ROBERT SIEGEL, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.

Our nation's leaders have called mild traumatic brain injury one of the signature injuries of the fighting in Iraq and Afghanistan. But an investigation by NPR and ProPublica has found that the military's system for helping troops with TBIs is broken.

For one thing, we have no good idea just how many troops suffer from these injuries. Rough estimates suggest there could be tens of thousands of soldiers who simply can't think straight anymore, and many of those have received little or no treatment.

NPR's Daniel Zwerdling has our story. It was also reported by T. Christian Miller of ProPublica.

(Soundbite of birds chirping)

DANIEL ZWERDLING: One of the faces of this tragedy is Michelle Dyarman.

Ms. MICHELLE DYARMAN (Military Veteran, Iraq War): We have a hundred acres. It's a family farm.

ZWERDLING: We met Dyarman next to the old farmhouse in southern Pennsylvania. You can smell the cattle in the barn.

Ms. DYARMAN: I grew up here and...

ZWERDLING: In this brick house right here?

Ms. DYARMAN: Yes, sir. Myself and my father. We're the only ones here now.

ZWERDLING: Michelle Dyarman was on the dean's list back in college. She got a master's. She became a captain in Iraq. Then in late 2005, Dyarman was in two explosions. The worst was two days before Christmas.

Ms. DYARMAN: And there was so much dust and dirt and debris flying around. We had to wait like, two minutes for it to settle. I realized I had a screaming bad headache. Take the worst headache you've ever had, and multiply it by about a thousand. And I've had an ongoing headache ever since.

ZWERDLING: Studies show that a blast wave shoots through metal. It shoots through skulls and brains, even if it doesn't draw blood. And the blast wave can damage the brain cells and circuits in ways that researchers don't fully understand. But Army doctors hardly treated Dyarman for her traumatic brain injury. And today, she slumps at the dining table. She says just that morning, she visited a friend in another town, and she couldn't find her way home.

Ms. DYARMAN: I got - I had - I got lost three times. I had to turn around and find my way three times. And I've driven that route many a time.

ZWERDLING: Dyarman left the Army two years ago, and she's gone back to the job she had before the war. She inspects doctors' X-ray machines for the state. One of her colleagues says: Sometimes, we have to cover for Michelle. She turns in inspection reports with lots of blanks.

Ms. DYARMAN: And I struggle with the reports. It's difficult to put together the whole report, to...

ZWERDLING: Officials at the Pentagon wouldn't talk to us about Dyarman or any specific soldiers, but we've spent four months investigating how the military is handling traumatic brain injuries. We've interviewed dozens of soldiers across the country. We've interviewed generals and medics. We've reviewed thousands of records. And the evidence suggests that the military system for diagnosing and treating TBIs has failed the troops at almost every step of the way.

It starts to break down on the battlefield.

Unidentified Man #1: IED.

Major REMINGTON NEVIN (Researcher, U.S. Army): We are significantly underestimating and underreporting the true burden of traumatic brain injury, absolutely.

ZWERDLING: Major Remington Nevin has been studying soldiers' health problems at the Pentagon's Health Surveillance Center. Nevin says, picture a battalion of soldiers on patrol. These sounds are from videos of actual battles that soldiers posted on YouTube.

Maj. NEVIN: So a convoy encounters some kind of enemy contact, an IED explosion.

(Soundbite of IED explosion)

Unidentified Man #2: Get out, get out, get out, get out.

Maj. NEVIN: And someone gets injured.

Unidentified Man #3: I hurt. My head kind of hurts.

Maj. NEVIN: We call in a medevac, a nine-line medevac.

(Soundbite of medevac helicopter)

ZWERDLING: And the medics rush the troops to an emergency station. The Pentagon's policy says that whenever troops are in explosions, the medical staff is supposed to diagnose and treat TBIs as soon as possible, but many doctors on the battlefield don't diagnose TBIs at all.

Lieutenant Colonel MICHAEL RUSSELL (Senior Neuropsychologist, U.S. Army): My name is Dr. Michael Russell. I'm the senior neuropsychologist for the Army Medical Command.

ZWERDLING: The Army sent Russell to Iraq early last year to study TBIs. One night, a rocket blew up part of a soldiers' housing unit at Camp Liberty, near Baghdad. Amazingly, all five soldiers survived. Russell visited them at the medical clinic, and the medical charts showed nothing serious.

Lt. Col. RUSSELL: Numerous cuts, abrasions, that sort of thing.

ZWERDLING: But when Russell examined the soldiers, he found that the medical staff had missed the main problem: All five had mild traumatic brain injuries.

Lt. Col. RUSSELL: Kind of a dazed expression, a little bit unfocused, a little bit slow to respond. The last thing they remember is they were playing videogames. The next thing they remember, they're outside the trailer in a shelter.

ZWERDLING: Russell and other Army doctors say the military has never trained many of its staff to diagnose TBIs. And here's why that can hurt so many troops. Studies show that most people who get mild TBIs recover spontaneously, in just a few days or weeks. On the other hand, a troubling number does not. Some researchers call them the miserable minority.

Dr. KEITH CICERONE (Neuropsychologist, JFK Medical Center): These are people who go on to live a lifelong, chronic disability.

Unidentified Woman: G Wing. Spotlight is beginning in G wing.

ZWERDLING: Keith Cicerone runs the brain rehab program at JFK Medical Center in New Jersey. Nobody knows how big that miserable minority is. Some studies suggest it's 5 to 15 percent of people with so-called mild TBIs. And since such a huge number of troops have been in explosions, that means there could be tens of thousands of soldiers who can't think straight anymore.

Cicerone and other specialists say the faster you can send the victims to rehabilitation, the better the chance they can live fairly normal lives. So he says the military is doing a terrible disservice when it doesn't diagnose troops fast and then send them to the best treatment.

Dr. CICERONE: I think it's very easy to say that we honor our servicemen. You know, talk is cheap. I don't think the services that we're giving to those servicemen - honors those servicemen.

ZWERDLING: Members of Congress were so upset that doctors weren't diagnosing TBIs that they passed a law about it three years ago. It ordered the Pentagon to screen every service member after an explosion, and the Pentagon sent two kinds of neurological tests to the battlefields.

One test is called the ANAM, but despite the law, Mike Russell says most doctors in the military have never used it. The other test is called the MACE.

Lt. Col. RUSSELL: That's the Military Acute Concussion Evaluation.

ZWERDLING: When soldiers take the MACE, they have to remember words, repeat numbers backward. But soldiers say the test is often a joke because the medics help them pass it.

Lt. Col. RUSSELL: There is, I think, considerable evidence that people were being coached or just practicing. They would get a copy of the MACE and they would rehearse the numbers. Sometimes, medics might be - just be trying to be helpful.

ZWERDLING: And soldiers have told us they wanted help to pass the test. For instance, just last summer, a sergeant named Victor Medina was leading a convoy in southern Iraq. There was an explosion. He was knocked unconscious for 20 minutes, and then he realized he couldn't process what people were saying to him anymore. It's hard to understand Medina. He's been stuttering since the blast.

Sergeant VICTOR MEDINA (Military Veteran, Iraq War): I could never put together what was going on, because I was trying to put it together in my head and I couldn't.

ZWERDLING: But Medina passed the MACE test anyway because he says the medic kept repeating the questions until he answered them right. Medina says he wanted to go back to duty and lead his soldiers.

Sgt. MEDINA: I'm the platoon daddy. (Unintelligible) honor and loyalty.

ZWERDLING: So the medical staff in Iraq never diagnosed Medina with a mild TBA. And that brings us to the next part of the system that's broken. Military researchers say that even when doctors do diagnose TBIs, that crucial information often does not get into the medical records.

Maj. NEVIN: These systems simply were not designed for war the way we fight it.

ZWERDLING: In fact, Remington Nevin and other researchers say the systems have been a fiasco. For instance, medics are supposed to record TBIs and other injuries on handheld computers, but the batteries go dead in the field.

Maj. NEVIN: A good number of these devices failed. They broke.

ZWERDLING: So, many doctors in Iraq and Afghanistan have recorded the injuries on paper, but Mike Russell and others say that many of those records have been abandoned or destroyed. He says it sounds surprising, but a lot of commanders don't know where to send them.

Lt. Col. RUSSELL: The reality is that for the first several years in Iraq, everything was burned. You know, you took it out, and you put it in a burn pit, and you burned it. I mean, so thats how things were done.

ZWERDLING: So Remington Nevin says when troops who have traumatic brain injuries come back to the States...

Maj. NEVIN: The fact they were in an IED blast is not documented.

ZWERDLING: In other words, months later, when the soldier is having trouble thinking, having trouble reading, having trouble remembering, doctors might say...

Maj. NEVIN: Well, there's no evidence you were in a blast. I don't see it in your medical records. Stop complaining.

ZWERDLING: Now, in theory, military doctors can catch that mistake the week the soldiers come home because they all have to fill out a questionnaire that's supposed to spot troops who might have TBIs. It's called the Post-Deployment Health Assessment, the PDHA.

But researchers like Heidi Terrio say the program has big problems.

Colonel HEIDI TERRIO (Researcher, U.S. Army): The standard screen on the PDHA fails to catch 40 percent of all those who have sustained a traumatic brain injury in theater.

ZWERDLING: Did you catch that? Terrio runs a research program at Fort Carson in Colorado. Their studies show that the Pentagon's screening program...

Col. TERRIO: Fails to catch 40 percent...

ZWERDLING: ...of all the soldiers who have had a traumatic brain injury, maybe more.

Maj. NEVIN: And this is having very real effects on the health of our soldiers.

ZWERDLING: Dr. Remington Nevin, the Army researcher.

Maj. NEVIN: The senior levels of leadership that should be responsible for this issue either don't care, can't understand the problem due to lack of experience or are so disengaged that they haven't fixed it.

(Soundbite of runway)

ZWERDLING: There's one top general who says he's trying to fix it. Peter Chiarelli is the vice chief of staff of the U.S. Army. I flew with him to Fort Carson one morning to see the medical program there. Chiarelli bounded off the jet and greeted the welcome party.

Unidentified Man #2: How are you doing?

Unidentified Man #3: It's good to see you again, buddy.

Unidentified Man #4: Welcome back.

ZWERDLING: Chiarelli has a reputation for being a straight-shooter, and he says he can't answer the basic question: How many troops are still suffering from mild traumatic brain injuries?

General PETER CHIARELLI (Vice Chief of Staff, United States Army): I can't. I can't tell you how many do.

ZWERDLING: And do you worry about those soldiers?

Gen. CHIARELLI: Of course I worry about those soldiers.

ZWERDLING: And Chiarelli says it's true: A lot of military doctors still don't diagnose traumatic brain injuries when they should.

Gen. CHIARELLI: Well, invisible wounds are definitely going to play second fiddle to blood and missing appendages, or gunshot wounds.

ZWERDLING: And the general says here's part of the problem: Despite all the rhetoric about signature injuries, many people in the military still don't believe that TBIs are a serious problem.

Gen. CHIARELLI: We've got to change the culture of the Army. We've got to change the culture of society. We don't want to recognize things we can't see.

ZWERDLING: I'm a little surprised and unprepared for this. I was sort of expecting you to put on a vigorous defense and say no, we're doing great screening. We're catching everybody with traumatic brain injury.

Gen. CHIARELLI: No. I have frustration about where we are on this particular problem.

ZWERDLING: Chiarelli says the military is launching new programs soon that should do a better job protecting troops from TBIs. The problem is, there are already all kinds of policies, and soldiers from privates to generals haven't followed them.

Daniel Zwerdling, NPR News.

(Soundbite of music)

SIEGEL: Tomorrow, soldiers at a major Army base have to fight to get good treatment for their traumatic brain injuries. To learn more, go to npr.org and propublica.org.

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