It started to click in nurse Kate Froede's mind as she listened to the hulking Army Ranger run down a list of his symptoms -- lack of sleep, aggressiveness, ringing in his ears.
"I said, 'Have you ever been near a blast?' And he said, 'I stopped counting at nine,' " Froede said. "I said, 'Well have you ever been checked out for post-concussive symptoms or any kind of brain injuries?' And he said no."
When she began to set up appointments for him to get help, the big Ranger broke down crying.
"He said, 'I thought I turned into a monster. I thought the deployments had turned me into a monster,' " Froede said.
They have been called the signature injury of the wars in Iraq and Afghanistan -- traumatic brain injuries from explosive blasts, often subtle and without any visible outward sign of injury. The military has stepped up efforts to screen and treat them, and during the summer instituted mandatory guidelines for screening after a blast or accident. One official said the program already has produced "significant" results. But where the statistics are not showing up is among the ranks of those earning a Purple Heart.
Froede and Jayna Brooks -- both nurses and military spouses -- founded the group Recognize the Sacrifice to change that. The group helps service members navigate the Purple Heart process and also seeks to raise awareness about and advocate for greater attention to TBI.
Froede, a nursing instructor at Medical College of Georgia, is a doctoral candidate at Vanderbilt University whose work focuses on TBI. She and Brooks met in Germany in December 2007 while their spouses were deployed, and they started talking about TBI.
"We both felt really strongly about identifying the injury, because at that point there wasn't really any standard paradigm for doing that," Froede said.
They formed the group in 2008 and ran across the problem of those with TBI being able to receive a Purple Heart as recognition of their combat injury. Most soldiers who get a TBI probably won't seek a Purple Heart but those who do are running into a problem, Froede said.
"We're seeing over and over and over that, A, the record and the assessment isn't there, and, B, even if it is there, for some reason it is getting kicked back and kicked back and kicked back," she said. "So we're trying to figure out, in a very collaborative and nonconfrontational way, where's the disconnect? Why is it that we have such dedicated commanders, and vice chiefs and soldiers and health care providers who really, really are committed to this issue but somewhere down the line, something is happening where it is not getting through?"
Reports hard to get
Getting reports back from a combat zone is always a problem, officials said.
"Paper records in theater in a war zone and ensuring that we can get the full complete story is a challenge," said Katherine M. Helmick, the senior executive director for Traumatic Brain Injury and the director of the TBI Clinical Standards of Care for the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
"It's very difficult to get medical records from the field," said Dr. Dennis Hollins, the medical director of the Active Duty Rehabilitation Unit at the Charlie Norwood VA Medical Center, which is a collaboration with the Department of Defense.
Despite the commitment from the very highest levels to TBI -- and Froede said the military is to be commended for that -- the breakdown points to a much more fundamental problem with TBI.
"If we can't figure out if these soldiers are eligible for a Purple Heart, then we haven't really figured out how to define this and how to assess this," she said. "And you can't move forward on anything if you don't know how to measure it, if you don't know how to assess it."
Numbers in dispute
It is perhaps for this reason that there is some uncertainty over just how many have suffered a TBI while deployed. The U.S. military said there have been 178,876 diagnosed cases of TBI between 2000 and May 20 of this year, according to the Defense and Veterans Brain Injury Center.
But a RAND Corp. survey estimated about 300,000, or 19 percent deployed, had suffered a TBI. Helmick said those numbers are just an estimate based upon telephone screening.
A 2009 study in the Journal of Head Trauma Rehabilitation , of which Helmick was a co-author, looked at 4,000 members of a U.S. Army Brigade Combat Team that served in Iraq and found 22.8 percent had suffered a TBI. But 15 percent of those had no lasting effects and only about 8 percent had any ongoing symptoms, Helmick said.
"We believe the rates to be anywhere from 5 to 10 percent of those that continue to have symptoms when they come back home and require intervention," she said.
The military does have a comprehensive TBI plan in place and on June 21 a directive went out that made assessments mandatory for everyone in certain situations, such as being in a vehicle hit by a blast or within 50 meters of a blast. The new requirements, which took effect Sept. 1, are already having a "significant" impact, Helmick said. While she said she wasn't authorized to release the results yet, "We are pleased with the impact that it's already had in theater in just a month," Helmick said.
Test is challenged
By the time the patients get to Augusta and rehab here, problems or suspicions are usually already noted in the records, Hollins said.
"They'd at least screened them or at least looked at them to determine (their status)," he said. "So I think the military is doing a lot better job than they were at the start of the war. My suspicion is that if you have milder symptoms, or if you have more subtle findings, I think that maybe some of those are getting through."
While Froede acknowledges that the military plan is thorough, it is not based on good science. She called the Military Acute Concussion Evaluation test often used in the field "unvalidated and unproven." A Perspective article in the New England Journal of Medicine in 2009 said the military's clinical definition of TBI was "inadequate for achieving the objectives of these well-intentioned initiatives." That article also sparked a couple of letters from experts questioning its findings.
The military is investing a lot in trying to come up with more objective measures of TBI, Helmick said.
"We are very excited that this investment into the future of TBI care is already beginning to bear some fruit and have strong expectations for the next 5-7 years that that's only going to continue," she said.
For her part, Froede is sacrificing personally for the cause. In addition to her teaching duties and doctoral work, she is working on the issue through her group while also raising two children under the age of 5.
"If sleeping 15 minutes a night is what I have to go through and my kids eat Cheerios for dinner sometimes then yeah, I think it's worth it," she said. "I think that's how everybody working on this issue feels."