Collaboration Improves Treatment of Unseen Scars of War

By Donna Miles

American Forces Press Service

BETHESDA, Md., Sept. 23, 2010 – Several times every week, a team of about 50 specialists gathers around a conference table at the National Naval Medical Center here to assess the progress of every wounded warrior undergoing treatment at the hospital.

They bring an array of expertise to the discussion, with specialties in everything from trauma surgery to pain management and physical and occupational therapy. Joining them at the table are social workers, case managers, a chaplain and military service liaisons.

And, even if there’s no immediate indication of a brain injury or post-traumatic stress, members of a new psychological health and traumatic brain injury team participate fully in talks about treatments being administered, medications prescribed and results seen.

“You have surgeons, neurosurgeons and trauma surgeons sitting next to psychiatrists and psychologists in the same room, talking about these patients,” said Dr. David Williamson, medical director for the hospital’s Inpatient Psychological Heath and Traumatic Brain Injury program. “It’s not a case of waiting to see if there is a problem and then saying, ‘Let’s consult psychology or psychiatry.’ We are automatically a part of the workout.”

This innovative, interdisciplinary approach to patient care is all but unheard-of in even the most respected civilian trauma centers, Williamson said. But it’s showing great promise, he reported, particularly in diagnosing traumatic brain injuries and other mental health issues early on, and bringing the full spectrum of services available to treat them.

The National Naval Medical Center stood up the psychological health and traumatic brain injury team about two years ago to address the complexities of brain and mental-health injuries.

“The idea was, ‘We know our wounded have a cluster of problems to do with brain injury or effects on the brain of being in the combat environment. Let’s get a team of doctors with all the specialties that need to be on that team to deal with that one cluster of issues,’” Williamson said.

The team assesses every single trauma casualty admitted to the hospital for signs of traumatic brain injury or other psychological or psychiatric complications. “It doesn’t matter if you come here with a gunshot wound to the leg or if you have a brain injury,” Williamson said. “Everybody sees the PHTBI team.”

That eliminates any possible sense of stigma on the patient’s part for talking to a psychiatrist, he said, “because everyone has to talk to the psychiatrist.”

It also helps to identify brain injuries early on, he added, particularly mild or moderate injuries that might otherwise be difficult to diagnose.

“Sometimes the brain injury is very obvious,” Williamson said. “But we also know that blasts can cause damage to the brain without necessarily causing physical scars or rendering someone unconscious.”

Integrating the PHTBI and trauma-care teams provides a more holistic approach to patient care that addresses not only the immediate, but also longer-term patient needs.

“The idea is to be able to predict and plan ahead what types of problems a patient will have so we can put services in place early, before they’re needed,” Williamson said.

He contrasted this approach to how civilian medicine treats patients who suffer brain injuries in car crashes and other accidents. Emergency medical services swarm in, flying patients to shock-trauma centers, where they receive aggressive treatment for their physical symptoms. Rehabilitation follows, including physical occupational therapy, then patients typically return home to complete their convalescence.

“At no point on that trajectory is there any behavioral health treatment,” Williamson said. In fact, patients -- or more frequently, their families -- often reach out for this kind of care only after problems involving explosive temper, severe depression or changes in judgment or decision-making get out of control.

“It’s when things are truly at a crisis that people reach out to behavioral health and say,‘Maybe they have something to offer,’” Williamson said.

Not so here, as the behavioral health team is incorporated into patient treatment from the start with a philosophy Williamson calls “proactive intervention.”

“Medicine traditionally very well understands that people can be paralyzed or weakened or have problems with coordination or balance or vision as a result of a head injury,” he said. “What’s not typically been part of the early workup is to include the emotional, cognitive and behavioral changes –- those higher brain functions that get affected by brain injuries -– as part of the assessment package.”

This collaboration provides patients the best, most aggressive treatment possible, he said, while also ensuring that medical specialists don’t inadvertently undermine one another’s efforts.

Because many wounded warriors have multiple traumas, they may be on a variety of different medications to stave off infection and pain.

“They may have a TBI, but they also have an amputation or a back injury, and they have chronic pain,” Williamson said. “So in some cases, they may already have been on six medications before behavioral health becomes involved. Then the behavioral health specialist comes along and says, ‘You’re not sleeping at night, so let’s give you a sedative. You look depressed, so we’ll give you an antidepressant.’

“In the end, people might end up on 10 different medications,” he continued, some that may cause memory loss or other brain impairments or lead to addiction.

“So we see complications and pathologies coming out of aggressive treatment – all of it well-intentioned and logical – by multiple, parallel medical teams,” Williamson said.

The collaborative treatment provided at Bethesda helps to prevent that by opening up communication among the different teams.

“The treatment process works a lot better when you have all the doctors and all the specialties represented in the same room,” Williamson said. “It allows us to simplify the whole package of treatment and make sure that nobody’s activities are interfering with someone else’s treatment process.”

That typically involves fewer, rather than more, drugs, he noted.

“It’s not unusual for people to leave here with less medicine than they came in on,” and frequently off all addictive medications, he said.

This integrated approach pays off in better patient care, and ultimately improves the rehabilitative process, Williamson said.

“We find that if we treat the psychiatric and psychological issues, people tend to do better in rehab. Their spark and motivation comes back,” he said. “We also see that if we treat their chronic pain, then their mental health improves. So these things are interrelated.”