Returning Soldiers: Advancing Medicine After Sacrifice In Battle

If the march of history has shown us anything, it is that technological advances are often the result of armed conflict. We have seen that in striking detail in the Iraq and Afghanistan conflicts. One of the most unfortunate consequences of these conflicts is that they have dramatically highlighted the armed services’ inability to effectively screen and treat traumatic brain injury (TBI) and post traumatic stress disorder (PTSD) in returning soldiers. Another consequence is that the fact that soldiers have suffered TBI and PTSD in ever increasing numbers has forced research forward concerning these intractable disorders. In recent weeks, several articles of note crossed our desks here at the Alaska Personal Injury Law Group.

The Government Accounting Office (GAO) just released a report that underscored the Dept. of Veteran’s Affairs’ (VA) continuing inability to identify and provide services to affected veterans. This is true despite a pledge by the VA Secretary, Jim Nicholson, last April to promote new screenings for brain injury and a personal promise to see the changes through. The GAO reviewed nine VA medical centers, and found that there were problems in securing follow-up appointments after the veterans initially tested positive under the VA’s TBI screening tool. Two of the medical centers did not follow the screening tools protocol because they failed to use the symptom checklist, which they said was because they didn’t know the checklist existed or because they had inadequate staffing. The GAO also identified poor rural access to services resulting in a 50% decrease in the ability to provide care. It is estimated that as many as 20% of US combat troops who fought in Iraq and Afghanistan are believed to leave with signs of TBI.

At the end of January, the New England Journal of Medicine published a study submitted by specialists at the Walter Reed Army Institute of Research that added further to the controversy about how veterans should be screened and treated upon their return. Studying outcomes for over 2500 soldiers, the researchers found that soldiers with mild traumatic brain injury, particularly those who had suffered loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and post-concussive symptoms than were soldiers with other injuries. After the data was adjusted, the researchers concluded that mild traumatic brain injury with loss of consciousness was strongly associated with PTSD and depression. Over 43% of soldiers reporting TBI with loss of consciousness met criteria for PTSD, compared with 27% of those with the lesser brain injury from an altered mental status following their injury. TBI with loss of consciousness was also significantly associated with major depression. The difficulties the soldiers faced may therefore be more attributable to the result of intense psychiatric reactions to battlefield events, rather than a structural injury to the brain. This may be good news in that there are treatments for PTSD and depression, and very few medical treatments available to those who have suffered a structural injury to the brain.

Finally, the February issue of the Journal of Nervous and Mental Disease published research concerning the link between PTSD and chronic inflammation and early death. Studying veterans diagnosed with PTSD after the Vietnam conflict, the researchers found high erythrocyte sedimentation rates (ESR), white cell counts (WBC), and cortisol/dehydroepiandrosterone sulfate ratios (DHEA-s). Death rates between the comparison groups was 13.6% among those suffering from PTSD and 5% for those without the diagnosis. In addition to PTSD predicting an increased all-cause mortality rate, PTSD and a high erythrocyte sedimentation rate were also associated with increased death rates from cardiovascular conditions. Thus, having PTSD, a high ESR, a high WBC count, and a high cortisol/DHEA-s ratio were associated with all-cause disease mortality. These study results suggest that physicians treating veterans should routinely screen for PTSD and these associated increased risks. The article provided further scientific explanation as to why the archaic mind-body duality relied upon by the law is medically unsupportable. This is simply because, if one’s mind (PTSD) is affected, one body will surely suffer consequence, as well.

Source:

VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain, GAO-08-276 February 8, 2008; http://www.gao.gov/docsearch/abstract.php?rptno=GAO-08-276.


Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq,
New England Journal of Medicine, Volume 358:453-463 January 31, 2008 Number 5; http://content.nejm.org/cgi/content/full/358/5/453.

Psychobiologic Predictors of Disease Mortality After Psychological Trauma: Implications for Research and Clinical Surveillance,
Journal of Nervous & Mental Disease. 196(2):100-107, February 2008.