"My Head Broke My Fall"

Kandahar, Afghanistan

Old Russian armored vehicles on our run route

"I was lucky because my head broke my fall."  This was the quote my running buddy, Franche, remembered from one of her many traumatic brain injury (TBI) patients.  We ran this morning and got sidetracked on the subject of TBI.  TBI will be remembered for generations to come as one of the hallmark injuries of this war, a result most often from victims of IED blasts.  We see many TBI patients, or more specifically mild TBI (mTBI), which can be likened to a concussion.

Mild is a true misnomer, and the implications of the word concussion come nowhere close to the injuries seen at our hospital.  Concussion is getting a fair amount of press coverage these days because of what retired NFL football players are experiencing after their careers are over.  I'm sure these injuries are terrible as well, but they cannot be comparable to what we see.  When one is exposed to an IED blast his or her head suffers acceleration-deceleration injury the likes of which one doesn't see that often in the "real world."  The shear forces may cause damage on a micro scale such that our best imaging techniques can't pick up where the damage lies.

The man who felt lucky that his head broke his fall was blown out of a second story building.  His buddy had tripped off an IED and died in the resulting explosion.  He was blown out of a window or wall and fell on his head when he hit the ground.  Franche told me that he had the typical severe headache and memory problems that she sees in dozens of patients each week.

The memory problems are strange and can be severe.  She recently had a patient who was in an IED blast who could not remember anything beyond a date more than one year prior to the blast.  Each morning she would see him he would forget that they had met the previous day and had established a medical relationship.  He would get rebooted to sometime in 2009 each morning as he awoke.  She finally wrote him a letter detailing the blast, what had transpired since the blast and what therapy was ongoing for him.  He kept the letter with him and read it every day before seeing her.  It was like a scene from the movie Memento, except he had a letter, not tattoos which served as his memory.  When he got to the States he wrote her a letter thanking her, and telling her he still carries the letter around.

Other side effects of mTBI are headaches of migraine proportions.  They are difficult to impossible to treat.  No one knows yet what the natural history of these headaches or the other mTBI symptoms will be.  Nine years into this IED driven, TBI-resulting war, and we still do not know if these are lifelong symptoms, or ones that will resolve in time.  I truly hope for the latter as these headaches are debilitating for many.

Mental anguish can accompany these headaches.  Even though they are debilitating, there is no scar or amputation that earmarks one as a war-injured.  Their peers or superiors may label them as malingerers (unfortunately, there are malingerers out there, which feeds this perception).  PTSD often accompanies TBI as well, for a wicked one-two punch.  The patient ends up feeling helpless and sometimes persecuted.  Guilt feelings may accompany these other two emotions.

Many soldiers and Marines do their best to mask the symptoms of mTBI so they can get back to their units.  The loyalty bond is strong.  They memorize the answers to the MACE exam (the military acute concussion exam) - a 30 point memory quiz which identifies them as mTBI victims.  We have good intel that this is being done;  there are three versions of the MACE so often they get foiled that way - they only know the answers to the first MACE.

Many patients have suffered multiple TBI events.  Franche's "winners" in this category are in the double digits - one with 11 and one with 12 prior events.  Unbelievable.

Many mTBI patients can resemble young Alzheimer's patients, their symptoms are so severe.  I remember being at Walter Reed or Bethesda Naval Hospital during my training and having some of these patients show up for pulmonary appointments: they would have no idea why they were there, they just had a sheet of paper telling them to be at my clinic at a certain time.  Many ultimately ended up with guides who would be responsible for getting them to their various appointments on the medical campus.

I fear that we will have a cohort - a large cohort - of young folks from this generation who will be wandering around our streets as homeless people, confused and cognitively disabled, victims of war without visible scars.  Please remember them in your thoughts, prayers, and deeds as I am certain you will see these unfortunate victims of war as time goes by.

Note: While waiting for photos to upload for this post I note a National Public Radio post sent to me via Facebook: "Please help us find veterans who experienced concussions while serving in Iraq or Afghanistan."  At npr.org.  Weird.