Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan

by Ronald Glasser M. D.

  Even if you manage to survive the flying debris and projectiles set into motion by the explosive charge, the concussive effects of both wave fronts are by themselves substantial and dangerous. Military physicians have learned that significant blast injuries should be expected in any soldier exposed to an IED, whatever the distance from the explosion.

  The new U.S. German-style helmets with flared earflaps may protect against projectiles, but are not designed to absorb the force of an explosion. In a blast, the weight of these helmets only adds to the injury.

  “It’s like a pan on your head, held by a shoestring webbing,” an Army combat engineer explained. “When you take a hit, it rings your head like a bell.”

  A 2005 medical paper on casualties resulting from blast injuries cautioned that such injuries are “notorious for their delayed onset.” In truth, very few are spared the blast effects of a car or roadside bomb. It is the newest legacy of these newest American wars and a legacy that keeps increasing each month.

  This susceptibility of the brain to the physics of trauma has to do with the unique way the brain is put together and where it sits in the body. Resting on the neck, it is basically hung out there in the wind, suspended within a rim of protective fluid inside of the hard, unyielding surrounding shell of bones that make up the skull.

  Encased within the skull, the brain has no place to go when it starts to move either forward or backward, starts to swell, or becomes compressed from an expanding blood clot.

  If you have a motorcycle or car accident on a freeway, hit your head, and manage to make it to a major trauma center hospital alive, the ER docs and the neurosurgeons know exactly what to do and in what order to do it. They will not only be able to keep you alive, but with a little luck, be able to save your brain, and by extension, your mind. Keeping the two together and intact is no small thing. Ask anyone who has to take care of one of the 1.4 million traumatic brain injuries that occur in this country each year and he or she will tell you how inseparable and intertwined the two have always been, a connection made decidedly more obvious once the brain has been injured.

  As soon as you enter the emergency room as a “head injury,” have your blood pressure and breathing stabilized, the ER docs, depending on the degree and severity of the injury, put you into a drug-induced coma to slow down any ongoing damage to the injured brain cells and protect any of the remaining healthy cells from undergoing any secondary or collateral damage. They will, if there is overt difficulty in breathing or maintaining heart rates, add a calcium channel blocker to help stabilize the outer membranes of the injured cells, while maintaining normal intracellular metabolism. If your blood pressure becomes too high, the ER personnel will lower the pressures to protect against any re-bleeding into the brain and the causing of more tissue damage. If the pressures are too low, they will add medications to raise the pressures to maintain adequate blood flow to the brain and central nervous system, even if an injury is present. But that kind of protecting against any ongoing brain damage requires great skill and constant monitoring and can, at its best, become a very “iffy” thing.

  If the brain itself does begin to swell, they will start IV solutions of concentrated saline in the hopes of drawing off the accumulating fluids to control the swelling. If that doesn’t work, they’ll add an IV diuretic to drain the body of it own waters in an effort to keep down intra-cranial pressure. If the hypertonic fluid and diuretics don’t work, they will take you to the OR and have the neurosurgeons remove the sides of your skull to allow the brain to swell without compressing and damaging any of the still-normal tissues.

  Since the brain resides in a closed rigid space, the overriding idea behind removing parts of the skull is to relieve any increasing intra-cranial pressure that could further damage the brain. When the swelling has finally begun to resolve and the brain is back to normal size, the surgeons will simply put back the part of the skull that had been removed and wait for the patient to recover. It works and has worked thousands of times each year in emergency rooms and major trauma centers around the country and around the world.

  But a brain damage from the shock wave of an IED is a different kind of injury. That first became evident when the usual treatments for head injuries didn’t work. There is something unexpected going on down at the cellular or sub-cellular level of the brain following an exposure to a pressure wave that is not the same as getting hit on the head during a car accident or from a fall in the bathroom. We have a new kind of war and should have expected new kinds of wounds and causalities. Brain injuries from IEDs are different from all the usual kinds of neurological war injuries such as damaged spinal cords, penetrating head wounds, or skulls simply blasted apart.

  And this new kind of war, with new kinds of wounds, is here. Roadside bombs killed 268 Americans in Afghanistan in 2010, a 60 percent increase over the previous year, even as the Pentagon tries to employ new methods to counter these weapons. The numbers of wounded by these weapons has also soared and is on an even higher trajectory for 2011, with over 3,000 U.S. service members injured enough to be evacuated from the combat areas. The problem in detecting these bombs in Afghanistan is that these IEDs are remarkably less sophisticated then the IEDs used in Iraq, typically relying on fertilizer and diesel fuel, these explosive devices made by the militants in Afghanistan cannot be scanned by electronic devices to jam their frequencies because these bombs lack the circuitry that make them easy to detect and disarm or destroy.

  A bewildered neurosurgeon at one of the Combat Surgical Hospitals in Iraq was heard to say in early 2004 that he’d rather take care of a patient with a penetrating head wound, “that way there is only the damage along the track of the bullet.”

  Congresswoman Gabrielle Giffords survival and recovery following being shot in the head at the Tucson supermarket is a graphic example of the neurosurgeon’s preference. Following the bullet entering the left side of her skull, the major damage to the congresswoman’s brain was only along the path of the bullet. The bullet itself did not cross the midline of the brain, where it surely would have damaged any number of vital structures, not only connecting the brain’s right and left hemispheres, but those areas necessary to maintain adequate respiration and normal heart rate. Apparently the speech center on the left side of her brain was significantly damaged, and the immediate surgery cleared away the damaged and dying tissues, along with any bullet fragments and pieces of bone and at the same time removing the blood clots, allowing the repair of any damaged blood vessels and hopefully limiting any further damage from infections or additional bleeding, giving the congresswoman the chance not only of surviving, but the ability to overcome what was sure to be significant speech, emotional, and cognitive defects. A gunshot wound to the dominant hemisphere is never fully recoverable. But the fact that the bullet was a 22-caliber round rather than a larger bullet helped to limit the type, degree, and severity of damage.

  Had the congresswoman been in Iraq or Afghanistan and instead of a 22-caliber bullet entering her brain, she’d been struck with a large shock wave an exploding roadside bomb or IED, she might well have survived, but the injury to other parts of her brain rather than just the damage along the track of the bullet would have made any chance of a major recovery close to zero.

  With a blast injury, you may have to deal with damage to most of the brain. Blast injuries affect more widespread parts of the brain than the typical shell fragment injury or bullet wound. It is an understanding that is shared by everyone involved with caring for a patient following a closed-head injury from a roadside bomb.

  The irony, as so often happens in any new war, is that ingenuity can always trump traditional tactics and weapons. IEDs employed by the insurgents in Iraq and the Taliban in Afghanistan have become the low-tech answer of an enemy that lacks the firepower to confront a modern army and so becomes, not only the weapon of necessity, but the weapon of choice.

  Strategically, IEDs have let the insurgents in Iraq and the Taliban in Afghanistan take ad
vantage of our tactical mistakes. There were not enough troops on the ground in either country to offer real security, forcing our units to be constantly shifted from one contested area to another. That movement opened up the poorly-guarded highways and undefended roads to both ambushes and the planting of increasingly sophisticated, and more lethal, IEDs.

  And all of this without forcing the enemy to concentrate their forces and run the risks from artillery, helicopter gun-ships, and bombing runs of low-flying fighter planes. In these untraditional wars, or what the military call “asymmetrical conflicts,” the enemy doesn’t have to win, they just have to not give up.

  It is clear though that neither Al Qaeda, the Shiites, the Sunnis, or the Taliban had any idea about the intrinsic subtleties of brain function or the effects of blast waves on the higher cognitive functions, or even basic neuronal activity, when they picked the suicide bomber, car and truck bombs, and roadside IEDs as their weapons of choice. For them, the unexpected brain damage is no more than a lucky battlefield by-product of their kind of war. But for us and our own, these weapons have become a terrible problem, not only as a sledge hammer able to disable tanks and kill a dozen of our troops at a time, but the cause of a new kind of collateral damage that we are only now beginning to understand and may some day be able to treat.

  The fact that the usual treatments for traumatic brain injuries turned out not to work as expected in Iraq and Afghanistan, came as its own kind of shock to the military neurologists and neurosurgeons. There were all kinds of initial but foolish theories about the neurological damage following exposures to the blasts, that ran from the release of tiny air bubbles within the microcirculation of the brain following exposure to a shock wave, to damaging individual brain cells through some kind of cellular injury due to the inhaling of neurotoxic substances from the acrid smoke of the explosive charges themselves.

  The point is that nobody understands why the brains of soldiers and marines exposed to blast waves do not recover. A Rand Report published this year stated that over 300,000 of our combat troops had been exposed to one or more IEDs during their deployment and those numbers do not contain the results from our latest “surge” in Afghanistan.

  Civilian neurologists have always worried about the long-term effects of concussive injuries. But they drew comfort for themselves and their patients if the head trauma did not result in immediate unconsciousness or confusion, or if the effects lasted less than a few minutes, and amnesia for the event didn’t exceed twenty-four hours. They drew even more comfort if routine CT scans or MRIs did not show any evidence of a significant anatomical injury, including hemorrhages or small areas of tissue swelling.

  If the injuries fit those criteria, the feeling was that there was little to worry about and few long-term concerns, even if there were a few days of headaches following some initial nausea. A general consensus developed within the medical community that a head trauma patient without any initial obvious signs of significant brain injury and negative imaging studies did not have a significant “concussive injury” whether as the result of an accident on the freeway, falling off a bicycle, helmet-to-helmet contact on the football field, or being near an IED.

  The standards for diagnosing a mild Traumatic Brain Injury or mTBI had been set quite high, which was comforting to everyone except patients and their families. But being comforted in medicine isn’t necessarily being correct. What is now becoming obvious is that exposure to the wave front of an exploding IED is different from hitting your head during a fall, being hit on the head with a hammer, or being thrown from a car during an accident.

  There was concern about this whole medical DWT or “Don’t Worry Thing” concerning the long term effects of mTBIs, or what some neurologists insisted on calling mild concussive injuries. After all, there was the medical, as well as the fictional, literature on the punch-drunk boxer. Traditional medical views aside, being hit in the head has always caused significant and unexpected neurological problems.

  During the 2008 baseball season, the center fielder for the Minnesota Twins, racing backwards to catch a fly ball, lost his balance, fell backwards, and hit his head on the Astroturf. The ballplayer experienced some initial confusion, which cleared by the next inning. The CT scans and MRIs showed nothing abnormal. But the player had lost his fine-tuned coordination, or at least the necessary coordination, to hit a ninety-seven mile an hour fastball. He was never again the hitter he had been before his head hit the Astroturf, and he was forced to withdraw from baseball at the end of the following season. Even seemingly minor head injuries can have profound and lasting effects.

  There have always been those few sports medicine physicians who point out the absence of any concussive injury in contact sports where the players do not wear helmets. According to those physicians, the brain is not put in danger from the risky behaviors of the helmeted sports where the players launch themselves full speed and head first at one another.

  Only recently has the National Football League documented severe dementias in former players at unexpectedly early ages. For the most part these are players who had multiple helmet-to-helmet episodes during their college and NFL careers. A few such contacts may have led to symptoms of disorientation, as well as headaches, for minutes if not hours, yet the majority of these helmet-to-helmet contacts were simply shaken off and the players put back into the game.

  The League has recently been challenged by family members, as well as some physicians, that the increased incidence of dementia in these professional players, the majority in their late fifties and early sixties, is out of proportion to the incidence of dementia in other men their ages in the general population. It appears that what initially can be dismissed as trivial head trauma—no loss of consciousness, no seizures, no persistent confusion or observable lethargy, especially if repeated—can and does lead to persistent and significant functional and cognitive disabilities.

  The National Football League, while still refusing to officially admit to the physical damage caused by head trauma, has instituted a policy that finally goes beyond the medical “Don’t Worry Thing” about being “dinged” or “having your bell rung.” Anyone experiencing helmet-to-helmet contact and showing any signs of a concussive injury will no longer be allowed to play again for a full week. If there are headaches or any signs of confusion, there will be no playing for two weeks or until all the symptoms have disappeared. Beginning in 2007, there was to be an additional cognitive evaluation that entailed problem-solving and mental nimbleness that the athlete had to pass before being allowed to play again. Football is violent, but then again, so is war.

  Everyone agrees to the explosive power of the present day IEDs, yet there is reluctance on the part of the Pentagon, military physicians, and the VA, to entertain the possibility that exposure to these blasts, even dozens of meters from the detonation points, can lead to significant neurological injury and the accompanying functional impairments.

  If there is reluctance on the part of the country to understand or be concerned about the dangers as well as the sufferings of those who currently fight our wars, there is an equally a great refusal on the part of the military to acknowledge the damage due to traumatic brain injuries.

  These are the soldiers and marines, men and women, who return home from deployments somewhat dazed and a bit forgetful, with headaches and poor balance. Their husbands and wives, fathers and mothers, sometimes wistfully mention to friends and relatives that their returning loved ones never acted like this before, adding simply that they are just not themselves anymore. Those in the Pentagon who refuse to acknowledge these changes as problems, much less as wounds, are caught in another time and in a different place. Reality has left them far behind and they are back to wishful thinking.

  The immediate medical issue though, is not whether exposures to IEDs at any distance can cause a TBI, but whether a single or multiple exposures can be the cause of Post Traumatic Stress Disorder. In short, is PTSD a disease of the mind, or is it a disease
of the brain? This is not simply an academic issue to the 50,000 troops left in Iraq, or the next 30,000 troops to be sent to Afghanistan. For them it is not merely an interesting or intriquing question, but truly a matter of life and death, pain and suffering. Just ask the family of any returning soldier or marine. Virtually every one of them will have been exposed to an IED at some time during their deployment.

  15.

  TRAUMATIC BRAIN INJURIES/PTSD/THE INVISIBLE WOUNDS

  The real question is whether the so-called mild Traumatic Brain Injuries (mTBIs) cause a lot more damage than we first suspected or were willing to admit. If they are more damaging, then we’re back to the shell shock of World War I.

  —Conversation: Neurologist, VA hospital

  Using numbers alone, one would think there might be a connection between exposures to the concussive effects of an IED and the development of Post Traumatic Stress Disorder. The Rand Corporation has documented that over 300,000 soldiers and marines have been exposed to IEDs, while the Veteran’s Administration has calculated that some 320,000 of the troops deployed to Iraq and Afghanistan over the last decade have developed a credible diagnosis of PTSD. It would not be unreasonable to assume that at some level of incidence similar numbers may well mean that the two conditions might be connected or at least be what is now called “co-morbid.”

  It is not that PTSD has been without its own explanation long before there were high explosives and roadside bombs. History’s most famous veteran, Odysseus, upon his return home from the Trojan Wars, looks around and, clearly confused and disoriented, wonders out loud; “Who are these people whose land I have come to…”

  Those feelings of Odysseus, of no longer belonging, of reaching home and suddenly being a stranger in a strange land, are shared in some form by virtually every soldier who has been in combat and, upon returning home, is expected to think and act as they did before they were forced to kill or be killed. That much about war has never changed. What we don’t know, and what Homer doesn’t tell us, is how many times Odysseus might have received blows to the head during his multiple battles in front of the walls of Troy, or on his decade-long adventures as he traveled home.