The wars in Iraq and Afghanistan have resulted in thousands of cases of serious multiple injuries to American service men and women. They will need a lot of help coming home.

By Tom Scott

At the recent North American Spinal Cord Injury Conference and Disability Exposition, which United Spinal Association sponsored in Orlando in August, Glenn Curtiss, PhD, clinical neuropsychologist at the James A. Haley VA Medical Center and Jay M. Uomoto, PhD, director of the Center for Polytrauma Care at the VA Puget Sound Healthcare System in Seattle discussed how polytrauma has impacted the lives of U.S. soldiers serving in recent conflicts in Iraq and Afghanistan. Drs. Curtiss and Uomoto discussed the need for coordinated and continued care, community re-entry, and long- term follow-up consultation for these individuals when they move beyond acute rehabilitation.

“The term polytrauma developed from clinical observations that we were seeing when people were returning from the theater of war,” said Curtiss. “These individuals had multiple injuries to multiple systems commonly from blasts and explosions [i.e., improvised explosive devices and rocket- propelled grenades]. They were life-threatening injuries and the probability of long-term disability was great. ‘Polytrauma’ tries to capture the severity and ramifications of these multiple traumatic injuries.”

Polytrauma Care System

On the battlefield, polytrauma usually occurs when soldiers are exposed to high-pressure waves, explosive fragments, and falling debris from blasts or explosions. Injuries can vary and include traumatic brain injuries (TBI); spinal cord injuries (SCI); loss of limbs, burns, fractures, blindness; hearing loss; and cognitive disorders (i.e., post traumatic stress disorder [PTSD]). There are complex factors that determine the types of injuries an individual will sustain and their severity (i.e., composition of explosive devices, proximity to explosion, structures or barriers near blast, type of body armor worn, etc.).

Recent studies show that for every death that occurs in Iraq or Afghanistan there is about a 10- to 20-fold higher number of U.S. service members returning with at least moderate to severe TBI.

Currently, four centers managed by the U.S. Department of Veterans Affairs (VA) specialize in polytrauma rehabilitation, in Minneapolis, Minnesota; Palo Alto, California; Richmond, Virginia; and Tampa, Florida. An additional 17 “Polytrauma Network Sites” nationwide assist with outpatient and long-term follow-up care. Established in 2005, the Veterans Health Agency (VHA) Polytrauma System of Care is composed of an integrated team of health care professionals comprising case managers, physicians, nurses, therapists, and psychologists. These professionals must work collaboratively to create a continuum of services for polytraumatized servicepeople.

The job of the polytrauma center is to provide a seamless transition for service members with polytraumatic injuries from military facilities to the VA. They offer a variety of programs for brain, spinal cord, and blast injuries, as well as family, caregiver, mental health, and consulting services and support. The programs emphasize intervention from family and caregivers and provide logistical, clinical, and emotional support for them (www.polytrauma.va.gov/family_support.asp). A majority of the centers are affiliated with teaching hospitals that can provide expertise and assistance when needed.

Additionally, the VA is working vigorously to coordinate care between service lines within each of the polytrauma facilities due to the large amount of care providers and case managers involved with each patient, the complexity of treatment, and the distance between the patient and available support.

Transitional Challenges

One of the major challenges in treating this patient population is a delay of many veterans and service members with polytraumatic injuries from entering the polytrauma system of care.

“It sometimes takes a long time to get some of these individuals into the system,” Uomoto said. “This happens frequently with the National Guard and Army Reservists, partly because there is a health screening form that all soldiers have to fill out when they [return from combat] which includes a checklist of symptoms. If you check yes to any of them you end up having to stay and may get transferred to a medical facility. You are then separated for longer periods of time from your family. So what are these people doing? Well they are saying ‘No, I have no problems,’ and return home. And these are patients with signifi cant muscular-skeletal injuries, significant headaches and visual and hearing impairments, and so forth. This is clearly a problem within the system where we have to encourage a lot of eyes and ears in the community to identify these individuals to make sure they are connecting with their local VAs.”

Adjusting to civilian life is another major challenge. “Many think, ‘Well, you know, I’m coming back from war, I just need some time to adjust,” Uomoto explained. “It’s after six to twelve months when family members and the veteran may start thinking, ‘Things aren’t right here; things are really falling apart.’ And then they enter the system.”

Some service members experiencing signifi cant pain problems and PTSD may also rely on self-medication. It has been reported that alcohol use is rampant within the population. “I’m sometimes shocked by the quantity of alcohol being consumed by some of these individuals and that they are even able to stand straight,” Uomoto added.

Geographic challenges, reluctance to enter the VA, and constraints on leaving work are other factors for many veterans and service members. “Long distance travel to rehab centers can be very burdensome. For many National Guard and Reservists, they go back to work after they are discharged,” Uomoto said. “In many cases it is very difficult to take time off from work. It means money out of their pocket. Currently there are no means by which these individuals get compensated for time off for medical appointments.”

According to Curtiss, there are no statistics presently available on the prevalence of polytraumatic injuries among U.S. soldiers. “The data actually are not applicable. We at lead polytrauma centers send our data up to Washington and it is then classified as top secret. So it’s hard to get information on how many people who are exposed to blasts, sustain brain injuries or spinal cord injuries,” Curtiss said.

Although polytrauma centers have made great strides in improving patient outcomes, more facilities are needed to care for this increasing veteran population. Service members who have completed acute rehabilitation care have lifelong care needs and complex health care issues that must be addressed through an integrated system of care that tracks these individuals and offers expert guidance and treatment strategies.

For more information on the VA’s polytrauma rehabilitation centers, please visit www.polytrauma.va.gov/index.asp.

Tom Scott is staff editor.