Taking On TBI in Theater

“We didn’t call it TBI. We called it a concussion.”

That was six years ago in Iraq—when U.S. convoys were constantly being hit by bone-rattling roadside bombs. But Staff Sergeant Michael Cavallo, an Army medic, remembers very little talk about traumatic brain injury back then.

Cavallo is currently serving at FOB Clark in eastern Afghanistan, and TBI screening is now mandatory for anybody who’s been within 50 meters of an explosion.

The screening, known as Military Acute Concussion Evaluation or MACE, is also required for troops after a blow to the head, a fall, a vehicle rollover or on the recommendation of a commander.

“It is great to have guidelines set out for TBI testing,” Cavallo, who regularly evaluates soldiers immediately after explosions and accidents, said.

The initial screening isn’t necessarily high-tech, but it’s effective.

“We tell them some numbers and they have to read [repeat] them back to us,” Major Luther Wiest, an Army physician at FOB Clark, said. “The months of the year in reverse order—things like that. And we do a neurological exam on them—seeing how well they balance, can they walk normally?”

The most important factors considered during screening are whether or not the patient lost consciousness for more than 30 minutes or experienced memory loss—like difficulty recalling what happened—for more than 24 hours. In those cases, the troops are usually evacuated to Germany or the United States.

But since 2010, the military has been treating milder cases of TBI in theater, keeping troops in Afghanistan at special treatment centers where they take a short break to recuperate, before heading back to the front lines.

Defense Department statistics show that more than 218,000 troops have suffered TBI since 2003. More than 70 percent of those troops were classified as having sustained a mild TBI.

Mild TBI is essentially a concussion. The patient might describe seeing stars or feeling dizzy and disoriented. But to be classified as mild, any memory lapse or loss of consciousness would be very brief.

The initial treatment is simple—24 to 48 hours of rest in a quiet, dimly lit room.

“If they get that nice uninterrupted rest for the first day or two, that makes such a difference in concussion,” said Army Major Steven Wasilewski, an occupational therapist and part of the medical team at the concussion specialty care center at Bagram Air Base outside Kabul.

Wasilewski said about 80 percent of mild TBI cases are resolved after a rest period at a soldier’s home base.

But in some cases, the patient needs to go to a Level 2 concussion care center at a larger base for further treatment. Occasionally, a Level 3 facility like the one at Bagram, is in order. Facilities like the one at Bagram offer neuropsychological testing and diagnostic equipment like MRI’s and CT scans.

At Bagram, troops recover in a row of air conditioned rooms—luxurious by military standards.

Each patient gets a private room with a comfortable bed and colorful quilt. On a hot summer day, when the rest of the base is choked with dust and bustling with noise and traffic, the TBI center is blissfully clean, cool and peaceful.

Rest remains the primary treatment, even two or three days after an explosion.

“By the time we see them, we’re seeing the other symptoms. They’re not dazed anymore but they are fatigued,” said Wasilewski. “Headache is very big. I’ve seen it in every single patient. They all come in here with a headache without exception, but also balance deficits.”

“Early on we don’t even let them watch TV… and we really don’t even want them to read,” he said. “Any of that kind of visual stimuli engages the brain … and we don’t want the brain to work. We want to let it rest.”

Some patients also have overlapping symptoms of post traumatic stress (PTS), so the medical team keeps a close eye on everyone’s progress. As their condition improves, they’re allowed to socialize, play chess or Yahtzee or build model cars. They can listen to soft music, but violent TV shows, video games or rigorous exercise are off limits.

Within five to seven days, the majority of patients are back to normal and ready to rejoin their units. But even with that relatively short recovery period, combat troops often shy away from testing and treatment because they don’t want to be taken out of the fight.

Cavallo, the front-line medic, tells his fellow soldiers that resisting treatment could put their whole team at risk.

“If you’re not a hundred percent out there on the battlefield, it can affect others’ lives, not just your own,” he said. “You have to cover one another.”

“That’s the role of education,” Wasilewski said. “We say, ‘You can either rest now and get back in five, six or seven days, or you can go for it now, and then you can have a headache for weeks and months.’”

The military recently recruited the NFL as an ally to share research and spread the word about TBI.

ESPN analyst Eric Mangini participated in a TBI focus group at the Pentagon in June, and visited FOB Clark in July as part of an NFL-USO tour. He understands how difficult it is for a player or a soldier to admit they have a concussion.

By Malini Wilkes

“They know it’s going to affect their livelihood or their career path or their unit,” the former Cleveland Browns and New York Jets head coach said.

But Mangini thinks education and improved diagnostic technology are having an impact in the NFL.

Vikings coach Leslie Frazier also sees signs that the message is being heard.

“We have their teammates that will say, ‘Hey, we need to get this guy checked out. So it’s changing. It’s changing,” he said.

The good news, according to Wasilewski, is that the majority of mild TBI cases are completely treatable.

“Concussion is mild TBI,” he said, “And we tell folks that at the end of your treatment here, you should be as if you had not had a concussion. You should be feeling that good.”

–Malini Wilkes is a former director of story development for the USO.