Recently a pediatric neurologist in the Department of Clinical Neuroscience at the University of Minnesota gave a lecture, “Mild Traumatic Brain Injury: What is the role of Brain Imaging, such as Diffusion Tensor Imaging, in the Evaluation of these Patients?” The objective of this lecture for the assembled physicians was to understand the value of this new brain imaging technique in the evaluation of a possible mTBI.
The take-home lesson was that if you are a parent and your child hits his or her head and is the least bit confused or disoriented or later has headaches or simply “isn’t themselves,” but otherwise looks and acts quite normal, you still want to see a physician and you might want to obtain a Diffusion Tensor MRI. You would certainly want to have the imaging test if there were any ongoing neurological or cognitive issues.
The Tensor MRI, unlike routine MRIs and CT scans, is exquisitely sensitive down below the cellular levels to any physical changes within the tiniest fibers of the white matter. Diffusion Tensor Imaging fills in the gap of brain damage investigation, that of evaluating the fibers that make up the brain’s circuitry. With a Tensor MRI, all of the brain can be adequately, equally, and definitively imaged, gray and white matter alike.
The experimental use of this new technique has demonstrated that conventional MR imaging underestimates the extent of axonal injury following even a mild TBI. With a new test, there are always new medical insights and new clinical understandings and the beginning use of the Tensor MRI is proving no different.
A recent study published in the American Journal of Neuropathology proves that fact. The radiologists using a Tensor MRI evaluated the brains of a group of patients with a diagnosis of mTBIs with persistent post-concussive symptoms determined by the use of the standard head injury checklist that included the presence of headaches, fatigue, dizziness, irritability, anxiety or depression, difficulty sleeping, and personality changes or apathy, as entrance into the study. Exclusion criteria included any history of neurological or psychiatric illness including drug or alcohol abuse.
Conventional MRI and CT scans had been read as normal in all the patients. But with the Tensor MRI, half of the patients who showed no bleeding clearly had obvious damage to their brain’s white matter. The article ended with this warning:
Patient reports of a post-concussion syndrome (including what neuropsychologists call the higher executive functions that allow for planning for future events) may be dismissed in the context of normal findings on CT or conventional MR Imaging. These studies indicate axonal shear injury to be the primary mechanism of (brain) damage in mild TBIs.
It seems that the Tensor MRIs are uniquely suited to detect significant microscopic white matter injuries, and just in time. With the sending of troops to Afghanistan, where they are sure to be exposed to more numerous and ever more powerful IEDs, there is sure to be more evidence of brain damage, along with significantly more symptoms of PTSD. Is it cause and effect, or merely an association? On our newest battlefields, that may well be a distinction without a difference.
Yet neither the Congress, a body rarely known for foresight that has never adequately funded the medical needs of our soldiers and marines, nor the last or current administration, nor the Pentagon or VA, has ordered or purchased a single Tensor MRI, which is basically a very sophisticated computer program running on an MRI platform. The hundreds of medical facilities along the evac-chain and all of the stateside hospitals will have to function without this technology to counter the new type of injuries suffered by the troops in the new type of warfare.
It might also be that a diagnosis of a TBI rather than PTSD may, by definition, result in a life-long service-connected disability claim to be paid to each disabled veteran for the rest of his or her life. VA Disability Claims, like Social Security and Medicare, are entitlements, and by law, entitlements once in place last for the lifetime of the recipient. PTSD, for all of its anguish, is considered a treatable psychological condition and so the liability of the VA, and the government, is limited to approved and time-limited treatment periods, with an expectation of ultimate success within relatively short periods of time. No need for long-term or life-time disability claims.
But that may just be the cynic’s view. Still, it is a view based on what occurred during the Vietnam War, when thousands of veterans were denied life-time claims after receiving a diagnosis of PTSD. It may also be the reason that the economists Linda Bilmes and Joseph Stiglitz have put the national costs for Iraq and Afghanistan at over 3 trillion dollars without PTSD becoming an entitlement.
And that number of 3 trillion dollars is if every one of our soldiers and marines went home today and there were no new deaths and no new injuries.
It is not that those running the military today don’t understand what is going on. The Chief of Staff of the Medical Corps for the Army, when asked in a recent interview on National Public Radio if TBIs had become the signature wounds of Afghanistan and Iraq, gave a qualified yes, admitting that based on the military’s own data from their Wounded Warriors Program, PTSD had to be considered the real signature wound of the wars, with 45 percent of those in the program being diagnosed with PTSD, followed by 17 percent with TBIs, and 12 percent with amputations.
When pushed, the general admitted that if PTSD were shown to be the result of TBIs, then brain injuries would clearly have to be these wars’ signature injury. What the general did not address was the distinct possibility that a TBI of any severity might well make the soldier or marine more susceptible to PTSD. In short, that one may make the soldier or marine more susceptible to the other. And that is the growing concern among the psychiatrists in the Department of Defense hospital system, as well as the physicians and psychologists in the VA’s poly-trauma and mental health units.
The general did admit that poor record-keeping in both Iraq and Afghanistan regarding who was exposed to an IED may indeed make these connections impossible. If there is nothing in the records, or those records are not available during or after deployments, then changing a diagnosis of PTSD to a mild TBI becomes impossible, whatever the symptoms.
So why not just do what some within the military do and VA systems are beginning to advocate? Simply being in a combat zone is to be exposed to an IED and goes on the record.
But in the end that may simply add to the 3 trillion dollars that these wars have already cost. And apparently that is not something this Congress or this administration is willing to do.
What is clear is that additional funding for research is needed to be able to distinguish PTSD from mTBIs. We certainly need the government to order a few Tensor MRIs. We owe that much to the few we have sent to do so much for all the rest of us.
16.
ALL THE JAKES/ADRIFT IN AFGHANISTAN/2010
The Korangal Valley is sort of the Afghanistan of Afghanistan: too remote to conquer, too poor to intimidate, too autonomous to buy off.
—Sebastian Junger, War
Since the end of the Civil War, we have had a Southern army. The majority of our company and general grade officers, as well as high-level NCOs come from southern cities and towns of less than 7,000 people. That’s not so bad. If you want leaders who understand the real meaning of victory, ask the ones who have been defeated.
But then again, the South might just be different. In many ways, it has never been “the United States is” so much as “the United States are.” And the South is part of that “are.” Nobody up North, out West, or in the East talks about being able to kill “your own snakes” or ever uses the words “splendid behavior” to talk about someone’s actions. I learned how to drink whiskey in the Army. There was not a single company grade officer or senior NCO I met during my two years on active duty in the military, or those decades afterwards of keeping up with old army friends while making new ones, who drank Scotch or bourbon. It is Old Grand Dad, Early Times, Wild Turkey, and Southern Comfort. Not so bad.
Yet despite the obvious difference in drinking habits, for many from the South it is all still G
ettysburg and Antietam, Spotsylvania and the Battle of the Wilderness. These officers and NCOs from below the Mason-Dixon line like to win, but they hate losing even more. And that must have been something that Jake picked up.
It wasn’t that Jake had not seen pictures of relatives in their uniforms all his life, but seeing is not necessarily believing. Still, he did look at the pictures on the walls of his parents’ home out in the hallways and going up the steps to the bedrooms for as long as he could remember. There was that sense of serving in the very air of the house, even though no one still alive ever talked about their time in the military and definitely never mentioned, even in passing, about having been in combat.
David Haberstram, the New York Times reporter in Vietnam and the author of The Making of a Quagmire, published in 1969 about the growing disaster unfolding in Vietnam, and seven years later, The Best and the Brightest, documenting the disaster that had indeed become Vietnam, explained that as a child in New York City in the late 1940s, he’d go out into the courtyards of the apartment buildings and watched his uncles and their friends, all veterans of the Second World War, play pick-up basketball after work or on their way back and forth from college paid for by the GI Bill.
They’d play shirts and skins. He remembered sitting on the steps of the fire escapes, startled and amazed that everyone who played skins had a scar, a part of a muscle or a limb gone, a bone that was clearly missing, or a strange limp when they ran.
The stunning part to the young Halberstam was that it was everybody. No one had escaped. No one had been spared. But no one ever said a word. No one offered an explanation for their wound or their infirmity, nor was anyone ever asked for or expected to give one. According to Halberstam, no one mentioned the war. No one complained or appeared offended or even troubled by the wounds. No one asked for help or to slow things down. And no one offered up an excuse, even if they tripped when they ran or couldn’t quite handle the ball as well as they should have. They were just there to play basketball. It was only much later in Vietnam that Halberstam was to realize that these were the ones who had survived.
In a very real way, watching those shirts and skins pick-up games, the young future reporter had caught the essence of combat. Everyone was at risk and what finally happened was simply a matter of chance or luck. That was what was so scary and so real and why everyone kept so silent about combat. No one talked about it and no one asked why half the muscles of a shoulder or along the neck were gone. They already knew. They didn’t have to ask.
Jake was not only raised in the quiet shadows of the military, but in the shadow of the Marines. Jake’s mother’s twin brother had been in the Marines. Two of her other brothers were in the Army. Jake’s father’s younger sister had been in the Army in the ’80s and his brother in the Marines. His father, too, had been in the Marines when the Marine barracks in Beirut had been blown up. There were two grandfathers, one who had been a captain of a frigate during the Korean War, and the other who fought in the Army throughout the whole of the Second World War in Italy and Germany.
Much like Halberstam was drawn to the silence of those wounded and crippled veterans playing basketball in the alleys of New York City, Jake had been drawn to the very silence of those pictures. Toward the end of Jake’s senior year in high school, his father, concerned about his son’s two older friends who had already graduated and not gone to college and were without jobs and just lying around all day, was determined that his son would not end up the same way. So he sat Jake down one Sunday and gave him three options after graduation: college, working full time, or the military.
Jake didn’t argue or, for that matter, even have to think about it. Later, his father would remember how simple it had been and how matter-of-fact. “That’s OK,” Jake said, “I don’t think I have the grades for a really good college. I’m going to enlist.” It was almost as if his son had grown up right there in front of him, even as they were talking.
That was March 2007. The war in Iraq was not going well. In fact, the whole country was approaching the abyss. Iraq had descended into a full-scale civil war, with 1,000 civilians dying each month. The gunmen of Al Qaeda, along with their suicide bombers, were carrying out large-scale massacres of Shiite civilians, and the Shiite militias, some in Iraqi Army uniforms and supported by Iran, retaliated by massacring thousands of young Sunni men. Iraq seemed lost, with American troops hopelessly caught up in the turmoil and being killed and wounded in increasing numbers by both sides.
None of this was of any real concern to Jake. He was right about not having the grades to get into a first-rate college and everyone, including his father, knew that an entrance-level job would have bored him, while still giving him plenty of time to goof off and get into trouble.
So Jake and his father went down to the recruiting offices inside the Air National Guard Terminal at the Metropolitan Airport. Jake kept his preference to himself as to which branch of the armed services he was considering.
The Navy was out from the beginning. Jake had no desire to go to war on a ship and had no interest in flying off aircraft carriers. The Army recruiter was almost too slick about the benefits of service, including bonus pay and the fact that having military experience would be a plus for any future civilian employment.
The Marine recruiter offered nothing except being the point of the spear. “The first in. And the last out.” Jake’s father went along because he thought that with his being there and being a veteran that none of the recruiters would go off the deep end or run the risk of lying. But he did feel that the Marine recruiter had offered more of the truth than any of the other recruiters. Jake saw that too and with his father having been in the Marines, made that same choice.
“It’s the Marines,” he said. Walking back to the car, his whole demeanor changed. They had gone to the recruiting offices as father and son, and had left as two marines. As they approached the car, Jake stopped. “If it’s all right with you,” he said, “I’d like to enlist right away. At least as soon as the paper work is ready. There’s no sense waiting.”
Jake went back on his own to the recruiting office early the next week. He called his parents to tell them that if they wanted to watch him sworn in that they should drive out to the recruiting center, that he’d wait until they got there. His mother managed to be proud.
Jake’s parents laid off him for those last few months of school, letting Jake do pretty much what he wanted. Iraq was still out there. But the surge was working. By degrading Al-Qaeda’s leadership, the influx of new troops was able to reduce the scope of the civil war. This allowed everyone to take a deep breath and step back from what had been an approaching catastrophe.
Afghanistan was back in the news. The Marines, who wanted no part of garrison duty and baby-sitting any kind of new Iraqi nation-building, had put Afghanistan back up on their front burner and were lobbying the Pentagon to send them to Helmand Province.
The surge had bought us time in Iraq to try to buy us time in Afghanistan. It might well have been the time for counter-insurgency rather than counter-terrorism, but even with counter-insurgency, you still have to kill the bad guys.
Jake took his parents up on their obvious lack of supervision during those last few months of school. But the two wars and the Marines were always out there, like a worrisome breeze blowing in from the future. The day after graduation, Jake said that it made no sense to wait until the end of September, which was his enlistment date. He had the date pushed up and went into the Marines on July 12, 2008.
It was the week that a unit of the 173rd Airborne Brigade occupying the Wanat Outpost in the Konregal Valley in Eastern Afghanistan was attacked by over 200 Taliban. The battle, described by those who were there as the “ Blackhawk Down” of the Afghanistan War, went on for almost half the day. The firefights in Iraq usually lasted no more than half an hour.
The forty-eight Americans and seventy-four Afghan soldiers were outnumbered three to one. At the end of the battle, nine U.S. troops were dead
and twenty-seven were wounded, a casualty rate of 80 percent. The 245-page After Action Report describes the fight “as remarkable as any small unit action in American military history,” including those in Vietnam. The report, created by a member of the Army’s Combat Study Institute at Fort Leavenworth, Kansas, details automatic weapons that turned white-hot and jammed from non-stop firing, while the severely wounded continued to feed ammunition to those still able to use their weapons. The battle ended only when helicopter gunships and F-15s strafed and bombed the Taliban positions, killing dozens of the attackers.
The AAR cited a lack of preparation time for the 173rd before being sent from Iraq to Afghanistan. The strong implication that fighting on the desert plains of Iraq within an urban population, with well-developed roads and other types of substantial infrastructure, was different, and should have been recognized as different, than fighting village tribesmen in isolated valleys and mountain areas.
There were also tactical concerns about the total absence of an operational plan for the combat that was sure to lie ahead for the 173rd. After all, the Russians had fought in those same mountains for more than a decade and were never able to occupy or control any of the major mountain passes or valleys. And the Russians had a force of over 250,000 troops with absolutely no rules of engagement—able to kill and blow up anyone and anything they wanted.
But the real explanation for the failure at Wanat was centered on the fact that the U.S. forces had faced off against a far more sophisticated enemy than they had faced in Iraq or in Afghanistan in 2001. The world of fighting in Afghanistan had changed in the eight years we’d been there and apparently nobody in charge had noticed.
The report stated that, “The Taliban can and does now operate as a disciplined armed force, using well-rehearsed small unit tactics that can challenge the American military for dominance on the conventional battlefield.”
Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan Page 17