Traumatic brain injury from concussions forces military to catch up

A decadelong push by the Pentagon has brought to light the startling frequency of brain injuries within the ranks of the U.S. military, helping to erase the concept that concussions can be simply brushed off.

Despite the progress, medical specialists warn that the true depth of the problem remains poorly understood, the symptoms difficult to diagnose and the invisible wounds too often dismissed as insignificant.

Iran’s ballistic missile attack on the Ain al-Asad air base in Iraq in January put a spotlight on brain injuries and underscored how difficult it is for military doctors to quickly make a diagnosis and determine the extent of the damage. The Pentagon initially said no Americans were injured in the attack but later revealed that scores of men and women serving at the base had suffered traumatic brain injuries (TBIs) as a result of the blasts.

The latest count stands at 110, though the vast majority returned to duty in short order.

Much like the National Football League and other corners of American society, the military has only relatively recently begun to delve deeply into brain injuries, their prevalence and the impact they could have on morale and performance.

Before June 2010, TBI screenings were not routine for combat troops in Iraq or Afghanistan, and there were no standardized protocols to catch recurrent brain injuries or plans for how to treat them, according to research published by the National Institutes of Health.

Since 2000, more than 408,000 cases of TBI have been diagnosed in U.S. service personnel serving around the world, said researchers from the Defense and Veterans Brain Injury Center.

The number shouldn’t be surprising, specialists say, despite rigorous health standards and the monitoring of all soldiers, sailors, airmen and Marines. The military, like the rest of the country, is struggling to come to grips with the scope of the problem.

“The military, really in many respects, just mimics the civilian population. Some days it’s ahead of the game, some days it’s behind the game and they’re playing catch-up,” said Michael V. Kaplen, a legal specialist in traumatic brain injuries and past president of the Brain Injury Association of New York State. “I think for a while they were playing catch-up. I think they’ve caught up now, but now I think the military and civilian providers have to have a deep dive into addressing this issue.”

“The problem now has to be focused on the long-term repercussions of brain injury, both mild brain injury and serious brain injury, and the long-term care and responsibilities we have to this population,” he said.

Window into the problem

The January attack on Ain al-Asad, specialists say, offers an important window into the military’s challenges of identifying brain injuries quickly. The most common symptoms — memory problems, irritability, mood swings, difficulty focusing, mild or severe headaches, loss of consciousness, among others — often take hours, days or even weeks to appear.

President Trump reflected in part the old thinking in his comments last month on the impact of the Iranian missile attack. He told reporters, “I heard that they had headaches, and a couple of other things, but I would say, and I can report, it’s not very serious.”

As the number of U.S. troops reporting problems continued to grow from the attack, Pentagon officials were quick to insist that they were taking the TBI threat seriously.

Although the slow-moving evaluation process was frustrating to those who wanted a quick, full accounting on the number of injuries, military doctors argue that their response to the Ain al-Asad incident validates the sweeping change in approach within the armed forces over the past decade. Specifically, they say, the military has instituted a host of medical screening procedures that monitor service members for days and weeks after an incident.

The national dialogue around concussions also seems to have prompted troops to be more cognizant of their own health and to become much more self-aware when symptoms arise.

“It was a real validation of the work over the last 15 years to change how we take care of people who develop traumatic brain injury,” Air Force Brig. Gen. Paul Friedrichs, Joint Staff surgeon, recently told reporters at the Pentagon. “If you go back through thousands of years of military history, go back to the Greeks and the Romans, they talked about people who were wounded warriors, or the walking wounded, shell-shocked — every war has had some term for them. What we’ve not had are good ways to evaluate these soldiers, sailors, airmen and Marines at the time that they were injured or afterwards, when they came and sought care.

“We recognized this beginning early in the current conflicts and began working with the [Department of Veterans Affairs], as well as with the NCAA, the NFL and other stakeholders to develop a series of screening measures, which we’ve updated over the years, and we’re able to use very effectively during this event,” he said.

Old attitudes

The revamped approach began in earnest with a June 2010 military directive to “identify, track and ensure the appropriate protection of service members exposed to potential concussive events, including blast events, to the maximum extent possible.”

Since then, the Pentagon, the VA and other government agencies have launched initiatives aimed at gaining a fuller understanding of the scope of the problem. Specialists say injuries are relatively easy to spot in some instances, such as direct bruising of the brain.

Other times, TBIs consist of microscopic injuries to nerves in the brain. Those wounds are more difficult to pick up in routine testing and sometimes don’t immediately lead to noticeable symptoms.

Despite the progress, specialists caution that troubling attitudes remain a major hurdle to diagnosing and treating TBI.

For the White House, the rising number of injuries from Tehran’s missile salvo intersected with geopolitical politics. Iran attacked Ain al-Asad just days after a U.S. airstrike killed top Iranian Maj. Gen. Qassem Soleimani, bringing the two nations to the brink of all-out war.

Mr. Trump ultimately decided against direct military retaliation for the Ain al-Asad strike after specifically noting that no Americans had been killed or seriously wounded.

At least 110 cases of brain injury seem to challenge that assessment.

Veterans’ advocates slammed the president for his comments.

“TBI is known to cause depression, memory loss, severe headaches, dizziness and fatigue — all injuries that come with both short- and long-term effect,” Veterans of Foreign Wars National Commander William Schmitz said in a statement. “The VFW expects an apology from the president to our service men and women for his misguided remarks.”

Specialists say it’s vital for the president and all other influential voices to speak responsibly about the issue and its ramifications for the health of American troops. They also stress that TBIs deserve attention even when not associated with high-profile missile strikes.

“Most of the brain injuries in the military … are not caused by blast injuries. They’re the same events that cause brain injuries in the civilian population,” said Mr. Kaplen, citing traffic accidents, falls and other common occurrences in military and civilian life.