The Stark Differences Between Military and Civilian Care for Brain Injury

Dr. Geoffrey Ling talks about what it would take to duplicate the military's top-notch standard of care for TBI in the civilian sector.

[Dr. Geoffrey Ling] So, the contrast between what's currently available in the military and what's in the civilian sector is actually quite stark. I will give you an example that everybody can quite understand. So, if you have a child who's playing sports—we'll say soccer for example— and John or Janie gets into a situation where they get hit in the head, and they may not have lost consciousness, they may have just be dazed or see stars. So, naturally as a parent you would be very concerned, and you would like to take them someplace. The most typical place we would take them is to an emergency room. Go to the emergency room right now—and all of us can know this experience— and you'll wait for a while. You may or may not see a doctor, and you may or may not get a CT scan. But, let's pretend that you do see something, and you may not get a CT scan, but they say "Johnny and Jane—they're alright. They're alright. We believe they've had a mild concussion. You take them home, you let them rest." And you do that. You take them home, you let them rest. And, what the doctors will tell you—by the way—is "Make sure that Johnny or Janie wakes up easily and go wake them up every couple of hours because you want to make sure they're not bleeding in the brain." Well, that's very reassuring as a parent. But, we'll go past that for a moment. So, you go home, and Johnny or Janie did not bleed into their brain overnight— thank goodness—and they're ready to go to school tomorrow. And so they go to school, and then you find out that they're coming home and complaining of a headache. Maybe they didn't do so well in the spelling test. And you know that it's probably because of the mild concussion. Now, you bring them back. Where do you go? Do you go to your pediatrician? Do you go to a neurologist? Some parents will probably take them back to the emergency department. In other words, it's not clear what is going on. Nobody gave you clear instructions on what to do. That is what you will get. Contrast that with what I just said. A soldier is in an event where he may or may not have gotten a traumatic brain injury. May or may not have, alright? The medic will run up and give them a MACE test. The MACE with then say "Oh, you did have some abnormalities on this test." You will now—you must go see your doctor. You will see a doctor or a PA. Once you see that advanced provider, and they diagnose you with a traumatic brain injury, a concussion, you will then go into a concussion restoration center. You will go directly into a place that that's all they do. They take care of concussions. And you will go through that—a process— headed by an Allied Health Professional—an occupational therapist. And there are metrics for when you are better and when you're not. And if you have symptoms, we actually have guidelines—published guidelines that are available on the VA website; this is something that the VA and DoD developed— the guidelines that tell you what to do. You have a headache, this is what they should do. You're dizzy, this is what they should do. You can't sleep, this is what they should do. Memory problems, this is what they should do. So, it's prescribed based upon good clinical evidence. That's what you want—evidence-based. Clinical guidelines to let you know what's going to happen. So, this system of care that I just articulated for the military, contrast that with what I just told you about the civilian, and the differences couldn't be more stark. What would it take to develop such a system in the civilian sector? And, what it would take is commitment. Commitment on behalf of the medical care systems. Commitment on behalf of the community. Commitment on behalf of our funding agencies, such as the Medicare/Medicaid systems, the insurance companies and the like. And—quite honestly—that's what it is. It always boils down to money. In the military that's less of a problem because ours is maintaining the fighting force. However, in the civilian sector, yes, money does play a role. But, I would argue that this is a small investment to regain a lot. Imagine that—and we know this—traumatic brain injury affects mainly the most productive members of our society. The 18- to 40-year-old group. And, if they are out of work—even for a day or two—what does that cost society? And if we can treat them properly, what do we regain? We regain a lot. And, so I would argue that the investment, the upfront investment, is small. But what would it take to develop such a system? It would take a commitment on behalf of a hospital system to create this process, it would encumber the insurance companies and the Medicare/Medicaid system to reimburse for these services, and—honestly—it would encumber our patients to go and seek this care. But I would argue that one of the things that we need to do is start to take medicine to the patient. We've got to learn how to put in the hands of parents— many of whom are the coaches for little league and soccer— the tools they need to be able to screen for this traumatic brain injury, so they can properly get this young player to getting medical care. And so we have to move these things out and move things back. It's kind of similar to teaching people about the dangers of heart attacks— knowing that for chest pain you need to call 911—that sort of thing. So, educating the public is not a little thing. It's a very important part of this.
Posted on BrainLine January 15, 2013.

Produced by Noel Gunther, Ashley Gilleland, and Erica Queen, BrainLine.