Stefano Rellandini/Reuters /Landov
Traumatic brain injuries are most often caused by powerful blasts from improvised explosive devices. A roadside bomb explodes, and the concussive effect violently shakes the brain inside the skull.
Stefano Rellandini/Reuters /Landov
Nineteen-year-old Army Pvt. Cody Dollman has a look in his eyes that makes you think he probably used to fight much bigger kids on the playground back home in Wichita, Kan. He says he always wanted to be a soldier — both his grandfathers served in the military — but he's the first in his family to see action overseas.
"I love it. It's what I signed up to do, you know?" says Dollman, who had been patrolling the battle-scarred villages around Kandahar, Afghanistan. "I get to go back home and tell stories. That's one of the coolest things. What did you do on Christmas? I got blown up."
An NPR and ProPublica investigation in 2010 reported on the military's failure to diagnose, treat and document brain injuries. Evidence suggested tens of thousands of soldiers were falling through the cracks.
He isn't joking. Since he deployed last April, Dollman has been "blown up" three times by roadside bombs that hit his convoy of armored trucks. The third time was the worst.
"We were rolling on a mounted patrol," he says. "I was in the lead vehicle, which hit an IED [improvised explosive device]. I hit my head, blacked out for a little bit."
At first Dollman shook it off as his platoon pursued the insurgent fighter who set off the bomb. Within an hour he was feeling the aftereffects of the blast: He threw up and his head hurt.
The medic said Dollman was a sure bet for traumatic brain injury. TBI is often caused by blasts: A roadside bomb explodes and the concussive effect violently shakes the brain inside the skull. Sometimes there are symptoms. Sometimes there are not.
Dollman wanted to stay with his platoon, but the medic wasn't having it. A chopper flew him to the hospital at Kandahar Airfield.
"It's one of those things that if you're treated, it shouldn't be anything to worry about, as long as you're not stubborn like me," he says.
The problem is, most soldiers — and many of their leaders — are a bit stubborn like Dollman. Soldiers don't like being taken away from their unit, especially for an injury they can't see.
The Army, in particular, has had a mixed record treating soldiers for TBI. Now it is trying to spot the injury close to the battlefield and get soldiers out of the fight.
Medics began carrying a laminated quiz that tests a soldier's ability to concentrate, but they soon found that soldiers were memorizing the answers. Now the medics carry several different versions of the quiz.
But that touches on a challenge with TBI: how to diagnose it.
The symptoms aren't always as obvious as Dollman's — sometimes there aren't any obvious symptoms at all.
"Everyone wants a pregnancy test for TBI," says Maj. Gen. Richard Thomas. The surgeon has just finished a tour as lead medical adviser to U.S. forces in Afghanistan. He says someday a blood test or brain scan may be able to indicate whether a soldier has TBI; the Army is researching both. But Thomas says those tests could be years away.
"While that's working, that takes time. What are we going to do immediately? Immediately we gotta identify these guys as soon as we can, get them out of the fight," he says. "Because we know that for concussion, the best thing to do immediately is take them away from the insult, rest them, let their brain recover."
TBI Vs. PTSD
That's what happens at the newly completed concussion care center at Kandahar Airfield, where Dollman is currently on bed rest. The facility has neurologists and occupational therapists; there's even an MRI machine in a trailer — a first in military field hospitals.
Once the soldier is here, it's easier to start tackling symptoms, but that's another tricky thing about TBI. Navy Cmdr. Greg Caron, a clinical psychiatrist, says the symptoms for TBI are easily mixed up with symptoms for other battle injuries, like post-traumatic stress disorder, or PTSD.
"What's interesting about blast-related concussion is that it impacts the same region of the brain that is implicated in anxiety disorders and mood disorders," he says. "About a third of the folks who are diagnosed with MTBI or concussion actually have other psychiatric diagnosis, whether that's depression or PTSD."
The challenge for doctors is to figure out which symptoms are from TBI and which aren't. Like with PTSD, some victims don't feel any effects until months after their injury. In fact, the Army's own studies show that as of a couple of years ago, most cases of TBI in Iraq went undiagnosed. Critics say the military took a long time to realize the enormity of the problem. That raises another issue, though: For the majority of both wars, the Army kept little data on concussions.
Returning To The Battlefield
The Kandahar concussion care center is trying to correct the military's course on TBI.
Dollman undergoes brain scans regularly. He takes cognitive tests almost every day. He recently got the news — bad news, if you ask him — that he can't go out on any more patrols.
"I'm not allowed to leave the wire as of now, just because it's my third [concussion]," he says.
That's one rule military doctors have come up with since they've been looking at TBI close to the fight. It's arbitrary — no one knows whether it's one concussion or five concussions that leads to the long-term problems — but doctors think it's a good rule of thumb. Dollman decided he would probably lose an argument with the neurologists here in Kandahar.
"It is hard, but I know it's for a reason, because I know I need to get treated," he says. "That way I'm not hurting my platoon, because when we go on missions they can't be worrying about me. ... I'm more of a danger going out to the line with TBI, so it's a big thing I get treated here before I go back out."
That argument works with soldiers: They'll do it for the guys in their unit. Another argument may be winning over their commanders. According to Thomas, the new procedures — getting soldiers to take a break and rest up, but stay in Afghanistan — is actually getting troops back to the battlefield sooner.
Before, many soldiers thought to have TBI would be flown all the way to Germany for treatment. Many would never get back to their units in Afghanistan.
Keeping soldiers healthier — but also getting them back in the fight — is the kind of result that may help senior military leadership embrace the new approach to TBI.