New war, new pain

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By Roger Lempke

New technologies and tactics have added distinct peculiarities to American wars and in turn caused new types of injuries and new treatments. At the time of the American Civil War, newly invented cylindrical lead bullets called minié balls produced an advanced level of deadliness. Torso penetrations were usually fatal and hits on extremities tended to crush and mash bones. Amputation became the main form of “treatment” for arms and legs damaged by large-caliber minié balls. Wooden prostheses were so much in demand after the war that lumber shortages resulted. World War I is remembered for the introduction of chemical warfare and its attendant injuries. World War II and the Korean Conflict saw dramatic improvements in battlefield evacuation (the helicopter was introduced during the Korean War) and field hospital treatment. Agent Orange and post-traumatic stress disorder (PTSD) became associated with the Vietnam War. The recent War on Terrorism in Afghanistan and Iraq, a fight generally against insurgents, has developed a signature injury known as traumatic brain injury—or TBI.

The term “traumatic brain injury” covers a wide range of injuries to the brain from sudden trauma. Classified from severe to mild, the milder forms of TBI can be difficult to diagnose and treat because of latent symptoms. Severe trauma is quickly suspected when visible signs such as bleeding, bruising, swelling and object penetration are evident. The mild form, or MTBI, is not as easily identified because external wounds do not exist and telltale signs, such as memory loss, dizziness and confusion can be somewhat subtle and slow to emerge, making diagnosis difficult. In many situations, treatment goes beyond repairing physical wounds, requiring medical rehabilitation programs to restore motion functions, vision, speech and memory.

Even though the recent conflicts overseas have made TBI a common term, the condition has been diagnosed and treated for many years.

Over 1.4 million cases of sudden trauma causing damage to the brain are reported in the United States each year, coming mainly from falls and vehicle accidents. Growth in the number of brain trauma injuries has energized the private medical sector to develop better, more specialized treatment and rehabilitation methods. Military service members had been a very small portion of the population treated over the years. But the surge in recoverable injuries from the war against terrorism has focused attention on the highly technical rehabilitation capabilities developed over the last half-century. As you will see a little further into this story, a modest mission started 50 years ago by Benedictine Sisters to care for people “with dignity and love” at a location on Normal Boulevard in Lincoln, Neb., would grow into a first-class rehabilitation facility offering people the opportunity to regain their abilities and recover from serious illness and injury.

As with injuries in previous wars, tactics and technology have played a major role in the emergence of TBI as a predominant injury. First, and most obvious, is the common insurgent tactic of using roadside bomb (or improvised explosive device—IED) explosions as a primarily means for attacking coalition troops. The sudden positive and negative pressure changes from powerful blasts can have subtle but damaging effects on the fragile brain mass inside the cranium. The second reason TBI has become a common battlefield injury is that troops today have better personal protection than the days of tin helmets and no body armor. In years past, high-energy blast projectiles typically produced lethal injuries. The Kevlar helmet, introduced around 20 years ago, and lightweight body armor protects the head and torso from high-energy shrapnel. Armored vehicles also mitigate blast affects. With these protections, the likelihood of a trooper being killed by an IED blast is low but the risk of incurring a mild to moderate TBI injury is still high. The chances of surviving a significant injury in Iraq is said to be about 95 percent, compared to a 67 percent survival rate during the Vietnam Conflict. A victim of a substantial IED attack can be removed from the battle area with substantial injuries and expect to live. Evacuation and field hospital treatment processes have been developed and refined to achieve this high probability of survival. But nerve damage and brain injuries from blast affects are often not diagnosed in a timely manner and, at times, have been misdiagnosed.

In 2005, the Department of Defense realized that it was not dealing effectively with brain trauma injuries. Over a decade ago a special function known as the Defense and Veterans Brain Injury Center was mandated by Congress to conduct research and coordinate general treatment capability. However, the services, particularly the Army, were unprepared for the scope of effort needed for brain trauma injuries from Iraq. Stories from wounded service members and families about inconsistent recognition, treatment and rehabilitation for TBI raised concerns among lawmakers. Nebraska Sen. Ben Nelson, chairman of the Personnel Subcommittee of the Senate Armed Services Committee, played a significant role in urging the department into more aggressive action. A Department of Defense study completed in 2006 highlighted key issues with treatment and rehabilitation and made a number of significant recommendations. Among these was to leverage the capacity and expertise the civilian medical community offered. This is where another Lincoln, Neb., organization enters this story.

What began as a church mission to simply care for people with dignity and love had grown into a world-class facility specializing in the treatment of spinal cord injury, traumatic brain injury and stroke—Nebraskans know it as the Madonna Rehabilitation Hospital. From a modest rehabilitation program started over 30 years ago, Madonna has expanded to a capability today of treating over 2,500 inpatients per year from throughout the Midwest and across the country. But the linking of Madonna’s premier facility with military medical care needs did not happen automatically.

An exposé by the Washington Post in 2007 prompted action by the secretary of veterans affairs. Secretary Jim Nicholson met with key rehabilitation experts, including Madonna President and CEO Marsha Lommel, to seek ways to leverage the tremendous capability that had emerged for treating brain-related injuries. Madonna would become one of 10 facilities selected to accept wounded troops for treatment and rehabilitation.

Madonna is one of only a few Mid­western hospitals to have earned international accreditation in both inpatient and outpatient brain injury rehabilitation. This gem on the plains is not fully appreciated for its accomplishments—I certainly was not aware of its extensive capabilities until Nebraska soldiers became involved. The Madonna program covers all aspects of TBI treatment and rehabilitation, including physical therapy, occupational therapy, speech language pathology, rehabilitation nursing, neuropsychology, respiratory therapy, recreation therapy, nutrition, social work and case management. Brain injury treatment is customized to suit the needs of each individual so that the best outcomes can be achieved. Technology also plays an important role—from Palm Pilots used to organize thoughts and remember appointments to special treadmills that support body weight when a person is learning again how to walk.

Marsha Lommel anticipated the military’s need to use civilian capability. With assistance from Sen. Ben Nelson, she began working through channels to engage the Veterans Administration and regional Department of Defense facilities to offer Madonna’s services. The first referral to Madonna was Sgt. Mack Richards who entered care in December 2006.

When injured Nebraska Army National Guard soldiers began returning to Army facilities in the United States for treatment, it became apparent to Nebraska’s military leadership that treating injured Nebraska troops hundreds of miles away from home for indeterminate amounts of time was a major issue. Often, wounded soldiers are first sent to specific Army treatment centers such as Walter Reed Hospital. After receiving specialized treatment, active-duty soldiers are transferred to their home base medical facilities near their families. National Guard soldiers, on the other hand, were being forced to stay at Army hospitals hundreds or thousands of miles away from their families for weeks and even months. Few families can afford to leave homes in Nebraska to be near their wounded loved ones. Initiatives were pursued to release soldiers undergoing extended treatment at military medical bases to return home and use local facilities for treatment and rehabilitation. While in local care, soldiers would be supervised by existing state National Guard organizations.

In early 2007, while visiting another Nebraska soldier at Walter Reed, I encountered Sgt. Jeremy Dillman, quite by accident. Jeremy had taken shrapnel in his hip from an IED attack that had damaged nerves in his left leg. He could barely walk with a cane. The first thing Jeremy told me was that he would not let the Army take him away from the infantry. He was a foot soldier and was going to find a way to work himself back into service condition. Jeremy also told me of his family at home in Nebraska that he sorely missed. Through persistence and determination we were able to convince the Army to move Jeremy to Lincoln, where he entered Madonna’s rehabilitation program and began work at the National Guard headquarters in Lincoln.

Madonna Rehabilitation Hospital enter­ed into a contract with the Department of Veterans Affairs in March 2008. Since then, more than 80 referrals have been evaluated going into the summer period. Of those, 36 have been diagnosed with varying degrees of TBI. Patients are evaluated and the results provided to the VA. The patients are then free to select where to go for treatment. True to its commitment to service members, Madonna accepts the military health system of payments, called Tricare. The hospital is undertaking plans to enhance its already renowned capabilities through an extensive hospital renovation, including new technology and research initiatives for advanced rehabilitation care—something more for Nebraskans to be proud of.

Today, Jeremy walks without a cane and can meet the Army’s physical fitness standards. He has been a model of determination in therapy and of great value in the Nebraska Military Department. I personally believe that for him to be near his family while undergoing rehabilitation has helped tremendously. I don’t speak to this from a knowledgeable medical perspective but as an old leader who has been around enough soldiers to sense what helps and what doesn’t. Many other service members will also overcome serious injuries and return to happy and productive lives—all thanks to a private hospital in Lincoln dedicated to providing first-rate care in the specialized field of traumatic brain injury.

 

1. Kevlar is a polymer product invented and manufactured by DuPont that, when woven, possesses significant energy absorption and distribution, making it ideal for lightweight body armor and protective clothing. The Lincoln, Neb., plant of Lincoln Composites, a division of Brunswick Corporation, helped the Department of Defense develop the Kevlar technology in use today. The plant now belongs to General Dynamics and continues to design and manufacture composite pressure vessels and other components for the defense industry.

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