Brain injuries become more prevalent for combat veterans

Roadside bombs and other explosives have injured the brains of almost a fifth of veterans returning from Iraq and Afghanistan.
Wednesday, September 16, 2009 | 12:01 a.m. CDT; updated 8:59 a.m. CDT, Thursday, September 17, 2009
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INTERACTIVE GRAPHIC: Traumatic brain injury can occur in an IED encounter even when the skull is not pierced or damaged. The three most common scenarios for this type of injury are known as Straight Line, Twisting and Compression.

COLUMBIA — Cpl. John McClellan has trouble remembering names and uses a Global Positioning System to find his way on unfamiliar streets.

Three years ago, he was shot through the head by an enemy sniper while serving as a Marine in Iraq. His mother, Connie McClellan, said the doctor in Iraq told her that if her son survived the brain swelling, he might not be the same and would more than likely be in a vegetative state.

Traumatic brain injury quick facts

Common symptoms of brain injury:

  • Difficulty organizing daily tasks
  • Blurred vision, or eyes tire easily
  • Headaches or ringing in the ears
  • Feeling sad, anxious or listless
  • Easily irritated or angered
  • Feeling tired all the time
  • Feeling light-headed or dizzy
  • Trouble with memory, attention or concentration
  • More sensitive to sounds, lights or distractions
  • Impaired decision making or problem solving
  • Difficulty inhibiting behavior — impulsive
  • Slowed thinking, moving speaking or reading
  • Easily confused, feeling easily overwhelmed
  • Change in sexual interest or behavior

Things that can help

  • Get plenty of rest and sleep
  • Increase activity slowly
  • Carry a notebook — write things down if you have trouble remembering
  • Establish a regular daily routine to structure activities
  • Do only one thing at a time if you are easily distracted; turn off the TV or radio while you work
  • Check with someone you trust when making decisions

Things that can hurt

  • Avoid activities that could lead to another brain injury; examples include contact sports, motorcycles, skiing
  • Avoid alcohol, as it may slow healing of the injury
  • Avoid caffeine or "energy-enhancing" products as they may increase symptoms
  • Avoid pseudoephedrine-containing products as they may increase symptoms — check labels on cough, cold, allergy and diet medications
  • Avoid excessive use of over-the-counter sleeping aids; they can slow thinking and memory

Source: U.S. Department of Defense, Deployment Health Clinical Center

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McClellan, now 23, had a 1 percent chance of survival three years ago; he is now moving to Jacksonville, Fla., having enrolled at Florida State College.

He is one of the many returning Iraq and Afghanistan veterans suffering from traumatic brain injury. Traumatic brain injury has become one of the signature wounds of veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom. Although McClellan's brain injury came from a bullet, improvised explosive devices are the most common cause of such injuries. IEDs can been made out of almost anything and can be hidden anywhere.

A 2008 study by RAND Corporation, a nonprofit research group, found that 19 percent of returning veterans reported some form of traumatic brain injury. RAND estimates that 1.64 million Americans have served in Iraq and Afghanistan since 2001, which means that 19 percent equates to a staggering figure of approximately 320,000 servicemen and women.

According to RAND, the one-year costs for service members who have accessed the health care system for treating mild traumatic brain injury ranged from $27,259 to $32,759, and cases involving moderate or severe cases ranged from $268,902 to $408,519 in 2005.

Psychological and cognitive damage have long been a part of war, and medical science has not always been able to keep up with the specific nature of the injuries. During the Vietnam War, a system was created for diagnosing and treating veterans for mental health issues and for what would later be named post-traumatic stress disorder, according to RAND.

More recently, the departments of Defense and Veterans Affairs have taken steps to cover and treat veterans' brain injuries. The Department of Veterans Affairs has refined its treatment of veterans who have these newly recognized injuries.

Traumatic brain injuries are now a major focus of military medicine due to their high occurrence in returning combat veterans. However, the emotional and cognitive deficiencies resulting from exposure to a blast still remain something of a mystery, according to the RAND study.

Veterans with the most severe cases of traumatic brain injury are now under the care of the Defense Department, while the Department of Veterans Affairs helps veterans with milder cases.

It's the latter kind of injury that's harder to diagnose. Many servicemen and women who have been exposed to blasts go home and find themselves experiencing headaches and having difficulty remembering things and multitasking. Furthermore, combat veterans also find themselves behaving differently, especially having a lot of anger and outbursts. They also sometimes experience sensitivity to light, sleep problems, dizziness and balance issues. If left undiagnosed, the problems may stay with the veteran for months, years or the rest of their lives, the RAND study found.

Traumatic brain injury varies greatly with each individual. "Each concussion, or blast injury, will vary based on what they were doing, what kind of blast occurred, what kind of protection and where they were in relation to it," said Truman Veterans Hospital staff neuropsychologist Zachary Osborn.

McClellan's injury was caused by the bullet that destroyed some of his brain matter and the swelling that came right after, swelling similar to that which would be caused by an IED. "A brain injury tends to be a brain injury; it is unique to that individual," Osborn said.

The variation in symptoms and disabilities calls for treatment that is tailored to each patient. "It is not as easy as if you broke your arm; we would put it in a cast — six to eight weeks later you have a nice healed bone," Osborn said. "The brain will heal in individual ways and really depends on where in the brain the injury is located."

Four years ago, Dr. Lana Zerrer became involved with brain-injury treatment after she returned from a support mission in Kyrgyzstan and began working for the VA as director of the primary care service line. Zerrer began the post-deployment clinic, which is part of the "seamless transition" program that aims to shorten the time it takes for returning combat veterans to receive services.

Zerrer realized there was nothing specifically set up to help returning veterans enroll in the hospital's network. At a VA conference in Las Vegas, Zerrer saw a demonstration on how a few veterans hospitals had started a multidisciplinary clinic, and when she returned she helped start one at the Truman Veterans Hospital.

The veterans in the seamless transition program are screened for the most common post-deployment conditions, like post-traumatic stress disorder and traumatic brain injury. Zerrer said a lot of veterans don't even know they have it, adding, "the most important thing is recognizing it and getting screened."

Zerrer said that while waiting won't make a brain injury worse, is it best for veterans to begin treatment as soon as possible to help make their lives easier.

The first step is to test the veteran to see if he or she might have a brain injury. Then he or she is evaluated by a physical medicine rehabilitation team. The veteran is asked when the injury happened, whether there was more than one, and about symptoms.

Then the veteran is sent to the behavioral health team for evaluation. That's where Osborn comes in. As part of the team, he helps evaluate veterans for cognitive and mental health issues.

Though researchers are exploring ways to rebuild the brain, Osborn said the veterans hospital uses a holistic approach to treating its patients, working to improve the veterans' quality of life through therapy, medication and assistant devices.

One of those devices is a Global Positioning System. Osborn said veterans with a brain injury will often talk about getting confused while driving. "The GPS takes away one thing they have to keep track of so they can focus on what they are doing and what cars around them are doing," Osborn said. "It helps them not miss their turn, but if they do, it helps them find their way back."

The veterans hospital also provides some veterans with hand-held computers. These help the veteran remember daily activities and appointments and create a place to store useful information.

Osborn uses other memory techniques to aid veterans with memory problems, one being a visual list. He used the example of a grocery list, which, "instead of being written out, it now has pictures of objects to purchase."

Veterans are also enrolled in therapy sessions to work on relaxation and are learning how to recognize different sensations and emotions to reduce anger outbursts.

Veterans are invited to bring their families or come to couples' sessions. Osborn said it's important for families to work as a unit to create an environment that helps veterans "get back to living a life that they want to live, that is relatively free of difficulties."

Connie McClellan has seen how that works. "John has said many times; it was a huge help and comfort knowing I was his advocate and constant companion," she said.

From the very beginning she was at her son's side, including for the two months he was in the hospital. "I was there to spoil him, and I did a darn good job," she said with a laugh.

Her son began occupational, speech and physical therapy in late October 2006 at the James A. Haley Veterans Hospital in Tampa, Fla.;he left almost a month later. Back in Columbia, McClellan resumed his therapy at Rusk Rehabilitation Center for the next year and a half.

Connie McClellan said when her son first came home he could barely walk. He'd been an active person, so immobility upset him deeply. Once he relearned how to walk, his next challenge was learning how to jog and then to run. On October 25 of this year, McClellan plans to run in the Marine Corps Marathon in Washington, D.C. John McClellan turned down a request for an interview for this story, saying he was tired of being in the public eye.

In March 2007, after being home for a few months, he moved in with some friends as he tried to make himself more independent. For a while, he continued to have friends and family drive him to his therapy sessions. Then, in January 2008, he was medically cleared to drive.

Throughout the time he has been back in Columbia, McClellan has received routine checkups and care at the Truman Veterans Hospital, where his primary family doctor works. McClellan's mother said that thankfully, he did not need any neuropsychological treatment, as test results showed he did not suffer from post-traumatic stress disorder.

In spring 2009, he took an intermediate algebra class at Columbia College and got an A, proving to himself and his mother that he could handle college. In early August 2009, he and his mother drove to Jacksonville, where he is enrolled in college for next year, all of which is being paid for by the Wounded Warrior Project. The Wounded Warrior Project works with veterans to help them adapt to a college environment and also helps them overcome any deficiencies caused by their war injuries.

Though he still has minor short-term memory problems, McClellan thinks of himself as almost completely normal, and no longer needs his GPS for driving around town. But, since he moved, he keeps the GPS in his car just in case. This brings comfort to his mother, who bought him several maps of the area before she left.

Next year John McClellan hopes to enroll at MU to finish his degree in exercise physiology.

Connie McClellan sees a miracle in her son's recovery and continues to believe that someday he will be 100 percent. However, she realizes it may take more time. She is thankful for her son's perseverance and the progress he has made since he was first injured. "He used to call me, and by the time we got through our salutations he would forget why he called," his mother said. "He has not done that in a long time."

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Ray Shapiro September 16, 2009 | 11:42 a.m.

Missouri Peers for Vets
(Peer support for Veterans w/Mental Health issues, PTSD and/or Traumatic Brain Injury)
Thursdays @ 3pm
Truman VA Hospital, Columbia
Rm. B205
contact: Mike Naughton

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