TBI in Returning Veterans: TBI in Returning Veterans: DoD/VHA System of Care for DoD/VHA System of Care for

Comprehensive TreatmentComprehensive Treatment

Rodney D. Vanderploeg, Ph.D., ABPPRodney D. Vanderploeg, Ph.D., ABPP--CNCNTampa VAMCTampa VAMC

Louis French, Psy.D.Louis French, Psy.D.WRAMCWRAMC

Key Iraq wound: Brain traumaBy Gregg Zoroya, USA TODAY A growing number of U.S. troops whose body armor helped them survive bomb and rocket attacks are suffering brain damage as a result of the blasts. It's a type of injury some military doctors say has become the signature wound of the Iraq war.

Shaun Radhay , a Marine, suffered brain damage and other injuries in a mortar blast.

By H. Darr Beiser, USA TODAY

American Congress of Rehabilitation American Congress of Rehabilitation Medicine Criteria for Mild TBIMedicine Criteria for Mild TBI

Traumatically induce physiologic disruption of brain Traumatically induce physiologic disruption of brain function, indicated by at least one of the following:function, indicated by at least one of the following:

Any period of loss of consciousnessAny period of loss of consciousnessAny loss of memory for events immediately before or Any loss of memory for events immediately before or after the accidentafter the accidentAny alteration in mental state at the time of the accidentAny alteration in mental state at the time of the accidentFocal neurologic deficits that may or may not be Focal neurologic deficits that may or may not be transient transient

Severity of the injury does not exceed: Severity of the injury does not exceed: Loss of consciousness of 30 minLoss of consciousness of 30 minGCS score of 13GCS score of 13--15 after 30 min15 after 30 minPosttraumatic amnesia of 24 hr Posttraumatic amnesia of 24 hr

Criteria for Severity of TBICriteria for Severity of TBI

PTA > 7daysPTA > 7daysPTA PTA << 7days7daysPTA PTA << 24hr24hr

GCS 3GCS 3--88GCS 9GCS 9--1212GCS 13GCS 13--1515

LOC > 6 hours LOC > 6 hours withwithabnormal CT abnormal CT &/or MRI&/or MRI

LOC LOC << 6 6 hours withhours withabnormal CT abnormal CT &/or MRI&/or MRI

LOC LOC << 30 min 30 min with with normal CT &/or normal CT &/or MRIMRI

SevereModerateMild

Severe Brain Injury Severe Brain Injury

Consequences of TBIConsequences of TBI

CognitiveCognitiveAttentionAttentionInformation processing Information processing (speed & efficiency)(speed & efficiency)

Memory and LearningMemory and LearningExecutive FunctionsExecutive Functions•• Problem solving, planning, Problem solving, planning,

insight/awareness, set shifting, sequencinginsight/awareness, set shifting, sequencing

Consequences of TBIConsequences of TBIBehavioralBehavioral--emotionalemotional

Affect Regulation: apathy, agitation, Affect Regulation: apathy, agitation, aggressionaggressionIrritabilityIrritabilityImpulsivityImpulsivityDepression, AnxietyDepression, AnxietySocial PragmaticsSocial Pragmatics

Cognitive and behavioral impairments Cognitive and behavioral impairments are the most disabling longare the most disabling long--term, more term, more so than physical injuriesso than physical injuries

Treatment ConsiderationsTreatment Considerations

Treatment varies based upon:Treatment varies based upon:Severity of injurySeverity of injuryTime since injuryTime since injuryConstellation of impairmentsConstellation of impairments

Wall of Air (Primary) Blast Wave (Primary)

Flying Debris(Secondary)

Displacement (Tertiary)

Collapse Building (Quaternary)

IEDIED’’s are theWeapon of Choice: s are theWeapon of Choice: OneOne Explosion/Blast has Explosion/Blast has

MultipleMultiple Mechanisms of InjuryMechanisms of Injury

TBI in Combat SettingsTBI in Combat Settings

New mechanism of injuryNew mechanism of injury

New constellation of injuriesNew constellation of injuries

New challenges for TBI rehabilitationNew challenges for TBI rehabilitation

Requires new expertise and new Requires new expertise and new model of caremodel of care

WRAMC Patients WRAMC Patients (1/2003 (1/2003 -- 4/2005)4/2005)

Patients with severe enough injuries Patients with severe enough injuries toto be evacuated be evacuated fromfrom the military the military theatertheaterBlastBlast--Related injury most common = Related injury most common = 68%68%Of all blast patients screened, Of all blast patients screened, 59%59% had head had head injuryinjury89% had closed head injury89% had closed head injury

Severity: Severity: 56.3%56.3% modmod--severe; severe; 43.7%43.7% mildmild

PainPain 95%95%BrainBrain 77%77%WoundsWounds 65%65%Ortho Ortho 46%46%Nerve Nerve 38%38%PsychiatricPsychiatric 35%35%VisualVisual 31%31%LungLung 31%31%IInfectionsnfections 27%27%HearingHearing 15%15%AmputeeAmputee 12%12%

War Injured Patients: War Injured Patients: Multiple Impairments (Tampa VAMC data)Multiple Impairments (Tampa VAMC data)

Average of Six Impairments

Level V MTFWRAMCNMMCBAMC

Level I – First AidLevel II ForwardSurgical team

Level III CSHLevel IV Landstuhl

Military EvacuationMilitary EvacuationInternational TrackingInternational Tracking

DoD Levels of CareDoD Levels of Care

Level ILevel I –– Basic Level of Care (First Aid; medic)Basic Level of Care (First Aid; medic)Level IILevel II –– At least one Emergency MedicineAt least one Emergency Medicine--trained physician and the basic equipment that trained physician and the basic equipment that allows the patients to be treated according to allows the patients to be treated according to standards of practice found in most CONUS standards of practice found in most CONUS Emergency Departments Emergency Departments Level IIILevel III –– That plus neuroimaging and specialty That plus neuroimaging and specialty evaluation (neurosurgery and neurology) evaluation (neurosurgery and neurology) Level IVLevel IV –– Major Medical Center with all trauma Major Medical Center with all trauma and specialty care LRMC (in this conflict)and specialty care LRMC (in this conflict)

VHA - Polytrauma System of Rehabilitation Care

VHA VHA -- Polytrauma System of Polytrauma System of Rehabilitation CareRehabilitation Care

A New Kind of Care in a New Era of Causalities

VHA Polytrauma: DefinitionVHA Polytrauma: Definition

Trauma to several body areas or Trauma to several body areas or organ systemsorgan systems

Occur at the same timeOccur at the same time

One or more is life threateningOne or more is life threatening

Polytrauma Centers (4)

Polytrauma Networks (22)

Polytrauma Support Clinics (76)

Polytrauma Case Management

Goal: Get HomeGoal: Get Home

Polytrauma Rehabilitation System of CarePolytrauma Rehabilitation System of Care(National Tracking)(National Tracking)

^

^^

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Palo Alto

1919 2323

1818

1616

2020

77

99

1515

66

2121

1717

11

2222

88

441111

221212

1010 55

33

Tampa

Minneapolis

Richmond

Four Polytrauma Rehabilitation CentersMinneapolis

Richmond

Tampa

Pal AltoVISN Boundary

Network of CareEasternSouthernMidwestWestern

^ Lead Center

VISN BoundaryNetwork of Care

EasternSouthernMidwestWestern

^ Lead Center

VHA Polytrauma Rehabilitation Centers VHA Polytrauma Rehabilitation Centers (PRCs) Level I(PRCs) Level I

““Brain Injury PlusBrain Injury Plus””

Brain injury drives the care processBrain injury drives the care process

Integrate care for complex polytrauma in single Integrate care for complex polytrauma in single location location ---- simultaneous tx of multiple injuriessimultaneous tx of multiple injuries

Higher level of medical acuityHigher level of medical acuity

Sequence and integrate treatment to meet Sequence and integrate treatment to meet patient needpatient need

Coordinated team effort with expanded team of Coordinated team effort with expanded team of consultantsconsultants

Interdisciplinary Team and Interdisciplinary Team and Interdisciplinary Rehab ApproachInterdisciplinary Rehab Approach

Rehab Medicine physicianRehab Medicine physicianRehab nurses (primary nurse model)Rehab nurses (primary nurse model)Rehabilitation PsychologistsRehabilitation PsychologistsNeuropsychologistsNeuropsychologistsPhysical, Occupational, Recreational, and Physical, Occupational, Recreational, and Vocational TherapistsVocational TherapistsSpeech TherapistsSpeech TherapistsSocial WorkersSocial WorkersCase Managers (including longCase Managers (including long--term)term)

Extensive Team of ConsultantsExtensive Team of ConsultantsAnesthesiologyAnesthesiologyAudiologyAudiologyChaplin ServicesChaplin ServicesDentistryDentistryDriver RehabilitationDriver RehabilitationGastroenterologyGastroenterologyGeneral SurgeryGeneral SurgeryInfectious DiseaseInfectious DiseaseMedicineMedicineNeurologyNeurologyNeuroNeuro--ophthalmologyophthalmologyNeurosurgeryNeurosurgeryNutritionistNutritionist

OptometryOptometryOral and Maxillofacial Oral and Maxillofacial SurgerySurgeryOrthopedicsOrthopedicsOrthoticsOrthoticsOtolaryngologyOtolaryngologyPharmacyPharmacyPlastic SurgeryPlastic SurgeryProstheticsProstheticsPsychiatryPsychiatryPulmonologyPulmonologyRadiologyRadiologyUrologyUrologyVocational SpecialistVocational Specialist

Inpatient Acute RehabilitationInpatient Acute Rehabilitation

33--5 hours of therapies per day (OT, PT, 5 hours of therapies per day (OT, PT, SP, Recreational, Psychology)SP, Recreational, Psychology)Average length of stay 1Average length of stay 1--3 months3 monthsTherapies include community outings Therapies include community outings planned and organized by the TBI patients planned and organized by the TBI patients together with the therapiststogether with the therapistsCase management begins before patients Case management begins before patients arrive and includes contacting familiesarrive and includes contacting familiesCase management continues following Case management continues following discharge, may last for yearsdischarge, may last for years

Other Lead TBI Center ProgramsOther Lead TBI Center Programs

Emerging Consciousness ProgramEmerging Consciousness Program: : For those with acute coma, NOT longFor those with acute coma, NOT long--term coma or vegetative state careterm coma or vegetative state careShortShort--stay admissionsstay admissions for:for:

Evaluation and treatment planningEvaluation and treatment planningTreatment trialsTreatment trialsVocational evaluations Vocational evaluations

Respite CareRespite Care upon occasionupon occasion

Other Lead TBI Center Programs Other Lead TBI Center Programs (cont.)(cont.)

New ProgramNew Program beginning July/August 2007beginning July/August 2007

Transitional Residential ProgramsTransitional Residential Programs6 6 –– 12 month program12 month programResidentialResidentialCommunity reCommunity re--entry program / servicesentry program / servicesCompensated Work TherapyCompensated Work TherapyWork trialsWork trials

Polytrauma Network Sites: Level IIPolytrauma Network Sites: Level II(Outpatient)(Outpatient)

Screen every returning Iraq or Afghanistan Screen every returning Iraq or Afghanistan veteran who seeks care in the VA for TBIveteran who seeks care in the VA for TBIEvaluate and treat on an outpatient basis mild Evaluate and treat on an outpatient basis mild TBI (or postTBI (or post--acute moderate/severe TBI)acute moderate/severe TBI)Refer any appropriate patient to the nearest PRC Refer any appropriate patient to the nearest PRC for specialized care, if neededfor specialized care, if neededDevelop innovative outpatient programs (e.g., Develop innovative outpatient programs (e.g., Day Treatment programs, Community ReDay Treatment programs, Community Re--entry entry programs)programs)Work with PRCs to provide Community ReWork with PRCs to provide Community Re--entry entry services to veterans discharged from PRCs to services to veterans discharged from PRCs to their catchment areatheir catchment areaAssist with ongoing Case ManagementAssist with ongoing Case Management

Polytrauma Support Clinical Polytrauma Support Clinical Teams: Level III (Outpatient)Teams: Level III (Outpatient)

Screen every returning Iraq or Afghanistan Screen every returning Iraq or Afghanistan veteran who seeks care in the VA for TBIveteran who seeks care in the VA for TBIEvaluate and triage (treat) TBI patients to Evaluate and triage (treat) TBI patients to appropriate local programsappropriate local programsRefer any appropriate patient to the nearest Refer any appropriate patient to the nearest PNS or PRC for specialized care, if neededPNS or PRC for specialized care, if neededWork with PRCs and PNSs to facilitate Work with PRCs and PNSs to facilitate Community ReCommunity Re--entry to veterans in their entry to veterans in their catchment areacatchment areaServe as a local resource for ongoing TBI case Serve as a local resource for ongoing TBI case managementmanagement

Family SupportFamily SupportCase ManagementCase ManagementBenefits ManagementBenefits Management

Polytrauma Rehabilitation Polytrauma Rehabilitation Lifetime Continuum of CareLifetime Continuum of Care

---- Supported Supported LivingLiving

---- VocationalVocational---- EducationalEducational---- Day ActivitiesDay Activities---- Support Support

GroupsGroups---- Outpatient Outpatient

followfollow--upup

Transitional/Community Transitional/Community ReRe--entry entry -- ResidentialResidential

Transitional/CommunityTransitional/CommunityReRe--entry entry -- Day ProgramDay Program

OutpatientOutpatient

---- InpatientInpatientAcuteAcute

---- InpatientInpatientemerging emerging consciousness consciousness

---- Inpatient Inpatient SubacuteSubacute

SurgicalSurgical

MedicalMedical

Acute TraumaAcute Traumacarecare

AcuteAcuteRehabilitationRehabilitation

Post AcutePost AcuteRehabilitationRehabilitation

LifetimeLifetimeCommunityCommunity

CareCare

DoD VHA VHDoD VHA VHA VHAA VHA