THE LONG ROAD AHEAD

RC VETERANS FACE COMPLEX CHALLENGES WITH DEPLOYMENT-RELATED TRAUMATIC BRAIN INJURIES

In 2012, during his third deployment to the Middle East, Sergeant 1st Class Jason Manella's vehicle was hit by an improvised explosive device. The explosion wasn't the first SFC Manella had experienced in combat, but the blast eventually landed him in the traumatic brain injury (TBI) rehabilitation clinic at his forward operating base.

SFC Manella, who serves in the Army Reserve, faced a new fight, one that had him battling headaches, dizziness, memory loss, and balance issues. He spent one week at the rehabilitation clinic and then another eight weeks doing physical therapy in theater. When he returned from his deployment, SFC Manella was offered two options: stay in the Warrior Transition Unit at Fort Dix, N.J., or return home to California to get care through the Department of Veterans Affairs system. He opted to go home.

"It wasn't the better option, but I was tired of being away from home," said SFC Manella as he reflected on his decision.

Often referred to as one of the signature injuries of the wars in Iraq and Afghanistan, TBIs can be frustrating for veterans, especially Reserve Component (RC) service members with lingering symptoms as they return from a deployment.

"Their mind is on trying to get home, believing at some level that everything is going to be fine if they just get back to the life they had in the past," said Dr. Rodney Vanderploeg, Ph.D, ABPP-CN, who conducted research on TBIs in the Florida National Guard. "It is only a month or two or three down the road when they realize that honeymoon is not realistic and the problems are still there."

Results of War

The latest Department of Defense numbers show 30,406 (noncombat and combat) TBIs diagnosed in 2012, up from 10,958 in 2000. A total of 280,734 TBIs have been diagnosed between 2000 and 2013. Soldiers in the Army have sustained the majority of TBIs (163,887), a quarter of which are Army Reserve and Army National Guard.

While more than 80 percent of TBIs sustained by service members occur in a nondeployed setting, the high number of blast injuries during recent conflicts has required the DoD to focus on the unique issues for veterans who sustain TBIs in combat.

According to Dr. David Cifu, national director of the Physical Medicine and Rehabilitation Office at the Veterans Health Administration, the VA has screened 760,000 veterans for TBIs, and approximately 8 percent have ongoing difficulties related to a brain injury in combat. Approximately 1,200 individuals who sustained TBIs during Operation Iraqi Freedom and Operation Enduring Freedom were classified as moderate to severe at the time of injury. The vast majority of TBIs sustained by service members are classified as mild, with a recovery and return to duty within seven to 10 days. But for some service members, the path back to normal is much longer.

One Family's Battle

"Every single thing has changed since my husband's injury," said Karen Harris, whose husband, Dean, was in three separate IED blasts within five months in 2010 while serving in Afghanistan with the 162nd Engineer Company of the Oregon National Guard. According to Mrs. Harris, her husband did not report losing consciousness during the blasts to avoid being taken away from his unit and "kept on going through pain and confusion." He now struggles to perform day-to-day functions because of his injuries.

As is common for other service members with combatrelated TBIs, Dean Harris has co-occurring conditions, including post-traumatic stress disorder (PTSD).

The first opportunity for his injuries to be recognized was months later at a physical health assessment when there wasn't much privacy, Mrs. Harris said. When her husband did get treatment, the military doctors sent him home without providing any information to her, leaving her in the dark about his TBI.

"I lost my husband, partner, and best friend," said Mrs. Harris, who added that she now feels she has the weight of their whole future on her shoulders.

Combat Complexities

Getting service members to report TBIs while deployed can be difficult. Many times they want to "stay in the fight" and ignore symptoms of mild TBIs that could be treated with rest. Mrs. Harris also said the military culture her husband faced at the time of the blasts and in subsequent treatment settings created an atmosphere that was not conducive to reporting his injuries. The DoD reports that it has been working on these issues.

"The message we are trying to get out is early detection, early treatment, better recovery," said Lieutenant Commander Cathleen Shields, the Defense and Veterans Brain Injury Center's acting director of education. "The best way to keep healthy and stay with your unit is to get treated even for mild concussions."

In September 2012, the DoD issued instruction on mandatory rest periods and medical evaluations of all service members who were involved in or near potentially concussive events. The purpose of the directive was to formalize a process that would detect problems earlier and catch more of the mild TBIs for care in theater, where TBI services have progressively moved to the front line over the course of the wars.

A Soldier's Return

Even when service members return home, the symptoms of TBI can result in difficulty managing the very system set up to help them recover.

SFC Manella left for home with his first appointments scheduled and contact information for services and care. But when he arrived, SFC Manella discovered his medical records had not followed him; when they did arrive, not everyone had access to them.

"I'd go to a new doctor and have to explain everything I had told the previous doctor," said SFC Manella, who still has problems with memory and irritability. "Then they would refer me to a specialist, and I'd have to re-explain the same story."

SFC Manella also found the rehabilitation process-with brain teasers such as "Simon," a push-button color memory game-tedious and childish. "I've deployed multiple times, and now I'm playing 'Where's Waldo'?" SFC Manella said. "It's frustrating doing that stuff, so I focused on something Army-related and useful, working on studying the Army Study Guide."

He also set a goal to work toward: the Best Warrior Competition. Ten months after being diagnosed, SFC Manella won the title of 2013 Army Reserve Best Warrior Non-Commissioned Officer of the Year.

After hours of "physical therapy and puzzles," SFC Manella said, his continued recovery will be through remaining focused on his military and education goals. The doctors "are still trying to figure out TBI," said SFC Manella, who wonders what can be done to really fix the symptoms he still experiences.

RC Hurdles

While TBI experts emphasize that the majority of service members who sustain TBIs will experience full recovery, challenges in serving the Reserve and National Guard population post-deployment may be inhibiting them from receiving the advice and care that will get them to that point.

LCDR Shields has concerns about Reserve and National Guard members neglecting to list potential TBI symptoms in their Post-Deployment Health Assessments (PDHAs) in their rush to get home. The veteran then returns to a family that does not recognize the symptoms of a TBI, further delaying treatment. Reconnecting for the 90-day reassessment also proves difficult, creating a scenario ripe for veterans to fall through the cracks as they return to their civilian life.

Over the past 10 years, the DoD has worked to get TBI education and treatment to community-based programs, medical liaisons at Yellow Ribbon Programs, and virtual resources. Regional care coordinators are now in place to help veterans manage their care. Dr. Vanderploeg said part of the problem may be that service members are getting too much information while they are in transition, leaving them feeling lost when they are settled back home and starting to recognize TBI symptoms.

Those in the trenches of serving the military say service members must continue to connect with their regional care coordinators, doctors, family members, and friends, especially if they feel they are unable to navigate their own care. However, the bigger challenge may be reaching veterans who already feel lost even as the system catches up to meet their problems.

Waiting to Heal

"In my view, the Reserve Component members clearly have a more complex path to recovery," said Brigadier General T. Patt Maney, USAR (Ret.), who sustained a TBI in Afghanistan in 2005. "Commanders and leaders are so busy and have such brief contact with subordinates that it is exponentially more difficult to detect the symptoms of TBI."

The blast BG Maney experienced caused severe and debilitating headaches, light sensitivity, and balance problems. His injury occurred at a time when the number of service members with combat TBIs was steadily growing, returning to a system that was not as prepared as it is today to handle them.

"Much of the medical staff at Walter Reed was excellent, but there were enough pockets of perceived hostility by hospital staff to Reserve Component personnel and 'invisible wound' patients as to create an environment that aggravated feelings of frustration and inadequacy," said BG Maney.

BG Maney said he was told he should get off active duty and go home to have his civilian insurance pay for his care, a situation echoed by the Harris family. BG Maney said several doctors told him they thought Reservists were using the medical process as a full employment program. And, at a time when his symptoms didn't allow him to navigate the system himself, BG Maney said, the issue of travel and housing for his spouse caused unnecessary complexities.

Going Forward

While many positive steps have been taken to address the issues veterans with TBIs have faced since 2001, Dr. Cifu acknowledged that reaching some veterans is still difficult.

"The system is very dynamic, and it's grown remarkably," said Dr. Cifu. He added that the system takes into consideration the unique challenges of TBIs by trying to make access as simple as possible for veterans and tying together services and clinics to catch the symptoms at different points in the VA system. "It's getting better and better."

Even with the number of options and opportunities for care within the VA system, critics continue to point to veterans who are frustrated with their recovery. Studies are being planned on the long-term impact of TBIs on the military population. For some families, this research will only reflect the realities of what they are dealing with today.

"There is no 'care' for him, as far as I know," Mrs. Harris said of her husband. "I try to make his life worth living, since he lost so much. I try to help him achieve his goals and be happy each day. He hasn't gotten any better in 3Vz years, and I've settled into the idea that he may not improve." k

"In my view, the Reserve Component members clearly have a more complex path to recovery. Commanders and leaders are so busy and have such brief contact with subordinates that it is exponentially more difficult to detect the symptoms of TBI."

- Brigadier General T. Patt Maney, USAR (Ret.), who sustained a TBI in Afghanistan in 2005

"Every single thing has changed since my husband's injury. I lost my husband, my partner, and my best friend."

- Karen Harris, whose husband was in three I ED blasts within five months while serving in Afghanistan with the 162nd Engineer Company of the Oregon National Guard

Janine Boldrin is a Tennessee-based freelance journalist who is a regular contributor to The Officer. She is married to an active-duty Army officer.