Dr. Barbara Sigford. Photograph by Mark Luinenburg

Until a few years ago, most of Dr. Barbara Sigford’s patients at the Minneapolis Veterans Affairs Medical Center were aging veterans contending with strokes, car accidents, or falls. Sigford (M.D. ’87) and her rehabilitation team worked to help them recover and get back to pursuits such as fishing, woodworking, and enjoying retirement.

Today, the population in her unit is much younger. These service members want to be able to shoot hoops again or play other sports. They want to continue their careers in military or civilian life. But these patients—primarily service members who were wounded in Iraq and Afghanistan—arrive with multiple catastrophic injuries, including traumatic brain injury (TBI). “We’ve treated people with amputations and brain injuries from previous wars, but these new combinations are different,” says Sigford, national program director for physical medicine and rehabilitation for the VA who is based at the Minneapolis VA medical center.

In the polytrauma unit, one floor up from Sigford’s office, Sergeant Steven Nesmith, 101st Army Airborne Division, walks with a cane up and down the hallway with his right arm extended to help him keep his balance. Flags from each branch of the military and pictures of robust, athletic men engaged in outdoor sports line the corridor. Nesmith, 24 years old and thinner than he was before his brain injury, could not walk or respond to pictures when he arrived here four weeks earlier.

“My son didn’t even know who his mother was,” says Tom Nesmith. “He was just a body that would look through you and stare at the wall. Nothing there.”

Like most U.S. soldiers who have served in Iraq or Afghanistan and come to this facility, Nesmith has a brain injury in combination with other severe wounds (his injury, however, happened back in the United States, between tours of duty). To regain as much function as possible, he’s in a recovery program that coordinates medical care and rehabilitation for all of his injuries at the same time. When he leaves, he will need ongoing specialized treatment from his local VA hospital as an outpatient. His family may also need specialized help, to attend to his medical needs and adjust to the family stresses a brain injury can cause.

The specialized polytrauma care developed by the VA medical system did not exist just a few years ago. It is being created in response to the new pattern of injuries coming from the theater in Iraq and Afghanistan. Sigford identifies the need for new programs and then develops and implements them for the national VA system. “I help develop systems not only for polytrauma patients, but for rehabilitation in general,” Sigford says. “We’ve been able to get a number of initiatives started, so I’m seeing more rehabilitation beds opening for us across the country.”

More services are needed because today’s soldiers are surviving injuries that would have killed them in earlier wars. Troops protected by heavy ceramic body armor and Kevlar helmets are less likely to receive a fatal penetrating wound to vital organs or to the back or side of the head. Better emergency medical treatment in the field and rapid evacuation methods are saving more lives. And a chain of treatment that emphasizes stabilization of patients in hospitals abroad and definitive treatment in U.S. hospitals is improving survival rates.

The bad news is that armor doesn’t protect everything, and arms, legs, necks, and faces are being severely injured. Blasts and explosions, such as from roadside bombs, have wounded more U.S. soldiers than any other hostile cause during the war in Iraq.

According to U.S. Department of Defense figures, as of early December 2006 nearly two-thirds (63 percent) of service people wounded in action in Iraq were injured by blasts from artillery, mortar, rockets, bombs, grenades, or other explosive devices. More than half of the U.S. soldiers killed in action in this conflict died as a result of one of these types of explosions. According to Sigford, 40 percent of troops injured by blasts and evacuated to Walter Reed Army Medical Center in Washington, D.C., are diagnosed with a brain injury.

“Someone in the past with injuries this grievous probably would not have survived,” Sigford says. “The lethality of this war is the lowest in United States history, but the rehabilitation task has become greater.”

Complex needs

In the Veterans’ Health Improvement Act of 2004, the U.S. Congress mandated the creation of centers to treat “complex multi-trauma associated with combat injuries.” In February 2005, four VA hospitals, including the Minneapolis Veterans Affairs Medical Center, were selected to develop specialized polytrauma units. The other three are in Palo Alto, California; Tampa, Florida; and Richmond, Virginia. As of early December 2006, the centers had treated more than 260 patients, more than 60 of them in Minneapolis.

Wounded soldiers arriving at a polytrauma unit have already been through a chain of military facilities. When injured, they are treated in the field or at a treatment station only as long as necessary to stabilize them for transportation—to a support hospital in Landstuhl, Germany, and then a medical facility in the United States, most often either National Naval Medical Center, in Bethesda, Maryland, or Walter Reed. There, they receive acute medical treatment such as amputation, surgery, infection control, or management of complex fractures.

Most patients with TBI severe enough to require inpatient rehabilitation then go to one of the four polytrauma units. “We coordinate the rehabilitation effort and account for all the impairments as we move through the rehabilitation process,” Sigford explains. “For example, to use a new prosthesis, you must have a certain amount of learning ability just to get it on or off. The brain injury may determine when we fit a prosthesis, the type we use, and how we train the patient to use it.”

The right setting

Understanding how obstacles to learning can block other types of development has been a focus of interest for Sigford since early in her career. For her Ph.D. in educational psychology from Berkeley, she wrote her dissertation on language and cognitive development in deaf people. At a school in Reedley, California, working with children with both learning disabilities and medical problems, she became intrigued by how medical interventions could help people learn and become functional members of their communities.

The turning point came during her research work with Bob Bruininks at the University of Minnesota in the late 1970s and early ’80s. Now president of the University, Bruininks joined the U in 1968 as an assistant professor in the Department of Educational Psychology.

Sigford co-authored numerous journal articles on deinstitutionalization with Bruininks. “It was the time in history when we were trying to move people out of institutions, people with developmental disability, into the community,” she says. “It was part of a large-scale survey of their characteristics, the kinds of facilities they were going to, and barriers in the community. Looking back, there were a lot of parallels to working with people with brain injury and trauma, getting them into the right settings and finding the right levels of services for vocational reentry or school.”

Working on a daily basis with medical staff brought Sigford back to the road she had not taken. In her teens, she had an interest in medicine. Two decades later, in her mid-30s with a husband, two children, and a full-time job, she entered the University of Minnesota Medical School.

Sigford went to work at the Minneapolis VA medical center in 1991. When the VA was charged with creating polytrauma centers more than a decade later, it already had four traumatic brain injury lead sites in its hospital system. Sigford had led the Traumatic Brain Injury Program at the Minneapolis VA medical center and was its director from 1991 to 2004. She also set up the national referral system that directs patients to TBI centers. In 2004, she worked with VA leadership in Washington, D.C., to demonstrate how the VA could use the TBI skills and experience it already had to create its new polytrauma system.

“Since 90 percent of patients who need a polytrauma center have brain injury, it was logical that TBI lead sites move into treating polytrauma patients,” Sigford says. “It’s really the traumatic brain injury that is driving the care.”

To retool the Minneapolis center for its new role, Sigford increased its bed capacity and staff, who were trained to treat a variety of injury combinations. To make families more comfortable, she added a lounge where they can warm up a meal, use the Internet, and play. The center also acquired a furnished apartment where patients relearn daily living skills and family members practice taking care of them.

Surviving it

Last September, Sergeant Nesmith completed his second tour of Iraq. He had served on patrols, been in combat, and maintained the electrical systems of Black Hawk helicopters. Back in the United States, he was heading home to Wichita, Kansas, for several months of leave before starting his third tour. Driving home from Fort Campbell, Kentucky, he crashed head-on into a semitruck on a hillside curve.

He arrived at St. John’s hospital in Springfield, Missouri, with cracked ribs; a bruised lung; glass fragments in his abdomen, hands, and feet; and a severe brain injury with hemorrhaging. For three weeks he lay in a coma.

“The first few days they worked on saving his life,” says Tom Nesmith. “Then he ended up with pneumonia, and then he ended up with a staph infection, and he survived it all.”

When his son roused from his coma, Nesmith says no one saw a response from him until shortly before he was transferred to the Minneapolis polytrauma unit. Steven’s friends from the 101st Airborne, just arrived stateside from Iraq, looked in the door of his hospital room.

“He saw them and he leaned up on his left arm and he grinned from ear to ear,” says Tom Nesmith. “It was the first time we had seen him make any expression at all, and it made me, and Mom, and the nurse all cry.”

“He needed his family,” adds Julie Nesmith, Steven’s mother. “But he also needed his buddies.”

Relearning everything

When patients arrive at the Minneapolis polytrauma unit, therapists begin working with them as soon as patients can tolerate it. “Most of these guys will have some sort of response,” says Michelle Peterson, Nesmith’s physical therapist. “Maybe it’s an eye blink. But they’re responding in some manner.”

Therapists begin moving limbs to maintain range of motion and stretch them to prevent contractures. They sit patients up in wheelchairs to build tolerance for supporting weight. In the physical therapy clinic, they are put on a tilt table to retrain their bodies to bear their weight. And therapists work at getting them to react to stimulation.

“We look at how they’re responding to different senses,” Peterson says. “Can they hear? Do they then look over at that sight? Can they smell and understand what that means? Can you present them with a ball and they grasp it? Can they start answering yes or no questions, even using a thumbs-up or a thumbs-down?”

Peterson says that once patients become more responsive, they work on speech and simple movements used in daily activities, such as brushing teeth. The various therapy specialists also coordinate their work in what Peterson calls “co-treating,” in which the goals for a patient overlap and reinforce each other. For example, the physical therapist might work with a patient on sitting balance and head control while the occupational therapist, working on fine motor skills, helps the patient use that ability to relearn to wash his face with a washcloth.

“The atmosphere down here is basically that it’s therapy 24/7,” says Tom Nesmith. “They’re working to bring him back into the real world.”

In physical therapy, Steven Nesmith is relearning to balance and walk. In occupational therapy, he works on relearning how to live within a budget and interacting with people in routine situations. In speech therapy, he works on multitasking, such as answering questions while writing.

He also sees a recreational therapist. “They go to the Mall of America, or sometimes they’ll take everybody in the unit and go watch a movie together. He is learning the camaraderie of it again, how to interact with other people,” Julie Nesmith says.

“These kids are basically being raised again because the brain injuries are so significant,” says Tom Nesmith. “In about four weeks now, they have taken my son from basically a vegetable back to my son again. . . . They’ve brought my son back.”

More to learn

Patients stay at the polytrauma unit from two weeks to more than five months, depending on how severely they’re injured. Sigford says data collection is in its early stages, but anecdotal evidence shows that today’s wounded soldiers are showing longer recovery curves than soldiers of past wars. There is surprisingly little evidence on what works best to rehabilitate people with brain injuries, Sigford notes. And everyone responding to the wounded of this war, from medical teams to government leaders, needs more information about the problem.

To remedy this, the four polytrauma centers are pooling their patient data to begin developing evidence-based best practices as part of a project called the Polytrauma Blast Related Injury QUERI, which Sigford co-directs. One goal of the QUERI (an acronym for Quality Enhancement Research Initiative) is to put procedures in place so that troops sustaining blast injuries will be screened for problems that might not be immediately obvious. This is important because an unknown number of soldiers are returning to their communities with undiagnosed brain injuries. Sigford calls this one of the little-known facts about the war.

A soldier may be exposed to a blast, experience only a momentary loss of consciousness, and show no obvious head injury or changes in thinking. But when he returns home, “things just don’t go quite right,” Sigford says. “Oftentimes it isn’t recognized that they’ve had a brain injury or multiple brain injuries. We could be helping them if we recognize it, but if we don’t, they will often lose jobs, lose homes, get divorces, or become estranged from their families.”

Sigford stresses that in these cases a little intervention may be all that’s needed, as the brain will recover in cases of mild injury. “A lot of these people just think they’re going crazy. So having a diagnosis, an explanation, some reassurance and tools at their disposal can go a long way.”

Most patients who are treated at the polytrauma center (77 percent) go directly home. Fourteen percent return to a military treatment facility for follow-up or additional procedures before going home. That leaves 9 percent who go to another VA facility or a long-term care facility. A few will ultimately return home, but some will require 24-hour lifelong care.

How the VA will provide such specialized care for a small number of patients poses a new challenge. “These people want to be close to home and go on with their lives, but many live in rural areas with limited resources and it takes a critical mass to develop a program,” Sigford says. “So that’s one of the things we are grappling with at the moment. We may have to find a way to help every facility develop a special niche for taking care of a patient like this. We know the type of care we want to provide, but providing it close to home can be difficult.”

Meanwhile, to meet the need for continuing specialized outpatient polytrauma care closer to veterans’ homes, the VA, under Sigford’s leadership, is in the final phase of preparing 21 facilities nationwide to provide this care. She is also organizing a conference to develop a program that will allow patients in the four polytrauma centers to transition to independent living.

In addition, the VA is continuing to learn more about the stress put on families of the severely wounded. Sigford has identified the work of Pauline Boss, professor emerita of family social science at the University of Minnesota, as a resource for helping families cope with permanent changes in their wounded relative. Boss, author of Loss, Trauma, and Resilience, is the principal theorist on a concept she has named “ambiguous loss.” This body of work examines the challenge of families whose loved ones have been lost to them, physically or psychologically, in a way that is incomplete—through disappearance, addiction, or pathologies such as Alzheimer’s disease or brain injury—and provides therapeutic approaches.

Sigford believes that a program incorporating this knowledge can help families cope with soldiers whose wounds have permanently changed them. This past December, Sigford arranged for VA leadership in Washington, D.C., to meet with Boss and plan how her work will be used in VA programs.

Getting him back

Steven Nesmith’s parents have been told he may be able to leave the polytrauma center by late December. His father believes that, with time, he will resume a normal life, although his ability to continue a career with the military is uncertain. His mother’s expectation is more measured.

“He’s going to be 90 to 95 percent back. There was so much damage to his brain that there’s going to be a little bit that’s not going to be there. The hope is that the brain will rewire itself, they tell us. Things will come back even though there will be some things that are not perfect or quite the same.”

“He walks with a cane,” Tom Nesmith concedes. “But the main thing is that his personality—the heart and soul of this kid—is there. . . . We wanted our same son back, and he’s back. He accepts what he’s got right now. He’s pretty happy, actually.”

“I think a lot of that is just the nurses, the therapists, and everybody—you know, they’re fun. He’s a fun-loving kid,” Julie Nesmith says, “and they joke with him and he jokes and laughs and he teases them.”

“Charmer,” Tom says.

Julie laughs. “Yeah, he’s Mr. Charmer.”

Suzanne Miller is a freelance medical writer based in Bloomington, Minnesota.