Our Returning Veterans, Are We Ready?

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Our Returning Veterans, Are We Ready?

• Brant A. (Bud) Elkind, MS, CBIS-T
• Director, Clinical Operations
• Robin Hill Farm, Inc.

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Traumatic Brain Injury (TBI)

• TBI - An insult to the brain, not of a
  degenerative or congenital nature but caused by
  an external force, that may produce a diminished
  or altered state of consciousness, which results
  in an impairment of cognitive abilities or
  physical functioning (AACBIS)

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Acquired Brain Injury

• An injury to the brain occurring after birth
  that is not hereditary, congenital or
  degenerative does not refer to brain injuries
  induced by birth trauma i.e. Stroke/CVA, Anoxia,
  Disease, Neuro-toxic Poisoning, Metabolic
  disorders (insulin shock, liver and kidney
  disease, or trauma (AACBIS)

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Brain Injury Range

• Mild characteristics include
• Loss of consciousness for les than 30 minutes or
  no loss
• Glasgow Coma Scale of 13-15
• Post-traumatic amnesia for less than 24 hours
• Temporary or permanently altered mental or
  neurological state with pos-concussive symptoms
  (AACBIS)

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Moderate Brain Injury

• Coma more than 20-30 minutes but less than 24
  hours
• Glasgow Coma Scale or 9-12
• Possible skull fractures with bruising bleeding
• Signs on EEG, CAT or MRI Scans
• Some long term problems in one or more areas
  (AACBIS)

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Sever Brain Injury

• Coma longer that 24 hours, often lasting day,
  weeks or longer
• Coma scale of 8 or less
• Bruising, bleeding in the brain, signs on EEG,
  CAT or MRI scans
• Long term impairment (AACBIS)

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TBI In The United States

• 1.4 million sustain a TBI each year
• 50,000 die
• 235,000 are hospitalized
• 1.1 million ER visits
• The number of people who sustain a TBI and do not
  receive treatment is unknown (BIAUSA)

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Leading Causes of TIBs

• Falls 29
• Motor Vehicle Accidents 20 (most are
  unrestrained)
• Stuck by/against 19
• Assaults 11
• Other 13
• Unknown 9 (BIAA)

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Long Term Consequences of TBI

• Direct and indirect costs of TBI in the US as of
  1995 was estimated at 60 Billion
• The CDC estimates 5.3 million Americans currently
  have long term, lifelong need to perform
  activities of daily living as a result of TBI
  (BIAA)

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Unmet Need for Services One Year After Injury

• Improving memory and problem solving
• Managing stress and emotions
• Controlling ones temper
• Improving ones job skills (CDC)

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The Wide Range of Functional Change

• Thinking, language, learning, emotions, behavior
  and or sensation
• TBI can also cause epilepsy, increase the
  potential for Alzheimers and Parkinsons and
  other brain disorders that become more prevalent
  with age (CDC)

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OIF OEF STATISTICS

• Approximately 1.6 million troops have to date
  been deployed to Afghanistan and Iraq
• 300,000 are estimated to have affected by
  Traumatic Brain Injury (TBI) and or Post
  Traumatic Stress Disorder (PTSD)
• 64 of all wounded are estimated to have
  sustained Blast Injuries
• 47 of all blast injuries affect the head (NABIS)

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Anatomy of a Blast Injury

• Instantaneous pressure wave with a rise and drop
  in pressure
• Results in cavitation occurring at the molecular
  level ((brain, inner ear, eyes, gastrointestinal
  tract, lungs and spinal fluid structures are
  liquefied)
• Over-pressurization wave dissipates
  instantaneously creating a vacuum
• Impact may also energize shrapnel, may exhaust
  gases and vapors that burn lung tissue and flesh
  (Wikipedia)

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What We Expect to See as Our Veterans Return Home

• The most severely injured continue to remain in
  Poly Trauma Hospitals
• Those returning with mild brain injuries pose a
  significant public health concern
• They will return with high expectations to their
  homes, families, jobs and communities

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Why there is Reason for Concern

• Many will return healthy
• Others will return, unaware of their brain injury
  (Agnosia, an inability to see their deficits)
  (DVBIC)

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What we will see!

• Difficulty with
• Thinking
• Receptive - Expressive
• Short Long-term memory
• Attention Initiation
• Expressive Receptive
• Multi-tasking

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What we will see (Continued)

• Adverse Behavior (Impulsivity, Disinhibition,
  Anger Control)
• Seizure activity
• ETOH (Alcohol and Substance Abuse)
• High-risk behavior
• Disorientation
• Tinitus and feelings of Isolation (EBIG)

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• Contrary to expectations, patients with mild to
  moderate TBI are actually much more affected by
  their emotional difficulties than by their
  physical disability (Glasser)
• Soldiers returning with mild to moderate brain
  injuries are 3 times more likely to incur a
  second brain injury and 8 times more likely to
  incur a third (CDC)

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Systems of Care

• Poly-trauma Centers (4)
• Poly-trauma Network Sites (21)
• Poly-trauma Support Clinics VISN (Specialized
  teams)
• Poly-trauma Point of Contact

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VA Poly-trauma Rehab System of care

• Proactive Case Mgt
• Telehealth Network
• Long-term follow-up proactive, specialized
• Care for those who cannot care for themselves

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So, is the Community Ready

• Probably not!
• 5 Professional Brain Injury Programs in NH
  representing a Continuum
• Facility based
• Residential
• Home based

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Community

• To welcome our soldiers with mild brain injury
  home we must be
• Inclusive not Integrative
• Be involved at all levels
• Social Service Agencies must understand needs
• Physicians and hospitals must be able to
  appropriately diagnose, medicate and care for
  people with mild brain injury

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Other Community Based resources

• OTs, PTs, SLPs and Psych Professionals must be
  trained in mild brain injury
• The community must be knowledgeable in the area
  of disability rights.

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Partnerships

• The VA cannot do everything
• Communities must be willing to include
• Support systems must be educated and capable to
  working with this specialized population

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References

• American Academy for the Certification of Brain
  Injury Specialists (AACBIS) www.aacbis.net
• Brain Injury/Professional vol. 4, issue 1, North
  American Brain Injury Society, Reintegrating
  Military Personnel after TBI, Community
  Integrated Rehabilitation Model in Practice,
  Trudel, Davanzo, Mattingly, Nideffer Barth
• Brain Injury/Professional vol. 4, issue 1, North
  American Brain Injury Society, Current Trends in
  Post Traumatic Stress Disorder TBI among
  Military Personnel, Nideffer, Errico and Barth
• The Essential Brain injury Guide, Edition 4.0,
  American Academy for the Certification of Brain
  Injury Specialists
• Blast Injuries, Wikipedia, the Free Encyclopedia,
  January 2008, NABIS, Blast Injury Institute,
  Ziejewski, Inz, Karami, Akhatov
• Defense Veterans Brain Injury Center
• Brain Injury Association of America,
  www.biausa.org