Transcripts For CSPAN2 Defense 20240704

[inaudible [inaudible conversations] the hearing will i welcome you all. [inaudible] we have a profound responsibility to do all that we can do. [inaudible] that could be trouble. All right. Can we get the rest on record as i get started here quick servicemembers put their lives and their health on the line when they put on theirand in return they have a profound responsibility to make sure that the nation is doing all that it can to keep us safe, to training casualties and provide the best possible care for those who are injured. We are holding this hearing because dod is not meeting its responsibility when it comes to traumatic brain injuries and other injuries that result from firing weapons. Injuries from the pressure thats caused by a shockwave that exceeds the normal atmospheric values have been signature with wounds of the wars in iraq and in afghanistan. But there are also injuries incurred in training home. They are invisible but they affect thousands of Service People causing headaches seizures hallucinations and ultimately significantly increased risk of depression and suicide. Over the course of just three months in 2023 dod provided tbi treatment to servicemembers nearly 50,000 times. The more we learned the more we came to understand blast exposures and ongoing threat to the health of individual servicemembers and to the wellbeing and morale and readin of ourir the support ive had on this issue from Ranking Member scott senator ernst and senator tillis and other members of this committee. I secured a longterm study of the blast pressure and injuriesin 2018 the National Defense authorization act and worked with senator ernst to introduce legislation on blast overpressure and secured additional requirements to track blast overpressure injuries in fy2020 in daa. D. O. T. Is workingov to implement this legislation but we still have problems. Last year the new yorkve times reported a heightened brain injury risks for u. S. Troops in syria fighting isis. For artillery batteries assigned to the region fired more weapons than any military american artillery since the vietnam war. The result was that each of these units had members with serious blast overpressure injuries and each had a least one member that committed suicide. These deaths are tragic. Ryan and navy s. E. A. L. Deployed to iraq and afghanistan was subject to significant blast from his own weapons over the course of his career and later died by suicide. His father mr. Frank larkin is here today to discuss the harm that last overpressure has caused servicemembers. The times reveals that even whend made policy changes to address risks those changes were not evident on the ground. Weapons known to deliver shockwaves well above 50 threshold were still widely used. Training does not involve basic Safety Measures and special operations were not issued blast exposure gauges needed to track the threats. Dod and congress both have a lot to do. Its my agenda to address this problem first. We need to establish mitigation strategies specific to the servicemember roles that are most at risk for blast overpressure. Second, we must require dod to create last exposure and traumatic brain injury laws for all servicemembers and to integrate these laws into their pda and dod health care records. Third, the department of defense should partner with innovative evidencebased partners like home base to help servicemembers get the care they need and i am going to have to here for just a few minutes. Home base is a Nonprofit Organization founded by Massachusetts General Hospital and the Boston Red Sox to take care of the invisible wounds of veterans, servicemembers military families and families of the fallen. The home base at clinics in massachusetts and in florida. Ranking member scott town. It has a brain health and Trauma Program specifically designed for special operati servicemembers were its been leading innovative treatment for veterans with cooccurring Substance Abuse and Mental Health issues but as we work through the ndaa i want to support those programs work and i appreciate home base doctor joining us today. We need to make sure the dod number of rounds that our servicemembers can safely fire and this includes consideration of exposure limits over an extended period of time. Dod must do its part and Congress Must do our part. So to eyewitnesses welcome and thank you for appearing. We are going to have to panel today are the first panel will consist of outside witnesses to provide their perspective on dod and overpressure. Dr. Samantha mcbirney and frank larkin chief operating officer of Troops First Foundation and leap at the National Warrior initiative. The second panel will consist of officials from the department of defense and walter reed to hear hoodtackling this. We will have dr. Last year martinezlopez assistant secretary for Health Affairs cathy lee director of policy at dod and Carlos Williams the director at walter reed. Ill turn to mr. Scott for his opening comments. Verso want to thank senator warren and her subcommittee and thank you for caring about this issue and for taking this job so seriously. Suchis an important topic. Tbi is one of the most common injury sustained by american servicemembers. In 2022 more than 20,000 military personnel were diagnosed with tbi. Think about that for a second. In 2022 there were more than 20,000 members of the military diagnosed with a traumatic brain injury. The vast majority you are 84 were classified as mild which is more commonly known as a concussion. Many of those who have raised kids and they have a concussion that scares the living daylights out of you. Servicemembers are forgot exposed to lowlevel blast that typically result in a clinically diagnosed concussion but but this is concerning because repeat exposure to lowlevel blast me cause similar symptoms. Lowlevel blast exposure from firing heavy weapons may cause a variety of symptoms including concentration memory problems irritability headaches increased handeye coordination. Each of theseen issues alone can be serious and disruptive someones life. Unfortunately remains a great deal of exposure that we do not know. Our researchter data requires military to mitigate the frequency of blast exposure where possible and treat those exposed to blast where necessary. We have taken action to do that. The National Defense authorization act congress requires the department of defense to do mental study on blast overpressure. The Committee Received a final reporter the study of the hearing present an opportunit the quality of the departments work. The legislation requires the study of specific individuals own extended period of time to include three elements. The department wants to the monitor recorded and analyzed data on blast pressure exposure for any servicemember likely to be exposed to a blast in training or combat. The second study was to assess the feasibility and advisability including blast exposure and history of the servicemembers medical record. Er and review precautions of heavy weaponsfe training and hemerick in their ports its clear the Department Still has more work to do. Particular its ability to monitor mccord blessed exposures for military personnel. Only a few hundred soldiers and marines were fitted with wearable devices that seem to suffer from Quality Control issues. While the departments report does say itt may be feasible to record blast exposure information servicemembers medical records is required to determine the way forward. In this hearing is like to learn more about how the Department Plans to conduct its Business Case analysis. This important issue up with the department is committed to getting this right and i believe the tbi center of Excellence Health initiatives arecellent initiatives that i hope will provide an military with information needed to better understand the effects of repetitive blast exposure. We must remember exposure to lowlevel blast could create an unnecessary risk or combat troops. We can do better but you better quantify the type of blast that could cause signature significant perhaps run it entry and we can make better decisions about how best to accomplish that particular mission. I want to hear from the witnesses what congress can do to ensure the department of defense has the resources it needs to conduct its work in where we canfe help. This is aboute the wellbeing of individuals in uniform. They are closest to the front lines and every servicemember diagnosed with tbi. We owe to them to ensure when they go into harms way they are welltrained have the right protective equipment achieves an objective with the understanding of the risk involved. Thank you to all the witnesses were being cared and i look forward to your testimony. I want to thank warren for convening this hearing. Chairwoman warned Ranking Member scott a members of the committee that afternoon and thank you for the opportunity to testify today. My name is dr. Beyer and im a bio engineer at the corporation. A researcher last 15 years not only a at but also the university of californiaberkeley and the university of Southern California and focused under dramatic brain injury today as a result of the impact in blessed overpressure. Today ies would like to speak with you about repeated exposure to lowlevel military occupational blast which are lowlevel blast exposures experienced while fulfilling occupational military duties. Evidence suggests servicemembers are exposed to these blast in the form of last overpressure where the pressure waves in an explosion. Theat pressure wave can cause concussion injuries which are not immediately detectable and did not qualify as tbi. Sure to blessed overpressure can occur both in combat and training as its been mentioned. During Training Exercise in the firing of increasingly powerfulul Weapons Systems. To provide some perspective on the level of exposure some servicemembers have one study found up to 32 of blast experience by instructors ask seated the recommended exposure. The cumulative effects of repeated lowlevel blast exposure can cause its similar to tbi but what variety of effects have been linked to lowlevel blast exposure as senator warner and senator scott have already mentioned there remains a lack of Scientific Evidence linking repeated exposure tone injury. One reason this is the difficulty of diagnosis. The very nature of lowlevel blast exposure is the fact its not one single event keynote of effects of repeated exposure over time. Symptoms typical manifest immediately whichms makes it unlikely that repeated exposure to lowlevel classes identified as the cause. Additionally injury is vastly underreported only obfuscating the issue of proper diagnosis. Theres also a lack of research occupational specialties at greatest risk of exposure to lowlevel blast. While theress no doubt certain occupational casualties or more expose and others are so research to support these hypotheses. There remains a lack of understanding of the direct impact of repeated exposures to lowlevel blast have on the health of servicemembers and occupational specialties. It cannot be delivered in time then its not useful. This go back from a 2019 report perfectly describes the current state and the reason many of us are here today. As the Research Committee we see th to be done however there are steps dod can make out of that affects servicemembers against blastighlight for recommendations in my written testimony in a bit like to bring your attention to one of them here. The creation and maintenance of blast exposure records previous record should include a number of exposures the context of each exposure and any mental or emotional ethics resulting from the exposure. This would allow the dod to better track exposure frequency among highrisk occupational ies, determine the connection between exposure and Health Outcomes and develop strategies to mitigate exposure ing environments. These records could be used to develop combat readiness and health risks. As their Weapon Systems continue to become more against an increasingly powerful lowlevel military occupational blast will remain at challenge for servicemembers. Addressing the issue of repeatedng exposure to blessed necessitate actionth and collaboration between dod and the community. Continued Research Efforts to close a substantial knowledge gap the dod has made significant strides to protecting the health and wellbeing of her servicemembers. Thank you and i look forward to your questions. Good afternoon chairwoman warren and Ranking Member Scott America the committee. Im honored to provide testament today entremed a brain injury and blast exposure. My career is centered around improving the lives of people with traumatic brain injury. He currently serves president spalding chair of the Rehabilitation Department at Harvard Medical School chief of the department of physical rehabilitation at the General Hospital in brigham and Womens Hospital and for the past 15 years excerpt as a Home Based Program directing its program. I actually do the research. Last overpressure is the sudden onset of the pressure wave from explosions occurring with ent in reaching buildings and improvised explosive devices. The bigger the explosion the more damaging the pressure wave. Tbi can have a wide range of physical and physiological effects that sometimes appear immediately. Others take days or weeks to occur. If since 2,004,000 u. S. Servicemembers experience at least one brain injury and 40 of those screened positive for comorbid Psychological Health conditions. Our own research has noted an elevated 10 year risk of hypertension cardiac disease endocrine or hormonal dysfunction and behavioral concerns such as depression even among the youngest ofie pat home base is located in massachusetts and which im proud to say as a native locations in florida in arizona offering one of the oldest and most impactful privatesector programs in the nation. For 15 years we service and a debater for innovative clinical model and research. To leverage the burgum Health System. Home base bridges the gap between research and clinical work. In 2018 home base was approached by the, negative social warfare with the problem facing navy s. E. A. L. S. But we quickly developed a conference of brain injury program. This program was named combathealth Treatment Program modeled after existing programs will be developed to provide integrated multidisciplinary specialist treatment, evaluation and care coordination for veterans and activeduty operators. Ve home base is treated nearly a thousand special operators there are program. 71. 9 of combat participants are activeduty and the overwhelming majority returned to duty so we are keeping the fighting force active. We currently have 178 active duty special operators waiting to be screened for combat and operators in 47 states, the district of columbia, puerto rico including 53 patients from massachusetts, 50 from florida six from connecticut, 22 from hawaii for from illinois, one from alaska and 54 from north carolina. Ombat program is highly efficient and preston to five day models. Patients a minimum of nine providers related to pertinent diagnostic imaging and other studies. We are grateful for the support especially chairwoman warren has shown this program the partnership and Financial Support provided. The program is successful and demand for care is growing at a steady pace. Treating patients at home base i would recommend the department of defense consider the following options. Invest and develop tools to measure [inaudible] funding, and sure all the traumatic brain injury get care. Develop novel the impacts the Health Effects and innovative measures. I also recommend the department of Homeland Security should develop on the multisystem advance and research for repeated brainies. Thank you for the opportunity to testify on this very important topic in your commitment to supporting us. Im happy to answer questions. Thank you dr. Zafonte. Thank you for the opportunity to testify. Where a voice for all those who wear the uniform. Wounds that transcend mental physical and spiritual wounds and knott [inaudible] [inaudible] following the combat for iraq and afghanistan, that manifest in difficulty sleeping hypervisual. He stopped smiling. He sought help but not what he needed. When the condition became complicated and the proposed solutions did not work, it pushed him out. It created more deep wounds. Year [inaudible] the navy he ended his life. He said something is wrong with my head. No one is listening, they keep telling me i am crazy. These are medications that were provided but did not help. It did not get to the root cause of the challenge [no audio ] no audio ] he was given 40 different medications. He never received a clinical diagnosis. He made me promise if anything ever happened to him he wanted his body donated to the tbi research. He then turned to me, no, dad, it will take more guys to kill themselves before the system wakes up and sees the problem. His body was donated. Two months we learned he had undiagnosed brain injury related to repeated blast ex [inaudible] died from his injuries suffered both in training for combat and combat operations. He didnt just die right away. These ones are hurt. They are not broken. They break when they are cut away from their teammates and are betrayed by the institutions where they have given theirits been 23 years since 9 11. Dod has almost 3 billion on Mental Health Substance Abuse Suicide Prevention ptsd, tbi and other warfighter systems programs. I give them it d c at best for the lack of measurable impact for those who need answers. Those were fighters are promised to take care of and not leave behind. Last exposures are key threat to war your brain health that potentially represents a significant threat to our force readiness and resiliency however whatever solutions they come up with a cant impact our iveness or lethality on the battlefield. We need to do this smarter and on the front end. Thank you for the opportunity to be a voice for others like ryan and happy to answer questions. Appreciate you being here and sharing the story and im sorry for your loss and im sorry for the tree may your son ryan received. I think you saidan it right traumatic brain injuries are considered quote a signature wound of our wars in iraq and afghanistan. While improvised explosive devices ieds may have caused some of these medical injuries and military medical Research Study found troops with mild dramatic injuries quote the most important cause of brain injury was a longterm exposure to explosive weapons. In 2011 the Defense Advanced Research projects agency determined that 75 of the blast exposure in afghanistan was coming from their own weapons. The effects of blast overpressure our terrible including memory loss, and risk of dementia and Substance Abuse problems. Despiteia the severity of these impacts on servicemembers help when these problems are diagnosed blast exposure is rarely identified as a potential cause. Doctors at 13 you have studied this for years n and why is it difficult to identify the blast were talking about. Take itt to great question senator warren ends a question that so many in the Research Community are committed to answering. He comes back to the nature of the injury itself. We are not looking at an injury thats caused by one isolated event. The fact that caused by repeated exposure to lowlevel blast that perhaps might happen throughout the course of an entire military career complicates injury recognition. Add to that the fact that symptoms typically dont manifest immediately as was mentioned and it becomes increasingly difficult to link symptoms to repeated exposures. I just want to pick up on this because i think this is a reallyms important point about the challenge in trying to diagnose because of the nature of what the injury looks like. Its not a single moment in time where this happens so i just want to pick up and take this forward, we need to know how often and i take it from your testimony, we need to know how often a servicemembers has been exposed to blast overpressure to get medical personnel the information that they need to identify underlying cause of their symptoms. So far the dod only has blast exposure data for at total of 500 servicemembers. We are missing data obviously for a whole lot more. Tracking this information through blast exposure traumaticvi brain injury logs for all servicemembers would be a good start but we also need to take pay special attention to servicemembers that are at especially highrisk for blast exposure. Some military occupational specialties such as Training Instructors are significantly more likely to expose the blas during training for operation becoming court found that the artillery community is also at a particularly highrisk and high rates of exposure could lead them back to s injuries faster than combat replacements can be trained to replace them. So doctors mcbirney i wanted to give you another chance since we are trying to push this forward is dod currently have strategies that needs to mitigate the risks from blast overpressure specific to each of the military occupational specialties that are most likely to be exposed . I cant say im aware of any of those strategies and in addition to that a lot of folks asis on the ground in these communities that are at risk to significant exposure are unaware. Anything more about what you want to say about what dod should be doing . Thank you senator. Mr. Larkin and i were discussing it and if i could choose the key take away for today it would be to not let perception interfere with progress but i think everyone here is looking for the right solution and what we really want to be sure of is we dont wait too long to implement what we think is the perfect solution. Theres a lota of research that still needs to be done coming from the Research Community and im always a supporter of more ysresearch. That being said we can berere looking to implementtudied those solutions while they are being implemented. Lets focus on that for just a second just a little bit more about the idea of collecting the data as we go along is the least itss a first step in getting the information that we need. I understand that if we are challenging to limit servicemember blast exposure during combat but theres no scuse for dod to continue to expose servicemembers to unnecessary levels of blast overpressure during training. This is an area we can make change. It is clear there is a lot to do. But, dod, it goes to your point, dod constantly says we need more research. I am a data nerd, i always want more research. I am very concerned about the idea that we are going to put off treatment. Let me put the question more specifically to you. Do you think we know enough now about the risks of blast overpressure Service Members health to start taking action now . In short. Absolutely, yes. All right. So we do know enough. There are a number of steps that the could take it to help us get more data so we can understand this over time. But more important a treatment. I will come back to it later on this. Senator scott . First of all i cant imagine losing one. Thank you for your service your sons service i hope as a result prevent Something Else wrapping can you explain what to do to the brain . Lets take a go shoot a shotgun each one of them how does it impact my brain . I think to my colleagues, good point too. Perfection is the enemy at the good. You can criticize all of the models but we know these concussion industries do a number things they probably disproportionately impact areas of theof brain gray matter, white matter m interfaces for the probably have a vascular effect. Its probably a premature aging effect to the brain itself. With multiple repetitive exposures went with post traumatic brain injury. Lifelong exposure, given that qualifications that senator warren talked about is critically important. And who how much what were they doing in what was the actual happened to the symptoms of the person and track that very carefully. Extra negative glu monitor and put all rooted in their pretty fast you could get a correlation, right . , so have you h opportunity when if you join the service we know going to have an boot camp. There anybody doing anything to say you put all this data on something and look at the model over a period are a number of groups including our own looking at biomarkers for people. Neuroimaging. All of those are critical as we understand the exposure in the diagnosis. But, wee also how those things in specific lifelong exposures impact the symptoms of the person. Theres not a onetoone relationship. There is a relative relationship. Cooks of every Service Member if you have the data to start today does anybody joints a boot camp an boot camp starts going through infancy infantry training and had that in front of you over time you can do predictive analysis over the problems are right . Right. But to the point that was just raised there are actions now we are compelled very much so to make this a Living Learning environment. And continue to collect data and change of policy, change programs change how we treat people as we understand more overtime. You do not have enough information today about what happens as these blacks happen. What you have is you see the result. Is what you have so far. That is right i think senator i think the excellent question is the series of smaller studies that show changes in your imaging. Changes in blood based biomarkers representative of injury of the brain. But how its is going to behave is one thing. I was going to behave in a bobby, or sue is sue is a very different thing. Right. Doctor how hard would it be to put up a program . It wouldnt be that hard could it . That is a great question. I find myself unqualified to answer. We do it like with glucose monitors are. It. And if you gave him an app that said every time you have exposure you put this in for you put exactly what you did. Some people are not going to do it well just like no one follows like they dont take the medicine. But it would not be that hard to do. We have all of this stuff on sugar levels. Why wouldnt that be the simplest thing to start doing . And then you could start seeing seeing if you had all of that day that you could pretty quickly do a predictive analysis of shortterm problems. It would take a long time to say what is my 20 year problem right . Following people over ain decade will be certain markers and in certain things change early on. E to remember its not an uncomplicated story. In the blood based biomarkers or other entitiesba such as imaging have a lot of variation. The brain, with my colleagues would support me, is an incredible structure. Its also a bit of ack box still within science. An understanding how Different Network relationships and how these nodes connect and one affects another is a challenge. You would actually know the result. You dont know exactly why you could overtime predict whats going to happen. If you are looking for symptomatic, senator prediction, i think with theelective data set you could draw some strong relation. We know this. We can get a blood test for cancer now and its very predictive of whether going to end up with cancer. Is it perfect . No. It depends on the cancer. It seems like this would be pretty easy to do not be this hard. Editor i would agree with you. We are all individual and differentindifferent people. These types of injuries that affect individuals in a different way. Eight series worth of years work of exposures is affected by who you were beforehand. The kinds of exposures in the treatment you had after words. Its a result not so easy to put in a box. Then on. Are lot of our Service Members to ied through their tenure so are you tracking the Service Members of the veteran stat are you tracking them for exposure to blast him wts happening to them, anybody . I used to be a Senior Leader within the department of defense and i can tell you that it was concerne and 2009 these blast exposures were creating a unique health riskin for our warriors. We had gotten to report we had Armored Vehicles surviving the blast for what got in that vehicle and what came out of that vehicle were two different states. It alerted us to the fact there were things that blast effect ye was having an effect on the human body that needed to be studied and in research. As far as having a handle and less as a catastrophic injury in usually one that was visible a lot of these folks came out of these vehicles and look fairly normal. Was it time started see cognitive dysfunction and so forth. I have no knowledge whether anyone attempted to formally collect on that data. And do anything with it. A thin important followup aso understand what the impact of the blasts are longterm. I would also think make it sound enough theres brain injury or that needs to be followed up on. I think a lot of them would develop positions like ringing in the ears thank you very much for the excellent point. We have long term for people such as bringing in the ear chronic headaches, pain is a big driver of the drives not only a headache or immediate perception it also invades behavior dont behave the same way and do not cognitively perform the same way. So what i am saying is that has a multisystem effects. Of course the brain is our principal and driving concern but itha has effects and things that are linked to the brain. Linked to the behavior that we need to know more about. For example tinnitus that does not cause pain. But it is annoyinndg a know if you are tracking the incidence of these kinds of issues. There seems to be no cureor these conditions. So i am very interested to know what kind of breakthroughs there are in treatment i know tennis is a ringing thats not related to problem with the ears. This is of the youre are also studying and tracking . Editor, all i can tell you is that i have it from explosives and weapons. It does not go away. I just have to live with it. Me too. It is very annoying. Sometimes it is some loud it interferes with sleeping. I think there are a lot more of our Service Members who have endured our enduring those conditions that we have to Pay Attention too. One more question. Re at 2022 report noted theres a critical gap and effective ppp and that most models represent the average human mail. And this is for doctor mcburney. Its surely important that we provide protective equipment to all of o sure this protective equipment is appropriate for women is that happening . Thats a great question very important topic and it is happening. Those findings are from the last date of what we had a blast on blast induced injury. We were happy to learn theres quite a bit of research being done in the com make sure the average of mail and specifically many instances the average caucasian mail is not the only subject thats beingia ed two test equipment. Is very important thank you. Thank you madam chair. Thank you senator ernst . Thank you very much and good afternoon. I would like to thank you chairwoman for the invitation to participate in this it is a very important discussion that we are having. About the impact on her Service Members and their families. It can arise from the combat deployments but from those routine Training Exercises that our men and women go through every single day. Even in when and when they are adhering to Safety Standards and establish safety guidelines the act of firing heavy weapons just as you stated can create those longterm effects. Other types of training sessions in preparation for combat deployments. Many can potentially lead to cognitive impairments affecting our function. And mr. Lark and i understand you shared the story about your son,un ryan. I want to thank you so much for your service as a navy seal and your sons service as a navy seal. It was through mr. Larkin, from frank assuring his sons story with me many years ago i finally understood the need to be involved with traumatic brain injuries. So thank you so much for sharing what is a very difficult story to tell but one that is an incredibly important for every young man and woman who puts on the uniform of our nation. So thank you for that. Mr. Larkin did you share the subcommittee how it was discovered that your son ryan, had traumatic brain injury . Thank you for the question, senator. Thank you for your comments. Ryan had expressed his desire if anything ever happened to him he wanted his body and his brain donated for traumatic brain injury syndrome research. That was consequently done and his brain was donated to an activity at walter reed that postmortem analysis revealed that he had undiagnosed microscopic level of brain injury that was uniquely aligned with the blast exposure but they only see this pattern of injuryy with blaster exposure. And, if we had not gotten that finding the narrative the navy had built around ryan and his struggle andis passing would have continued on would have continued to damage his reputation. This finding wasas indisputable that he was injured. He was knocked and his terms crazy. Exactly mr. Larkin. I want everyone to understand so many of these injuries go undetected through cat scans through mri pet scanss a followfollowup to that i am very grateful ryan had chosen to do that. You wouldan not have known about those injuries otherwise. But then for you dr. Kagan i want to make sure i g correct. Is the automated metrics test nd accurate method of detecting those changes. Senator for the excellent question. I think we are searching for gold standard. A number of these measures including five significant flaws in them. Everything from the way they are administered to challenges on their consistency and their internal behavior within individual and external to other individual while it is an interesting screen it is far from perfect. Yes i hope we continue to work toward alternative ways that we find that gold standard. That is something the subcommittee is working on. You have spoken a little bit about wearable devices as well that might be able to diagnose tbi or blast exposure. All of these things require research developments, recommendations. Are you confident you can get to a point where you are able to make recommendation to congress and dod by protecting these men and women . Any thoughts . I would thank you for your question. I would say in my good colleagues said this before, perfection is the enemy. There are things we know to do now and as we learn more we should do better. If we act and think responsibility to make this a dynamic learning positive environment for our Service Members, we can do thingsile evaluating data and relate making positivereallymaking positive change in the future. Si as more of the microscopic injury than we had ever believed. And in certain people that its is going to have somenificant. I believe are absolutely correct. Their Service Members out there that have sustained micro chairs or injuries to their brain. I was reminded of this not too long ago and it is an old one so forgive me. If the human brain were so simple we could understand it, we would be so simple we couldnt. Let that sink in. We are always going to be striving to find the answer thattraumatic brain injury. We may never reach the one 100 solution just because of the dynamics doesnt mean we shouldnt let it go. There are aolutes disruptions to families just as we have heard from mr. Larkin. It is incredibly important that we pursue not only ways to prevent traumatic brain injury but that we also find ways if it does occur and we wont be able to prevent it in one 100 of cases. But if it is to occur we need to find ways to treat it and mitigate the impact her families. So thank you againr chairwoman i really appreciate the opportunity to beop here today. Own to say a special thank you to use senator ernst. Senator ernst is not on the subcommittee. Sh like many in the senate she has hasnt absently packed schedule. But she has been engaged for years now on the issues around traumatic brain injury. And working toward changes and a lot to the documentation that will lead us to better diagnoses and also for the resources to begin treatment now for those who need it. She wanted to be here today and i appreciate coming in doing this. Thank you, thank you. Click senator kaine. Thank you chair warren into the subcommittee this is really important spray and going to ask the same question both panels i have one question i would like to get your taken off so question the only country that employs weapons that can have brain health. What have we learned what can we learn from the experience of other nations and military about strategies to prevent and strategies to treat . Senator, again and my role in my role as a Senior Leader of a joint organization and dod during the heights of iraq and afghanistan this is not a u. S. Only problem. We were very much in the trenches with her allies and partners who were all experiencing loosely troubled use ofyouth maneuvering on the battlefield because it paralyzed our movement. It was the Weapon System the enemy against us that literally brought home all of the casualties and fatalities of those two conflicts in africa. If we dont Bridge Communications with those countries as we tried to solve this problem or missing a great part of it. Theres greaern about what we are talking about as we are. Really we need a task force to bring together the government industry academia and our foreign partners for unity of effort to mask the data the intellectual capability and our technology to solvelo it. We can solve it. We have different ad hoc efforts going on right now. Theyre not coordinated. We are handicap by a lack of data sharing. Unlike his head and got to get everyone on the same. He was on her own family panel two hasly dod. I know in the richmond d. A. Its a high priority. Sharing within our family but with her allies have the same expenses really important. Going to add to that at all . One i know for some of our allies are considering at this time it was published in a report on 2018 by center for new american security. Reviewing and updating firing limits for a lot of these Weapon Systems. Those of firing limits have not been revisited in some time. Theres a direct quotation from that report in 2018 that details exactly what information to revisit in the weapons weapons system manual and perhaps consider updating to really get at mitigating exposure or Service Members eense and training in particular. Center thank you for the question and i agree the commentssteemed colleague. I would add one other thing you are completely right. Theres power in numbers theres power andin togetherness. Theres a power and the thehe opportunity to discover and serve our allies throughout the world. I would advocate for common data elements, dana set to come across our allies as we think about these kinds of exposures both immediate or to someone felt now and what are the expensing years later . Those kinds of things would be incredibly important and doable in many other Health Systems for a. Thank you very much i yield back. Thank you and senator scott for holding this hearing. Its really important one and i want to thank the witnesses for their attention to this really importantto issues. I got here late at this is been discussed bear with me. I want to dig into this New York Times article deployed in syria make really struggled with ptsd issues. That wasnt from direct combat appears significant amount of firing. And it kind of toot senator keynes points we had military members and different wars in vietnam, korea world war ii of course fire thousands and thousands of pallets of rounds. So we have seen this before. But these marines seem to really have struggled. Have either of you read this report or this story . And ernst and tillis asked a lot of questions related to this and other issues that relate to tbi. This is a different tbi. Sometimes i worry i just retired from the marine corps at myself andmyself andi love the marine corps. But like all big organizations they can be bureaucratic. I am not sure these marines are treated very well. And i am wondering from your experience, maybe it will start with you dr. Kagan what is your report its well done reporting in my view from the New York Times. What do you think the next steps should be . Obviously we will ask the government witnesses in the next panel on this topic. I would just like to get your assessment from this particular episode of print lot of my constituents ine. Alaska read this article and were quite disturbed by it. We do not even have a big marine corps present at i would like all of you to comment on what your thoughts were. A much deeper dive. What are your thoughts on it . They brought up a series of issues. Took the cover off some made that more public. It talked about many of the longterm near terming laws that are being seen clinically and this a population of people. Are extreme individuals many of them they are the 1 of the 1 . They are the biggest the swiftest and yet they are clinically apparent problem. They are also in many ways the most resilience, their selected many times. So that raises for me some real concerns. It may be related to the density la of the exposure. It may be related to a global element of a life and that kind of stress for significant period of time. So we need to learn a lot more about the longterm issues here and the shortterm ones. And i think part of the way we do te exposure over time. Great. I thought the New York Times article was very well written and investigated and reported. Times article was very well written and investigated. Just for the record i dont believe everything that the New York Times writes, and so [ laughter ] senator warren might, no, just kidding. So, i have points in there, that were probably not saying it was a Perfect Piece but it raised an importan issue. These young men, these are the best that we have in america, and we certainly, you know, and we certainly need to take care of them. Absolutely agreed. I think that one of the main take aways for me when i read that article was the fact that theres a culture that is pervasive across the dod unfortunately, that really contradicts to this underreporting that we see of injuries and i think the way that these men were treated is indicative of this culture and the fear that a lot of Service Members have when it comes to reporting injuries. There have been many studies done on the underreporting of traumatic brain injury. There are a variety of reasons that Service Members dont report injuries. But fear of negative repercussions on their military careers certainly a huge one. So i think when i read that New York Times article in series of articles that really came to my mind is a culture that needs changing we hope to improve this. Yep. Mr. Lark sorry madam chair i dont know if you have a s viewen this. Weve had many wars with m thousands of artillery rounds, fired i had a 481 mill meet o platoon and marines fired all kinds of 81 millimeter thats not as big but its a big mortar in, you know, you feel it when youre firing those and your ears hurt have ear protection on because it is so loud but whats your sense on how we need to look to that article and compare to other wars wherehousands and thousands of rounds . So you know if im going to put mismoney it is on the topreventive end as much as we can to buy down these injuries. But i completely agree with mr. Bernie here unless theres trust between that operator or that warrior and the system. We have collected data on a variety of different efforts on artillery too. Just in you know, a variety of different settings where blast gauges so forth have been worn by our warriors. We have no idea where that date has gone. So again it never comes back to the war fire like it would for radiation. So they say well you know we wear these things but we dont hear anything back. One of the i things that might be a novel idea is when we procure acquire Weapon Systems ammunitions why dont we ask those manufactures to provide us with blast overpressure data according to strict criteria that they all have to follow that ultimately will allow to craft training protocols and potentially surveillance programs for the more high risk occupation . Like again, we have been calling this by different name calling off the battlefield since world war i and all rested in a psychiatric Mental Health diagnosis and were now starting to realize this is a biolodge scall injury caused by blast overpressure i have another round of questions i want to do inn senator scott does and anyone else does were glad to do it but i want to pick up on whatking about and that is trust. That Service Members who have been affected by blast overpressure, arent getting the help they need and the question is why not . And ill go back to the New York Times article because it does give us some on the ground an anecdotes so a marine saying he was experiencing severe headaches seizures. But, quote worried it wouldnt be acknowledged because there wasnt any knowledge that he was exposed to anything serious and weve heard of recordkeeping and how that could fundamentally change what happens in this area but i want to talk about where we are right now. And the consequences of the failure to diagnose early and what that means. Mr. Larkin youre the one who is focused on this more than anyone. I think you said in written testimony, that you estimate that about 80 of your sons exposure occurred during training. Is that right . Thats what i understood. Yes senator if you talk to other veterans that have tra been in combat, they will pretty much confirm that the majority of their exposures is in the trainee environment an environment that we can control. So if i can ask you we know about what happened to ryan b he he donated his brain. Post mortem and they were able to do an analysis. But can you speak to what happened when ryan was still alive and whether you and your family got the appropriate support that ryan needed as he clearly demonstrated that he was inncreasing trouble . So one thing i didnt share about ryan is that after he passed what we found on his computer were he download numerous studies on blast exposure and tbi and researching medication to the guy so he was locked on this. I didnt like what we did and support what he did but ive grown to understand why he did it it was foris teammates he was going to prove that something was wrong now when he went to get help he did more for his teammates than for himself. But again we didnt know what we didnt know. I think a lot of people are trying to do their best for him. T that they could because we lack the science we lack the knowledge. Tbi was not mentioned. Very little it was not taken seriously because they couldnt see it. We still cant see this level of injury in a living operator a living war fighter which is again within the medical enterprise if, you dont have a blood marker that a like a heart attack we look at heart, you know, enzymes so forth that alert us that hey theres muscle damage an we see an ekg that tells us things are going wrong but then within the heart we dont have that right now. And hand caps our ability to triage these folks early on in the evolution to your point. That in the opportunity here and i dont know if my colleagues would agree with me but the opportunity that we have here is to get at this early not wait to it gets to catastrophic, you know, point you know that this is ease process and injury process where things have gone too far. So let me pick up on this. I understand that this is hard to diagnose. And that its we collectne way to make it easier to diagnose i understand we would like start early in the process as we can. But theres another feature of this that we have some control over right now. That when someone has any concern who is the advocate to make sure they get the help they need . My sense of this is that it is just a patch work you go here you get sent there then you end up someplace else, and the patient is put in a position of having to advocate for a diagnose that it is not the patients responsibility or expertise to have to make. I am grateful that ryan did what he did in order to help his teammates. But ultimately, we have a bigger responsibility here. So i i just want to know if you can speak a little bit to the notion that starting now before we have perfect information. That we need a single way for people to go into this system to be able to raise a hand say i have problems like the marine quoted in the New York Times piece. I have problems, and know there will be one person there who will advocate at least get them to the best possible treatment that we can can you speak to that mr. Larkin . Yes. I think the number one word i would pick out is the listen. The system needs to listen as they step forward you know and we need to understand. This is a this is a leadership problem. And we need to educate leadership as to what is going on here so that they can properly usher these folks down the right paths. So that we can stop their injury process and that we can start a level of treatment that one size fits one not one size fits all which is Precision Medicine and i think as the science develops as our medical capabilities develop, were going get better and better at doing that. Butme again ryan became disenfranchised. He became, you know, adversarial because the system turns on him a system i depended on this was my community too. And so this is why im here today. And i realized this isnt a Perfect World but you know, the ultimateed greater what have we do or not do are the veterans, war fight ergs fighters and their family. Are we doing the right thing for them . I very much appreciate that and appreciate your comments here. And if i can i want to go to the treatment part of this, doctor you work at home base. And home base tries to be the one place that and gives a response it is on site. And to our Service Member, youre on the front lines you see people with tbi every day. Can you talk just a little bit about how home base has organized itself and what youre seeing and what kind of needs you have. e senator thank you for the excellent question. I think we see ourselves as a partner with dod and that we are auxiliary in an important differential way that we take a look at the whole person, and what we try to understand is that you know, i think mr. Larkin captured it brilliantly. Somebody is not just but we bring multiple specialists to bare on this person for a very intense evaluation that might take as i said months and years in standard environment and try to emerge them in a team based behavior where we listen to the patients and we develop a problematic plan toth treat if we cant treat the microscopic injury right away lets treat their symptom them relatively well. Im so proud of the work that home base does, and really want to underscore the importance. There is help, there are things we can do and i take if i can have you underscore it again doctor you actually return people to active duty military service. Can youai say just a little more about that . Im happy to thank you senator. I think one of the most extraordinary things especially for our special operators is the very high degree of return to duty. Return to the force return to fighting. Because if you think about it as a person thats what they want to do. They want to be and go back to their teammates and contribute at a high level and indeed that is the goal. The goal is give People Agency over their own health again. And that is what we do very high rates of return large numbers of people still waiting for service which we hope tola provide. And i think that we see this as a means of enhancing problematic excellence serving as that bridge from midcareer early career people who really need a bowlous of help. Thank you doctor larkin thank you for the work you do. Senator scott. Thank you. Nfl players are wearing some of them are wearing the cue collar. Yes sir. Can you tell me how it weerntion what you think of it. Thank you very much for that excellent question, it ryis an area of debate. That is certainly of interest in the field of traumatic brain injury the theory behind the cue collar is that compression here at the necks like compression would result in less fore shaking within the brain its rolast related injury i believe unless doctor has more data is unclear. In sport related injury, it is received preliminary approval although the enthusiasm in many investigators is modest. Okay. All right. Know whatit yall know know knowing service is a service. So if you have a child or grand child that was 18 years old lets be a war fighter listen whatever. What would your advice be to him . You start doctor is not enlisting an option . And i mean that as a serious question. Traumatic brain injury is such theres such a huge risk of getting this injury, and as weve heard today detection this have injury treatment of this injury is not guaranteed. I would in sitting here, i now have a 14 month old daughter so this question is very relevant. I would strongly urge her to reconsider her decision and unfortunately thats a decision i know many veterans that i personally know have asked their children to reconsider as well. So ryan is with me here today in spirit. And muchwe of what im saying is actually him talking through me. He would tell you he loved beingrade anything. Just that we have to do it better. And i will say that my own naval Seal Community ryans story has deeply affected them and they have moved aggressively to try to make a difference along with the parent command uso up to the commanding general. Theyre leading the way in my opinion within the department of defense. And very often, you know, what special operations does the conventional forces follow. So thanks ryan. Certainly i think this is a a pointnt of great debate but i guess what i would say and we see this in contact sport we see in the military. The first we can do is know what we know to do now which is eliminate unnecessary exposure. Rules changes and sports have made i believe we can eliminate unnecessary exposure in this population of people where there isnt a lot of return either to their training or for their longterm health. Or for their team members and that would be an awfully good place to start in enhanceing force health. If we care about our freedoms we actually dont have a choice. We dont have a choice we have to thank god everybody somebody is willing to put on the uniform if we get to the point where people say theres too much risk say goodbye to all so i hope we get to the point where nobody would say he shouldnt go in because of the risk so thank you. Senator king. Just to close a closing comment on that question senator scott you know thinking about what you would say to your kid one of my three kids is a marine. Who was eight year commander and reservist and how he might answer that question as i think about the question i want to recount a amazing story from doug wilder who was former governor of georgia first africanamerican elected governor. He was drafted into the military in the korean war. The military like society at this time was still the dealing with a lot of racial prejudices he was in a unit with many africanamerican caucasian and others and doug will stand up himself he had a Commanding Officer who said i want everybody to be treated fairly and he believed as did others in his units in the middle rarely difficult battles and africanamericans at unit were not being treated well they all agree they were going to talk to their ceo and they said to doug now you do it. And so he laid out his concerns about the way they were beingding officer said youve done what i asked you to do now you all go back to work and let me do what i need to do and things didnt change for three or four weeks and then everything changed. Because he did what he was supposed to do. He stood up and he said this isnt right and were a unit and if we make some changes things can be better. It so i would hope that people grappling with the decision maybe your daughter might be in this position 17 and a half years remember the people grappling with the decision will realize thingst just get better by themselves or just change as most it takes people at all levels from the you know, private first class all the way up until four star standing up and saying we will be better if we make these changes, and i think an awful lot of our young people or people of all ages but i think young people have a lot of wisdom to offer so i would hope they might say yes im doing this and also going to be committed to speaking up if i see areas where we can be betters. Thank you. Sp thank you senator cain, and i will be calling on you as were doing the mdaa both tighten up the rules on reporting and get more resources into treatment. That surely has to come out of a hearing like this so thank you. Thank you all for being with us today. And i would like to call up the second panel. Thank you. [silence] yeah. I had l two million [inaudible conversations] all right are we ready . Secretary Martinez Lopez if you can givee us an Opening Statement please. Ranking member scott distinguish members of committee, we are pleased to represent the officers secretary of defense to discuss the department of the defense commitment to address war fighter brain Health Issues and initiatives. We are honored to represent the dedicated military and medical professionals in a military Health System providing direct support to our Combatant Commanders delivering arranging health care for our 9. 6 million beneficiaries. We will inform the committee about the department initiatives who understand the causes and impact of brain injuries and exposure so support ongoing training of medical professional inform development of treatment protocols and improve the cognitive and physical performanceen of our se the department of defense primary mission is to defend the nation. Of failing this mission means war fighters need ability to make expedient effective decisions on the battlefield promoting brain Health Enables effectiveness as i thought pooing force operationally with the brain injury in all of its form is top priority of dod so we focus on near, longterm health care of our Service Members. Support this priority dod established joangt effort between the operational and medical forces called the war fighter, brain health initiative. This initiative finalized in 2022 to qualify a policy and direction is unify efforts across the military to address tvi and blast over pressure. The war Fighter Health Initiative Focuses on cognitive and physical performance of known emerging brainth threats military environments and methods to immediately detect and treat brain injury. The initiative is an important according function for our Department Wide efforts to address brain injury related diagnose such as ptsd and suicide between 2000 and 2023, 485,553 Service Members were diagnosed with tbi. Members of tbi grew from just above 10,000 per year, in 2,000 to a peak of 23,000 per year in 2011. The dod responded to this increasing rate of tbi in combat during freedom and Operation Enduring freedom through rocket expansion or tbi care and research to support military forces around the dploab. Globe. We recognize however that more research and in both care to better understand the risk, how to protect war fighters and how to treat brain injuries more effectively. Our strategic approach to this issue iss of one involving policy to coordinate clinical changes and researchoa investment where policies work,ow to refine for broader effectiveness when they do not work as suspected we review why them to research to advance alternative solutions. With that overarching policy mindset we mope to we see pivotal actions Research Findings and under impact on our current approach as implemented within the hi we comiewngt this insight not because we believe they are foolproof solution rather enable collective action through shared knowledge. We know theres still match to learn about the brain and not everybody responses in the same way to similar exposures or injuries. We seek to integrate solutions for the future as we provide recommendations to inform and affect change to safety doctrine and policy. This mission is for both personal and professional. As providers researchers and military leaders we are committed to mediating the risk of an improving the treatment for bop exposures and tbi. We appreciate your continued support of military medicine. And for inviting us to be here with you today to discuss the po im the brain health of our war fighters. We thank senator warren, senator scott and the members of the Sub Committee for leading continue congressional attention on exposures and brain injuries and we look forward to your questions. Tha i appreciate it doctor martinez. So i appreciate that dod has begun to take steps toward mitt gadget the risks associated with traumatic brain injury. Starting this year, new troops will be given regular cognitive assessment to monitor from blast exposure on their brain health. This help medical recognize brain injuries and cognitive function more quickly and it will help Service Members get the clinical help that they need. Dod is taking this critical step but it is important that we do this right. Captain williams your organization the National Intrepid Center of excellence works with Service Members with tbi and other invisible wounds of war as you know, one of the and weve discussed here repeatedly today one of the most significant ways that troops are exposed to blast overpressure is through training. To ensure that were accurately monitoring the impact of blast exposure on Service Members brain health, would it be he thinkful to give a cognitive test before the Service Member begins training and firing weapons . Thank you senator for the and thank you for the opportunity to talk about this important issue. Absolutely yes and let me start out by saying yes it is critically important. Baselining ask something that we utilize aspects of medicine for surveillance we use it prior to treatment use it prior to modalities that we know cause risk so we have moved to now this year we hope to move to allno members once they join the military. Before they start the initial miliry training, they get cognitive testing. They get cognitive testing because we know that high and risk of tbi in the military are in training environment. So it would be valuable want to use the same Precision Medicine weve been using in the past for other modalities do a tbi. So the Baseline Assessment is not starting until after training that it is not an accurate measure of the Service Members brain Health Changes overtime. Were going to miss the front end of this. And as we have talked about the importance of isola problem early is absolutely critical. It after the Baseline Assessment. Special Operations Command will conduct these tests every threesp years, dod is currently planning to retest troops every five years. Doctor martinez you are responsible for assessing the effects of and improving how dod tracts last pressure exposure. Would annual cognitive testing for Service Members help increase the chance that we detect changes in cognitive function and detect them earlier when intervention would be more effective . The department is looking into this. I think if there is value doing it everywhere we dont know. So it may be three years maybe five years there is more data and more science we need to look into. I amye not looking at tenure research but i am looking shortterm research to see will be the best frequency of during thee test. Not only that what kind of testing we should have two the battery process to assess the condition of the soldiers are the Service Members. The one to set the little bit frustrated here. Special Operations Command already clearly says a five years is not enough there at three. And frankly, until we have better data i dont know why we wouldnt be saying lets do an annual test and see what we can detect. Is that the data that shows us three years is often enough interval to be able to do changes thats fine. Give it what else we know and how catastrophic the implications of untreated tbi can be we ought to be airing on that site of at least collecting the data annually. I really want to push on this, waiting five years to test is just not often enough. Another way dod eight need to show its serious about protecting Service Members from blast overpressure is by establishing effective weapon use safety limits. We had some conversation about this earlier. Irected services to a maximum allowable number of rounds for Service Members to service m to fire to mitigate blast overpressure injury risk. Now, good start. But i see two problems with this. First the limits dont include a brain injury risk. A blast ofblast pressure experts have voiced concern our current safety threshold are built on things like whether or not its likely to cause your eardrum to burst. They are not about traumatic brain injury. Miss leah you are in charge of overseeing a dod brain health policy. Why is it important dod establish a maximum allowable number of rounds members to fire that takes into account brain injury as well as injury to the ears . Quickset or war and thank you you us here today to talk about brain health and traumatic brain injury. N excellent question. Itsbr imperative we have allowable number of rounds for all Weapon Systems that are commonly used so that we can avoid unn plastics poster and or Service Members we believe this gives us an opportunity to be ae to correct the crew position, proximity and all those pieces can come together. Our policies are moving in that direction to be able to look at the brain. As you mention historically is been through ear and long. In however we are looking at what the brain affects our and will follow suit with our policies as such. I went to see again i feel a little bit of frustration here. I appreciate you are working on establishing these limits. But weve got to get this off the ground we know enough to start moving in the right direction. My office has heard stories of Service Members having to take their own initiative and setting limitations for their troops. We have Training Instructors who said i have decided thats enough. And thats not enough to get this job done. So again i urge it better to make your these weapons manufacturers will be able to give us thats how we measure weapons of safety safety limits. Dod own studies found it took 72 96 hours to reserve cognitive deficits after firing heavy weapons. That is about how long it appears before people are back to their original steady state. Dod guidelines say theyre only going to test for the first 48 hours. Ms. Leah could Service Members a benefit from e weapons use safety limits for longer periods of time like 72 hours . X yes maam we are looking to expand the time frame so that weor the differences that are coming up with blast overpressure. Thats again were the direction our policies are headed so that cover that time. We are firmly committed for early protectionto provides the opportunity to treat and maximizes our outcome. I hope you do this soon. The department of defense Inspector General have been raising concerns Health System providers are not consistently providing a 72 hour fouith mild tbi. So clearly a longer timeframe is something dod itself recognizes is important and we need to get done. I get it, this is hard and i am grateful you are doing the work youre i want to be a partner move faster to deliver mor possible. We need to do better for for our troops and we need to do better right now. Senator scott . Looks in future i will ask the same question. What would you tell your son or daughter whos going to go be a war fire, 18 years old going to enlist heard about you telling today . Based on what you know. I have three boys who have served in the military one is still in the reserves. Im very proud of their service. Ht of them. There is a great opportunity in the Service Value to develop service toic country is very important even if you do it for a short period of time that it makes a big difference. I dont care where you serve or how you serve its critical now. They need to understand this is a risky business. Rs so they need to come out with eyes wide open, right . My kids knew that. I made it very clear still very proud i will tell my grandkids they think about there is something that triggers them to serve, then go fetch. Thank you for the question, sir. I have no children at this point too. I have many nephews nieces and friends of family who have encouraged on the military. This is been the greatest honor of my lifetime to serve in uniform. I would not change that requirement for anyone or request for anyone. So tell them to follow their heart and encourage them to know job our job is to make sure the people you are entrusting your life to i have a responsibility to care for your for the reason im here today is saying we want to make sure our men and women in uniform for them every possible way. Thank you. I have five children and one grandchild. I would absolutely say to support and defend our homeland. To join the military during our services one is a marine. And through that service it is about the trust. Ive suit working in this environment for the past 20 years especially on the traumatic brain injury rome you do need to be credible and have integrity based on that trust and ensuring we are going to do right by it we are a family and going to take care of you. Mr. Larkin is part of our team we are all in this together with the same mission to take care of our Service Members who make a sacrifice for. Thank you. The departments report to congress on t blast of the Department Plans to conduct Business Case analysis and review Lessons Learned with blast moni conducting the analysis, when youreys expected to be completed . What factors does the department including in its analysis . Quick serve to you mind if i defer . Business Case Analysis kick off meeting was the 14th of february. I think its conducted by a Contract Service we are expecting the results in september of 2024. We have extensively involved in military departments in this so the outcome and a recommendation will be able to be implemented by the military department. Both the Service Community and the Operational Community are heavily invested. We can review the necessary resources. Look at how to establish a Program Throughout the force. When you think you will be completed . Best Case Analysis in september. The 23 fiscal year 23 nda authorized did not require the director of the agency to conduct a Pilot Program to monitor blast exposure to the use of commercially available sensors. Doa. Do you plan to do it . Only sensors in mind we are awaiting the results the Case Analysis in september. Whether or not the pilot could be the segway for in section 734 work into a fullblown standard monetary Program Throughout the so again thoseme decisions september 24 time. It turns a blast of sensors we have various communities to include the special Operations Command that have been looking at the three commercially available products. Those decisions are world and fielding exercises. An individual community. Cooks good. Also fiscal year 23 nda report described in the strategy and Implementation Plan is due at the end of last year. Is that different than the others . It is the strategy and action plan that has five lines of effort i believe that tentative your way right now. Okay all right. Thank you. Could i justcan i just ask one more question . What are you going to do. [inaudible] memo that was produced before we had finished section 734 secretary of defense for readiness put out this interim guidance memo. Before we had completed all of the information all of the data we thought it was imperative to try to get brain Health Guidance out at that time. So he sent the memo out and are included are six actions to try to avoid unnecessary blast exposures. What we are doing in the meantime is something that memo with more data we have Market Research studies in the blast community of researchers so that we can provide direction and guidance on how they can have environment. There anecdotes that suggest remote policy changes we talk to each other appear in the abstract and down at the ground nothing has changed. The first issue is, this is a joint effort between the Operational Forces into medical leadership they dont work it out. The other way we exercise at dods counsel. We are meeting withl. The services and laid out the guidance we rely on the services to push it down. Its an issue of policy its an issue of training in the services but equipping in the services. Given the medical guidance the best knowledge we have those things have to b exercised. I went over to Fort Campbell and i talked to the ceo and i told him that simple less is better less often is better so really Pay Attention to that. Want to admit than that . Give a glucose monitor and how they work . Hink so. Duncan put in my exercise i can put in my i can do it myself i contract to see i feel my glucose goes up. Why dont we have simple people can do on their own i get headaches i have sleeping problems or any of these issues i cannot do this any this technology is so simple. There are two companies it that did the glucose one. When you give us the technology and we can implement this and give it to everybody let them monitor it themselves. [inaudible] said anything above that are below that. But we have to determine that threshold. Would look at is ith will put the information in their and ill say here is what i noticed if i do this number of blasts i get a headache. I do this many i cant sleeps in sleep sinister saying to myself okay im not going to do that. Im not doing that to myself anymore. This has happened to me so im not an expert on this. Were all going to be better if we self monitor ourselves top down program that tries to tell us everything you are at body is going to be different than my with my height level should be different than yours. I am just saying put the information in there its a real simple model. Give it to everybody let them start following int own unlike on those anybody you can connect you send going to allow this person to their sick company out there that allows people to connect called levels i think they have 50000 people or so on a study and they do it on their own as a private sector. Just with everyone volunteering to put their data in there. , if i may put one of the most important things what youre speaking about is really truly Precision Medicine in targeted therapy to the individual. For each individual has a tbi the symptoms that they of the things the past nda said dod need to partner with private industry and private organizations to improve research and treatment. That look at. What type of modalities are out there that can be developed to allow patients to focus on their individual symptoms. Baseline is first for that individual. Biofeedback is something we do we help pients understand how to control their own individual symptoms. But each person is different that is going to be a chalnitoring tool to create that is possible we continue to do research we can get there soon. I just gave you my answer. That is the Big Government answer. You might be right im not saying youre wrong. I actually do believe i will do a better job of monitoring my health then anyone else will do my help i dont care what you said yes i will do a better job. Personally if i eat something and i dont feel good im never touching it again. These are smart kids going in the service. All of these people getting smarter about this in sync im not doing this to my brain. I think we ought to all the in but its prettysi simple to let the person monitors themselves their bodies going to be totally different than everyone else. Your blood glucose level is different than mine i guarantee you. I totally agree with you sir sir i always listen to the patient and i listen to the parents its very important. [laughter] i do want to say i agree withyou. As a medical professional and even as a researcher we want to come up i pathway forward for the patients to monitor their own. So we need to come up with the baseline, with normals that we just dont have at this point in time for tbi in general. And when we move towards blood biomarkers when we move towards much more concrete evidence we can come up with the tools youre talking about and it monitor themselves. I want to thank you all for being here. [laughter] absolutely. Absolutely. Thank you all for being here. So Northland University including East Carolina University chapel hill, and Healthcare Providers Like Atrium Health have care and support for Service Members and veterans diagnosed with tbis label to see that when i was in the state last week so again i appreciate this hearing. Ia further understand the causes of tbi will significantly improve that care that they offer and look forward to supporting their ongoing efforts. Doctor martinez, and the study on blast pressure exposure members of the Armed Services you published in december of one of the key findings is a greater likelihood of tbi can you n explain what you mean by a greater likelihood . And quantify the increased likelihood of tbi so what percentage were exposed into what level blast likely to develop . Certainly thank you. Section 7 30 four longitudinal study you are referencing where we looked at monitoring and documenting blast exposure and also offering a review of Weapons Systems which we codified as a 15 Weapon Systems most commonly used. We went deep to figure out what all the safety regulations were about those. And under the safety rubric as well looked at health and performance effects are the brain Health Effects. And in the report we reviewed 40 studies, 26 studies were funded by the department ofst defense. We looked at what type of effects happen and where you have concerns about traumatic brain injury. Most ofe the areas we found correlations were in the on the neurocognitive and thinking areas. Also in som ns to try to see if there was any will bear fruit but right now there is no clear trend in that regard. We are relying on the symptom recording as being the most indicative of someone who would have a traumatic brain injury and again Early Detection through evaluation of multiple domains like their balance and their five movement and their thinking skills and their sense of reporting. X thank you for that. What recommendations would you make to improve the departmentsu ability to diagnose and treat military personnel who have repeatedly exposed to low level reblast . Think of a question, senator. As we spoke earlier in terms of baselining early. Itsea been said several times when you know better you do better one of the most important things we can do ass a baseline are members from that moment they come into the military. That means that allows us to follow them over time. I admit we have to find the right baselining tool right now it focuses on cognition thats an appropriate component but we can do more, we can do better and our goal is to start early so we continue to monitor. Thank you. Its the proud home of the Warfare Center in school at fort liberty. Research suggests special Operation Forces experience higher rates of blast exposures in combat than other military personnel in an elevated risk for repeated blast exposure related to brain injury but with that track with your research . Absolutely. Thank you. We certainly need to conduct more research we have to do better job protecting our Service Membe today. That lines up with what you are just sharing. I am concerned they department is not moving quickly enough to address these risks. Theres tested fda approved devices that can limit tbi so currently being used by special operators just like you see in the nfl hearing however theres years at dod testing that is a take place before they can be fielded for the broader so for the panel for each of you why are we expanding the fda approved wearable devices to gipper war fighters safer from tbi inducing head trauma rather than waiting for duplicate of testing to be completed within the department and how can we expedite those devices the use of those devices . I was are the simple answer i would go would do no harm. Right now we need more information for some of devices are determined they would do hom harmony operational said and perhaps even doctor if they are fda apply understand fda approved but often times not tested in our population. That is a different story we realize now a lot of Times Research being done is not inclusive of operators especially high Level Operators that we care for. Our goal is to make sure we do no harm to the general population for. Thank you, secretary. You may have to look at the k at the science. If you make a difference we will. Well put them through our internal processes industrial for every that we do. Thank you ms. Lee . The compression devices you are speaking about have mainly been studied in the community so pivoting to blast overpressure has different mechanisms of injury is worth a look definitely worth more than a look it is to do more research to make sure it is safe and effective in both the military population as will as the mechanism. Understood, thank you all. I yield. Think you senator. You all. All of our witnesses are being here today. I want to thank you for the work you do every day. My takeaways from this are to do better. We need to identify those who are most at risk for tbi because of the particular work they do and we need to collect better data. We need to do all of this on a much faster Congress Also needs to do better. We need to make sure you have the resources to do your work we also need to make sure that those who are treating tbi like homebase have the resources they need. It iy military who have what appears to beat be tbi and they cannot be treated because the resources simply are and that not there a waiting list in a place like homebase is our failure. We need thoseese to treat those who have suffered a brain injuries because of their service to our nation. We owe that to our Service Members so again thank you all for being here and want to thank the senators who have been known to thank my partner senator scott in this. This will be an issue we take up during the next round of negotiations. Thank you. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] conversations] coming up on cspan2 top intelligence officials justify an illegal entry into the u. S. And other Global Threats facingthe country. A hearing on the use of financial surveillance by federal law enforcement. Later for Trump Forward Trump Administration staffers discussxperiences speak out against the former president. My report my best effort to explain what i declined recommending charge imprisoned by the analyze the evidence as prosecutors routinely do by assessing its strengths and weaknesses. It just amazing the way the president s defense lawyers might poke holes in the governments case. If were a trial and seek the government cannot prove his guilt beyond a reasonable doubt. Theres been a lot of attention paid to language in the report about the president s memories would say a few words about that. My task was to determine whether the present retained or disclosed National Defense information willfully. That means knowing and with the intent to do something for the law for bids. I could not make that determination without assessing the president s state of mind. For that reason i had to consider the president s of memory and overall mental state and how a jury it likely would perceive his memory and mental state in a criminal trial. These are the types of issues that prosecutors analyze every day. And because these issues were important to my ultimate decision i had to pecialfied w he you c also now are freed mobile video app and online at cspan. Org. Cspan is your unfiltered view of government. Funded by these Television Companies and more i