TESTIMONY IN SUPPORT OF FUNDING THE DEFENSE AND VETERANS HEAD INJURY PROGRAM SUBMITTED TO THE SENATE APPROPRIATIONS COMMITTEE SUBCOMMITTEE ON DEFENSE BY Martin B. Foil, Jr. Member, Board of Directors National Brain Injury Research, Treatment, and Training Foundation
May 5, 2004
My name is Martin B. Foil, Jr. and I am the father of Philip Foil, a young man with a severe brain injury. I serve as a volunteer on the Board of Directors of the National Brain Injury Research, Treatment and Training Foundation (NBIRTT) and Virginia NeuroCare in Charlottesville, Virginia (VANC). Professionally, I am the Chief Executive Officer and Chairman of Tuscarora Yarns in Mt. Pleasant, North Carolina.
On behalf of the thousands of military personnel that receive brain injury treatment and services annually, I respectfully request that $7 million be added to the Department of Defense (DoD) Health Affairs budget for Fiscal Year 2005 under Operation and Maintenance for the Defense and Veterans Head Injury Program (DVHIP).
I. Traumatic brain injury is a leading combat concern in modern warfare. Previously accounting for up to 25% of combat casualties, today the incidence of TBI may be as high as 40-70% of casualties.
The incidence of traumatic brain injury (TBI) is believed to be greater now than in previous hostilities for a number of reasons:
1. The use of effective body armor has saved more lives;
2. Medical personnel are more aware of the significance of mild closed TBIs and concussions and are therefore more likely to identify them; and
3. The incidence of blast injuries in Iraq and Afghanistan is high.
As a result, the current incidence of TBI sustained in theater is expected to be higher than in previous conflicts. Major General Kevin C. Kiley, Commanding General of the Walter Reed Army Medical Center (WRAMC) and the North Atlantic Regional Medical Command said at the October 2003 Congressional Brain Injury Task Force Awareness Fair on Capitol Hill that as many as 40-70% of casualties have the possibility of including TBI. The incidence of TBI was recently discussed at a two day conference held by the DVHIP along with the Joint Readiness Clinical Advisory Board on March 23-24, 2004, and evidence was presented that 61% of at-risk soldiers seen at WRAMC were assessed to have TBIs. While this does not reflect the entire population of wounded in action, the high percentage suggests that brain injury acquired in theater is an increasing problem that needs to be addressed.
II. The Defense and Veterans Head Injury Program (DVHIP)
Established in 1992, the DVHIP is a component of the military health care system that integrates clinical care and clinical follow-up, with applied research, treatment and training. The program was created after the first Gulf War to address the need for an overall systemic program for providing brain injury specific care and rehabilitation within DoD and DVA. The DVHIP seeks to ensure that all military personnel and veterans with brain injury receive brain injury-specific evaluation, treatment and follow-up. Clinical care and research is currently undertaken at seven DoD and DVA sites and one civilian treatment site. In addition to providing treatment, rehabilitation and case management at each of the 8 primary DVHIP centers, the DVHIP includes a regional network of additional secondary veterans’ hospitals capable of providing TBI rehabilitation, and linked to the primary lead centers for training, referrals and consultation. This is coordinated by a dedicated central DVA TBI coordinator and includes an active TBI case manager training program.
III. As of March 31, 2004 more than 350 combat casualties from the Global War on Terrorism have been served by DVHIP.
Congressional support over the years has helped create the existing DVHIP infrastructure that has been critical in evaluating and caring for active duty personnel who are being injured in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Thorough evaluation, referral for appropriate clinical supports, prompt discharge to home or military unit, and focus on returning service members to active duty have been the primary goals of the clinical care provided to these war fighters. Additional service members have been identified who were cared for and promptly discharged back to their units. DVHIP is working with the appropriate military institutions to ensure that these individuals will be actively followed to ensure they receive specialized clinical care and follow-up as needed.
WRAMC and Bethesda Naval Hospital (for Marines) have been the main destinations of injured personnel sent from Iraq and Afghanistan via Landstuhl Regional Medical Center in Germany. According to data from the Office of the Surgeon General, approximately 70% of those wounded in action are sent to the general surgery or orthopedic surgery services at the receiving medical center because of the most severe injuries of the individual. Because the most common cause of wounded in action is currently blast injury, DVHIP is working with the Command at WRAMC to screen all of the incoming wounded who have been injured in blast, falls or motor vehicle accident. An estimated 61% of those screened at WRAMC were identified as having sustained a traumatic brain injury.
IV. Examples of Military Personnel Injured, Treated and Returning to Work
The following are examples of injured active duty military personnel who recently received care provided by the DVHIP:
A. First Sgt. Colin Robert Rich, A Company, 1st Battalion 504th Parachute Infantry Regiment, was shot in the head on December 28, 2002 while serving in Afghanistan. Rich received initial acute care at a hospital in Germany within 15 hours of being shot and arrived at WRAMC on January 4, 2002 where he was cared for by DVHIP staff before being discharged home on January 16, 2002. Rich continues to receive follow up care from DVHIP and spoke before Members of Congress at the October, 2003 Congressional Brain Injury Task Force Awareness Fair. Rich returned to limited active duty in December of 2003.
B. Warrant Officer John Sims, U.S. Air pilot and member of the Maryland Guard was piloting a Black Hawk helicopter in Iraq when his helicopter went down, and he suffered brain injuries. His wife was initially told he probably would not survive. After being admitted to WRAMC, he was cared for at the Richmond VA hospital before being transferred to Virginia Neurocare, DVHIP’s civilian community reentry treatment site. Although he has made remarkable recovery, his ability to pilot a plane again is in doubt. Simms also spoke before Members of Congress at the October 2003 Congressional Brain Injury Task Force Awareness Fair.
C. PFC Alan Lewis was driving a Humvee in Baghdad on July 16, 2003 in Iraq when an explosive device tore off his legs. Lewis was identified as a potential TBI patient through DVHIP screening and was found to have sustained a mild TBI. DVHIP clinical staff helped him cope with memory problems and other neurobehavioral difficulties from his head injury throughout the rehabilitation process. He has been an articulate spokesperson for the dedication and resolve of our fighting force and the potential for recovery after a serious injury.
These are just a few examples of what DVHIP does for hundreds of military personnel each year; from being ready to care for injured troops in the acute care setting to neuro-rehabilitation involving the entire patient to full community integration.
V. Improving Medical Care, Training and Diagnostics
Along with the Joint Readiness Clinical Advisory Board (JRCAB) at Ft. Detrick, DVHIP co-sponsored a first-of-its-kind conference entitled “Neurotrauma in Theater: Lessons Learned from Iraq and Afghanistan.” The conference brought together neurosurgeons, neurologists, physician assistants, medic, nurses and general medical officers who served in Iraq and Afghanistan. Expert opinion from every branch of the armed forces was shared and debated. In addition to helping address immediate needs and guide future research for the safety of the Active Duty, the conference informed a specialty neurotrauma panel with recommendations going to the Office of the Surgeon General.
A recurring theme throughout the neurotrauma conference was the need for training for management of closed head injury. Education of corpsmen and other military medical providers on concussion care continues to be one of the primary objectives at the DVHIP at Camp Pendleton. Standardized educational programs are being developed this year by the DVHIP educational core in order to reach a greater number of medical providers. DVHIP plans to make these educational materials available on its website to enhance this outreach and provide information to providers in austere locations where travel for on-site training would not be possible.
In anticipation of large numbers of troops returning home in July, the DVHIP screening process has been developed into a manual in order to assist physicians at military sites without a DVHIP component. A DVHIP Web-based patient assessment was also developed for physicians at distant sites who would like to incorporate this in their clinical practice.
Another way that DVHIP is assisting military and VA providers in treating individuals with TBI is by disseminating thousands of copies of “Heads Up: Brain Injury in Your Practice Tool Kit,” a new physician tool kit to improve clinical diagnosis and management of mild TBI. The kit was developed by the Centers for Disease Control and Prevention in collaboration with DVHIP. This past year DVHIP also teamed up with the Veterans Health Administration to produce an independent TBI study program as part of the Veterans Health Initiative. This program offers any military or VA physician Continuing Medical Education credits for its completion. An online version ensures that clinicians serving in theater can receive up-to-date training in TBI care.
VI. Additional DVHIP Accomplishments and Ongoing Research Initiatives
• Provided successful rehabilitation and return to work and community re-entry for active duty military personnel and veterans.
• Established an archive of military neurotrauma cases and statistics from military physicians who were deployed to Afghanistan, Kuwait, and Iraq. These data are still being reviewed and complied into a single archive that will be available for military use.
• Developed The War on Terrorism Brain Injury Registry to identify individuals with brain injury and examine clinically relevant issues in the management of brain injury sustained in theatre. These records will provide the basis for future efforts to follow these individuals to understand better the longer term implications of these injuries.
• Submitted a proposal to determine if an enhanced program of telephonic nursing will improve the outcome of Active Duty with mild brain injury. Establishing effectiveness of telephonic nursing will be critical to treating individuals who are at distance from other care providers, thus serving soldiers and saving taxpayer money.
• Ongoing studies are being conducted with Army paratroopers and cadets and U.S. Marines at Fort Bragg, West Point, and Camp Pendleton. These studies are investigating brief evaluation instruments for use on the battlefield to determine which injured service members require immediate treatment and which can return to duty. The goal of these studies is to preserve our nation's fighting strength while conserving medical resources for those injured and requiring treatment.
• Completed enrolling patients in a research protocol on functional rehabilitation versus cognitive rehabilitation for severe brain injury.
• A randomized controlled study of sertraline for post concussive syndrome is being carried out in all DVHIP military and VA sites. This study targets the symptoms of irritability, depression and anxiety which many soldiers report after TBI. • Published a study on the recovery pattern from concussion from the West Point boxing study in Neurosurgery (Bleiberg, et al, May, 2004), an epidemiologic study on TBI in Ft. Bragg paratroopers (Ivins et al, Journal of Trauma, October 2003), and an invited editorial on the effects of concussion (Warden, Neurology, 11 May 2004).
• Developed a free standing website www.dvbic.org to provide information for clinical providers, patients and family members.
• Added TBI specific questions to WRAMC’s Post-Deployment Questionnaire which is administered to all soldiers who were recently deployed and sent to WRAMC.
VII. Additional funding is needed in Fiscal Year 2005 to address the following needs:
A. Continue to provide clinical care of active duty personnel and veterans:
• Expand clinical capacity to meet the need to care for an increasing number of injured military personnel and veterans.
• Increase use of DVHIP resources by medical assets at other military and veteran sites with large troop/vet concentrations, e.g., by web-based initiatives, medical staff presentations by DVHIP personnel, etc. • Implement TBI outpatient clinics at DVHIP lead centers. As the needs of the returning veterans after blast injury are expected to be largely outpatient, the DVHIP will be prepared to meet those needs.
• Ensure all necessary care has been received by military personnel and veterans who have sustained brain injuries by using the DVHIP Registry to identify individuals in need of additional treatment and support.
B. Continue military and veteran specific education and training:
• Develop an algorithm for return to duty management to be used by first responders in the military. These management guidelines will be based on new data analysis from existing concussion studies at West Point, Fort Bragg, and Camp Pendleton.
• Report to the U.S. Army the findings from the War on Terrorism Brain Injury Registry regarding incidence of closed head injury and the impact of early wound closure in penetrating brain injury.
• Disseminate evidence-based guidelines on pharmacological management of neurobehavioral consequences of brain injury.
• Expand the content and services of the DVHIP website. Future website applications will include enhanced educational materials and the capability to make referrals and gain access to care.
C. Military and Veteran Relevant Clinical Research
• Determine the incidence of brain injury from the most commonly occurring blast injuries.
• Initiate a VA multi-center trial to provide the first evidence on the effectiveness of cognitive rehabilitation and stimulant medication early in recovery from severe brain injury.
• Conduct the study of enhanced protection from parachute injury by field-testing approved novel helmet configurations at Fort Bragg.
• Implement the feasibility study of biomarkers in mild brain injury and injury recovery in collaboration with Ron Hayes, Ph.D. at the Evelyn F. and William L. McKnight Brain Institute at the University of Florida
• Extend outcomes research through the evaluation of long-term work and duty status in DVHIP rehabilitation trial participants.
VIII. DVHIP Support for Families after Brain Injury
Every military commander and soldier knows the importance of taking care of their families so that they may focus on performing their critical duties. This is especially important in times of conflict, as demonstrated during Operation Iraqi Freedom. When soldiers sustain brain injuries in conflict, taking care of families is even more important. This is because the impact of brain injury on the family is particularly traumatic, in that not only life and death are at stake, but there are also significant disruptions to family systems for months or years thereafter as the rehabilitation and recovery process ensues. DVHIP family support groups provide a great deal of assistance, education, and information to families. For example, the family support program at the Tampa VA also holds bi-annual reunions in which former patients and families come from around the country.
IX. Conclusion
There is no greater time than today to support injured personnel sustaining brain injuries. There is nothing more patriotic than caring for the men and women who serve our country and protect our interests. Our men and women in uniform are sustaining brain injuries and need brain injury specific care and state of the art treatment and rehabilitation. The incidence of TBI is higher in theater than it has ever been in history, and the numbers of injured personnel present a challenge to the military medical system. DVHIP continues to be an important part of the military health care system and needs additional funding to continue its work. Please support $7 million for the DVHIP in the Fiscal Year 2005 Defense Appropriations bill in the DoD Health Affairs budget under Operation and Maintenance to continue this important program.
