|
|
"I want the quietness, the serenity of knowing that I'm in the country," said Pepper, a powerfully built man in his late 20s. "You don't have the hustle and bustle of all the traffic. You don't have the honking of horns, the sirens. You hear gunshots, but it's target practice or hunting." He grinned. "The crickets get kind of annoying."
Pepper and another soldier, David Emme, were profiled in the Journal last year while they were undergoing treatment and rehabilitation at Walter Reed Army Medical Center in Washington, D.C. As sergeants in the U.S. Army serving in Iraq, both had been wounded by improvised explosive devices and had traumatic brain injury (TBI), which has been called the signature wound of this war. Both also had symptoms of post-traumatic stress disorder (PTSD). Among more than 22,600 U.S. soldiers wounded in the conflicts in Iraq, Afghanistan, and other locations as of November 4, 2006,1,2 blasts have been by far the most common cause of injury, and 59% of blast-exposed patients at Walter Reed have been found to have a TBI.3 As thousands of brain-injured veterans come home to recover and rebuild their lives, medical experts have expressed concern about the challenges of providing them with continuing medical care and vocational and emotional support, especially because cognitive and psychological aftereffects of TBI can predispose them to falling through the cracks of the health care system. Officials in the Departments of Defense and Veterans Affairs (VA) have planned for what they term a "seamless transition" from military medicine to the VA or civilian health care. To see how two transitions are going, I recently revisited Sergeants Pepper and Emme.
Technology has become Pepper's lifeline. Mechanically talented and computer-savvy, he loved video games before he lost his vision; now, computers help him to find his way, read, do homework assignments, and prepare for a career in computer networking and information security. For today's wounded soldiers, "prosthetics" is a term encompassing far more than artificial limbs. "A prosthetic is any augmentative equipment that helps you survive or do things you need to do on a day-to-day basis," Pepper explained. His prosthetics include a personal GPS device that can direct him to his destination by voice or in braille, software that lets him operate his computer by voice, and software enabling the computer to read aloud to him. Pepper spent most of his time at Hines learning to use such tools. He soon lost patience with braille and with learning to cook, focusing instead on mobility training and computer classes.
Learning to function as a blind man was one of many challenges in a life-wrenching transition. Separated from his wife, Heather, and young daughter, Naomi, Pepper spent 12 lonely weeks at Hines last summer, then returned to Walter Reed for more reconstructive hand surgery. Last fall, he returned to Germany, where he and Heather had met. He had spent 10 years in the Army and had intended to stay for his entire career; being discharged was enormously painful. "If I could," he said, "I'd still go back." Forced to choose where they would relocate, the couple picked the Nashville area on the basis of Internet research. Naomi stayed with her grandparents in Germany until the Peppers were able to move into a house. "We've been going through kind of a financial strain, but we're still able to put food on the table, still able to pay the bills," Pepper said. "Now everybody has a bed."
|
Nonetheless, Pepper intends to return to work — but not until he gets a bachelor's degree and finds a job that pays well enough to make up for the loss of his Social Security disability payments and the other expenses he would incur by working. Heather is not currently employed and plans to stay at home with Naomi and the new baby.
|
Pepper has severe migraines almost daily, for which he has taken escalating doses of a barbiturate-containing pain medication left over from Walter Reed. "I'll just be sitting here and all of a sudden the headache will start," he said. "Then it will sit just right behind [my left eye], and I'll rub my head for hours." He also takes medications intermittently to reduce anxiety and to help him sleep, but he has halved his dose of an antidepressant: "I just don't like the way it makes me feel." He smokes heavily and said he hates the fact that, being blind, he can't get vigorous exercise safely: he can't run on a road or a treadmill because of the risk of falling. He weighed 187 pounds at discharge from Walter Reed; now, he weighs 240 or 250: "I'm fat, lethargic, and have no energy."
For David Emme, the worst part of each day is bedtime. He postpones it as long as possible, because he dreads the feeling that comes as he is dozing off. "It has happened ever since I got wounded," he said. "It feels like there's an explosion inside my brain — like a shock-wave effect. It lasts a few minutes. Sometimes my whole face, neck, and head will hurt. It's almost like getting blown up again. . . . When it really hurts, I've felt like . . . my spirit was leaving my body. I would wake up real quick and try to stay awake as long as I could."
In November 2004, while riding in a convoy in Talafar, Iraq, Emme was exposed to the full force explosion of an improvised device and incurred a severe brain injury. Twice, he went into cardiac arrest and was resuscitated while being transported to a hospital in Mosul. He remained in a coma for 10 days and awoke at Walter Reed with profound aphasia. He remembers none of these events and has made a remarkable recovery. Yet there are consequences: a large section of prosthetic bone in his skull, partial deafness in his left ear, shrapnel in his brain — and the almost-nightly feeling that he is about to die. "Some suggest that it might be post-traumatic stress disorder, but I want to get that checked out," said Emme, 34. "Not that I've ever been scared to die, but . . . I want to know if this is something that might cause it. I'm too young — I've got a long life to live still."
|
|
On the day I visited, the small, cluttered house was dimly lit and redolent of stale tobacco smoke. Emme's father, who requires supplementary oxygen and has limited mobility, sat at a computer in the living room while Emme and I talked nearby in the kitchen. Emme does the cleaning and shopping, drives his father to medical appointments, and calms him when he has an anxiety attack — a practiced skill for someone familiar with PTSD. "I learn how he works, and he learns how I work," Emme said.
|
Early next year, Emme hopes to enroll in a business program part-time at a nearby college, but for now, he is taking things slowly. He would like to work someday for a company or perhaps for the federal government, helping other disabled soldiers. "I know I can't go to school and work at the same time," he said. "I want to get my degree."
|
Emme's strongest emotional ties are with fellow soldiers from his Army Stryker brigade, many of whom believed that he had not survived the explosion. Describing his wounding and the reaction of friends in his unit, he said, "When you're ripped from your family and you no longer see them . . . it was hard for them, but it was harder for me. They lost one. I lost 82." Last fall, he traveled to Fort Lewis, Washington, for a reunion ball attended by members of his brigade. "It was one of the greatest times of my life," he said, "because everybody thought I had died."
Pepper and Emme acknowledged that, as compared with many Americans, they have a wealth of medical choices: they can seek treatment at military medical centers, at VA facilities, or from civilian physicians and hospitals using their Tricare coverage. Like thousands of other soldiers, they received state-of-the-art treatment at military hospitals. However, delivering similar care to severely injured veterans dispersed throughout the country is a greater challenge. Many live in rural areas far from military or VA facilities. Of the options available, the VA system offers the most comprehensive services for soldiers with TBI and "polytrauma" — including teams of specialists, mental health counseling for PTSD and social workers to support families, and an individualized treatment plan. Yet, like about 80% of soldiers recently discharged after returning from Iraq, Pepper and Emme have not enrolled as patients in the VA system.
Moreover, although a recent government report on the long-term treatment of veterans with TBI emphasizes the importance of a case manager — someone who keeps in regular contact with the patient, helps to arrange appointments, and ensures continuity of care — neither Pepper nor Emme has one.4 Each of the four military services has established a program to serve members who have been severely wounded, and soldiers or family members can also call a toll-free number at the Military Severely Injured Center to get help in obtaining health care. Seriously wounded Army soldiers are supposed to be assigned a case manager by the U.S. Army Wounded Warrior Program, the VA, or Tricare. Given their injuries, both men "would certainly qualify" for this service, said a Tricare spokesman, but "there is a certain degree of responsibility for the service member or veteran to be in touch." According to public affairs officer Timothy Poch, the Wounded Warrior Program has case workers stationed around the country to facilitate the transition between military hospitals and care by the VA or civilians and to link patients with needed services for 5 or more years after discharge. "We're the ones that can open doors for that," he said. "We'll act as their advocate."
Under a new system established by the Veterans Health Administration early last year, severely injured soldiers with TBI are being referred earlier in their treatment to one of four VA medical centers (in Richmond, Virginia; Tampa, Florida; Palo Alto, California; and Minneapolis) designated as Polytrauma Rehabilitation Centers, according to Harriet Zeiner, the lead neuropsychologist at the Palo Alto center. "You get a case manager, but more than that, you get a complete evaluation and treatment plan" that can be followed at the VA facility closest to the soldier's home, with periodic expert reassessment for at least 5 years, she said. "It's to prevent . . . people being sent home and told, `Go to your local VA.'" Zeiner added that during treatment at military hospitals, soldiers often minimize or deny having TBI symptoms because they hope to return to active duty. Yet even a mild TBI can cause long-lasting cognitive and behavioral problems. She urges physicians to ask recent returnees whether they were exposed to a blast, saw stars, or partially lost consciousness and to be alert for symptoms such as headaches, difficulty concentrating, and trouble with memory. Each of the four Polytrauma Rehabilitation Centers has been identifying 6 to 10 cases of TBI per month that were missed in military hospitals, Zeiner said.
Large numbers of wounded soldiers are returning home at a time when the philosophy, ethics, and economics of the military disability system are being reassessed by a presidential commission and four committees of the Institute of Medicine. Department of Defense officials, grappling with exploding expenses for disability entitlement programs, are concerned about the cost of potentially lifelong treatment for brain-injured veterans. Although Army doctors now screen for TBI when treating casualties in Iraq, in Afghanistan, and at military hospitals, the Pentagon has not yet implemented a policy to begin routinely screening all soldiers. A Department of Defense official said that new clinical guidelines, soon to be issued, are likely to include recommendations that all returning soldiers be questioned about exposure to blasts, head trauma, and possible TBI symptoms as part of their initial postdeployment medical assessment.
"We should screen for brain injury and mental health issues — there's such a high percentage of both" in returning veterans, said Representative Bob Filner (D-CA), who is likely to become chairman of the House Committee on Veterans' Affairs. "They talk about the seamless transition, but there is no such thing. The proactive approach is just not part of their culture."
"I give the military and the VA credit" for creating programs to treat brain-injured veterans, "but there are not enough of them, and I think that's the bottom line," said Gene Bolles, an assistant professor of neurosurgery at the University of Colorado at Denver, who treated soldiers wounded in Afghanistan and Iraq at the military's Landstuhl Regional Medical Center in Germany from 2001 to 2003. "The best thing the military could do is to recognize that this is a serious problem, help them get jobs, and give them the disability [payments] that they deserve."
Source Information
Dr. Okie is a contributing editor of the Journal.
Interviews with Jason Pepper and Harriet Zeiner can be heard at www.nejm.org.
References
| |||||||||||||||||||||||||||||||||||||||||
This article has been cited by other articles:
HOME | SUBSCRIBE | SEARCH | CURRENT ISSUE | PAST ISSUES | COLLECTIONS | PRIVACY | TERMS OF USE | HELP | beta.nejm.org Comments and questions? Please contact us. The New England Journal of Medicine is owned, published, and copyrighted © 2010 Massachusetts Medical Society. All rights reserved. |
Audio Interviews
Slide Presentation
