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A roadside explosion throws a Soldier against the side of his vehicle hard enough to shake his brain inside his skull. Another Soldier is in a traffic accident on the way to work, and her head is thrown forward into the windshield. A family member takes a hard fall during a sports game, hitting his head on the ground.
Different situations often have the same result: a mild traumatic brain injury, better known as a concussion.
A concussion is an injury that causes an alteration of a person's mental status. You had your "bell rung". You are dazed and confused. More serious brain injuries that cause unconsciousness for 30 minutes or more are usually quickly recognized, but concussions may be dismissed and go untreated.
"It's the same as we see in a football game on TV, but no one comes out and holds up two fingers for you to count," said Lt. Col. Lynne Lowe, TBI program director in the Office of the Surgeon General of the Army.
"If you have a car accident and the EMTs come, they are likely to tend to your bleeding and not check for concussion. You are likely to be so happy you're alive, you don't think about concussion," she added.
Most people recover from concussions in a short time – as long as they do not repeat the injury.
"If someone has a concussion, we want them to be evaluated. It is very important that we protect them from getting another concussion before their brain heals," Lowe said.
Symptoms of concussion can include confusion, headaches, dizziness, ringing in the ears or nausea. These symptoms are usually resolved within hours or a few days. Some people do have more persistent symptoms, however, which can include trouble sleeping, irritability or blurred vision.
"Providers can give medication for headaches or dizziness and reassure them that they will be OK, because most people will be OK," Lowe said. "We teach them about what it means to have a concussion and some of the warning signs of a worsening condition. If symptoms last longer, more formal testing can be done…It's a step care model. Give them what they need, while always using our best judgment and available guidance.
"Just reassurance is very therapeutic in itself. Research proves that reassurance and education contribute to better outcomes," she said.
The military has developed two tools to help medical professionals diagnose concussions. The Mild Acute Concussive Evaluation is part of treatment protocols used in the Department of Defense for injuries less than seven days old.
A doctor or medic will ask about the subject's medical history and test memory and thinking ability. The subject may be asked to repeat a sequence of words or count backward.
"It isn't that a bad score means you have a TBI," Lowe said. "The score means nothing by itself. It informs the decision, but doesn't form a diagnosis."
The Automated Neuropsychological Assessment Metric is a computer-based neurocognitive test. From the full 45-minute test battery, the military has extracted several tests associated with brain injury that take about 15 minutes to complete.
Soldiers complete this test before deploying. If there is an incident that might produce a concussion, medical personnel on site can e-mail for the baseline results and compare them to a post-injury test.
Again, ANAM is not diagnostic, but it is a tool a trained health care provider can use to help make a diagnosis.
The Army has carried out a well-publicized campaign to convince Soldiers who may have suffered a concussion in combat to seek treatment, but TBIs are not injuries limited to combat and can result from sports, vehicle accidents or everyday activities that produce falls or bumps.
"Whether you're going down a snow ramp on a tube, riding a bicycle or playing contact sports, it's a good idea to wear a helmet," said Larry Whisenant, chief of the safety office at Army Medical Command Headquarters. "Even children on a bicycle carrier should have helmets. It's such an easy thing to do, and it can prevent a lot of grief.
"Some states don't require a helmet when riding a motorcycle, but the Army requires it of Soldiers, regardless of state law," he added.
Whisenant said safe helmets should bear a seal of approval from either the U.S. Department of Transportation or the Snell Memorial Foundation.
"A…helmet that lacks a DOT or Snell seal is not good. It may look good riding down the highway, but it doesn't provide the protection you need," he said.