MEDALS
Purple Heart, 2 Army Commendation Medals, Global War on Terror, National Service Medal, Afghanistan Campaign Medal, Combat Infantry Badge, Airborne Tab and Wings, Combat Patch with the 82nd Airborne Division.
“It is a black box of injuries. It’s is one of the most complicated injuries to one of the most complicated parts of the body.”
—Dr. Alisa D. Gean, in “War Veterans’ Concussions Are Often Overlooked,” The New York Times, August 26, 2008
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THE EXPERT CONSULTANTS: OUR PATIENTS
By Kelly Petska, PhD, and Donald MacLennan, PhD
Shortly after the invasion of Iraq in March of 2003, service members wounded in combat began to be referred to Department of Veterans Affairs (VA) hospitals for rehabilitation. The injuries sustained by these young men and women ranged from mild to severe, and were often complicated by cognitive impairments associated with brain injury and/or post-concussive syndrome, mental health disorders, or a combination of the two. This pattern of injuries to multiple body parts or systems has been termed Polytrauma. The VA responded to this challenge by rapidly developing a continuum of rehabilitation services called the Polytrauma System of Care (PSC).
Initial efforts of the PSC focused on acute rehabilitation. While VA’s acute care facilities were providing comprehensive, state of the art rehabilitation, transitional rehabilitation services were extremely limited in the VA system. In 2006, a summit was held in Washington DC, gathering experts in brain injury rehabilitation from the VA, the Department of Defense (DoD), and the private sector. These experts outlined a plan for the development of transitional care within the VA system.
Transitional rehabilitation typically occurs between acute—the initial period of hospitalization after injury—and outpatient services, but these services can be helpful to those who are struggling in the community as well. The mission is to improve the transition from a medical environment back into the soldiers’ own community. Programming emphasizes skills needed to independently manage daily living, resume social roles, and engage in the workforce, school system or a volunteer setting.
While many people with brain injury and/or post-concussive syndrome are able to successfully transition into their community, supported by outpatient services, others require additional services to successfully resume their former roles. Cognitive impairments—meaning problems in thinking skills such as memory, perception, problem-solving, conceptualization or attentional deficits—present more significant barriers to community participation than do physical impairments after a brain injury. For this reason, cognitive rehabilitation becomes the centerpiece of transitional rehabilitation programs.
To develop the Polytrauma Transitional Rehabilitation Program (PTRP) at the Minneapolis VA Medical Center, we turned to the 35–40 years of literature on cognitive rehabilitation to develop programming that was consistent with best practice in the treatment of cognitive impairments, social skills, independent living skills and vocational pursuits. As patients came into our program, it became clear that they reflected both ends of the spectrum: half the patients presented with moderate-severe Traumatic Brain Injury (TBI) and the other half presented with mild TBI and symptoms of Post-Traumatic Stress Disorder (mild TBI/PTSD). Review of outcomes revealed that those with moderate to severe TBI were clearly benefiting from the programming; however, those patients with mild TBI/PTSD were showing less benefit.
While there were similarities among patients with moderate-severe TBI and those with mild TBI/PTSD, there were also distinct differences. Both groups presented with impairments in attention and memory as well as difficulty in social situations. However, patients with mild TBI/PTSD were aware of their impaired abilities as opposed to those with moderate-severe TBI, who had greater struggles with insight. In fact, some of the mild TBI/ PTSD patients showed a hyperawareness of symptoms. This presented itself when patients would have frequent physical complaints based on minor changes from their own personal baseline and spend considerable time focusing on these differences. For example, some patients focused on their physical symptoms; these complaints changed frequently, and even after being evaluated by proper medical staff were found to have no medical basis; thus the symptoms were likely psychological or emotional presenting as physical symptoms.
In addition, patients with mild TBI/PTSD showed an ability to learn readily, while patients with moderate-severe TBI often required extensive practice to develop skills. For example, when learning how to utilize an external memory aid, such as a palm pilot, the patients with mild TBI/ PTSD showed rapid learning and often required minimal instruction, while the moderate-severe patients required extensive practice and multiple cues. We also witnessed mild TBI patients who learned to use complex functions of the palm pilot, without staff instruction, over a single weekend and taught other patients in the program how to download audio and video files and to surf the internet with the palm. Given this faster rate of learning, patients with mild TBI/ PTSD appear better able to accelerate their participation in vocational programs than do patients with moderate-severe TBI. While this may seem like an obvious conclusion, it took increasing tension to make the point clear.
As the cohort of patients with mild TBI/PTSD grew, patients increasingly began to complain about particular aspects of PTRP. The complaints centered mainly on policy and procedural aspects of the program. For example, patients became agitated with locked cabinets that couldn’t be accessed without staff assistance. This fell under hospital policy and was not specific PTRP policy. While this cohort was focusing on their displeasure on program policy and procedure, it became apparent to staff that the real issue may have been that the clinical programming being offered was not meeting their specific needs.
The literature on cognitive rehabilitation is overwhelmingly focused on people with moderate-severe TBI. While literature exists for treatment of mild TBI and treatment of PTSD individually, there is little to no literature on how to treat those with both mild TBI and PTSD. This raised the question: “What do we do now?”
We chose to use the patients as expert consultants to assist us in developing programming that would better meet the needs of patients with both mild TBI and PTSD. We held a focus group and asked these mild TBI/PTSD patients what they wanted to achieve and their barriers to achieving these goals. Three main responses came out of this focus group: 1) Their struggle with social anxiety and social issues due to symptoms of PTSD; 2) Their cognitive impairments, such as attention and memory; and 3) Their concerns about their ability to return to or attend college/additional training. This focus group allowed the multidisciplinary PTRP team to develop additional, more appropriate programming based on these expert opinions.
Based on the feedback from the focus group, we created additional programming for the mild TBI/PTSD patients focusing on their issues related to PTSD and other trauma-related symptoms such as depression or anxiety. For example, we started a group focusing on emotion regulation, with emphasis on healthy, appropriate expression of anger. This group included psychoeducation, processing of current stressors (not trauma), and learning new skills/strategies for expression. For example, some patients learned how to verbally communicate their emotions more effectively while others learned how to recognize their anger based on their physiological response (e.g. increased heart rate, sweaty palms, or clenched jaw). Recognizing their physiological responses allowed them to use relaxation strategies to calm themselves down, versus responding out of anger or succumbing to other emotions and thus increasing the escalation.
Other changes included mental health providers modifying current PTSD treatments to accommodate for the cognitive impairments that each patient experiences for one-on-one sessions. Some examples of modifications included shortening handouts to make them individualized and less complex, using more bullet points and less technical language, making handouts/homework specific to the patient’s struggles, and offering shorter sessions with more repetition.
While both
groups of patients endorsed, or were identified, as having difficulty with social situations, it was clear that the differences were significant. Mild TBI/PTSD patients noticed that their anxiety often involved specific social situations, which led to their avoidance. They also reported feeling over-stimulated or fatigued, likely due to a combination of attentional impairment, hyper-vigilance and social anxiety. For example, one patient reported having a party in his home with close friends with whom he knew and trusted. The over-stimulation of multiple conversations and music resulted in a feeling of increased anxiety. This increased anxiety, over time, caused the patient to avoid such social situations.
In addition, their insight into their deficits can cause increased social anxiety (e.g., “I know I can’t follow this conversation, what if they ask me a question?”) Finally, they also reported a reduced range of emotions, often with the exception of anger. This reduced range of emotions often led to statements such as, “I know I should be happy that I have a new healthy baby, but I just don’t ‘feel’ anything.”
This presentation is quite different from moderate-severe TBI patients, who often have difficulty with social situations due to impulsivity, the need to learn or re-learn social skills, and an inability to pick up on social or non-verbal cues. Thus it made sense that we have different groups of social skills for these two distinctly different populations. The mild TBI/PTSD patients participated in social skills groups. These groups included psychoeducation regarding relaxed breathing training (including sympathetic and parasympathetic nervous system education), PTSD and other mental health symptoms, biofeedback (technology that allows patients to immediately see their physiological response, such as heart rate or body temperature), and gradual exposure to uncomfortable emotions/feelings by going into perceived stressful situations or community settings. Sometimes the exposure can be as small as walking through the VA cafeteria during lunch time or as big as going to the Mall of America. The idea was that it would start with a small outing on the VA campus, and gradually increase to outings outside of the hospital with increasing stimulation (an increase in the number of people, crowds, noise, distractions).
One area in which patients with mild TBI/PTSD and moderatesevere TBI showed great similarity was the area of cognitive impairment. Patients with mild TBI/PTSD ranked memory difficulties as one of their greatest concerns, often on a par with PTSD/trauma-related symptoms (including depression). Patients with mild TBI/PTSD also endorsed difficulty with attention. Often, their complaints centered not so much on slowed cognitive processing but rather on distractibility. They shared with us that they could be engaged in conversation, smiling and nodding, but mentally they were distracted to the point of not following the conversation up to several times per minute.
Patients speculated that this might be related to the skilled vigilance they developed while in the combat theater. They reported being taught to develop a 360-degree sense of vigilance. They indicated that their ability to divide their attentional focus over a wide-area may have come at a cost of losing their ability to selectively focus their attention on one thing. Patients believed the consequence of this attentional impairment to be quite significant. Three of the patients with mild TBI/PTSD wanted to go to school but expressed concerns regarding their ability to listen to a lecture and take notes.
One treatment approach that worked well for attentional impairment was self-instructional training, or self-talk, which is a technique used successfully to improve attention with children with attention deficit disorder (ADD). Self instructional training involves periodic mental rehearsal of adaptive behaviors that may improve functional behavior, for these purposes, listening. Patients practiced thinking the phrase, “I will focus on the speaker, and try to echo each word in my head as it is said” at intervals as they engaged in conversation or school lectures. Over time this approach improved patients conversational listening skills. Two patients used this technique to improve concentration while watching videos of school lectures by actual college professors. Initially, both patients identified well over 40 episodes of distractibility while viewing a 30-minute lecture. After extensive practice, over a 3–4 week period, the moments of distractibility for each patient decreased by nearly two-thirds.
Three out of four of our expert patient consultants expressed an interest in going, or returning to, college to pursue a career. They all voiced concerns about their ability to return to school with cognitive impairments in attention and memory. Our consultants participated in a simulated college experience, including a series of lectures and tests that assessed their ability to learn college-level information. Lecture content focused on the nature and consequences of brain injury (e.g. cognitive impairments and treatment strategies) as well as on academic strategies (e.g. how to read and retain information from chapters and test-taking strategies). In between lectures and tests they were coached on study-techniques and compensatory cognitive strategies to improve cognitive skills.
All three of our consultants experienced considerable difficulty learning information as they began the college simulation. Two clearly showed improved performance as they progressed through the program (and they are currently taking college courses). Unfortunately, one of the patient’s injuries aggravated his pre-existing ADD and dyslexia. Based on this experience, he came to the realization that he was unlikely to succeed in college. However, this realization has allowed him to pursue a vocational track, which he began working toward in our PTRP program and continued in his home community upon discharge.
Traumatic Brain Injury has been described as the “signature injury” of the wars in Afghanistan and Iraq; however, we suspect this perception may change given the significant number of combat veterans with symptoms of mild TBI and PTSD (and potentially other mental health symptoms) that are so prevalent in these conflicts. We believe it is this combination of mild TBI with PTSD that will ultimately come to be seen as the signature injury for returning OEF/OIF service members. Oddly, war has a way of advancing medical practice and forcing providers to make changes in health care delivery, as we described above. The Chinese word for crisis is “dangerous opportunity.” The crises experienced by the heroic men and women coming home with a complex presentation of injuries may in fact be an opportunity to change the face of rehabilitation—to find a way to blend traditional rehabilitation practices with those of mental health treatments in order to provide the best treatment future to those we serve. Not only are these men and women changing the course of history with their military contributions; their contributions as expert consultants are helping to change the future of rehabilitation.
“Some soldiers who suffer from PTSD are reluctant to share their experiences in traditional psychiatric therapy, said Colonel Charles Engel, an Army psychiatric epidemiologist. He said those soldiers may be more willing to use acupuncture and other alternatives if they are effective.”
—“Pentagon Researches Alternative Treatments,” Gregg Zoroya, USA Today, October 9, 2008
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WAR CHANT
The Story of Sergeant John “Medicine Bear” Radell
“We knew not everyone was the enemy, but no one told us how to tell the difference. I wound up killing a 12-year-old boy because I thought he was an insurgent getting ready to throw a grenade. I killed a man and his wife and the small child she was holding in her arms when their car wouldn’t stop at our roadblock. When reality set in and I realized what I had done I tried to talk to my superiors, but they basically said, ‘Suck it up and drive on.’ It’s one of those demons I’ll always live with as a soldier.”
John “Bear” Radell deployed for war in Iraq with the California National Guard’s 1498th Transportation Company on May 15, 2003. He was thirty-five. His mission was to supply, service, live in, drive and provide protection for Heavy Equipment Transporter Systems (HETS), recovering and hauling everything from M-1 battle tanks and Humvees to Port-o-Johns across war-torn Iraq. He would be attacked, ambushed, blinded in sandstorms, swelter
in 130-degree heat and perform dangerous, two-week-long convoy missions without adequate body armor, radios or supplies, including, at times, basic parts to his truck such as cab doors that could open and shut. For John the roads crisscrossing Iraq were like the endless rice paddies of Vietnam. By the time he was injured on July 22, 2003, he had either experienced firsthand or observed enough violence, killing, torture and mayhem to sear his psyche forever.
“Camp Liberty in Kuwait was a grim, hot, sandy tent-city. There was a military mess tent and not much else. We lived in containers for the first couple of weeks to acclimate, and then we were off and running. What we found out was that, despite what they told us at briefings, each time our supply convoy went out the action changed to front line combat conditions. This was nothing remotely like simple supply runs. To make things more disorienting, our rules of engagement changed on a daily basis.”
Most roads held the potential of ambush, and some, like the highway between Baghdad and its airport, guaranteed a drive fraught with danger. Bear got used to living out of the truck for fifteen days at a time and driving for days without sleep in dust so thick he could seldom see the truck in front of him. Since he was trained as a weapons specialist it wasn’t long before he was moved from the driver’s seat to the turret of a converted Humvee with a 50mm machine gun in hand instead of a steering wheel.
On his “Alive Day” the convoy was traveling north to Mosul to supply the 4th Infantry Division. Suddenly an IED hit the truck in front of the one Bear was protecting. It was the start of an ambush. For an instant he could neither see nor hear, the blast was so close. Moments later a bullet from an AK47 slammed into his right leg just below the knee. “At the time I was oblivious to my injury. We were in the midst of a firefight, and guys were going down all around me. Then I saw the corporal. He had grabbed his video camera and was taping the action while four of our personnel lay dying on the ground at his feet. I was so angry that when the firing stopped I went after him; and then his brother, who was also in our unit, went after me. Two days later I took after him again, but this time a battle buddy knocked the rifle out of my hands.”
Hidden Battles on Unseen Fronts Page 7