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Department of Defense Informational Session on Traumatic Brain Injury

Feb. 24, 2020
Principal Director for Military Community and Family Policy Joseph Ludovici and Joint Staff Surgeon Air Force Brigadier General Paul Friedrichs

STAFF: Good morning, everyone. Thank you all for being here.

Again, so today, obviously, this is going to be something a little bit different than what you usually get. More or less, this is considered an informational session. You will have an opportunity to ask questions. It is on the record, off camera.

And again, with what we're planning to do here – we're going to have subject matter experts go on the Hill and they're going to brief congressional members, and then following that engagement, we're going to have them come here and do a media engagement with you all. You all will have an opportunity to, kind of, hear exactly what we're talking about on the Hill, again, on those hot topics as they arise.

But to more or less give you the ability to understand, again, in general, what's been talked about at large across the spectrum, so both congressional and here within the Department of Defense.

Today we're scheduled for about 40 minutes. Please, you know, one at a time, after the – the SMEs give their introduction, we're going to go from there, and then go into the Q&A session. But, please raise your hand, I'll call on you from there.

If you have anything – if there are any additional questions following the engagement and we haven't gotten to you, please follow up with me and I will relay your questions and have those responded to as quickly as possible.

So without further ado, I will turn it over to our SMEs.

PRINCIPAL DIRECTOR FOR MILITARY COMMUNITY AND FAMILY POLICY JOSEPH LUDOVICI: Okay, good afternoon.

My name is Joe Ludovici. I'm the principal director of Military Communities – Military Community and Family Policy. One of the things we're responsible for in our shop – it's under the Personnel and Readiness Directorate – is casualty and mortuary affairs. So in that light, we're responsible for the casualty reporting process, so I'm here today to answer questions you might have or to address questions that were brought up last week or on the Hill on casualty reporting.

JOINT STAFF SURGEON BRIGADIER GENERAL PAUL FRIEDRICHS: Thanks, and I'm Paul Friedrichs. I'm the joint staff surgeon, and I'm going to spend a few minutes, if you'll indulge me, just walking through the background on traumatic brain injury, a little bit about what happened with this specific attack, and then we'll open it up for questions.

My personal background Is I've deployed – I have taken care of casualties with traumatic brain injury. I'm a neurologic surgeon by training, but have done a variety of other jobs in the military, including taking care on the receiving end of these casualties coming back. So you'll hear some of this personal experiences coming through.

So why is this attack so important for us? I think first, it was a real validation of the work over the last 15 years to change how we take care of people who develop traumatic brain injury. If you go back through thousands of years of military history, go back to the Greeks and the Romans, they talked about people who were wounded warriors, or the walking wounded, shell-shocked – every war has had some term for them. What we've not had are good ways to evaluate these soldiers, sailors, airmen and Marines at the time that they were injured or afterwards, when they came and sought care.

We recognized this beginning early in the current conflicts and began working with the Veterans Administration, as well as with the NCAA, the NFL and other stakeholders to develop a series of screening measures, which we've updated over the years, and we're able to use very effectively during this event.

In this particular event, the nature of the munitions was different than what I experienced at Balad or in other locations.

So if you're familiar – and many of you have been down-range over the last 15 or 20 years – you know, we had small munitions; we had small rockets that would hit bases. Balad used to be called "Mortaritaville." There’d be the frequent attacks on the base.

And they were obviously dangerous, but very different than what happened at Al Asad, when theater ballistic missiles landed.

Why is that important?

The magnitude, or the size of the munition, certainly creates a different exposure for the service members who are in the area of the blast. And that's something that I'll come back to several times in my comments here.

First thing that happens after any attack like this is looking to see who was acutely injured. And in this case, when they went through, they identified that no one had any acute injuries. No one lost a leg. No one lost an eye. No one lost a limb, which, you know, was remarkable, given the strength of these munitions.

The next thing that we have taught our service members and our leaders to look for are those invisible wounds, like traumatic brain injury. And in this case, we've developed a series of rules that we've actually codified in a Department of Defense Instruction.

And some of those say – and I'm just going to quote directly – that regardless of what people may be complaining of, what a service member says they may be experiencing after an attack, if they meet certain criteria, they must be evaluated.

And so those criteria are "If they're involved in a vehicle blast, event, collision or rollover."

And that's specific to the IED blasts that we've seen throughout the conflict in Iraq and Afghanistan. If you're in an IED blast, you have to be evaluated. It didn't apply here, but it's one that we've learned is important. All those folks get evaluated.

"If you're within 50 meters of a blast and if you're inside or outside," you have to be evaluated.

That absolutely did apply in this case. Because we had folks who were within 50 meters, but said they were feeling fine. And we still went ahead and put them through the evaluation to identify whether or not they'd experienced a traumatic brain injury.

And then the other mandatory reporting criteria are "a direct blow to the head," which in this case didn't happen, fortunately, and somewhat surprisingly, given the magnitude of the attack.

And then the last mandatory reporting is "exposure to more than one blast event."

And in this case, because there were 10 events that happened in a very short period of time in one location, we did have some service members that were near a place that had more than one blast event.

This also applies to people who have deployed multiple times. So you'll not be surprised to hear that, you know, with these small arms – or smaller munitions that are used, we've had service members who have been exposed to blast attacks in the past. If they said they'd previously been exposed to a blast attack and they were at Al Asad, we also pre-emptively evaluated them to identify whether they showed any signs of traumatic brain injury.

So those are the ones that had to be evaluated. And then the other group that we looked at were the ones who came forward days, and in some cases weeks, afterwards and were complaining of a variety of symptoms.

And as we've looked back at our experience with service members, we've found that there are pretty – there's some symptoms that are more common in folks with traumatic brain injury. And those include headache, dizziness, memory problems, balance problems, nausea, vomiting, difficulty concentrating, irritability, visual disturbance and ringing in the ears.

Now, you may think that's, kind of, a non-specific list. And my wife regularly accuses me of being irritable and having difficulty concentrating. That does not mean that I have traumatic brain injury.

And I think that's important in this discussion because a lot of people have said, well, why didn't we immediately identify everybody with a traumatic brain injury? Because the signs sometimes are fairly non-specific.

And if you're 18 or 19 or 20 years old, even though we've trained everybody who deploys down-range on what to look for, it's quite common that we'll have folks who will say, you know, 'I just was blasted; of course I'm not going to feel quite right, I'm going to ride this out for a few days,' or 'I'm going to wait and see if this gets better.' And then they come in, several days or weeks after the fact.

And that's indeed what we saw, that there were some folks who came in relatively soon after the attack and said, 'you know, I'm having these symptoms, I want to be evaluated.' Others came in weeks later and said, 'you know, this hasn't gotten any better, I thought that I – I thought it would go away, it hasn't. Now I want to be evaluated for it, I need to be evaluated.' Or, in some cases, it was their coworkers who said, 'you know, you keep complaining you're having headaches, you should go in and be evaluated.'

I think the point in all of that is, there are – there are different cohorts of folks that we identified with mild traumatic brain injury in this event. There were those who we immediately evaluated because they met the criteria, and then there were those who came in, over a period of weeks after the event, and sought evaluation.

The last group were a small number who came in for some other reason, for what ultimately was diagnosed as a mental health concern or some – you know, a sprained knee or whatever, and in the course of evaluating them and asking them the questions that we know to ask, they tripped some of the concerns about, maybe this person has traumatic brain injury, let's go ahead and do the full evaluation.

So that kind of describes who we evaluated, and perhaps helps to shed a little more light on why the evaluations weren't all done on the day of the event, with answers on the day of the event.

Now, I'll talk a little bit about the evaluation itself. So there's been a number of comments about, well, we don't have any good tools for evaluating these folks. I would disagree. We work very carefully with the best experts – as I mentioned before – both in academia, in the Veterans Administration, within DOD, with the NFL and NCAA to develop screening tools to help us identify people who are at risk for having sustained a traumatic brain injury.

One of those tools that we use – and some of you have heard this – it's called the Military Acute Concussion Evaluation. Because we love acronyms, it's called the MACE tool. That came out, I think about eight years ago, and was updated again in 2016. So it's now called the MACE 2, M-A-C-E-2.

And that's a very detailed evaluation that includes a physical exam; it also includes listening to what the individual says he or she has experienced or is still experiencing.

And then it includes a series of tests; things like memory tests where, at the beginning, you'll say, 'I want you to remember these five terms.' And then later in the interview, you'll ask them, 'what were those five terms I asked you to remember?' Some quick, very well validated evidence-based test of cognition and how well the brain is functioning at the time of the interview.

And so that is what I would call – and what I think most people would call – an evidence-based or very well-researched evaluation tool that we use as our initial screening.

If someone tests positive on that, if their initial evaluation is positive, we then move into our concussion evaluation algorithm. And the next step is to actually let them rest for 24 hours and repeat the MACE test.

So I've been asked several times, well, 'how come you didn't know right away that someone had a traumatic brain injury?' Because we purposefully built in a rest period to re-evaluate people to see if whatever it is they're complaining of goes away. If it completely resolves within 24 hours, typically that does not then translate into having truly had a mild traumatic brain injury.

And this then also leads into a series of further evaluations. Some folks will get an absolute, clear, positive, yes, they had a mild traumatic brain injury. With some rest and appropriate therapy, within a matter of days, they're ready to go back to work. And many of the people that we evaluated at Al Asad were able to go back to work within days to a couple of weeks after the event.

There is also a subset, however, in which it's not as clear-cut. And so we do our evaluation in the field; we're still not coming up with a clear answer; they're not a 100% better or the tests that we're doing in the field are equivocal. And then those are folks who we decide need to have additional evaluations. I'm hoping that that means that this is valuable.

So, you know, in some cases, if we can't clearly get to a diagnosis in the field, we'll then move on to additional testing. And one of the most frequent tests that we'll do next is called an MRI. And I know many of you are familiar with that. Magnetic resonance imaging is a type of imaging that helps us get a good look at the anatomy of the brain.

The challenge for us with MRIs is, we don't have an MRI at Al Asad. In fact, we don't have one in that part of Iraq. And so you've heard that some of the casualties from this event, some of the folks that we've ultimately diagnosed with mild traumatic brain injury had to go to Germany. For many of them, it was so that they could get an MRI.

And I've been asked the question, 'why didn't we just do an MRI downtown – fill in the blank, whatever town they were near' – we found that it's helpful to do these at places where the staff are accustomed to looking for traumatic brain injury and accustomed to the protocols that we've developed over time.

So it – to get reproducible results, we found that the best thing – and the easiest thing to do, in this case – was to fly them up to Germany and do the MRI there, and evaluate them there.

So the MRI is a typical test that we do if we can't make a definitive diagnosis in the field. There are other tests that can be done. One is called Neurocognitive Assessment, which is a more detailed assessment of how well the brain is functioning; sometimes occupational therapists or physical therapists will be involved.

We were very comfortable making the diagnosis of mild traumatic brain injury in all of the folks that we've identified. And if you saw the press release from last week, right now, we're at 110 service members who were diagnosed with mild traumatic brain injury.

Some of those – about 25 of them now – we've flown back to the United States. And in almost every case, those that have come back – back to the United States are people who were diagnosed with mild traumatic brain injury and were determined to need follow-on outpatient care.

Nobody has had a requirement for sustained inpatient care; nobody was diagnosed with a severe injury. But in some cases, they need follow-up that simply can't easily be provided at a place like Al Asad. And rather than keeping them in Germany, we felt it was better for them to go back to their home unit, where they've got their support system, their family or unit support system around them, and get that outpatient care at their home unit. So that's a little bit about what happened once the evaluation is done.

And then the last thing that I'll touch on is, so what are we doing to continue to improve? You know, we've been working on this now for years. As I mentioned on the Hill on Friday, we're very grateful for the support from Congress. We've collectively spent about $1.5 billion on research on traumatic brain injury.

There was an assertion, somewhere along the way, that the DOD really isn't focusing on that. I would disagree. I mean, this is something that we've been talking about and looking at for years. And not just within DOD, but partnering with experts across the United States.

And that research has gone in different directions. Some of it is the evaluation tools that I described earlier, that we're using today. Some of it was looking at better treatments or what's the most effective treatment to help people once they're diagnosed with a traumatic brain injury.

Some of it is sensors. How do we not just have to rely on these very subjective symptoms or the physical proximity to a blast? And so there's a device, for example, that we've deployed now in a field test phase that's a series of sensors – it's three sensors that you can wear under your body armor that will detect whether you were exposed to a blast event. So even if you weren't within 50 meters and you don't come in saying, 'I've got' any of these symptoms that I described previously, if your tracker shows that you were exposed to a blast event, then we're going ahead and evaluating those folks to see whether they have traumatic brain injury.

I think that's going to be really exciting going forward because that takes some of the subjectivity out of this. It's – you know you don't have to measure, 'was it 50 yards or 50 meters? What was the number I was supposed to look for?' It's did your sensor show you were exposed to a traumatic blast event or not?

And there's a lot of research continuing within the department here and – or within the building here. We have the Comprehensive Brain – yes, I want to make sure I get the acronym right because it's a long one – the Comprehensive Strategy for Warfighter Brain Health Executive Committee, which is a mouthful. I'll say it one more time, Comprehensive Strategy for Warfighter Brain Health Executive Committee.

That's a group that is led by senior officials within the Office of the Secretary of Defense and within the services that is looking across the department at all of the efforts, integrating them, identifying road blocks, moving them and helping us to keep moving forward in this area. Last meeting was late last year, another meeting coming up next month. But it looks at the full portfolio of what the department is doing in this area.

Some of you are also familiar with the Close Combat Lethality Task Force, which has been looking at this. And then a group that I'm particularly proud of, and that's the Joint Trauma System that has helped to develop what we call clinical practice guidelines. And so we have the Joint Trauma System series of trauma experts that look at how do we improve the care that we provide after a traumatic event, linked in with all these efforts that I've just described.

There's a lot more that, you know, I could go into on this. And I'll just – I'll close by saying, as a physician who's been in combat, where we are today is light-years ahead of where we were five or 10 years ago. There is no military in the world that has invested as much or has fielded as many evidence-based tools as what we have right now.

Do I think that we've answered all the questions? Absolutely not. There's nothing in medicine that I can say with certainty we have answered all the questions on.

But I am very proud of the care that these service members received. And I can tell you with absolute confidence every single person who has come forward, or who was in proximity and needed to be evaluated, was fully evaluated, got the care they needed and continues to get the care that they needed; and they'll be tracked over time so that we can continue to both make sure they get the care they need and we can continue to learn from this event so that we can keep updating our algorithms.

So with that, I'll pause and I think Joe and I will take whatever questions you all have.

Q: Hi. Lolita Baldor with the Associated Press.

Just a quick question. Do you, at this point, believe you've reached the end of the flow of people coming in with some sort of symptoms? And, of the people who have come back to the United States or to Germany or wherever, can you assess how many may or may not have either some sort of permanent damage or something that will requires that they leave the service? Or I'm wondering if you can talk about mild TBI but still what the severity is.

BRIG. GEN. FRIEDRICHS: Yeah. So all of them are – all of them have been diagnosed with mild TBI. So that's the first piece. But none of them had indications of a more severe injury upfront. So I think that – that part, very comfortable in.

Could that change over time? Possible. But I think it’s unlikely, based on what we know about this. It's very uncommon for someone with mild TBI to then be diagnosed later with a more severe injury, months after the event.

Have we diagnosed everybody that we're going to? I think we still have six people that are going through diagnosis right now, to assess the extent of the mild traumatic brain injury, what specific type of injury they've experienced.

So for that group, we'll probably have, you know, a little bit more refinement of what their specific long-term follow-up is, whether they can go back to duty, or whether they need long-term outpatient – longer-term outpatient treatment.

Have we seen everybody coming forward? Probably pretty close to it.

I mean, if you look at the bell curve, we had the biggest tranche, or the biggest group, was within the first three weeks. And it's really tapered off since then.

Some of you may have seen the article on the "Miracle on Ice" hockey team. If you remember when the United States was in the Olympics and when we beat the Russian team and, you know, it was called the –

Q: They’re too young.

BRIG. GEN. FRIEDRICHS: Well, you know, for those of us who were there and remember it, it was a wonderful time, remarkable story. This young hockey team went out there and beat the Russians. And Disney made a movie about it called "The Miracle on Ice."

Why do I bring that up? So there was just an article within the last 72 hours on that, that pointed out that one of the members of that team is not going to be able to go to their reunion because he's in jail. And he is being tried for a variety of offenses. But one of the things that came out in that was long-term unrecognized traumatic brain injury.

This is why we're so careful about trying to identify this proactively. I think, you know, if you look at the literature, there's a lot of reporting on football players with unrecognized traumatic brain injury, other athletes or other people with unrecognized traumatic brain injury.

Is it possible to have unrecognized injury? We've got great evidence to show, yes, it's possible.

I'm very confident with what we've done here, that it would be extraordinary for someone to not have been identified at this point, with all of the things that we've put in place, and then be identified years later with a significant brain injury as a result of this.

I mean, from a medical, physical, physiological standpoint, I think that would be extraordinary.

So is it possible that it could happen? Yes. In this group, I think it's extremely unlikely.

Q: Well, just as a follow-up, then, can you explain, then, the difference between those who have had to come back for additional treatment, versus those who went back to work?

If everyone has mild TBI, what is the difference in severity or symptoms or whatever? What is it that these others have that the others didn't?

BRIG. GEN. FRIEDRICHS: So in some cases, if the symptoms completely resolve, as they often do, within about 30 days, the majority of folks with mild TBI, their symptoms will resolve within about 30 days in the majority of cases.

If they don't resolve within 30 days, we still consider it mild TBI, based on the original diagnosis. But we'll offer additional treatment.

So, for example, you know, if you're continuing to have headaches, it may be that, you know, there's some therapy that we can offer to help with that. If you're continuing to be more irritable than usual, there's therapy that we can offer to help with that.

So that – what we don't want to do is say, you know, 'You had your bell rung; get back in the fight,' if there's still something that we can do to help folks.

And so, while they're all mild traumatic brain injuries, in the scope of badness, you know, these are all still classified as mild traumatic brain injuries. And the majority of them, as we expected, have seen their symptoms completely go away within the first 30 days.

For those that haven't, we're putting them in a place, usually back with their home unit, where they can continue to get support for whatever symptoms they're still experiencing.

Q: Yeah, Missy Ryan of The Washington Post. Thanks for being here.

I have a clarification, and then a question.

So for the – you said that some people who ended up being diagnosed with mild TBIs came in days or weeks later, or came in for something else, and then they showed symptoms. So would those have been people who were outside the 50-meter blast area? Because everybody –

BRIG. GEN. FRIEDRICHS: Yes.

Q: Okay. That's the clarification.

And then can you talk a little bit about either, you know, the – the physics of the – of how the physics of the ballistic missile impact, you know, medically or biologically impact differently? You know, why this attack – any more details in why this attack, the ballistic missile strikes would have been different from the rocket or mortar attacks that you were citing as, you know, the common occurrences (inaudible) –

BRIG. GEN. FRIEDRICHS: Yeah, it's the size of the munition. It – you know, it's just the –

Q: What does that do to the brain specifically? Can you just talk about that?

BRIG. GEN. FRIEDRICHS: So if – I'll – I'm going to try using an analogy which may be helpful. You know, firecrackers on the Fourth of July – you've got a small firecracker that has a small blast, goes off for a short period of time; much larger firecracker, larger blast, goes off for a longer period of time. The larger munition – the larger the munition, the larger the blast that's created, the more effect there will be on the human body. And the brain is, you know, an extraordinary part of our body and it's – our body is designed to protect the brain quite a bit. It sits inside the skull. It is surrounded by fluid to help cushion it as you're moving. It – if you have a large blast, that larger blast will have a greater impact on the brain than a smaller blast will, and that's the point that I was trying to make.

Q: But what does it do to the brain? Could you just spell it out so we can convey that to our – our readers?

BRIG. GEN. FRIEDRICHS: Yeah, so it can do a variety of things. The most obvious one is if it actually causes an immediate bruise to the brain itself, and, you know, sometimes that can cause bleeding within the skull, or an – an injury that usually is going to be readily apparent. Other times, it can cause injury at the microscopic level, not as readily apparent, where individual nerves are damaged or torn, sometimes called shearing. And if you can picture a nerve that kind of gets pulled by the blast effect, that's something that is harder to see on imaging studies and – but still, a very real damage within the individual nerves that are damaged there, going forward.

So it can be the spectrum of injury, from individual nerves being damaged to larger areas of the brain being damaged. In this case, we really did not see people with significant injuries where large areas of the brain were damaged, which I think, you know, again, is good news. It – it shows that as we've improved our protective equipment over time, it is much more effective than what was available in years past, especially with a blast like this.

But, some of this injury is not going to be readily apparent until you get down to the microscopic level and can see it there, and that's why these evaluations and things like MRIs are – are very valuable.

Q: Hi. Luis Martinez of ABC.

I was doing some quick mental math here, trying to figure out the numbers. Based on how many service members are actually at Al Asad when the attack happened, I mean, with 110, it's almost either going to be 5%, 7% or 10% of the total force that was there when this attack occurred. I mean, how significant is that for one event, where something with that many service members are affected by something like this? And how typical is it to have something like that?

BRIG. GEN. FRIEDRICHS: So from a medical standpoint, I – I don't have the number of folks who were on the ground at the time the event occurred, so I can't tell you if it was five, or seven, or whatever percent along the way. You know, having been under rocket attacks, if you're on the receiving end, they're all significant; and I think from the folks who were there, I'd suspect they would all say that it was significant just by virtue of having lived through the experience along the way.

From a military standpoint, I'll have to defer to our operational guys and my colleagues to – to speak to the significance of it. Part of what we found over time and the reason why – one of the reasons we've invested so much in this is, we want to sustain the greatest number of soldiers, sailors, airmen and Marines; make sure that we identify if people are injured and get them back in the fight.

I’ll go back to what I started with – you know, if you watched "1917", the movie that came out a couple of months ago; you know, World War I had a tremendous amount of writing after the war on shell shock, and what that was like and how that was not well-recognized. People were kept in the fight. We weren't well-prepared in the medical community 100 years ago to identify or to treat people with those injuries, and many of them lived for a long time afterwards with the sequelae of those injuries.

Part of what we've been working very hard to do is to identify even people who are not complaining of any symptoms and make sure they get the right treatment up front so that we put them back in the fight only if they're ready to be back in the fight. That's – you know, if you remember the Army's "Preserve the fighting force," that's part of that whole approach to, how do we make sure we've identified people who need help, get them the help when they need it, and only put them back in the fight if they're really ready to be back in the fight? I'm not sure if that answers your question.

Q: (inaudible), but a follow-on here about the administrative reporting, because I think that was one of Secretary Esper's concerns, was initially we had no reporting of injuries; and then it seemed that the insinuation was that there was different categories of how that information flowed and who received that information; and so that it didn't get here in a timely fashion that, yes, there were these injuries. Can you talk about that?

MR. LUDOVICI: I can't, because I think the general wove it into his comments. As the blast – after the blast occurred, commanders went out and assessed everybody, and there was no visible injuries. So that's an operational assessment. There's no losses to the unit. ‘I see everybody walking around and everything,’ and so there was no – there's three basic categories: non-significant, serious – seriously ill or – or injured, or very seriously ill or injured, and Doc could probably talk to the serious or – or very serious kind of differences. But in the first one, there's no reporting if there's not seriously ill or injured.

But as he also said, they went out and they did some, okay, some potential symptoms that were not visible. The official casualty reporting is for – primarily for the notification of next of kin and the beneficiaries, if there's something that's happened. And so usually when it's not significantly injured, the service members will call home and say, ‘Mom, this just happened. There's no – I'm okay.’ Might have a headache or something like that. But the counter for casualties has not started yet. Until the commander and the doc go in and do assessment and look at the categorization and see, does it raise to a level of a certain threshold, will it become a reportable casualty. So I think that's your question.

I think as it applied to the MACE test, and they said, 'OK, we went from one number to another' as they found more symptoms, in some cases they wait the next day to see if it resolves itself. It still hasn't counted as a casualty yet. I think that's what the general was alluding to. There are – if there's a delay – but for our purposes for notifying the next of kin we have 12 hours to notify the service headquarters, and then they have 12 hours to notify the – the next of kin if it's classified by the commander and the doc as a potential serious injury. So those didn't happen, you know, for a couple weeks after the incident.

Q: Could you be more specific about the symptoms? You say headaches, but there are headaches, and then there are crippling headaches, and the same with irritability: are you grouchy, or do you fly into an uncontrollable rage? So which is it in this case?

BRIG. GEN. FRIEDRICHS: So, all of the above. And – and we've actually deliberately trained leaders and service members, that that full spectrum – is sufficient – anywhere on that spectrum is sufficient to come in and ask to be seen, or recommend that your battle buddy go in and be seen.

So you know, the obvious ones are, you know, you kind of described a couple of the extremes, the left and the right boundaries there. But we want to see all of them. If – you know, whether it's, I just have – every morning I'm waking up, and I've got a headache. It's – you know, I've never had them before the attack, I'm still having them, three weeks later – God bless you – you know, we want to see those just as much as we do the guy who comes in and says, this is the worst headache of my life.

Q: In this case of 110 diagnosed, and the 25 sent back. I mean, how many of them were suffering from symptoms that you would, for instance, describe as a crippling headache?

BRIG. GEN. FRIEDRICHS: Sir, I don't have that breakdown of the specific symptoms that each are – each of them had. I'm sorry, I don't have that breakdown. It’s – it really was a spectrum, but I don't remember anything leaping out that said they all had this specific symptom along the way.

Q: Nancy Youssef with the Wall Street Journal.

You mentioned the bunkers at places like Al Asad that were designed for rockets and mortars. Is there any evidence that, given the nature and the magnitude of the blast, that those – those bunkers were not ideal for a place to put soldiers who faced a potential ballistic missile attack, is there any sort of evidence that the number of people there or anything along those lines, actually increased potential effects of TBI?

BRIG. GEN. FRIEDRICHS: So I – I'm not going to be able to speak to the operational side of that from a non-medical standpoint. From a medical standpoint, the fact that exactly zero people on this base suffered an acute traumatic injury is extraordinary, you know?

When I was at Balad in 2004, some of you may have traveled through there at the time. You know, we had these rocket attacks and they were random events, wherever they landed, shrapnel and other things would cause injuries.

Theater ballistic missiles are really big munitions, and the fact that nobody had a physical injury is, frankly, extraordinary. So from a medical standpoint, I think they were very effective at protecting people from acute traumatic injuries. And that's a good news story that these service members who were exposed to a very significant attack did not have shrapnel or other life, limb or eyesight-type injuries there.

Q: Right, but what I'm asking is, is there anything that indicates that they contributed to TBI injuries?

BRIG. GEN. FRIEDRICHS: No.

Q: It seems to me, that there's a lesson. If there's a lesson learned in terms of re-evaluating how bunkers are built or how many people you put in them, is there any discussion along those lines?

BRIG. GEN. FRIEDRICHS: So I say no, because at this point I don't know. Part of what we're going to now be looking at is, for these folks, you know, going back then and parsing out – and this sort of gets back, I think, to your question, sir. You know, what are the specific characteristics for each of these 110 people?

You know, where were they located, we know which ones were within 50 meters, which ones weren't. Were they in the bunker, what type of bunker were they in. Those are all questions that we still are going to want to go back through and tease out in more detail to understand, is there something more that we can learn from this, going forward.

So we're not there yet. We've got multiple groups looking at that. The Joint Trauma System that I mentioned before, the Defense Veterans Brain Injury Center that's here in D.C. is looking at that, and then the Naval Health Research Center out in San Diego is also looking at that.

So I think as – as we pore through all of the data on each of these service members – and also those who were not injured, because that's kind of the control group, those who did not sustain a traumatic brain injury – we'll be able to better answer the question. But, no, we're not able to answer that right now.

Q: Phil Stewart from Reuters.

Were you – were there any kind of – you talked about blast pressure sensors. Were – are there – any of those at – were there any of those at Al Asad? And are there at any bases anywhere? And are you looking at that right now, as something maybe that you should do if you haven't already?

BRIG. GEN. FRIEDRICHS: So I don't know if there were any at Al Asad. I don't think so. I'll find out and then try and confirm that, but I'm not aware that they were with any of the units that were Al Asad.

I do know that we are field-testing them right now at multiple units. And I can get you those locations also – Ma'am, if you could help me with that, we could follow up on where they're being field-tested right now.

Q: And then just to be clear, on the 25 that came back to the U.S., the symptoms were irritability? The –

BRIG. GEN. FRIEDRICHS: It could be any number of things.

Q: The ones – the actual ones that came back; I just wasn't clear on, you know, why they were brought back.

BRIG. GEN. FRIEDRICHS: And, again, I don't have that breakdown for each individual or, you know, why each of them came back. But I don't have that level of detail on why each of them came back.

(CROSSTALK)

BRIG. GEN. FRIEDRICHS: You bet.

Q: Barbara Starr from CNN.

Going back on MRIs, I wanted to make sure I understood a couple of things. Is there anything that an MRI could not show you on microscopic injury to the brain? Is there – is – is there – or the other test that you mentioned, sorry I don't remember the name of it. There's things that an MRI would not show you?

BRIG. GEN. FRIEDRICHS: Yes, ma'am. So the MRI is exquisitely sensitive in imaging the brain itself. But at the most – at the individual neuron level, it does not get down to that level. That's really where you need a microscope to see it.

And so –

Q: So that means for an actual real – I don't mean a final – a complete, comprehensive diagnosis of TBI, you would need the person to be deceased so you could sample brain tissue?

BRIG. GEN. FRIEDRICHS: So I'm going to give you a perhaps unsatisfactory answer. The most definitive diagnosis is done after someone has died, and we're able to do an autopsy. That's always – as a surgeon, that, you know, taking a piece of tissue out and looking at it under a microscope is the best way to know with 100% certainty what's in that tissue. But we’d prefer not to get to that point.

Q: The other thing I wanted to ask you, I was not clear; in this event, did you sample – did you go out and ask people questions, do the MACE or whatever it is, beyond 50 meters? Or was your assertive sampling only within 50 meters?

BRIG. GEN. FRIEDRICHS: So it was within 50 meters, or some reason to suspect that there was a reason to do it.

Q: So you had people, nonetheless, that were outside the 50 meters that came and reported symptoms to you after the fact?

BRIG. GEN. FRIEDRICHS: Yes. Or – or a coworker, you know, a battle buddy –

Q: You had reports of symptoms outside 50 meters?

BRIG. GEN. FRIEDRICHS: Yes.

Q: So what is the – what now? Do you change the MACE? Do you do something in your own protocols to – in additional events down the road – assertively go out and sample beyond 50 meters now?

BRIG. GEN. FRIEDRICHS: So that's part of doing that very detailed analysis now, not just of the 110 who were diagnosed with mild traumatic brain injury, but of those who were not, to understand what that risk tradeoff –

(CROSSTALK)

Q: Does that mean, now you're going to go out and sample everyone else who was at Al Asad? I'm not sure what you –

BRIG. GEN. FRIEDRICHS: I'm sorry, I wasn't clear on that. So the first thing that we're doing already is going through each of these individual cases and making sure we have all the data that we can on each of the individuals who's diagnosed. We then want to look at that in the context of everybody who was there.

So, no, I don't think that we're going to go back and look at everybody.

But to the question that was asked earlier by the gentleman in the back there about what was the percentage, if 2% of the people had a particular symptom, and they all have some shared characteristic, whatever that was, that is going to be very noteworthy. If 20% have it, that's even more noteworthy.

So that's the analysis that we're doing right now is, going back and looking at those people who –

(CROSSTALK)

Q: … the people who had TBI who were more than 50 meters out.

BRIG. GEN. FRIEDRICHS: So we'll look at the full cohort of the 110 people who were diagnosed to get as much learning from that as we can, yes.

STAFF: I have time for two more questions.

Q: Thank you. (Inaudible) with Al Jazeera.

For historical reference, what was the last time the military experienced such a situation on this scale with these type of injuries? Can you tell us?

BRIG. GEN. FRIEDRICHS: I – as a doc, I'm sorry, I can't answer that question.

I – it's certainly not been recent. You know, theater ballistic missiles are not something that have been typically used by our adversaries in the recent past. But I don't know when the last adversary was that used a theater ballistic missile.

(CROSSTALK)

Q: Well, that – if – I mean, if it's not recent, then this is something fairly new for the U.S. troops to experience. And taking into consideration that we're still stationed in Iraq and the potential of confrontation is still there, what is – what are the main lessons or lesson to be drawn from this, as – from your medical point of view?

BRIG. GEN. FRIEDRICHS: Yes, from a medical standpoint I think the most important lesson for anybody that should be drawn from this is, we have developed the ability to screen, diagnose and treat people that's far superior to anything that we've had at any point in military medical history. And we used it and every single person that we've identified is getting the treatment that they need.

That is a big step forward; based on research, testing and evolving our capabilities as military medics from where we were even five years ago.

That's the first big lesson.

The second big lesson is, and I'll go back to Ms. Starr's question, we're a learning organization. We're going to tear this data apart, in all likelihood, for years, comparing it with other datasets. You know we have terabytes of data. It's not complete for every war, but we've got different datasets from different conflicts along the way. And we're going to compare it and try and learn as much from this as we can, so that we can identify whether we need better algorithms, better whatever; change what we have, keep what we have.

So I think there's going to be a continuous learning process as a result of this that will go on for a long time as we continue to learn as much as we can from this.

Q: Sylvie Lanteaume from AFP.

I would like to go back to the symptoms. You said that they were – you gave the symptoms for TBI generally, or in case of more serious TBI, are the symptoms different?

BRIG. GEN. FRIEDRICHS: So they are. In more serious TBI, they're – they're much less subtle. You know if the person can't get up from the ground, that's pretty serious traumatic brain injury. If the person gets up from the ground and can't tell you her name, that's – you know, that's a more serious symptom of a traumatic – more serious traumatic brain injury.

We didn't see anyone with symptoms like that. But, you know, there's a whole hierarchy, if you will, of, you know, mild traumatic brain injury to much more severe. And the most severe are the people who are unable to open their eyes, unable to get up from the ground; those are really bad brain injuries.

Does that answer your question ma’am?

Q: Yes.

STAFF: All right, ladies and gentlemen, thank you, thank you again for your time. If you have any follow-up question, please feel free to follow up with me (inaudible).