neurosurgical units."

Even for those with milder head injuries, long term monitoring is crucial, says Tien. So is research on the effects of the trauma.

"The challenge is to find out about those who are further from the centre of the explosion," he says. "A blast wave hits and a soldier may be knocked unconscious for two seconds. Then he gets up and says `I feel great.' Even a CAT scan may be negative. But the question is, will he develop a problem in the future?"


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## Colin Parkinson (29 Aug 2007)

Sunil Ram, now he is a Brain Surgeron? Interesting how this fellow gets around.


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## Greymatters (30 Aug 2007)

Its not that he is presenting himself as a brain surgeon, but as an expert on physical damage from explosive devices.  While some of his previous material is pretty good, I dont see any evidence of expertise in this field based on his biography (http://www.unitarpoci.org/staff_bio.php?name=ram)...

Previous article on our forum mentioning him (http://forums.army.ca/forums/threads/65100.0.html)...


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## krustyrl (30 Aug 2007)

Very interesting topic 3rd Herd , might open up some interesting discussion that  would be some good reading.


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## oldlineman (7 Sep 2007)

I am suprised by the sarcasm here---this has nothing to do with me but about the people serving in Afghanistan--- this is a really serious problem that could be effecting hundreds of our soldiers who have been within the blast radius of any type of explosion.

Actually, I was asked what I knew about it... what I found was increadibly troubling... it was based on looking into the impact of IEDs and their strategic impact on the conflict in Iraq -if you care I will be giving a talk on this at the RCMI on Oct 10th. 

Lookinginto the casualty rates what I found was mainly that soldiers were being misdiagnosed initially with PTSD instead of TBI--- which is serious. The limited studies the US did in the early 2000s (2003 if I recall correctly) were limited but pointed to a clear trend. Thisled to Congress pressing the military to deal with the issue a year later--since no one wanted to see another Gulf War Syndrom debacle

The US casulaty estimates based on and a number of other factors could be as high as 150,000 .... the estimate for the down stream cost for treatment is in excess of 35billion USD as I recall. Point is how come our guys don't get the same care and concern that the US military wounded do. Can you self-identify yourself with TBI--- I can't and as I understand that was the policy in place as of this summer.

Luckly I was able to get part of the message out so at least there is a public record, which means DND can be called to account should this become a compensation/pension issue...
look how many people got screwed fromour adventures in the Balkans

cheers
Sunil


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## GAP (7 Sep 2007)

Without an MRI, the only way to diagnose is through symptoms, is it not? 

Is there any treatment? Rehab, etc?


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## oldlineman (7 Sep 2007)

Dear Gap
as I understand now the US is taking brain scans... then doing comparative analsysis if you are involved in an incident. However, many of my students who are in Iraq or had been there after I asked them, said that no one had told them! 

What is clear is that the US military is certainly trying to address the issue... but its like closing the barn door after the horses have left.
there are a number of excellent vetran's sites that I have pointed my soldiers to for this - the best one I found is below.
http://www.dvbic.org/
http://www.dvbic.org/education.html

An MRI or CATSCAN are the definative tests ... given the micro bubbles that can form in the brain cells. However, I don't understand what the actual treatment is for this level of injury. You need a medical expert for that... and as I understand the above link is a good starting point.
Hope this was useful
cheers
Sunil


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## Blackadder1916 (7 Sep 2007)

GAP said:
			
		

> Without an MRI, the only way to diagnose is through symptoms, is it not?
> 
> Is there any treatment? Rehab, etc?



 Traumatic Brain Injury: Traumatic Brain Injury (TBI): Merck Manual Professional (much more at link)


> Traumatic brain injury is physical injury to brain tissue that temporarily or permanently impairs brain function. *Diagnosis is suspected clinically and confirmed by imaging (primarily CT, although MRI is sometimes of additional value).* Treatment initially consists of support of respiration, oxygenation, and BP to prevent additional injury and subsequently may include surgery and rehabilitation.



Traumatic Brain Injury - Diagnosis - neurologychannel (more at link)


> Diagnosis
> 
> Patients suffering TBI are typically brought to a hospital emergency room for initial diagnosis and treatment. Once vital signs are assessed and stabilized, and other life-threatening injuries are identified and treated, the process of diagnosing the extent of brain injury begins.
> 
> ...


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## Danjanou (7 Sep 2007)

Ok children play nice and stay on topic or you know what happens.  >

This has the potential to be an interesting thread lets not derail it too soon.

As for sarcasm that and soldiers go together like peanut butter and jelly ( if the CQMS ever remembers to bring the jelly).  8)


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## GAP (7 Sep 2007)

Blackadder1916 said:
			
		

> Traumatic Brain Injury: Traumatic Brain Injury (TBI): Merck Manual Professional (much more at link)
> 
> Traumatic Brain Injury - Diagnosis - neurologychannel (more at link)



Thanks, that answered a lot of questions..


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## Greymatters (7 Sep 2007)

oldlineman said:
			
		

> Looking into the casualty rates what I found was mainly that soldiers were being misdiagnosed initially with PTSD instead of TBI--- which is serious.



That is intriguing - is there a table of some kind out there that shows what effects an explosion has on the brain, i.e. how close to x size of explosion does a person have to be to have sustained an injury? And would it cover effects on vital internal organs?  Or is it the same one used for PSI overpressure?


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## Blackadder1916 (7 Sep 2007)

GreyMatter said:
			
		

> That is intriguing - is there a table of some kind out there that shows what effects an explosion has on the brain, i.e. how close to x size of explosion does a person have to be to have sustained an injury? And would it cover effects on vital internal organs?  Or is it the same one used for PSI overpressure?



CDC Mass Casualties | Explosions and Blast Injuries: A Primer for Clinicians


> Blast Injuries
> The four basic mechanisms of blast injury are termed as primary, secondary, tertiary, and quaternary (Table 1). “Blast Wave” (primary) refers to the intense over-pressurization impulse created by a detonated HE. Blast injuries are characterized by anatomical and physiological changes from the direct or reflective over-pressurization force impacting the body’s surface. The HE “blast wave” (over-pressure component) should be distinguished from “blast wind” (forced super-heated air flow). The latter may be encountered with both HE and LE.


See Table1: Mechanism of Blast Injuries http://www.bt.cdc.gov/masscasualties/explosions.asp#blast


Selected Blast Injuries http://www.bt.cdc.gov/masscasualties/explosions.asp#selected


> Brain Injury
> Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head. Consider the proximity of the victim to the blast particularly when given complaints of headache, fatigue, poor concentration, lethargy, depression, anxiety, insomnia, or other constitutional symptoms. *The symptoms of concussion and post traumatic stress disorder can be similar.*


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## Greymatters (7 Sep 2007)

Not quite what I was thinking of, but still useful information...


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## oldlineman (8 Sep 2007)

Dear Grey Matter

http://www.dvbic.org/cms.php?p=Blast_injury
this link has some basic useful facts... but look into the sources at the end if you have time, there are some very good resources there.

The problem with measuring the impact of the blast wave ref TBI is there are too many variables involved. Some are listed below:
(1) size and type of munition
(2) location/angle of a attack-- that is -is it landmine, some sort of IED (single, multi-layered, is it home made or and old arty shell etc etc) or was it a mortar/rocket round coming in
(3) Other factors --and here is the kicker--- the nature of the vehicle one is riding in... the more protected and sealed you are there might be a bigger pressure effect from both the initial blast wave and then the secondary wind that fills the air void created by the initial blast wave... this assumes you survive the explosion, or you are within the blast wave radius but not in the actual explosive radius.
(4) Also the type of protective gear the soldier is wearing at the time of the blast
(5) surrounding terrain and buildings
(6) how the blast wave is disrupted by the presence of obstacles (including the vehicle/s that may be in the explosion)
(7) type of explosive

From what I understand you can still be effected even at the edge of the blast wave (how far that is depends on how big the explosion is)  
In short you have to take each incident on a case-by-case basis. Below is a recent short paper on the topic that addresses some of your questions
http://neurophilosophy.wordpress.com/2007/05/14/traumatic-brain-injury-on-the-front-line/

Because the process was not well understood the US military kept his under wraps for at least two years -- this had more to do with politics in the White House than actual concern about the soldiers. The politics had a lot to do with the old DU and Gulf War syndrome issues and the pension/compensation payouts.

The below is a good general article from the NEJM from 2005
http://content.nejm.org/cgi/content/full/352/20/2043
it is a useful read on some of the factors I mentioned above.

cheers
Sunil


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## Greymatters (8 Sep 2007)

Unfortunately nothing new for me there.  I am thinking more along the lines of the DIA guide that was put out several years ago that identified lethal/non-lethal ranges for varying ranges of explosives ranging from suicide vests to 18-wheelers (it was labelled OUO, but not sure if it has been downgraded).  Although there are many factors to consider, there should be a guideline for the minimum distance in open ground where a person is likely to suffer TBI, or would be recommended for medical check for such injuries.  

I.e. Explosion equivalent to 50 kg of TNT:
Has a lethal range of X
Has a non-lethal range of Y
Persons within Z distance of the explosion must go to medical unit for surveillance/checkup.   

Although it would not be able to predict the effects for every explosion (i.e. compound type, charge shape, container, etc.) or objects/ground that would deflect, reflect, or compound blast and pressure effects, or protective gear that soldiers might wear to minimize blast effects, but it would at least provide soldiers with an awareness that they still need to get checked out even if they lack visible injuries.


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## medic45 (8 Sep 2007)

The CDC has some really good resources on this topic.

http://www.bt.cdc.gov/masscasualties/bombings_injurycare.asp

There is a fair bit of data in their course which looks to have come primarily from Iraq.


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## Greymatters (8 Sep 2007)

medic45 said:
			
		

> The CDC has some really good resources on this topic.



Excellent link, has some really good up to date information, thanks for the help!


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## oldlineman (8 Sep 2007)

I think that the biggest issue for CF personnel is the "self-identification"... given the various criteria we have been discussing, it seems rather inane to ask someone to consider if they are a TBI casualty! Now keep in mind this was the policy as of early August 2007... so it could have changed. I am wondering if anyone out there who has done a tour of Afghanistan and can speak freely about this ... what were you told about TBI? This is a critical point, because if the policy re TBI was not stringent or ignored then there may be a lot of people out there who need help.

I doubt most soldiers are going to make it an issue unless they were educated about it. Certainly from anecdotal information from my US military students who knew about TBI they did not report any problems unless someone took them aside and checked them out--- that old "soldier on" attitude. Its an interesting cultural reality of military organizations when dealing with non-visible wounds. I should note that this view has changed dramatically in the past 2 years in regards to TBI for US forces.

I am wondering if anyone knows what the actual TBI stats for CF personnel are? Both Olivia Ward (Tor Star) and Bill Gillespie (CBC Radio) were unable to find clear numbers. If the US numbers are any indication our real casualties could be five times higher than indicated given that more than 50% of our killed have been from IEDs/explosive devices (we break-out suicide bombers, the US does not as they are considered a command detonated IED-humerous in a sick sort of way). What I am also curious about is where the CF policy originated and why... definitely something worth following up on.

cheers
Sunil


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