Navy captain crusades against TBI in Anbar

28 Dec 2008 | Sgt. GP Ingersoll 1st Marine Logistics Group

His crusade spanned two years.

He travelled to triages and hospitals across Anbar in 2006. He worked tirelessly with his stateside colleagues in 2007. Two years of toiling all to gather enough evidence, or “data” as he calls it, to make his case.

Now, back in Iraq, Navy Capt. Michael H. Hoffer feels he has won a significant victory against arguably the military’s most serious and common casualty: Traumatic Brain Injury.

Traumatic Brain Injuries, or TBI’s, occur when an individual experiences shock waves from a blast, acceleration-deceleration (collision), or an impact or penetration directly to the skull. Doctors divide TBI into severe, moderate or mild. 

“Right now, 92 percent of all battlefield injuries in Iraq and Afghanistan are classified as (mild) TBI,” said Hoffer, Otolaryngologist (the ears, nose and throat physician), Surgical Company, 1st Maintenance Battalion (-) (Reinforced), 1st Marine Logistics Group.

 A recent study conducted by the Rand Corporation concluded that 20 percent of all service members who have deployed to Iraq or Afghanistan have at least mild TBI.

“Now imagine what the rate is amongst infantry … we do have a problem,” said Hoffer. “So we recognized the fact that although we’re set up to do ‘blood and guts’ surgery, (Taqaddum Surgical) can take on a secondary mission.”

Taqaddum Surgical’s secondary mission: the Theater TBI Center of Excellence.

The center, a result of Hoffer’s two-year initiative, is the first of its kind here in Anbar. It was established initially in September and finalized as the province’s hub of TBI treatment in December. With the cooperation of corpsmen on the ground and company commanders, the center now rehabilitates every casualty who experiences events associated with causing TBI.

Now if Marines experience a blast of any size, or a collision, crews medevac them to Camp Taqaddum for immediate treatment.

“So what we have here are experts who see these blast injury patients within 24 hours of the injury,” said Hoffer, 42, San Diego.

Once patients arrive, doctors administer a battery of tests to make a diagnosis. An audiometer, or hearing test, determines the state of the patient’s inner ear. A challenged, or dynamic, gait test, kind of like a more complex version of a roadside sobriety test, provides trained doctors with indications of TBI.

Cognitive skills exercises, like memory quizzes and timed maze completions, round off the tests.

Early diagnosis is critical, said Hoffer, and the biggest obstacle to early diagnosis is actually Marines themselves.

“Someone’s got to protect the Marines against themselves, you know, even if they have a sucking chest wound, they would put something on it and keep going,” said Hoffer. “So a Marine gets blasted, denies it, and then he gets back to (the states) and the wife sends him out for cheese and coffee, and he comes back with eggs and milk.”

Hoffer said oftentimes wives refer their husbands to medical for dizziness or forgetfulness, resulting from mild TBI.

“Marines are a tremendously brave bunch, in some ways it takes more courage to say ‘yes I had an impact’ … rather than deny it and have effects that are long term,” said Hoffer.

Mild TBI’s, more commonly known as concussions, worry doctors the most. Moderate or severe TBI’s are usually accompanied by other injuries which require patients to receive treatment in the states. Mild TBIs frequently go unnoticed or unreported because their severity is not immediately recognized.

Left untreated, long term effects of mild TBI could end a Marine’s career, said Hoffer.

“There are 2,500 people at Balboa (Medical Center) who have (symptoms and effects) from mild TBI, six to nine months after the blast,” said Hoffer.

The number of people isn’t what troubles Hoffer, it’s the amount of time wasted prior to proper diagnosis and rehabilitation.

“The earlier we start, the quicker we cure it, and the less long term effects,” said Hoffer.

Past treatments have shown that patients who sought care within three to six weeks of the causal event made a full recovery in six weeks. Patients who received treatment 11 months after the event took significantly longer, at 16 weeks, to feel better.

“If we could see patients (within) 24 hours (of the event), I bet I could get them better in two weeks,” said Hoffer.

Quicker recovery time isn’t the only benefit to early reporting. Whereas late patients on average only recovered to approximately 85 percent normalcy, patients seen immediately tend to recover to 100 percent normalcy, said Hoffer.

Not to mention that their careers can continue as if nothing ever happened.

“The effects that are long term, they really prevent you from ever going back to the fight,” said Hoffer. “This program allows Marines to continue serving in the Corps.”

Hoffer said once patients are diagnosed, a treatment is designed based on the symptoms they exhibit. Not all TBIs affect the same parts of the brain, so treatments, though somewhat standard, deviate from each other based on what each patient needs.

Hoffer also introduced a new TBI rehabilitation treatment, which is in its test phase, but may also prove to be somewhat preventative.

“When a brain cell dies, it releases oxygen free radicals and these free radicals attack nearby cells,” said Hoffer.

So initial damage worsens steadily over time.

“A cell has its own outside defense against invaders, but (in the case of TBI) it’s like a platoon sized defense against a brigade,” said Hoffer. “If we put in antioxidants, we increase that cell’s natural defenses.”

At least that’s the theory. Hoffer is staging the first ever double-blind, placebo-controlled test performed in Iraq here at the center to gather evidence that antioxidants improve recovery from TBI symptoms.

If proven effective, they could be issued to corpsmen to give to Marines immediately following an event, and therapy could start immediately, said Hoffer.

Hoffer’s efforts, along with the efforts of his colleagues, have improved the well- being of Marines in Iraq.

“Mild TBI robs us of a Marine’s full capabilities and has a dramatic effect on the lives of affected Marines and their families,” said Brig. Gen. Robert R. Ruark, commanding general, 1st MLG. Ruark, 48, Salem, Ohio, said not only the quality of a Marine’s life, but the quality of the Corps itself improves as doctors like Hoffer refine their treatment of TBI.

Since the center has opened, 40 patients have received treatment. Thirty-five have returned to finish their deployments, 100 percent recovered.

“Service members evaluated by Capt. Hoffer get state-of-the-art treatment and evaluation, and are put on the path to rapid recovery,” said Cmdr. Joseph F. Penta, group surgeon, Surgical Co., 1st Maintenance Bn. (-) (Reinforced), 1st MLG.

Penta, 38, San Clemente, Calif., said although the center is a victory, the crusade is far from over.

“Our next goal is to expand mTBI treatment centers to other locations in Iraq and Afghanistan,” said Penta.

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