Army Refines Medical Management of Concussion

By Cheryl Pellerin

American Forces Press Service

WASHINGTON  – Over the past 20 months, the Army has been working to refine the way it tracks and treats the most common form of battlefield brain injuries -- concussion, also called mild traumatic brain injury, or mTBI.

The job isn’t easy, because even in the United States, where civilians experience traumatic brain injuries at the rate of 1.7 million a year, according to the Centers for Disease Control and Prevention, no single diagnostic standard exists for TBI.

In the words of experts at the 2nd Annual Traumatic Brain Injury Conference last month in Washington, treatment of TBI and especially acute, or rapid-onset, TBI is still “a major unmet medical need” worldwide.

“This is why we have our program,” Army Col. (Dr.) Dallas Hack, director of the Army’s Combat Casualty Care Research Program, told American Forces Press Service.

“This is why Congress in 2007 issued a special appropriation of $300 million to start funding traumatic brain injury and psychological health research for our troops,” he added, “and has continued to [add] significant amounts of funding,” up to $633 million today.

In the research program, scientists try to find ways to look into the brain noninvasively to measure the effects of brain trauma, using brain scans, electroencephalograms for measuring brain electrical activity, eye-tracking systems that offer a window into the brain, and more.

Objective measurements are critical for mild brain trauma, which is called an invisible injury because effects on the brain of falls or explosions or vehicle accidents aren’t always obvious.

Today, while processes and devices sensitive enough to measure mild brain trauma are in development, on the battlefield and at home mild TBI tends to be assessed in large part using the best tools available -- questionnaire-type assessments.

During a recent briefing at the Pentagon, Army specialists in behavioral health and in rehabilitation discussed the evolving behavioral health system of care for TBI.

A hallmark of the Army’s standard of behavioral health care is a screening process administered to soldiers before they deploy, while they are in theater, as they prepare to return home, and while they are in garrison, said the behavioral health specialist.

The assessment process includes the following questionnaires:

-- Predeployment: All incoming service members are screened with the neurocognitive assessment tool, called NCAT, which is used as a baseline for future concussion or mTBI injuries.

-- In theater: Immediately after injury, the Military Acute Concussion Evaluation, called MACE, is used to quickly measure orientation, immediate memory, concentration, and memory recall. Combined with clinical information, a MACE score can guide recommendations, including evacuation to a higher care level.

-- Postdeployment: Because mTBI is not always recognized in the combat setting, active duty service members receive postdeployment health assessments. Four questions adapted from the Brief Traumatic Brain Injury Survey are asked during the assessments. Positive responses on all four prompt an interview with a doctor for an mTBI evaluation.

-- Veterans: Vets are screened for mTBI when they enter the Veterans Health Administration system. A TBI clinical reminder tracking system identifies all who were deployed to Iraq or Afghanistan. Those who report such deployment and don’t have a prior mTBI diagnosis are screened using four sets of questions based on the Brief Traumatic Brain Injury Survey. Those who screen positive for mTBI are offered further evaluation.

“Part of what they do is complete those questionnaires,” the rehabilitation specialist said. “The other part of any of those screenings is a face-to-face interview with a primary care provider. If there’s something the primary care provider or the screening instrument identify as indicating some kind of psychological distress, then the soldier will also see a behavioral health provider face to face.

“The other part of our system of care includes something we call embedded behavioral health that we’re rolling out across the Army right now,” the behavioral health specialist said.

This involves putting behavioral health specialists in the physical location of brigade combat teams, she said. In such a setting, she explained, “[care] providers develop a habitual relationship with the commanders so they feel trust about communicating appropriate information about the soldier’s health.”

The Army is reaching out, she added, “trying to connect with soldiers at the various touch points, in their unit areas and also in primary care clinics, so they have every opportunity to access behavioral health care at any point in their health care and in their daily lives.”

The current protocol for the traumatic brain injury system of care in theater, said the rehabilitation specialist, comes from a 2010 Defense Department directive-type memorandum that makes screening mandatory for soldiers who are involved in four kinds of events, even if they don’t appear to be hurt.

Those who must be screened have been near a blast, sustained a blow to the head, are involved in a vehicle accident, or have commanders who are concerned about them and want to enter them in the protocol.

Anyone involved in a mandatory event receives the MACE evaluation, a medical evaluation and at least 24 hours of rest. And they must be cleared by a medical provider before returning to duty, the rehab specialist said.

Slightly different guidelines cover those who have had multiple concussions.

For somebody who has suffered a second concussion in theater, she added, the minimal 24-hour down time is extended to a minimum of seven days.

Those who have a third diagnosed concussion in theater receive seven days of down time and a comprehensive concussion assessment that consists of consultations with specialty care providers and a functional assessment -- for example, one that assesses their ability to keep their balance.

Also in theater are 11 concussion care centers with specialty providers and a restful environment.

In Afghanistan, for moderate or severe TBI, three neurologists staff Role 3 advanced hospitals, along with a neurology consultant who oversees the TBI neurology specialists.

Telemedicine -- the remote diagnosis and treatment of patients using telecommunications technology -- is also used to treat TBI, and those visits doubled from fiscal 2011 to 2012, the behavioral health specialist said.

The Army has invested more than $530 million to improve access to care, quality of care and research, and TBI screening and surveillance. But the best clinical treatment for service members and civilians with mild TBI may be months and years in the future.

Hack says it’s the state of the science.

The Defense Department’s protocol “is as good as we have,” he said. “I am completely supportive of it. I’m trying to do better,” he added.

USS Oak Hill, GTMO Weapons Department Conduct Ammo On-Load

By Mass Communication Specialist 2nd Class (SW/AW) Justin Ailes Naval Station Guantanamo Bay, Cuba Public Affairs

GUANTANAMO BAY, Cuba (NNS) -- USS Oak Hill (LSD 51) visited Naval Station (NS) Guantanamo Bay, Cuba, to assist the installation's Weapons department with an ammunition on-load, April 14-15.

The Harpers Ferry-class dock landing ship provided a landing craft utility (LCU) vessel as transport to bring aboard 172 pallets of mortars. The ordnance is set to be off-loaded in Earle, New Jersey, and utilized as training aides for U.S. Marines.

"The importance was geared towards Marines having the opportunity to use live ordnance in training before using it in combat," said Lt. Timothy Proctor, NS Guantanamo Bay weapons officer. "This was the first time in over 20 years that NS Guantanamo Bay has conducted this scale of an on-load to a ship. The efforts of the Weapons Department personnel contributed significantly to completing the on-load in a safe and efficient manner."

The installation's Weapons department conducted the on-load, with the Operations department assisting with coordination, the Security department providing escorts for all transports, and the Safety department ensuring proper operational risk management (ORM) was observed.

"We follow instructions and directives," said Joseph Perfetto, NS Guantanamo Bay safety manager and explosive safety officer. "We have a comprehensive standard operating procedure (SOP) for what will be accomplished. The evolution took more than 70 days to plan. ORM was conducted every day for a week to ensure that everyone knew what was going on. The ammunition move went without a hitch."

Dempsey: Sesame Workshop Gives Top Support to Families

By Lisa Daniel

American Forces Press Service

WASHINGTON  – Sesame Workshop’s resources and outreach have done more to help families cope with repeated deployments during a decade of war than anything the military could have done alone, the military’s top officer said here today.

Army Gen. Martin E. Dempsey, chairman of the Joint Chiefs of Staff, said Sesame’s “Talk, Listen, Connect: Deployments, Homecomings, Changes” campaign -- a kit of DVDs and booklets designed to get families to discuss the unique challenges of military service with young children -- sends “a powerful signal and produces a better outcome” than the Defense Department or military services could do on their own.

Dempsey made the comments as part of a Sesame Workshop panel discussion with other military and veteran advocates. ABC News correspondent Bob Woodruff, who suffered a traumatic brain injury while reporting on the war in Iraq, and his wife, Lee, also an author and journalist, hosted the event at the National Press Club.

“I bet you’ll pay more attention to what Rosita says than what any four-star general says,” Dempsey said, as the green furry monster puppet made an appearance at the lectern next to him.

In creating the programming, Sesame writers had to determine “how we take the child’s perspective so the adult is willing to go through that door with them,” said Jeanette Betancourt, Sesame’s senior vice president of outreach and education.

Sesame created three episodes for the campaign, each with celebrity guest hosts: “When Parents are Deployed,” with Cuba Gooding Jr.; “Coming Home: Military Families Cope With Change,” featuring Queen Latifah and John Mayer; and “When Families Grieve” with Katie Couric. The shows aired nationwide on television and are streamed on Sesame’s website.

The episodes depict the Sesame characters experiencing the same events military children may have to cope with, such as when Elmo’s father leaves for deployment, and Rosita’s father returns from deployment in a wheelchair.

“Talking is so important, and sharing,” 5-year-old Rosita said. “My family went through big changes, because my poppy got hurt and he couldn’t walk anymore.”

Retired Marine Corps Maj. Nico Marcolongo, program manager for the Challenged Athletes Foundation Operation Rebound, spoke from the panel about returning from his second deployment in Iraq, and suffering post-traumatic stress.

“My circle got very small when I was first home,” Marcolongo said. He described being self-absorbed, distracted and detached. “The most disconcerting was I felt no love for my family,” he said.

Marcolongo’s then 3-year-old son mimicked him, he said, pacing back and forth in the house like his father. “It was real tough coming home with a wound I couldn’t see and nobody else could see,” he said. Marcolongo got help, and helped his son with the “Talk, Listen, Connect” videos, which he said teach families how to talk about the changes, accept their feelings and know they are not alone.

Patty Shinseki, wife of Veterans Affairs Secretary Eric K. Shinseki, spoke of her decades as a military wife and mother.

“This absolutely zeroed in on those feelings that military families experience,” said Shinseki, who serves on the Military Child Education Coalition board. Her husband is a retired Army general.

“The single, most wonderful change” for military families since her family served, Shinseki said, is that now families can receive help and resources 24/7 through programs like Sesame’s. “We can’t go back through that gate,” she said. “We’ve got to keep this conversation alive for the children.”

Dempsey described the Sesame initiative -- funded by a consortium of public, private and nonprofit entities -- as the perfect partnership to help military families. Rather than “just another government program,” he said, the program shows military families that the nation cares.

The chairman added that such initiatives are important to keeping trust with military families who all sacrifice for the nation.

“The equipment won’t always be perfect, my orders won’t always be perfect, and the organization we create won’t always be perfect,” he said. “What has to be perfect is that trust with the families.”

Dempsey, who is known for occasionally breaking into song, closed the event with a surprise a cappella rendition of the Sesame Street theme song.

Soldier Missing in Action from Korean War Identified

The Department of Defense POW/Missing Personnel Office announced today that the remains of a U.S. serviceman, missing in action from the Korean War, have been identified and will be returned to his family for burial with full military honors.

Army Pfc. Richard E. Clapp, 19, of Seattle, Wash., will be buried April 25, at Arlington National Cemetery near Washington, D.C.

On Sept. 2, 1950, Clapp and the C Company, 1st Battalion, 27th Infantry Regiment came under fire near Yulchon, South Korea, and Clapp was killed in action.  The Army was unable to identify his remains at the time, and the remains were buried as “Unknown” in a military cemetery on the Korean Peninsula.

In 1951, the U.S. consolidated cemeteries on the peninsula.  The unknown remains were interred in the National Memorial Cemetery of the Pacific.

In 2011, due to advances in identification technology, the remains were exhumed for identification.  Scientists from the Joint POW/MIA Accounting Command and the Armed Forces DNA Identification Laboratory used circumstantial evidence and forensic identification tools such as radiograph comparison, and dental records to identify Clapp.

Today, more than 7,900 Americans remain unaccounted-for from the Korean War.  Identifications continue to be made from the remains that were returned to the United States, using forensic and DNA technology.

For additional information on the Defense Department’s mission to account for missing Americans, visit the DPMO web site at http://www.dtic.mil/dpmo or call 703-901-7097.