The Changing VA Population: Young, Active Duty and Brain Injured or It’s A Co-Morbid World Harriet Katz Zeiner, PhD Har

1. The Changing VA Population: Young, Active Duty and Brain Injured  or It’s A Co-Morbid World Harriet Katz Zeiner, PhD Harriet.Zeiner@va.gov

2. There’s a New Population in Town And They Require Systemic Change To Deal With Them Effectively Why? How Big Is The Problem? Why Won’t The Old Ways Work? What Do I Have To Change To Deal Effectively With Them?

3. While serving in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), military service members are sustaining multiple severe injuries as a result of explosions and blasts.

4. Improvised explosive devices, blasts, landmines and fragments account for 65% of combat injuries • (Peake JB, N Engl J Med 2005 jan 20, 352 (3):219-222)

5. Of these injured military personnel, 60% have some degree of traumatic brain injury http://www.dvbic.org

6. If the War Ended Today: • 30,000 WIA • 65% of these are IED = 19,500 • 60% of IED injuries involve head injuries = 11,070 • 1500 combat-wounded polytrauma patients have been treated at the 4 PRCs Currently, 10,200 people with head injury have been discharged home—and don’t know why they think, feel and behave differently * These numbers are from April 2008-Underestimate since only includes the wounded, not the exposed

7. 10,000 people with undiagnosed mild TBI have been sent home. • Mild TBI refers to the time period of unconsciousness, not to the effects on the person’s life. • Mild TBI can have MAJOR impact on marriages, jobs, relationships, children and roles • This is not a political issue—it is a major health care problem in America, which the VA is charged to deal with.

8. Occult (Hidden) Brain Injury • How many people with TBI you find depends on whether or not you are looking • Degree to which you look is the degree to which you find • If your facility uses PTSD/BI screen, you will find them in the outpatient clinics—at a large VA the rate is 10 new cases per month

9. Clinical Reminder Did the Vet serve in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) after Sept 11, 2001? • Afghanistan • Iraq • Kuwait • Saudi Arabia • Turkey • Other OIF services

10. PTSD Screen • Have you had an experience in the past month that was so frightening or upsetting that you: • Had nightmares or unwanted thoughts • Went out of your way to avoid reminders • Constantly on guard, watchful, or easily startled • Felt numb or detached from others

11. Brain Injury Screen Did you have any injuries during your deployment from: • Fragments • Bullets • Vehicular crash including airplane • Fall • Blast (IED, RPG, grenade, land mine) • Other injury

12. Brain Injury Screen Did any injury result in: • Being dazed, confused, seeing stars • Not remembering the injury • Losing consciousness for any amount of time • Concussion • Head injury

13. Brain Injury Screen Are you experiencing any of the following from a head injury/concussion: • Headaches • Dizziness • Memory problems • Balance problems • Ringing in the ears • Irritability • Sleep problems • Other

14. Occult (Hidden) Brain Injury • Half the patients with head injury will be blast exposed • Half will be the result of motor vehicle accidents

15. There are also a large number of post-combat head injuries • Look for an unusually large number of motor vehicle accidents with head injuries in recently-returned Iraq/Afghanistan returnees—within 1 month of discharge and return home. • The army reports a 70% increase in motor vehicle accidents

16. Issues for Brain-Injured Active Duty/Vets: Problems in memory Problems in attention Problems in problem solving Problems in social appropriateness Problems in organization Problems in fatigue Slowed speed of information processing Anger outbursts

17. What Does BI Do to People? • Unable to utilize the medical system as it was constituted • Difficulty in maintaining social roles, marriages • Difficulty holding jobs • Difficulty in school/training (vocational/college/WBRC)

18. The four Traumatic Brain Injury Centers within the VA had already treated a majority of the severely combat injured requiring inpatient rehabilitation Since Desert Storm (Iraq 1) 1992

19. The VA reorganized the TBI lead centers Polytrauma Rehabilitation Centers, dividing the USA into 4 geographical zones • Palo Alto VAHCS, CA • Maguire VAMC, Richmond VA • James Haley VAMC, Tampa FL • Minneapolis VAMC, Minneapolis MN

20. VISNVA integrated system network

21. Polytrauma Network Sites (PNS) Each PNS Team consists of: • Physiarist • Neuropsychologist • Occupational Therapist • Case Manager • Social Worker • Physical Therapist • Speech Pathologist • Prosthetist

22. The Mission of the Polytrauma Center • Provide comprehensive inpatient rehabilitation services for individuals with complex physical and mental health sequelae of severe and disabling trauma and provide support to their families.

23. Intensive case management is essential to coordinate complex components of care for polytrauma patients and their families • Coordination of care from combat theater to acute hospitalization to acute rehabilitation to his/her home community ultimately MUST OCCUR SEAMLESSLY • The treatment of brain injury sequelae needs to occur before or in conjunction with rehabilitation of other disabling conditions

24. IED Mechanisms of Injury • 1. Dynamic pressure wave • 2. Shrapnel • 3. Acceleration / De-acceleration injury from hitting objects • 4. Crush injuries from collapsing buildings

25. Polytrauma Sequelae Auditory: TM rupture, ossicular disruption, cochlear damage, foreign body Eye, Orbit, Face: Perforated globe, foreign body, air embolism, fractures Respiratory: Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, A-V fistulas (source of embolism), airway epithelial damage, aspiration pneumonitis, sepsis

26. Digestive: Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric ischemia from air embolism • Circulatory: Cardiac contusion, myocardial infarction from air embolism, shock, vasovagal hypertension, peripheral vascular injury, air embolism induced injury

27. CNS injury: Concussion, closed and open brain injury, stroke, spinal cord injury, air embolism induced injury, anoxia, hypoxia

28. Renal injury: Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and hypovolemia • Extremity injury: Traumatic amputation, fractures, crush injuries, compartment syndrome, burns, cuts, lacerations, acute arterial occlusion, air embolism induced injury

29. Who Are The Head Injured? • 18-25 age group • Active duty Army • Marines • 35-45 age group • National Guard • National Reserve 20% are women Family constellations are different

30. Culture Clash (Old VA vs New VA) • Communication among patients who band together like birds in a flock • They Google you and everything you say. Get used to being challenged—it’s a sign of their involvement in the process.

31. They are in the early stages of adult development • Issues of late adolescence—separation, anger, appearance, jewelry, body piercing, make-up, clothes—in VA setting • First job, beginning job skills • Worried about appearance, “date-ability”—developmental task is to find a partner

32. Problems for women in the military: Pregnancy Family with children Vocation (MOS) Friendly fire issues Sexual harassment Rape

33. Problems for women who sustain brain injury in the military Seen as insubordinate Seen as lazy Seen as disorganized Seen as passive Frequently demoted or threatened with court martial—offered separation as an alternative

34. Problems for women who sustain brain injury in the military Several were offered separation for pregnancy—no mention of brain injury C&P affected No service connection for brain injury

35. Issues for Women Warriors on Polytrauma Too open and vulnerable for civilian world Don’t read social or sexual cues Give out wrong sexual cues—wrong means “unintended cues” Gum-balling—saying what you think

36. Issues for Women Warriors on Polytrauma Failure to use birth control Failure to self-protect during sex: STD, HIV No memory of pregnancy No memory of infant daughter’s first milestones

37. Issues for Women Warriors on Polytrauma • Women Warriors are different in the abilities they bring to war—they are not simply “little men” • Women Warriors are different in how they are treated in the military after they sustain an unrecognized head injury • Women Warriors have different social issues and place in society, and their head injuries affect them in their roles and in their place in the family and society

38. Training of Staff Not just clinical staff—all staff needs training in: • Polytrauma/Co-morbidity • Traumatic Brain Injury (TBI) • Post Traumatic Stress Disorder (PTSD) • Issues of late adolescence • Military vs civilian culture

39. Issues for Brain-Injured Active Duty/Vets: Problems in Visuo spatial functioning Problems in memory Problems in attention Problems in problem solving Problems in social appropriateness Problems in organization Problems in fatigue Slowed speed of information processing Anger outbursts

40. One of the major difficulties in assessing BI is that symptoms of BI are not pathognomonic, and are often confused with psychiatric symptoms.

41. This can have several negative effects: • People may be placed on inappropriate medications that do not treat the symptomatology • They can be inappropriately labeled with a psychiatric diagnosis • They have no understanding about the nature and course of the cognitive and emotional changes that have occurred

42. For Community College/Educational Centers: This means the presence of students who have no idea what their learning and memory characteristics are.

43. The purpose of this next section is: • To present the most common “complaints” regarding changes in behavior, function, and personality that result from TBI.

44. Teachers, family members , employers of people with Mild TBI, often complain of “personality” changes. When questioned specifically, they mention: • fatigue • anger • emotional outbursts • problems with concentration/attention • slowed information processing • memory problems • Spatial perception problems

45. 1. Why are people with TBI so tired all the time?

46. Fatigue:Many of the cognitive functions, which are automatic and reflexive for people without cognitive impairment, take 2-3 times the mental effort for people with TBI. This is due to the fact that people with TBI often have to think about, and do with conscious effort, what the rest of the world does automatically, without thinking.  

47. All thinking requires some expenditure of mental energy:Paying attention, Switching attention to a new person, Keeping up with the topic of conversation, Organizing an answer to a question, Making a decision, Trying to decide what to do next, Organizing your day’s activities

48. Concept of Energy Budget

49. How to Compensate for the TBI Symptom of Fatigue.• Make important decisions when the person has the greatest amount of mental energy, usually in the morning. • Make as many activities as possible into a routine to minimize choice. This saves mental energy. • Do not fill up the student’s day with scheduled activities.Do one important thing/day• The use of an organizer, either written, taped or electronic is essential.

50. 2. Why are people with TBI angry so much of the time?