CTE, Chronic Traumatic Encephalopathy due to failure to diagnose and treat Traumatic Brain Injury

“But we may be able to learn that early treatment of the initial acute [brain] injury may avoid this cascade from brain injury to CTE.”

As a civilian contractor you will be denied early treatment by the defense base act insurance company. 

David Woods The Huffington Post  September 20, 2012

WASHINGTON — Almost a quarter million American troops diagnosed with traumatic brain injury are at risk of developing a degenerative disease that causes bursts of anger and depression and can lead to memory loss, difficulty walking and speaking, paranoia and suicide, according to military researchers.

At present, medical officials cannot diagnose or prevent the disease, called Chronic Traumatic Encephalopathy, and there is no known treatment for it, said Army Col. Dallas Hack, director of the Army’s Combat Casualty Care Research Program.

But researchers are hot on the trail of new procedures to detect and diagnose the disease, and there is hope that early detection of brain injury among troops exposed to blasts from improvised explosive devices in Afghanistan could prevent them from falling victim to CTE.

“We don’t fully understand the incidence of CTE with the occurrence of traumatic brain injury,” said Air Force Lt. Col. Randall McCafferty, chief of neurosurgery at the San Antonio Military Medical Center. “But we may be able to learn that early treatment of the initial acute [brain] injury may avoid this cascade from brain injury to CTE.”

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War is Brain Damaging

The Defense Base Act Insurance Companies and the Department of Labor are as negligent as the Department of Defense when it comes denying the dangers of Post Traumatic Stress Disorder and Traumatic Brain Injury, and most negligently when a contractor suffers from both.

“a potentially lethal combination of post-traumatic stress disorder and traumatic brain injury. When the frontal lobe — which controls emotions — is damaged, it simply can’t put on the brakes if a PTSD flashback unleashes powerful feelings. Seeing his buddy’s leg blown off may have unleashed a PTSD episode his damaged brain couldn’t stop”

The New York Times Sunday Review

These vets suffer from a particular kind of brain damage that results from repeated exposure to the concussive force of improvised explosive devices — I.E.D.’s — a regular event for troops traveling the roads in Iraq and Afghanistan.

“It’s Russian roulette,” one vet told me, “We had one guy in our company who got hit nine times before the 10th one waxed him.” An I.E.D. explosion can mean death or at least a lost arm or leg, but you don’t have to take a direct hit to feel its effects. A veteran who’d been in 26 blasts explained, “It feels like you’re whacked in the head with a shovel. When you come to, you don’t know whether you’re dead or alive.”

The news that Robert Bales, an Army staff sergeant accused of having killed 16 Afghan civilians last week, had suffered a traumatic brain injury unleashed a flurry of e-mails among those of us who have been trying to beat the drums about this widespread — and often undiagnosed — war injury. New facts about Staff Sgt. Bales are coming out daily. After we heard about the brain injury that resulted when his vehicle rolled over in an I.E.D. blast, we were told that he had lost part of his foot in a separate incident. Then we learned that the day before his rampage, he’d been standing by a buddy when that man’s leg was blown off. There are also reports of alcohol use.

People with more appropriate professional skills than mine will have to parse these facts, but from what I have learned in my work as a storyteller, this tragedy may be related to something I heard about in my interviews: a potentially lethal combination of post-traumatic stress disorder and traumatic brain injury. When the frontal lobe — which controls emotions — is damaged, it simply can’t put on the brakes if a PTSD flashback unleashes powerful feelings. Seeing his buddy’s leg blown off may have unleashed a PTSD episode his damaged brain couldn’t stop. If alcohol was indeed part of the picture, it could have further undermined his compromised frontal lobe function

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U.S. serviceman kills 16 in house-to-house village shooting, Afghan officials say

By msnbc.com staff and news services  March 14, 2012

Updated at 7:59 a.m. ET: KABUL, Afghanistan — The U.S. soldier who allegedly shot 16 Afghan villagers was caught on surveillance video that showed him walking up to his base and raising his arms in surrender, Afghan officials who viewed the footage said.

The video reportedly was shot from a blimp and showed the soldier walking up to his base covered in a traditional Afghan shawl. The soldier removed the shawl and put his weapon on the ground, then raised his arms in surrender, unidentified Afghan officials told Reuters and The Associated Press.

---

The video had been shown to investigators to help dispel a widely held belief among Afghans, including many members of parliament, that more than one soldier must have been involved because of the high death toll, the officials told journalists.

Shooting suspect was trained sniper  March12, 2012

The soldier detained for the shootings in Afghanistan was a qualified infantry sniper, a senior Department of Defense official told CNN. (See also: heightened security in Afghanistan)

The soldier was injured in a vehicle rollover while in Iraq in 2010, according to the official. The official described it as a non-combat rollover. He was diagnosed with Traumatic Brain Injury (TBI) but was found fit for duty.

His family has been moved on to Joint Base Lewis-McChord for their safety, the official said.

After an Afghan soldier alerted the U.S. military at the base of the soldier’s initial departure, the U.S. military put up an aircraft to search for the missing soldier. Soon after, Afghan civilians came to the gate carrying wounded civilians, the first indication the military had of the shooting.

When the soldier turned himself over to the search party, he immediately invoked his rights not to speak. He has been moved to Kandahar and put in pre-trial confinement, a congressional source told CNN.

Seattle Times  March 11, 2012 10pm

“It appears he walked off post and later returned and turned himself in,” said Lt. Cmdr. James Williams, a military spokesman. The NATO force said the assailant acknowledged he had inflicted an unspecified number of casualties during the shootings, which began about 3 a.m.

The soldier’s name has not been released, but a U.S. official told ABC News he is a 38-year-old staff sergeant who is married with two children and had served three tours in Iraq. This was his first tour in Afghanistan, where he has been since early December, the official said.

Separately, a senior U.S. military official confirmed that the sergeant was attached to a unit based at Lewis-McChord, located near Tacoma, and that he had been part of what is called a village-stabilization operation in Afghanistan, in which teams of Green Berets, supported by other soldiers, try to develop close ties with village elders, organize local police units and track down Taliban leaders. The official said the sergeant was not a Green Beret himself.

Soldier accused in Afghan killings from Lewis-McChord

JOINT BASE LEWIS-MCCHORD, Wash. – A soldier accused of killing 16 Afghan civilians in cold blood is based at Joint Base Lewis-McChord, ABC News is reporting.

The soldier is reported to be a 38-year-old staff sergeant. His name and unit were not immediately available.

LA Times  March 11, 2012

Reporting from Kabul, Afghanistan — A lone American serviceman slipped away from his base in southern Afghanistan before dawn Sunday and went on a methodical house-to-house shooting spree in a nearby village, killing 16 people, nearly all of them women and children, according to Afghan officials who visited the scene.

The NATO force confirmed that the assailant was in military custody, and that he had inflicted an unspecified number of casualties during the shooting spree at about 3 a.m. Sunday. The U.S. Embassy called for calm and expressed deep condolences; the Taliban referred to the killings as an “act of genocide.”

The British Broadcasting Corp. reported that the shooter was a staff sergeant and a member of the U.S. special operations forces who had been involved in training the Afghan police.

The incident, potentially the worst atrocity of the 10-year war to be deliberately carried out by a single member of the Western military, represents a stunning setback to U.S.-Afghan relations, already shaken by last month’s burning of copies of the Koran at a U.S. military base north of Kabul

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Testing Program Fails Soldiers, Leaving Brain Injuries Undetected

A version [1] of this story was co-produced with NPR and aired on All Things Considered [2]. (Check here for local listings [3].)

T Christian Miller and Joaquin Sapien at ProPublica  and Daniel Zwerdling at NPR

In 2007, with roadside bombs exploding across Iraq, Congress moved to improve care for soldiers who had suffered one of the war’s signature wounds, traumatic brain injury

Lawmakers passed a measure requiring the military to test soldiers’ brain function before they deployed and again when they returned. The test was supposed to ensure that soldiers received proper treatment.

Instead, an investigation by ProPublica and NPR has found, the testing program has failed to deliver on its promise, offering soldiers the appearance of help, but not the reality.

Racing to satisfy Congress’ mandate, the military chose a test that wasn’t actually proven to detect TBI: the Automated Neuropsychological Assessment Metric, or ANAM.

Four years later, more than a million troops have taken the test at a cost of more than $42 million to taxpayers, yet the military still has no reliable way to catch brain injuries. When such injuries are left undetected, it can delay healing and put soldiers at risk for further mental damage.

Based on corporate and government records, confidential documents, scores of interviews and emails obtained under the Freedom of Information Act, our investigation found:

• The people who invented ANAM and stood to make money from it were involved in the military’s decision to use it, prompting questions about the impartiality of the selection process. No other tests received serious consideration. A report [4] by the Army’s top neuropsychologist circulated last year to key members of Congress labeled the selection process “nepotistic.”
• The Pentagon’s civilian leadership has ignored years of warnings, public and private, that there was insufficient scientific evidence the ANAM can screen for or diagnose traumatic brain injury. The military’s highest-ranking medical official said the test was “fraught with problems.” Another high-ranking officer said it could yield misleading results.
• Compounding flaws in the ANAM’s design, the military has not administered the test as recommended and has rarely used its results. The Army has so little confidence in the test that its top medical officer issued an explicit order [5] that soldiers whose scores indicated cognitive problems should not be sent for further medical evaluation.
• Top Pentagon officials have misrepresented the cost of the test, indicating that because the Army invented the ANAM, the military could use it for free. In fact, because the military licensed its invention to outside contractors, it has paid millions of dollars to use its own technology.
• The military has not conducted a long-promised head-to-head study to make sure the ANAM is the best available test, delaying it for years. Instead, a series of committees have given lukewarm approval to continue using the ANAM, largely to avoid losing the data gathered so far.

Several current and former military medical officials criticized the Defense Department’s embrace of a scientifically unproven tool to use on hundreds of thousands of soldiers with TBIs.

“The test was not developed for the purposes of identifying the kinds of problems that we see in concussions,” said Dr. Stephen Xenakis, a retired brigadier general and former adviser on mental health issues to the chairman of the joint chiefs of staff. The test was picked “without asking ourselves the questions: what are we trying to achieve here and what are we going to use the screenings for?

Please read the entire article at ProPublica

Gov’t Watchdog Criticizes Pentagon Center for PTSD, Brain Injuries

By T Christian Miller and Joaquin Sapien at ProPublica  July 11, 2011

If you want more explanation about the military’s troubles in treating troops with traumatic brain injuries and post-traumatic stress, read no further than two recent but largely unnoticed reports from the Government Accountability Office.

It turns out the Pentagon’s solution to the problems is an organization plagued by weak leadership, uncertain priorities and a money trail so tangled that even the GAO’s investigators couldn’t sort it out. The GAO findings on the Pentagon’s Defense Centers of Excellence (DCOE) echo our own series [1] on the military’s difficulty in handling the so-called invisible wounds of war.

“We have an organization that exists, but we have considerable concern about what it is that it’s actually accomplishing,” said Denise Fantone, a GAO director who supervised research on one of the reports. She added: “I can’t say with any certainty that I know what DCOE does, and I think that’s a concern.”

First, some background. After the 2007 scandal over poor care delivered to soldiers at the Walter Reed Army Medical Center, Congress ordered the Pentagon to do a better job treating soldiers suffering from post-traumatic stress disorder and traumatic brain injury. The Pentagon’s answer was to create DCOE [2]. The new organization was supposed to be a clearinghouse to foster cutting-edge research in treatments.

DCOE was rushed into existence in late 2007. Since then, it has churned through three leaders, including one let go after alleged sexual harassment of subordinates [3]. It takes more than five months to hire each employee because of the federal government’s glacial process. As a result, private contractors make up much of the center’s staff.

“DCOE’s development has been challenged by a mission that lacks clarity and by time-consuming hiring processes,” according to the first report in the GAO series [4], focusing on “management weakness” at DCOE.

Just as concerning, the GAO says that it can’t quite figure out how much money DCOE has received or where it has all gone. DCOE has never submitted a budget document that fully conformed to typical federal standards, according to a GAO report released last month [5]. In one year, the center simply turned in a spreadsheet without detailed explanations.

Please read the entire article at ProPublica

In harm’s way

Press Democrat.com  July 3, 2011

As the sun blazed on a rocky southern Afghanistan hillside, Air Force Staff Sgt. Mark Badger watched his bomb squad teammate get blown up by a buried explosive device.

Moments earlier, Badger, 30, who was born and raised in Santa Rosa, had stepped away from Senior Airman Daniel Johnson along the road where they were clearing bombs in the violence-prone Kandahar province, a Taliban stronghold.

Johnson took a single step in exactly the same direction Badger had just walked, and 40 pounds of chemicals packed in a plastic jug exploded beneath his feet.

“I remember it like it happened yesterday,” said Badger, now stationed at Peterson Air Force Base in Colorado Springs, Colo. He lives near the base with his wife, Trisha, and their 8-month-old daughter, Scarlet, and still suffers headaches, confusion, sleep loss and other symptoms of brain injury from two bomb blasts in the span of three days last October.

There are about 5,500 bomb techs in the four branches of the service, and their job is probably the most dangerous one in Afghanistan. Unable to match American firepower on the ground or in the air, the Taliban plant roads, fields and some buildings with IEDs (improvised explosive devices), most of them buried and triggered by pressure plates or by command wires up to a half-mile long.

“Anywhere you step could be an IED that will blow off your legs or kill you,” Badger said.

Please read the entire story at the Press Democrat

Army Plans New Guidelines to Resolve Denials of Purple Hearts to Brain-Injured Soldiers

T Christian Miller and Dan Zwerdling ProPublica and NPR March 18, 2011

Acknowledging that commanders have sometimes wrongly denied the Purple Heart to soldiers who suffered battlefield concussions, the Army plans to issue new guidance to clarify when such recognition is warranted, Army officials said Wednesday.

In addition, the Army is planning to prioritize appeals from brain-injured soldiers who feel they should not have been turned down for the medal, a hallowed military honor that recognizes those injured in combat.

Gen. Peter Chiarelli, the Army’s second in command, said hereviewed the Army’s policies on the Purple Heart and called for the new guidelines as a result of an investigation byProPublica and NPR [1]. In a report published last September [2], we found that Army commanders denied Purple Hearts to some soldiers who sustained concussions, despite regulations that make those who suffer such wounds eligible for the medal.

Please read the entire article here

Deployment brain injuries, amputations jumped in 2010, U.S. Army reports

There are no numbers available for Contractors though there are more Contractors than Military in the War Zones.

By Bryant Furlow at Epinewswire

Despite the Obama administration’s ramping down of combat operations in Iraq, 2010 saw the highest number of troops with reported traumatic brain injuries (TBIs) for any year of the U.S. occupations of Iraq and Afghanistan — and more than twice the number of deployment-related amputations seen in 2009, according to a newly-released report by the Armed Forces Health Surveillance Center.

2010 saw 7,270 deployed troops hospitalized or treated for TBIs, or about 20 new cases per day, the report shows.

That is more than any other year between 2003 and 2010, and represents a 34 percent jump from 2009′s count of 5,818 soldiers with TBI. Only 2008 came close to matching the 2010 numbers, with 7,263 soldiers with brain injuries during deployment. Between 2003 and 2010, a total of 33,446 soldiers have been hospitalized or treated for TBIs during or within 30 days of deployments, according to the report.

Only raw counts, not incidence rates, were described in the report.

The actual numbers are likely higher than reported, however. Data for 2010 was compiled in January and February 2011, for example, before administrative records for hospitalizations in late 2010 had all been reported. And even though the Pentagon acknowledges TBI symptoms may not emerge, or may not be recognized, until after soldiers return home from combat deployments, the new study only reports TBIs diagnosed during deployment or within 30 days of the end of a soldier’s deployment. Furthermore, a footnote in the report reveals that more than 2,700 soldiers hospitalized or treated for TBI during deployment were excluded from analysis because of pre-deployment histories of TBI.

Only a soldier’s first TBI diagnosis is counted, so the report does not reveal how many soldiers have suffered repeated brain injuries.

Reported brain injuries prior to 2008 are also likely underestimates.  During that time, military physicians noted in memos obtained by epiNewswire that reporting of combat injuries was incomplete. And as epiNewswire revealed in 2007, the Army had not yet implemented by that year a long-standing order to screen returning combat veterans for brain injuries.

Last year also saw a dramatic rise in amputations during or within a year of deployment, from 88 amputations in 2009 to 182 in 2010, the report shows. That’s more than any year of combat operations in Iraq and Afghanistan except 2007, when 205 soldiers underwent deployment-related amputations.

A total of 1,138 soldiers had deployment-associated limb amputations between 2003 and 2010, according to the new report.

The report shows a slight increase in sand fly-vectored leishmaniasis infections (called the “Baghdad boil” by soldiers), from 48 cases in 2009 to 65 cases in 2010. While those numbers likely represent genuine declines from the 622 cases reported in 2003, epiNewswire reported in 2007 that the Army had curtailed field reporting of leishmaniasis infections from Iraq, resulting in underestimations of actual infection rates.

The new report was released March 4, and details the numbers of deployment-associated TBIs, pulmonary emboli and deep-vein thrombosis, amputations, heterotopic ossification (aberrant bone growth following trauma), severe pneumonia, and leishmaniasis between 2003 and 2010.

Source: U.S. Armed Forces Health Surveillance Center. Deployment related conditions of special surveillance interest, U.S. Armed Forces, by month and service, January 2003-January 2011 (data as of 01 March 2011). Medical Surveillance Monthly Report, February 2011;18(2):13. (Report released March 4, 2011.)

Please see the original at Epinewswire

Invisible Wounds can be Fatal

AUSTRALIAN families, friends and communities have buried 23 soldiers killed in Afghanistan since 2002.   The Courier Mail Sunday Mail Australia

Each one was hailed for their heroism, remembered for their larrikinism and commended for their dedication to their mates and their mission.

But there is an even sadder and often silent statistic that is forgotten – the number of soldiers, sailors and airmen and women who have ended their lives for reasons that don’t command a full military funeral or public acknowledgement by politicians.

New Defence figures show that 31 enlisted Defence personnel have, or are believed to have, committed suicide since 2005.

Of those, 10 were in Queensland  the highest among the states, with seven suspected suicide cases in NSW and six in the ACT.

The suspected suicide deaths of two other Queensland soldiers earlier this year are also being investigated by the coroner but are not included in the figures at this stage.

Young Diggers president John Jarratt believes the number of confirmed suicides is just the tip of the iceberg with many more going unaccounted for once they have been discharged from the defence forces.

“Look at Vietnam. The number killed was far outweighed by the number who took their own life in the years after their service,” Mr Jarratt said.

“We call it the invisible wounds of war, people dying not in combat but as a result of combat, years later.”

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ProPublica Honored With Two George Polk Awards

by Minhee Cho at ProPublica

ProPublica is pleased to announce that it has won two George Polk Awards this year, in collaboration with our partners NPR and Frontline, for the series “Brain Wars” and “Law & Disorder.”

A collaborative project by ProPublica’s T. Christian Miller and NPR’s Daniel Zwerdling and Susanne Reber, “Brain Wars ” found that the U.S. military was failing to diagnose and treat traumatic brain injuries suffered by soldiers. It has been selected for the George Polk Award for Radio Reporting.

ProPublica’s A.C. Thompson along with our partners Raney Aronson and Tom Jennings at Frontline and Laura Maggi and Brendan McCarthy at The Times-Picayune won the George Polk Award for Television Reporting for “Law & Disorder,” which took an in-depth look at the controversial and often brutal actions taken by the New Orleans Police Department in the aftermath of Hurricane Katrina.

The George Polk Awards are conferred every year to honor special achievement in journalism, particularly investigative and enterprise reporting. ProPublica’s Abrahm Lustgarten [3] was among the winners last year for his reporting on the dangers of drilling for natural gas [4].

Congratulations to all of the winners [5].  Please see the original here

Congress to Investigate Pentagon Decision to Deny Coverage for Brain Injured Troops

By T Christian Miller ProPublica and Daniel Zwerdling at NPR

WASHINGTON, D.C.–A key congressional oversight committee announced [1] today that it was opening an investigation into the basis of a decision by the Pentagon’s health plan to deny a type of medical treatment to troops with brain injuries.

Sen. Claire McCaskill, D-Mo., the chairman of the subcommittee on contracting oversight, said she wanted to examine a contract issued by Tricare, an insurance-style program used by soldiers and many veterans, to a private company to study cognitive rehabilitation therapy for traumatic brain injury. Such injuries are considered among the signature wounds of the wars in Afghanistan and Iraq.

The study, by Pennsylvania-based ECRI Institute, found insufficient or weak evidence to support the therapy. Often lengthy and expensive, cognitive rehabilitation programs are designed to rewire soldiers’ brains to conduct basic life tasks, such as reading books, remembering information and following instructions. ECRI’s findings ran counter to several other studies, including ones sponsored by the Pentagon and the National Institutes of Health, which concluded that cognitive rehabilitation was beneficial.

In a letter to Defense Secretary Robert Gates, McCaskill cited an investigation [2] by ProPublica and NPR in December, which found that top scientific experts had questioned the Tricare-funded study in confidential reviews, calling it “deeply flawed” and “unacceptable.”

“If true, these reports raise significant questions regarding the Department’s award and management of the contract with ECRI Institute, and may have profound implications for hundreds of thousands of injured service members and their families,” McCaskill wrote. “We owe it to our brave service members to find the truth.”

The ProPublica and NPR investigation also found that senior Pentagon officials have worried about the high price of the care, which can cost more than $50,000 per patient. Some studies estimate that as many as 400,000 troops have suffered traumatic brain injuries in the war zones, though only a small percentage of them would need a full-scale program of cognitive rehabilitation therapy.

McCaskill joins a growing chorus demanding that Tricare reconsider its decision to deny coverage for cognitive rehabilitation. In recent weeks, the American Legion, the nation’s largest veterans’ organization, called [3] on Tricare to provide treatment. Sen. Bob Casey, D-Penn., chairman of the Senate Foreign Relations subcommittee with oversight of the Middle East, sent a letter [4] to Gates asking for an explanation of Tricare’s stance.

McCaskill was also one of the senators who signed a letter [5] in 2008 asking Gates to direct Tricare to begin providing cognitive rehabilitation to troops. This November, the Pentagon sent a response [6] to Congress informing them of the Tricare study’s findings. George Peach Taylor Jr., then-acting assistant secretary of defense for health affairs, said the Pentagon would continue to study the treatment, with another report expected later this year.

In strongly worded response [7] on Jan. 19, McCaskill said that the senators who signed the original letter believed that enough evidence existed on the treatment’s benefits to justify covering the cost for brain-damaged soldiers.

She asked for Gates to provide her committee with a series of documents on the contract and critical scientific reviews by Feb. 18.

“While we agreed that further research on cognitive rehabilitation therapy was appropriate, we also called on the Defense Department to err on the side of providing this proven treatment to service members,” McCaskill wrote.

ProPublica and NPR have filed a similar request under the Freedom of Information Act, but Tricare has denied access to the documents, giving contradictory explanations [8] for why. ProPublica and NPR have appealed.

Tricare officials have said their decision to deny cognitive rehabilitation is based on regulations requiring scientific proof of the efficacy and quality of treatment. They have said that the study by ECRI highlighted a lack of rigorous evidence proving the therapy’s benefits.

Tricare officials also noted that the agency does cover some types of treatment considered part of cognitive rehabilitative therapy. For instance, Tricare will pay for speech and occupational therapy, which plays a role in cognitive rehabilitation. Tricare officials deny that cost played any role in their decision. In a statement [9], Tricare said the care of troops was their “utmost” concern.

Tricare did not immediately return requests for comment on McCaskill’s investigation.

ECRI defended its study. The non-profit institute, which has carried out numerous health reviews for Tricare, other agencies and hospital and medical groups, said they applied standard protocols in reviewing scientific literature about the efficacy of cognitive rehabilitation therapy. ECRI provided a document explaining its review here [10].

“The issue of how well cognitive rehabilitation therapy works for traumatic brain injury is important,” said Jeffrey C. Lerner, the president and CEO of ECRI Institute. “ECRI Institute is fully committed to providing information to the U.S. Senate on our report and methodology.”

Pentagon Health Plan Won’t Cover Brain-Damage Therapy for Troops

Brain Wars How the Military Is Failing Its Wounded

by T Christian Miller at ProPublica and Daniel Zwedling at NPR

Versions of this story were co-published with NPR [1] and Stars and Stripes [2]. For more coverage, listen to NPR’s All Things Considered [3] starting today at 4 p.m.

Sarah Wade, 36, and her husband, Ted Wade, 33, are seen in front of the Capitol building in Washington, D.C., on Dec. 18, 2010. Ted suffered a traumatic brain injury, along with multiple other injuries, while riding in a Humvee in Iraq in 2004. Although Ted gets health insurance through the Defense Department, Sarah says "it doesn't cover what it needs to" and that he needs "more options, and less bureaucracy." The Wades live in Chapel Hill, N.C., but regularly travel to Washington for medical appointments and meetings. (Coburn Dukehart/NPR)

During the past few decades, scientists have become increasingly persuaded that people who suffer brain injuries benefit from what is called cognitive rehabilitation therapy — a lengthy, painstaking process in which patients relearn basic life tasks such as counting, cooking or remembering directions to get home

Many neurologists, several major insurance companies and even some medical facilities run by the Pentagon agree that the therapy can help people whose functioning has been diminished by blows to the head.

But despite pressure from Congress and the recommendations of military and civilian experts, the Pentagon’s health plan for troops and many veterans refuses to cover the treatment — a decision that could affect the tens of thousands of service members who have suffered brain damage while fighting in Iraq and Afghanistan.

Tricare, an insurance-style program covering nearly 4 million active-duty military and retirees, says the scientific evidence does not justify providing comprehensive cognitive rehabilitation. Tricare officials say an assessment of the available research [4] that they commissioned last year shows that the therapy is not well proven.

But an investigation by NPR and ProPublica found that internal and external reviewers of the Tricare-funded assessment criticized it as fundamentally misguided. Confidential documents obtained by NPR and ProPublica show that reviewers called the Tricare study “deeply flawed,” “unacceptable” and “dismaying.” One top scientist called the assessment a “misuse” of science designed to deny treatment for service members.

Tricare’s stance is also at odds with some medical groups, years of research and even other branches of the Pentagon. Last year, a panel of 50 civilian and military brain specialists convened by the Pentagon unanimously concluded that cognitive therapy was an effective treatment that would help many brain-damaged troops. More than a decade ago, a similar panel convened by the National Institutes of Health reached a similar consensus. Several peer-reviewed studies in the past few years have also endorsed cognitive therapy as a treatment for brain injury.

Tricare officials said their decisions are based on regulations requiring scientific proof of the efficacy and quality of treatment. But our investigation found that Tricare officials have worried in private meetings about the high cost of cognitive rehabilitation, which can cost $15,000 to $50,000 per soldier.

With so many troops and veterans suffering long-term symptoms from head injuries, treatment costs could quickly soar into the hundreds of millions, or even billions of dollars — a crippling burden to the military’s already overtaxed medical system.

The battle over science and money has made it difficult for wounded troops to get a treatment recommended by many doctors for one of the wars’ signature injuries, according to the NPR and ProPublica investigation. The six-month investigation was based on scores of interviews with military and civilian doctors and researchers, troops and their families, visits to treatment centers across the country, confidential scientific reviews and documents obtained under the Freedom of Information Act.

“I’m horrified,” said James Malec, research director at the Rehabilitation Hospital of Indiana and one of the reviewers of the Tricare study. “I think it’s appalling that we’re not knocking ourselves out to do the very best” for troops and veterans.

Defense Secretary Robert Gates, who has complained over the past year about the growing cost of the Pentagon’s health care budget, declined a request for an interview. George Peach Taylor, the newly appointed acting assistant secretary of defense for health affairs, the top ranking Pentagon health official, also declined repeated interview requests. Tricare officials defended the agency’s decision not to cover cognitive rehabilitative therapy and said it was not linked to budget concerns.

Capt. Robert DeMartino, a U.S. Public Health Service official who directs Tricare’s behavioral health department, said Tricare is mandated to ensure the quality, consistency and safety of medical care delivered to service members.

He said those standards can be difficult to meet with cognitive rehabilitation. Therapists design highly individualized treatment plans, often relying on a variety of different techniques. The holistic approach and lack of standardization makes it hard to measure the effects of the therapy, he added.

DeMartino noted that the agency covers some types of treatment considered part of cognitive rehabilitative therapy. For instance, Tricare will pay for speech and occupational therapy, which can play a role in cognitive rehabilitation.

DeMartino said cost played no role in the agency’s decision, calling such a suggestion “completely wrong.” He defended the agency’s studies of cognitive rehabilitation, calling them objective scientific reviews designed to ensure troops and retirees receive the best treatment possible.

Cognitive rehabilitation therapy “is a new field for us,” DeMartino said. “We don’t know what it is. That’s really an important thing. You don’t want to send people out when you don’t know what treatment they’re going to get and what the services are going to be.”

Officials at the Pentagon are themselves divided on the value of the treatment. A handful of military and veteran facilities provide cognitive rehabilitation therapy, though most do not have the capacity or offer programs of limited scope.

Tricare was designed to fill in such gaps in the military health system by allowing troops and veterans access to civilian medical providers. But since Tricare has a policy against covering cognitive rehabilitation, service members and retirees who seek treatment at one of the nation’s hundred of civilian rehabilitation centers could have their claims denied, or only partly paid.

The contradictory policies have resulted in unequal care. Some troops and their families have relied upon high level contacts or fought lengthy bureaucratic battles to gain access to civilian cognitive rehabilitation programs which provide up to 30 hours of therapy a week. Soldiers without strong advocates have been turned away from such programs, or never sought care, due to Tricare’s policy of refusing to cover cognitive rehabilitation therapy.

As a result, many soldiers, Marines and sailors with brain injuries wind up in understaffed and underfunded military programs providing only a few hours of therapy a week focused on restoring cognitive deficits.

Sarah Wade’s husband, Ted, was a sergeant with the 82nd Airborne Division when a roadside bomb tore through his Humvee in February 2004. The blast severed his right arm above the elbow, shattered his body and left him with severe brain damage.

After the military medically retired her husband later that year, Wade struggled to find appropriate care for him. The closest VA hospital set up to handle such complex injuries was in Richmond, Va., a 320-mile drive from their home in North Carolina.

Tricare, however, would not pay for cognitive rehabilitation at a nearby civilian program. Wade, who once worked as an intern on Capitol Hill, turned herself into a one-woman lobbyist on her husband’s behalf. She called her representatives and met with senior VA and DOD officials. She testified before Congress [5], met President George W. Bush and Gates, and was recently invited to the White House by President Barack Obama for a bill signing ceremony [6].

Wade managed to set up a special contract between the VA and a local rehabilitation doctor to help her husband. But now she wants to move back to Washington, D.C., to be closer to family.

She must begin her fight all over again — more phone calls to Tricare, more visits to government offices, more battles to get Ted Wade the care he needs.

“We go to Capitol Hill like some people go to the grocery store,” Wade joked one afternoon during a recent visit to Washington. “If we can’t figure it out, then probably nobody can.”

Brain Campaign

The campaign to persuade Tricare to cover cognitive rehabilitation therapy began in earnest after the scandal at Walter Reed Army Medical Center in Washington in 2007. News reports [7] featured brain-damaged soldiers living in squalid conditions and receiving substandard care.

The Brain Injury Association of America, a grassroots advocacy group for head trauma victims, started lobbying Congress and the Defense Department to order Tricare to cover rehabilitation for service members.

The campaign was a natural extension of the association’s mission. Each year, more than 1.4 million American civilians suffer brain injuries in car accidents, strokes and other medical emergencies. They and their families often have to battle private insurance companies for cognitive rehabilitation.

The insurance industry is divided: Five of 12 major carriers will pay for cognitive rehabilitation therapy for head trauma, according to Tricare’s study. Aetna, United Healthcare and Humana cite national evidence-based studies and industry-recognized clinical recommendations that point to the therapy’s benefits.

The federal Centers for Medicare and Medicaid Services does not have a single national policy on cognitive rehabilitation. Instead, it leaves decisions to local contractors, often insurance carriers who process claims for the agency. The contractors are able to provide the therapy case by case, so long as they determine the treatment is “reasonable and necessary,” a Medicare spokesman said.

“The totality of the evidence appears to support the value of cognitive rehabilitation for people with traumatic brain injury in improving their function,” said Robert McDonough, the head of clinical policy at Aetna. “We feel on balance the evidence leads us to conclude that cognitive rehabilitation is effective.”

Carriers and doctors providing the service can point to a long list of medical associations and scientific studies backing the effectiveness of cognitive therapy: The National Institutes of Health; the National Academy of Neuropsychology and the British Society of Rehabilitation Medicine, among others, have weighed in supporting the treatment.

Armed with such evidence, brain injury association lobbyists did not have much trouble finding support in Congress. By 2008, more than 70 House [8] and Senate members [9] had signed letters to Gates asking him to support funding for cognitive rehabilitation therapy. Then-Sen. Obama led a group of 10 senators urging Tricare to pay for therapy.

They noted that the Pentagon and the VA have improved their efforts to treat brain injury, including increases in the number of doctors and therapists available at facilities.

But the military needed to do more, they said. They wrote that Tricare should cover cognitive rehabilitation so all troops “can benefit from the best brain injury care this country has to offer.”

“Given the prevalence of TBI among returning service personnel, it is difficult to comprehend why the military’s managed healthcare plan does not cover the very therapies that give our soldiers the best opportunities to recover and live full and productive lives,” the letter said [10].

A response letter [11] from the Pentagon told the representatives that Tricare officials had not been convinced by available evidence. “The rigor of the research … has not yet met the required standard,” wrote Gordon England, then the deputy defense secretary.

Everyone Agrees

On an unusually hot spring day in April 2009, 50 of America’s leading brain specialists gathered for two days in a sterile hotel ballroom in suburban Washington, D.C.

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, the Pentagon’s lead program for the treatment of brain injury, convened the conference to help settle the debate about cognitive rehabilitation therapy.

The participants were top researchers and doctors from the military and civilian world: neurologists, neuropsychologists, psychiatrists, therapists, family doctors and rehabilitation experts.

After two days of discussion, the group hammered out a consensus report [12], representing the combined wisdom of the field. Their unanimous conclusion: Cognitive therapy improved the thinking skills and quality of life for people suffering from severe and moderate head injuries. Troops with lingering problems from a mild traumatic brain injury, or concussion, also could benefit from the therapy, the experts said.

The consensus was not binding. But those in attendance believed that their opinion — based on the decades of combined clinical experience and academic study present in the room — would lead to troops’ receiving better treatment.

“When you get the right people in the right room at the right time, you’d expect it would influence the decision makers,” said Maria Mouratidis, chairwoman of psychology and sociology at the College of Notre Dame in Baltimore and a conference participant.

Shortly after the conference ended, however, a handful of top officials from the military’s medical system met to discuss the findings at Tricare’s headquarters, an anonymous sprawl of office buildings in Falls Church, Va., known as Skyline 5.

One person familiar with the discussion, who did not want to be identified for fear of reprisal, said money was part of the debate.

Official Pentagon figures show that 188,000 service members have suffered brain injuries since 2000. Of those, 44,000 suffered moderate or severe head injuries. Another 144,000 had mild traumatic brain injuries. However, previous ProPublica and NPR reports [13] showed that number likely understates the true toll by tens of thousands of troops. Some estimates put the number of brain injuries at 400,000 service members.

Mild traumatic brain injuries are the most common head trauma in Iraq and Afghanistan. Commonly caused by blast waves from roadside bombs, such injuries are defined as a blow to the head resulting in an alteration or loss of consciousness of less than 30 minutes. Studies suggest that while most troops with concussions heal quickly, some 5 percent to 15 percent go on to suffer lasting difficulties in memory, concentration and multitasking.

For the military’s health system, the costs of treating brain damaged soldiers with cognitive rehabilitative therapy added up quickly. If tens of thousands of service members and veterans were authorized to receive such treatment, the bill might be in the billions, using high-end estimates for the cost of treatment from the Brain Injury Association [14].

The costs could swell the Pentagon’s annual $50 billion health budget — at a time when Gates has said the military is being “eaten alive” by skyrocketing medical bills.

Tricare “is basically an insurance company. They’ll take no action to provide more service,” said the person familiar with the conversation, who would only discuss it in general terms. “If they do it, it’s an enormous cost.”

At the meeting following the consensus conference, the person said, Tricare staked out its own position: “They had already decided not to do it,” the person said.

NPR and ProPublica contacted two others who attended the meeting. Jack Smith, Tricare’s acting chief medical officer, said through a spokesman that he could not recall the meeting, but “can’t say for sure there wasn’t one.” Rear Adm. David J. Smith, the joint staff surgeon, declined comment through a spokesman.

The Contract

Soon after the meeting, Tricare sprang into action. In May 2009, records show, it issued a $21,000 contract to the ECRI Institute, a respected nonprofit research center best known for evaluating the safety of medical devices.

The contract called for ECRI to review the available scientific literature to weigh the evidence for whether cognitive rehabilitation therapy helped improve patients with traumatic brain injuries.

Tricare routinely hires contractors to carry out assessments to help determine which medical treatments to fund. But in selecting ECRI, Tricare had a pretty good idea of the response it would receive. ECRI had conducted a similar review for Tricare in 2007 [15] that cast doubts on the evidence supporting cognitive rehabilitation therapy.

To carry out the new review, ECRI followed its standard protocol. It chose to include only randomized, controlled studies. Such studies randomly divide patients into groups that receive different treatments in order to compare their effects.

ECRI gave more credence to blind studies, meaning that patients did not know whether they were receiving genuine therapy or a placebo — a fake treatment. Blinding reduces bias and is considered one of the most rigorous standards that can be used in scientific testing.

ECRI also excluded studies deemed irrelevant; those studies with fewer than 10 patients; and studies where 15 percent or more of the patients were injured from a nontraumatic blow, such as stroke.

The criteria resulted in the elimination of much of the published scientific literature on cognitive rehabilitative therapy. Before applying the protocol, ECRI identified 318 articles as potential sources of information about cognitive rehabilitative therapy. The firm’s final report examined 18.

Based on this limited pool, ECRI graded the evidence for the benefits of cognitive therapy as being “inconclusive” or offering only “low” or “moderate” support of improvement in patients’ cognitive functions.

The final report [4], delivered to Tricare in October 2009, noted some areas of benefit. For instance, “tentative” evidence showed cognitive therapy significantly improved quality of life for brain-damaged patients.

ECRI’s review wasn’t limited only to science. The review noted one study that found that comprehensive cognitive rehabilitative therapy could cost as much as $51,480 per patient. By contrast, sending patients home from the hospital to get a weekly phone call from a therapist amounted to only $504 per patient.

Overall, the report concluded, the evidence for most benefits from cognitive rehabilitation therapy remained inconclusive, especially when compared to cheaper programs.

“The evidence is insufficient to determine if comprehensive, holistic (cognitive rehabilitation therapy) is more effective than less intensive care” in helping patients, the 2009 report concluded [16].

Tricare Criticized

By the summer 2009, ECRI researchers had finished a draft of the study. ECRI, later joined by Tricare, asked outside scientific experts to review it.

The reviews, according to interviews and copies obtained by NPR and ProPublica, were uniformly critical.

(NPR and ProPublica obtained a copy of the ECRI reports through the Freedom of Information Act [17]. However, Tricare denied access to reviews of the reports. ProPublica and NPR have appealed the request, but obtained copies of the reports and information on the reports from sources.)

The reviewers acknowledged that more research was needed on cognitive rehabilitation therapy. However, they noted that the Tricare report ran counter to several other so-called meta-analyses, which combine multiple, individual scientific studies to achieve greater statistical reliability.

For instance, a 2005 article in the Archives of Physical Medicine and Rehabilitation, a peer-reviewed journal that is one of the mostly widely respected in the field, examined 258 studies. It concluded that “substantial evidence” supported cognitive rehabilitation. The review included 46 randomized control studies — more than double the number in the Tricare study.

Reviewer Keith Cicerone [18], a leading civilian researcher who runs the JFK Johnson Rehabilitation Institute’s Center for Head Injuries in New Jersey, disputed Tricare’s contention that the treatment was new and untested.

“We have a significant body of evidence describing cognitive rehabilitation and showing what works in cognitive rehabilitation,” Cicerone said. “The idea that cognitive rehabilitation is new and untested is simply not true. It’s got a better evidence base than most things that we do in rehabilitation.”

Asked to explain in plain terms, Cicerone grew animated: “The arguments that are being made against” cognitive rehabilitation “in terms of the level of research that has been conducted are hooey,” he said. “It is baloney.”

The outside experts also attacked Tricare and ECRI for relying upon a methodology that ruled out important research. ECRI’s protocols, they acknowledged, are well-suited for drug studies, where it is easy to prevent patients from knowing which pill they are receiving.

But ECRI’s protocols do a poor job in assessing rehabilitation therapy where patients and doctors constantly interact in face-to-face treatment sessions. Other well-accepted methodologies, they said, have been designed to examine the benefits of therapeutic interventions.

They also questioned the reasons for excluding studies with a small number of patients, or with differing causes for brain injury, since a stroke can produce the same types of symptoms as a blow to the head.

Malec, the research director at the Rehabilitation Hospital of Indiana, said Tricare’s study sounded like it came from a private insurance company seeking to cut costs. His review [19] said that Tricare’s study “fails to represent the evidence relevant to evaluating the effectiveness of cognitive rehabilitation after traumatic brain injury.”

In an interview, he said Tricare’s demand for conclusive evidence was understandable, but ill-advised. While research continues, existing evidence indicates that the therapy helps, with no studies showing that it harms troops.

“They missed the forest for the trees. They missed the big picture,” he said.

Some of the researchers accused Tricare of using ECRI’s strict assessment protocols as a cover to justify denying troops’ coverage.

Wayne Gordon, director of rehabilitation psychology and neuropsychology services at Mt. Sinai School of Medicine in New York, called the review “dismaying” and “unacceptable.” He compared it to tobacco companies that dismissed studies that showed a link between smoking and cancer.

“The ECRI Institute seems to be stating that, while sufficient evidence exists for there to be consensus among diverse groups that cognitive rehabilitation is a useful service, this evidence is ‘not good enough’ for Tricare,” wrote Gordon, who declined to explain his comments further in an interview. He wrote that the ECRI study was “designed to reach a negative conclusion.”

ECRI also asked two additional researchers to examine the report, John Corrigan, director of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation in Columbus, and John Whyte, the director of Moss Rehabilitation Research Institute in Pennsylvania, both leading researchers in the field.

Both men declined to comment, citing their contractual obligations with ECRI, and Tricare declined to release their reviews. People familiar with their contents said Corrigan and Whyte closely mirrored the views of their fellow critics. They recommended that ECRI use a different method to judge studies of cognitive therapy, but the institute refused.

ECRI “said thank you very much, but we’re not changing anything,” said one person familiar with the review process.

More Studies, More Waiting

In an interview, ECRI Institute officials defended their firm’s methodology. The system is designed to provide a rigorous review free from researchers’ bias, they said.

Karen Schoelles, ECRI’s medical director for the health technology assessment group, acknowledged that some of the institute’s criteria — such as accepting only studies with 10 or more patients — were “arbitrary.” But she said they were widely accepted in the assessment industry.

She also noted that Tricare officials were aware of the criteria and made no attempt to change or adjust them. Tricare used ECRI Institute for almost 10 years to carry out health reviews, though the agency recently terminated the contract and selected a new firm to carry out assessments.

Cognitive rehabilitation “may be on to something,” Schoelles said. “But it needs more research.”

Schoelles acknowledged that ECRI’s own reviewers had criticized the report. ECRI offered to provide copies of the reviews, but later said that Tricare ordered them not to release them.

Stacey Uhl, the lead researcher on the review, said the criticism did not change her view that randomized controlled trials were the best way to assess the quality of evidence.

She noted the review found evidence that cognitive therapy did help in some way and said she would not rule out seeking such care for a loved one.

“I as a parent would want my child to receive all available therapies,” she said.

DeMartino, the Tricare official who commissioned the report, acknowledged the outside reviewers had “very, very strong opinions” that were “of concern.”

He said Tricare was conducting a review to determine whether ECRI’s techniques were best suited to measure cognitive therapy’s benefits. He denied submitting cognitive therapy to overly-strict review standards.

“You get what you ask for,” DeMartino said. “They tell us what they’re going to give us, and it’s our job to sort of say, ‘Okay, we understand that within the limitations of their methodology, this is the information that we get.'”

He added: “The better the information you have, the better that you can move forward and do the best thing.” The Tricare reports, coupled with high cost projections, ended the legislative push to get cognitive rehabilitation for service members and veterans.

Last year, Congress ordered the Pentagon to conduct further studies to review the effectiveness of the therapy, but those studies have not yet begun and results are not expected for several years.

Tricare said it would conduct regular reviews to monitor developments in the field. DeMartino first said Tricare would carry out a new review beginning in September. A spokesman later clarified that the National Academy of Sciences Institutes of Medicine would perform the review. It is scheduled to be completed by the end of 2011.

Susan Connors, president of the brain injury association, said she was stunned by the need for legislation at all. As the Pentagon conducts yet more studies, thousands of troops and veterans may be going without the best known treatment available. Thousands more would have to rely on military hospitals or veterans clinics far from their homes, or with substandard programs. The Tricare refusal shut down access to the hundreds of civilian rehabilitation clinics nationwide.

“I’m very disappointed by the resistance,” she said. “The military should want to do this.”

Struggling for Care

Tricare’s stance has not made it impossible to get cognitive rehabilitative. But it has discouraged civilian clinics from treating soldiers.

In interviews, several clinic owners and medical directors described their frustrations.

On some occasions, they were paid after developing relationships with individual Tricare claims processors or case managers, only to have the arrangements fall apart if the person left.

“We have tried to get Tricare and just beat our head against the wall,” said Brent Masel, the president of the Transitional Learning Center in Galveston, Texas. “It took forever to get paid. It was always a fight.”

Mark Ashley, the president of the Centre for Neuro Skills, a chain of rehabilitation clinics, said Tricare and other insurance providers were unwilling to pay because those with brain injuries can often perform basic functions that let them get through their daily lives.

They are “able to walk around, able to maneuver, but can’t function cognitively in a manner that’s safe, appropriate or competent,” said Ashley, a past president of the brain injury association. “We can fix much of that, but it takes an exhaustive amount of time and effort. That’s where the payers are out of touch.”

One of the nation’s top brain injury centers set up a charity program to help cover gaps left by Tricare. Susan Johnson, who runs Project Share at the Shepherd Center in Atlanta, said Tricare pays only about 40 cents of each dollar of care provided for the type of comprehensive program that the clinic has found successful. The rest comes from Bernie Marcus, a billionaire philanthropist, and income from inpatient services.

“These guys go and they put their lives on the line and we put them in this situation that’s difficult for some and less difficult for others to get care,” Johnson said. “I find it frustrating.”

Other clinic owners said they were able to game the system by providing cognitive therapy, but billing for other Tricare-covered services — putting them at risk of being accused of false billing.

One clinic manager acknowledged being “creative” when submitting bills to Tricare. He said that he submitted bills to Tricare for occupational therapy when the treatment focused more on improving memory.

“They won’t pay for this, but they will pay for that,” said the manager, who did not want to be identified for fear of damaging his ability to receive payments. “You just have to figure out how to work the system.”

Soldiers and families agreed that Tricare’s stance has made getting care a battle.

Sarah Wade said she patched together adequate care for Ted, arranging for him to go to a VA hospital for some services and to travel to Walter Reed Army Medical Hospital for others.

Tricare would have paid for some things, such as a physical therapist to help him learn to walk again. But she has had no luck trying to persuade Tricare to pay to treat his brain injury.

In frustration, Wade personally visited a high-ranking official at the Veterans Affairs Department. He, in turn, ordered a VA hospital to fund a special contract with a local civilian rehabilitation doctor near the Wades’ North Carolina home.

“Yes, we have been able to get [cognitive rehabilitation] paid for, but it’s been with a lot fighting, red tape, and bureaucracy,” Sarah Wade said. “It’s his greatest injury and the one that impacts his life the most, that impacts his ability to be a human.” She added, “It shouldn’t be this hard.”

The Wades credit the rehabilitation that Ted has received with markedly improving his cognitive problems. After his 2004 injury, Ted spent months regaining consciousness. Doctors were unsure about his mental state, not certain he would ever talk or even think rationally.

Today, Ted speaks in slow, sure sentences, even cracking jokes. He can make decisions — choices that seem simple enough to someone with normal cognitive skills, but which often stymie those with brain injury.

He knows, for example, to buy cherry tomatoes at the store rather than big tomatoes, which are hard for him to chop and slice with only one arm. He can read through a menu, and pick food that’s nutritious. He can wash and fold his own laundry.

One recent day after dining at a Mexican restaurant in Washington, Ted smiled when Sarah reminded him that he was once unable to figure out whether he liked hot sauce on his tacos.

“It’s been a long, slow process,” he said.

Inform our investigations: Do you have information or expertise relevant to this story? Help us and journalists around the country by sharing your stories and experiences [20].

Eric Sandoval, Former Marine, military contractor dies suddenly at home in Covina

SGB Tribune

COVINA – After multiple tours of duty as a scout sniper and a stint as a contractor in war-torn Iraq and Afghanistan, a former Marine died unexpectedly at home last week.

Eric Sandoval, 30, of Covina had come home from the Middle East in October to help his wife, who had knee surgery, according to a family friend. After a week of head aches and neck pain, Sandoval died suddenly November 12.

He had been working for contractor MVM Inc. in Iraq.

“It was such a shock,” said sister-in-law Jamie York. “Nothing raised a red flag to anybody.”

The cause of Sandoval’s death is being investigated by L.A. County coroner’s office, York said, and the family is wondering if it’s a result of possible brain injury from a bomb blast he survived while a serving as a soldier.

Friends and family described Sandoval as family-oriented, smart, hard-working and loving.

“He was like a father to so many people,” said Nancy Muniz, a family friend. “He took a parental role for his family.”

Sandoval’s wife Sandy said in an email he helped people less fortunate by doing things, such as building homes in Guam.

“Perhaps his biggest gift was the ability to bring family and friends together. Having him home meant barbecues, family, and many laughs,” she wrote.

Sandoval graduated early from Pomona High School and enlisted in the Marine Corps at 17, his family said.

He also earned a degree in accounting and a Master’s degree in business administration, Muniz said.

“He was like an onion – he was so multidimensional,” York said. “His laugh could make anyone smile.”

Sandoval is survived by his wife, Sandy, his 6-year-old son Isaiah, and siblings Robert, Danny, Gabby, Alejandra, Jonathan and Steven.

A viewing and rosary from 5 p.m. to 9 p.m. on Sunday and funeral services at 9 a.m. on Monday at Forest Lawn in Covina.

Soldiers With Brain Trauma Denied Purple Hearts, Adding Insult to Injury

By T Christian Miller ProPublica and Daniel Zwerdling NPR

The U.S. Army honors soldiers wounded or killed in combat with the Purple Heart, a powerful symbol designed to recognize their sacrifice and service.

Yet Army commanders have routinely denied Purple Hearts to soldiers who have sustained concussions in Iraq, despite regulations that make such wounds eligible for the medal, an investigation by NPR and ProPublica has found.

Soldiers have had to battle for months and sometimes years to prove that these wounds [1], also called mild traumatic brain injuries, merit the honor, our reporting showed. Commanders turned down some soldiers despite well-documented blast wounds that wrenched their minds, altered their lives and wracked their families.

Please see the entire presentation here

Leader of Military’s Program to Treat Brain Injuries Steps Down Abruptly

by T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR

WASHINGTON, D.C.–The leader of the Pentagon’s premiere program for treatment and research into brain injury and post traumatic stress disorders has unexpectedly stepped down from her post, according to senior medical and congressional officials.

Brig. Gen. Loree Sutton told staff members at the Defense Centers of Excellence [1], or DCOE, on Monday that she was giving up her position as director. Sutton, who launched the center in November 2007, had been expected to retire next year, officials with knowledge of the situation said. The center has not publicly announced her leaving.

Sutton’s departure follows criticism in Congress [3] over the performace of the center and in recent reports [4] by NPR and ProPublica that the military is failing to diagnose and treat soldiers suffering from so-called mild traumatic brain injuries, also called concussions.

It comes just as the Pentagon prepares to open a new, multimillion-dollar showcase treatment facility outside Washington, D.C., for troops with brain injuries [5] and post traumatic stress disorder, often referred to as the signature wounds of the wars in Iraq and Afghanistan.

Late Wednesday, in a sign of disarray within the program, Sutton cancelled a scheduled appearance at the opening of the National Intrepid Center of Excellence [6], a gleaming new facility of waving glass and futuristic virtual reality treatment rooms in Bethesda.  Read the Entire Story here