With great internet. Wow supports cspan as a Public Service along with these other Television Providers giving you a frontrow seat to democracy. [inaudible conversations] [inaudible conversations] [inaudibleh conversations] the hearing will come to order. I welcome you all to todays hearing [inaudible] servicemembers put their lives on the line [inaudible] make sure the nations [inaudible] okay. That could be trouble. All right. Can we get the other brokerages like a started here . Servicemembers put their lives and their health on the line when they put on their uniforms here and in return we have a profound responsibility to make sure that the nation is doing all that he can to keep them safe, to prevent battlefields and training casualties, and to provide the best possible care for those who are injured. We are holding this hearing over there . Good. We are holding this hearing because dod is not beating its responsibilities when it comes to traumatic brain injuries and other injuries that results from firing weapons. Injuries from last overpressure, the pressure that is caused bya shockwave that exceeds normal atmospheric values, have been the signature wounds of the war in iraq and afghanistan. But there are also injuries incurred in training here at home. They are invisible that they affect thousands of servicemembers, causing headaches, seizures, hallucinations, and ultimately significantly increased risks 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 learn, the more we come to understand that blast exposure is an ongoing threat to the health of individuals servicemembers, and to the wellbeing, the morale and readiness of our entire force. I appreciate the supportrt i hae that on this issue from Ranking Member scott, from senator tillis, and from other members of this committee. I secured a longterm study a blast overpressure injuries in 2018, National Defense authorization act, and i have worked with senator ernst to introduce legislation on blast overpressure and to secure additional requirements to track blast overpressure injuries in fy 2020 ndaa. Dod is working to implement this legislation, but we still have significant problems. Last year the New York Times reported on heightened brain energy risks for u. S. Troops in syria fighting isis. Four 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 have members with serious blast overpressure injuries. And each had at least one member that committed suicide. These of deaths are a tragedy. Ryan, a navy seal the point to iraq and afghanistan subjected significant blast from his own weapons over the course of his career and later died by suicide. His father is here today to discuss the harm the last overpressure has cost to servicemembers and to their families. The times also revealed that even when dod has made policy changes to address risks, those changes were not evident on ground. Weapons known to deliver shock well about safety thresholds were stillll widely used. Training did not involve basic safety measures, and special operations horses were not issued last exposure gauges, they gauges that are needed to track the threats they faced. So dod and congress both have a lot to do. Heres my agenda to address this problem. First, we need to establish mitigation strategies specific to the service of member roles that are most at risk for blast overpressure. Second, we must require dod to create blast exposure and traumatic brain injury logs for all servicemembers and to integrate these logs into their va and dod health care records. Third, the department of defense should partner with innovative evidencebased programs like home base to help servicemembers get the care they need. And up going to have to brag here for just a minute. 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. Homebase has clinic in massachusetts and in florida, Ranking Member scott state. Homebase has a conference of brainin health and trauma progrm specifically designed for special operations veterans and servicemembers where its been leading innovation treatment for veterans with cooccurring coog Substance Abuse and Mental Health conditions. As a work through this use ndaa i want support this programs work and i appreciate dr. Zafonte from homebase joining us today. One more item. We need to make sure that dod sets a special on the maximum number of rounds of servicemembers can safely fire and that this includes consideration of exposure limit over an extended time. Dod must do its part, and Congress Must do our part. So to our witnesses, welcome and thank you for appearing. Were going to have two panels today. The first, first panel will consist of size witnesses to provide their perspective on where dod and the services are falling short on protecting servicemembers from blast overpressure. Doctor samantha, professor policy analysis at party brand. Dr. Zafonte, and Wellness Programs at home base, and frank larkin, chief operating officer of troops first foundation, and lead of the National Warrior called the initiative. The second panel will consist of officials of the department of f defense and walter reed to hear about out dod is tackling this issue. We will have doctor lester martinezlopez, assistant secretary of defense for health affairs, kathy lee, director of Warfighter Brain HealthHealth Policy dod, and captain carlos williams, director of the National Intrepid Center of excellence at Walter Reed National military medical center. I will now turn to Ranking Member scott for his comments to open this hearing. First i want to thank senator moran, chairwoman of thisi committee and subcommittee and thank her for caring about this issue and for taking this job so seriously. Chairwoman warren i want to thank you for holding the threat of such an important topic. Traumatic brain injury or tbi is one of the most common injuries sustained by american servicemembers. In 2022 more than 20,000 military 20,000 military personnel were diagnosed with tbi. Think about that for a second. Just in 2022 there were more than 20,000, 20,000 members of our military who were diagnosed with a traumatic brain injury. Thats pretty bad. The vast majority of over 84 were classified as mild which is more, no as a concussion. But if anync of us, when you rae kids and they have a concussion, it scares the living daylights out of you. Missing from this data are servicemembers are frequent exposed to low level blasts that did not typically result in a clinically diagnosable concussion. This is considered because repeat exposure to low level blasts they cause similar symptoms as more severe cases of tbi. We know lowlevel blast exposure from firing heavy Weapon System for explosives may cause a variety of symptoms including concentration,lo memory probl, irritability, headaches, and decrease hand eye coordination. Each of these issues can be very serious and disrupt somebodys life. Unfortunately the remains a great dealli about exposure to these blast that we yet do not know. More research and better data requirements of military and Healthcare Providers can mitigate the frequency of blast exposure or possible and treat those exposed to blasts, where necessary. We have actually taken action to do that in the 22 National Defense authorization act, congress required, required the department of defense to conduct a medical study of last pressure exposure. Too much of the Committee Received the departments fought a report on the study. The serene presents an opportunity to assess the quality of the departments work. Legislature required the study which follows specific and vigils over an extended period of time to include three specific elements. First the department was to quote monitor record and analyze data on blast pressure exposure for any Service Member quote likely to be exposed to blast in training for combat. Second, the study was to assess the feasibility and devise ability of last exposure history into servicemembers medical record. The departments review the precautions of heavy weapons training in light of emerging research on blast exposure. In reviewing the final report submitted this past december it is clear the Department Still has more work to do. Particularly in its ability to monitor and record blast exposures for militaryri fopersonnel. Only a few hundred soldiers and marines were fitted with wearable devices that are unfortunate he seems Quality Control issues. While the Department Report that say it may be feasible to record blast information in a servicemembers medical record a Business Case analysis is required to determine the way forward. Now i wouldi like to learn more about how the Department Plans to conduct this Business Case analysis. Or niche oblique the department is committed to getting this right and avoid the tbi center of excellence and Warfighter Brain Health initiatives are an Excellent Initiative that i hope will provide the military with understand the effects of repetitive last exposure. We almost member exposure to low level blasts continued the unnecessary risk for frontline combat troops. But we can do better if we can better quantify the type and number of blasts have the potential to cause significant perhaps permanent injuries, then we can use that information to make better decisions about how best to looks up with a missio. Ii would like to hear from the witnesses what congress can do to ensure the department of defense has the resources it needs to conduct its plan and where we can help. This is about the wellbeing of the individuals willing to put on uniform who are closest to the front line of combat and every Service Member that is diagnosed with tbi. We owe it to them to ensure and their families to ensure that when they go in harms way they are welltrained, have the right protective equipment, and are utilizing the manner that achieves the object of a dentist and at the risk involved. I want to thank you to all the witnesses for being here today. I look forward to your testament and again what you think senator warren for putting this together. Thank you. Chairwoman warren, Ranking Member scott, members of the committee, good afternoon and thank you for the opportunity to testify today. My name is doctor Samantha Mcbirney and im a biomedical engineer at the nonprofit nonpartisan rand corporation. My research for the last 15 years that only at rand but also to university of california berkeley and university of Southern California has focus of dramatic brain injury, or tbi. Those that result of blunt impact and blast overpressure. Today i would like to speak about repeated exposure to lowlevel militaryto occupationl blasts which of lowlevel blast exposures experienced while fulfilling military occupational duties. Evidence suggests servicemembers are exposed to these blast and former blast overpressure, or the pressure waves that emanates esfrom the source of an explosi. This pressure wave can cause some concussive injuries which are not immediately detectable and woulde not qualify as a tb. Exposure to bless overpressure can occur both in combat and in training as has already been mentioned. During training exposurengre cae due to breaching exercises and the firing of increasingly powerful Weapon Systems, such as the recoilless rifle and vat format. To provide perspective of the level of exposure some servicemembers have one study found up to 32 of blasts experienced by preaching and structures exceeded the recommended exposure limit. Ceacstudies have shown a cumulae effect of repeated lowlevel blast exposure can cause symptoms similar too tbi. While a variety of effects have been linked to lowlevel blast exposure, as senator warren and senator scotts have already mentioned, the remains of lack of Scientific Evidence linking repeated exposure to injury. En one reason for this is the difficulty of diagnosis. The very nature of lowlevel blast exposure and theth fact it is not one single event that causes an issue but rather the cumulative effect of repeated exposure overtime complicates injury recognition. Symptoms typically do noted manifest immediately which makes it unlikely repeated exposure to lowlevel blast is identified as the cause. Additionally, injuries are bows and report among servicemembers only obfuscated the issue of proper diagnosis further. Theres also a lack of research about the military occupational specialties at greatest risk of exposure to lowlevel blast. While theres no doubt certain occupational specialties are more frequently exposed and others, there is Little Research to support these hypotheses. So the remains a a lack of understanding of the direct impact of repeated exposure to lowlevel blast has on the health of servicemembers in different occupational specialties. If the preventive intervention is perfectly effective it cannot be delivered in time, it is not useful. This quote from a 2019 rand reportrt perfectly describes the current state and the reason many of us are here today. As a Research Community we clearly seeun the Additional Research needs to be done. However, there are steps that dod can take that to better protect servicemembers against blast induced injury. I highlight four recommendations in my written testimony and i would like to bring attention to one of them here. D the creation and maintenance of blast exposure records. These records should include rdnumber of exposures, the contt of each exposure and any physical, mental or emotional effects resulting from said exposure. This would allow the dod to better track exposure frequency, says the occurrence among highrisk occupational specialties, determines the e connection between exposure ad health outcomes, and develop strategies to mitigate exposure in training environments. Ultimately these records could be used to develop an index score to update an individual combat readiness and potential health risk. As i Weapon Systems continue to become more advanced and increasingly powerful, lowlevel military occupational blasts will remain anoc enduring challenge for servicemembers. Addressing the issue of repeated exposure to these blasts ssa take action and collaboration between the dod and the Research Community. The recommendations as outlined, alongside continued Research Efforts to close substantial knowledge gap, the dod can take significant strides towards better protecting the health and well being of our Service Members. Thank you and i look forward to thank you and i look forward to i am honored to provide testimony today on dramatic brain energy. My career is centered around improving the lives of people with traumatic brain injury. Chair of the rehabilitation harvard medical school. Hospitals and womens hospitals in 15 years directing the brain injury program. Over precious we just heard, artillery and deploymentt and reaching buildings and explosive devices. The more damaging the pressure. Tbi can have a wide range of physiological effects sometimes medially there may result in cognitive behavioral impacts. According to the department of defense since 2000, over 400,000 u. S. Service members had at least one brain injury. Comorbid Ecological Health conditions. Our search has noted an elevated ten year risk of hypertension, already activities, hormonal dysfunction and behavioral concerns such as depression, even among the youngest of patients. Hormonal dysfunction even among the youngest patients. We are located in massachusetts which i am proud to say is a native floridian, satellite locations in florida and arizona and operate one of the oldest and most impactful private sector in the nation. For 15 years we served as an incubator for it. Allowing us to leverage the faculty. Homebase bridges the gap between research and Clinical Care. Now, in 2018, we were approached by the Naval Warfare with a complex set of problems facing navy seals. We quickly developed a brain injury and polytrauma program. It is named combat or the comprehensive brain and Health Treatment program. Modeled after programs we developed for elite athletes and it has specialist treatments, evaluation and care coordination for veterans and active duty operators. Home base has treated nearly 1,000 special operators through our intensive programs. 71. 9 of combat participants are active duty and the overwhelming returned to active duty. We currently have 178 active duty special operators waiting to be screened and scheduled for combat. Puerto rico including 53 patient from massachusetts, 60 from florida, 6 from connecticut, 22 from hawaii, 278 from virginia, 4 from illinois, one from alaska and 54 f