Findings of those Tested in a government sample study of Veterans diagnosed with TBI from inside Iraq and Afghanistan during military service, about half reporting multiple head injuries, related to higher rates of PTSD, depression, back pain, and suicidal ideation. Most common mechanisms of TBI included blast (33.1%), object hitting head (31.7%), and fall (13.5%). The Defense and Veterans Brain Injury Center (DVBIC) report nearly 350,000 incident diagnoses of TBI in the U.S. military since 2000.² Among those deployed, estimated rates of probable TBI range from 11–23%.^3– NIH

Joint Staff Doctor Explains TBI Diagnosis Procedures

FEB. 24, 2020 | BY JIM GARAMONE, DOD NEWS

Traumatic brain injuries can’t be quickly diagnosed — as was the case with the Iranian missile attack on Al Asad Air Base in Iraq on Jan. 8, the Joint Staff surgeon said.

At a Pentagon news conference today, Air Force Brig. Gen. (Dr.) Paul Friedrichs said 110 service members have been diagnosed with mild traumatic brain injuries from the attack. Most have returned to duty, while 25 returned to the United States for further treatment, he said, and six more are still undergoing testing.

Following an attack, commanders assess injuries, Friedrichs said, and in this case, no one immediately appeared to have had acute injuries. “No one lost a leg, no one lost an eye, no one lost a limb — which was remarkable given the strength of these munitions,” the doctor said.

Therefore, he explained, reports went up the chain of command saying no one had an acute injury. But a TBI takes time to diagnose, and the process is involved. Protocols call for TBI testing of service members who were within 50 meters of an explosion, were exposed to a series of explosions, had a direct blow to the head, or who exhibit symptoms such as headache, dizziness, memory problems, balance problems, nausea, vomiting, difficulty concentrating, irritability and visual disturbance.

The tests take up to two days to complete. But service members may have TBI and feel they can power through and just go back to duty. They may have symptoms, but they don’t go away and may get worse, Friedrichs said.

A lot of people have said, ‘Well, why didn’t we immediately identify everybody with a traumatic brain injury?'” the general said. “[It’s] because the signs sometimes are fairly nonspecific. And … even though we’ve trained everybody who deploys downrange on what to look for, it’s quite common that we’ll have folks who will say, ‘I just was blasted. Of course, I’m not going to feel quite right. I’m going to ride this out for a few days.’ Or ‘I’m going to wait and see if this gets better.’ And then they come in several days or weeks after the fact.”

While there are tests that can point to TBI, some cases also require an MRI. The closest MRI testing facility to Iraq is in Germany, adding to the delay in diagnosis.

The department takes TBI extremely seriously, the doctor said, and has invested $1.5 billion in diagnosing and treating the condition. Test groups are wearing sensors to measure blast effects that could give medical professionals better information when making diagnoses, he noted.

“I think that’s going to be really exciting going forward because that takes some of the subjectivity out,” he said. “There is no military in the world that has invested as much or has fielded as many evidence-based tools as what we have right now.”

Department of Defense Informational Session on Traumatic Brain Injury

FEB. 24, 2020Principal Director for Military Community and Family Policy Joseph Ludovici and Joint Staff Surgeon Air Force Brigadier General Paul Friedrichs

PRINCIPAL DIRECTOR FOR MILITARY COMMUNITY AND FAMILY POLICY JOSEPH LUDOVICI: Okay, good afternoon.

My name is Joe Ludovici. I’m the principal director of Military Communities – Military Community and Family Policy. One of the things we’re responsible for in our shop – it’s under the Personnel and Readiness Directorate – is casualty and mortuary affairs. So in that light, we’re responsible for the casualty reporting process, so I’m here today to answer questions you might have or to address questions that were brought up last week or on the Hill on casualty reporting.

JOINT STAFF SURGEON BRIGADIER GENERAL PAUL FRIEDRICHS: Thanks, and I’m Paul Friedrichs. I’m the joint staff surgeon, and I’m going to spend a few minutes, if you’ll indulge me, just walking through the background on traumatic brain injury, a little bit about what happened with this specific attack, and then we’ll open it up for questions.

My personal background Is I’ve deployed – I have taken care of casualties with traumatic brain injury. I’m a neurologic surgeon by training, but have done a variety of other jobs in the military, including taking care on the receiving end of these casualties coming back. So you’ll hear some of this personal experiences coming through.

So why is this attack so important for us? I think first, it was a real validation of the work over the last 15 years to change how we take care of people who develop traumatic brain injury. If you go back through thousands of years of military history, go back to the Greeks and the Romans, they talked about people who were wounded warriors, or the walking wounded, shell-shocked – every war has had some term for them. What we’ve not had are good ways to evaluate these soldiers, sailors, airmen and Marines at the time that they were injured or afterwards, when they came and sought care.

We recognized this beginning early in the current conflicts and began working with the Veterans Administration, as well as with the NCAA, the NFL and other stakeholders to develop a series of screening measures, which we’ve updated over the years, and we’re able to use very effectively during this event.

In this particular event, the nature of the munitions was different than what I experienced at Balad or in other locations.

So if you’re familiar – and many of you have been down-range over the last 15 or 20 years – you know, we had small munitions; we had small rockets that would hit bases. Balad used to be called “Mortaritaville.” There’d be the frequent attacks on the base.

And they were obviously dangerous, but very different than what happened at Al Asad, when theater ballistic missiles landed.

Why is that important?

The magnitude, or the size of the munition, certainly creates a different exposure for the service members who are in the area of the blast. And that’s something that I’ll come back to several times in my comments here.

First thing that happens after any attack like this is looking to see who was acutely injured. And in this case, when they went through, they identified that no one had any acute injuries. No one lost a leg. No one lost an eye. No one lost a limb, which, you know, was remarkable, given the strength of these munitions.

The next thing that we have taught our service members and our leaders to look for are those invisible wounds, like traumatic brain injury. And in this case, we’ve developed a series of rules that we’ve actually codified in a Department of Defense Instruction.

And some of those say – and I’m just going to quote directly – that regardless of what people may be complaining of, what a service member says they may be experiencing after an attack, if they meet certain criteria, they must be evaluated.

And so those criteria are “If they’re involved in a vehicle blast, event, collision or rollover.”

And that’s specific to the IED blasts that we’ve seen throughout the conflict in Iraq and Afghanistan. If you’re in an IED blast, you have to be evaluated. It didn’t apply here, but it’s one that we’ve learned is important. All those folks get evaluated.

“If you’re within 50 meters of a blast and if you’re inside or outside,” you have to be evaluated.

That absolutely did apply in this case. Because we had folks who were within 50 meters, but said they were feeling fine. And we still went ahead and put them through the evaluation to identify whether or not they’d experienced a traumatic brain injury.

And then the other mandatory reporting criteria are “a direct blow to the head,” which in this case didn’t happen, fortunately, and somewhat surprisingly, given the magnitude of the attack.

And then the last mandatory reporting is “exposure to more than one blast event.”

And in this case, because there were 10 events that happened in a very short period of time in one location, we did have some service members that were near a place that had more than one blast event.

This also applies to people who have deployed multiple times. So you’ll not be surprised to hear that, you know, with these small arms – or smaller munitions that are used, we’ve had service members who have been exposed to blast attacks in the past. If they said they’d previously been exposed to a blast attack and they were at Al Asad, we also pre-emptively evaluated them to identify whether they showed any signs of traumatic brain injury.

So those are the ones that had to be evaluated. And then the other group that we looked at were the ones who came forward days, and in some cases weeks, afterwards and were complaining of a variety of symptoms.

And as we’ve looked back at our experience with service members, we’ve found that there are pretty – there’s some symptoms that are more common in folks with traumatic brain injury. And those include headache, dizziness, memory problems, balance problems, nausea, vomiting, difficulty concentrating, irritability, visual disturbance and ringing in the ears.

Now, you may think that’s, kind of, a non-specific list. And my wife regularly accuses me of being irritable and having difficulty concentrating. That does not mean that I have traumatic brain injury.

And I think that’s important in this discussion because a lot of people have said, well, why didn’t we immediately identify everybody with a traumatic brain injury? Because the signs sometimes are fairly non-specific.

And if you’re 18 or 19 or 20 years old, even though we’ve trained everybody who deploys down-range on what to look for, it’s quite common that we’ll have folks who will say, you know, ‘I just was blasted; of course I’m not going to feel quite right, I’m going to ride this out for a few days,’ or ‘I’m going to wait and see if this gets better.’ And then they come in, several days or weeks after the fact.

And that’s indeed what we saw, that there were some folks who came in relatively soon after the attack and said, ‘you know, I’m having these symptoms, I want to be evaluated.’ Others came in weeks later and said, ‘you know, this hasn’t gotten any better, I thought that I – I thought it would go away, it hasn’t. Now I want to be evaluated for it, I need to be evaluated.’ Or, in some cases, it was their coworkers who said, ‘you know, you keep complaining you’re having headaches, you should go in and be evaluated.’

I think the point in all of that is, there are – there are different cohorts of folks that we identified with mild traumatic brain injury in this event. There were those who we immediately evaluated because they met the criteria, and then there were those who came in, over a period of weeks after the event, and sought evaluation.

The last group were a small number who came in for some other reason, for what ultimately was diagnosed as a mental health concern or some – you know, a sprained knee or whatever, and in the course of evaluating them and asking them the questions that we know to ask, they tripped some of the concerns about, maybe this person has traumatic brain injury, let’s go ahead and do the full evaluation.

So that kind of describes who we evaluated, and perhaps helps to shed a little more light on why the evaluations weren’t all done on the day of the event, with answers on the day of the event.

Now, I’ll talk a little bit about the evaluation itself. So there’s been a number of comments about, well, we don’t have any good tools for evaluating these folks. I would disagree. We work very carefully with the best experts – as I mentioned before – both in academia, in the Veterans Administration, within DOD, with the NFL and NCAA to develop screening tools to help us identify people who are at risk for having sustained a traumatic brain injury.

One of those tools that we use – and some of you have heard this – it’s called the Military Acute Concussion Evaluation. Because we love acronyms, it’s called the MACE tool. That came out, I think about eight years ago, and was updated again in 2016. So it’s now called the MACE 2, M-A-C-E-2.

And that’s a very detailed evaluation that includes a physical exam; it also includes listening to what the individual says he or she has experienced or is still experiencing.

And then it includes a series of tests; things like memory tests where, at the beginning, you’ll say, ‘I want you to remember these five terms.’ And then later in the interview, you’ll ask them, ‘what were those five terms I asked you to remember?’ Some quick, very well validated evidence-based test of cognition and how well the brain is functioning at the time of the interview.

And so that is what I would call – and what I think most people would call – an evidence-based or very well-researched evaluation tool that we use as our initial screening.

If someone tests positive on that, if their initial evaluation is positive, we then move into our concussion evaluation algorithm. And the next step is to actually let them rest for 24 hours and repeat the MACE test.

So I’ve been asked several times, well, ‘how come you didn’t know right away that someone had a traumatic brain injury?’ Because we purposefully built in a rest period to re-evaluate people to see if whatever it is they’re complaining of goes away. If it completely resolves within 24 hours, typically that does not then translate into having truly had a mild traumatic brain injury.

And this then also leads into a series of further evaluations. Some folks will get an absolute, clear, positive, yes, they had a mild traumatic brain injury. With some rest and appropriate therapy, within a matter of days, they’re ready to go back to work. And many of the people that we evaluated at Al Asad were able to go back to work within days to a couple of weeks after the event.

There is also a subset, however, in which it’s not as clear-cut. And so we do our evaluation in the field; we’re still not coming up with a clear answer; they’re not a 100% better or the tests that we’re doing in the field are equivocal. And then those are folks who we decide need to have additional evaluations. I’m hoping that that means that this is valuable.

So, you know, in some cases, if we can’t clearly get to a diagnosis in the field, we’ll then move on to additional testing. And one of the most frequent tests that we’ll do next is called an MRI. And I know many of you are familiar with that. Magnetic resonance imaging is a type of imaging that helps us get a good look at the anatomy of the brain.

The challenge for us with MRIs is, we don’t have an MRI at Al Asad. In fact, we don’t have one in that part of Iraq. And so you’ve heard that some of the casualties from this event, some of the folks that we’ve ultimately diagnosed with mild traumatic brain injury had to go to Germany. For many of them, it was so that they could get an MRI.

And I’ve been asked the question, ‘why didn’t we just do an MRI downtown – fill in the blank, whatever town they were near’ – we found that it’s helpful to do these at places where the staff are accustomed to looking for traumatic brain injury and accustomed to the protocols that we’ve developed over time.

So it – to get reproducible results, we found that the best thing – and the easiest thing to do, in this case – was to fly them up to Germany and do the MRI there, and evaluate them there.

So the MRI is a typical test that we do if we can’t make a definitive diagnosis in the field. There are other tests that can be done. One is called Neurocognitive Assessment, which is a more detailed assessment of how well the brain is functioning; sometimes occupational therapists or physical therapists will be involved.

We were very comfortable making the diagnosis of mild traumatic brain injury in all of the folks that we’ve identified. And if you saw the press release from last week, right now, we’re at 110 service members who were diagnosed with mild traumatic brain injury.

Some of those – about 25 of them now – we’ve flown back to the United States. And in almost every case, those that have come back – back to the United States are people who were diagnosed with mild traumatic brain injury and were determined to need follow-on outpatient care.

Nobody has had a requirement for sustained inpatient care; nobody was diagnosed with a severe injury. But in some cases, they need follow-up that simply can’t easily be provided at a place like Al Asad. And rather than keeping them in Germany, we felt it was better for them to go back to their home unit, where they’ve got their support system, their family or unit support system around them, and get that outpatient care at their home unit. So that’s a little bit about what happened once the evaluation is done.

And then the last thing that I’ll touch on is, so what are we doing to continue to improve? You know, we’ve been working on this now for years. As I mentioned on the Hill on Friday, we’re very grateful for the support from Congress. We’ve collectively spent about $1.5 billion on research on traumatic brain injury.

There was an assertion, somewhere along the way, that the DOD really isn’t focusing on that. I would disagree. I mean, this is something that we’ve been talking about and looking at for years. And not just within DOD, but partnering with experts across the United States.

And that research has gone in different directions. Some of it is the evaluation tools that I described earlier, that we’re using today. Some of it was looking at better treatments or what’s the most effective treatment to help people once they’re diagnosed with a traumatic brain injury.

Some of it is sensors. How do we not just have to rely on these very subjective symptoms or the physical proximity to a blast? And so there’s a device, for example, that we’ve deployed now in a field test phase that’s a series of sensors – it’s three sensors that you can wear under your body armor that will detect whether you were exposed to a blast event. So even if you weren’t within 50 meters and you don’t come in saying, ‘I’ve got’ any of these symptoms that I described previously, if your tracker shows that you were exposed to a blast event, then we’re going ahead and evaluating those folks to see whether they have traumatic brain injury.

I think that’s going to be really exciting going forward because that takes some of the subjectivity out of this. It’s – you know you don’t have to measure, ‘was it 50 yards or 50 meters? What was the number I was supposed to look for?’ It’s did your sensor show you were exposed to a traumatic blast event or not?

And there’s a lot of research continuing within the department here and – or within the building here. We have the Comprehensive Brain – yes, I want to make sure I get the acronym right because it’s a long one – the Comprehensive Strategy for Warfighter Brain Health Executive Committee, which is a mouthful. I’ll say it one more time, Comprehensive Strategy for Warfighter Brain Health Executive Committee.

That’s a group that is led by senior officials within the Office of the Secretary of Defense and within the services that is looking across the department at all of the efforts, integrating them, identifying road blocks, moving them and helping us to keep moving forward in this area. Last meeting was late last year, another meeting coming up next month. But it looks at the full portfolio of what the department is doing in this area.

Some of you are also familiar with the Close Combat Lethality Task Force, which has been looking at this. And then a group that I’m particularly proud of, and that’s the Joint Trauma System that has helped to develop what we call clinical practice guidelines. And so we have the Joint Trauma System series of trauma experts that look at how do we improve the care that we provide after a traumatic event, linked in with all these efforts that I’ve just described.

There’s a lot more that, you know, I could go into on this. And I’ll just – I’ll close by saying, as a physician who’s been in combat, where we are today is light-years ahead of where we were five or 10 years ago. There is no military in the world that has invested as much or has fielded as many evidence-based tools as what we have right now.

Do I think that we’ve answered all the questions? Absolutely not. There’s nothing in medicine that I can say with certainty we have answered all the questions on.

But I am very proud of the care that these service members received. And I can tell you with absolute confidence every single person who has come forward, or who was in proximity and needed to be evaluated, was fully evaluated, got the care they needed and continues to get the care that they needed; and they’ll be tracked over time so that we can continue to both make sure they get the care they need and we can continue to learn from this event so that we can keep updating our algorithms.

For those who want to know much more about traumatic brain injury’s visit HERE