A recent University of North Carolina study showed that the average college football player receives over 900 blows to the head in a single season. In the pros it is even higher. In Iraq and Afghanistan virtually every soldier and marine is exposed to blast waves during each deployment and there are numerous Marine and Army units who have been deployed multiple times.
There are now autopsy studies that show that NFL players with early dementia do have significant anatomical changes to their brains and one would expect that much of the bizarre, if not anti-social, behavior of professional football players may well be the result of brain changes secondary to the repeated traumatic injuries.
In February of 2011, the former Bear safety Dave Duerson died of a gunshot wound. His death at age fifty was ruled a suicide. Duerson was picked by the Chicago Bears in 1983 after four years of football at Notre Dame, playing eleven seasons in the NFL, including two Super Bowls and four Pro Bowls. Experiencing bankruptcy and depression and apparently overwhelmed by the anguish of feeling that he was not the same person he had been, without quite being able to figure out why—so much a part of having a traumatic brain injury—he shot himself in the chest and not in his head in order to save his brain for analysis. Before he killed himself, Duerson left a message for his family to donate his brain to the NFL-supported Center for the Study of Traumatic Encephalopathy, a collaborative venture between Boston University Medical School and the Sports Legacy Institute that is engaged in research into the causes, progression, and characteristics of what is now called the “concussive crisis” in contact sports. If there is a potential crisis in contact sports, there is surely a concussive crisis in Afghanistan.
It is this whole issue of the cumulative effects of so-called mild sports-related concussive injuries that led to a first for the media. On Saturday, December 11, 2010, The New York Times reported that a rookie corner back had been arrested on a charge of felony sexual assault. What was different about the Associated Press report was the last paragraph. “The assault was said to have occurred after the player sustained a concussion …” What the reporter felt compelled to add to the article is ignored by the Government and the Pentagon. What is clear is that the accused player did have multiple helmet-to-helmet collisions. There is every reason to expect similar strange, if not dangerous, behaviors in those troopers repeatedly exposed to IEDS.
The researchers in neurology and neurosurgery, as well as neurophysiology, have predicted that the Twenty-first Century will be the century of the brain. The advances in real-time brain imaging techniques, nerve cell physiology, neuro-anatomy, neuronal receptor site analysis, along with reliable cognitive function testing, is beginning to bring to the study of the brain the same understanding that heart scans, stress tests, echocardiograms, lipid profiles, EKGs, and coronary angiograms have brought to heart disease and heart attacks.
That knowledge has proved so accurate and so universal that the husband who is a smoker, overweight, doesn’t exercise, has a high cholesterol level, and who wakes in the middle of the night with “heart burn” and says to his wife that it must have been the pizza he ate, is simply ignored as the wife reaches for the phone and calls 911.
But actual brain damage from head injuries remains a contentious issue. The problem is what it has always been in medicine, that in order to have a physical cause for a symptom you need to find a physical change or some other measurable abnormality, anatomical or biochemical, somewhere within that organ system that is supposedly not functioning normally. You need a real cause to go with the observed effect. And that is where we now stand with brain injuries. The real issue is whether we have diseases of the brain or simply diseases of the mind, or maybe, like mass and energy, that the two are inextricably intertwined.
Occasionally in medicine, the history of a single person can best and most dramatically represent the struggle to first understand and then begin to cure a disease or treat a physical abnormality. Pasteur’s history is the science of first discovering the cause of rabies and then actually treating the disease. Jonas Salk’s and Albert Sabin’s biographies are the story of curing polio. And in a very real, if less dramatic way, the professional story of Marilyn Lash is the history of brain injuries and the struggle not only to get things right, but to do something to treat, or prevent, the injury.
In the mid 1970s, Marilyn was a social worker in a regional hospital’s rehabilitation center. At the time, the Vietnam veterans were being treated in VA hospitals and outpatient clinics. Very few of those soldiers and marines with significant enough brain injuries to have ended up in a rehab center survived to make it back to the States. The majority of them were usually killed where they were hit. But at the time, the rehab facilities in the States were beginning to receive significant numbers of civilian survivors of brain injuries. With the advances in emergency room medicine and trauma care, civilians were surviving serious brain injuries.
The early 70s had seen the development of CT scans to help diagnose severe brain injuries, while intra-cranial pressure monitors, measuring pressures within the brain and the skull, had begun to be used in the nation’s neurosurgery units. It is the rapid rise in intra-cranial pressure following head injuries, rather than the initial trauma, that leads to the real brain damage and ongoing neurological damage, by compressing the brain and cutting off the blood supply and oxygen, causing brain cells to die.
The ability to monitor pressure warned physicians that things were quickly worsening. This allowed them to begin medical treatments to lower the pressure or to surgically remove any expanding blood clots surrounding the brain before any additional and irreversible damage to the brain cells occurred.
But survival did not mean a cure. The higher salvage rates meant that more patients were surviving but with more serious brain injuries and ever greater long-term disabilities. At times medicine can be a zero sum game. Most of these survivors were truly in desperate shape and needed all types of rehabilitation from physical therapy to occupational therapy, to cognitive interventions along with seizure control, and the prescribing of the appropriate psychotropic medications. The need for social workers to organize the rehabilitation programs for brain-injured patients escalated as the numbers of patients who survived significant injuries continued to increase.
When this was happening, the cost of care was skyrocketing. Insurance companies were increasing reimbursements for all kinds of medical services under, what at the time, were the basically unlimited fee-for-service contracts.
It was before HMOs and Managed Health Care. Insurance companies were issuing medical and hospitalization coverage much the same way that they handled car and home insurance; they simply charged premiums and then paid what was asked. That didn’t last long, but it lasted long enough. A number of private for-profit rehabilitation companies, including some national chains, taking advantage of the generous reimbursements, entered the market, and with these companies in play and the influx of cash, there was an explosion of brain research as well as treatment programs.
Marilyn and others within the brain injury rehabilitation field were able to expand their programs and services, along with hospital stays that allowed comprehensive care, resulting in considerable improvement in the patients, as well as a growing sense of relief among family members.
But with the arrival of HMOs and managed care, reimbursements for hospital stays for patients with brain injuries went from an average of several weeks, and sometimes months, to under two weeks. Rehabilitation services in all their forms were drastically cut, with the care of these patients simply outsourced to their families.
Marilyn Lash, like so many in the field of medical rehab, was unable to do her job. Frustrated with the growing gaps in services, along with decreased funding of virtually everything to do with hands-on patient care, she shifted from clinical social work to program development, hoping to get federal grants to continue some funding for rehabilitation programs. It was slow going but she eventually became the director of The Researc
h and Training Center on Childhood Trauma at Tuft’s New England Medical Center. But there was also a personal commitment to the treatment of brain injuries.
With the death of her parents in the middle 70s, she, and an older brother, had become responsible for the care and support of a middle brother who had suffered multiple concussions while playing both high school and college football. He eventually had to drop out of graduate school and, over the years, became increasingly disabled and eventually unable to live independently.
Marilyn had not only seen the professional lack of interest in brain injuries become a major medical problem, but was now having to deal with that disinterest personally. She had seen as a program director, as well as a caregiver, that both organized medicine and the health care industry would not address, much less fund or support, the long-term treatment needs of those with chronic conditions, including brain-damaged patients. There was no understanding, much less an acceptance, of the long-term effects of what were considered to be no more than minor concussive injuries.
Frustrated and angry, she experienced the terrible struggles shared by so many caregivers as they try to pull together services and supports within their local communities for loved ones abandoned by their physicians and their health plans.
She eventually tired of the cycles of writing grant proposals and reports for federal and state agencies that were ignored, and decided to go directly to the patients and their families. In the early 1990s, with her husband, Bob Cluett, who overcame a traumatic brain injury as a child, she launched a publishing company that provided user-friendly, practical information to individuals, family members, and caregivers struggling with the results of brain damage and brain injuries. If the medical community, the health care industry, and the federal and state governments would not take care of these patients, they and their families would have to learn how to do it for themselves.
What Marilyn understood, two decades ago, and even more so today, was that the institutions dealing with the brain-damaged patient had become dysfunctional, while the brain injury research field, as well as the diagnostic and treatment facilities, had become so decentralized that everyone and no one was in charge.
Patients with brain injuries were under the care of neurologists, neurosurgeons, brain trauma experts, emergency room doctors, psychiatrists, psychologists, physiatrists, physical therapists, occupational therapists, speech and language pathologists and researchers—all doing their own thing. There was little if any coordination across disciplines or among experts.
Initially, the problem for brain-injured patients and their families had been diagnosis, and while that was in many cases still an issue, the real problem had become who did you call, or could you call, at two in the morning when things were not going well or as expected? The caregivers would not only have to learn the facts about brain injury as they were known, but they would have to learn the trade of brain injury care.
Marilyn and her husband formed Lash & Associates Publishing/Training Inc., a publishing house devoted entirely to making it easier to understand, help, treat, and live with brain injuries in children, adults, and veterans. Lash and Associates quickly became a leading publisher on acquired brain injuries and published individual research papers, while putting together seminars featuring the various experts in the many fields of brain injury. The company also developed an editorial board made up of academics who were leaders in the various fields of neurological disorders and injuries.
Lash and Associates became a cutting edge resource for both practical and user-friendly information on brain injuries. The new business venture allowed Marilyn to maintain her own expertise in the administrative areas involved with brain injuries along with the newest advances in diagnosis and treatments while remaining focused first and foremost on patient care.
With the beginning of the Iraq/Afghan Wars, soldiers and marines began experiencing different kinds of shock wave brain injuries. The insurgents in Iraq and the Taliban in Afghanistan had switched from organized ambushes and frontal attacks to IEDs and roadside bombs targeted against vehicles and foot patrols. These casualties quickly become the largest and newest group of brain-damaged patients. They also proved to be the most problematical for both diagnosis and treatment and were initially ignored by the medical establishment, the military, and certainly the country. The increasing numbers of these patients made the decades-long efforts of Marilyn and her husband more timely and more important. Yet, even today, these damaged brains, along with their concussive injuries, have not yet been acknowledged as the signature injury of our latest two wars, even as they increase every day.
Marilyn and her husband have made it a priority to address these newest forms of battlefield injuries by publishing and distributing books dealing with battlefield brain injuries including Down Range to Iraq and Back, a book that contains information and resource materials for returning troops and their loved ones. Once a Warrior followed, dealing with the tens of thousands of troops who have shown serious stress reactions upon their return home, and that was followed by Explaining Brain Injury, Blast Injury and PTSD to Children and Teens. It helps parents explain the physical, cognitive, behavioral, social, and communicative changes that can follow a brain injury from a blast wave as well as the development of PTSD as a symptom of a concussive injury.
The number of brain injuries occurring in both civilian life as well as the military is astonishing, especially when compared to the prevalence of other diseases and injuries within the population. There were 10,000 women diagnosed with breast cancer in 2010, 75,000 men with prostate cancer, and 150,000 hip and knee replacement surgeries in what is obviously an aging population, Yet across America, during that same year, well over 2.5 million people were seen in private clinics and hospital ERs and given a diagnosis of Traumatic Brain Injury (TBI). 500,000 of these patients were hospitalized with over 50,000 eventually dying from the initial trauma and over 80,000 of the survivors going on to develop long-term disabilities. Many of these survivors will go on to suffer severe depression as a result of the TBI. Add to this mix the fastest growing number of brain-injured patients in history—the combat blast victims fighting now in Iraq and Afghanistan—and you have a sense of the size and scope of the problem. It doesn’t help that blast injuries are clearly different and more confusing and longer lasting with a wider variety of presentations and symptoms than the usual civilian injuries— mostly falls, car accidents, and collisions on football fields—that result in blows to the head.
The Pentagon for its part has played down the ferocity of the fighting in Iraq and Afghanistan, but its refusal to acknowledge the growing importance of blast injuries as battlefield wounds is no more obvious than its refusal to award Purple Hearts to those with medically-documented evidence of concussive injuries from exposures to the blasts of IEDs. Indeed, at one time early in the Iraq War, the Departments of Defense, with the approval of Donald Rumsfeld, then Secretary of Defense, issued a moratorium on the release of all information regarding possible brain-damaged casualties, as well as those diagnosed with PTSD, among deployed active duty personnel, to any private organization or medical group.
The embargo of information extended to all public and private organizations, with a further restriction that these private organizations could not supply materials, nor give out any information or brochures, to patients or family members within any VA medical facility or outpatient clinic. Like so many of the official pronouncements about our wars in Iraq and Afghanistan, the reason for this moratorium was unknown and basically unexplainable. That embargo, however, ended with the shift to transparency under Secretary of Defense Gates and just in time for the 2010 surge of troops into Afghanistan.
The Department of Defense has become a major consumer of Lash and Associates publications. But just as the whole issue of AIDs finally came out of the closet with Rock Hudson’s acknowledgement that he had the disease, it was the traumatic brain injury to Bob Woodward of CBS News in 2005, resulting from an IED expl
oding under his Humvee, that raised awareness of blast wave injuries among the American public. The spotlighting of Woodward on the evening news made him both the victim as well as the poster-boy for this new type of battlefield wound. The military could no longer ignore the fact that its soldiers and marines are being blown up and that damage from blast waves is a real problem, both for the troops and for military medicine.
Recently the Pentagon released information that puts the number of troops with TBIs since 2000 at slightly over 180,000. Those in the field of brain injuries view that number as preposterously low. A recent Rand Corporation report, challenging the official data, raises that number to over 300,000 of all deployed personnel. But the real numbers of those injured by blast waves are likely much higher, the result of what is now being called mild traumatic brain injuries or mTBIs. These are patients who suffer episodes of lack of energy, listlessness, emotional liability, startle reactions, surprising lapses of memory, reduced decision-making functions, along with depression and loss of word skills—any or all, without ever losing consciousness or having any evidence of a focal injury or any changes on a CT Scan or MRI.
These so called “concussive effects” are notoriously difficult to confirm medically and most likely account for well over 85 percent of all brain injuries in civilian and active duty military populations. What is important is that these concussive effects can become more severe and more persistent with each additional head injury, or in the military with each exposure to a blast wave from another IED.
Still, the military is particularly reluctant to acknowledge a neurological condition that can elude the current imaging techniques as well as sophisticated brain scans. Yet, these are the very injuries that may unfold slowly over the course of weeks and months, becoming the kinds of symptoms that family members explain embarrassedly to their family physicians “I just don’t know what’s wrong, he’s just not himself anymore.”
Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan Page 13