1. Our Returning Veterans, Are We Ready?
Brant A. (Bud) Elkind, MS, CBIS-T
Director, Clinical Operations
Robin Hill Farm, Inc.
11/20/2018

2. Traumatic Brain Injury (TBI)
TBI - “An insult to the brain, not of a degenerative or congenital nature but caused by an external force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning” (AACBIS)
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3. Acquired Brain Injury
“An injury to the brain occurring after birth that is not hereditary, congenital or degenerative; does not refer to brain injuries induced by birth trauma” i.e. Stroke/CVA, Anoxia, Disease, Neuro-toxic Poisoning, Metabolic disorders (insulin shock, liver and kidney disease, or trauma (AACBIS)
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4. Brain Injury Range Mild characteristics include:
Loss of consciousness for les than 30 minutes or no loss
Glasgow Coma Scale of 13-15
Post-traumatic amnesia for less than 24 hours
Temporary or permanently altered mental or neurological state with pos-concussive symptoms (AACBIS)
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5. Moderate Brain Injury
Coma more than minutes but less than 24 hours
Glasgow Coma Scale or 9-12
Possible skull fractures with bruising & bleeding
Signs on EEG, CAT or MRI Scans
Some long term problems in one or more areas (AACBIS)
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6. Sever Brain Injury
Coma longer that 24 hours, often lasting day, weeks or longer
Coma scale of 8 or less
Bruising, bleeding in the brain, signs on EEG, CAT or MRI scans
Long term impairment (AACBIS)
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7. TBI In The United States
1.4 million sustain a TBI each year
50,000 die
235,000 are hospitalized
1.1 million ER visits
The number of people who sustain a TBI and do not receive treatment is unknown (BIAUSA)
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8. Leading Causes of TIB’s
Falls 29%
Motor Vehicle Accidents 20% (most are unrestrained)
Stuck by/against 19%
Assaults 11%
Other 13%
Unknown 9% (BIAA)
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9. Long Term Consequences of TBI
Direct and indirect costs of TBI in the US as of 1995 was estimated at $60 Billion
The CDC estimates 5.3 million Americans currently have long term, lifelong need to perform activities of daily living as a result of TBI (BIAA)
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10. Unmet Need for Services One Year After Injury
Improving memory and problem solving
Managing stress and emotions
Controlling one’s temper
Improving one’s job skills (CDC)
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11. The Wide Range of Functional Change
Thinking, language, learning, emotions, behavior and or sensation
TBI can also cause epilepsy, increase the potential for Alzheimer’s and Parkinson’s and other brain disorders that become more prevalent with age (CDC)
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12. OIF – OEF STATISTICS
Approximately 1.6 million troops have to date been deployed to Afghanistan and Iraq
300,000 are estimated to have affected by Traumatic Brain Injury (TBI) and or Post Traumatic Stress Disorder (PTSD)
64% of all wounded are estimated to have sustained “Blast Injuries”
47% of all blast injuries affect the head (NABIS)
11/20/2018

13. Anatomy of a Blast Injury
Instantaneous pressure wave with a rise and drop in pressure
Results in cavitation occurring at the molecular level ((brain, inner ear, eyes, gastrointestinal tract, lungs and spinal fluid structures are liquefied)
Over-pressurization wave dissipates instantaneously creating a vacuum
Impact may also energize shrapnel, may exhaust gases and vapors that burn lung tissue and flesh (Wikipedia)
11/20/2018

14. What We Expect to See as Our Veterans Return Home
The most severely injured continue to remain in Poly Trauma Hospitals
Those returning with mild brain injuries pose a significant public health concern
They will return with high expectations to their homes, families, jobs and communities
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15. Why there is Reason for Concern
Many will return healthy
Others will return, unaware of their brain injury (Agnosia, an inability to see their deficits) (D&VBIC)
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16. What we will see! Difficulty with: Thinking Receptive - Expressive
Short – Long-term memory
Attention – Initiation
Expressive – Receptive
Multi-tasking
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17. What we will see (Continued)
Adverse Behavior (Impulsivity, Disinhibition, Anger Control)
Seizure activity
ETOH – (Alcohol and Substance Abuse)
High-risk behavior
Disorientation
Tinitus and feelings of Isolation (EBIG)
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18. “Contrary to expectations, patients with mild to moderate TBI are actually much more affected by their emotional difficulties than by their physical disability” (Glasser)
Soldiers returning with mild to moderate brain injuries are 3 times more likely to incur a second brain injury and 8 times more likely to incur a third” (CDC)
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19. Systems of Care Poly-trauma Centers (4) Poly-trauma Network Sites (21)
Poly-trauma Support Clinics – VISN (Specialized teams)
Poly-trauma Point of Contact
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20. VA Poly-trauma Rehab System of care
Proactive Case Mgt
Telehealth Network
Long-term follow-up; proactive, specialized
Care for those who cannot care for themselves
11/20/2018

21. So, is the Community Ready
Probably not!
5 Professional Brain Injury Programs in NH representing a Continuum
Facility based
Residential
Home based
11/20/2018

22. Community
To welcome our soldiers with mild brain injury home we must be:
Inclusive not Integrative
Be involved at all levels
Social Service Agencies must understand needs
Physicians and hospitals must be able to appropriately diagnose, medicate and care for people with mild brain injury
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23. Other Community Based resources
OT’s, PT’s, SLP’s and Psych Professionals must be trained in mild brain injury
The community must be knowledgeable in the area of disability rights.
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24. Partnerships The VA cannot do everything
Communities must be willing to include
Support systems must be educated and capable to working with this specialized population
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25. References
American Academy for the Certification of Brain Injury Specialists (AACBIS)
Brain Injury/Professional vol. 4, issue 1, North American Brain Injury Society, “Reintegrating Military Personnel after TBI, Community Integrated Rehabilitation Model in Practice, Trudel, Davanzo, Mattingly, Nideffer & Barth
Brain Injury/Professional vol. 4, issue 1, North American Brain Injury Society, Current Trends in Post Traumatic Stress Disorder & TBI among Military Personnel, Nideffer, Errico and Barth
The Essential Brain injury Guide, Edition 4.0, American Academy for the Certification of Brain Injury Specialists
Blast Injuries, Wikipedia, the Free Encyclopedia, January 2008, NABIS, Blast Injury Institute, Ziejewski, Inz, Karami, Akhatov
Defense Veterans Brain Injury Center
Brain Injury Association of America,
11/20/2018