Official Shares DOD Brain Injury Trends With Civilian Nurses

By Terri Moon Cronk
American Forces Press Service

BALTIMORE, June 25, 2013 – When symptoms of traumatic brain injury began to surface among service members in combat, the Defense Department had to ensure the injuries were fully understood and pathways to cures were planned, the deputy director and acting national director of the Defense and Veterans Brain Injury Center said here yesterday.

Addressing the Maryland Nurses Association 2013 neuroscience nursing symposium at Sinai Hospital, Kathy Helmick presented an overview of DOD’s policies and programs for TBI diagnosis and treatment. The center performs clinical care, research and education on TBI.

“Close to 20 percent of TBIs occur in the reserve components, and … these are folks who sustain injury while in service and then go back to our communities,” Helmick told the civilian nurse audience.

Many TBIs occurring in combat went undetected for months, Helmick said, and officials stepped up efforts for early detection. Undetected and untreated TBIs can affect unit readiness when service members have substandard reaction time, decreased awareness and difficulty multitasking, she noted. “We also had to think about how we delivered care in a [combat] theater environment like Afghanistan,” she added.

In developing standards of care for TBI, Helmick said, DOD officials had to examine where such injuries occurred, how soon patients were seen by medical staff in the field, and contingencies for battlefield medicine. To make sure injured troops were medically evaluated, DOD issued a policy in June 2010, she said, describing it as “symptom-driven.”

“If you’re involved in a blast in a vehicle, or if you’re within 50 meters of a blast, you have direct blow to your head, or are exposed to more than one blast event, you are mandated by this policy to go get checked out to see if there’s been a concussion,” Helmick said. Exposure to blasts results in TBIs in service members about 15 percent of the time, she noted.

DOD’s main tool to evaluate concussion is called MACE -- the Military Acute Concussion Evaluation -- and is performed by an Army medic or Navy corpsman, she said.

“It’s a simple tool to test symptoms and [get a] cognitive score,” Helmick explained. “MACE helps us determine if a concussion occurred. It really is the hallmark tool that guides us to further assessment.”
The onsite evaluations, using manuals and even cellphone applications as guides, help doctors treat the injured service member, she said.

If a TBI is detected early, service members have a better chance of returning to duty, Helmick said.
“If not, they’re going to get some rest and go through standardized care to ensure they’re safe to go back to duty,” she added.

When service members suffer multiple concussions –- three or more injuries within 12 months –- they go through several evaluations, such as neuropsychological testing; neuroimaging, such as MRI; and functional outcome measures to determine how they’re functioning after several concurrent concussions, Helmick said. “If they can’t go back to duty, they go to comprehensive rehabilitation to address those issues,” she added.
In determining whether a service member has had a TBI, medical staff members consider the obvious signs of concussion: a change that can leave a service member temporarily dazed and confused, the inability to assimilate the environment through smell, visual and tactile means, and the inability to process information, Helmick said. Medical professionals also look for signs of post-traumatic amnesia, memory loss and a lack of consciousness. Witnesses to injuries also are critical.

More than a single test could be inevitable in the future, she said.

“We think we will have an arsenal, maybe two or three tests, to [determine] if a person had a concussion from an objective standpoint,” Helmick told the nurse audience. “We’re trying to promulgate policies within DOD to make sure we detect concussion, have the science related to it, and that we’re getting that [information] out to the mainstream [community]”.

Other future endeavors at the center include a comprehensive look at dizziness symptoms, Helmick said.
“The No. 1 reported concussion symptom is headache, followed by dizziness,” she said. A guideline on sleep disturbances from TBI also is expected to be available next month, she added.

And because tests such has MRIs are not always indicated and are determined on a case-by-case basis, military medical professionals soon will have a standardized approach on who should have MRIs, Helmick said.

After 12 years of war, DOD has “copious amounts” of TBI research, Helmick said. The question that remains to be answered is the long-term effects of TBI, she added.