ProPublica: Health & Science

California Eyes Discipline for 2,000 Nurses Sanctioned by Other States

2010-06-27T18:00:04-05:00

Tracy Weber and Charles Ornstein

Is Chinese Drywall Making Habitat for Humanity’s Houses Uninhabitable?

2010-06-27T00:17:56-05:00

Joaquin Sapien

Leader of Military’s Program to Treat Brain Injuries Steps Down Abruptly

2010-06-23T17:33:29-05:00

by T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR -

WASHINGTON, D.C.--The leader of the Pentagon's premiere program for treatment and research into brain injury and post traumatic stress disorders has unexpectedly stepped down from her post, according to senior medical and congressional officials.

Brig. Gen. Loree Sutton told staff members at the Defense Centers of Excellence, or DCOE, on Monday that she was giving up her position as director. Sutton, who launched the center in November 2007, had been expected to retire next year, officials with knowledge of the situation said. The center has not publicly announced her leaving.

Tell Us Your Story

Did you or a loved one suffer a traumatic brain injury while serving? ProPublica and NPR want to hear your story. Tell us about your experiences with TBI.

Sutton's departure follows criticism in Congress over the performace of the center and in recent reports by NPR and ProPublica that the military is failing to diagnose and treat soldiers suffering from so-called mild traumatic brain injuries, also called concussions.

It comes just as the Pentagon prepares to open a new, multimillion-dollar showcase treatment facility outside Washington, D.C., for troops with brain injuries and post traumatic stress disorder, often referred to as the signature wounds of the wars in Iraq and Afghanistan.

Late Wednesday, in a sign of disarray within the program, Sutton cancelled a scheduled appearance at the opening of the National Intrepid Center of Excellence, a gleaming new facility of waving glass and futuristic virtual reality treatment rooms in Bethesda.

"The war in Iraq and Afghanistan could end tomorrow; our mission to restore health, hope and humanity will endure for decades," Sutton wrote in her farewell message. "We simply must uphold our commitment to all who have borne the burdens of war on our behalf."

Sutton did not respond to requests for comment. Her replacement, U.S. Army Col. Bob Saum, also declined to comment.

Cathy Haight, the acting spokeswoman for DCOE, said Sutton's departure, though apparently well ahead of schedule, was part of a routine command rotation. Haight said Sutton decided to leave after turning down the Army's offer to take a new position overseeing the military medical system in Europe.

"If a general officer declines (a new position)...they are in a transition to retire," Haight said.

In recent months, legislators have questioned Sutton's ability to carry out the mission of the centers, which is to catalyze research and treatment across the military for soldiers returning with brain injuries and psychological wounds.

Congress directed the military in 2008 to create the brain injury center and other facilities for wounded soldiers. At an April hearing of a House Armed Services subcommittee, Rep. Susan Davis, D-Calif., said that the center had failed to carry out its role.

"The Defense Center of Excellence, while having achieved some notable small scale successes, has not inspired great confidence or enthusiasm thus far. The great hope that it would serve as an information clearinghouse has not yet materialized," Davis said.

"The center has also made some serious management missteps that call into question its ability to properly administer such a large and important function," Davis continued.

Scrutiny of Sutton rose another notch earlier this month, when NPR and ProPublica reported on the military's problems in handling soldiers with mild traumatic brain injuries. Such injuries leave no visible scars, but can cause lasting mental and physical difficulties.

Military statistics show that about 115,000 troops have suffered such injuries since 2002, but in interviews, Army experts acknowledged the true toll may be far higher. Unpublished research we reviewed suggests that tens of thousands of soldiers may have gone undiagnosed. Our reporting also showed that even when soldiers were diagnosed, at one of America's largest Army bases, they have had to fight to receive appropriate treatment.

Still, some veterans' advocates were shocked and saddened that Sutton was leaving. They said she had been a forceful, visible advocate for wounded troops and their families who had never received the full support of the military's medical establishment.

Critics of the military's health system have noted a power vaccum at the top of the military medical structure. Four people in just over three years have rotated through the Pentagon's top health policy position, the assistant secretary of defense for health affairs.

"She was always there for the troops," said one veterans' advocate, who did not want to be named for fear of criticizing the military. "She's become the scapegoat."

In an April interview with NPR and ProPublica, Sutton shrugged off the criticism. "Leading change," she said, "is a journey not for the faint of heart."

"We are very proud of the team that we have built, the concept in terms of the center of centers, the network of networks," she said. "Are we anywhere close to where we want and need to be? No. Of course not."

Congress Questions Military Leaders on Suicides, Traumatic Brain Injury

2010-06-22T16:44:35-05:00

by T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR -

WASHINGTON, D.C.—Senators pressed senior military leaders today to improve their efforts to address traumatic brain injuries, suicide and other wounds suffered by soldiers returning from the wars in Iraq and Afghanistan.

Responding to what he called "disconcerting" reports by NPR and ProPublica, Sen. Carl Levin, D-Mich., said at a hearing before the Senate Armed Services Committee that the military needed to better address the wide range of medical and behavioral problems affecting troops.

Tell Us Your Story

Did you or a loved one suffer a traumatic brain injury while serving? ProPublica and NPR want to hear your story. Tell us about your experiences with TBI.

Earlier this month, we reported that the military was failing to diagnose and adequately treat troops with brain injuries. Since 2002, official military figures show more than 115,000 soldiers have suffered mild traumatic brain injuries, also called concussions, which leave no visible scars but can cause lasting problems with memory, concentration and other cognitive functions.

But the unpublished studies that we obtained and the experts that we talked to said that military screens were missing tens of thousands of additional cases. We also talked to soldiers at one of the military's largest bases, who complained of trouble getting treatment.

"I am greatly concerned about the increasing number of troops returning from combat with post-traumatic stress and traumatic brain injuries, and the number of those troops who may have experienced concussive injuries that were never diagnosed," Levin, chairman of the committee, said as he opened today's hearing.

Gen. Peter Chiarelli, the Army's vice chief of staff, said the Army had made strides in identifying soldiers at risk of committing suicide, setting up new treatment centers and deploying a new system of "telemental health services," allowing soldiers to talk with counselors by computer video chat programs.

Chiarelli's remarks were echoed by other senior military commanders at the hearing from the Navy, Air Force and Marine Corps.

"Our success notwithstanding, we still have much more to do," said Chiarelli, who has emerged as the Army's point man on mental health issues. "We face an Army-wide problem that will be only be solved by the coordinated efforts of our commanders, leaders, soldiers and program managers and health providers. This is a holistic problem with holistic solutions and that is how we're approaching it."

Chiarelli acknowledged that the Army continues to have problems with properly diagnosing soldiers with mild traumatic brain injuries, saying that it was an emerging area of medicine. And he acknowledged that soldiers at bases throughout the Army have sometimes had trouble receiving treatment for mild traumatic brain injuries and post-traumatic stress.

Chiarelli took issue with our reporting, however. He said the NPR and ProPublica reports were wrong to blame military doctors for failing to diagnose the problem, or to accuse senior military officials of not taking the issue seriously. He also said that NPR and ProPublica had tried to draw a distinction between traumatic brain injury, or TBI, and post-traumatic stress, or PTS, two conditions which frequently occur together.

"I think the great disservice that NPR did to everyone was to try to isolate TBI from PTS. And that is just not possible," Chiarelli said. "The co-morbidity of these two is what's giving us the difficulty today. And I also think that they did a disservice when they indicated that PTS is a psychological problem. It's not just at a psychological problem. It is a physical injury that occurs."

Chiarelli did not cite any factual errors in the stories and we stand by our reporting. But we also think he is mischaracterizing our reporting, which was based on dozens of interviews with senior military researchers, commanders and soldiers, and thousands of pages of unpublished studies, e-mails and medical records.

First, we did address the overlap of TBI and PTSD in our stories: "To be sure, brain injuries and PTSD sometimes share common symptoms and co-exist in soldiers, brought on by the same terrifying events," we wrote.

We also did not downplay the seriousness of PTSD -- a wound which NPR has reported on extensively in past stories.

We found several instances in which military doctors expressed skepticism about mild traumatic brain injury and its effects. Dr. Charles Hoge, one of the Army's senior health advisers, referred to the "illusory demands" of mild traumatic brain injury in an opinion piece in the New England Journal of Medicine last year. In an April 2010 e-mail that we obtained, he wrote: "What's the harm in missing the diagnosis of mild TBI?" In an interview, Hoge told us that he was concerned with treating soldiers' symptoms, no matter the cause.

We also turned up extensive evidence that military doctors weren't diagnosing mild traumatic brain injuries, both on the battlefield and when troops came home. Battlefield medics, overwhelmed by life-threatening wounds, can miss the signs of concussions. Screening tools now in place often fail to catch soldiers who have suffered concussions. Soldiers often try to hide their symptoms to return to battle with their comrades.

One of the Army's senior neuropsychologists told us of examining five soldiers who had survived a rocket attack in Iraq last year. Medical staff had treated their visible wounds, but failed to diagnose them as suffering from mild traumatic brain injury -- even though they were suffering "classic" symptoms, according to Lt. Col. Mike Russell.

It is important to diagnose mild traumatic brain injury and quickly provide treatment for any lingering effects, according to the Pentagon's own experts. While the majority of soldiers recover quickly from concussions, some report lasting mental and physical problems. Studies show that such soldiers can be helped by providing cognitive rehabilitative therapy, an intensive program to retrain the brain to perform mental tasks.

Sen. Mark Udall, D-Colo., asked Chiarelli several questions about the military's efforts to improve how it diagnoses traumatic brain injury. Afterwards, he said that he appreciated Chiarelli's efforts, but planned to continue pressing Army officials on the issue.

Udall "remains concerned about the impact of TBI and PTSD on our service members," Tara Trujillo, a Udall spokeswoman. "As discussed at the hearing, there is much still to learn, different approaches to take and ways to continue to improve."

After the hearing, Levin said he was convinced that the services were trying to properly diagnose mild traumatic brain injury.

"I remain concerned about the diagnosis of traumatic brain injuries, and especially of mild traumatic brain injuries, but it is not for lack of the services trying to do the best they can with existing science, tools, and methods," Levin said in a statement. "There is still much to be learned in both the military and civilian medical environments about the diagnosis, treatment, and care of traumatic brain injury, and its relationship to other combat-related injuries such as post traumatic stress. I believe each of the services is taking the issues of detection, tracking, and follow-up care very seriously, but there is still work to be done."

Freddie Mac Offers Relief to Homeowners Dealing With Chinese Drywall

2010-06-18T17:05:22-05:00

Joaquin Sapien

Government-backed mortgage giant Freddie Mac, announced that it will allow borrowers to temporarily suspend or reduce monthly payments to help pay the cost of repairing homes contaminated by bad drywall.

Defective drywall, most of which was imported from China during the height of the housing boom, has corroded wiring and caused appliances like refrigerators and air conditioners to fail in thousands of homes. Remediation costs vary widely, but one Florida couple spent more than $100,000 on repairs.

Do You Have Defective Drywall?

Are you dealing with defective drywall? Is it causing health problems, or damage to your home? If so, we at ProPublica want to hear your story.

The announcement from Freddie Mac is a response to recent guidance from the Consumer Product Safety Commission, which said the only way to fix the problem is to remove all the drywall and the wiring from a contaminated home.

The commission, which is the lead federal agency investigating defective drywall, has received complaints from more than 3,300 homeowners in 37 states, with many coming from Florida, Louisiana and Virginia.

Freddie Mac said it would allow loan servicers – banks or other firms that process payments on the mortgages it owns – approve payment relief on a case-by-case basis.

Freddie Mac’s policies allow for a three-month break from mortgage payments or reduced payments for up to six months. The reduction and the length of the forbearance will depend on the expense of the damage in the borrower’s home.

To qualify, a homeowner will have to prove that the home is indeed affected by bad drywall.

Spokesperson Brad German said Freddie Mac has been receiving a small number of requests from loan servicers and borrowers for relief in recent years and had approved some forbearances.

“The issue has cropped up,” he said German, “so the purpose of today’s announcement is to let our servicers and borrowers know what relief was available under our guidelines.”

Separately, the Sarasota Herald-Tribune reported that a settlement was reached between Chinese drywall manufacturer Knauf Plasterboard Tianjin Co. Ltd. and plaintiffs in two Louisiana drywall cases that had been set for trial next week.

More Companies Knew About Tainted Drywall but Stayed Quiet—and Kept Selling It

2010-06-18T00:00:02-05:00

by Joaquin Sapien, ProPublica and Aaron Kessler, Sarasota Herald-Tribune -

At least a half-dozen homebuilders, installers and environmental consultants knew as early as 2006 that foul smells were coming from drywall imported from China – but they didn’t share their early concerns with the public, even when homeowners began complaining about the drywall in 2008.

ProPublica and the Sarasota Herald-Tribune reported last month that two U.S. companies – WCI Communities, a major Florida homebuilder, and Banner Supply, a Miami-based distributor – knew about the problem in 2006. But according to recently released sworn depositions by current and former executives at Banner, other companies also were aware of the problem.

Do You Have Defective Drywall?

Are you dealing with defective drywall? Is it causing health problems, or damage to your home? If so, we at ProPublica want to hear your story.

The U.S. Consumer Product Safety Commission has since linked the foul odor to sulfur gases that can corrode electrical wiring and household appliances, including air conditioners and refrigerators. The long-term health effects of the air are still being studied, although homeowners have complained of respiratory problems, bloody noses and severe headaches.

As WCI was ripping the smelly drywall out of homes on Florida’s east coast, the company was selling houses built with the same material on the west coast. Several homeowners in the Sun City Center and the Venetian Golf and River Club in North Venice told ProPublica and the Herald-Tribune that they bought homes from WCI as late as March 2007 — eight months after the builder had found problems with Chinese drywall — but received no warning.

When WCI filed for bankruptcy protection in 2008, it promised many homeowners it would fix the contaminated homes once it emerged from bankruptcy. The company exited Chapter 11 bankruptcy protection last September as a privately held company and recently announced plans to build new homes throughout Florida. Meanwhile, scores of its former customers are still living in WCI homes built with Chinese drywall.

Calls to WCI executives were routed to the company’s public affairs office, which did not respond to questions, including whether WCI still plans to repair the homes.

Banner and its attorneys didn’t respond to calls for this story either.

The president of one company mentioned in the depositions, PDC Drywall Contractors Inc., said in an interview with ProPublica and the Herald-Tribune that Banner delivered Chinese wallboard to PDC’s job sites in 2006 against PDC’s wishes.

The president, Peter Cuomo, said he had noticed that some of the drywall being imported from China crumbled more easily and couldn’t be cut as finely as American-made drywall. More important, it did not carry the usual markings and had no warranties — leaving installers at risk if there was a future problem, Cuomo said.

“I told Banner I didn’t want any of it,” Cuomo said. “I sent them a letter, and told them again. But they kept sending it to me, sneaking it in with the deliveries hoping we wouldn’t notice.”

Cuomo said he wasn’t aware of the odor problem in 2006, but the other issues were worrisome enough. When one of his workers called to tell him that Banner had delivered several sheets of the problematic board to a construction site, he said he had the drywall removed. He said he also contacted Gus Coffinas, then the head of Banner’s Port St. Lucie operation, to complain again.

Coffinas couldn’t be reached for comment.

“I told him we don’t want any Chinese board, what’s going on here?” Cuomo said. “He promised to take care of it. But that didn’t happen.”

Cuomo said he told all his workers to alert him if more of the Chinese board showed up, but heard nothing. It wasn’t until 2009, when the Chinese drywall problem became a public crisis, that he discovered that dozens of the homes PDC worked on had received the problematic board. The Consumer Product Safety Commission has since received more than 3,300 complaints from homeowners in 37 states.

“Nobody on the jobs said something to me after that first time,” Cuomo said. “The trouble is they all get paid by what they hang, so I guess there wasn’t a motivation to alert me. That, and if you’re talking about 300 sheets being there on a job and only five or 20 sheets were Chinese, they might have just missed it." He added, "That’s why Banner did it that way. They hoped nobody would realize they’d slipped us a little bit of it with the rest. Now my whole reputation has been tarnished.”

Cuomo said about 40 of the 90 homes that PDC helped build in a Vero Beach development, The Antilles, have now been confirmed as having Chinese drywall.

“We’ve found as little as three and up to 30 Chinese boards in the homes,” he said. “But it’s like being a little bit pregnant. Once you’ve got a little of it, these homes are having the problems with corrosion and the rest of it.”

Cuomo said it was Coffinas himself who first alerted PDC to a potential problem with the Chinese-made drywall. In 2006, when the housing boom was in full swing and drywall was scarce, Cuomo said a European broker approached him with an offer that sounded almost too good to be true: a train car full of drywall from China, available for a fraction of the market price.

“Banner and other suppliers were charging me $20 a sheet back then, and this guy’s offering me a train car’s worth for only $3 a sheet,” Cuomo said.

There was only one problem: Cuomo didn’t have a way to unload the car and get the material to his construction sites. So he turned to Coffinas for help.

“I went to Gus and said: ‘What do you think, can you help me out? We can both profit.’”

But Cuomo said Coffinas warned him off. “He said, ‘You don’t want to touch that Chinese board, it’s nothing but problems,’” Cuomo recalled.

Cuomo said Coffinas never mentioned an odor problem – he just indicated that the board was of poor quality. Cuomo said PDC inspected some of the Chinese board and reached the same conclusion. Not only did Cuomo turn down the discounted board, but he said he also told Banner that in the future his company wanted only American board.

It is not clear why Banner would have included small amounts of Chinese dry wall in its deliveries to Cuomo since both sides in the transaction were aware of its defects.

***

In October 2006, a WCI employee began alerting other Florida builders that Chinese drywall sold by Banner was emitting a foul odor, according to the sworn testimony of Donald “Mickey” Coblentz, a Banner executive.

“He was e-mailing builders and telling them that if you have Chinese drywall you have a problem,” Coblentz said in a deposition that is part of an ongoing civil suit against Banner in Miami-Dade Circuit Court. Coblentz added later in his testimony that he had never actually seen one of the e-mails but heard about them from other builders.

Coblentz, who sold the Chinese drywall to WCI and its installer, said he offered to remove Chinese drywall that any builder complained about and replace it with American-made drywall. He said he replaced material used by at least four different builders and drywall installers.

But Coblentz removed the drywall only for companies that complained to him. Scott Giering, another Banner executive, said in his deposition that Banner never told its other customers about the drywall problems.

Coblentz said most of the drywall he replaced was sitting in unfinished houses and had not yet been installed or “hung” on the walls. He said only two companies actually tore down problematic drywall after it had been installed and asked him to replace it with American product: WCI and GL Homes.

A spokesman for GL Homes did not respond to questions about whether it replaced drywall in 2006, but confirmed that the company learned of the odor issue from WCI that year.

As ProPublica and the Herald-Tribune first reported, WCI discovered odor problems in several of its homes as early as July 2006 and commissioned scientific testing. According to documents revealed in litigation, WCI told Banner that the tests concluded that drywall manufactured by Knauf Plasterboard Tianjin Co. Ltd. was to blame.

But Patrick M. O’Donnell, president of Pompano Beach-based Enviro Team, confirmed that his company conducted tests in 2006 that involved air sampling from homes and sniff testing of the board. He would not disclose the names of his clients or the results of the tests.

“We recognized back in 2006 that the wallboard was responsible for the sulfur odors, yes,” O’Donnell said. “But we didn’t measure anything that indicated a health hazard.”

The Banner executives apparently confused Enviro Team with another testing company, Environ International, in their depositions. Bob DeMott, a Florida-based managing principal for Environ International, told ProPublica and the Herald-Tribune that “no one from Environ had ever even heard of Chinese drywall in 2006.” DeMott said that the company did not do any tests related to Chinese drywall until 2008, when it was hired by Miami-based builder Lennar Corp. to investigate that builder’s own problems. DeMott said he could not recall when the Lennar testing began, but testing reports obtained by the Herald-Tribune and ProPublica show Environ was evaluating Southwest Florida homes for Lennar as early as the spring of 2008.

Environ International shared some of its testing with the Florida Department of Health that September, after local and state health officials learned of its work. To this day it has not publicly disclosed the results of testing it has conducted for more than a dozen Florida builders.

In his deposition, Coblentz said that by mid-October 2006 “word was spreading” fast throughout the industry about the drywall problem. But no one contacted customers or regulators.

In late 2006, Palm City-based D&A Construction Services told Banner there was “a bad smell” in the house of one of its customers, Coffinas said in his deposition.

Coffinas said he met David Hatcher, D&A’s president, at the house and watched as workers cut big circles of drywall from the walls so they could be sent for testing.

The samples were sent to the “independent lab that Dave had.” In his deposition, Coffinas, who was laid off from Banner last fall, could not remember the identity of that lab and said he never saw the test results.

Hatcher could not be reached for comment.

Meanwhile, word of the Chinese board was spreading within the South Florida building industry in 2006, Coffinas testified. In fact, it was being used by Banner’s competitors to persuade customers to go elsewhere, cutting into Banner’s bottom line. “Our competitors were using that as a negative sales tool against us,” he said.

GE Violated Danish Drug Reporting Law in Omniscan Case

2010-06-17T16:59:32-05:00

Jeff Gerth

General Electric's health care unit failed to promptly and completely inform regulators about a patient who died after experiencing adverse effects from the company's MRI drug Omniscan, Danish drug regulators concluded in a ruling last month.

The finding by the Danish Medicines Agency comes in the case of a Danish woman who had been injected with Omniscan for a magnetic resonance scan in 2002 and gradually became immobilized and died of a lung embolism the following year.

The woman, Birthe Madsen, is believed to be among the first patients whose use of Omniscan and similar medical imaging drugs was associated with a rare and potentially crippling disease now known as nephrogenic systemic fibrosis, or NSF. Hundreds of patients became ill after Madsen's death, before regulators and drug companies learned enough about the risks to begin issuing alerting doctors a few years later.

Reviewing the reasons Madsen died, a Danish government insurance agency determined in 2004 that Omniscan caused her immobility and in turn her death. Although this was relayed to GE Healthcare, the company did not immediately report it to the medicines agency as required, nor did a follow-up include the insurance agency's conclusion that Madsen's death could be attributed to the drug.

Although the reporting lapses violated Danish drug law, the medicines agency told GE Healthcare in a May 21 letter that the statute of limitations had expired and that it would not pursue further action against the company.

GE Healthcare maintains that its reporting about Omniscan's side effects has been proper, and spokesman Jeff DeMarrais said in an e-mail that the woman's death was not initially attributed to Omniscan because the fatal embolism occurred during a lengthy course of treatment "following the patient's adverse reaction."

The ruling by the Danish Medicine Agency, coming years after the reporting lapse, appears to have been prompted by an inquiry last October from a member of the Danish parliament about the agency's response after cases of NSF first came to light in early 2006.

GE currently is contesting more than 400 lawsuits involving U.S. patients who say they contracted NSF after being injected with Omniscan. The company says it acted properly to protect patients and denies its drug causes NSF. Some manufacturers of competing products also have been sued, but in far fewer numbers than GE.

One of the major points of debate in the litigation concerns what GE Healthcare knew and disclosed to regulators about Omniscan's risks. The company contends it has been proactive and cooperative, while the plaintiffs claim the company failed to disclose damaging information about the drug and put patients in jeopardy.

Critics of GE Healthcare say more forthright disclosure might have helped doctors and regulators respond earlier and more effectively. Among them is Madsen's son, Casper Schmidt, a Copenhagen lawyer who has carefully documented her case and the actions of various Danish authorities.

"If my mother's case had been reported more accurately, and if the company had to explain why a patient died," Schmidt said in an e-mail, "it would have helped enable doctors and regulators to better understand the disease earlier."

Drug manufacturers in the United States and Europe are required to promptly report serious adverse reactions so that regulators and medical providers can monitor a product's safety. They also must update the reports as new information about a case develops. In the U.S., the Food and Drug Administration logs the reports in a database.

At the time Madsen was exposed to Omniscan in 2004, tens of millions of patients who had undergone MRIs had been safely injected with such products, known as contrast agents, to enhance the images.

Omniscan, approved for use in the United States in 1993, is among a class of such agents that rely on gadolinium, a highly toxic metal. The body normally eliminates the drug quickly after treatment, except in some patients who have impaired kidney function.

Madsen was such a patient. According to Schmidt's timeline of her treatment, she had at least one dialysis treatment before being injected with Omniscan in January 2002 to evaluate whether her veins were healthy enough for a kidney transplant. She experienced a cascade of crippling symptoms until her death in October 2003 at age 55.

Madsen's adverse reactions prompted a medical review by a Danish government insurance agency, called Patientforsikringen, or Patient Insurance Agency, to see whether she had suffered drug side effects that might qualify her for state compensation.

The review determined that while Madsen died of a pulmonary embolism, her "immobilization was caused by the acknowledged pharmaceutical injury."

That conclusion was reported to GE Healthcare on June 1, 2004, but the company failed to relay the information as required, the Danish Medicines Agency said in its May letter. In addition, the agency said a follow-up report from GE Healthcare, while noting several of Madsen's adverse reactions, was insufficient because it did not repeat the state insurance agency's finding that she died from an embolism due to being immobilized.

DeMarrais, the GE spokesman, said that at the time, the company's drug safety experts had a different understanding of Madsen's death.

"Our filings regarding the case in question reflect that, as of 2004," DeMarrais wrote, the drug safety unit "had not concluded, based on the information available at the time and in good faith, that the patient's death had been caused by the adverse event that had been linked to the administration of Omniscan, but rather by a pulmonary embolism occurring during a protracted medical course following the patient's adverse reaction."

In its May letter, the Danish Medicines Agency said it had combed its files and could find no report from GE about Madsen in June 2004. DeMarrais, however, said the company believes a report was sent that month "at the same time as it was sent to other regulators, as confirmed by the FDA's receipt of this filing."

At ProPublica's request, Conor McKechnie, another company spokesman, provided a copy of the FDA filing with Madsen's name and some other information redacted. (The filing was on the letterhead of Amersham Health, the British maker of scanning drugs that GE acquired in late 2003 and early 2004.)

The filing references "new information" from the Danish insurance agency and states that the patient involved "suffered pulmonary embolism due to immobilization and died." But it does not quote the insurance agency's conclusion that "pharmaceutical injury" was to blame for Madsen's immobility.

McKechnie said the FDA filing is accurate and mentioned immobilization, the embolism and death. DeMarrais said GE Healthcare also has submitted half a dozen more supplemental filings on the case over the last six years. "It would be a mistake," he added, "to attach unwarranted significance to this particular case at this juncture."

"It is our position that, consistent with the relevant health risk communication protocols, we provided complete and timely reports to the DMA and other global authorities regarding the adverse events associated with Omniscan that were reported to us," DeMarrais said in his e-mail.

Dr. Sidney Wolfe, director of the health research group at the consumer watchdog organization Public Citizen, said GE should have been more forthcoming in 2004.

"Incomplete and misleading reports such as this undermine the ability of the government to make decisions more quickly to improve the public health," said Wolfe, who is on an FDA advisory committee that late last year reviewed Omniscan and other contrast agents.

In May 2006, following the disclosure of 20 NSF cases in Copenhagen, GE Healthcare issued a safety alert to the DMA and regulators around the world. It discussed the new cases and attached a brief description of each one. In the section involving Madsen, the company reported her death as "unrelated to Omniscan."

By 2007, at the urging of regulators, the manufacturers of gadolinium-based agents put warnings about NSF on their labels. Three years later, much about the disease remains a mystery, including the exact cause. Patients experience a painful hardening or thickening of skin around the joints. The disease can be disfiguring and may attack internal organs.

As of last fall, the Patientforsikringen had reviewed 38 cases in which people exposed to Omniscan had suffered injury or death. In 26 cases, the insurance agency determined that GE Healthcare's drug was the likely cause, according to a spokesman. In those cases, including Madsen's, the agency made payments to the victims or their relatives.

GE Healthcare has the opportunity to appeal the insurance agency's decisions but has not done so, the Patientforsikringen spokesman said in an e-mail last fall. McKechnie said the company did not appeal because it was not a direct party to the agency's decision.

DeMarrais said the company would respond to the Danish Medicines Agency's finding of a reporting violation, which can be appealed.

Madsen's name is redacted in the May 21 letter from the agency, but it was confirmed by her son and by matching the details in the letter with other public information.

Congress Demands Answers on Brain Injury Care at Texas Base

2010-06-16T20:30:50-05:00

by T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR -

WASHINGTON, D.C.--In response to an investigation by ProPublica and NPR, three congressmen are demanding answers from Fort Bliss medical officials about the care being provided to soldiers with traumatic brain injuries.

Rep. Harry Teague, D-N.M., Rep. Silvestre Reyes, D-Texas, and Rep. Ciro Rodriguez, D-Texas, sent a letter to Fort Bliss' William Beaumont Army Medical Center on Tuesday expressing concern over our report that soldiers encountered debilitating delays and frustrating bureaucracy when seeking help at the base, America's third largest by number of soldiers.

Tell Us Your Story

Did you or a loved one suffer a traumatic brain injury while serving? ProPublica and NPR want to hear your story. Tell us about your experiences with TBI.

A spokeswoman for Teague said today that the congressman was also considering calling for the U.S. Government Accountability Office to review the military's handling of traumatic brain injuries and may pay a visit to Fort Bliss to personally inspect the facilities.

"We are deeply concerned that our government could be failing those to whom we owe the most," the three men wrote in their letter. "These reports must be investigated and receive the full attention of the United States Congress and government."

In our investigation, we found that soldiers at Fort Bliss struggled to receive diagnosis and treatment for so-called mild traumatic brain injury. Such head traumas, also called concussions, often leave no visible signs of damage, but can result in long-term mental and physical problems.

Official military figures show that about 115,000 troops have suffered mild traumatic brain injuries since 2002. But we found that many troops have injuries that go undiagnosed or that are never documented in their medical records. Top Pentagon officials acknowledged in interviews that the true toll is likely far higher. Unpublished military studies reviewed by ProPublica and NPR suggest tens of thousands of mild traumatic brain injuries have gone uncounted.

Most soldiers with concussions recover quickly, but civilian studies indicate that 5 percent to 15 percent of those who suffer such injuries have lingering cognitive problems.

The Senate Armed Services Committee announced Wednesday that it will hold a hearing on June 22 to look into suicide, traumatic brain injury and other so-called invisible wounds.

Our investigation found that Fort Bliss had erected billions of dollars of new housing and accommodations for additional troops to deploy to war zones, but had failed to open the doors of Building 805, a traumatic brain injury clinic completed nearly a year ago. Although the Pentagon designated the base as a site for enhanced treatment for brain-injured soldiers in 2007, the base did not hire a full-time director for the program until October 2009.

Soldiers at Fort Bliss told us they waited weeks or months just to get appointments to see doctors and often received far fewer hours of therapy than patients at well-regarded civilian clinics. Some were prescribed therapy for psychological problems that did little to relieve their troubles with memory, balance and reasoning.

The three congressmen, who are part of the bipartisan Congressional Invisible Wounds Caucus, have asked the medical commander at Fort Bliss, Col. James Baunchalk, to answer several questions about the base hospital's treatment program.

They asked to know how many patients with traumatic brain injury, or TBI, were being treated at Fort Bliss, how long soldiers had to wait for appointments, and whether the hospital had systems in place to address soldiers' complaints.

"It's pretty important that (Fort Bliss) be at the front of addressing TBI and PTSD," Teague said in an interview. PTSD, or post-traumatic stress disorder, is a psychological wound that often accompanies TBI.

Fort Bliss officials have declined to answer such questions from ProPublica and NPR. Baunchalk also denied ever having received complaints regarding brain injury care, despite e-mails and letters written to his assistants and superiors by soldiers and family members.

Fort Bliss officials have defended their treatment of soldiers. In a response this evening, a base spokesman said they would respond to all questions posed by the congressmen by June 21.

"Our commitment is to provide quality health care, in a timely manner, to those who serve in our military," the statement said.

Top Officer Says Military Takes Brain Injuries ‘Extremely Seriously’

2010-06-09T17:15:30-05:00

by T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR -

June 10: This post has been corrected.

WASHINGTON, D.C.— Gen. Peter Chiarelli, the Army's vice chief of staff, defended the military's handling of soldiers who suffered brain injuries in Iraq and Afghanistan.

"We are taking this extremely seriously," Chiarelli said Wednesday in response to an investigation by National Public Radio and ProPublica which found the military is failing to identify and treat soldiers with so-called mild traumatic brain injuries. "There's no reason for us not to try to diagnose it."

Mild traumatic brain injuries, which are frequently caused by roadside blasts, leave no visible scars, but can cause lingering mental and physical damage. Officially, military figures show that about 115,000 soldiers have suffered mild traumatic brain injury since 2002. But we talked to military doctors and reviewed unpublished studies that suggest far more soldiers could have sustained such wounds. While most recovery quickly, estimates suggest that between 5 percent to 15 percent go on to develop cognitive problems.

In an interview on the NPR program "Talk of the Nation," Chiarelli said that the military had diagnosed thousands of soldiers with traumatic brain injuries, also called TBIs. But he said it was important to focus not only on TBI. Many soldiers are also suffering from post-traumatic stress, or PTS, a debilitating psychological wound that can be caused by the intense terror of being involved in a roadside blast.

Many soldiers suffer from both conditions at the same time, making it important to treat the symptoms, whatever the cause. He said the military was diagnosing and treating soldiers suffering from both wounds, which he described as the signature injuries of the wars.

"It's time we realize that TBI and PTS are real injuries," Chiarelli told Talk of the Nation host Neal Conan. "We've got to ensure our soldiers get the care that they need."

Chiarelli noted that the military is planning to implement a policy where soldiers exposed to nearby blasts will be evaluated by two separate tests to determine whether they have suffered a concussion before being returned to the battlefield. He said that doctors have advised him that soldiers at most risk of developing long-term problems suffer from multiple mild traumatic brain injuries, which are also called concussions.

"If either one of the exams in that 24-hour period indicates the individual had a concussion, they are pulled out of the fight until the concussion has an opportunity to heal," Chiarelli said. "The key here is not to have that second concussion while the brain has not recovered from the first."

But the NPR and ProPublica investigation found major problems with the two primary screening systems now used in the field. After a blast or blow to the head, soldiers take a paper-and-pencil exam called the MACE, or Military Acute Concussion Evaluation. In interviews, doctors and soldiers acknowledged that troops often manipulate the test to obtain a passing score and rejoin their comrades in battle.

A second computerized test used on the battlefield, known as the ANAM, or Automated Neuropsychological Assessment Metrics, failed to catch nearly half of all soldiers who had suffered a concussion, according to a recent unpublished study obtained by ProPublica and NPR. Lt. Gen. Eric Scoomaker, the Army's top medical official, recently testified in Congress that results from the test are no better than a "coin flip."

In recognition of the military's problems with screening, two Congressmen called for the military to implement legislation that would require veterans to receive individual, one-on-one evaluations for traumatic brain injuries and other battlefield illnesses.

Reps. Tom Rooney, R-Fla., and Michael E. McMahon, D-N.Y., cited the ProPublica and NPR investigation as further evidence of the need to pass the legislation, known as the Veterans Mental Health Screening and Assessment Act.

"Our troops and veterans deserve action to improve screening and detection of traumatic brain injuries," Rooney and McMahon said in a joint press release. "We hope the House of Representatives will move quickly to take up and pass this critical legislation."

Correction: This post originally said Gen. Peter Chiarelli was the Army's second in command. He is in fact the Army's vice chief of staff.

At Fort Bliss, Brain Injury Treatments Can Be as Elusive as Diagnosis

2010-06-08T21:00:29-05:00

by T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR -

FORT BLISS, Texas -- At this rapidly expanding base along the U.S.-Mexico border, the military is racing to build new homes for 10,000 additional soldiers. Cranes stack prefabricated containers like children's blocks to erect barracks overnight. Bulldozers grind sagebrush desert into roads and runways.

Just down the street from the construction boom squats a tan, featureless building about the size of a convenience store. Completed nearly a year ago, it remains unopened, the doors locked.

Building 805 was supposed to house a clinic for traumatic brain injury, often called the signature wound of the wars in Iraq and Afghanistan. Instead, it has become a symbol for soldiers here of what they call commanders' indifference to their problems.

"The system here has no mercy," said Sgt. Victor Medina, a decorated combat veteran who fought to receive treatment at Fort Bliss after suffering a brain injury during a roadside blast in Iraq last June. Since the explosion, Medina has had trouble reading, comprehending and doing simple tasks. "It's struggle after struggle."

Tell Us Your Story

Did you or a loved one suffer a traumatic brain injury while serving? ProPublica and NPR want to hear your story. Tell us about your experiences with TBI.

Previously, ProPublica and NPR reported that the military has failed to diagnose brain injuries in troops who served in Iraq and Afghanistan. Mild traumatic brain injuries, which doctors also call concussions, do not leave visible scars but can cause lasting mental and physical problems.

At Fort Bliss, we found that even soldiers who are diagnosed with such injuries often do not receive the treatment they need.

Most specialists say it is critical for patients who show lingering effects from head trauma to get intensive therapy as soon as possible. In the civilian world, such therapy is increasingly seen as the best way to minimize permanent damage, helping to retrain the mind to compensate for deficits.

Yet brain-injured soldiers at Fort Bliss have had to wait weeks and sometimes months just to get appointments with doctors, medical records show. Many have received far less therapy than is typical at well-regarded civilian clinics. In some instances, Fort Bliss medical officers have suggested that the soldiers are malingerers or that the main root of their cognitive problems is psychological.

"Here you have all these soldiers looking for help, and it was just getting swept under the carpet," said Sgt. Brandon Sanford, 28, a dog handler who survived two roadside blasts in Iraq. Sanford endured a year of balance problems and mental fog before Fort Bliss officials sent him for cognitive therapy. "I served my country. I've got an injury to prove it."

It is impossible for civilians to know how Fort Bliss' care for brain-injured soldiers compares in quality or scale to that of other bases. Base officials would not give ProPublica and NPR data on how many soldiers are being treated there and the Pentagon would not provide this information for bases elsewhere.

Fort Bliss -- the third-largest base in the U.S. military and a vital nerve center for deploying and returning troops -- is supposed to be among the best. In 2007, the Pentagon designated it as one of 20 bases nationally that would develop augmented treatment programs for traumatic brain injury.

Yet while base commanders have spent more than $3 billion to expand and improve Fort Bliss over the past several years, they have directed just $5 million to facilities and clinicians to treat TBI. The program had no full-time director until October 2009. A neuropsychologist was hired only recently, after a two-year search.

Fort Bliss' commander, Maj. Gen. Howard Bromberg, declined repeated requests for an interview. Col. James Baunchalk, the base hospital's commander, acknowledged that the TBI program had encountered some delays, but said that it now had 12 clinicians -- four full-time and eight part-time -- who were delivering comprehensive care.

"I honestly believe that we've done a good job of meeting the needs for the community," Baunchalk said.

He promised in April that Building 805 would open by the end of May, saying they were just waiting until computer cabling was installed.

Apparently, they missed their deadline. As of early June, the clinic to screen soldiers for traumatic brain injury had not opened its doors to a single patient.

The Soldiers

Traumatic brain injuries are among the most common wounds sustained in Iraq and Afghanistan. Shock waves from bombs can pass through helmets and through the brain. Secondary trauma can occur when soldiers are thrown up against vehicles or walls, shaking the brain again.

Officially, the military says about 150,000 soldiers have suffered some form of brain injury since the wars began. But a 2008 Rand study suggests the toll is much higher, perhaps more than 400,000 troops. The most common type are so-called mild traumatic brain injuries. Most people recover quickly from such injuries, but studies have shown between 5 percent and 15 percent of patients may suffer long-term problems.

ProPublica and NPR interviewed more than a dozen soldiers at Fort Bliss who are among that so-called miserable minority. All were diagnosed by military doctors with at least one mild traumatic brain injury. All had persistent symptoms, ranging from headaches and vertigo to difficulties with memory and reasoning.

They described the bewildering ways in which their injuries had changed them. A sergeant who once commanded 60 men in battle got lost in a supermarket. A soldier who once plotted sniper attacks could no longer assemble a bird house. Most of them did not want their names used, for fear of harm to their military careers.

All felt the treatment they received was inadequate. At leading neurocognitive rehabilitation centers, some patients with mild traumatic brain injury often receive three to six hours a day of therapy for months from teams of highly trained specialists.

By contrast, many soldiers at Fort Bliss attended two to four hours of cognitive treatment per week. For some soldiers, weeks passed by with little or no treatment. The therapists who provided the soldiers with speech and occupational therapy for their brain injuries sometimes had only minimal training in cognitive rehabilitation, records show.

Staffing shortfalls also meant soldiers had long waits before beginning rehabilitative therapies. While clinical research is still developing, the consensus recommendation of a group of military and civilian experts convened by the Pentagon last year was to provide rehabilitation therapy as promptly as possible.

"The longer you go without therapy, the greater likelihood there is of falling into what I would call a mental disuse syndrome, where the brain is not being used at the same level," said Keith Cicerone, a leading rehabilitation researcher and the director of neuropsychology at the JFK Johnson Rehabilitation Institute in New Jersey. The brain "is in essence going to develop bad habits."

Sgt. Raymond Hisey, 32, a convoy driver in the 1st Armored Division, survived a roadside blast in Iraq in July 2009. He remained in the field, but endured constant headaches and balance problems. His short-term memory suffered and he struggled to think of words to express himself.

When he returned to Fort Bliss in October, he was diagnosed as having suffered a mild traumatic brain injury and was prescribed several courses of therapy. But a speech therapist cancelled several appointments, he said, and he clashed with the occupational therapist. Hisey was suddenly left without any treatment at all for his symptoms.

"You just get lost in the system," he said. "I could have pushed more, sure. But people kept saying it gets better over time. I thought I was just losing my damn mind, to be honest with you."

Fort Bliss is supposed to provide treatment to troops at smaller bases in the surrounding area. But one such soldier who developed headaches and balance problems after working on a mining detail in Afghanistan was told that no therapists could make regular trips to see him. Instead, the soldier, whose base was about an hour away from Ft. Bliss, was given antidepressants, which he did not take. He recently deployed for a second tour.

"As much as the military is making of TBI and the effects it's having on the soldiers and their families, I think for something as big as Fort Bliss, there'd be more people" to treat it, said the soldier, a specialist who did not want his name used for fear of damaging his career. "I was told there were no resources, no facilities."

Baunchalk, the hospital commander, said he had never heard such complaints from soldiers or their spouses. Soldiers were often reluctant to seek care, he said, because they perceived a stigma attached to traumatic brain injury.

"It's tough for them to step forward and say ... I need some help," he said. "I don't think we have that many soldiers who have fallen through the cracks."

Several soldiers told ProPublica and NPR, however, that they and their families had reached out to base commanders, sent e-mails to generals throughout the Pentagon, and even written to members of Congress, pleading for care.

When their efforts proved futile, they felt abandoned. Nobody paid attention, they said, to a soldier with an injury that nobody could see.

"No one listens to the soldier," said Sgt. William Fraas, an 18-year military veteran and Bronze Star recipient who struggled for nearly two years to get help for problems with his balance and vision. "They are there and they are crying for help."

The Neurologist

Fort Bliss soldiers struggling with the effects of brain injuries were often sent to the base's sole neurologist, Capt. Brett Theeler. Theeler, records show, sometimes blamed psychological disorders rather than blast wounds as the likely source of soldiers' cognitive problems.

A convoy commander in the 121st Brigade of the 1st Armored Division, Sgt. Victor Medina can see the moment he suffered his invisible injury. He was rumbling down a highway in southern Iraq June 2009 in a convoy of fuel, ammunition and supplies. Just behind him, in another armored troop carrier, one of Medina's soldiers was videotaping. Suddenly, the screen shakes. Black smoke jets into the air. Noise, swearing, confusion erupts.

A roadside bomb had exploded directly beside Medina. Metal slag ripped through his vehicle's heavy armor, destroying radio equipment and blowing open Medina's door.

Outwardly, Medina did not appear seriously injured. But in the weeks and months that followed, his mind began to fail him. He slurred his words, then started stuttering. An avid reader, he struggled to get through a single page. A punctilious soldier, he began showing up late for missions.

Medina was sent to Germany in August, where Army doctors diagnosed him as suffering from a traumatic brain injury. But when he returned to Fort Bliss for treatment, he and his wife, Roxana, found themselves fighting for care.

Medina had his first appointment with Theeler a month after his return to Ft. Bliss. Afterwards, Theeler wrote that Medina had "multiple cognitive symptoms including poor concentration, short-term memory loss, and difficulty multi-tasking." Theeler said those symptoms were "possibly" related to lingering effects from his concussion, but were "likely" caused by "chronic headaches" and "anxiety." He wrote that Medina's stuttering was probably caused by anxiety, too.

After a follow-up session with Medina in December, Theeler wrote:, "I am concerned that he may be slipping into a cycle of playing the sick role." He pointed to the fact that Medina was using crutches -- apparently unaware that a physical therapist had asked Medina to use the crutches because of back pain.

To Medina, 34, a tall, broad-chested man with an intense stare, Theeler's words were insulting. Once praised by superiors for his leadership abilities, Medina worked relentlessly to overcome the staccato stutter that had made him difficult to understand. He was fighting to get better, fighting to remain in the Army. He said he felt he was being labeled a liar.

"You have all these values that you live for and fight for. And you go to the medical side and you don't see those values," Medina said. "I can understand being injured by insurgents. But I can't understand being injured by my own people."

Other soldiers had similar experiences with Theeler.

By the time Spec. Ron Kapture got to Fort Bliss in July 2009, he had suffered six concussions in which he was knocked unconscious from blasts, according to medical records and his own recollections.

He was suffering headaches on a daily basis. He noticed that he could no longer do simple mental tasks. Before joining the Army, Kapture had gone to vocational school to learn cabinet making. After returning from Iraq, he struggled to put together a bird house with his son.

"It took us about a month," said Kapture, 28. "I could build a whole living room full of furniture in a day seven years ago. It took me a month to build a bird house. That is frustrating stuff."

Five months after his return, Kapture finally got an appointment to see Theeler after making repeated requests. Theeler noted that Kapture had a history of "mild concussions," but blamed his cognitive problems on "chronic headaches, sleep disorder and underlying mood anxiety disorders and depressions," records show.

Kapture received counseling and medication for post-traumatic stress disorder, or PTSD, but his problems with memory and concentration persisted. He had planned to make the Army his career, but became so embittered at the handling of his care that he is applying for a medical dismissal.

"If that's the best help they ... can give us, then God help us all," Kapture said. "If that's the best they have to offer, I feel sorry for the guys coming home."

In an interview at the base, Theeler declined to comment on individual cases, even in cases where soldiers had signed a waiver of their privacy rights. He said, more generally, that he understood why soldiers like Medina and Kapture were frustrated. Mild traumatic brain injury can be difficult to pinpoint as a cause for soldiers' problems since there are no readily available biological markers to indicate that a concussion has occurred, he said.

Theeler said he concentrated on treating soldiers' symptoms regardless of the cause.

Soldiers "say, 'Sir, what's wrong with me?'" Theeler said. "We're honest. I say, 'I don't know what's wrong.' This is an area that we're working very hard at to get our hands around. I don't know the answers."

The PTSD Clinic

Some doctors and soldiers at Fort Bliss said medical commanders have placed a higher priority on treating post-traumatic stress disorder, a psychological condition, than on mild traumatic brain injury.

As evidence, they point to the fate of two clinics. While Building 805 remains unopened, the base has poured money and effort into an experimental PTSD clinic that has attracted widespread attention within the military, including a visit from Defense Secretary Robert Gates.

Known as the Restoration and Resilience Center, the clinic offers intensive, six-month-long treatment for chronic PTSD sufferers, including controversial techniques such as reiki, in which practitioners hover their hands over patients' bodies to improve the flow of "life energy," according to a pamphlet distributed at the center.

Brain injuries and PTSD sometimes share common symptoms and co-exist in soldiers, brought on by the same terrifying events. Neuropsychologists said that treatments for the conditions can differ, however. A typical PTSD program, for instance, doesn't provide cognitive rehabilitation therapy. Someone with nightmares associated with PTSD might be prescribed sleep medication, which could leave a brain-injured patient overly sedated without having a therapeutic effect.

One doctor at Ft. Bliss said that base commanders' focus on the PTSD clinic resulted in soldiers not getting adequate treatment for brain injuries.

"The way our philosophy is in this hospital ... we took away their belief that they truly have something," said the doctor, who did not want his name used for fear of retaliation from commanders. "I don't think we gave them the opportunity to heal and that's what I find really disgusting."

Some soldiers said they spent months receiving PTSD treatment while their cognitive problems went unaddressed.

Sgt. William Fraas, 38, the sergeant who was awarded the Bronze Star With Valor, served three tours in Iraq, helping to train the Iraqi soldiers as part of the 101st Airborne Division, 320th Field Artillery. He was given his medal after after rescuing an Army major and six Iraqi soldiers pinned down by gunfire. Driving in his Humvee, he used to keep track of the roadside bombs with a black grease pencil on the windshield. After 10, he stopped counting.

When he was sent home to Fort Bliss in 2008, he was diagnosed with PTSD and entered the experimental clinic. He spent eight months there before being cleared to return to active duty.

But Fraas realized he was still having problems. He was constantly dizzy. He had debilitating headaches. He would call his wife when driving, so she could keep him oriented and awake.

He began having blackouts. Once, he awoke to find his 12-year-old son struggling to lift him after he collapsed in front of his home computer.

"They have these meetings for PTSD. But nowhere did they tell you anything about TBIs. We had no idea what was going on," he said. "It feels like my head is loose. Like my brain is loose. Like it's rattling inside my head."

Finally, last summer, Fort Bliss doctors sent him to see a physical therapist at the base to improve his balance. But the appointments were irregular. And with his inability to drive, he had trouble getting around the sprawling base. A case manager who was supposed to coordinate his care asked one of Fraas' friends if he was faking it. A second case manager never even contacted him.

After putting nearly 20 years into the military, he was stunned.

"I could not get help. I called and called and called. I was hurting," he said. "It was just terrible. I'm a senior non-commissioned officer and I couldn't get help. I couldn't get help anywhere."

Mentis

Some Fort Bliss soldiers have discovered that if they protest long and loud enough about their care, base commanders occasionally will pay to send them for help -- outside the military.

On a hot afternoon earlier this spring, Sgt. Brandon Sanford was digging a small trench in the black soil of a rose garden at Mentis, a private neurological rehabilitation facility perched on the mountains just outside of El Paso.

He was installing an irrigation drip line as part of a therapy program designed to help him follow instructions. He set in one line, then covered up the trench. Then, looking down, he suddenly realized that he had failed to install the second drip line he was holding in his hand.

It was a typical problem for a brain-injury patient. Concentration deficits can make even simple tasks complex and confusing. Sanford immediately began pulling up the first line, digging again.

"That can be frustrating," the therapist overseeing the exercise said sympathetically.

"Never," said Sanford cheerfully. "I ate my Wheaties this morning."

Almost two years ago to the day, Sanford, a dog handler working with the 4th Infantry Division, was inside his Stryker troop carrier near Taji in central Iraq when a bomb exploded. The blast sent Sanford and his dog, Rexo, hurtling against the walls. Both were awarded the Purple Heart for shrapnel wounds they received in the explosion. Although dazed, Sanford shrugged off the headaches and dizziness he experienced and continued working.

When Sanford returned to Fort Bliss in January 2009, he began having seizures, along with continued headaches and balance problems. He saw the base neurologist, Theeler, who diagnosed him as having "shaking syndrome," medical records show.

He entered the PTSD clinic, received counseling and was released, but was still so mentally foggy he couldn't understand his 10-year-old son's math homework. His wife would open the cupboard where they kept cleaning supplies and find that her husband had put the milk carton next to the bleach. Sanford's wife and mother badgered military commanders unrelentingly until, nearly a year after his return from Iraq, they finally sent him to Mentis.

There, Sanford is an in-patient: he spends eight hours a day, five days a week, on rehabilitation exercises. He goes on weekly outings to help him navigate the noise and confusion of public spaces, such as shopping malls. And he practices real-world tasks, like following cooking recipes -- or laying out plans for a garden.

Today, Sanford said that he is able to finish making meals more quickly. He can now perform two tasks at once, instead of only one. He is getting better at managing his own medications and his balance has improved.

"You can only do so much sitting inside a hospital. It was like pulling teeth from a tiger to try to get in here. Once I got in here, it was like a whole new ray of light."

Eric Spier, Mentis' medical director, said he has asked the military to send him more patients. But base commanders have sent only a few dozen in almost three years.

"I've made sure to tell everyone I can tell that I'm ready to help, but that's all I can do," Spier said. The base has not sent "very many. It's surprisingly few."

Fraas and Medina now attend sessions at Mentis. They praised the facility, but expressed disappointment that they had had to go outside the Army to receive help.

Medina started in February. The staff at Mentis say his reading and concentration abilities are improving. His growing optimism is apparent in the blog he has started to chronicle his recovery.

"I might be slower right now, but I think it's all going to get better and I want to go back to what I love doing, which is soldiering," Medina said. "It's what I love to do."