For many returning soldiers, traumatic brain injuries — the most-common wound suffered in the wars in Iraq and Afghanistan — remain encased in a black box of secrets and science we still don’t understand.

Some injuries are so severe they require skulls to be pieced back together. Others, called mild TBIs, are often completely hidden by a series of mazes, wispy threads and tissues within the brain.

Another war matter continues to go unnoticed by many: The Minnesota medical community is not adequately prepared to care for the potentially thousands of returning veterans dealing with a complex set of symptoms caused by TBIs, according to a recent study.

Mild TBIs, which occur after a concussive blast from improvised explosive devices, can impair decision-making, memory and concentration, and cause unexplained anger. But unlike post-traumatic stress disorder, another affliction associated with war, TBIs are injuries to the actual brain — not just the psyche. 

20 percent of troops affected
The U.S. Department of Defense estimates that nearly 20 percent of troops are suffering from mild TBIs. That's 340,000 of the 1.7 million service members deployed to Iraq and Afghanistan, says Paul Sullivan, the Washington, D.C.-based executive director for Veterans for Common Sense.

According to a study released in November by the Minnesota Department of Veterans Affairs, soldiers from outstate Minnesota are disproportionately affected. For one thing, most of the Minnesotans serving in the wars are from outlying areas of the state. For another, they're dealing with unmet needs resulting from the lack of trained specialists where they live. Meanwhile, their counterparts from the Twin Cities area have easier access to the VA Medical Center in Minneapolis.

Dr. William Sheehan, a psychiatrist and former head of psychiatry in the department of neurosciences at the University of North Dakota, surveyed 45 general hospitals, psychiatric hospitals and community mental-heath centers across Minnesota for the state study, and concluded: "The current system is very haphazard and patchwork for meeting needs of these veterans and Guardsmen, and in particular there are enormous obstacles — both logistical and institutional — to veterans seeking care in local, and especially rural, areas. Apart from the VA system [based in Minneapolis], there is virtually nothing available to meet their service-related needs of brain-injured veterans."

These results come even as 24 percent of the facilities surveyed in the state offered specialized services, including treatment of traumatic brain injuries.

VA already short on funds
This doesn't surprise Paul Sullivan, who served in the Gulf War and gave up his work two years ago as a VA analyst in Washington to fight for veterans' rights. Yet he also offers this warning: The VA, which already is suffering from inadequate funding and lengthy waiting periods, does not have a plan in place to treat these injuries. 

"While VA opened four polytrauma centers (and they plan to open more soon) to handle the thousands of severe TBI, VA has no plan to identify and treat all TBI patients, from mild to severe," he says.

"TBI is critical, yet so is PTSD," he adds. "Most of the soldiers with TBI also have cognitive plus mental health conditions. So VA needs to screen, examine and treat for TBI and PTSD at the same time." Sullivan thinks the VA is "passive" on this issue. While the VA screens veterans seeking care at its facilities, there is no mandatory examination for service members.
 
And what about the growing number of soldiers who still are not receiving adequate care once they are "officially" diagnosed? "The simple solution is for President George W. Bush to institute a limited draft of physicians, especially psychiatrists and TBI specialists, so DoD and VA can meet the crush of demand," he says.

Meanwhile, in Minnesota, a simple solution could take years. The state study's authors, along with state Rep. Al Juhnke, DFL-Willmar, recommend creating a state-of-the-art diagnostic and treatment facility to meet the needs of the thousands of outstate soldiers. Sheehan plans to present his findings during the next legislative session.