Aftershock: The Blast That Shook Psycho Platoon
Five soldiers injured in the same 2009 bomb blast are a case study in a new epidemic among America’s troops, who are grappling with a combination of concussion and post-traumatic stress disorder.
The New Epidemic
War has always fueled innovation, helpful and horrible. Better body armor and battlefield medicine have helped soldiers survive injuries in Iraq and Afghanistan that would have proven fatal in previous conflicts. But the advances that have saved soldiers' bodies cannot protect their minds from insurgents' primary weapon, the roadside bomb. Blast waves penetrate through Humvee doors, bulletproof vests and Kevlar helmets, rattling soldiers' brains and altering cells and circuitry. Most recover quickly, but some suffer lasting damage to their cognitive abilities. At the same time, the terrifying experience of surviving such blasts haunts them, seeping out in violent nightmares and emotional outbursts.
Given the number of troops deployed, tens of thousands of soldiers, Marines, sailors and airmen may be suffering from this pernicious combination of PTSD and lasting problems from mild traumatic brain injury. They become, quite literally, different men and women than they used to be, a generation of warriors whose fight has shifted from external combat zones to invisible internal battlefields.
The issue has ignited debate in scientific and military circles, where much of the basic science remains in dispute. Are the two conditions related? If so, how? Does having a mild traumatic brain injury increase the chance of developing post-traumatic stress disorder? Or does surviving a terrifying event somehow make it more difficult for the brain to recover from a concussion? Doctors also struggle to tell the two conditions apart. PTSD and traumatic brain injury can produce similar symptoms, such as problems with memory and concentration. Yet both conditions escape detection by medical imaging devices, hindering diagnosis. Other conditions further complicate the picture. Besides PTSD and cognitive problems stemming from brain injury, soldiers also face chronic pain, missing limbs, vision, hearing and other physical problems. "It's very complicated," said Jennifer Vasterling, who has studied the issue and treated soldiers as chief of psychology at the Boston Veteran's Administration Hospital. "There are no simple scenarios."
Until recently, concussions were not even seen as particularly serious. Boxers boasted of returning to the ring after being knocked out. Soldiers in combat shook off feeling dazed and unfocused. Symptoms of concussions can include headaches, dizziness, difficulty speaking, memory troubles and sometimes balance and visions problems. Most people recover within four to six weeks. But for some, the symptoms can persist for months or even years. Civilian studies have found that between 5 percent and 15 percent of concussion victims endure long-term problems -- a condition formally known as post-concussion syndrome. Recent studies of athletes in the NFL and other sports have shown that repeated concussions can result in chronic traumatic encephalopathy, a condition associated with dementia and other Alzheimer's-like disorders.
Some researchers believe that soldiers' concussions may pose an even more complex medical challenge. Soldiers sustain their injuries in settings dramatically different from those encountered by athletes or car accident victims. Civilian concussions are typically caused by a physical blow to the head. But nobody is sure exactly how the brain is damaged in a blast concussion. Do blast waves rupture miniature blood vessels inside the brain? Does the force sever connections between neurons? Does it damage individual brain cells? Or does it simply slam the helmet into the head hard enough to injure the brain?
After the blast, soldiers face a different environment than typical concussion victims. No fans applaud as they rise from the field. Medics often can't rush them to the safety of a hospital right away. Instead, they remain on a hostile battlefield, fighting for their lives, the violence and rush of combat filling their brain with abnormal levels of chemicals such as adrenaline. Those left dazed, but not unconscious, experience a fear so fierce that it may simultaneously trigger post-traumatic stress. Paradoxically, patients who suffer severe traumatic brain injuries are less likely to develop PTSD -- perhaps because, knocked unconscious, they do not actually experience the horror unfolding around them.
"The scientific literature does not capture or mention the kind of patient that we are seeing," said Maria Mouritidas, psychology chair at Baltimore's College of Notre Dame, who worked with soldiers returning from the battlefield. "You can't compare this to a football game or a car injury. In a football game, if you go down, the game stops. On the battlefield, the game doesn't stop. Your survival depends on it."
For decades, the military has struggled to sort out the mysteries of concussions. In response to soldiers suffering head injuries during the Gulf War, the Pentagon and the Veterans Affairs joined forces to create what is today called the Defense and Veterans Brain Injury Center, a network of research and treatment clinics. But the wars in Afghanistan and Iraq dramatically expanded the need. Military doctors began noticing a wave of troops suffering brain injuries in blasts. In August 2006, the Armed Forces Epidemiological Board, responsible for monitoring health trends among troops, noted the growing number of head injuries. In a memo first disclosed by USA Today, the board warned senior Pentagon health officials that the military's medical system "lacks a system-wide approach for proper identification, management, and surveillance for individuals who sustain a TBI, in particular mild TBI/concussion."
However, it wasn't until the Walter Reed Hospital scandal of 2007 that the military dramatically increased attention to the so-called "invisible" wounds of war. The Washington Post revealed that officials at the hospital, the crown jewel of the military medical system, housed soldiers with brain damage in moldy hospital rooms, often ignoring their needs. The scandal caused an uproar in Congress and across the nation. Lawmakers passed legislation devoting more than $300 million in new research funds to brain injuries and PTSD. They ordered the military to conduct cognitive screenings of soldiers before and after deployment. President Bush created a commission headed by retired Sen. Bob Dole and former Health Secretary Donna Shalala to suggest recommendations to improve care for soldiers with PTSD and brain injury. In 2008, the Rand Corporation produced a groundbreaking report estimating that 19 percent of soldiers in Iraq and Afghanistan had suffered a probable traumatic brain injury, while another 18 percent reported symptoms of PTSD or depression. About 5 percent reported a combination.
Yet, despite the pressure and the growing numbers, the Pentagon's response was uneven, at best. ProPublica and NPR reported last year that the military continues to have problems diagnosing and treating brain-injured soldiers. The military's standard screens failed to catch as many as 40 percent of concussions, according to a study published earlier this month. Injuries weren't always noted in soldiers' medical files because of poor recordkeeping. In some cases, soldiers resisted admitting that they had sustained head traumas because of a desire to remain on the battlefield with comrades. In the command echelons, some high-ranking military officers dismissed the effects of mild traumatic brain injuries.
Col. Heidi Terrio, an Army doctor who has worked extensively with soldiers returning from the combat field, conducted a study published in the Journal of Head Trauma Rehabilitation that reported that 7.5 percent of combat soldiers returning from Iraq and Afghanistan showed three or more symptoms associated with post-concussion syndrome, with another 20 percent reporting one symptom. Terrio said her study showed that it was important to pay attention to soldiers with concussions. "Mild traumatic injury does not mean it's a mild problem," she said. "Mild doesn't necessarily mean mild consequences. One concussion may cause you to have lifelong problems. Most of the time it doesn't but it can."
The military has failed to diagnose brain injuries in thousands of soldiers returning from overseas.
The Story So Far
Traumatic brain injury is considered the “signature wound” of soldiers fighting in Iraq and Afghanistan. Official military statistics show that more than 115,000 soldiers have suffered mild traumatic brain injuries since the wars began. Shock waves from roadside bombs can ripple through soldiers’ brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.