Injury careers after blast exposure among combat veterans deployed to Iraq or Afghanistan

Highlights

• Examines accounts of OEF/OIF veterans exposed to blast before routine TBI screening.

• The study delineates a seven-phase model of veteran post-blast injury careers.

• Veterans downplay, are oblivious to, and deny the insidious effects of blasts.

• Careseeking is often preceded by a low point in the lives of veterans and their families.

• Veteran and family needs are under-addressed throughout the injury career.

Abstract

During the Iraq and Afghanistan wars, blasts were the most common cause of combat injuries, including traumatic brain injury (TBI). Prior to 2007, service members were not systematically screened for TBI, and estimates suggest that tens of thousands of mild TBIs went undiagnosed. This study sought to understand post-acute “injury careers,” documenting the life- and health-related narratives of veterans who were at high risk of undocumented TBI due to being blast-exposed before 2007. Researchers conducted 38 in-depth interviews between May 2013 and August 2014 with Army veterans who served in combat-intense settings (n = 16) and their family members (n = 10). Respondents detailed a series of experiences in the months and years following blast exposure. We present this series as a model that draws upon the vernacular of participants who described veterans “downplaying” their injuries and later “detaching” themselves from friends, family, and communities, and “denying” or being “oblivious” to their circumstances until a “wake-up call” pushed them to “get help.” Looking to the future, veterans grapple with uncertainties related to personal identity and professional or social expectations. This model is presented within a member-checked metaphor of an individual being hurled into – and emerging from – a canyon. Policies and programs addressing veteran health, particularly among those exposed to multiple blasts prior to systematic TBI documentation, must consider the personal, social, and health system challenges faced by veterans and their families throughout their injury careers.

Introduction

Military personnel engaged in Operation Enduring Freedom Afghanistan (OEF-A; 2001–2014) and Operation Iraqi Freedom (OIF; 2003–2010) encountered a greater number of explosive blasts – especially from improvised explosive devices (IEDs) – than service members of previous wars (Owens et al., 2008). Close-range blast exposures can be all-encompassing and full-body experiences, causing both immediate and long-term psychological effects and physical effects. Blast injuries can be primary (e.g., from overpressure due to the blast wave), secondary (e.g., penetrating wounds caused by shrapnel), tertiary (e.g., blunt injury from sudden acceleration of the body), or quaternary (e.g., flash burns from a blast's intense heat) (Cernak and Noble-Haeusslein, 2010). While similar combat injuries might have proven fatal decades ago, advances in both protective gear and emergency medicine have enhanced the survival rates, albeit with increased morbidities including traumatic brain injury (TBI), that is, a brain injury caused by an external force. Before the US military established routine screening for TBI in late 2006, an estimated 80% of deployment-related TBIs went undiagnosed (Chase and Nevin, 2015).

It is unknown how service members with undiagnosed TBI experienced and responded to their situations medically, socially, and professionally. Although a physical injury, TBI can cause changes that can be perceived as physical or mental health issues. Attempts to study TBI-related experiences are complicated by continued difficulties in diagnosing and attributing symptoms to TBI.

A growing body of research is now directed at understanding how a valid TBI diagnosis relates to signs, symptoms, brain scan imaging, injury exposure, and physiological damage (Cernak and Noble-Haeusslein, 2010, Hulkower et al., 2013, Taber et al., 2014). It is often difficult to distinguish which injuries are causing what signs and symptoms, thereby making TBI prognosis and treatment difficult and debatable. For example, both TBI and posttraumatic stress can cause similar neurochemical changes, irritability, anxiety, depression, sleep disturbance, cognitive impairment, mood instability, aggression, memory problems, and apathy; both are also associated with suicidality and substance use disorders (Tanielian and Jaycox, 2008). Both might also be caused by similar combat exposures. Determining symptom causality is of practical importance in the case of veterans, especially because therapeutic decisions and disability assessments are predicated on these determinations.

The long-term medical and social effects of severe and moderate TBI have been studied for decades (Ylvisaker et al., 2005). Mild TBIs – the most likely to go undiagnosed – are less well understood, in part due to a polarization of two ideological camps: those who claim that all uncomplicated mild TBIs resolve within 3 months (indicating that long-term studies of mild TBI-related experiences are misguided), and those who claim that a small proportion of mild TBIs result in chronic, brain-based effects (Ruff, 2011). This debate has immediate importance to service members and veterans for whom a short-term injury is treated differently from a chronic or progressive condition, both clinically and via the benefit structure of the military and Department of Veterans Affairs (VA). In the conflicts in Iraq and Afghanistan, an estimated 20% of service members sustained a TBI (Defense and Veterans Brain Injury Center, 2014), but most TBIs went undocumented prior to 2007, suggesting that thousands of veterans may be unknowingly grappling with this war wound (Chase and Nevin, 2015).

Social science research plays an important role in understanding coping and careseeking issues for health conditions generally and TBIs specifically. Post-TBI changes in self-concept have been described among individuals with mild, moderate, or severe TBI as a “loss of self,” wherein individuals contend with a changed perception of themselves while also recognizing how others view them differently (Nochi, 1998). These individuals are also forced to rebuild “spheres of identity” as they contend with a new “tentatively balanced sense of self” (Muenchberger et al., 2008). Although other conditions can change and challenge self-identity (Charmaz, 1991), Nochi specifies how memory loss is an especially poignant TBI symptom: Memory allows us to sense that we know who we once were and, therefore, we can maintain our identity and move with confidence into our future.

The concept of “illness careers,” as conceptualized for this study, dates to the mid-20th century if not earlier (Glaser and Strauss, 1968, Pescosolido et al., 1998). It is informed by illness narrative research (Charmaz, 1991), and shares a history with other career studies including Goffman's work on the “moral careers” of individuals institutionalized in “total institutions” such as prisons and psychiatric institutions (Goffman, 1961). In all career studies, emphasis is placed on how individuals' trajectories are shaped by context and an accumulation of experience.

Due to continued difficulties in diagnosing combat-related TBI and sequelae, this study sought to build on existing social science, brain injury, and illness and patient career literature by understanding “injury careers” among blast-exposed war veterans who were at high risk of TBI during deployment and at high risk of having an uncertain injury status. These injury careers start with the contexts in which service members were placed at risk of an injury, then progress through the injury (if any), symptom development (if any, TBI related or not), careseeking (if any), and finally their prospects for the future. We present segments of these injury careers as described by combat veterans who were deployed to Iraq or Afghanistan before 2007 and exposed to potentially injurious combat. This time period was chosen because the lack of TBI screening policies prior to 2007 hindered access to immediate care, monitoring, and disability benefits related to TBI. The purpose of this work is to help researchers and practitioners understand experiences of veterans who faced not only a high risk of sustaining multiple blast-induced TBIs but also uncertainty during their injury careers given the lack of – and debates regarding – diagnosis, documentation, and care.

It is to be noted that we use the term “veterans” to describe those who served in the military regardless of whether they were active-duty, retired, or separated from the military at the time of the study.