The War Medicine Scandal
words by Maryann Brinley
Interview experts in war-related injuries and even the toughest, cool-headed doctor is likely to be frustrated about the current state of caring for soldiers wounded in the Iraqi or Afghanistan war zones. We know better. We know more. We have standardized models of care for these multiply-injured veterans that aren’t being utilized. We have diagnostic tools and information about pharmaceuticals, hormones and nutrients, which are being ignored.
cross the country, there are 14 specialized hospital network systems, centers of excellence, established by an act of Congress — UMDNJ-NJMS University Hospital / Kessler Institute of Rehabilitation are included on this list — which should be a first stop for answers to the war-related medical nightmares of not only traumatic brain injury but also spinal cord injury.
First established back in the 1970s, “these distinguished centers have learned how to treat people through patients who have come through the systems.” All 14 have been providing data to a national collection center so this longitudinal information is having a huge impact on knowledge of SCI and TBI. “With war comes great opportunity for medical advancement,” says Elie Elovic, MD, Director of Traumatic Brain Injury Research at Kessler Medical Rehabilitation Research and Education Center.
Yet, Elovic says, “A large number of state-of-the-art novel treatments intended for traumatic brain injury are not being tried” in the military at this time. John DeLuca, PhD, NJMS professor and Director of Neuroscience Research at KMRREC, points out that Near Infrared Spectroscopy (NIRS), for example, is an inexpensive imaging tool that could be used right in battle to determine whether or not a soldier had suffered even mild TBI. There would be no need to ship someone off to Germany for a functional MRI or to accuse an individual of faking to escape the stress of war.
This portable tool offers a true working picture of the brain “so you don’t have to simply look at behavior or emotions. You can see the brain scan right there on the field so a commander could say, ‘Ok, we’re not sending you back in.’ We are working on NIRS right now,” DeLuca says. He’s also developed programs to improve mental processing in victims of TBI so that memory problems can be partially overcome. “If you were a Pentium computer before your TBI, sadly your brain is more like a 286 processor afterward,” he explains. In fact, memory, which is more than a single entity and involves learning, storing and retrieving information, is the number one complaint in mild TBI.
“We have techniques to help improve these functions,” DeLuca says, “really good studies to show they work. Are we applying them to soldiers and veterans?” The military is simply identifying the disorder and sending victims with this cognitive burden off with little help, according to DeLuca. “This brain injury becomes cumulative. You start failing at work and at home. Friends think something is wrong with you. You lose your job, your house, your family, your life. You get upset. You get depressed. It all accumulates.”
|David Tulsky, PhD associate professor, physical medicine and rehabilitation, UMDNJ-New Jersey Medical School|
While Elovic admits that the Kessler team is testing and utilizing modalities that are more aggressive than standard treatments, he says, “I think we owe our soldiers who have put their lives on the line the most aggressive care. Frankly, that window for recovery can easily be 12 to 18 months and too often, aggressive treatment isn’t looked at until after this window has closed.” Emails asking for his advice come from all over the country. “I try to give people the most hope. If you only use evidence-based practice, working with what people have absolutely proven beyond a shadow of a doubt, you would never advance medicine.” As Elovic says, “We have to be scientific and concrete and measure our success but decision–making must be guided by the improvement in someone’s function, not what happens in the general population. No one ever did a double-blind controlled trial for parachutes.”
David Tulsky, PhD, Vice President of Outcomes and Assessment Research and the Director of Spinal Cord Injury at KMRREC, explains, “Spinal cord injury was the first model systems program and offers the most comprehensive data base from which this field has learned. The traumatic brain injury program has been around for more than 20 years and offers similar comprehensive information for TBI injuries.” KMRREC and UMDNJ were awarded big grants to establish these centers of care and to study quality of life for these patients. To be distinguished as a model system, Tulsky adds, you need to have all of the facilities within your partner organizations for integrated comprehensive care from the Level 1 Trauma Center at University Hospital to Kessler with its full range of services. Funding for this wealth of information has been ongoing and provided by the government’s own National Institute on Disability and Rehabilitation Research (NIDRR). “The big question is: why haven’t these important data bases and programs been used more extensively to help treat deployment related injuries? Why haven’t the Department of Defense or VA formed a greater liaison with these established networks as their launching points for treatment and care? I don’t know the answer.”
Tulsky and the KMRREC team are participating in large scale initiatives to measure outcomes, “which could be very helpful to the military.” He has received extensive funding from the NIH and NIDRR to lead collaborative research projects developing a patient reported outcome measurement information system, known as SCI - QOL, for people with SCI and TBI - QOL for patients with TBI. Both are to be integrated with NIH multi-million dollar projects known as Neuro-QOL and PROMIS. Leading rehabilitation centers around the country are focusing on neurological disorders, and these systems hold the promise of helping the VA and DOD keep track of injured soldiers.
“We are practicing state of the art medicine,” Tulsky says, “Does it make sense for the Department of Defense and the VA to do things so independently or is there a way to collaborate better and develop longstanding research and clinical programs? I certainly hope that these collaborations happen. They would really benefit our wounded warriors.”