Providing better care for TBI patients

Former Staff Sergeant Julie-Anne Fulford completed two tours of Afghanistan during her 16 years of service in the British army and is now a member of the clinical team at the military veterans charity, Help for Heroes. She oversees the care of many veterans with TBIs...

Julie-Anne - The big thing with brain injuries is, there's nothing you can do about the initial brain injury. The biggest thing in the very short term, the acute phase, is to prevent the secondary brain injury. You have your brain, cerebrospinal fluid - which is the fluid that cushions the brain - and blood. If one of those things increases, then the other has to decrease. We really worry about the pressure inside the brain. In the very early stages, a lot of the interventions that happen are very small. It's a very long period of time before you start to see any big changes.

James - You mentioned earlier TBIs, they disrupt the functioning of the brain. What does that look like over the medium to long term? What can it look like?

Julie-Anne - It can be very interchangeable. It's quite easy to recognise when somebody's had a massive brain injury because often you'll be able to see this physical disability, their speech might be impaired, there's easier things to spot. What we sometimes start with is a patient who can be very agitated, confused, and often quite different to the person that they were before. A lot of my veterans were injured when they were really young, so it's almost like the brain has stopped and the last thing they remember is being that 26, 27-year-old, young soldier, sailor, airman, airwoman. Then, we are picking up the pieces from there and trying to help them now become the person that they are post-injury.

James - Looking at mild TBIs, these can be quite difficult sometimes to even recognise they've happened, can't they? It's more obvious when someone's had a moderate to severe one, their trauma's more extreme, but the mild ones can be difficult to diagnose but still play a part in long-term health consequences.

Julie-Anne - I look at these as like the walking wounded or the silent sick. Sometimes mild brain injuries often are diagnosed late because they don't show up on scans and it's often other practitioners that might pick up on it like your occupational therapists, your physiotherapists, or somebody who's involved, family members, because they're not quite acting the way that they used to act. Often, with brain injuries, people can be perceived as being aggressive or having anger issues, but most of the cases I see there isn't anger, it's anxiety, it's them not understanding how to explain to people that they do have a brain injury.

James - I wonder if you could go into some detail on the mental health conditions like anxiety, depression and PTSD that people might suffer as a result of a TBI?

Julie-Anne - Many of our veterans will have sustained their traumatic brain injuries in unusual traumatic circumstances. On the whole, the population, civilian and military, about 6% suffer PTSD. So we're quite balanced in that respect. However, the trigger is different. A lot of our veterans, the last thing they will remember from their injury is, say, being out on patrol, being out on the ground with their friends, and then this catastrophic event happening and then waking up back in the UK thinking, what's happened to me? Where am I? And trying to reexamine their lives. Some of the anxiety and depression, what we have to remember is people join the military because often they want the excitement or they want a challenge. When they sustain an injury, their lives completely change. That's a huge shock and a huge adjustment. So I think that has a lot to play with the anxiety and depression side of things.

James - I suppose that could be a theory as to why, as I understand it, some of the mainstream treatments for conditions like anxiety, depression and PTSD, so things like antidepressants or cognitive behavioural therapy, CBT, they seem to be less effective treatments when applied to military veterans who've acquired those conditions as a result of TBIs.

Julie-Anne - Yeah, I think the big thing is recognising what the issue is. As I said, there's nothing we can do about the initial brain injury, but what's really important is understanding what the trigger is, what's triggering the anxiety, what's triggering the depression. Is that what the veteran remembers from the situation? Is it the loss, the grief, that they've sustained? Not just losing a friend, loss of who they are. I think what works really well for veterans is the holistic approach, ensuring that everyone's involved who can be within their care. A huge part of the treatment is getting the individual to accept that they might not necessarily ever get back to their pre-injury state and then allowing them to understand what's left and how we can utilise that to help them move forward.