Our Returning Veterans, Are We Ready?

1. Our Returning Veterans, Are We Ready? Brant A. (Bud) Elkind, MS, CBIS-T Director, Clinical Operations Robin Hill Farm, Inc.

2. Traumatic Brain Injury (TBI) • TBI - “An insult to the brain, not of a degenerative or congenital nature but caused by an external force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning” (AACBIS)

3. Acquired Brain Injury “An injury to the brain occurring after birth that is not hereditary, congenital or degenerative; does not refer to brain injuries induced by birth trauma” i.e. Stroke/CVA, Anoxia, Disease, Neuro-toxic Poisoning, Metabolic disorders (insulin shock, liver and kidney disease, or trauma (AACBIS)

4. Brain Injury Range • Mild characteristics include: Loss of consciousness for les than 30 minutes or no loss Glasgow Coma Scale of 13-15 Post-traumatic amnesia for less than 24 hours Temporary or permanently altered mental or neurological state with pos-concussive symptoms (AACBIS)

5. Moderate Brain Injury • Coma more than 20-30 minutes but less than 24 hours • Glasgow Coma Scale or 9-12 • Possible skull fractures with bruising & bleeding • Signs on EEG, CAT or MRI Scans • Some long term problems in one or more areas (AACBIS)

6. Sever Brain Injury • Coma longer that 24 hours, often lasting day, weeks or longer • Coma scale of 8 or less • Bruising, bleeding in the brain, signs on EEG, CAT or MRI scans • Long term impairment (AACBIS)

7. TBI In The United States • 1.4 million sustain a TBI each year • 50,000 die • 235,000 are hospitalized • 1.1 million ER visits • The number of people who sustain a TBI and do not receive treatment is unknown (BIAUSA)

8. Leading Causes of TIB’s • Falls 29% • Motor Vehicle Accidents 20% (most are unrestrained) • Stuck by/against 19% • Assaults 11% • Other 13% • Unknown 9% (BIAA)

9. Long Term Consequences of TBI • Direct and indirect costs of TBI in the US as of 1995 was estimated at $60 Billion • The CDC estimates 5.3 million Americans currently have long term, lifelong need to perform activities of daily living as a result of TBI (BIAA)

10. Unmet Need for Services One Year After Injury • Improving memory and problem solving • Managing stress and emotions • Controlling one’s temper • Improving one’s job skills (CDC)

11. The Wide Range of Functional Change • Thinking, language, learning, emotions, behavior and or sensation • TBI can also cause epilepsy, increase the potential for Alzheimer’s and Parkinson’s and other brain disorders that become more prevalent with age (CDC)

12. OIF – OEF STATISTICS • Approximately 1.6 million troops have to date been deployed to Afghanistan and Iraq • 300,000 are estimated to have affected by Traumatic Brain Injury (TBI) and or Post Traumatic Stress Disorder (PTSD) • 64% of all wounded are estimated to have sustained “Blast Injuries” • 47% of all blast injuries affect the head (NABIS)

13. Anatomy of a Blast Injury • Instantaneous pressure wave with a rise and drop in pressure • Results in cavitation occurring at the molecular level ((brain, inner ear, eyes, gastrointestinal tract, lungs and spinal fluid structures are liquefied) • Over-pressurization wave dissipates instantaneously creating a vacuum • Impact may also energize shrapnel, may exhaust gases and vapors that burn lung tissue and flesh (Wikipedia)

14. What We Expect to See as Our Veterans Return Home • The most severely injured continue to remain in Poly Trauma Hospitals • Those returning with mild brain injuries pose a significant public health concern • They will return with high expectations to their homes, families, jobs and communities

15. Why there is Reason for Concern • Many will return healthy • Others will return, unaware of their brain injury (Agnosia, an inability to see their deficits) (D&VBIC)

16. What we will see! • Difficulty with: • Thinking • Receptive - Expressive • Short – Long-term memory • Attention – Initiation • Expressive – Receptive • Multi-tasking

17. What we will see (Continued) • Adverse Behavior (Impulsivity, Disinhibition, Anger Control) • Seizure activity • ETOH – (Alcohol and Substance Abuse) • High-risk behavior • Disorientation • Tinitus and feelings of Isolation (EBIG)

18. “Contrary to expectations, patients with mild to moderate TBI are actually much more affected by their emotional difficulties than by their physical disability” (Glasser) • Soldiers returning with mild to moderate brain injuries are 3 times more likely to incur a second brain injury and 8 times more likely to incur a third” (CDC)

19. Systems of Care • Poly-trauma Centers (4) • Poly-trauma Network Sites (21) • Poly-trauma Support Clinics – VISN (Specialized teams) • Poly-trauma Point of Contact

20. VA Poly-trauma Rehab System of care • Proactive Case Mgt • Telehealth Network • Long-term follow-up; proactive, specialized • Care for those who cannot care for themselves

21. So, is the Community Ready • Probably not! • 5 Professional Brain Injury Programs in NH representing a Continuum • Facility based • Residential • Home based

22. Community • To welcome our soldiers with mild brain injury home we must be: • Inclusive not Integrative • Be involved at all levels • Social Service Agencies must understand needs • Physicians and hospitals must be able to appropriately diagnose, medicate and care for people with mild brain injury

23. Other Community Based resources • OT’s, PT’s, SLP’s and Psych Professionals must be trained in mild brain injury • The community must be knowledgeable in the area of disability rights.

24. Partnerships • The VA cannot do everything • Communities must be willing to include • Support systems must be educated and capable to working with this specialized population

25. References American Academy for the Certification of Brain Injury Specialists (AACBIS) www.aacbis.net Brain Injury/Professional vol. 4, issue 1, North American Brain Injury Society, “Reintegrating Military Personnel after TBI, Community Integrated Rehabilitation Model in Practice, Trudel, Davanzo, Mattingly, Nideffer & Barth Brain Injury/Professional vol. 4, issue 1, North American Brain Injury Society, Current Trends in Post Traumatic Stress Disorder & TBI among Military Personnel, Nideffer, Errico and Barth The Essential Brain injury Guide, Edition 4.0, American Academy for the Certification of Brain Injury Specialists Blast Injuries, Wikipedia, the Free Encyclopedia, January 2008, NABIS, Blast Injury Institute, Ziejewski, Inz, Karami, Akhatov Defense Veterans Brain Injury Center Brain Injury Association of America, www.biausa.org