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On the night of March 29, 200* Sgt. Pat Hanley of Alpha Company, 4th Infantry Brigade, 1st Infantry Division, and three fellow soldiers were returning to command outpost Cajimat in Iraq after delivering supplies to troops.
A shell suddenly smashed through their Humvee's window, killing the driver and the gunner and severing an arm off a third solider. Hanley, riding shotgun, lost his right arm also, and the explosion ripped into one side of his head.
Within 27 minutes of the explosion, Hanley was rushed to the operating room of the closest Army medical hospital in Balad, about 45 miles north of Baghdad. The surgeons immediately removed part of Hanley's skull to relieve pressure on the brain, and the Army then flew the gravely wounded warrior to Landstuhl, Germany. Two days later, still in a coma, Hanley was wheeled on a gurney into Bethesda Naval Hospital, in which he remained for five weeks.
Well before Hanley emerged from his coma, Hanley's wife Cat and her in-laws began planning the soldier's rehabilitation. After consulting doctors at the Walter Reed Army Medical Center in Washington, D.C., Hanley's family decided that inpatient rehabilitation would best be provided by a hospital outside of the Veterans Affairs system.
So they sent Hanlcy, who was still enrolled in the Army, to Spaulding Rehabilitation in Boston, where he is now being treated.
"The army does a lot of things really well and a lot of things not well," said Cat Hanley. "Cognitive rehab is one of the things they are still learning about."
Cognitive rehabilitation, part of the rehabilitation of the brain, is essential to restoring memory, thinking and expression, and it complements the physical recovery of wounded soldiers.
Brain rehabilitation, however, is often a much longer and more expensive process than mending shattered limbs.
Even mild brain injuries are not to be treated lightly. Jason Zullo, a physical therapist at the VA Hospital in White River Junction, Vt., is familiar with the thinking of a patient suffering from a mild brain injury.
After coming back from the front, soldiers often lament how much more difficult it is for them to get a good night's sleep, or even how easy it is for them to be curt with their wives and the kids, according to Zullo.
He described the thoughts of a patient suffering from brain injury in the following way: "I am not as organized as I used to be. I used to do five or six tasks at once, now I am lucky to do one or two."
Most gut-wrenching, perhaps, is that patients suffering from mild brain injuries especially are cognizant enough to know that something is wrong. They function well enough to know that they are not exactly the same person they were before leaving for duty.
"I feel there is something missing, and I can't put my finger on it," is how Zullo put the thoughts of patients suffering from mild brain injury.
For all of the hardship having befallen Hanley, he's one of the lucky ones. He and his wife live in northern Virginia, not far from Walter Reed where Hanley is receiving outpatient therapy daily. The road to recovery will be long, arduous and often painful.
The Hanleys, along with the families of thousands of other U.S. servicemen and women injured in Iraq and Afghanistan, are learning the hard way that the government cannot ensure that returning veterans suffering from head wounds ever recover or lead normal lives once more.
Despite the military's dazzling combat achievements and its ability to fly injured soldiers on the brink of death across continents, a performance gap persists between the stated obligations to support veterans and executing on the promise by providing medical care to return soldiers to a "normal" life in the civilian sector.
Some critics even go so far as to blame the government for foisting the cost of rehabilitating wounded vets onto the backs of families.
"The whole paperwork transition when you come back, they need to discharge you and push you out." said Lt. Ben Flanders, who served with the National Guard in lraq in 2004. "The Guard soldiers need to get into a coaching program. How do you budget that? The general attitude is, 'Support the troops, not the veterans.' This is not a good way to deal with people who put their ass on the line."
Neither the Pentagon nor Veterans Affairs is held accountable for ensuring that wounded soldiers recover to their maximum potential in the civilian workforce. The federal departments don't even keep track of soldiers' experience with civilian work.
Today's top troop health problems are post-traumatic stress disorder (PTSD), depression and traumatic brain injury, but it is the brain injuries that have proliferated in Iraq and Afghanistan. Cheap, devastatingly effective improvised explosive devices have taught the government a nasty economics lesson.
A $5 explosive can cost taxpayers millions of dollars in rehabilitation costs for soldiers suffering from brain injuries. Ironically, it is better, faster battlefield medical care that has kept alive soldiers who in former wars would not have stood a chance.
In prior wars, soldiers suffering from brain damage and physical injury would have been far more likely than they are in today's wars to succumb to physical injury.
That's not the case with today's U.S. soldiers, so skilled have doctors and nurses become at rescuing life so close to the precipice of death.
Combat veterans, doctors and National Guard executives say they are grateful for what the government has done--so far--to help.
They point to initiatives by the armed services and Veterans Affairs to prevent and treat PTSD, depression and brain injuries, such as embedding mental health teams in combat units and requiring regular health checks after injured military personnel return home.
Yet these health problems are difficult to diagnose in the first place. PTSD and brain injuries can present similar symptoms, which make it difficult to tell whether a combat veteran is suffering from a brain injury or from posttranmatic stress.
Symptoms sometimes do not become evident until months after demobilization, and then are detected by a soldier's spouse or civilian employer, not by doctors, therapists or other trained medical professionals.
Even when soldiers know they are suffering, some don't want to let on, according to National Guard executives who acknowledge resistance to being diagnosed out of fear of being discharged.
"The soldier doesn't want to disclose, thinking, 'If I get found out, I won't be in the Guard anymore,' " said Lt. Col. Carl Hausler of the Vermont National Guard.
By the end of 2007, the military reported that about 30,000 troops in the Iraq and Afghanistan theaters had been injured out of about 1.6 million troops deployed.
The Pentagon, mindful of mental conditions, revised its procedures for health reviews when troops returned and has sought a more accurate count of soldiers suffering from brain injury.
Among the 1.6 million troops deployed through 2007 in Iraq and Afghanistan, 19 percent screened positive for traumatic brain injury, 12 percent for PTSD and 10 percent for depression, according to a 2008 report issued by Rand Corp.
For every officially reported injured soldier, assume at least 10 more need attention, for a total of roughly 300,000, according to Rand.
Rand's findings of the number of soldiers suffering from brain injury stand in stark contrast to the statistics used by the Pentagon. Narrow screening rules resulted in 2,000 cases of brain injury being documented by the Pentagon by the end of 2007.
In contrast, the Rand Corp., using a broader definition of brain injury and drawing on post-deployment survey data, estimated that through 2007 at least 160,000 soldiers involved in Iraq and Afghanistan had developed symptoms of brain injury.
PETER ROUSMANIERE is an expert on the workers' compensation industry. He can be reached at riskletters@lrp.com.
summary
* Cognitive rehabilitation is an essential part of restoring memory, thinking and expression for veterans with brain injuries.
* In prior wars, soldiers suffering from brain damage and physical injury would have been far more likely to succumb to physical injury.
* Post-traumatic stress disorder and brain injuries can present similar symptoms, which make it difficult to tell whether a combat veteran is suffering from one or the other.
Wounded Warriors
A Three-Part Series
Veterans of the Iraq and Afghanistan wars, and the other numerous conflicts and training episodes around the globe, are return U.S. workforce in growing numbers ... and with growing numbers of phy behavioral impairments. It's a surge of issues that's likely to overcome employers unless they prepare now.
riskandinsurance.com
July 2009
Part 1: Sergeant Stephen Kinney
A night-time insurgent attack in Iraq led National Guard Sgt. Stephen Kinney to abandon not only his military but also his civilian career. For months after the event, military medics in Iraq misdiagnosed his conditions. Then after he returned to the United States, he had to wait for a year until the full scope of his injuries was identified. Eventually, it became clear that Kinney suffered from two signature wounds of today's anti-insurgent wars: post-traumatic stress disorder and brain injury. He tried to return to his letter-carrier job but is now retired and on disability, his life in limbo.
riskandinsurance.com
August 2009
Part 2: Dropping the Baton
Doctors in the military and VA hospitals have been trying to respond to the surprisingly large number of indications of war injuries among returning troops from Iraq and Afghanistan. Brain injuries are the most disturbing of the signature wounds from these wars, along with post-traumatic stress disorder, depression and soldier-on-soldier sexual assault. National Guard and Reserve troops are specifically at risk of undertreatment as they disperse into the civilian world and try to disguise their conditions.
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