Afghan war vets, researchers seek answers on head injuries
Dan Golby, a karate instructor with mild traumatic brain injury, has a brain scan done in an MRI machine at St. Louis University Hospital on Jan. 16, 2014. Golby, a civilian, is part of a study by SLU researchers looking into TBI in war veterans.
St. Louis Post-Dispatch
ST. LOUIS — For hours on route clearance missions in southern Afghanistan, Sgt. Michael Ritchey crammed his short body into a Husky, a single-seat vehicle that loosely resembles an armored road-grader.
His job was to use ground penetrating radar to detect pressure-plate bombs hidden under endless stretches of rough gravel and dirt roadways.
And he did it well. In two tours, Ritchey sniffed out 27 improvised explosive devices, or IEDs — most recently sparing fellow members of Missouri’s 1138th Engineer Company the kinds of explosions that account for most of the war’s injuries.
Still, he couldn’t stop them all. Four IEDs went off near him, three of which tore his vehicle apart. Ritchey’s wife and sister used to laugh at him after his first deployment because he’d become so forgetful and confused.
“Then they realized I wasn’t playing,” said Ritchey, 26, who is now home again in Columbia, Mo.
Ritchey suspects he suffers from mild traumatic brain injury — by far the most common injury suffered by troops in Afghanistan and Iraq.
But like many, Ritchey is impatient with an inability to accurately diagnose his condition.
So are researchers — including teams at St. Louis University and Washington University — who are chasing discoveries that some day might offer a way to easily diagnose mild TBI, which is similar to concussion. An estimated 20 percent of more than 2 million people who deployed since 2001 were exposed to the injury.
Those who sustained a concussive blast had headaches and struggled with awareness. A few blacked out. Many recovered from the injury with rest. Others didn’t and were kept in the fight despite being near multiple blasts in short time periods. Officials and advocates say countless troops haven’t been diagnosed.
New policies are in place to screen for TBI in the battlefield, but it’s still a finicky area. Concussions don’t show up on traditional CT or MRI scans the way a broken leg or cancer will.
Instead, doctors rely on analyzing symptoms and cognitive testing.
Ritchey said those techniques were used at a veterans hospital screening to clear him of a diagnosis of mild TBI.
During the four-hour exam, he was told 25 words and asked to recite as many as he could from memory; he remembered about six. He was shown a picture, then asked to draw it by memory, then asked to draw it again. He did fine. A senior architecture studies student at Mizzou, he teaches 3-D design on the side.
“It’s not realistic,” he said of the testing. “They sit me in a quiet room with one person and that’s all I have to focus on. You let my 2-year-old in that room and I don’t know what’s going on.”
In real life, he relies on lists to get by. Multi-tasking isn’t an option.
He’s been diagnosed with Post Traumatic Stress Disorder, but he said weekly counseling sessions aren’t helping his memory loss. He’s asking the VA to do another TBI evaluation.
“I have been to the store three times in the same day and never got what I went for,” he said. “How do you explain that?”
When the war in Afghanistan broke out in 2001, the military was concerned about getting troops home alive. And it did a much better job compared to previous wars because of advances in armor, air evacuation and treatment for trauma. With that, more people are living from blasts that otherwise would have killed them. A common side effect is TBI.
There are four kinds of TBI — mild, moderate, severe and penetrating. Since 2000, nearly 300,000 active-duty military personnel have been diagnosed with TBI. Most of the cases were mild.
But it wasn’t until 2008 that TBI diagnoses jumped significantly. About that time, the Department of Defense started doing post-deployment screenings for it. Then in 2010, there was a theater-wide policy change on reporting concussions in the battlefield. The policy used to be voluntary. Raise your hand if you have a headache.
Now, there are mandatory evaluations for all service members who are exposed to within 50 meters of a blast — from an IED, mortar or RPG. Depending on the results, they can be pulled out of duty for rest. Three concussions in a 12-month period are supposed to result in a comprehensive evaluation.
Katherine Helmick, deputy director of the Defense and Veterans Brain Injury Center in Silver Spring, Md., which was created by the government after the first Gulf War, stressed the importance of detection. Without it, soldiers perform worse on the battlefield. Then, as veterans, life can be different for them and their families.
“The natural trajectory is that you get better,” Helmick said of mild TBI. “It becomes more complex if you don’t get this detected early.”
Though there is a focus on the wars, 80 percent of military TBI diagnoses occurred in non-deployment settings, for instance in training.
Scores of service members were never screened prior to the new policies and may be living with TBI.
“I am sure the numbers are underreported,” Helmick said.
Trying to catch up on diagnoses poses enormous challenge, said Jason Hansman, program manager for health programs at the nonprofit Iraq and Afghanistan Veterans of America. Half of the veteran population relies on civilian hospitals that haven’t seen the volume and variety of blast-induced TBI as the Veterans Affairs medical system. And the VA does better in some areas than others.
“If you are lucky enough to be near a polytrauma center, you are good to go,” Hansman said. “If you are not, your standard of care is not as high.”
Chrisanne Gordon, a physician in Ohio, said only 10 percent of healthcare providers in the country are familiar and actively treat mild TBI. Many who display symptoms don’t seek treatment anywhere.
“Thirteen years into the wars, we ought to know a little more,” said Gordon.
Gordon helped create the Resurrecting Lives Foundation, a group that advocates for better cooperation between the Veterans Administration, Department of Defense, and civilian health care systems so there will be better solutions for hundreds of thousands of veterans who suffer brain trauma, many without diagnosis.
Gordon is particularly adamant about the issue. A former TBI screener for the VA, she was questioned over her high diagnosis numbers. Also, she personally recovered from TBI after falling into a wall one Christmas while putting up decorations. She said it took more than a year to feel steady again. Her memory was never the same.
Yet her brain scan at the time of injury came back normal.
“That’s why I am so passionate about this,” she said, adding: “The brain totally affects ability to function in our fast-paced society.”
The U.S. government has spent millions of dollars trying to develop objective testing methods to diagnose mild TBI.
As part of a $5.3 million grant, researchers at St. Louis University are working on a study of brain scans and cognitive testing in dozens of veterans with blast-induced mild TBI and civilians with mild TBI, as well as healthy controls for comparison.
So far researchers have found that the civilians tended to recover a few weeks after suffering a concussion. Veterans described more persistent symptoms, such as memory loss, ability to concentrate and regulate emotions.
Researchers believe the symptoms may be backed up on screen with so-called diffusion tensor imaging, a function on a standard MRI machine that hones in on neural pathways in brain white matter. Researchers say the imaging could pick up on minuscule disruptions in nerve track fibers that might indicate mild-TBI in veterans, even several years after suffering a blast.
“The diffusor tensor imaging has the potential to help us understand why injured members of the military are reporting these issues,” neuropsychologist P. Tyler Roskos wrote in a recent statement about a small preliminary study of the material. “It also may help service members feel justified that the ‘invisible injuries’ they experience are real.”
Researchers cautioned that final results could be inconclusive or different than what they have presently. Complicating matters, many of the 75 veterans who participated in the study have PTSD and depression. Some wrestle with substance abuse. Those factors and others could contribute to their symptoms.
Though researchers say they are a long way off, they hope that more sensitive brain scans can show how blasts affect veterans long term. Veterans have a tougher puzzle to put together compared to civilians because vets often sustain multiple head injuries as well as the psychological trauma of warfare itself.
Washington University School of Medicine has caught attention with its TBI research, including the use of diffusion tensor imaging technology.
David Brody, an associate professor of neurology there, said researchers just closed enrollment on a study of 178 military personnel.
“The goal was to use advanced MRI scans to differentially assess both blast and non-blast related concussive military TBI,” Brody wrote in an email.
He said another Washington University study also recently closed involving the brain scans of injured service members at Camp Leatherneck, a Marine base in Afghanistan’s volatile Helmand Province, and in nearby Kandahar.
'Brightest and darkest thing'
Kandahar is the area where Sgt. Michael Ritchey and others in his company of Missouri Guardsmen worked. Many of them were exposed to blasts while clearing the roadways of bombs. Some of them will remember the anniversaries of the explosions similar to their birthdays.
Colleagues who shared the experience now share a text on the anniversary: Drive safe to work today.
Experts say surviving a close explosion is different than being hit hard in football or hockey. Bomb blasts usually don’t discriminate to one side of the helmet. Pressure and sound waves can cause tiny rips and tears throughout the 3-pound brain by compression and expansion. There’s often secondary exposure to chemicals, flying debris and smacking against something.
“It’s like the loudest and quietest and brightest and darkest thing,” explained Sgt. Michael O’Callaghan, of St. Louis, one of Ritchey’s comrades in the 1138th Engineer Company. “You see the initial blast. Your ears start ringing. Then, with all the debris that goes up in the air, it’s just pitch dark — you can’t see the hand in front of your face. Then, all of sudden, your hearing comes back, and you start hearing all the debris raining down.”
After initial shock wore off, he and the others in the damaged vehicle laughed.
“We were laughing after the second one, too,” said O’Callaghan, 40. “Then after the third one, the big one, I was like (shoot) I don’t think I am going to see my kids again.”
All three blasts happened within two weeks in 2012. O’Callaghan flunked the mandatory field tests for TBI and was yanked from the field for a time. He was officially diagnosed with mild TBI months later, on the way home. Now he’s treated for a form of anxiety and TBI at the polytrauma center at Jefferson Barracks in South St. Louis County. Still, he said, his left ear won’t stop ringing and mild headaches haven’t receded.
His wife has noticed a change in mood swings and sleep patterns.
“I have no patience anymore,” he said. “I’d really love to be able to sleep more than anything else.”
O’Callaghan, a medic, received a Purple Heart medal for his injuries. Out of the 1138th, he was hit the most during the last tour and was seen as the unlucky Irishman.
Though O’Callaghan has been diagnosed with TBI and Ritchey hasn’t, they are both moving forward in the Missouri Army National Guard. A unit from Festus is deploying to Afghanistan soon to help tear down bases. Neither of them is going on this trip, but they re-enlisted for another six years in the Guard. Ritchey says he likes being a citizen soldier, so does O’Callaghan.
In fact, O’Callaghan re-enlisted when he was still in Afghanistan. He was recovering from the blasts at the time. He said the opportunity was hard to beat with a $10,000 tax-free signing bonus.