Nightmare of a Combat Brain Injury
Modern warfare has become such a nightmare, that when our soldiers come home from war with nightmares, we don’t even bother to consider whether those nightmares could be caused by injuries to their brains. The mind is the most complex thing studied by man, perhaps the least understood. The 20th century saw an explosion of theories and treatments to mend the broken psyche, yet very little increased understanding as to how vulnerable the organic components of the mind are. It is as if when our computer didn’t work after we dropped it, the only fix we considered was reloading the software, not an examination to see if any of the hardware had been damaged.
Combat Brain Injury and War
Combat Brain Injury and war have always gone hand in hand. Before there were arrows, bullets and bombs, there was the club. Before there was body armor and bulletproof vests, there was the helmet. No soldier goes to war without his helmet. Yet the helmet is primarily another carton, designed to protect the brain’s natural egg carton, the skull. Never have helmets eliminated all injury to the egg inside the carton. The skull may be intact, yet its ward the brain, severely injured.
What is perplexing is that when we look at the troubled soldier, we fail to evaluate how much of that trouble could have come from a scrambling of the egg. Each new war seems to come up with its new label for the psychiatric consequences of warfare. World War I had its “shell shock”, Vietnam its PTSD (post traumatic stress disorder.) There was a recognition as early as World War I that modern medicine was saving the lives of those with injured brains who might have died, yet little has been done to recognize that repairing the shell, does not restore its contents to their pre-war status.
The last few years have brought us to a crossroads in this dialectic of Combat Brain Injury. The Iraq war is one where brain injury is reaching center stage. IADs are more likely to kill and injure through concussion than through penetrating injuries. Faster, more advanced surgical and intervention techniques identify those most likely to suffer catastrophic outcomes. Yet as in real life situations, in warfare there is a 20 fold more likelihood to injure the brain in situations where the injury and its lasting effects are subtle. And because of the stressors of combat, there is little likelihood that acute triage and diagnosis is likely to occur. One does not med-evac the walking, talking soldier. A detailed analysis of amnesia is probably the only sensitive way to identify most lasting concussions, yet no one is going to bother to investigate for amnesia with someone who is not obviously confused.
The issue of the degree of Combat Brain Injury in the undiagnosed vet is not a new topic for investigation. It was the topic of both medical study, as well as considerable literature after World War I. Immense contributions were made both based on acute studies and the development of surgical techniques during World War II and the Korean War. Vietnam had numerous studies, including the remarkable development of the PTSD diagnosis. Even brain damage from disease processes such as malaria, got some study after Vietnam. See http://www.va.gov/OCA/testimony/hvac/16JY98NV.asp. Further, longitudinal studies from throughout our 20th century wars, gave us a much more complete view of the long term affects of brain injury.
While just the changes in combat and war time triage would make this topic worthy of a reevaluation as we discharge from active duty those injured in the so-called “War on Terror”, there is perhaps a more compelling reason to revisit this topic:
Our understanding of the vulnerability of the brain to suffer permanent damage as a result of what typically would be labeled a concussion, has increased exponentially since the last time this country engaged in a sustained conflict. The principles of Diffuse Axonal Injury to the brain have been described and researched. See http://subtlebraininjury.com/biomechanics1.html. The perceived threshold of acute symptomotology requisite for a potentially permanent brain injury has been significantly lowered. See http://www.cdc.gov/ncipc/tbi/mtbi/mtbireport.pdf Quite significantly, neuro-imaging has developed to the point that at least the tip of the iceberg of neuropathology can be seen.
Yet, this inquiry is not limited to helping recent war veterans with Combat Brain Injury but has a broader goal. It is our hope that this commentary can impact the analysis and treatment of one of United States most troubled population subgroups: the Vietnam War vet.
Lastly, it is our hope that we might significantly advance our understanding of civilian brain injury. War, by necessity, becomes a laboratory to learn about brain injury. Much of what we have learned about brain injury was learned from military medicine. We must use the sacrifices of our soldiers to assist in civilian medicine.