Brain Injury Association of Oregon

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					The Changing VA Population:
Young, Active Duty and Brain
           Injured

   Harriet Katz Zeiner, PhD

    Harriet.Zeiner@va.gov
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?
• 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.
• 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)
Of these injured military personnel,
60% have some degree of traumatic
              brain injury
       http://www.dvbic.org
            If the War Ended Today:

• 27,848 WIA
• 65% of these are IED = 18,101
• 60% of IED injuries involve head injuries =
  10,860
• 500 combat-wounded polytrauma patients have been
  treated at the 4 PRCs

  Currently, 10,000 people with head injury have been
  discharged home—and don’t know why they think, feel
  and behave differently


* These numbers are from September 2007
• 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.
  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
   Occult (Hidden) Brain Injury
• Half the patients with head injury will be
  blast exposed
• Half will be the result of motor vehicle
  accidents
• 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
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
  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 (vocational/college)
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
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
    Polytrauma Network Sites (PNS)
Each PNS Team consists of:

•   Physiarist
•   Neuropsychologist
•   Occupational Therapist
•   Case Manager
•   Social Worker
•   Physical Therapist
•   Speech Pathologist
•   Prosthetist
          VISN
VA integrated system network
   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.
• 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
• Scope of services to include inpatient,
  transitional, and outpatient rehabilitation
  as well as:
  – community re-entry tailored to the individual
    pattern of impairment sustained in the
    trauma
  – and management of associated conditions
    through consultation


• All levels of injury are included
 (Rancho Los Amigos Cognitive Levels 1-8)
Location of service



 Screen for PTSD




 Screen for Depression
    IED Mechanisms of Injury
• 1. Dynamic pressure wave
• 2. Shrapnel
• 3. Acceleration / De-acceleration injury
  from hitting objects
• 4. Crush injuries from collapsing buildings
         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
• 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
•   CNS injury: Concussion,
    closed and open brain injury,
    stroke, spinal cord injury, air
    embolism induced injury,
    anoxia, hypoxia
• 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
  Who Are The Head Injured?
• 18-25 age group
  – Active duty Army
  – Marines

• 35-45 age group
  – National Guard
  – National Reserve

  20% are women
    Effects of Military vs Civilian
               Culture
• 1. Civil rights, privacy issues
• 2. Ecological validity of military system
• 3. Decisional capacity determinations
• 4. Attitude toward war and injury, return to
  service
• 5. VA regarded as ―civilian‖- They know
  their way around the military system. They
  are clueless about the VA (SC, C&P).
Culture Clash (Old VA vs New VA)

 • Signs of ―culture clash‖

   – We provide something we never have before –
     faster than ever before (and expect gratitude
     for doing things so fast)


   – They expect no mistakes and think we are ―not
     as efficient as the military‖
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.
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
Problems for women in the military:

Pregnancy
Family with children
Vocation (MOS)
Friendly fire issues
Sexual harassment
Rape
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
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
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‖

Gumballing—saying what you think
Issues for Women Warriors on Polytrauma

Failure to use birth control

Failure to self-protect during sex: VD, HIV

No memory of pregnancy

No memory of infant daughter’s first
 milestones
Issues for Women Warriors on Polytrauma

Custody battles in divorce

Visitation versus care of children

Supervision of children and household

Driving and being dependent

Financial dependence

Being competent to make decisions over medical
  needs, legal needs, personal needs
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
        Systemic Changes

• Loss of ―I just do windows‖ mentality—
  staff needs cross training—becomes not
  multidisciplinary but trans-disciplinary
  (more interesting for staff, more
  challenges for admin)
• Greater number of competencies
  required—increases educational needs for
  staff
             Training of Staff
Not just clinical staff—all staff needs training
  in:
• Polytrauma
• Traumatic Brain Injury (TBI)
• Issues of late adolescence
• Military vs civilian culture
         Systemic Changes

• Development of two-tier system
• Not of treatments, but of priority for
  treatment, equipment and support of
  family systems
• Subversive nature of this re-organization—
  potential to change the entire American
  health care system
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
One of the major difficulties in

     assessing BI is that

   symptoms of BI are not

       pathognomonic,

         and are often

  confused with psychiatric

          symptoms.
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
For Community College:

This means the presence of students who
have no idea what their learning and
memory characteristics are.
• The purpose of this next section is:



• To present the most common
  “complaints” regarding changes in
  behavior, function, and personality.
Teachers, family members , employers of
   people with Mild TBI, often complain of
   “personality” changes.

When questioned specifically, they mention:
1. fatigue
2. anger
3. emotional outbursts
4. problems with concentration/attention
5. slowed information processing
6. memory problems
Frequently Asked Questions
        About TBI
1. Why are people with TBI
   so tired all the time?
                 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.
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
• Concept of Energy Budget
2. Why are people with TBI
angry so much of the time?
                  Cognitive deficits —

 slowed rate of information processing, reduced span
of attention, loss of the ability to multitask (“Now I’m a
      one-trick pony”), memory problems for new
  information, visuospatial difficulty in perceiving the
                     environment —

all serve to make the world seem a more difficult place
                    to comprehend.

  The anger expressed by people with TBI is often a
          symptom of stimulus overload.
“Catastrophic reactions”
 are emotional responses of neurologically
impaired people when the environment is
too complex for them cognitively.

There are four variants:
silly laughing
flight
tears
anger
                  Cognition

Defined as the process of knowing. It
  includes:
• Discrimination between and the selection
  of relevant information
• Acquisition of information
• Understanding of information
• Retention of information
• Expression of and application of
  knowledge in the appropriate situation
            Cognitive Disability


• Reduced efficiency, pace and persistence
  of functioning
• Decreased effectiveness in the
  performance of routine activities of daily
  living (ADLs)
• Failure to adapt to novel or problematic
  situations
Cognitive Impairments—the object of Cognitive
                 Retraining

•   Attention
•   Visuospatial
•   Learning and Memory
•   Non-interpersonal Problem Solving
•   Problem Solving involving Social Content
•   Executive Function: integrative goal-directed
    and purposive behavior, superordinate in the
    orderly execution of daily life functions
   TBI often challenges people’s
 assumptions about how the world
works. We all hold some false beliefs
     about the world, such as:
° Life’s fair. This is untrue. In dealing with
unfairness, it helps to change the frame of
                   reference.
For example: Everyone who is alive today has
beaten the odds. The odds are 100,000,000 to 1
that a particular sperm would fertilize the egg,
which resulted in a particular individual. Those
are the odds we all win at conception. After we
are born, everything else is gratis, icing on the
                     cake.

This is offered as an alternative viewpoint for
those who feel cheated of a fair share of good
health and long life with any untoward events.
   Characteristics of Mild Brain Injury
  that Your Departments Will Have To
               Deal With

Inefficient memory: especially for appointments,
     episodic events

   1. 3 missed appointments, clinics drop them
   2. Need for memory prostheses and training (often
      too slow)
   3. Can’t come back later—they will disappear; solve
      the issue now
   4. Allow tape recording of information