Mild Traumatic Brain Injury/Concussion Training Program for Line Leaders Mild Traumatic Brain Injury/Concussion “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Objectives Understand how a concussion/mild traumatic brain injury (mTBI) can affect service members Understand leadership’s responsibility in the mTBI recovery process Understand how concussion impacts mission readiness Review of Concussion Basics Causes, signs, symptoms, recovery Discuss available resources related to concussion “Medically Ready Force…Ready Medical Force”

Warrior Management for mTBI Goal: Create a military-wide cultural change following concussive events Vision: Every Warrior treated appropriately to minimize concussive injury and maximize recovery Mission: Produce an educated force trained and prepared to provide early recognition, treatment & tracking of concussive injuries in order to protect Warrior health “Medically Ready Force…Ready Medical Force”

Department of Defense Definition* of Traumatic Brain Injury TBI is a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force. TBI is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: Any period of loss of consciousness (LOC) Any loss of memory for events immediately before or after the injury (PTA) Any alteration in mental state at the time of the injury (AOC) Neurological deficits that may or may not be transient (or permanent) Intracranial lesion *Woodson memo; ASD-HE Memo, April, 2015 TBI: Updated Definition and Reporting “Medically Ready Force…Ready Medical Force”

Concussion/mTBI Definition Concussion is also known as a mild traumatic brain injury (mTBI) Concussion: Is caused by a blow or jolt to the head Can occur even without being knocked out Can temporarily change the way the brain works Important to seek medical attention after a concussion, no matter how mild it may seem “Medically Ready Force…Ready Medical Force”

Knowledge Check 1 According to the Department of Defense a traumatic brain injury could be defined as (check all that apply) any period of loss of consciousness any loss of memory for events before or after the injury a prolonged period of nausea and vomiting any alteration in mental state at the time of the injury physiological disruption of brain function

Knowledge Check 1 (answer) According to the Department of Defense definition, a traumatic brain injury could be defined as (check all that apply) any period of loss of consciousness any loss of memory for events before or after the injury a prolonged period of nausea and vomiting any alteration in mental state at the time of the injury physiological disruption of brain function

“Medically Ready Force…Ready Medical Force” TBI Classification TBI is classified as Mild, Moderate, Severe, or Penetrating Classification describes the severity at the time of injury It does not describe the resulting impairments or duration of symptoms The majority of Soldiers can expect a full recovery, even with multiple concussions Early detection and treatment are essential Recovery may take longer with recurrent concussions “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Vital Information The brain is complex. Leaders need to understand that concussed Soldiers may have different symptoms. Soldiers recover at different rates and respond differently to treatment Essential for Commanders to support medical guidance after a concussion Will include restriction of physical activity and mental rest “Medically Ready Force…Ready Medical Force”

Common Concussion Symptoms Headache Sleep disturbance Fatigue Dizziness/Balance problems Visual disturbance/Light sensitivity Ringing in ears Slowed thinking Difficulty finding words Poor concentration Memory problems Anxiety/Depression Irritability/Mood swings “Medically Ready Force…Ready Medical Force”

The Impact of Concussion Concussion symptoms may decrease a Soldier’s effectiveness and ability to do his/her job and negatively impact the Soldier’s unit “Medically Ready Force…Ready Medical Force”

Short Term Impact of Concussion Symptoms Symptoms Headache Sleep disturbance Fatigue Dizziness / balance problems Visual disturbance and light sensitivity Ringing in ears Slowed thinking Difficulty finding words Poor concentration Memory problems Anxiety / depression Irritability / mood swings Manifestation Manifestation Failure to sleep at night Decreased energy Slower reaction time Difficulty negotiating uneven terrain Easily distracted Difficulty processing multiple sources of information Interpersonal problems Impact Impact Poor marksmanship Decreased situational awareness Difficulty performing quickly under time pressures Difficulty multi-tasking: such as driving a vehicle while listening to instructions via radio Performance difficulties that can affect self-esteem and confidence Fear of performing in certain operational environments “Medically Ready Force…Ready Medical Force”

As a Result Soldiers May Experience . . . Difficulty sleeping at night Decreased energy and alertness Reduced work performance Trouble multi-tasking Easily distracted Difficulty processing multiple sources of information Interpersonal problems “Medically Ready Force…Ready Medical Force”

Knowledge Check 2 Which of the following is not one of the impacts of untreated and undiagnosed concussion? Decreased Soldier performance Enhanced teamwork Compromised unit safety Reduced unit readiness

Knowledge Check 2 (answer) Which of the following is not one of the impacts of untreated and undiagnosed concussion? Decreased Soldier performance Enhanced teamwork Compromised unit safety Reduced unit readiness

Common Causes of Concussion Being near a blast Multiple Causes Falls resulting in a head injury Blow to the head during sports or combatives Vehicle Accident “Medically Ready Force…Ready Medical Force”

Concussion Treatment and Recovery The majority of Soldiers can expect a full recovery with symptoms resolving within hours to days Full recovery is expected with multiple concussions. However, recovery may take longer Cornerstones of recovery: Patient education: emphasize recovery Physical & mental rest Treat symptoms “Medically Ready Force…Ready Medical Force”

Approaches to Recovery Rest HELPS Recovery Body- Keep heart rate low Stay out of heat Limit physical activity Mind- Allow downtime during the day Allow adequate sleep at night Exertion HURTS Recovery Body- Working Heavy lifting Alcohol use Prevent another concussion Mind- Intensive writing Intensive concentration Playing video games Inadequate sleep Caffeine “Medically Ready Force…Ready Medical Force”

Impact of Multiple Concussions Symptoms may be more severe with each additional concussion and they may take longer to resolve Theater Medical Management requires a longer rest period after 2 concussions (minimum 7 days) and a more in-depth evaluation for those who have sustained 3 or more concussions in 12 months Leaders need to take steps to prevent a second concussion during recovery No combatives, sports, etc. until cleared by medical “Medically Ready Force…Ready Medical Force”

Knowledge Check 3 The key approaches to concussion treatment and recovery require the Care Provider to consider (check all that apply) that concussion patients need physical and mental rest that symptoms maybe more severe with each additional concussion that service Members with concussion must be cleared by medical providers before returning to duty that service members experiencing symptoms of concussion can wait up to 12 hours before getting checked out.

Knowledge Check 3 (answer) The key approaches to concussion treatment and recovery require the Care Provider to consider (check all that apply) that concussion patients need physical and mental rest that symptoms maybe more severe with each additional concussion that service Members with concussion must be cleared by medical providers before returning to duty that service members experiencing symptoms of concussion can wait up to 12 hours before getting checked out.

Concussion in a Garrison Setting Soldiers are at elevated risk for concussion both in Garrison and Deployed environments They lead active lifestyles both at home and in the workplace Training activities such as combatives, contact sports, and operational exercises may increase risk for concussion “Medically Ready Force…Ready Medical Force”

Highlights from the DTM for Deploying Leaders Event driven protocols: Exposure to potentially concussive events require mandatory medical evaluation and 24-hour rest period (downtime) All sports and activities with risk of concussion are prohibited until medically cleared Minimum 7 day mandatory rest period (down time) for Soldiers sustaining a second concussion within 12 months In depth medical evaluation required for any Soldier sustaining multiple concussions (3 or more) within 12 months Shared responsibilities between medical and line “Medically Ready Force…Ready Medical Force”

“Mandatory Events” defined in DTM 09-033 Any Service Member in a vehicle associated with a blast event, collision or rollover All within 50 meters of a blast (inside or outside) Anyone who sustains a direct blow to the head Command directed, including (but not limited to) repeated exposures to blasts “Medically Ready Force…Ready Medical Force”

Knowledge Check 4 After a service member is exposed to a potential concussive event, all of the following required actions must take place except? Leadership should refrain from acting, allowing the soldier to self-evaluate Line leaders must report the incident and circumstances All leadership must evaluate the service member’s medical examination All leadership should utilize medical algorithms to better understand the service member’s condition

Knowledge Check 4 (answer) After a service member is exposed to a potential concussive event, all of the following required actions must take place except? Leadership should refrain from acting, allowing the soldier to self-evaluate Line leaders must report the incident and circumstances All leadership must evaluate the service member’s medical examination All leadership should utilize medical algorithms to better understand the service member’s condition

Required Actions Following a Mandatory Event Leadership Actions Screen: Injury Evaluation Distance (IED) Safety net to ensure “eyes-on” all Soldiers It does not replace the medical evaluation Enforce: 24-hour mandatory rest Unit/Leader Actions Report: SIGACTs Combined Information Data Network Exchange (CIDNE) Blast Exposure and Concussion Incident Report (BECIR) Medical Actions Evaluate: Medical examination Utilize medical algorthms Report: Screening and treatment encounters Enter note into electronic medical record (EMR) “Medically Ready Force…Ready Medical Force”

Required Actions Following a Mandatory Event (con’t) Leadership Actions Screen: Injury Evaluation Distance (IED) Safety net to ensure “eyes-on” all Soldiers It does not replace the medical evaluation Enforce: 24-hour mandatory rest Unit/Leader Actions Report: SIGACTs Combined Information Data Network Exchange (CIDNE) Blast Exposure and Concussion Incident Report (BECIR) Medical Actions Evaluate: Medical examination Utilize medical algorthms Report: Screening and treatment encounters Enter note into electronic medical record (EMR) “Medically Ready Force…Ready Medical Force”

Leadership Assessment (part 1) Commanders are required to report on all Soldiers involved in a mandatory event using the I.E.D. and H.E.A.D.S. checklist Can also be used to assess Soldiers without apparent injury and who were not exposed to a mandatory event Use three-step assessment process 1. Injury ( Yes or No) Is there physical damage to SM body or body part? “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Training Requirement This training deck is intended for Primary Care Providers & Health Care Providers …and satisfies the following: Department of Defense Instruction (DoDI) 6490.11 (Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting) NAVMED Policy 11-004 (Navy Medicine Training Requirements for Health Care Professionals in Traumatic Brain Injury) MARADMIN 294/12 (Marine Corps Traumatic Brain Injury Program) “Medically Ready Force…Ready Medical Force”

Leadership Assessment (Part 2) 2. Evaluation: H.E.A.D.S (Yes/No) H – Headache and/or vomiting E – Ears ringing A – Amnesia and/or Alteration of consciousness/Loss of Consciousness D – Double vision and/or dizziness S – Something feels wrong or is not right “Medically Ready Force…Ready Medical Force”

Leadership Assessment ( Part 3) 3. Distance Was SM within 50M of blast? (Y/N) Record the distance from blast for ALL SM “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” H.E.A.D.S acronym Encourage Soldiers to remember the HEADS acronym This does not replace medical evaluation Soldiers need to see medical immediately to assess for concussion E-mail info@dvbic.org to order HEADS cards for your Deploying Soldiers Consider mandating that Soldiers carry their HEADS card or validating that they know the symptoms of concussion/mTBI “Medically Ready Force…Ready Medical Force”

Knowledge Check 5 According to this training, the Leadership Assessment is: Leadership concussion reporting requirements Guidelines for returning to duty after a concussion The I.E.D and H.E.A.D.S checklist that commanders are required to use to report concussion events Key point for how to diagnose a concussion

Knowledge Check 5 (answer) According to this training, the Leadership Assessment is: Leadership concussion reporting requirements Guidelines for returning to duty after a concussion The I.E.D and H.E.A.D.S checklist that commanders are required to use to report concussion events Key point for how to diagnose a concussion

Commander/Leader Reporting Requirements (CENTCOM FRAGO 09-1656) Monthly reports to CENTCOM will contain at a minimum the following data: Date of Blast/Mandatory Event Unit Type of Mandatory Event triggering evaluation Results of I.E.D Leader Screening (Yes/No for each part, plus distance from blast) SIGACT number (if applicable) 24 Hour rest period waved by commander (Y/N) Service (Navy, Air Force, Marine) Combatant Command in which event occurred Social Security Number / Name Disposition of any mandated medical evaluation (RTD after 24hrs) “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Returning to Duty The medical provider will advise when it is safe for your soldiers to return to duty Theater medical protocols may require exertional testing Testing procedures are similar to those used for professional athletes for usual return to playing The majority of symptoms resolve with proper treatment “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Key Points for Leaders Concussion /mTBI continues to be a major military concern with operational impact Over 15,000 Soldiers were diagnosed with concussion/mTBI in 2010 and over 87,000 total since 2000 Early detection, leading to appropriate treatment, is the cornerstone for successful recovery Soldiers need to get checked medical evaluation as soon as possible after the injury Avoidance of a second concussion before adequate recovery is key to preventing a more serious injury After a concussion, Soldiers need both physical and mental rest to allow the brain to heal “Medically Ready Force…Ready Medical Force”

Concussion/mTBi Tools These items are free upon request Contact the Defense and Veterans Brain Injury Center (DVBIC) dvbic.dcoe.mil OR info@dvbic.org “Medically Ready Force…Ready Medical Force”

Questions/Discussion TBI POCs: Medical Director: Rank, Name, (mobile phone/text) email TBI Director: Name, (mobile phone/text) email “Medically Ready Force…Ready Medical Force”