Tom,

Vets with diagnosed, service-connected conditions are eligible for no-cost VA Medical Care. Objectively, this would be a substantial savings to an employer, no? Therefore, I don't think the issue is the cost of health care?

Moreover, here is verbatim language from the VA re: post-discharge health benefits to all combat-theater veterans:

"lf you are a combat theater veteran who was discharged or released from active duty
after January 28, 2003, you are eligible to receive five years of free VA healthcare and enhanced enrollment priority for any illness or condition possibly related to your combat service beginning on the date of your discharge or release. lf you were discharged or released before January 28, 2003, but never enrolled in VA's health care system, you now have three years of extended eligibility (until January 28, 2011) to enroll to receive this important benefit."

Close-head TBI diagnosis is spotty at best, because the nerve-death cascade takes days and weeks, the common latent sequalae of seizure delays 10-20 years, the damage is diffuse, and the injury often isn't documented on the day of combat, fall or vehicle crash. At the time, maybe it was just a bad army day in a bad year. The blood gets the medic's attention, and nobody wants to admit they are brain injured, not even to themselves.

Does anyone know what happened to the accel-recording kevlar helmets that were mandated and deployed, I think with a 101st brigade, during or prior to the surge. In concert with the pre-testing on laptop software that is supposed to be universal now, an injury event can be recorded with specificity, and the degradation in vision, memory and reflexes compared and used to determine whether '3 hots and a cot' was sufficient treatment for the concussion.

If this sounds like too much neuroscience for the infantry, consider that it comes out of college football sports-medicine. Teams use it to reduce re-injury of brain-bruised 'put me in coach' athletes. An infantryman and his COIN or training sergeant mission is at least as important as a sports team's liability exposure.

Two brigade sets in 2009, six brigade sets in 2010. The Marines are in a different food chain.

http://thetension.blogspot.com/2009/09/us-army-helmet-sensor-program-may-help.html
THURSDAY, SEPTEMBER 3, 2009
US Army: Helmet Sensor Program May Help Decrease Brain Injuries

Agree with IRR Soldier here.

Media and left-leaning "veteran-support" groups are comparing apples and oranges. 10% of the US population (including by definition everyone who currently has a job and people who have had jobs for decades) is out of work, but oh-my-gosh 20% of recent veterans (ONLY people who by definition JUST left their job) are out of work.

How about we compare either
1. the complete US population unemployment rate (10%) with the COMPLETE service member/veteran population (including currently employed by the military like me, and people who left the service decades ago and are currently employed like my brother) unemployment rate (probably 5%)
2. or compare the unemployment rate of American who JUST left (quit/fired/laid off) their job (probably 50%) with service members who JUST left their military job (20%)

In either of the examples above, veteran employment rates are great. And as IRR Soldier notes, a lot of these recent veterans have benefits and are have no intention of immediately going back to work. Of course media will always find and highlight a heart-wrenching example of an unemployed vet, and those examples are emotionally powerful, but intellectually barren.

Thus the comparison of percentage rates of unemployed vets vs. general population is bogus, but the bandy it about unquestioned because it fits into their preconceived narrative: Soldiers are stupid losers anyway, and when they are forced to kill or be kill (we all know every service member has killed lots of people) in the hellish unjustified immoral maelstrom that is Bush's legacy in Iraq and Afghanistan they are damaged just like all those poor suckers from Vietnam.

Oh yeah, I am an Army PAO but this comment has nothing to do with my current duties.

Cycle Doc,

The VA adjudicates post-service disability claims. It's well known that the VA is exceptionally liberal in its rating and interpretation than the DoD. It is not uncommon for folks rated 0% disabled by DoD to get a 30, 40, 50 or higher % disability rating from the VA. I advise any veteran - from any era - to file a claim for VA disability no matter how minor the issue. I filed a claim for an issue that I assumed would garner - at best a 0% disability rating. Guess what, the VA found me 40% disabled. A coworker filed a VA disability claim and was found 50% disabled for kidney stones!

Re: Families. Familes of Veterans who are deemed totally disabled (for behavioral health or physical reasons) are eligible for CHAMPVA. CHAMPVA is essentially the same as TRICARE Standard (the old CHAMPUS).

As you say, both TBI and PTSD are complicated, and often not what they seem, often mis-diagosed bot positively and negatively. One cluster of 'confusers' is that TBI and PTSD share symptoms like impaired memory,attention span and judgement, but the treatment isn't the same. Whether caused by TBI, PTSD, or both, those look a LOT like poor performance and bad attitude.

Your call for more research in both prevention and diagnosis is spot-on. I think Doc Bob Meaders and his Operation Helmet, donating 48,000+ SF-type milspec padding kits for kevlars, deserves a Medal of Freedom. Talk about a no-brainer, sending guys with old helmet suspension rigs out to get bat-whacked by the inside of their own brain-bucket!

I volunteer weekly with (mostly) active duty injured in a sanctioned sports-rehab group. The rehab staff tell us what injuries to allow for, including maybe 50% with some TBI. That may become the primary diagnosis, as bone and muscle recover. The soldiers, marines and sailors that we get are motivated and impressive in how they acquire advanced new skills. A person with TBI (or PTSD) is still himself, able to grow and contribute in ways they never dreamed of before being injured. Some ignore their new limitations and moving on, which can work for them. Others are forced to engage and get help in new compensating skills. Bless them all.

One promising diagnostic initiative was a large-scale test-placement of recording accelerometers, on the helmets of a 101st brigade. This went with pre-testing of cognitive/perception skills, and comparing those personal results with post-concussion performance on the same standard post-test, using a PC.

I'm hoping that someone reading here has knowledge of that research. DoD has played TBI research very close to the vest, and something of a shell game in moving, renaming and handwaving responsibility for medical TBI research and response.

Eric, I would challenge your assertion that TBI is rare. Prior to the current War on IEDs, brain injury was known to be THE MOST COMMON disabling injury type, in civilian males under the age of heart disease onset. Hence the proliferation of helmet laws and regulations. We don't need to get into how blast injuries differ from sports, work and auto-crash brain damage. But we can assume that brain injury will always be a major military disability category, combat and otherwise, until hard data shows otherwise.

The DVBIC (Defense-Veterans Brain Injury Center) research has challenged the 90's assumption that lung and ear puncture will occur before any primary blast brain injury. There is proof that vehicle armor is capable of blast reflection-amplification, and kevlar may 'lens' the blast into the cranium, under certain conditions. There's no question that multiple concussions can occur in a single IED event, as a vehicle is blasted, its ocuppants zapped and caromed inside, followed by external collision and smoke inhallation.

As on the football field, ANY period of unconsiousness is strong evidence of moderate TBI. Repeat at extreme peril. A brain injury, whether avoided, ignored or properly treated, is a million dollar issue. Especially to the vet and his family.

I'm still looking for analysis of the recorded data. Special blessings on the 101st guys that lugged a 6 oz 1st gen. device on their kevlar for a year. ww
--
http://www.defense.gov/news/newsarticle.aspx?id=48590
New Helmet Sensors to Measure Blast Impact
FORT BELVOIR, Va., Jan. 7, 2008 – Soldiers from the 101st Airborne Division preparing to deploy to Afghanistan are being issued sensors that attach to their helmets to measure the impact from blasts, roadside bombs and other activities.
snip>
A longer-term application – one Schaffer emphasized the medical community isn’t yet ready for – is to use impact data to help diagnose traumatic brain injuries.

http://thetension.blogspot.com/2009/09/us-army-helmet-sensor-program-may-help.html
THURSDAY, SEPTEMBER 3, 2009
US Army: Helmet Sensor Program May Help Decrease Brain Injuries
snip>
Metz, who is responsible for combat helmet programs, said the Army plans to procure enough Generation II helmet sensors, beginning in fiscal year 2010, to equip the equivalent of six brigade combat teams - three to support Operation Iraqi Freedom and three to support Operation Enduring Freedom in Afghanistan.

You have to keep in mind that a small percentage of the overall military is engaged in direct combat operations or even combat convoys on a regular basis. Add in the factor that currently over about 10 years of fighting we have suffered a little over 5k dead, in the big picture it is rare for a military vet to have TBI. It may change as the TB use more and more IEDs but then again we are slowing going out of Iraq as well at the same time. I do not know the total number of diagnosed TBI's from combat, but I am willing to bet that when taken as a whole in the military they are small in numbers. We have always had Close Head Injuries (CHIs) and people who get knocked out via a concussion from a Motor Vehicle Accident that pretty much get similar injuries and the way the TBIs from Explosions occur is a bit more difficult to diagnose due to Mechanism of Injury (MOI) and Hx. The Military is not a small group and in the end TBIs, while more frequently diagnosed now are still a small part of our wounded forces, couple that with MDs just diagnosing it as TBIs if the troops were involved in any type of close by explosion and you will see the numbers go up but still, even if 40k for instance were diagnosed with TBI then it would still be pretty rare in the big picture.

The actual diagnosed cases of TBI in the Military from 01-07' were 4471, that is direct from the DoD via BUMED and Army Medical Corps. The Numbers, now let's say they doubled from 08-09' and were at 8,942, or even tripled to 13,413 to 09-10', combined they are still way under a number I threw out at 40k. Concussions are also not TBIs and when you start down the road of a "huge fraction of brigade type troops taken out of the fight. 5,000 KIA's is a defendable number. But it's provided by an organization that is expert and active at undercounting the cost of war. " and this "We now know that many of those, even if returned to temporarily limited duty, were concussions that should have been taken out of the fight, for their own sake, and in some cases for the sake of the mission", how do you know? 5k is a "defendable" number? Do you think really think they are covering up the number of dead too? Also, concussions should be returned to duty if TBI is ruled out, this is a war, not a football game. Honestly, at times you sound more like someone who thinks the DoD is in a giant conspiracy instead of being what it really is, an large, bureaucracy that did not expect the numbers of wounded physically, did not prepare for the numbers of dependents and service members seeking help both medically and psychologically and is reacting slowly but not involved in some sort of crazy conspiracy and you take away a lot from any argument when you might have had when you do that. Also, the military medical community goes overboard now in looking to diagnose for TBI, so much in fact that if they cannot rule it out then they often assume you have it via the Mechanism of Injury (MOI) -ie; a nearby explosion. So please, if you want to have an argument about the slow reaction of the DoD to TBI, fine. If you want to say that TBI is a problem, fine but to act as though it is a common injury and not rare in the military when there are over 2 million people eligible to cycle through the OCO theaters at any one time, then you are wrong. When you imply that the DoD is somehow intentionally undercounting but offer no proof except innuendo, then you are headed in the wrong direction too. Also, who are your "experts" and how good are they when they pick a number that varies from 45k-134k? What do they base it on?
You often sound like a very well informed historian who I am sure could lecture me on matters of military history but on a lot of topics you use innuendo and nefarious motives too often and it seems like you have some dark mis-trust of ANY motives by the Dod or are perhaps stirred easily by stories of tragedy that have hit certain vets? Whatever the reason, it does tend to take away from your point in my view. While I am sympathetic to the plights of vets, the world, nor the DoD will ever be perfect and in my opinion the VA and the DoD have done a pretty good job overall, especially when one considers the sheer numbers of claims they have been swamped with compared to their expectations.

320,000? From TBI? I again have to question the numbers, with so few people who see actual combat, combined with those not alway seeing explosions, 320k seems a far stretch and as someone who has seen the testing we do and as I posted previously, we go overboard and if it cannot be ruled out it is diagnosed and will be over diagnosed. So, 10-20% have suffered a mild concussion? What was the MOI? So, every single time a guy falls down and hits his head he has TBI now? So, that means no more combatives training? No more demo or rocket training since they both have over pressure and cause explosions? So, if an explosion goes off nearby me then I have TBI? All these things need to be factored in and with the large swath of numbers you and others seem to post that is the road we are going down and again, your prior post tended to imply that everyone was hiding something. TSo, what is it? They were hiding things before, now they are not? It was under Diagnosed before but are they still doing it? Doesn't MOI count? Are you saying a concussion is the same and should be treated the same? Are the motives of the DoD good now and not prior? Anyway, the 4700+ TBIs were not BS, those were what was DIAGNOSED as ACTUAL TBI's and people are not in WWII type battles all over the place with large explosions going off 1000 times a day in OEF or OIF around causing thousands of injuries among our troops every day, despite what many on this board seem to think. You need to be realistic, as someone who has had to do the TBI card on folks more than once it is not the "plague" you make it out to be nor the result of some evil conspiracy as you seem to often think.
Do the math on the 1.8 Million vs the 320,000 TBI injuries alone, sorry, it does not cut it with the numbers who see actual combat and as a result TBI will be over diagnosed if anything and do not think FOBITS will not try to collect as well. Sutton and many others are why it is over diagnosed now and any knock on the head, fall, strike, etc...can, for a short time, meet the criteria for TBI but is actually and usually just a that, a concussion, perhaps from diving from cover, a MVA during a Fire Fight, etc...TBI has far deeper problems and effects than a concussion but because they cannot rule it out it seems you and many studies would call it all TBI. Again, I am sympathetic to the plight of vets but I also know how the DoD is slow to react and when it does react it goes overboard, you can see it everyday on BAF or KAF where people have to wear reflector belts for safety in a war zone during the day, cannot go out on operations if the safety belt for gunner turrets are not up to par, protective armor on shoulders, groin, neck on top of torso in the summer hear of Iraq-screw mobility! lol etc...etc...all things I have seen and continue to see in the large, lumbering, risk adverse DoD. So, I am skeptical of Sutton and the numbers knowing how once they move on a topic they tend to over react.

Sigh, not flip flopping, giving examples and hypos in my posts and not sure how you got that I flip flopped but people see what they want to see I guess. I see people go through the initial screening all the time and it gets documented in their records as possible TBI, is does not mean they have it all the time and the numbers they are claiming for TBI per year are not from war which says that you are including MVA and other incidents as well and like I said, I can bet it is over diagnosed now since they cannot easily rule it out from any concussion. Go look at my posts again and 4,141 per year includes ALL incidents, and I can bet my bottom dollar once the diagnosis gets better those numbers will come back as inflated. You need to get current with how they DoD actually goes through the process of doing diagnosis, treatment and as someone who says he is an historian you should be more skeptical of numbers when they do not seem to add up on the surface and should see how they came about the numbers in the first place. Lastly, you first implied that they the TBIs were suffered in war, it did not make sense and now you are saying that if you include ALL cases of TBIs, you can come to that number of 4, 141. So if that is 4,141 per year does that magically get to your previous number of up to 320K projections? The numbers you post do not all jive, many come up different from other studies, so what is it? And again, you continue to ignore the other questions I posed-how does the study come up with the numbers? What is the MOI? How does this effect training? Etc...But in short, the numbers do not add up and it will come out as being over diagnosed down the road, a well intentioned policy but not an accurate one.

Eric, The range of current published TBI estimates that I've provided, attributed to DoD by their sources, is 45-90K, and 134K respectively. The DoD/Rand study identified 360K as an 'exposed to blast/other events', from which they attempted to estimate the fraction of actual battle/war TBInjuries. 320K is your creation, so far as I can see.

The only published estimate you've come up with is the totally discredited BuMed number (4,400?), which was actively offered for publication at that time. You saluted BuMed, then immediately multiplied it up to something you liked better. You pull 40K as an upper limit out of your own hat, then repeatedly attribute '320K TBI' to me, a straw-man attack.

You talk about my false assumptions, question my honesty? Check the log in your own eye, brother. Either engage with the best info available, or stay home.

The current TBI statistics (and TBI reportage) linked in my previous post are provided first-hand by DoD, actual diagnoses of symptomatic TBI. They are conservative, and don't include VA-diagnosed TBI. There are obvious problems with the stats (ie moderate TBI diagnoses dropped in 2003-6 compared to the previous 3 years) but they are much improved over anything made available before 2008. You can break the TBI numbers down by service and severity. They don't tell us how many separated for TBI injuries. But 'moderate TBI' recovery may not be all that moderate in its drag on the man or the force.

The range of credible estimates and statistical evidence indicates that TBI attrition in Iraq was in itself much higher than the 4:1 wound/KIA attrition that PAO officers were pushing for publication prior to 2009. Contrary to that '4:1' misinformation, TBI alone was/is a force level and readiness issue, in the brigades. Brigadier Sutton was speaking on record at a TBI awareness event, in her area expertise, when she said the Army had not been forthcoming on TBI in past years. Force level and readiness are the most basic military metrics, back to 'beans + VD vs bullets + trenchfoot' calculus.

And if it can be counted, it will be spun too. BS is an MOS.

Remember, primary blast TBI results in a lot of closed head injury. The blast-wave effect on the brain was not understood, was ignored and denied as unlikely. It's still dismissed as unimportant. The folks at DVBIC must have been tearing their hair out in 2004. They were threatened with budget cuts, while the IED problem multiplied, and undiagnosed TBI's piled up on a system that had no TBI code for a closed head injury. Sometimes, men with TBI were redeployed, or discharged for poor performance. "Battle Mind" taught that the tough get going.

Diffuse Axon Injury (DIA) from only a few atmosphere (bar) overpressure is now a medical fact. The mechanism of primary blast injury is still poorly understood.

TBI is a 'silent injury', delayed and cummulative in effect. With no wound to point to, the warrior wants to deny brain injury to himself, seeks to conceal symptoms of lost capacity from his community. That's why the new TBI doctrine calls for post-blast testing, within the weapon radius. Mandated pre-deployment training teaches what to look for, and urges peer intervention. It's easy to dismiss TBI symptoms as stress, when that's huge too. For the best chance of recovery, and the good of the force, early diagnosis and avoiding near-term reinjury is the military prescription. That's been doctrine for any wound since Florence Nightingale, but a long slog to get applied to TBI.

360K is there in the 2008 Rand study cited, with whatever caveats, and whoever funded that. My bad, and I apologise.

Brig. Sutton was the one who cites a Pentagon estimate of 360K 'may have' brain injuries from OIF/OEF, in which she reportedly included 45-90K who's 'symptoms persist and warrant specialised care'.

But note that the '45-90K clinical out of 360K maybe' number is specific to the 1.8 mil Iraq-Afghanistan vets, not the larger number cycling thru the service. That leads to a reasonable guess that the moderate TBI's are concentrated among the same folks who took the KIA's; the brigade combat component and field support units exposed to the IED blast weapons that cause more than half our combat casualties.

Judging severity is a big part of sizing the impact of TBI on the force, the families, and the national budget. Everybody hopes that the mild-TBI component (which you dismiss as mere concussion) recovers fully, and isn't reinjured in a way that multiplies the risk. I agree with you that 320K or 360K (RAND, DOD) guesstimates are mostly mild TBI, under DVBIC definitions.

But blast-induced Diffuse Axon Injury, the death of neurons and their supporting cells, is a fresh area of research. The imaging tools and cell biology didn't exist, back when 'shell shock' was being separated from tissue trauma injuries. Since blast is different from ordinary TBI, the increased downstream risk of epilepsy and dementia, two known TBI sequalae, isn't yet quantified.

When I was reading myself into TBI in 2007-8, when '4,400 TBI's' was being disseminated, the questions I raised were
1. Can primary blast effect knock a man out of the fight, without external injury or ear-drum rupture.
(The answer to that was 'yes, but we don't know the how and why of it.)
2. Has blast effect TBI attrition swelled to 10,000, or 100,000. That much uncertainty existed, and to some extent still does. Is TBI a billion dollar problem, or $100B?

Squinting my eyes at what's been released, my readers guess is 20-40,000 war vets were rendered combat/COIN ineffective by TBI in Iraq, with most of those serving out their tours. So on a surface level, we're not as far apart on THE NUMBER, as we are on the effect on the force/capability. Perhaps twice that number are already suffering diffuse and hard to define ill effects, along with their families.

You can pin that guess on me Eric, and decide for yourself which MOS's war TBI falls on the heaviest.

It's a dread powerpoint, but vetted thru Marine HQ, Jan 25 2010, and worth browsing the heroic heartbreak.

A large fraction of this casualty/medical care presentation focusses on TBI, failed and ongoing experimental treatments, which suggests it's not a small problem. Going back to DVBIC data for 2007, I see they report a mild TBI hard-count about 5X the moderate-severe-penetrating-multitrauma TBIs, about the same as the service average for Iraq.

Using that 5:1 ratio on the Marine mTBI number below, I get 10,000 moderate-severe TBI casualties, against a 1,000 Marine KIA's. 10:1. That's why TBI has the full attention of big and little armies. If the whole MRAPS thing hadn't clued you in.

A couple of the 2010 MHS Conference bullets from USMC:

- Estimated ~ 50K suffered mild Traumatic Brain Injury (mTBI)
- Identified ~ 20K with Post Traumatic Stress Disorder (PTSD)

http://www.health.mil/Libraries/2010_MHS_Conference_Presentations/MP1_R_Jeffries.pdf

One, that is the USMC. Two, TBI, Moderate to Severe, is still rare in the Military as whole when you take the numbers, if it was common then our entire military would be done. Three, Mild = Concussions or any head trauma, it can be anything from a bump on the head to a concussion that does not cause LoC, or even if does, along the lines of a punch, it is not resulting from combat.
Combat TBIs are still pretty rare when taken as a whole of the military, my original point. You cannot count ANY case of TBI as being included in the DoD wars and it is being over diagnosed now and there is a large difference between one caused by punch, MVA, fall, etc... versus one caused by a nearby explosion.

I think we agree that 50K+ would be a problem, if it was mostly primary blast injury, and concentrated in the combat component, true 'war wound' attrition.

You assert (with reasons) that is not the case, that TBI is now over-diagnosed among troops IED-exposed, and that the rare TBI war casualty count is conflated with force-wide sports and vehicle injuries. I assert that the detailed active duty diagnostic counts provided online by information General Sutton (MD, Neuro) and DVBIC have to be disregarded before you can reach the conclusion that TBI is not a force level and readiness issue.

Since the stats are internally inconsistent, the blast-TBI field having evolved thru this war experience, they can be argued more than one way. I see a real danger that you're improperly averaging the undercount '4K severe multitrauma TBI' number thrown about before 2008, against a pretty conservative (and partial, without VA numbers) DVBIC clinical record. To me DVBIC's 'best current info', offered by command-rated subject-expert Sutton's 'Center For Excellence', appears to be a 'hard floor' for forming an impact range estimate, for the 2003-2007 period of elevated mine/RPG warfare.

Thx for the discussion Eric.