USA — Collaboration Improves Treatment of Unseen Scars of War

BETHESDA, Md. — Sev­er­al times every week, a team of about 50 spe­cial­ists gath­ers around a con­fer­ence table at the Nation­al Naval Med­ical Cen­ter here to assess the progress of every wound­ed war­rior under­go­ing treat­ment at the hos­pi­tal.

They bring an array of exper­tise to the dis­cus­sion, with spe­cial­ties in every­thing from trau­ma surgery to pain man­age­ment and phys­i­cal and occu­pa­tion­al ther­a­py. Join­ing them at the table are social work­ers, case man­agers, a chap­lain and mil­i­tary ser­vice liaisons.

And, even if there’s no imme­di­ate indi­ca­tion of a brain injury or post-trau­mat­ic stress, mem­bers of a new psy­cho­log­i­cal health and trau­mat­ic brain injury team par­tic­i­pate ful­ly in talks about treat­ments being admin­is­tered, med­ica­tions pre­scribed and results seen.

“You have sur­geons, neu­ro­sur­geons and trau­ma sur­geons sit­ting next to psy­chi­a­trists and psy­chol­o­gists in the same room, talk­ing about these patients,” said Dr. David Williamson, med­ical direc­tor for the hospital’s Inpa­tient Psy­cho­log­i­cal Heath and Trau­mat­ic Brain Injury pro­gram. “It’s not a case of wait­ing to see if there is a prob­lem and then say­ing, ‘Let’s con­sult psy­chol­o­gy or psy­chi­a­try.’ We are auto­mat­i­cal­ly a part of the work­out.”

This inno­v­a­tive, inter­dis­ci­pli­nary approach to patient care is all but unheard-of in even the most respect­ed civil­ian trau­ma cen­ters, Williamson said. But it’s show­ing great promise, he report­ed, par­tic­u­lar­ly in diag­nos­ing trau­mat­ic brain injuries and oth­er men­tal health issues ear­ly on, and bring­ing the full spec­trum of ser­vices avail­able to treat them.

The Nation­al Naval Med­ical Cen­ter stood up the psy­cho­log­i­cal health and trau­mat­ic brain injury team about two years ago to address the com­plex­i­ties of brain and men­tal-health injuries.

“The idea was, ‘We know our wound­ed have a clus­ter of prob­lems to do with brain injury or effects on the brain of being in the com­bat envi­ron­ment. Let’s get a team of doc­tors with all the spe­cial­ties that need to be on that team to deal with that one clus­ter of issues,’ ” Williamson said.

The team assess­es every sin­gle trau­ma casu­al­ty admit­ted to the hos­pi­tal for signs of trau­mat­ic brain injury or oth­er psy­cho­log­i­cal or psy­chi­atric com­pli­ca­tions. “It does­n’t mat­ter if you come here with a gun­shot wound to the leg or if you have a brain injury,” Williamson said. “Every­body sees the PHTBI team.”

That elim­i­nates any pos­si­ble sense of stig­ma on the patient’s part for talk­ing to a psy­chi­a­trist, he said, “because every­one has to talk to the psy­chi­a­trist.”

It also helps to iden­ti­fy brain injuries ear­ly on, he added, par­tic­u­lar­ly mild or mod­er­ate injuries that might oth­er­wise be dif­fi­cult to diag­nose.

“Some­times the brain injury is very obvi­ous,” Williamson said. “But we also know that blasts can cause dam­age to the brain with­out nec­es­sar­i­ly caus­ing phys­i­cal scars or ren­der­ing some­one uncon­scious.”

Inte­grat­ing the PHTBI and trau­ma-care teams pro­vides a more holis­tic approach to patient care that address­es not only the imme­di­ate, but also longer-term patient needs.

“The idea is to be able to pre­dict and plan ahead what types of prob­lems a patient will have so we can put ser­vices in place ear­ly, before they’re need­ed,” Williamson said.

He con­trast­ed this approach to how civil­ian med­i­cine treats patients who suf­fer brain injuries in car crash­es and oth­er acci­dents. Emer­gency med­ical ser­vices swarm in, fly­ing patients to shock-trau­ma cen­ters, where they receive aggres­sive treat­ment for their phys­i­cal symp­toms. Reha­bil­i­ta­tion fol­lows, includ­ing phys­i­cal occu­pa­tion­al ther­a­py, then patients typ­i­cal­ly return home to com­plete their con­va­les­cence.

“At no point on that tra­jec­to­ry is there any behav­ioral health treat­ment,” Williamson said. In fact, patients — or more fre­quent­ly, their fam­i­lies — often reach out for this kind of care only after prob­lems involv­ing explo­sive tem­per, severe depres­sion or changes in judg­ment or deci­sion-mak­ing get out of con­trol.

“It’s when things are tru­ly at a cri­sis that peo­ple reach out to behav­ioral health and say,‘Maybe they have some­thing to offer,’ ” Williamson said.

Not so here, as the behav­ioral health team is incor­po­rat­ed into patient treat­ment from the start with a phi­los­o­phy Williamson calls “proac­tive inter­ven­tion.”

“Med­i­cine tra­di­tion­al­ly very well under­stands that peo­ple can be par­a­lyzed or weak­ened or have prob­lems with coor­di­na­tion or bal­ance or vision as a result of a head injury,” he said. “What’s not typ­i­cal­ly been part of the ear­ly workup is to include the emo­tion­al, cog­ni­tive and behav­ioral changes –- those high­er brain func­tions that get affect­ed by brain injuries -– as part of the assess­ment pack­age.”

This col­lab­o­ra­tion pro­vides patients the best, most aggres­sive treat­ment pos­si­ble, he said, while also ensur­ing that med­ical spe­cial­ists don’t inad­ver­tent­ly under­mine one another’s efforts.

Because many wound­ed war­riors have mul­ti­ple trau­mas, they may be on a vari­ety of dif­fer­ent med­ica­tions to stave off infec­tion and pain.

“They may have a TBI, but they also have an ampu­ta­tion or a back injury, and they have chron­ic pain,” Williamson said. “So in some cas­es, they may already have been on six med­ica­tions before behav­ioral health becomes involved. Then the behav­ioral health spe­cial­ist comes along and says, ‘You’re not sleep­ing at night, so let’s give you a seda­tive. You look depressed, so we’ll give you an anti­de­pres­sant.’

“In the end, peo­ple might end up on 10 dif­fer­ent med­ica­tions,” he con­tin­ued, some that may cause mem­o­ry loss or oth­er brain impair­ments or lead to addic­tion.

“So we see com­pli­ca­tions and patholo­gies com­ing out of aggres­sive treat­ment – all of it well-inten­tioned and log­i­cal – by mul­ti­ple, par­al­lel med­ical teams,” Williamson said.

The col­lab­o­ra­tive treat­ment pro­vid­ed at Bethes­da helps to pre­vent that by open­ing up com­mu­ni­ca­tion among the dif­fer­ent teams.

“The treat­ment process works a lot bet­ter when you have all the doc­tors and all the spe­cial­ties rep­re­sent­ed in the same room,” Williamson said. “It allows us to sim­pli­fy the whole pack­age of treat­ment and make sure that nobody’s activ­i­ties are inter­fer­ing with some­one else’s treat­ment process.”

That typ­i­cal­ly involves few­er, rather than more, drugs, he not­ed.

“It’s not unusu­al for peo­ple to leave here with less med­i­cine than they came in on,” and fre­quent­ly off all addic­tive med­ica­tions, he said.

This inte­grat­ed approach pays off in bet­ter patient care, and ulti­mate­ly improves the reha­bil­i­ta­tive process, Williamson said.

“We find that if we treat the psy­chi­atric and psy­cho­log­i­cal issues, peo­ple tend to do bet­ter in rehab. Their spark and moti­va­tion comes back,” he said. “We also see that if we treat their chron­ic pain, then their men­tal health improves. So these things are inter­re­lat­ed.”

(This is the sec­ond in a series of four arti­cles about the military’s rev­o­lu­tion­ary new approach­es to treat­ing patients with trau­mat­ic brain injuries and post-trau­mat­ic stress.)

U.S. Depart­ment of Defense
Office of the Assis­tant Sec­re­tary of Defense (Pub­lic Affairs)

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