Brain Warrior: Retired Army Gen. Peter Chiarelli on ‘dumb’ sports commentators, ‘horrible’ concussion tests and medicine’s chance to help people on and off the battlefield
Q: When did you first realize that traumatic brain injuries (TBI) were a significant problem?
A: I spent two tours in Iraq, and quite frankly, I didn’t know what TBI was. A traumatic brain injury to me was a concussion, and a concussion was my football coach telling me when I got dinged that I should just shake it off and get back in the game and I would be fine. That’s what I knew about traumatic brain injury from my two tours.
I became vice chief of staff in 2008, and the fourth day on the job they showed me a chart that showed traumatic brain injury and post-traumatic stress made up 36 percent of our most seriously wounded, as opposed to 10 percent who had lost an arm or leg or multiple limbs. These were by far the most prolific wounds coming out of the war, and I didn’t know anything about them.
Q: And you started to educate yourself?
A: Yes, traumatic brain injuries and post-traumatic stress are “co-morbid” in the military. A kid can get bonked on the head, but in the same engagement, he might see his buddy lose a leg or arm or multiple limbs. Or he might see his buddy die and spend three or four hours picking up body pieces to put into a body bag to send back home. He might do this even though he had been concussed. His injury was not only the blow to the head, but also the traumatic event that occurred after that. We had that time after time again.
But I was like most Americans who, when they think something is wrong with them, go to the doctor, who takes some tests and tells you what the problem is. I thought that was going to happen with TBI, that diagnoses would be based on something definitive. What I’ve come to find out in time is that nothing can be further from the truth.
There are people who will tell you that they can diagnose TBI, but they’re lying to you. They can’t. No one has a good outcome measure for a concussion that will tell you what you’re going to be like in six months. At the end of six months, some people (with concussions) might not have missed a day of work. Others who are told they have a mild traumatic brain injury won’t work another day and will develop huge cognitive issues.
Q: So you don’t think much of existing tests (such as the Automated Neuropsychological Assessment Metrics, or ANAM, and Glasgow Coma test)?
A: Glasgow Coma and ANAM are horrible tests. But they’re probably the best we have. And it’s even worse when it comes to post-traumatic stress. We have 17 questions we give people, and based on the score they get, they are given or not given a diagnosis of post-traumatic stress.
Q: How did you address the issue?
A: I’m a pretty analytical guy. If we have a problem, we go to the experts and find out how to fix it. In this case, the experts didn’t know a God-dang thing about how to fix the problem. If you dig into this, you’ll find out that there’s 3.4 million Americans who will get head traumas this year, and that the National Institutes of Health is spending just $84 million on head trauma research. This is a $78 billion problem in direct medical costs, and all you’re doing is spending $84 million to get at it? If you were a CEO of a company with a $78 billion problem, and your R&D budget was $84 million, you wouldn’t be CEO for very long.
Q: So when you came to realize the significance of the problem, you went to David Hovda (director of the University of California-Los Angeles’ Brain Injury Research Center)?
A: I went to the guys who I thought would tell me how to fix the problem. (Gen.) Jim Amos, who at that time was assistant commandant of the Marine Corps and is now commandant, brought (David Hovda) to Washington, D.C.
David had done some amazing stuff with positron emission tomography, which was really helpful to Jim and I. Because we could show a kid that his football coach was wrong, that when he was concussed, there was a change in his brain. It was a real eye-opener. It got at the stigma associated with something you couldn’t see. Now you could see it and show a concussed brain, and how it shuts down.
We brought him back, got him in a room with a bunch of our doctors, and we came to find out that no one would agree. They attacked David, saying, “What do you mean taking a kid out of a fight. You’re going to hurt him forever if you do that.” They said, “We don’t know that these concussions are dangerous.” We heard all this bickering. You would stick a hypothesis on the table with 15 people and you would get 16 answers, and someone would contradict himself by the time we got around the table.
We stormed out of that meeting. We were disgusted. So we established a blue-ribbon panel of 15 of the most pre-eminent TBI experts and only allowed one Army doctor to come to the panel, the surgeon general. They came up within two days with protocols for how we were going to handle our kids downrange.
Q: That was the spark?
A: That was the spark. I said, “We’ve got to do something. We’re having a kid on Tuesday get a concussion and get another on Thursday.” Everyone agreed that if you get a concussion and get a second one before the first heals you are at great and high risk of having cognitive issues associated with that. So if you get 99 percent of the people to agree with something, Jim and I said, “Well, why don’t we take that out of play?”
So we put a protocol in place that you’re automatically screened for a concussion if you’re in a vehicle that’s damaged, if you’re outside a vehicle within 50 meters of an explosion, or inside a building where an explosion takes place, and if you lose consciousness for any period of time. If you failed the test, you were immediately sent to a concussion recovery center, or a place where a multidisciplinary team watched over your healing. And then once that concussion healed, you were sent back to your unit.
Q: All this was pretty late in the game. We had been in Iraq and Afghanistan for about seven years.
A: Yeah, it was, but how long have we been playing football in this country? We beat them (the NFL). And when it comes to football, I hear all kinds of stupidity on the TV today with these commentators. I heard the dumbest comment I’ve heard in my life from a coach about this idea of hitting them high or low. His comment was something to the effect that the most highly technical piece of equipment on the field is the helmet, so why are we telling people to hit low at the knee when there’s no protection at the knee. We should tell them to hit high at the head because that’s where the protection is.
I wanted to say: Listen dumb (expletive), do you understand that your head is already in a helmet called the skull? The helmet protects against cracking the skull, but it does not help against the acceleration that takes place when the head is whipped. That helmet does absolutely no good, and most concussions are caused by the acceleration of the head, up, down, left, right. And the movement of the brain inside the skull. The helmet does not protect at all against that. That is the level of ridiculousness we have of people not understanding what the issue is.
Q: You’re very outspoken about your concerns about TBI research?
A: I thought I worked in the most inefficient place in the world in the Pentagon, but we look so efficient compared to the way medical research is done in this country.
You probably found out about me from Google and then called me up. Well, medicine doesn’t do this. How do we pass out our research findings? We do it through overpriced refereed journals that can delay publication of key findings for months and years based on a publisher’s schedule. We put up with that crap? So, you know, I find it to be unbelievable. But it is what it is.
Q: You are very passionate about this.
A: I want to help these kids. There are 265,000 of them. That’s from this war. What about the other wars?
Q: When it comes to TBI and post-traumatic stress, where are we on the spectrum today compared to, say, 2009?
A: We’ve done a heck of a lot to at least eliminate a stigma from invisible wounds. I know some people criticize the term “invisible wounds,” but they are invisible. They’re different than the loss of a leg or a bullet hole in the arm. And there’s always been a stigma associated with injuries to the brain.
We’ve done a lot to provide care to our folks when they’re concussed.
The safest place to get a concussion in the world today is the Marine Corps sector in Afghanistan. They have one of the finest facilities I’ve ever seen to care for someone with a concussion, to evaluate them, put a multidisciplinary team to get them well. That’s all good.
But we’ve been an abysmal failure when it comes to research. I heard a senior Army official say recently that since 2006 we spent $700 million on TBI research. So what? What have you got out of it? You haven’t even replaced Glasgow Coma. You ought to say, “I’ve spent $700 million, and I don’t have ... much to show for it.”
Q: The Colorado Springs newspaper did a series recently showing that soldiers were getting kicked out for misbehavior when their actions likely were related to TBI. How do you differentiate those with real problems from those who don’t?
A: The symptoms of post-traumatic stress also are the symptoms of a bad soldier, issues of anger, alcohol, periods of hyper-arousal — all things that get people into trouble. But we don’t have (good) tests for PTS or TBI, so what’s hard here is how you differentiate between that person who is demonstrating bad behavior because they’re not a good person as opposed to something related to a traumatic experience. We need to go beyond asking 17 questions, beyond ANAM, MACE. That’s why research is so important.
Q: Have there been any other defining moments for you on this issue?
A: Yes, one was reading an article by (New York Times columnist) Nicholas Kristof about Ben Richards, a story called the Wounds of War in August of last year. In that article, Richards, who had really debilitating traumatic brain injuries, said he would have much rather lost a leg than had TBI. To me, that was a real indictment. I’ve come to know Ben since then, and that to me says it all. We owe these folks more, and we’ve got to find a way to help them out.