Warfare has a way of generating new medical challenges for our military community, due to combat and exposure to stressful environments not typically experienced in ordinary life. For my last column, I can think of no better topic to share with you than that of a serious health issue affecting our men and women in the field: traumatic brain injury. The Department of Defense and the Department of Veteran Affairs are working together to raise awareness of TBI during March, which is Brain Injury Awareness Month. This campaign is designed to provide information and identify resources for TBI, a condition that has risen in incidence with our servicemembers and veterans as a result of combat in Operation Enduring Freedom and Operation Iraqi Freedom.

TBI is defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain; however, not all blows or jolts to the head result in TBI. The severity of such an injury may range from mild, i.e., a brief change in mental status or consciousness, to severe, i.e., an extended period of unconsciousness or amnesia after the injury. TBI can result in short- or long-term problems for individuals to function independently.

The signs and symptoms can be subtle and may not appear until days or weeks following the injury or may even be missed. In a blast, brain injuries can also occur by other means such as impact from blast-energized debris, the individual being physically thrown, burns and/or inhalation of gases and vapors. Although the number of people with TBI who do not seek care is unknown, it is estimated that only one third of OEF/OIF servicemembers and veterans suffering from TBI actually seek help.

Defense and Veterans Brain Injury Center

As America’s armed forces are sustaining attacks by rocket-propelled grenades, improvised explosive devices and land mines almost daily in Iraq and Afghanistan, these injured servicemembers require specialized care from providers experienced in treating TBI.

To answer that need, the Defense and Veterans Brain Injury Center (DVBIC), a tri-service collaboration between DoD and VA located at 16 sites around the world, works to identify all servicemembers who have sustained a head injury during combat operations and to ensure that they receive the best care available. In November 2007, DVBIC became the primary operational TBI component of the Defense Centers of Excellence for Psychological Health and TBI. The DVBIC is specifically committed to the effort to prevent, treat and provide research and education on TBI for U.S. military members currently on active duty; National Guard; reservists; veterans recently injured in the line of duty; their dependents; and retired military personnel. The DVBIC teams review all incoming casualty reports and provide clinical and screening standards for all patients injured in blasts, motor vehicle crashes, falls and gunshot wounds to the head. Brain injury specialists evaluate these patients and recommendations are made for treatment and duty status. Additionally, TBI educational materials are given to patients and families.

DVBIC Sets the Standard

DVBIC has been successful in addressing TBI through various working levels. As the DoD office of responsibility assigned by the Office of the Assistant Secretary of Defense for Health Affairs (OASD/ HA), the Center develops and maintains a TBI database that captures 25 variables on each patient with TBI. As the executive agency, DVBIC continues to work closely with the Armed Forces Health Surveillance Center and representatives from each branch of service to revise and upgrade surveillance methods and ensure accurate reporting. DVBIC has also been designated as the office of responsibility by OASD/ HA for oversight of pre-deployment neurocognitive testing through use of the Neurocognitive Assessment Tool Testing.

In January 2008, DVBIC provided recommendations for clinical guidance for acute and sub-acute evaluation and management of concussions in the continental U.S. These recommendations were compiled into a guidance document and were approved for immediate release by OASD/HA in May 2008. In August 2008, DVBIC participated in a consensus conference to evaluate and update the guidelines for the management of concussion in the deployed setting. This product was finalized and approved by the Military Department Joint Chiefs and the Central Commands, and adapted in November 2008 for immediate use.

Some other key accomplishments include the following:

DVBIC is congressionally mandated to work with VA to provide age-appropriate assisted living programs to severely injured TBI patients.

DVBIC established the first DoD virtual TBI clinic to provide remote screening, assessment and management of TBI. This program is being integrated with the Army Medical Department Tele-TBI initiative, as well as Air Force and Navy efforts to address similar resource issues.

Development of online TBI resources, Web applications and user forums which will allow patients, family members and providers to share common experiences and discuss challenges that relate to TBI in an environment that supports healing and personal growth, including an electronic consult service for providers with TBI patients (TBI.consult@us.army.mil).

Continued support for clinical transition of polytrauma patients between military and VA sites as needed by allowing interactive video communication between clinical teams, patients and families in remote locations.

In September 2008, www.brainline.org was launched in collaboration with WETA, the local PBS station in Arlington, VA, to provide information on preventing, treating and living with TBI.

DVBIC is currently conducting a 15-year longitudinal TBI study as mandated by Congress to determine the long-term consequences of combat-related TBI.

DVBIC is conducting a study to validate use of the Military Acute Concussion Evaluation in an austere environment.

The emergence of TBI within our military and veteran community will continue to pose many challenges for our healthcare providers. However, I share the sentiment of the DCoE’s Director, Brigadier General Loree Sutton, in citing that we are fortunate to have the experienced collaboration of DVBIC. As the primary operational TBI component for our armed forces, I am pleased with their success in addressing this serious health issue. I am confident that we will continue to make great strides in military medicine to provide the most advanced healthcare for our servicemembers and veterans who serve our country so bravely.

I pass on to my successor the importance of strong DoD and VA collaboration in providing the best continuum of care for those we are here to serve and of which it has been my utmost honor to do so. I thank U.S. Medicine for the opportunity to share our work.