Photos: Vic Davis, MD

Alisa Gean, MD, has just finished her second voluntary tour at the U.S. Army's Regional Medical Center, in Landstuhl, Germany. Gean went there, intent on making a difference. Acknowledging the emotional toll of working with wounded soldiers, she still came back feeling that her time had been "incredibly rewarding."

Gean is chief of neuroradiology at San Francisco General Hospital, as well as professor of radiology, neurology, and neurosurgery at UCSF and a worldwide expert on traumatic brain injury (TBI). Her 1994 book, Imaging of Head Trauma, remains the standard for the field. She decided to go to Landstuhl after a neurosurgeon friend, Guy Rosenthal, came back from his two-week stint there and encouraged her to go as well.

"He told me they had only one neurosurgeon and no neuroradiologist," Gean says. "I have a lot of experience with civilian TBI, but not a lot of experience with battlefield TBI, so I thought it would be an opportunity to both help and learn."

As the largest military hospital in Europe, the Landstuhl Regional Medical Center is the first stop for all wounded troops after leaving Iraq and Afghanistan. It takes in about 30-40 injured U.S. soldiers per day. After triage, the hospital stabilizes the soldiers before sending them back to the States.

Gean first went to Landstuhl in March of this year. During her two-week stay, she lectured on the neuroradiology of TBI, but the bulk of her time was spent as a clinician and consultant. "I was in the ICU and the operating room every day," she says, "interviewing patients and consulting with the doctors. I learned a tremendous amount about what it might be like to be wounded on the battlefield or working on combat victims."

Gean decided to go back in June to continue with both her consultations and her research. "I wanted to better understand how combat trauma differs from civilian trauma," she explains. "What system is in place to take care of these patients, and how effective is it?"

Gean's questions stem from her belief that the United States will suffer more terrorist attacks in the future – and that the resulting injuries could be similar to those sustained by soldiers in Iraq.

"Eighty-percent of the injuries in Iraq are due to 'improvised explosive devices' or IEDs: pieces of metal – like nails, screws, ball-bearings, even hunks of car bumpers – packed into homemade bombs. But increasingly, we're also seeing injuries from 'explosively formed projectiles' or EFPs." (EFPs are shaped specifically to penetrate armor.)

TBI typically occurs when a soldier is thrown through the air by the force of a bomb's blast wave or by penetrating injuries from the bomb fragments. Troops also suffer from mutilating systemic injuries, such as multiple amputations, and from blast wounds caused by the supersonic shockwaves created by a bomb (e.g., ruptured tympanic membranes and intestinal and lung injuries.) These systemic injuries complicate both the identification and the treatment of TBI.


Alisa Gean, MD, in the ICU in Landstuhl

Deducing the extent of brain injuries is further complicated by a number of factors. First, the patients often arrive in Landstuhl under sedation, which makes it hard to assess their neurological status. Second, patients are understandably distracted by their other injuries. Third, TBI does not always show up on x-rays, MRIs, or CT scans.

"Sometimes, the only abnormality is persistent cognitive deficits, which might not rear its ugly head, so to speak, until the soldier gets home," Gean says. Still, she was pleasantly surprised by the number of soldiers who did not have definite evidence of TBI, despite having suffered other severe injuries. "You could be talking to a young soldier who had just lost three of his four limbs," she says. "Yet he was able to describe the accident to me. His brain was protected by his skull, his helmet, plus a number of factors that we don't fully understand – including sheer luck."

In addition to learning more about how bomb blasts affect the brain, Alisa Gean wants to increase the public's awareness of the frequency of domestic TBI. "In the U.S., TBI is the most common cause of death in adults under the age of 45. It is more common than HIV/AIDS, MS, spinal cord injury, and breast cancer combined." (more >>)

Along with her colleague at SFGH, Geoff Manley, Gean is currently serving on an NIH committee that is working on a new classification system for TBIs. (The Glasgow Coma Scale is "crude, to be kind," she notes). She's also advocating for more federal research funding. "The VA system is being inundated with these young soldiers," she says. "We have to know how to better identify and treat them, and that takes money."

For Gean, who primarily works as a neuroradiologist, dealing with so many injured young people was "very rough," emotionally.
"I was in a daze on the flight home after my first 'tour of duty'," she says. "I think I was silent the whole trip, which my friends and family will tell you is rare. The second time around, I handled it a little better. I sought advice from a good friend, Dr. Cheryl Jay, who told me that in order to continue this work, I had to deal with my emotions. Otherwise I'd just be paralyzed."

"This has been a life-changing experience," she concludes. "I was truly honored to serve these wounded warriors, and I've realized that the primary goal in my life is to use the gifts I have to make a difference in the lives of others."

Source: Susan Davis