I've been involved with DVBIC, the Defense and Veterans Brain Injury Center,
trying to develop some guidelines for how to treat mild traumatic brain injury
and also for how to diagnose it in the field.
And I think that DVBIC and the military are really leading the way in that regard,
especially with the mild traumatic brain injury, with the milder forms of TBI.
There's no civilian organization that has guidelines for how to treat
the various symptoms that come up after someone has a concussion.
There's no civilian organization that has specific guidelines
for how a blow to the head should then lead to some diagnosis of mild TBI
in a really systematic way.
So I've been really impressed by the amount of effort
that's gone into producing both of these.
I've also been involved with the Institute of Medicine
in a committee to try to determine what the long-term health effects
of traumatic brain injury are or would be.
So if you have a soldier who is hit and has a concussion
or a more severe traumatic brain injury, what kind of problems that may crop up in the future
could reasonably be ascribed to the initial brain injury.
This conflict in Iraq and Afghanistan has really accelerated the pace of research.
The Department of Defense has disbursed quite a bit of funds for research
in TBI and post-traumatic stress disorder,
and I think that we've gotten a long way in the last five years
in terms of diagnosis and in treatment.
There's several clinical trials that are about to be started related to TBI,
and there's several new diagnostic modalities.
One of them is an eye tracking device that's supposed to be a biomarker
of a brain injury after a concussion.
The serum markers, a field device that could be used to put someone's blood on it
and see whether they've had some brain injury.
And all of this has really been as a result of these two conflicts.
So most of the traumatic brain injuries that are occurring in Iraq and Afghanistan
involve, at least in part, a blast--
not solely a blast but, at least in part, some blast from a bomb.
And what we've found--I shouldn't say we because it's really the researchers
that have been involved in the military in Iraq--
is that these blast-related injuries behave in special ways.
So for example, soldiers who get knocked out from a blast
may actually be okay for an hour or two and then start to develop symptoms
kind of in a delayed fashion,
where we found in the civilian world that doesn't happen.
People who get hit in the head in a car accident start to develop symptoms
pretty soon after the brain injury, within minutes, vomiting and headache.
So the symptoms seem to be a little delayed after a blast.
After a blast, it also looks like the brain swells up a lot more
than it does after non-blast mechanisms.
So soldiers who have had moderate and severe TBI
have a lot, a lot of brain swelling, much more than a similar severity of brain injury
from a non-blast mechanism in the civilian world.
And this is what's led to neurosurgeons being really aggressive about craniectomies--
removing a part of the skull immediately and allowing the brain to swell
through that hole in the skull.
An interesting finding was there have been many, many cases
of blast-related mild traumatic brain injury where a CAT scan has been done
and has been absolutely negative, no blood at all.
In the civilian world, as I told you before, about 5 to 7 percent of mild traumatic brain injury
will have some kind of bleeding on it,
but in these blast-related brain injuries, very few, like zero.
That's a very different type of injury.
And it may be because there is more swelling and less bleeding with a blast injury
than there is with a non-blast.
It's a very different animal, I think.
After a neurosurgeon performs a craniectomy--
and I'm an emergency physician, not a neurosurgeon,
but my understanding is that the brain does swell out through the opening
that's made in the skull, and that actually helps relieve the pressure inside the skull
so that the brain isn't forced through the base of the skull.
If the brain is forced through the base of the skull,
then the patient's heartbeat and breathing will stop and they die.
So this prevents them from dying.
But as the brain swells out, it does press against the edges of the skull,
and sometimes that's a problem, at least for the brain around the edges of the skull.
The skull is almost always discarded, and I'm told because it's usually contaminated
from the initial blast, and the brain is covered with a protective covering
so that it doesn't get infected.
Then after the swelling goes down, which is often weeks to months later,
that defect in the skull is repaired.
There's a lot of interest in trying to sort out the interplay
between the symptoms of a concussion
and the symptoms of post-traumatic stress disorder.
It seems like they potentiate each other, they interact somehow.
And this is very different in civilian life because in civilian life
post-traumatic stress disorder is rarely seen as a complication of concussion.
But it's very common after military TBI.
And so we're trying to figure out what the interplay is.
I think the leading hypothesis is that the mild brain injury that occurs
probably exacerbates or interacts with the combat stress that soldiers undergo,
and the symptoms are much worse than if either one of them was there alone.
In a way, it's hard to think about these things
because a soldier may have one or two isolated brain injuries
but may be consistently and continuously exposed to stress.
So that stress is there all the time, all the time.
And then interject a brain injury in there, and you could see how they would interact.
So there's this interplay,
there's a lot of work being done in this area.
From my way of thinking, this underscores the need to really have an objective way
to know whether someone has had a brain injury.
When we know that for sure, then it will really help us understand
what the contribution of post-traumatic stress disorder is to the outcome
after these events.
But until we have a good way of nailing down whether there's brain injury, yes or no,
we have to rely on symptoms,
which are kind of not exact ways to know what's happening in the brain.