Invisible Wounds

What stress does to the soul

TBI Challenge II

Iraqi vet seeks justice for himself and others

Gatlin’s appeal essentially argues two main points: that the VA’s test wasn’t sufficiently capable of evaluating the damage to the brain of a high-functioning individual like Gatlin, and that the psychologist who examined him wasn’t qualified or trained well enough to administer the VA’s tests and interpret the results.

Gatlin was administered the RBANS test at Fort Harrison. “But it’s just a screening tool, not a diagnostic test,” Del Negro objects. “It’s just used to raise red flags that show whether a patient needs fuller evaluation.”

RBANS (Repeatable Battery for the Assessment of Neuropsychological Status) tests immediate memory by asking a subject to remember 10 unrelated words or a list of 12 items in a story, visuospatial/construction by asking him to copy a geometrical figure or identify patterns in lines, language by naming pictures or providing examples of classes of objects, attention by repeating varying numbers of digits in a string, and delayed memory by recalling the unrelated words and story elements presented earlier.

But those weren’t much of a challenge to Gatlin, who’d been working to overcome those problems for the past six years.

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“One of my concerns is that he’s so high functioning,” says Del Negro. “When we were in San Diego, one of the neuropsychologists told me that their tests might not be able to detect the extent of his injuries because he is so high-functioning. He was taught compensatory strategies to overcome his limitations during the rehab, plus he’s quite creative himself. Now he’s learned how to navigate around a problem to find a solution.”

Those strengths allowed him to continue functioning academically despite his injuries. And Del Negro said he was profoundly insulted when she was told that her husband couldn’t be cognitively disabled because he’s a graduate student at the University of Montana.

“They say that because he’s able to do this, he can’t be impaired,” says Del Negro. “But instead he should be recognized for his diligence and determination and tenacity and strength for overcoming those problems.”

Gatlin’s second major challenge to the VA’s disability determination is that VA examiners weren’t adequately qualified or trained to make that determination.

For example, the VA denied service connection for his fine motor skill deficit due to TBI. In his notice of disagreement filed last July 31, Gatlin wrote: “The board relied on the opinion of an examiner, a nurse practitioner, who was neither licensed nor trained in the required specialty to ascertain a proper diagnosis. This was reflected by her medical entry, stating that she could not explain the reasoning for my deficits. Simply put, she could not explain the reasoning because she lacked the required expertise to lend a credible and accurate medical opinion.

“Of note, three individual and comprehensive batteries of neuropsychological testing had been previously conducted consistently showing that my motor/dexterity/speed on the grooved pegboard test was ‘impaired below the 1st percentile’—deficits identified by licensed specialists as a specific consequence of my TBI,” Gatlin said. “What should have been abundantly clear to both the examiner at Fort Harrison and the Board was that there had been absolutely no improvement in such deficits, and thus reconfirmed the previous diagnoses opined by the expert clinicians.”

Gatlin also challenged the credentials of the psychologist who examined him at Fort Harrison, arguing that he is a clinical psychologist, not trained in neuropsychology. “Robert Bateen, Ph.D., the examiner at Fort Harrison assigned to determine the veteran’s degree of disability for residuals of TBI, was not professionally qualified to conduct or interpret the necessary neuropsychological tests required to determine the presence or absence of ‘objective evidence of testing,’” he wrote in his appeal to the Board of Veterans’ Appeals.

But Fort Harrison’s director, Christine Gregory, disagrees. “All VA Montana Compensation and Pension (C&P) examiners are state licensed and Compensation and Pension Examination Program (CPEP) certified within their areas of responsibility per VHA Directive 1603,” she wrote Rep. Steve Daines last August. “Examiners who perform exams for TBI residual have completed CPEP Traumatic Brain Injury training.”

According to Dr. David Cifu, national director of the VA’s Physical Medicine and Rehabilitation Services, a four-question screening exam was devised to determine the existence of a traumatic brain injury, not the RBANS test. “I’m really not a fan of the RBANS test,” he said. “It just has a lot of flaws to it that don't allow us to screen for TBI.”

Instead, Cifu said the VA relies on the VA TBI Screening Tool, a test that’s taken from a TBI expert consensus approach that has been around since 1993 and is a better tool than the RBANS to screen rapidly for TBI. It asks whether a vet has experienced a blast event, whether he suffered a loss or alteration of consciousness, whether he experienced symptoms after the blast, and whether those systems persist. “If the answer to those questions is yes,” Cifu said, “that will get them into a higher level evaluation, the Comprehensive TBI Evaluation (CTBIE).”

Cifu said the VA has screened 760,250 OEF/OIF vets through July 31, 2013, for possible TBI and found 143,029 who screened positive and agreed to further testing. But there have only been 61,769 confirmed TBI diagnoses from the CTBIE.

A positive screen will get a vet into one of 108 TBI-Polytrauma specialty centers, which currently have an average wait time of only 18 days, Cifu said. “A comprehensive evaluation takes between two hours and six hours, depending on the extent of the symptoms. There’s no single test to determine brain injury, so we use a multi-dimensional test. And we have to rely on our experts to determine the diagnoses and management paradigms using the art of interpretation, rather than just hearing the symptoms.”

Cifu said each of these TBI specialty centers has, at a minimum, a seven-member team: a physician trained in in brain injury, a psychologist, a speech and language therapist, an occupational  therapist, a physical therapist, a rehab specialty nurse, and a social worker to provide support and access to other services.

Within these 108 teams, there are 23 TBI specialty centers that have multiple teams, and another five centers, which are “polytrauma centers of excellence with full inpatient, outpatient and telehealth teams, and dedicated neuroscientists who do research work,” according to Cifu.

Furthermore, the CTBIE tests can be used on individuals functioning on all levels and without knowing how well an individual functions before his or her injury. “We know what the norms are,” Cifu explained. “These tests have been normalized on thousands of people without brain injury and used on millions of people with brain injury, so we can recognize patterns of normality and abnormality.”

All vets who have suffered an alteration of consciousness in combat remain in a registry so that they can be identified if they experience later problems, Cifu said, but only those who have experienced symptoms lasting three months or longer are offered treatment if they wish it. Without symptoms, he said, there’s no need for treatment, just education, reassurance and primary care management. The average vet suffering brain injury has multiple symptoms, averaging between 17 and 21 symptoms.

But the number of vets diagnosed by the VA with TBI is far less than the number of active-duty soldiers diagnosed by the Department of Defense.

VA’s most recent statistics show that about 899,750 Iraqi/Afghan vets, 56 percent of the 1.6 million returning soldiers, have applied for health care, with more than half of that number seeking mental health care, a number that’s sure to grow larger as those who returned home recently begin acknowledging cases of delayed-onset PTSD. PTSD was the most common mental health complaint, with nearly 262,000 vets seeking help—which is about 29 percent of the vets in the VA system. By comparison, there are fewer than 62,000 confirmed TBI diagnoses by the VA.     

However according to the Defense and Veterans Brain Injury Center, 266,810 soldiers were diagnosed with TBI from 2000-12. And even the DoD figures fall short of what the Rand Report had predicted five years ago.

In 2008, the Rand Corp. did an independent survey of 1,965 service members and veterans. Due primarily to the prevalence of roadside bombs (improvised explosive devices, or IEDs), it estimated that 19 percent of the 1.6 million soldiers serving in Iraq and Afghanistan—about 320,000 soldiers—would come home with possible TBIs.

Fighting the VA’s TBI disability rating has taken its toll on Gatlin’s studies at UM, which is a significant problem given the fact that Gatlin has to work particularly hard to hold his own in graduate school.

“I have a hard time driving at night, and I still get headaches,” he says. “I have to re-read things that I could have breezed through back in the day. I have to take notes because I’m always forgetting something, and then I have to review that stuff. Typing is a bitch because my left hand doesn’t work so well. I still get vertigo, fatigue and mental fatigue—and the anger comes with it.”

Gatlin refuses to be disheartened, however. “The things I could take for granted, reading a book and remembering every chapter, those all have changed,” he says. “It’s sort of disheartening, but I’m alive—I’m not sure exactly how—and I have to take a positive view.”

But it also makes him want to be an advocate for vets who have it worse than he does.

For more information, go to the full story at www.greatfallstribune.com

Eric Newhouse is a Pulitzer Prize-winning journalist and the author of Alcohol: Cradle to Grave and Faces of Combat: PTSD and TBI.

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