VA-Milwaukee Polytrauma/TBI Presentation
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Transcript of VA-Milwaukee Polytrauma/TBI Presentation
Polytrauma Support
Clinic Team
Polytrauma and Traumatic Brain Injuries
Zablocki VA Medical Center
Milwaukee, Wisconsin
August 19, 2010
Objectives
• To introduce the VHA Polytrauma System of
Care
• To learn about combat related Polytrauma and
Traumatic Brain Injury conditions
• To appreciate the complexities of diagnosis
and management of post deployment health
and reintegration issues facing returning
soldiers and families
Polytrauma Injuries and TBI
Evaluation: Milwaukee
Polytrauma Support Clinic Team
Judith B. Kosasih, M.D.
Director, Polytrauma Support Clinic Team,
Zablocki VAMC
Associate Professor, PM&R,
Medical College of Wisconsin
“To Care For Him Who Shall Have
Borne the Battle, And For His Widow
and Orphan”
- Abraham Lincoln
How close does a soldier have to be to
a blast to cause an injury?
The answer is that we don’t know……
Background • New war, new injuries, new generation of veterans, new
system of care
• 90% of soldiers injured in combat are surviving
• Blast exposure has become the most frequent cause of combat related injury
• TBI is often referred to as the ―signature injury of the war‖
• Many of those returning from current combats had IED/blasts events, that put them AT RISK for TBI
• Symptoms of mild TBI may be difficult to recognize, or confused with other overlapping conditions
Implementation of the VA
Polytrauma System of Care
February 05: Four Polytrauma Rehabilitation Centers
December 05: 22 Polytrauma Network Sites
March 07:
80 Polytrauma Support Clinic Teams,
50 Polytrauma Points of Contact
1992: VHA TBI Lead Centers Selected
July 06: Polytrauma Telehealth Network
April 07: TBI Screening
VISN 12 Polytrauma System of Care
• Regional Polytrauma Rehabilitation Center – Minneapolis VAMC (Component I)
• VISN 12 Polytrauma Network Site (PNS) – Hines VAH (Component II)
• VISN 12 Polytrauma Support Clinic (Component III)
– Milwaukee VAMC
– Madison VAH
– Jesse Brown VAMC
– North Chicago VAMC
– Tomah VAMC
• VISN 12 Polytrauma Point of Contact – Iron Mountain VAMC (Component IV)
Polytrauma Support Clinic Team
VISN 12: Zablocki VA Medical Center
• Director: Judith Kosasih, MD, Physiatrist
• Neuropsychologist: Thomas Hammeke, Ph.D.
• Point of Contact: Jennifer Kiefer, MSW
• Nurse Practitioner: Susan Giulianetti, APN, BC
• Physiatrist: Merle Orr, MD
• Psychologist: Peter Graskamp, PhD
• Speech Pathologist: Terilynn Nitschke, MS-CCC
• Physical Therapist: Jennifer Batie Mueller, P.T.
• Occupational Therapist: Mary Van Derven, OTR
TBI initiatives • VHA Directive 2007-013
• Policy and procedure for screening and evaluation of possible Traumatic Brain Injury in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans
• TBI Screening Clinical Reminder • Activated April 2, 2007
• TBI Performance Measures • To ensure that all returning soldiers presenting for
care at a VA facility are screened and evaluated for possible TBI
• TBI National Database/Tracking System • Activated June 2008
426,413 Total OEF/OIF Veterans Screened
79,754
21,292
Veterans Consenting to Further Evaluation (94.9%)
Mandatory TBI Screening Results
14 April 2007 – 31 May 2010
84,008
12,583
Veterans Requiring Further Evaluation (19.7%)
Veterans with Self Reported Prior TBI (3.0%)
TBI Confirmed (54.7%)
TBI Ruled Out Diagnosis Pending
58,781 Veterans Completed Comprehensive Evaluation (73.7%)
32,148
26,391
242
Sources of TBI During Combat
• Blast Injuries—Limited or no physical signs
– Improvised Explosive Devices (IED), Rocket
Propelled Grenades (RPG) , Mortars
• Impact Injuries-Physical injuries noted
– MVC, Bullets, Falls/Accidents
• Each incident can potentially cause multiple
system injuries.
POLYTRAUMA
• Defined as:
– ―two or more injuries to physical regions or
organ systems, one of which may be life
threatening, resulting in physical, cognitive,
psychological, or psychosocial impairments
and functional disability.‖
• Blast injuries are often polytraumatic,
given the various mechanism of injury
POLYTRAUMA
• Multi-Dimensional injuries, unique in this population.
• TBI frequently occurs in polytrauma combat injuries in combination with other disabling conditions such as: – Amputation
– Auditory and visual impairments
– Nerve injuries, burns, musculoskeletal, complex fractures
– Chronic pain
– Spinal Cord Injury
– PTSD (Post Traumatic Stress Disorder) and other mental health conditions.
Post-Deployment Syndrome
• 5-20% OEF-OIF Service members are returning with
persistent physical and psychological symptoms after
combat exposure.
• Controversies concerning etiology of symptoms
– Blast exposure
– Post-concussive syndrome
– Post-traumatic stress disorder
– Depression
– P3+ (PTSD, Polytrauma, Polysubstance Use, Pain)
– Environmental factors
– Impact of multiple exposures (blast, trauma)
POLYTRAUMA CLINIC
• The setting for comprehensive TBI evaluation and other polytrauma issues.
• Team approach, directed by PM&R physicians.
• Interdisciplinary PSCT team: Physiatrist, Neuropsychologist, Social Worker, Nurse Practitioner, Psychologist, Physical Therapist, Occupational Therapist, Speech and Language Pathologist.
TBI/Polytrauma Evaluation • DIAGNOSIS: mild TBI = Concussion
– Determine if TBI occurred
– Evaluate symptoms and determine, if possible, the etiology of residual symptoms (TBI, mental health, or combination)
– Describe the functional impairments
• Evaluate other Polytrauma injuries
• Specialty Consults: Mental Health, Neurology, Eye/Optometry, Audiology, Visual Impaired Service, Electrodiagnosis, ENT, Orthopedic, Plastic, etc.
• Integration and coordination of treatments and resources.
Comprehensive Evaluation
• Physical problems
• Cognitive deficits
• Emotional/behavioral issues
• Community reintegration • Money management
• Employment
• School/Academic
• Recreational activities
• Family/Significant Other
• Social interaction
• Psychosocial complexity
Diagnostic Challenges
• Reliance on self-report history; limited supporting documentation and baseline clinical information
• Non-specific diagnostic criteria, normal imaging, normal neurological exam
• Often difficult to confirm/make a mTBI diagnosis
What causes the prolonged symptoms
reported by many soldiers
– Overlapping symptoms: symptoms may
be due to multiple sources
• Due to mTBI only
• Due to mTBI and adjustment stress
• Due to mTBI and PTSD or depression
• Due to premorbid difficulities
–Started prior to military; possibly
exacerbated by the combat duty
Sources of Sustained Residuals • Severity, multiple incidence, and mechanism of
TBI
• PTSD
• Prior history of psychiatric distress (depression/anxiety)
• Military onset of psychiatric distress
• Drug use (especially cocaine and marijuana)
• Alcohol abuse
• Previous brain/head injury
• Previous childhood learning conditions (LD, AD/HD)
• Chronic and/or acute pain
Potential Clinical Presentation
Attentional
problems
Depression
Flashbacks
Nightmares
Anxiety
PTSD
Dizziness
TBI
Headaches
Irritability
Insomnia
PTSD
N=232
68.2% 2.9%
16.5%
42.1%
6.8%
5.3%
10.3%
12.6%
TBI
N=227
66.8%
Chronic
Pain
N=277
81.5%
Prevalence of Chronic Pain, PTSD and TBI
in a PNS clinic sample
Lew et al., (2009). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-
concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. Journal of
Rehabilitation Research and Development, 46, 697-702.
N = 340
PTSD Re-experiencing
Avoidance
Social withdrawal
Memory gaps
Apathy
Mild TBI Residua
Difficulty with decisions
Mental slowness
Concentration
Headaches
Dizzy
Appetite changes
Fatigue
Sadness
Suicidality
Altered Arousal
Sensitive to noise
Concentration
Insomnia
Irritability
Depression
Substance
Use (Poly)
Pain
Medication effects
Pain
PTSD
Mild TBI
Depression
Anxiety
Pain
Substance Use Disorder
Physical Injuries
Deployment Stress &
Post-Deployment
Re-Adjustment
Who are the OEF/OIF patients?
29
Blast Exposure
TBI
Depression
PTSD
Marital Stress
Medical Diagnosis Impairment in Function and
Social Reintegration
Musculoskeletal
Pain
Deficits in
Social Role
Functioning
Vocational
Challenges Financial
Stress
So what can be done to ameliorate symptoms
and encourage successful reintegration in
soldiers
Early Identification & Intervention Education of Expected Recovery Proactive Reintegration Efforts
Early Identification
• DOD – Field evaluations
– Military Treatment Facilities
• DOD and VA Liaisons
• VA
– TBI screening
– Polytrauma/TBI system of care
• Private Sector collaboration
Early Intervention
• Value of Early Intervention
– Improves short and long term outcomes
– Education/positive reassurance
– Symptoms treatment: analgesics, antidepressants, sleeping aid/sleep hygiene, psychological intervention
– Cognitive remediation/compensatory strategies
– Care coordination/Case management
– Close follow-up/monitor progress: symptoms, life/job performance
Education of Expected Recovery
• Post Traumatic Growth:
– ―… emphasizing the potential for FULL RECOVERY
may minimize the unnecessary attribution of common
stress reactions to pathology and facilitate resilience
after mild TBI.‖
– Richard A. Bryant, PhD
PTSD specialist, University of New South Wales,
Australia
---Tom Valeo, Neurology Today, March 20, 2008
Proactive Reintegration Efforts
• Community Reintegration: • Vocational Rehabilitation
• Work Hardening program
• Recreation/Exercise, Recreation Therapist
• Psychosocial/Family support and resources
• Adaptive equipments: PDAs, recorders, etc.
• Active duty/reserve: • Redeployment/return to combat
Resources • Women’s Health Clinic: female focused
treatment in women’s clinic – Wellness Fair for women’s veterans
• OEF/OIF Connection Team (Outreach)
• Homeless Veteran program – HUD/VASH: Housing & Urban Development/VA
Supportive Housing Program
• Caregiver Support Program
Initiatives/Resources
• VA initiatives: – Staff Education and Communication
• Conferences, Teleconference calls, Live meetings
• VHI: TBI Independent Study Course: April 2010
– Patient Education • Study skills group, Sleep education group,
Pain school
• Family support: children/spouse education materials
– Innovative treatments • Heart Math biofeedback
• Battle –body retraining: relaxation training (Yoga)
• Wii games
– Telehealth rehabilitation
37
RECOVERY CONTINUUM
RESILIENCE CONTINUUM
Medical
Physical
Social
Mental
Occupational
Cognitive
Rehabilitation
Future Directions • Research opportunities:
– Blast related conditions: diagnostic imaging, pathophysiology, etc.
– Polytrauma Pain
– Post traumatic headaches
– Sensory: Visual and hearing issues
– Advances in prosthetic devices
– Telehealth Rehabilitation initiatives
• Local:
– Zablocki VAMC Advanced Low Vision Outpatient Clinic
• National:
– New: VHA Interprofessional Polytrauma/TBI Rehabilitation Clinical Fellowship
– New: VHA Amputation System of Care
– VHA PM&R Transitional Rehabilitation (PMRTR) program
– VHA TBI Specific Ocular Health and Visual Functioning Examinations for Polytrauma Rehabilitation Center Patients
– Post Deployment Care Initiatives
Website resources
• vaww1.va.gov/rehab4veterans (VA PM&RS)
• www.biaw.org (Brain Injury Assoc. of Wisconsin)
• www.neuro.pmr.vcu.edu (National resource
Center for Traumatic Brain Injury)
• www.pdhealth.mil/TBI.asp (Deployment Health
Clinical Center (TBI)
• www.va.gov/health_benefits (VA Benefits)
• www.vetsuccess.gov (Voc Rehab and
Independent Living Services)