As the Nature of War Changes, Making Changes in Diagnosis and Treament for TBI

"War is now an intermingled mess of insurgencies ... making injuries different from previous wars."

The challenges with the military in Iraq and Afghanistan have been multifaceted. And when I was growing up, we had the Vietnam war. And war and conflict have changed so much over the years that now it doesn't look at all in Afghanistan and Iraq, or you know, hopefully not, but maybe Libya. It won't look the same as it did when we had these nice clean lines and we would advance in armies, and they would advance in armies. Now it's an intermingled mass of insurgencies. So, the reason I bring that up is that the injuries are different. And so in World War I, we used to have what was called shell shock syndrome. And people knew what that was. In World War II, there was a certain number of days an individual would stay in active duty in World War II and I think it was about 160 days and at the end of 160 days, they had to be taken off the line. And they found that either they were...after that, either they were wounded, dead, or crazy. So that's where they came up with 160 days. And the military has very analytical. It, you know, so you'll hear statements about Well, you don't have a concussion because you were not within 50 meters of the blast. And they don't care about how big the blast was, or where it came from or...but they're very analytical about those types of things. And the challenges were, first, to try to get past the differentiation between the Department of Defense and the VA and the different branches of the service. Ah, because they're not very good at talking with each other to begin with. And second of all, the disabilities that are paid out for individuals that are in the VA are much different than what I had envisioned for people with head injuries and with concussions. And people with post-traumatic stress were thought to be just weak and not have the...and were trying to play the system and game the system and be malingerers to get this through. And if you were a Marine or a soldier, and you were in Afghanistan you wanted to perform at the highest level. This is now an all-volunteer army or all-volunteer service. Whereas before, in Vietnam, we had draft people. People didn't want to be there. These kids want to be there. So, the first big challenge was to, when I was asked to give a briefing at the Pentagon was to try to tell it...try to advise the Vice Chief of the Army, Pete Chiarelli and the then Vice Commandant of the Marine Corp, Jim Amos what concussion was and how can you diagnose this. And I remember at dinner at General Chiarelli's house where we were discussing this, and I said Well here, this is how you can image it. And this is what happens to the brain and this is why it is vulnerable to second insults. And this is why you want to take individuals away from a football field from a boxing match or from a battlefield. And they looked at me, and they said, we've never heard this before. And I said...I can remember telling them I said my father served in the Navy. He was a doctor. You've got great physicians here, this is not a problem. There's got to be some doctors that will help you with this here in the military. And they asked me to give a briefing the very next day in the Pentagon, and this was in 2009. And I gave that briefing, and the room was... had General Chiarelli and General Amos and then it had their medical expertise staff of about 20 neurologists, psychiatrists around the room. And so I gave the same briefing about concussions and then individuals would get up in the room, and they would say You know, Dr Hovda, we respect your authority and your expertise but you don't understand, this is not a problem in the military. We don't have concussions in the military. And if you take individuals out and away from the battlefield or inside, what they call inside the wire, after a brain injury or a concussion, this is bad medicine. You're gonna make things worse because you're gonna label them as a brain-injured person, and they're going to perseverate and they're going to become a brain-injured person. And I said, you know, I respectfully disagree and that ended up being a very loud debate which lasted for a long time. And so then Pete...General Chiarelli and General Amos asked if I would put together a blue ribbon symposium of civilian expertise. And they did not want anybody in the military to be a part of this. And so we brought in what I felt were the best people that were here with the National Neurotrauma Society that knew concussions and traumatic brain injury and also the best experts I knew of that did post-traumatic stress. Because there's a lot of co-morbidity between these 2 events. And we held 2 sessions, and we put out a series of suggestions to them and then they, through Admiral Mullen, they sent out the orders and they implemented the program. Much quicker than...That's one of the beautiful things about the military. When somebody up high says we're gonna do something it actually happens, as opposed to the National Football League where you have to have committees and figure out what you're gonna do.
Posted on BrainLine October 24, 2011.

Produced by Noel Gunther, Ashley Gilleland, and Brain King, BrainLine.

About the author: David Hovda, PhD

David Hovda, PhD is the director of the UCLA Brain Injury Research Center. He is past president of the National Neurotrauma Society and past president of the International Neurotrauma Society.  He has served as chair of study sections for the National Institute for Neurological Disease and Stroke.

David Hovda