ALASKA STATE LEGISLATURE  HOUSE SPECIAL COMMITTEE ON MILITARY AND VETERANS' AFFAIRS  February 7, 2008 9:08 a.m. MEMBERS PRESENT Representative Bob Roses, Chair Representative Anna Fairclough Representative Gabrielle LeDoux Representative Jay Ramras Representative Robert L. "Bob" Buch Representative Scott Kawasaki MEMBERS ABSENT  Representative Nancy Dahlstrom COMMITTEE CALENDAR    PRESENTATION BY THE ALASKA BRAIN INJURY NETWORK - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER JILL HODGES, Executive Director The Alaska Brain Injury Network Anchorage, Alaska POSITION STATEMENT: Gave the presentation by the Alaska Brain Injury Network. CAPTAIN (DR.) RICHARD BARKER, Clinical Psychologist Elmendorf Air Force Base Anchorage, Alaska POSITION STATEMENT: Testified during the presentation by the Alaska Brain Injury Network. STEPHANIE TANNER Anchorage, Alaska POSITION STATEMENT: Testified during the presentation by the Alaska Brain Injury Network. RICHARD WARRINGTON, Ambassador Alaska Brain Injury Network Kenai, Alaska POSITION STATEMENT: Testified during the presentation by the Alaska Brain Injury Network. ACTION NARRATIVE CHAIR BOB ROSES called the House Special Committee on Military and Veterans' Affairs meeting to order at 9:08:09 AM. Representatives Fairclough, LeDoux, Kawasaki, Buch, Ramras, and Roses were present at the call to order. ^PRESENTATION BY THE ALASKA BRAIN INJURY NETWORK 9:08:37 AM CHAIR ROSES announced that the only order of business would be a presentation by the Alaska Brain Injury Network, with supporting testimony from a representative of Elmendorf Air Force Base and a member of the public. 9:08:42 AM JILL HODGES, Executive Director, the Alaska Brain Injury Network [(Network)], informed the committee that the mission of the Alaska Brain Injury Network is to educate, plan, coordinate, and advocate for comprehensive service delivery systems to survivors of traumatic brain injury [(TBI)] and their families. Her organization feels that the returning military population will need an increase in advocacy efforts on behalf of veterans with TBI in the near future. The presentation will include information on TBI and the steps the military is taking, in Alaska, to assist returning veterans who have suffered a TBI. In addition, there will be testimony from the spouse of a soldier who suffered a TBI during his military service. Ms. Hodges explained that, with the return of many soldiers from combat, the military must address the issue of the treatment of TBI at the base hospital. She opined that the military must plan the continuing care of the injured veterans for the rest of their lives. She described the procedures that the National Guard has taken to assist returning guard members who have suffered a TBI, such as: family briefings and counselors; assistance from a transition assistance advisor; and grand round teams that include representatives from the Department of Defense Military Health System TRICARE, the medical and psychiatric community, the Alaska National Guard, and the Department of Veterans' Affairs (VA). The grand round teams visit villages and other remote areas regularly to inquire about the health of the returning soldiers. She emphasized that the military has recognized the need of continuing care and has funded positions to support injured soldiers. Turning to the issue of TBI in the civilian population, Ms. Hodges stated that TBI is recognized by the state as one of the highest disabilities for children. The Network has items in the governor's budget for provider training in the treatment of brain injuries, and she expressed her hope that the items will be funded and, thereby, assist the private sector with the coming increase in TBI cases. Ms. Hodges stressed that case management is very important for the treatment of TBI because clients with brain injuries cannot plan appointments and look for help independently. In addition, most survivors are unable to work, and are susceptible to substance abuse and other dangers. She related her personal experience with her brother who continues to suffer symptoms two years after a TBI. In Alaska, 10,000 families are affected by TBI and 2,000 have lost a family member. Ms. Hodges further explained that other states have TBI service delivery systems that include funding, medical insurance waivers, rehabilitation, and day housing. Ms. Hodges concluded by saying the Network has been asked by the Alaska Mental Health Trust Authority (AMHTA) and the Department of Health and Social Services (DHSS) to develop a five year plan for the state and she informed the committee that budget recommendations and information about priority projects are forthcoming. 9:18:06 AM CAPTAIN RICHARD BARKER, Clinical Psychologist, Elmendorf Air Force Base, informed the committee that Elmendorf Air Force Base is working closely with Fort Richardson Army Base to address TBI injuries and other issues. Captain Barker explained that there are "above ground" and "vehicle borne" improvised explosive devices (IEDs), and one of the injuries they cause is the signature injury of the war; traumatic brain injury, or post concussive syndrome. Although the most severely injured will remain in the Lower 48 for treatment, Captain Barker stated that many soldiers with the "milder" injuries will be coming home to Alaska. It is possible for the symptoms of mild post concussive syndrome to go away after six months or a year; however, some symptoms may last a lifetime, and the repeated exposure, common during a war, makes recovery more difficult. Captain Barker further explained that the definition of a TBI is an injury to the brain resulting from a blast, a fall, direct impact, or a motor vehicle accident, which causes an alteration in mental status resulting in headache, nausea, vomiting, dizziness, balance problems, fatigue, sleep disturbance, drowsiness, sensitivity to light and noise, blurred vision, memory problems, and or difficulty concentrating. Moreover, the brain in a blast is injured in a different way by the blast wave, fragmentation, and the effects of the blast on the body. These injuries are unlike sports injuries and are more damaging to the axons in the brain. Captain Barker pointed out that more soldiers are surviving injuries from the war, but many have long lasting head injuries that will need to be dealt with by their families and society. 9:24:15 AM CAPTAIN BARKER provided the following facts: approximately 1.4 million TBIs occur in the U. S. every year; successive concussions lead to more significant damage; twenty-two percent of Operation Iraqi Freedom veterans report a TBI inducing event; and seven percent report continued symptoms. Overall, the number of victims has become a major public concern. Military physicians try to diagnose this condition immediately after the injury, but often traumas are not reported by soldiers; attempts to ignore the symptoms increase the chance for re-injury and slow the recovery rate. Moreover, some soldiers will not report their symptoms on the post deployment health assessment at the end of their tour. Regarding diagnosis and treatment, he noted that neuro-imaging studies are negative with mild TBI, which often leads to misdiagnosis. 9:29:05 AM CHAIR ROSES asked what type of neuro-imaging is generally used. 9:29:18 AM CAPTAIN BARKER stated that computed tomography (CT) scans and magnetic resonance imaging (MRI) images are used. 9:29:31 AM CHAIR ROSES asked whether positron emission tomography (PET-CT) radioactive processing is used. 9:29:43 AM CAPTAIN BARKER said that he will find out what type of imaging is now being used and inform the committee. He continued to explain that TBI is a hidden injury that complicates the diagnosis of physical and psychological problems. At this time, the military wants to begin giving the Automated Neuropsychological Assessment Metric 4 prior to deployment. The assessment can then be re-administered after the soldier comes home and the comparison to the baseline will indicate damage to cognitive functioning. 9:33:03 AM CAPTAIN BARKER observed that treatment for TBI must also include treatment of post traumatic stress disorder, depression, medical disorders, and other disorders. Research support for cognitive rehabilitation treatment is weak; therefore, education about TBI must begin prior to deployment and continue through treatment and recovery. Education must also be available to unit commanders and family members. For Alaska veterans, the Defense & Veteran Brain Injury Center (DVBIC) in Palo Alto, California, will provide research and vestibular rehabilitation. Captain Barker pointed out that injured soldiers must be treated for headaches, irritability, memory problems, and sleep problems first, and that recovery depends on: education and reassurance; rest, and a gradual return to activity; and instruction in cognitive and memory coping strategies. Barriers to recovery are: high stress duty; repeated injury; and comorbid conditions. 9:35:49 AM CAPTAIN BARKER concluded by comparing the symptoms of TBI versus post traumatic stress disorder symptoms. He then advised the committee that Elmendorf Air Force Base has developed a center for the treatment of mild to moderate TBI. The center has a staff of 50, including neuropsychologists, a neurologist, physical and occupational therapists, audiologists, and technicians. He cited the lack of a sufficient number of case managers who are needed to ensure that service members are participating in their treatment options. So far, 100 patients from the 425th Brigade have been treated by the TBI center, and many more are expected. 9:39:02 AM REPRESENTATIVE KAWASAKI asked what is being done by the Department of Veterans' Affairs (VA) for veterans, especially those living in rural areas of Alaska. 9:39:49 AM CAPTAIN BARKER stated that there are five neuropsychologists in Anchorage. 9:40:37 AM MS. HODGES stated that her organization could not speak for the VA or the National Guard and offered to provide the names of representatives of the VA and the Alaska National Guard. 9:41:16 AM REPRESENTATIVE LEDOUX asked whether Captain Barker worked in partnership with any of the Native medical services in the Bush. 9:41:44 AM CAPTAIN BARKER said no. In answer to a further question, he expressed his belief that the VA has done some education in rural areas, and offered to provide further information. 9:42:13 AM REPRESENTATIVE BUCH asked for more information about pre- deployment education. 9:42:39 AM CAPTAIN BARKER answered that the Air Force will do mass briefings and talk about the potential exposures. The Army is working to educate spouses so that they can recognize symptoms after the return of the soldier. Prior to deployment, other issues, such as exhaustion and mental health, are also covered. 9:44:14 AM REPRESENTATIVE BUCH affirmed the value of pre-deployment education. 9:44:36 AM CHAIR ROSES asked whether the testifiers feel that the present facilities, nationally and locally, are inadequate. 9:45:03 AM CAPTAIN BARKER said no. The facilities are not inadequate; however, they are not ideal. He pointed out that the service is integrated and providers from around the state, and other military branches, are being brought in to staff a separate TBI clinic for about six months. He opined that short term needs are being met. 9:46:06 AM CHAIR ROSES observed that, as more brigades come back, there will be a significant increase in the need to treat TBI. 9:46:20 AM CAPTAIN BARKER agreed. 9:46:28 AM CHAIR ROSES asked what policy makers should do to address this concern. 9:46:39 AM CAPTAIN BARKER deferred the question to Ms. Hodges. He added that his purpose was to inform the committee on the military's goal to raise public awareness of TBI. 9:47:35 AM STEPHANIE TANNER, Anchorage, Alaska, informed the committee that her husband, Sgt. Scott Tanner, was exposed to more than 30 IED explosions during his service tour in Iraq from 2004 to 2005. He received little treatment in theatre, and began to suffer many symptoms after his return. Sgt. Tanner's TBI injury was finally diagnosed in 2007 and he began receiving medication and therapy at Providence Medical Center. In addition, he is now receiving support from the Warrior Transition Unit; however, there are so many injured returning soldiers, the case managers are stretched too thin, and Ms. Tanner is functioning as her husband's case manager. Sgt. Tanner is receiving active duty pay, but he will be medically retired out at half pay if he does not recover. Ms. Tanner said that her husband will never recover to his potential because of the eighteen month delay in the treatment of his injuries. 9:51:12 AM REPRESENTATIVE RAMRAS offered his admiration for Ms. Tanner's courage and her husband's service. 9:52:22 AM REPRESENTATIVE BUCH stated his appreciation for Ms. Tanner's testimony and asked her to review the protocol that did not provide medical care for her husband. 9:53:10 AM MS. TANNER explained that the main problem was, in 2005, TBI was not recognized, even though many of the returning brigade had symptoms. Sgt. Tanner transferred to Alaska and began training duties, but, without treatment, his symptoms increased. Ms. Tanner opined that, because of the Warrior Transition Unit, there is more support available now. 9:55:25 AM RICHARD WARRINGTON, Ambassador, Alaska Brain Injury Network, informed the committee that he is a veteran and received a severe TBI 30 years ago. As an ambassador to the Alaska Brain Injury Network, he urged the committee to ensure that military veterans do not fall through the cracks of services that are needed for TBI. He described TBI injuries and said that he is still disabled after 30 years. 9:57:04 AM MS. HODGES related that Alaska is small state and does not have a system in place for the treatment of its population that suffers from TBI. This is true of the civilian sector and for veterans living in rural areas. The Alaska Brain Injury Network, DHSS, and AMHTA have begun to meet monthly with the VA, the National Guard, the Third Medical Unit, the Wounded Warrior Project, and the VA Vocational Rehabilitation and Employment group. She opined that this dialog will help address the problem in Alaska. In Illinois, legislation mandates that TBI screening be available for veterans on a voluntary basis. Ms. Hodges stressed the need to continue education. 9:59:44 AM CHAIR ROSES suggested that the Military Family Association should also be represented at the meetings with the VA and other entities. He then recalled that a funding request for a statewide assessment of the needs of veterans and their families was cut from the budget. Chair Roses expressed his hope for the restoration of this request. ADJOURNMENT  10:00:33 AM There being no further business before the committee, the House Special Committee on Military and Veterans' Affairs meeting was adjourned at 10:01 a.m.