CCN Series Blog

Purple Hearts - Broken Brains

Troops and Vets

UPDATE: Be sure to visit Paul Rieckhoff's Blog at the Huffington Post entitled "Adding Insult To Injury"

“The PURPLE HEART is awarded to members of the armed forces of the U.S. who are wounded by an instrument of war in the hands of the enemy and posthumously to the next of kin in the name of those who are killed in action or die of wounds received in action. It is specifically a combat decoration."

At the Polytrauma Unit of the VA medical center in Palo Alto, we meet four patients who are working to put their lives back together. (1)

Jay struggles to pick up a paper clip. His responses and speech are slowed; he cries easily.

Claudia can't remember giving birth to her 2-year old daughter and needs pictures in her room to remember her family. She uses a PDA as a "memory prosthesis" and says "My memory's not in my head any more, it's in my hands."

Frank's speech is slurred, and he needs a wheelchair to get around. He must wear a helmet to protect his brain, left vulnerable when his skull was badly damaged.

Eric must monitor carefully what he says and does because his injury impaired the part of his brain responsible for impulse control. Since his injury, he's had to re-learn how to speak and how to walk and he still needs help with coordination and simple skills like getting into a car.

These veterans must relearn everyday things that we take for granted. Not all of them bear obvious wounds, such as a lost eye or a missing part of a skull, but all share in common serious injuries to their brains.(2)

Traumatic brain injury (TBI) has been called the “signature injury” of the Iraq war. Despite improved body armor, the head remains vulnerable and with the preponderance of explosive devices used in the war, brain injuries are a common result. With improved and swift medical care close to the front, many injuries that once would have been fatal have been survived.

Some brain injuries are obvious – those resulting from shrapnel, debris or gun shots penetrating the skull into the brain. These types of penetrating injuries have occurred in previous wars.

Other types of brain injuries, sometimes called “closed injuries”M/i> are more specific to explosions and vehicular crashes.

The brain is injured by the force of impact when it moves within the skull. It may suffer concussive injury (bruising) and/or the axons of nerve cells may be twisted, stretched or broken. For a good explanation of the mechanisms of brain injuries, check How the Brain is Hurt from a guide to brain injury survival written for patients and their families.

Severe injuries may result in coma for indefinite time periods. These are readily diagnosed and can be further differentiated with CT scans. As with injuries to other parts of the body, swelling and bleeding is a typical response to trauma. But because the skull provides a hard cover around the brain, there is little space for the brain to swell or for blood to accumulate. The only outlet is the opening at the base of the skull. If swelling is not relieved quickly, the brainstem, which controls breathing and cardiac function, will be compressed, resulting in death. In these cases, surgery is done immediately at combat support hospitals to reduce the impact of swelling – frequently by removing a part of the skull temporarily. (The resected part of the skull is typically stored in the patient’s abdomen until it can be safely replaced.)

The injuries are sometimes so severe that neurosurgeons in one of the combat hospitals say that if they saw such injuries in the States, they would consider them non-survivable and not perform surgery. However, in Iraq, they do the surgeries no matter how severe the injuries, in hopes of getting the patients out of the war zone to enable the families to see them at least one more time. (3)

For those patients who do survive beyond the first few days, the recovery period is likely to be very long and slow, with uncertain outcomes. The period of coma, or minimal responsiveness, can last for months , during which time they’re completely dependent for all their physical needs, including respiratory and nutritional support and extensive care measures to prevent complications from extended immobility.

And for those whose responsiveness does eventually begin to improve, there can be significant medical, functional and cognitive hurdles to overcome.

• When the brain is not providing the necessary controls over muscles and coordination, swallowing may be severely impaired, placing patients at risk of aspiration.
• Control of bowel and bladder function is typically impaired.
• Extremity muscles may remain tightly flexed because of the inability of the brain to mediate the necessary balance between stretching and contracting, leading to a condition called spasticity. Conversely, some muscles may receive no signals from the brain and become limp. Both conditions complicate mobility and other basic tasks of daily living.
• Additionally, the injured brain is far more prone to seizures.
• Vision may be impaired because of disruption of the nerve pathways from the eyes to the brain.
• The motor coordination needed for speech may be impaired as well as the cognitive capacity for communication.
• Blood pressure, heart rate, and even functions such as metabolism and temperature regulation can be affected.

Less severe injuries may not be apparent - especially those that involve minimal or no loss of consciousness. The victim may have other more obvious and serious injuries requiring emergency treatment, or may not have any visible injuries at all. In the latter case, troops are often returned to active duty without intervention. Their deficits may be subtle and, if noticed, may be attributed to post-traumatic stress disorder (PTSD). Symptoms of brain injury can overlap those of PTSD. Some troops may be suffering from both conditions. Changes in performance may be attributed to bad behavior or attitude problems.

Someone with a mild or moderate brain injury may feel an undefined sense of “cloudiness”, loss of short-term memory, slower response times, quicker temper, difficulty focusing, decrease in physical coordination or balance, seizures – a myriad of symptoms, depending on exactly what parts of the brain are affected. In some cases, it’s not until a soldier returns home, and family notices changes in behavior and personality, that a diagnosis is made and proper treatment can be initiated.

Whether severe or mild, when troops suffer TBI's, the impact on their families is significant. For those with severe injuries, family members might have to give up jobs to devote full time to care giving. For those with milder injuries, families must learn what problems are precipitated by the injuries and make adjustments in how they relate. The service member affected may have deficits that prevent doing the type of job he/she previously held, contributing to economic pressures on the family as well as the effects that such losses have on self-image and family roles.

Over the next few weeks, we'll meet some of the troops and families who've been affected by brain injuries. The first will be the four veterans introduced above, who were featured in a recent documentary produced by the PBS series California Connected :

War Stories from Ward 7-D

Jason Poole is another young veteran of the Iraq war, also treated for TBI at the Palo Alto facility. His story was documented in a story called The Hidden Epidemic by a UK television reporter. This is the video from that story:

The Hidden Epidemic