Providence VA Medical Center, Rhode Island
The PVAMC OEF/OIF/OND Polytrauma/TBI Program
The Providence VAMC has developed a well defined, well tuned system for identifying and treating Veteran's with Polytrauma/TBI. The identification of TBI (Traumatic Brain Injury) has been covered widely in the media often leaving some misunderstandings about what TBI is and is not. The Polytrauma/TBI Team here has embraced and implemented the VHA Directive to screen all service members returning from deployment in OEF/OIF to determine if a deployment-related traumatic brain injury/concussion had been sustained.
The Initial screen is called the TBI Clinical Reminder. This reminder is completed with all returning Veterans as they enter the VA Health Care System. The reminder is composed of a set of yes/no questions which when administered will identify exposures to events with risk for TBI. Assessment for alteration of consciousness, immediate onset of post concussive symptoms and persistence of these symptoms currently are critical to accurate determination of a positive or negative TBI Screen.
Veterans who screen positive are referred for a Comprehensive Second Level Evaluation. Education is provided to the Veteran of the process/purpose of this evaluation. Providers involved in this evaluation are a Neurologist, Neuropsychologist and Social Worker. Our Neurologist, Dr. Mernoff leads the Team; Dr. Correia and Dr. Spencer complete the neuropsychological evaluation and Marie Sullivan LICSW, CCM, completes the initial psychosocial assessment at the beginning of each Second Level Evaluation. The intention of this Evaluation is to assess the likelihood a Veteran sustained a TBI and to estimate the severity of the injury. The nature of current symptoms are assessed and clinicians' opinion about the extent to which these symptoms are due to TBI and/or other factors such as psychosocial factors. The process is limited by reliance on Veterans’ self-report of their injury since documentation at the time of injury is rarely available. Here at the PVAMC, Drs. Mernoff, Correia and Spencer have "adopted a fairly simplified clinical guideline for determining the presence or absence of TBI; a patient who can relate a continuous narrative before/during and after an event seems unlikely to have suffered a physiologic disruption of brain function. We have found this guideline to be quite helpful in deciding ambiguous cases."*
Education about TBI is provided to each Veteran. The result is the establishment of a comprehensive treatment plan one in which the Veteran is actively involved. The written Treatment Plan, with provider contact information, is given to the Veteran at the end of the Second Level Evaluation. Support is in place with the social worker providing case management to the Veteran.
Our Polytrauma/TBI program is now identified nationwide as a Polytrauma Support Clinic Team (PSCT). This designation is due to the volume, intensity of care and resources the PVAMC has invested in providing outstanding assessment and treatment to our Veterans. The Team is led by Dr. Mernoff and includes many additional committed disciplines such as Neuropsychology, a Primary Care Physician, Psychologist specializing in PTSD, Physical, Occupational and Speech Therapists and the Social Worker/Case Manager. Each Veteran completing the Second Level Evaluation is reviewed the following week at Team Meeting. This allows the Team to discuss and make recommendations for any additional care the Veteran may benefit from. Each Polytrauma/TBI Veteran is reviewed by the team about once every three months or more frequently, if needed, and monitored for progress and participation in their treatment plan. The goal of our program is to identify the issues that are treatable for our Veterans (such as PTSD, depression, anxiety disorders, substance abuse, sleep deprivation, chronic pain, employment, marital distress, returning to school, and adjustment to civilian life). In treating these co-occurring conditions our goal is to lessen symptoms and improve the Veteran's quality of life.
*Excerpted from the article: Military Blast Injury in Iraq and Afghanistan: The Veterans Health Administration’s Polytrauma System of Care; by Stephen T. Mernoff, MD,FAAN, and Stephen Correia, PhD. Published in Medicine & Health Rhode Island, Vol 93, No1, Jan.2010