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THE VA PROMISED..............
War Veterans’ Concussions Are Often Overlooked
By LIZETTE ALVAREZ
Published: August 25, 2008
Former Staff Sgt. Kevin Owsley is not quite sure what rattled his brain in 2004: the roadside bomb that exploded about a yard from his Humvee or the rocket-propelled grenade that flung him across a road as he walked to a Porta Potti on base six weeks later.
J.D. Pooley for The New York Times
"When you get injured, you should be recognized, even if you don't see it over there," said former Staff Sgt. Kevin Owsley. Denied a Purple Heart, he had a brain injury that went undiagnosed for years.
Courtesy of Tony Wood
Traumatic brain injury "has impacted my ability to get a good job," said Sgt. Tony Wood. His Humvee hit a bomb cemented into this curb in Ashraf, Iraq, in July 2005.
Isaac Brekken for The New York Times
"I hear things, but it doesn't throw it in the memory box," said former Staff Sgt. Bryan Lane, who sustained a concussion and almost lost his right arm in a bombing in Baghdad.
After each attack, he did what so many soldiers do in Iraq. He shrugged off his ailments — headaches, dizzy spells, persistent ringing in his ears and numbness in his right arm — chalking them up to fatigue or dehydration. Given that he never lost consciousness, he figured the discomfort would work itself out and kept it to himself.
“You keep doing your job with your injuries,” said Mr. Owsley, 47, an Indiana reservist who served as a gunner for a year outside Baghdad beginning in March 2004. “You don’t think about it.”
But more than three years after coming home, Mr. Owsley’s days have been irrevocably changed by the explosions. He struggles to unscramble his memory and thoughts. He often gets lost on the road, even with directions. He writes all his appointments down but still forgets a few. He wears a hearing aid, cannot bear sunlight on his eyes, still succumbs to nightmares and considers four hours of sleep a night a gift.
Mr. Owsley is part of a growing tide of combat veterans who come home from Iraq and Afghanistan with mild traumatic brain injuries, or concussions, caused by powerful explosions. As many as 300,000, or 20 percent, of combat veterans who regularly worked outside the wire, away from bases, have suffered at least one concussion, according to the latest Pentagon estimates. About half the soldiers get better within hours, days or several months and require little if any medical assistance. But tens of thousands of others have longer-term problems that can include, to varying degrees, persistent memory loss, headaches, mood swings, dizziness, hearing problems and light sensitivity.
These symptoms, which may be subtle and may not surface for weeks or months after their return, are often debilitating enough to hobble lives and livelihoods.
To this day, some veterans — it is impossible to know how many — remain unscreened, their symptoms undiagnosed. Mild brain injury was widely overlooked by the military and the veterans health system until recently.
Even now, with traumatic brain injury called the signature injury of the Iraq war, some soldiers and their advocates say that complications from mild concussions often are not recognized.
Mr. Owsley’s request for a Purple Heart, given to troops wounded or killed in action, was denied by the military, a devastating blow. Others say that their mild brain injury entitled them only to low disability payments, or, if the diagnosis was inconclusive, to none at all.
This has happened in large part because there is no quantifiable diagnostic test for the injury, and the language used by the Veterans Affairs Department to rate traumatic brain injury, or T.B.I., is vague. The military, in particular, seldom rates each symptom from a concussion separately, which it is required to do, said Kerry Baker, associate national legislative director for Disabled American Veterans.
“The criteria remains ambiguous,” Mr. Baker said. “The military way underrates T.B.I. and its symptoms.”
Scant Medical Knowledge
Little is known medically by doctors or scientists about what happens to a brain as a result of a powerful bomb blast, as opposed to car crashes on a highway, blows to the head on a football field or a bullet wound. These are the first wars in which soldiers, protected by strong armor and rapid medical care, routinely survive explosions at close range and then return to combat.
The bomb blasts, which throw off energy waves — atmospheric overpressures and underpressures — that are absorbed by the body, add a little-studied dimension to the trauma. Scientists are only now beginning to study the extent of the damage.
That soldiers are sometimes exposed to multiple blasts during a deployment, or can suffer from a vast combination of wounds, including shrapnel, burns, blows to the head, blast waves, lost limbs or internal injuries, can exacerbate brain trauma in ways unseen among civilians. “It is the black box of injuries,” said Dr. Alisa D. Gean, the chief of neuroradiology at San Francisco General Hospital and a traumatic brain injury expert who spent time treating soldiers at Landstuhl Regional Medical Center in Germany. “We’re at the tip of the iceberg of understanding it. It is one of the most complicated injuries to one of the most complicated parts of the body.”
These mild concussions, which do not necessarily lead to loss of consciousness, are easy to dismiss, simple to misdiagnose and difficult to detect. The injured soldiers can walk and talk. Their heads usually show no obvious signs of trauma. CT scans cannot see the injuries. And the symptoms often mirror those found in post-traumatic stress disorder, making it hard to distinguish between them. In fact, the two ailments often go hand in hand.
But the consequences of these seemingly small concussions can be far-reaching, leading to financial problems, job losses, divorce and mental health issues. The ramifications often go unseen by the military because symptoms often worsen once veterans leave the structure of the Army or Marine Corps for the unpredictability of civilian life.
Take the case of Mr. Owsley, a father of three, whose brain injury so impaired his reaction time and memory that doctors advised him not to work.
“I almost lost everything,” said Mr. Owsley, whose wife brought home the family paycheck for two years, working at a nursing home. “We were at the point of getting ready to lose the house and the cars. Then you start planning out things. I was planning to do suicide and make it look like an accident so my family would get the insurance.”
At first, he said, doctors missed his traumatic brain injury. “She told me nothing was wrong with me, but she gave me like 18 different medications, for pain, to go to sleep, for lots of other things,” he said of his first visit to a Veterans Affairs doctor at a facility in Fort Wayne, Ind.
Later that year, another veterans hospital said he had mild traumatic brain injury, post-traumatic stress disorder, anxiety, hearing loss and injuries to his hand, ankles, eye and back. He was rated 100 percent disabled by the Veterans Affairs Department and now receives a monthly check for $2,711, easing the financial pressure somewhat.
Yet Mr. Owsley, referring to his Purple Heart denial letter, said he felt his injuries had gone unrecognized by the military “because there was no blood” and because he chose to work through his pain.
“They said it was because I didn’t report it in the field and seek medical attention at the time, and there was no proof” of any obvious injury, Mr. Owsley said. “I had guys write statements for me to prove it had happened. As a soldier with 23 years in the Army, them badges mean more than anything. When you get injured, you should be recognized, even if you don’t see it over there.”
It was not until 2006, three years into the Iraq war, that the Departments of Defense and Veterans Affairs began to pay close attention to mild traumatic brain injuries. The Pentagon last year opened the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, a clearinghouse for treatment, training, prevention, research and education. This year it is spending a record $300 million on research for traumatic brain injury and post-traumatic stress disorder.
“We are more attuned to brain injuries now,” said Lt. Col. Michael Jaffee, the director of the Defense and Veterans Brain Injury Center. “There has not been as aggressive an effort before.”
That effort begins with screening. As of May, service members who deploy longer than 30 days will undergo neurocognitive testing before leaving, to establish a baseline for changes that may occur later, and again upon returning. At the same time, soldiers in battle who lose consciousness or feel dazed after a blast or other event must be screened by a medical provider and are either approved for duty in the field, told to rest for several days on base or sent to Landstuhl for further evaluation.
Last year, Veterans Affairs started screening all Iraq and Afghanistan war veterans who come in for clinical help. So far, 33,000 of 227,015, about 15 percent, have screened positive for mild brain injury since April 2007.
It is unclear how many service members, particularly those who fought earlier in the war, remain unscreened and whose injuries go undiagnosed.
“No doubt that there are significant numbers out there,” said Dr. Barbara Sigford, director of physical medicine and rehabilitation for the Department of Veterans Affairs.
Bryan Lane, 31, a former sergeant first class in Special Forces, did not zero in on his head injury until more than a year after a bomb exploded next to him in a house in Baghdad in 2005. The reasons were understandable. He lost a huge chunk of his right arm in the explosion and was fortunate not to have lost the limb altogether.
He did not realize that his brain had taken a hit until five months later, when he saw the gaping hole in the front of his helmet. He never lost consciousness after the blast, but the soldier next to him was knocked out for two hours.
The possibility that he might have suffered a concussion was never mentioned during his many months at Womack Army Medical Center in Fort Bragg, N.C., where he had several operations to save his arm. Six months after he was medically discharged, when he was putting in a Veterans Affairs disability claim for his arm injury, a V.A. doctor brought up a possibility overlooked at Womack: he might still be suffering symptoms from a concussion.
It explained his shortened attention span, his frequent search for the right word during conversation and his forgetfulness. “I hear things, but it doesn’t throw it in the memory box,” he said.
“I was completely honest and said I don’t think I have T.B.I.,” said Mr. Lane, who is still articulate, though less so today, he said. “A lot of guys, myself included, fight the label of T.B.I. no matter how mild. In a way, it’s like people are calling you stupid or retarded, and I know that’s not P.C.”
The Veterans Affairs Department, which has become increasingly vigilant about mild traumatic brain injury, thought otherwise and did something unusual. It attached a brain injury claim alongside one for post-traumatic stress disorder, covering all bases. “Since no one understands the relation they have to each other, they said, ‘If you have one, you have the other,’ ” said Mr. Lane, who receives benefits for mental and physical injuries. He now works for the Armed Forces Foundation, a nonprofit group that provides troops, many of them injured, with financial support, among other things.
Delayed Symptoms Explained
Post-traumatic stress disorder and traumatic brain injury are closely tied, although the precise relationship between the two is unknown.
This connection was most recently established in a study in The New England Journal of Medicine in January by Col. Charles W. Hoge, an Army psychiatrist who is leading efforts to identify mental health problems among combat troops. His survey of 2,500 Army infantry soldiers found that more than 40 percent of those who reported loss of consciousness also met the criteria for post-traumatic stress disorder. That was a much higher percentage than those who had suffered other injuries, like Humvee accidents or falls.
Dr. Hoge cautioned, though, that some symptoms — anger, headaches, depression, sleeplessness, mood swings — may stem solely from combat stress, a psychiatric disorder, and not traumatic brain injury. Combat, he emphasized, often goes hand in hand with traumatic experiences, including a near loss of life or the death or injury of others.
For years most troops with mild concussions stayed on the job, immersing themselves in combat again and re-exposing themselves to additional blasts with little or no time to rest and recover. This pattern only heightened the risk of brain injury and post-traumatic stress disorder, doctors say.
Civilians with brain injury, on the other hand, are given time to recuperate for long periods in a safe environment, which may explain why they respond differently to stress.
Dr. Ibolja Cernak, a brain injury expert who is medical director of the applied physics laboratory at Johns Hopkins University and is conducting research into blast injuries, said she had noted other differences between blast-injured soldiers and mildly brain-injured civilians. Soldiers, she said, can develop symptoms two years after a blast. Some also have greater difficulty walking or talking, or with aggression.
“Civilians don’t have the frequency of these symptoms,” Dr. Cernak said. There is no cure for those with prolonged concussion symptoms, only methods to help them learn to adapt.
Sgt. Tony Wood, 41, now based at Schofield Barracks in Hawaii, keeps a large color-coded board by the door with reminders about his appointments, his chores and his belongings, all part of the Brain Injury Recovery Kit he received from a nonprofit group called the 10 in 10 Project. His wife calls him all day with reminders, and after losing his keys countless times, he attaches them to his pants. Notebooks fill his pockets.
In his view, the military is still failing to grasp the depths of his injury, and those of other soldiers like him.
In July 2005, Sergeant Wood’s Humvee hit a roadside bomb cemented into the curb. The blast set off a chain reaction, triggering two American fragmentation grenades inside the Humvee along with an antitank weapon and countless rounds of ammunition. The two other soldiers riding with him died in the blast. The explosion tore through Sergeant Wood’s arm and abdomen and then ricocheted inside his body, leaving only his heart untouched. His liver had a fist-size hole, he lost his spleen and part of his stomach, and he sustained damage to his lungs and diaphragm.
Sergeant Wood’s first memory after the bomb was opening his eyes at Walter Reed Army Medical Center about a month later, seeing his wife, and asking, “Why are you in Iraq?”
Doctors patched up most of his physical wounds over five months. But his wife, who was born with mild brain injuries, noticed that Sergeant Wood, a military policeman, was not himself mentally. He did not remember someone who had just walked out of the room. He forgot questions he had just asked. He struggled to read one chapter of a book.
Still a Soldier, and Struggling
While he was at Walter Reed in December 2005, Sergeant Wood said doctors gave him a brain injury test. But it was inconclusive. “They tried to say I had A.D.D., I needed a good night’s sleep, you name it,” he said, referring to attention deficit disorder.
As he recovered in the Warrior Transition Unit at Tripler Army Medical Center in Hawaii, Sergeant Wood tried to decide whether to stay in the military by switching to less taxing jobs, an idea he hated, or to leave, collect his benefits and find a civilian job. But his previous jobs — professional cowboy, scuba instructor, construction worker — were out of the question.
“My T.B.I. has impacted my ability to get a good job,” he said, adding that he fears the best position he can get now is as “a greeter at Wal-Mart.”
With four foster children, two biological children and a wife, he steered the safe course and applied to try to stay in the military. The Army Medical Board deemed him unfit for active duty and sent him to the Physical Evaluation Board for a disability rating that would determine his benefits package once discharged from the Army.
When he saw his rating in March, he was floored. Despite his extensive wounds — brain injury, constant pain, failing hips, headaches, noise sensitivity, no spleen, lung damage, liver damage, panic attacks and chronic esophagitis — he received only a 50 percent rating. His brain injury made up 10 percent of the total. A memorandum from the board said that his “stated difficulties are more consistent” with post-traumatic stress disorder.
As a last resort, Sergeant Wood can turn to the federal courts. (He said he had not made that decision yet.)
He is not the first soldier to receive a low rating for his injuries from the Army since the Iraq war began. The ratings so distressed Congress that as of January, it ordered the military to follow solely the ratings schedule issued by the Veterans Affairs Department, which consistently grants veterans more money for the same injuries.
“The Army was raking these guys over the coals,” said Mr. Baker, of Disabled American Veterans.
Asked by The New York Times to review Sergeant Wood’s paperwork, Mr. Baker said his extensive injuries easily should have been rated 100 percent, according to the Veterans Affairs schedule. “This was completely wrong,” Mr. Baker added.
Sergeant Wood has stayed in the Army under a program for soldiers injured in combat. He sits at a Hawaiian jail and alerts the military when a soldier gets locked up. He fears he will get an even lower rating the next time he goes before the Army Medical Board, simply because he is doing his job well.
“You are still treated like you are trying to beat the government out of money,” Sergeant Wood said. “It’s not like I fell off a barstool.”