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Trauma and Resilience: Mind, Body, and Spirit - Transcript

Dr. Donald Lindberg: Welcome. I'm Don Lindberg. I am Director of National Library of Medicine. Last fall I attended an international meeting on Traumatic Brain Injury and Post Traumatic Stress Disorder as a representative of NLM. And at the meeting in New Jersey were lots of experts, from military people to neurosurgeons from here and abroad. But I had an opportunity on a bus-- they gave us a tour of urban New Jersey, which is lovely-- but I had a chance to talk with Dr. Maria Mouratidis and I concluded that she had, in a lot of ways, the most authentic view of this problem, and I am very happy that she came to talk with us. The reason I bring it to your attention is that I was completely personally amazed at, first of all, the difficulty of the problem. We don't really know enough about, even, football injuries, let alone these Iraq/Afghanistan problems, and the magnitude of the problem. There are estimates by experts as to what percentage of individuals who have a Traumatic Brain Injury-- call it a concussion, if you will-- actually have a subsequent Post Traumatic Stress Disorder. They vary all over the map, but I mean they start at somewhere around 15-20 percent, and end up somewhere around 70 percent. So the magnitude of the problem is much, much greater than I thought it was. So if I contributed anything at the meeting, it was to report on MedlinePlus and what our good people have done. So you will hear about that at the end, too. But I did ask Maria-- pushing, I guess, when maybe I shouldn't have been. She is at the Naval Medical Center. She is a neuropsychologist. She trained in Maryland and also at Yale. But I asked her, "Well, is there a database about fellas at Navy?" I guess mostly Marines probably now. She said, "No." I said, "Well, I mean do you have any kind of records yourself "that can be studied?" She said, "Well, sure-- I have some of that, too." I said, "Why don't they make a database?" She said, "Well, I discussed that. I came to work there..." I think I have the date right. You will have to correct me if I am wrong, but, "...first quarter of 2002." And she said, "So I suggested that and they said,  "'Well don't worry about that 'because the war will be over in three months'. '" And I asked, "Well, how many of these guys "have you actually seen in this little ward of yours?" And she said, "Well, I stopped counting at 1,086." Truly amazing that one healthcare professional would see that many of these poor guys. Anyway, she has the most authentic knowledge, I think, of all of the people from that meeting and I am very pleased that she has come here to tell you her story,  but I think she also agreed to take questions, and we'll have some coffee following the talk if you want to convey any personal questions. Dr. Mouratidis. [ applause ]

Dr. Maria Mouratidis: Well, thank you, Dr. Lindberg and Ms. Roaff, really for having me for this opportunity, really, to share the story of what I call the Battle of Bethesda of our service members, their families, and really our staff. And certainly to give the authorized government disclaimer, anything I am about to say does not reflect the views of the Department of the Navy, National Medical Center, the government, or anyone other than myself. So that's my disclaimer. Also, any stories that I will share with you about the witnessing and what we have learned from our patients and their families will not disclose any personal information for their privacy and their confidentiality. And I would like for this to be a dialogue. So please feel free, not just to ask a question-- share an observation. Share something you are wondering about. Share your experience and your thought. And I believe you all have microphones at your desks there, so please feel free to interrupt. I would like this to be very much a multiple perspective, multiple interdisciplinary discussion. I'd like to share with you just a little bit about what we have learned and what we have learned through listening of the story from our patients and their families and those who serve them. Just by way of background, I came by a sort of traditional academic medicine. I spent about 10 years of my career at Hopkins, about five at Yale, worked for two different VAs. I really sort of grew up being very grounded in science, grounded in clinical practice-- Lots of books on my shelf, things on the walls. I would not know anything that I know now after spending the past four years at Bethesda. I have learned that there are so many other ways of knowing than, "What does the literature say?" Which many of us, at least in my field trained as a psychologist say, "Well, is that empirically based? "What does the literature say about that?" Well, not to throw the baby out with the bathwater, certainly, and I still support and, of course, turn to literature to guide what we do in our thinking. However, in 2005 when I first came to Bethesda, we didn't know what was hitting us. We started getting MedEvac after MedEvac. And MedEvacs aren't sort of like the helicopter that lands on "Grey's Anatomy" on the rooftop. I mean these are flying ICU's where we are having patients who are arriving in our hospital often times just 48 hours after being wounded on the ground in Iraq or Afghanistan. The advances in military medicine in the era of transport... In Vietnam it took about two weeks to have anybody get back to the United States. But to be able to transport, one, the surgeons, especially, so far forward that our patients are getting their first surgery sometimes in less than an hour from the time of injury. To be able to be back in the United States within 48 hours, they could still have Baghdad time on their watches still. They come unconscious and they wake up at Bethesda, and most often times, the first person they see is their mother, their father, their spouse, because we have been committed to... When we know someone is en route to Bethesda, we call their family and say, "Your son or daughter has been injured. "They are in en route to Bethesda. "Do you want to come?" Invariably, they say yes. They get called back with e-ticket numbers. They get picked up at the airport. They get brought to the bedside before, even, all of their arrangements, which are taken care of, of where they are going to stay, so that when that service member comes through those doors, often times their family is already here before they even get here. And that when they open their eyes when they get here, they see their mom, their wife, their kids. And the power of patient and family-centered care is tremendous, that taking care of the patient means taking care of the family at the same time. And creating a system of care that acknowledges that and celebrates that has been tremendous. It has been one of our many lessons learned. So early on, patients are coming in from war. There is no reason to think that there is anything different about this war, about these injuries, so they have been getting good regular medical care, and also, advances in the field in terms of military medicine. And military medicine often advances healthcare for the whole world in a time of war, because new things that are learned are innovative, and that we can then share with the rest of the world. So patients actually, from these wars, meaning Iraq and Afghanistan, are living, where, if this was Vietnam, they would have been dead. So when you look at the casualty rates, the injury rates are much higher than they were, perhaps, in Vietnam. And so what are we learning about these injuries? So at first there was no reason to believe they were any different than anybody else's injury until we started listening. We started to hear and observe. And that is one of the things that has been really powerful, this element of listening, of being on that tip of the spear, and of listening to what story is coming together with this. It's actually one of the reasons why I don't use PowerPoints very much anymore, because you all have PowerPoint PTSD, or seizures from the clicking of the PowerPoint. [ laughter ] But I was giving-- again I'm guilty of being one of those clinical scientists-- giving those PowerPoints. You know, of course, three times is too many slides for the time you have allotted. And it was in one talk that I was giving where I decided not to use PowerPoints at all. And a Corpsman, Medic-- they're called Corpsmen in the Navy, Medics in the Army-- waited until everyone else was gone from the room, and he came up to me afterwards and he said,  "Thank you." He had tears in his eyes, and was almost kind of embarrassed for having tears in his eyes. And he said, "Thank you, "you were the only one who made us a person." That it wasn't about P-values, and it wasn't about graphs, and it wasn't about pictures of brains. Which, neuros-- we get really excited about pictures of the brain, I mean they're really cool! And the anterior singular cortex is absolutely my favorite part of the brain. [ laughter ]

Dr. Mouratidis: I know you probably have your favorite parts too but, that's just my all time favorite. And the cerebellum is making a comeback-- keep an eye on it. It kind of goes in and out like fashion, but it's coming back. So you know, really hearing that from him, that was part of his story of needing to feel like they're a person, so we're not losing that in the midst of this. So when our patients started you know having symptoms that we didn't necessarily understand, or calls from family members, like, "My son bought a truck yesterday and doesn't remember, "should I be worried?" Yeah, let's bring him back in and take a look. We started to see that symptoms of concussion that were related to exposure to a blast may not look like what we see in concussion from football injuries or other sports injuries or car accidents. That the pressure of the wave-- now the IED-- it'd be much better for us if the enemy used standardized explosive devices instead of improvised explosive devices. Because that means every bomb is different. And so we're learning the shape of the bomb makes a difference. It matters what's in it, makes a difference. It matters differently if you're being blown up from in front of you or behind you, or if it's from the side of you. And certainly all of that information is not always being collected there in the middle of a battlefield. So we when try to compare what the literature says about sports concussion or motor vehicle concussion to war situations-- completely different. Now that doesn't mean that there aren't some things that we can learn from that, that it's not generalizable. Certainly some of it is. However, think about when there's a football game, which I won't say which team we're going to root for in the Super Bowl. I'm a Giants fan but I'm from New York, you can take a girl out of New York but not the New York out of the girl. So, there we go, another Giants fan. That when someone gets hurt in a football game, somebody blows a whistle, everybody stops, you get 14 doctors surrounding this guy. He's getting all these things measured, attended to, and there's immediate intervention in that same way. If you're in the middle of a fire fight and someone's dazed and confused, your life is threatened. You're going to get up and keep fighting. That guy who's on the ground because he got hit in a tackle isn't moving. But if his life was dependant on that, he'd get up and move. And so there are a lot of differences. And also the impact of the force of the blast itself-- the blast pressure wave-- we're learning a lot about it. If it's enough to bring down a building, how could it be not enough to affect the tissue, the fluid, the air pockets in your brain and body, especially brain and pulmonary system? So, we started to listen and learn and also seeing what happens over time. So a family member, a mother, called me once and said, "Well, my son was in a bar," you already know it's not going to go well, "minding his own business," as only a mother would say, "and somebody broke a chair over his head." Well, I'm sure there were some other things that probably happened in that sequence of events. But what we're learning was that, what are the symptoms of a brain injury, or Post Traumatic Stress Disorder, that may not look like what we see in other kinds of brain injury and what we see in and other kinds of PTSD? So, for example, we would hurry to the PTSD literature. We learned so much about PTSD from Vietnam. Well, I would say, hold on a second. Is the PTSD that we see from Vietnam the same kind of PTSD that we see in OIF/OEF? Is it the same kind of  PTSD that we see in rape victims or domestic violence victims, the same as we see in OIF/OEF kind of trauma? I would hazard to say no. The reason why is that we have learned a lot from Vietnam, certainly, and about PTSD, but it was diagnosed and treated 20 years after it was acquired. If you're living for 20 years with horrible symptoms of anxiety, nightmares, flashbacks, avoidance symptoms, hyper-arousal, you've made so many accommodations in your life to really function that it really becomes very much characterological, because you've had to adapt in so many ways. That's very different than two days ago you saw your buddy get blown up, and you have his guts all over you now. That's a different kind of PTSD. Or the chronic stressor. The PTSD would be more like domestic violence than rape PTSD, for example. Where there's that you never know what's going to happen next. You never know when the enemy is coming again. You don't know when you're going to get deployed again. And having that feeling that the other shoe is going to drop is a very real stressor. And so what are the consequences of also acquiring a brain injury in a highly stressful event? If you get a brain injury because you're driving to work, technically you're not very stressed unless you're on the Beltway. But you're really in a fairly normal state. But if you acquire a brain injury in the context of a very stressful environment, what happens in the brain? Some authors have postulated that maybe actually  having a brain injury can protect you against PTSD because if the parts of the brain that encode memory are impaired at the time of the trauma, perhaps you might not encode that. And it's been an interesting phenomenon. We've had patients actually in the hospital for months sometimes. And so we have a program where everyone has a mental health provider assigned to them whether they need it or not or want it or not. And that has decreased the elements of stigma because you're not special because you get a mental health provider. And it's actually one of the ways we've learned so much about resilience. So, for example, they see me coming-- they must have my picture posted in places-- and they say, "Doc, I'm fine." Before I even open my mouth. And so it has engaged us in a lot of conversations about, how are you fine? And I'll share some of those with you. But everyone having a mental health provider helps us to be able to follow them overtime to understand what to expect because we're learning about these injuries. What is the nature and course of blast-related brain injury and  PTSD? We don't really know. It's different than, let's say, in Vietnam, when just a bomb went off and you've got some shrapnel in you. And also, shrapnel from bombs from World War II or Vietnam, you know, they were metal. You've got nice, clean fragments. The fragments from an IED are rocks and rat poison and ball bearings and all sorts of crap, really, that don't actually enter or leave the body in as clean of a way. But by following patients over time and their symptoms, we learned that there was one patient that was in the hospital for about three months, and at about three months we start to see that something changes and we don't know why. Denied symptoms of PTSD every day; no symptoms, no symptoms, no symptoms, then one day nurse comes in, turns on the light, it mimics the flash of the blast and the guy is on the ground crawling around thinking he is in Iraq. Why that day? Why not the day before? Why not tomorrow? One hypothesis is that as his brain injury started to heal and his brain checked the box, "OK going to live," sort of moving down the priority of processing list, it got to "holy crap, something bad happened to me." And until that material started to get processed it's hard to think that you'll actually have symptoms until that happens. Which is really important because it helps us to educate our patients and their families that symptoms could happen later. And that doesn't mean they're malingering. It doesn't mean that they weren't assessed properly. It doesn't mean any of those things. It means that the phenomenology of the manifestation of the symptoms for each person could be very different, and that we need to listen. We need to listen and to pay attention to what we're hearing. And actually this was very challenging in 2005 and 2006 where we really didn't know blasts. How do we know? Well, we needed to actually start at that time to take some of those steps and say, "Well, we need to realize that maybe we don't know." And that we need to really listen to what our patients and the family members are telling us. And what our nurses are observing, for example. They spend a lot of time with the patients. And to really craft a policy procedures clinical practice around what we're learning from our patients. So we train medical students, all sorts of students. You know they sort of already have their white coats with their pockets and all their stuff in it. [ rustling ] Sorry about that. I'm Greek, too, so I just can't help but talk with my hands, and feed you. [ laughter ] So, that's what we do. So they have their pockets full of all their stuff, and you're trying to tell them, "You really don't need that." And they're like, "What do you mean?" "I need my coat and my pockets." And I'm like, "For what?" And they're like, "My stuff." And, you know, helping them to understand the only things you need are attached to the side of your head. They don't fit in a pocket. So we need to listen and that to hear the heart of our patients doesn't require a stethoscope. And that has been really very powerful in terms of creating really very much a sacred space. When you're standing with some of our service members and their families, you really feel like you need to take your shoes off when you're standing next to them. It is that powerful. In learning about resilience where I had a young service member, really severely injured. And so he's telling me, "Yeah, Doc, I don't have PTSD, I'm fine, I'm fine, I'm fine." So talking to him about well, OK you're fine, how are you fine? How is it possible that you are fine? And so through talking with him and listening to him he said, "While I was waiting to be air-evac'd out of the theater "my unit leader held my head close to his chest "and his heart and told me I was a good Marine." That's real leadership. That unit leader without knowing it bought that kid an insurance policy against PTSD. Much more powerful than anything I would have in my pocket, on my shelf or on my wall to do. That power of standing there. And there have been times where I have not known what to say. And usually I'm a little bit of a chatterbox, to stand there and witness someone-- what do you say to someone who has no arms of legs? Sorry? But to be able to sit with them and their family, and that presence, I have to say has changed me fundamentally as a scientist, as a scholar, as a doctor, as a person. And that's where the resilience and the hope is. For all of us really. Because we're all carrying some kind of story. And our family members-- and Lee Woodruff talks a lot about this in her book that she wrote with Bob. And sort of coincidentally, it's about a year around this time that he was injured two years ago. And talks about what the family goes through. Talks about her own experience of becoming the general. And I'm not sharing anything that wasn't in the book even though I was one of his doctors on his team. That-- what are the changes in the roles of the family? How do you talk to the children about what's happened? I had a family member say to me once, you know, we're talking about his brain again, all these kinds of things, here are some pictures of his brain and this is what we're going to do. And she said, "But is he going to know to love me anymore?" That's what she wanted to know. And that's where really witnessing-- how that-- love isn't in the brain. I guess some would argue with me, perhaps. And, it transcends all of our cognitive functions, and our wiring per se. And I've really witnessed it when children of family members, of injured members have come in, where family members will say, "Oh look, he squeezed my hand, or he moved!" And you're kind of thinking not really but OK. You don't want to take away their hope sometimes. And then other times where patient's not really responding to spouse or staff or anyone, their child comes in and in one powerful case I saw myself, just the tears started to roll down his face when his child touched him and spoke to him. Very powerful. So even with the brain injury, even in a coma, the person is still there. Now how we have contact with that person, how that person has contact with themselves as they knew-- and most of our patients will say, "I want to get back to where I was." It's really not about getting back to where we've been, it's about moving forward to where we want to be. And Lee Woodruff talks about this in her book-- well, is he going to be able to work or anchor or you know? I said, "Well maybe he's not going to want to do that anyway." And so really being open to that, to where that's taking a person and the family as a whole. And these are some of the things that we talk about the importance of community reintegration for patients, bringing services closer to their home and making them accessible to them, where family members... Not everyone has the Family Medical Leave Act. I can't tell you how many letters I've had to write to employers that say, "Dear So-and-So Employer, "please don't fire Lance Corporal So-and-So's mother who is at the bedside of her son "who was severely wounded in his service to our country "for your freedom and for mine." The burden on the families can be tremendous. And recognizing that if we can help mobilize the services around the patient where they are, bring resources to them, and really in the way that in our day and age comes to-- Facebook, which I don't even understand, but using technology, using the resources that are available to us that help bring those resources to them. I had a patient who was a double amputee who was also paralyzed, which means he wouldn't be able to use prosthetics and we were talking about him getting back home and reintegrating into his community, and he said, "Well, I can't give my daughter a piggyback ride, "but I have a lap." That lap needed a child in it. Much more powerful than again anything I might be able to do for him. The powerful of being around his family and friends. I mean think about it. Those of you who have dogs or cats or pets, just think about if you had to be separated from your dog or your cat. You know, those things that help us to feel better are very much broad. And realizing that there's a whole community for us to embrace and to educate. Yeah?

Audience Member: I just finished a degree in social work and exactly what you're saying is what I have seen we need to do. Which is to build communities of inclusion that bridge between the civilian community that doesn't understand the military, and the military community that is under great stress. And one of the things that you mentioned earlier that seems to be something that civilians don't understand so much is that when that Marine officer said that to that soldier, that Marine-- they're not soldiers-- that Marine, that is the power of command and leadership. And I know at West Point now they're beefing up their leadership classes and this is also one of the things that differs amongst the military branches-- how they view leadership and their platoons. And all this stuff that I don't really understand, but we have to understand I think that the family is extremely important. And yet for that person coming back the people that they were in combat with is also incredibly important. So you are actually having a person that you are merging two families with. So I mean, I don't know.

Dr. Mouratidis: That's a great point. And it's sort of interesting, I've noticed even over the past few years, those of us that were at sort of what I call the "Battle of Bethesda" under Admiral Robinson's leadership, who is now the Navy Surgeon General. He was the unit leader in many ways, it's even somewhat different now. Because the casualty counts are thank God lower, but in the thick of it when you're bound together around a mission like that, it is hard for other people to understand. So I can't-- dealing with what I was dealing with, especially in 2005, 2006 and a little bit of 2007 especially, you can't go home to your family and say, "Boy I had a rough day." It just doesn't seem to really translate in the same way. Whereas my peers that I was working elbow to elbow with taking care of our injured, sometimes no one even needed to say anything. You just knew when somebody needed a little bit of care, needed a little bit of attention. Or, you never know what room someone just walked out of, or what just happened. You just had to tell one of your patients that your whole unit was just killed. And how to provide these services to patients that are brain injured was a huge learning curve to develop that. So here you have someone with a brain injury, how do you share that information with them in a way that they can process cognitively? In a way that they can handle emotionally and process emotionally? Realizing that if they have a brain injury they may not process their emotions in the same way we might. So how can we do that? How can we modify the treatments for example, for Post Traumatic Stress Disorder for patients who have a brain injury? So, for example, exposure therapies are empirically supported for the treatment of Post Traumatic Stress Disorder. However, I encourage you to read that literature carefully. The dropout rates are huge in those studies, which means that it is empirically supported for a select group of patients, which is fine as long as that's the kind of patient you have. That these studies haven't been done in patients that have a brain injury. We don't know that those same treatments either work or that they're safe. So, it's really reinventing how we're thinking about questions or diseases that we thought were familiar to us. How we're using existing resources In making them accessible to patients that may have a brain injury and how are we including the family and community in that process? How are we paying attention to really the psycho-spiritual approaches? And you know, I think really, especially doing this work, I really have been so struck and learned so much about the importance of attention to that whole spiritual domain. That when healing from trauma especially, that when one of the hallmarks of trauma, whether it be brain trauma, physical trauma or psychological trauma is this shattered world view. You thought the world was a certain way and you learn from the traumatic event that it isn't. There's a shattered view of self. Of what you thought you were or could do. Of others. And how do you reframe that? Remake that? How does that story unfold for that person? And what is our role in a healing relationship? And a healing relationship is not just as a healthcare provider. It could be as a parent, as a neighbor, as a spouse, as a minister, as a Rabbi, as a teacher, as a colleague, as a friend. How can that healing relationship help that person really author their story about what this is going to mean for them over time? Because it's not predetermined. And we see that, a whole unit could be exposed to the same traumatic event. One person may develop PTSD one may develop depression, one may develop alcoholism, one may become homeless. One may be absolutely fine. What's the difference there between all of those people? Part of it is biological. Certainly genetic factors are something that we're learning much more about. Part of it also may be just brain and brain development, differences in physical constitution. I'm not saying anyone is weaker or stronger, but different. We're not all wired the same. Or part of it is what meaning do we make of that? So a young Marine, I was asking him, how he was doing with giving his left eye? We never say you "lose an eye" or you "lose a leg" and some may argue well, it's just semantics. But here at the National Library of Medicine I'm hoping that you'll see that semantics is about meaning and can appreciate that. It is about meaning, and he said, "Well, Ma'am, my right eye is getting stronger all the time." That's how he was looking at it. That was his story, is "My right eye is getting stronger all the time." Or another young Marine, again, why he didn't have PTSD? And he said, "Well, I expected to get hurt. "I'm just glad I'm not dead." So he's thinking he came out ahead. That was his story that he was making with that. And that's a very powerful element to be able to co-create your own story. Which all of us have that power. But especially during a time when your world view is shattered in that way. And also how do you do that with everyone in your life who's also adjusting? Because the service member is not just injured, so is the family. And so how does that spouse deal with that sense of distance from their loved one? A lot of times patients with a brain injury or PTSD have that distance. And some of it is that emotional processing and connection that you see in frontal lobe disturbance especially. But some of it is that isolation that you see with PTSD. And actually isolation is one of the biggest risk factors for Post Traumatic Stress Disorder. How does that family member connect when you can't connect in the same familiar way? And so how do you help that whole family heal so that the service member can connect as well? You'll talk to them and they'll say, "Oh I love her as much as I always did." He doesn't think he's acting any differently. But she feels differently. And that's why really listening to everyone's experience in the family is so very important around that so they can heal together. We see that the divorce rate is about a year from a brain injury, at least from this conflict, goes through the roof. Now why is that important? Well, one, certainly it's the breakdown of that primary relationship. And that's difficult as it is. But also, if someone has a brain injury, and now let's say they're divorced, they may not be able to live independently, or as independently in the community. And now they may need another kind of placement. So it really is a loss for them of their independence to some degree because of the loss of that primary relationship. So it is so multi-factorial that as much as we can help shore up and support families, and for children, what is their experience of that? Especially from a developmental perspective. Actually Bob Woodruff is an interesting case because he had kids at all age ranges. I think he is probably one of our oldest, not that he is old, people who have been injured. He had kids that were older than most of our service members have. In terms of how to communicate information to five-year-olds versus 12-year-olds, very different. It is not one size fits all. And we do know there are differences about brain injury in terms of is it better to have a young, more plastic brain that's undercooked? So basically, our frontal lobes, which are basically half your brains, so people think, "Oh, it is just your frontal lobe." Well, that is a lot of real estate. That is half your brain. It isn't really fully developed until 21, 23 years old. So think, most of our service members are around 19, 20 years old. So you have a young, underdeveloped brain. Now one of the beautiful things about a young brain is that it is so sensitive to environmental conditions. Well, what if one of those environmental conditions is war or injury? However, on the flipside, having a younger more plastic brain is able to adapt and to, perhaps, be more plastic and take over other functions that, let's say, in your 30-some year old brain, which we do start to see normal age-related changes in your cognition as early as 30, so if you are thinking that your memory is not as good as it was, it probably isn't. But when you are over 30,  your brain actually has a lot more connections in it. Life experience, education, reading develops more connections in the brain. So if one connection is taken out... So for example, if we are trying to get from here to New York and we are taking I-95. If you are 19, you may just have I-95. Well, if you are 30-some, 40-some, 50-some, you have I-95, 295, the Amtrak. You have multiple ways to get there. So if one area is taken out, you have an alternate pathway. That is one of the interesting things that we saw in Bob Woodruff's case. He has recovered remarkably well, surprisingly well. Now he is obviously older and highly educated. He actually started speaking Chinese first out of his coma, and people thought it was just sort of like gibberish until one of our nurses that was there who actually spoke Chinese said, "He is speaking Chinese!" And so, we talked to his wife and said, "Does he speak Chinese?" And she was like, "Actually, he does." Very interesting, too, that he started speaking Chinese before he started speaking English. Where that happens in the brain is amazing. But the capacity for the brain to overcome, and the human spirit to overcome, is tremendous. And so the treatments that we are developing, especially around cognitive remediation and cognitive rehabilitation, look, really, at compensation of function. So many times, I like to give patients who have memory problems a notebook and a calendar. Well what do you think happens as soon as you give them a notebook and a calendar? They throw it away, they can't find it, they don't know where it is. So someone said, "Well, great. "’We will give them Palm Pilots instead." Oh, great. Now they have lost a more expensive item! And it beeps at them and they don't know what to do with it. So that is really not the only solution. Those are what we call compensatory strategies-- making yourself a note and things like that. But really looking at restoration of function-- what can we do to restore the brain? And so that is really the cognitive remediation where we look at reopening I-95. So in the compensatory approaches, while you are working on reopening I-95, let's say, you are helping them with these compensatory skills and strategies. Well, we are really looking at how do we retrain the brain? Either get alternate parts or the brain to come on board and take those functions, or actually reopen those damaged, those injured parts of the brain so that they function well again. It actually leads to a whole field of even cognitive enhancement in terms of how do we... because some of the literature suggest that even if you don't have cognitive impairments, that if you did cognitive rehabilitation techniques, you can actually enhance the performance you already have of your brain. So really learning about where do we need to focus our treatment efforts so that our patients and their families... And again, this isn't just limited only to people with combat injuries. Traumatic Brain Injury is a tremendous problem in this country. The instance of TBI in this country is larger than diabetes and breast cancer combined, but we don't hear about it. It has actually been, dare I say, one of those lessons learned from this war. It has brought the attention to Traumatic Brain Injury for our country, and hopefully, leading to treatment development and prevention efforts of how to prevent brain injury. And so, really listening to our patients, too, about using technology that can help them. And I know that we will talk about that a little bit today, about some technology that is available for information here through the National Library of Medicine. But, using technology like through the use of computers. Yes?

Audience Member: You made a really good case for observation and the power in developing a hypothesis. But can you give some advice for somebody wanting to go to the next step and begin to amass evidence? And the second part of that is how do you differentiate what you are doing for these soldiers as part of standard clinical care, and what is more on the research side in investigation and experiment?

Dr. Mouratidis: That is a great question. One, I think, of the first steps is observation certainly, but there is quite a bit of data that is around in terms of, especially in the national capitol region. Most of the patients come to Bethesda or Walter Reed from theater and are followed up, not necessarily here as much, although many do choose to come back to the national capitol area for follow up, but really have been working very closely with our VA partners. There are ways to partner with clinicians and scientists that are not just the military health system, but the VA and private academia to come together to answer, bring the science to bear, on some of these questions. And that is important. And that absolutely needs to be done. The part that we have been limited to until most recently has been in, "What do you do when the science isn't there?" And that has been partly listening and observation and looking at trends. Now, with the resources that the Defense Center of Excellence is bringing, the National Intrepid Center of Excellence is bringing, Center for Regenerative Medicine, there are many opportunities to take what we have learned from a clinical perspective and apply the scientific method to. And so, how do we know what to do? We use the science that exists. And as good scientists, we are critical consumers of the literature. So if it applies, if that sample matches who we are serving-- most of these are very clean samples, which, my patients, honestly, don't look like any of those. My patients are usually 19 years old. They usually have a mild brain injury. They usually have some kind of traumatic stress response. Now notice I say traumatic stress. Not everything is PTSD. There is a range of traumatic stress responses that deserve attention. They might have substance abuse problem. They might have chronic pain. And they might have some significant injury, as well. It is very difficult, because the existing literature-- and I was purist by training, too. Those samples don't look like these patients do. So how do we take what the literature shows, and is relevant to our patients, to do that? And then when to know what modifications to make. So, for example, a patient with a brain injury, if I am doing CBT psychotherapy with them, they may not be able to have a one hour psychotherapy session once a week. Maybe they need three 20 minute sessions throughout the week. Is it still CBT? Yes. But have I modified that in a responsible way for someone who has cognitive impairments so that they can engage in that? And perhaps they may need to do the same homework assignments several times than just one time. So it is... we are in that very exciting, but it feels a little treacherous, period because we feel grounded in the literature when it is there. Yes?

Audience Member: You mentioned the effect of education, and I wondered whether you based different therapies on levels of education or social class.

Dr. Mouratidis: I would say one of the important variables, more so than social class, in my opinion, is cultural, making sure that we're being culturally relevant and recognizing that different cultures have different ways of expressing symptoms. Different cultures engage in different kinds of treatment differently and have a different kind of perception and relationship with the therapist, and what have you. So, definitely being culturally sensitive, and that's true, I would say, across-the-board of whatever kind of treatment we're doing, medical, psychological or what have you, to be aware of that. The educational piece isn't as much of a factor in choosing the treatment, but depending on where your client is, your patient is, needing to tailor it specifically to their needs, their abilities, so that it is relevant and accessible to them, ultimately is what seems to be most useful.

Audience Member: I have a question about communication. I write for MedlinePlus magazine and we're doing a series on PTSD. I did interview Lee Woodruff for our first piece, and she's an extraordinary person in an extraordinary family with an extraordinary set of resources. Most of us don't have what they had. He was treated 48 minutes. He was on the table after he got blown up and flown back here, and ABC took out everything. The wider point that I keep hearing here is how do we translate these specifics, which you say are sui generis? They're one by one-- everybody's different. But from a communication point in this violence-based society, which is what we are, and its domestic as well as military, this is just a variation on the theme which this country needs to deal with. How do we handle it in communication in the wider sense? How do we get across what you're learning? What in your experience would help to send the message that we shouldn't study war anymore-- pardon me, I'm a '60s liberal-- but that's the issue. Because in an era of finite resources, we really need to get this thing thought about in the widest sense. How can we bring this to bear? What works for you in talking to groups? What do you leave? What's the message about communication in this technological society? I see the strength of the Internet. I'm a dinosaur-- I started my career writing on a Royal typewriter, on a Royal Standard. So here it is. We're Internet-- we're all connected. Maybe it's too big a question, but it's certainly relevant for what we do in producing a magazine that talks to people in waiting rooms and tries to give them advice about how they can handle it. In the current issue just coming out this month, we'll say evidence-based therapy, cognitive therapy sessions one-on-one, is best with drugs, and that's about all we know in new developing therapies. But what do we say?

Dr. Mouratidis: That's a very complicated, certainly, question and problem.

Audience Member: It is. I'm sorry.

Dr. Mouratidis: One of the messages that can certainly come out is-- one, there's hope, that it is not a sentence. It doesn't necessarily mean just because someone has had a TBI or PTSD, that they will never recover function, enjoy their life or have the things that are important to them. So, I think that's one of the messages that is accessible to everyone, that there's hope. Part of it is also prevention. We obviously want to prevent head injuries, prevent PTSD. And so, what efforts towards prevention can there be to being more peaceful? Very much so. Also, and Dr. Bazarian talks about this-- he's an ER doc out at Rochester-- concussion is not necessarily innocuous. And that's one of the things that can be communicated, is that if there is any concern that someone's had a concussion, they should have a medical evaluation. Sometimes, we hear, "Oh, they just saw stars. "They were just dazed and confused." One of the things that we've learned about concussion through this conflict is that you don't need to be unconscious to have a concussion. You can have that feeling of seeing stars, feeling dazed and confused. If that happens on the sports field or anywhere, and we're talking if it's midget soccer, whatever it is that kids are playing, that needs to be taken seriously. Now, in general, the literature shows that most people recover from concussion, but we don't know that about blast injury, per se, in the same way. We don't have those data, per se. But that's making sure people are evaluated. Also, I have to say the Woodruffs, at least at Bethesda and on the field, they got the same treatment anybody else got, absolutely.

Audience Member: And they did call it the best in the world, and they are most complimentary, but they say it is a family disaster.

Dr. Mouratidis: It is.

Audience Member: This is the aftermath, and Lee is very, very eloquent and passionate about the need to speak and involve families and communities. The recent interview that I did with her is very... I commend it to everybody here, if you haven't read it in the magazine, or read her books. But, again, we're talking about issues that are very relevant. The NFL just had its sixth identified person die. OK?

Dr. Mouratidis: That's true.

Audience Member: So, there's the societal message again. So, it's prevention, it's hope. Are you saying then that perhaps we should talk about that in an organized sense? Perhaps we cite the NFL as an area to look closer at? I don't want to get off the subject.

Dr. Mouratidis: I certainly think again that dialogue and programs like this help us to think about this as a community and to dialogue about it, and I'm hoping that we all, when we go back to our respective work areas and homes and communities, that we are continuing this dialogue in that same way. It really is a larger problem of how can we bring to bear what we're learning in military medicine to help civilian medicine. And we're doing that in many different ways. We've had many workshops, many meetings, many conferences about taking our lessons learned, opportunities such as this for someone like me to come and share some of the things that we've learned, to develop research projects in a collaborative fashion between public and private-- military, civilian, VA together-- to help bring the best to bear of what we know, to not only help our service members and their families, but anyone suffering from a traumatic injury-- again, brain, psychological, physical or spiritual, or otherwise. Other questions?

Audience Member: You touched briefly in one of the anecdotes, as well as later, about the possible complication of alcohol abuse. I work at the Alcohol Institute, and we're very interested in possible combined etiology, learning and memory problems, and so forth, with alcohol use/abuse interacting with some sort of long term consequences of a Traumatic Brain Injury. Also, there's the treatment aspect of how it could complicate your efforts, cognitive behavioral therapy, and so forth, to try to bring them through that process. Can you elaborate a little bit more?

Dr. Mouratidis: That's especially relevant, in that part of one of the goals when someone's had a head injury is to prevent a secondary head injury. The statistics of when you've had one head injury, the chance of you having another one is very high. So, if you have a head injury, and let's say your judgment and your impulsivity is perhaps compromised-- let's say you may drink more than you probably need to be drinking and let's say then you end up falling down the stairs or getting into a fight. Now you have another head injury on top of the head injury that you had from however you acquired it. So, really, the interface between substance use and head injury and PTSD... For example, many people, not just service members, choose to treat their PTSD with alcohol, as opposed to other kinds of treatment in general, which only then certainly serves as a depressant. And if you already have problems with response inhibition or impulsivity, and you're adding alcohol, especially if you're on medications for other things, it really does complicate the whole clinical picture.  And certainly whatever we can do to help understand those relationships and intervene has tremendous value, absolutely. Yeah.

Audience Member:  And you mentioned again, the Marines. The Marine Corps does have an incredible leadership and set of resources amongst themselves. But I was thinking also about the Reservists and the people who are in the National Guard. Those units do not have the same resources, structurally, as the Marines. So I think that there is something to take away, also, in thinking about how each one of the forces really is different in resources and in structure. And this affects what they are able to do or not able to do, or structured to do for their injured people and the families. Could you talk a little about the Reservists, too?

Dr. Mouratidis: Certainly the Reserve component members, which are such a valued part of our military, it is very much like culture. There is Army culture, Navy culture, Air Force culture, and there is Reserve component cultures, too, National Guard cultures, and they are structured differently. And it is not necessarily that any one is better or worse than another, it is just different, just like we are talking about being culturally sensitive. In the same kind of way, depending on what branch of the service they are in, there are culture specific attitudes, approaches, resources. And really, the goal is to, one, have awareness that you probably do have Reserve component members, National Guard members, that are living in your communities, and they do need the support of the community around that they live in, more so, perhaps, than someone who is part of the unit, or the spouse of a deployed Reserve component member who is more isolated because they are not around other military wives may need more support from the people in her community or his community. And so that is something for all of us to be aware of. Yes, Ma'am?

Audience Member: Any guidelines developing on how to support families... For example, what is effective in helping to prevent divorce?

Dr. Mouratidis: We are working on resources. We are working in collaboration with the Army, developing a TBI education series for patients, providers, and family members. We are also working to develop educational materials. The Defense Center of Excellence worked closely with Sesame Street to develop a whole series for kids on deployed parents, and they are also working on one for injured parents. And so as we are learning more because we have been on this huge learning curve. It's been hard to develop any guidelines until we truly knew what we were dealing with, because we didn't necessarily, again, know what to expect. So now that we are gaining this amount of knowledge and experience, and we see from year out that this is a vulnerable time, then now we can start to develop more resources and supports. But it's ongoing. And in all these things there is plenty of room for "all hands on deck." So no matter what your area of interest is, your area of expertise, where you work, where you live, there is a way that you can contribute.

Audience Member: I am interested in the acute treatment of Traumatic Brain Injury. You mentioned at the very beginning that these MedEvac helicopters, that they are flying ICUs. And I wonder if you could just elaborate a little bit about some of the new and improved things that we are learning from very acute early on treatment of these head injury folks. And then, to follow up on that, if you are seeing an impact with the kind of treatment they have received early on and how that affects their chronic course of recovery, and if it has an impact on these other things that they are dealing with.

Dr. Mouratidis: Those are really important questions, and certainly all of this is subject to scientific investigation and review, so I qualify that with everything. One of the major differences that we have uncovered or we have been practicing in this ward is really the Craniectomy procedure. And Dr. Rocco Armanda, who is an Army Colonel who works at Bethesda and at Walter Reed, has really done more of these, probably, than most anyone. And what we have learned is if you can take a portion of the skull off, really, and allow the brain to swell, because a lot of what we see in brain injuries is edema, a lot of swelling, such that it doesn't bump against the bones of your skull, causing a secondary injury, and be able to equalize those inter-cranial pressures in a way, that can help what we call secondary injury. So one of the primary interventions for brain injury is to prevent secondary injury like seizure, stroke, and what have you. So really, the Craniectomy procedure... We find around three months they get Cranioplasty, which we have gotten fabulous at. I mean their heads look amazing. And we have really improved over the years where we can actually do even some computer modeling. And really, to talk about multidisciplinary care, working with the dentists, the maxiofacial specialists, because that really involves the whole skull. That has been one of the major areas. The other area is really early identification of brain injury. So at Bethesda, we went to a screening process where everyone who was in or around or near a blast has an evaluation for brain injury and traumatic stress. So part of that is recognizing... If we can identify who is at risk, then we can observe them. We can intervene early and can minimize also, again, secondary effects of, let's say, depression, which is highly co-morbid with Traumatic Brain Injury, and then also mitigate potential suicide from depression or from brain injury. Suicide and brain injury is a very difficult problem. If you think about, again, depending on what parts of your brain are impaired by the injury, if you are more impulsive, you can't make decisions as well, you can't handle frustration and stress in the same way you used to, those are a lot of vulnerabilities. If you are drinking more, it adds all of those risk factors. And also, suicidal ideation or depression may not behave or look like depression in someone who doesn't have a brain injury. So you may say, "Well they deny having going through," if you are being a good psychologist or psychiatrist going through your little checklist, "Do you have a plan?" They say no. Well in general, that is kind of helpful, if you are non-brain injured, to be reassuring. Brain injured people don't need a plan, don't want a plan. They act in the moment. And so, really understanding how we are assessing for depression, suicidal ideation, all these things, that is all part of early intervention, as well. And how that impacts later functioning, our patients... You know, again, these are really good, certainly, research questions about what are the parameters about... Someone actually just wrote a paper recently. What is the outcome of treatment of depression? Is it just less depressed systems? Well, it is really asking the patient what's important to them, and that's the outcome. So it is really challenging what we are measuring, how we are measuring it, so that we are actually getting good data out on the backend.

Dr. Lindberg: It was a wonderful talk. I wonder if we could ask one more thing of you.

Dr. Mouratidis: Sure. 

Dr. Lindberg: To look at what NLM has produced in the way of MedlinePlus because that is aimed at providing information to patients' families and the public. And then if you and the audience would give us your reaction to it. Are we headed in the right direction or being helpful?

Dr. Mouratidis: Can I just close with one last thing?

Dr. Lindberg: Well, you are not closing. We are coming back to you. We have to get your opinion on what we've done. But it is really aimed at the idea I found in the meeting we both attended, that if ypu wait for a psychiatrist to diagnose PTSD following TBI, you are about 18 months too late to do any good. So what we are doing is trying to put information in the hands of the patients and the families and the community. Joyce has got, what, five minutes maybe? Tell us if we are headed in the right direction. And members of the audience, please do that as well.

Joyce Backus: OK. Well as Dr. Lindberg said, for about the last 10 years or so, the National Library of Medicine has been very involved in selecting and curating health information for the public through a website we call MedlinePlus. So after the wonderful presentation about the psychosocial factors, you may be wondering, "Gee, what kind of information "could I bring back to family members? "I think I may have somebody who needs some information. "Or where can I learn more about health information?" And I am sure it will be coming up on the screen any moment. [ laughs ] Well, the National Library of Medicine has an answer for that and that is MedlinePlus. I'll show you how we link, not just to authoritative health information from organizations here at NIH, the defense establishment, the CDC, and other consumer-oriented organizations who are providing health information. But also how we tie it all together to our own clinicaltrials.gov, which we manage for us and for other organizations. Also how we link to PubMed, because you may be wondering, "Gee, what clinical trials are out there for this information? "Or what's available through PubMed?" So this is MedlinePlus. Presumably many of you have seen it. It has focus on all kinds of diseases and conditions, including PTSD and TBI. Health topics is the core of this organization. I'll show you this, in a moment. But we also have drug and supplement information. Our medical encyclopedia has wonderful illustrations of the brain and other parts of the anatomy and procedures. We have current news. And also I'll look a little bit into our Go Local information. So, all of you use the Web and know one of the first things you like to do is to search, so we have our search box here on MedlinePlus. The first thing you get is the beginning of a brief summary on PTSD. We learn, from working with patients and families, that often times they're looking for just a brief, simple definition. They don't know a lot about this. Maybe they don't even know it stood for Post Traumatic Stress Disorder. They just heard the initials. So we start people here with a brief summary and you can see we've taken this from the National Institute of Mental Health here at NIH. Then the next thing we do is to select just a few key information resources, because if you're new to this topic, you're not really looking probably first for a PubMed article with a detailed research study. The first thing we have here is an easy to read article from the NIMH. We also have a series of interactive tutorials. These tutorials have very basic information that walks you through the various aspects of a condition. For example, the one on PTSD talks about what it is, the symptoms, the diagnosis, the treatment. And it reads aloud to you, so if there are unfamiliar medical terms or maybe your reading level is not as strong, you get to hear the information, as well as see it.

Computer: If you have PTSD, you may startle easily, feel emotionally numb, especially towards people you used to be close to, act irritable, lose interest in the things you used to enjoy, or become aggressive or even violent.

Joyce: So these are tutorials that patients and family members can page through at their own pace.

Computer: Press the right arrow to continue.

Joyce: Thank you. [ laughter ] You can do it on your own. There's no pressure between you and another individual or families can sit down together and page through and gain an understanding at their own pace of what this condition is. The other source we're recommending people start with on this topic is from the National Center for PTSD, which is from the Department of Veteran's Administration, Veteran's Affairs. You can see that we link out to a variety of information resources, maybe you're an interactive tutorial person, maybe you want a document to print, but we link to a variety of sources. So whatever works for you. If you're wondering what clinical trials might be available. You're interested in maybe what research is going on or your provider thinks you might be a candidate for a clinical trial. They're listed right here. The first one that's listed today, 157 studies on PTSD that are recruiting or are about to recruit. We'll just click on the first one which happens to be at Louisiana State University on hyperbaric oxygen therapy. This information won't be for all patients, but it does let people know what clinical trials are taking place and, for health care providers, what options there might be for their patients. Again, down to journal articles. We list three recent titles from PubMed, but you can click on "See More Articles" and if you're the kind of reader, or if you're a professional yourself, that is at the level that you want to know what's going on in the research literature, it's right there on the MedlinePlus page. So you can quickly go and find out what's been published very recently in PubMed. Another important aspect of the pages are our Go Local service. Go Local brings information about what services are available and in the case of PTSD, it would be things like counseling, things like therapy. So, if you're not fortunate enough to be in the system that we've been hearing about this morning, there are other options. For example, in the District of Columbia-- and we have to select our areas to say we're interested in services in the Southeast-- these are the kind of services that are available. And if we look at the resources serving the Southeast, for example, here's an organization called Give An Hour and it's linked right here. This DC Go Local is maintained and created by medical librarians at Georgetown University and the George Washington University Medical Center libraries. For example, Give An Hour is an organization that brings counseling to military personnel and families. Depending on what services might be available, this is a place they can go. So Go Local links to these services, the librarians are maintaining, writing the descriptions, and providing a new way for people to be linked up. We have a special page just for Veterans and military health and, on this page, we're sure to link people back to the Veteran's Administration through My Healthy Vet and the TRICARE System for Active Duty and Retired Service Personnel. Hold on a second, General Powell. OK. [ laughter ] So we also have your picture of the brain on our Traumatic Brain Injury page. Another kind of learning, and another type of resource we link to, are videos. So, for example, on the Traumatic Brain Injury page, we link to this video which comes from a not-for-profit organization, the Defense and Veterans Brain Injury Center. It's a 30-minute video, but we're just going to listen to a few minutes, so you can hear a little bit of General Powell's introduction. And then see another kind of learning, if people are interested in a video for the family or individually and maybe they're not as attuned to reading a document.

General Powell: With proper treatment and rehabilitation, those with brain injuries can enjoy rich, full, and productive lives. And many are. That's why I encourage you to watch this documentary. Together we can increase awareness. We can foster understanding and we can help welcome those who have survived a brain injury back into our families, our workplaces, and our communities. On behalf of the Defense and Veterans Brain Injury Center and the Survive, Thrive, and Alive Campaign, I thank you for your interest.

Joyce: So, now, after the requisite disclaimer, you'll see the introduction to this 30-minute program. [ music ]

Man 1: I don't remember the car accident at all.

Man 2: Car bomb blew up, just hit me in the face.

Man 3: I just heard him screaming, "I'm hit, I'm hit."

Woman 1: Each one of us is susceptible to a Traumatic Brain Injury.

Woman 2: A healthy brain weighs about three pounds and it has a 100 billion neurons.

Man 4: By the year 2020, brain injury will become the number one public health problem in the world.

Man 5: It's referred to as the silent epidemic.

Man 6: I'm lucky to be where I am at all. The fact remains, I'm not how I used to be.

Man 7: People can look at you from the outside and say...

Joyce: So that gives you an idea of another kind of resource that MedlinePlus can link you to on these topics of PTSD and TBI. So that was a very quick tour. Give you an idea of the samples of what we do.

Dr. Lindberg: Great, Joyce, thank you very much. Maria, why don't you comment on that and take any comments from the audience.

Dr. Mouratidis: OK.

Dr. Lindberg: That would be helpful to us.

Dr. Mouratidis: Thank you. What's useful about the way this is set up, in particular, is that it's multimedia. In terms of, we all learn differently anyway, but given our sensory deficits, given our cognitive difficulties, anything that might be particular to someone who's injured, or not, this allows information to be delivered in a variety of ways that makes it accessible. Also, sometimes you need to hear things in some different kinds of ways. It also shows that there is nothing sort of wrong with you because you have these difficulties, these problems. This really helps to bring awareness to, really, invisible injuries. PTSD and brain injury are often invisible. And because of that, even service members will talk about, "Well I have both my legs-- I shouldn't be complaining." Their wounds-- and I forget what we did this piece for-- but there were two patients sharing a room. One had severe physical injuries and the other didn't have a scratch on him but had a moderate brain injury. And the question was, really, which one of these two patients is more severely injured? Who is going to have a better outcome? And in this case, the patient who had the brain injury was more severely injured. Putting up information like this that makes it accessible helps to communicate that these are valid problems and that there is hope. And so, it also integrates. It becomes a place where, if you are clinician, or a family member, or a patient, or a neighbor, you can also come to the same site. And it does become a place of community based on what you need. And actually, sometimes even as a provider or a scientist, I want to keep track of what patients are seeing and hearing. And sometimes, it helps me look at things differently, too. So I think from that point of view, it seems user friendly, which again, not everyone is comfortable with the web, but certainly, being able to click. And also, one of the useful things, I think, it brings you to the websites of other, really, reputable and leading institutions like the National Center for PTS.

Computer: Press the right arrow to continue.

Dr. Mouratidis: Sure. I guess that is my cue! [ laughter ]

Dr. Mouratidis: So, thoughts from the group?

Audience Member: When I was looking at it, it reminded me of Jonathan Shay's most recent book where he uses the travels of Ulysses coming back from combat and talks about returning veterans. And he talks about the power of the label "Post Traumatic Stress Disorder" and how "disorder" increases the stigma. And he says... You know, actually, he works with a lot of people at the VA in Boston to say what you are responding to, your responses are natural to a traumatic event, so it is not a disorder. It wasn't a disorder when it occurred then, but let's talk about-- it is an injury. It is a post traumatic stress injury, and how do we heal from that injury? So that is the power of language and how it creates impressions with people. And I think we need to also pay attention to that.

Dr. Mouratidis: Absolutely. More thoughts? Yes?

Audience Member: I think it is beautiful, but there may be another way to go about this. The CDC works really hard to come up with ways to predict outbreak and epidemic, and then Google comes along and predicts flu outbreaks two weeks in advance by just looking at who searches for runny nose, stuffy head... So I am wondering if there is a way we could take a cue from that and learn something about the systems of PTSD or TBI.

Dr. Mouratidis: That is a great idea.

Audience Member: One way to attack the stigma that everybody has might be post traumatic growth. I mean, because your priorities totally shift and you realize what is valuable in your life and what isn't.

Dr. Mouratidis: That attitude, really, of turning it upside down that we are looking at post traumatic growth...

Audience Member: A military person isn't interested in feeling sorry for themself.

Dr. Mouratidis: Especially of helping us understand resilience. Absolutely. In terms of, how do we bounce back from when something difficult happens in our lives? How do we actually grow past that and transcend that and really become really developed in a way we might not otherwise have? So absolutely. And that is why I think the language is important in really looking at resilience, which is a whole area of research that is growing tremendously now, too, certainly. But protective factors, resilience factors-- and there are literature really looking at that in terms of after 9/11, what kinds of things helped New Yorkers? And part of that was their attitude, their resilience, how they came together as a city and transcended that. So thank you.

Dr. Lindberg: Maria, thank you very much for a wonderful talk. You are all invited to coffee. I am pretty sure we will not have spanakopita.

Dr. Mouratidis: That's okay, it's early.

Dr. Lindberg: Thank you. [ applause ]

Dr. Mouratidis: I would like to close with a poem from one of my Marines. And they are my Marines. I can't apologize for that. And this is his story in his words-- "There are times in our life when we are struck by tragedy, "And you know you would not make it through it without your family. "Something very similar just happened to me. "Fighting in Iraq is what starts my story, "walking through the streets trying to keep people safe. "Then a pain. "Then a bang. "Then I landed on my face. "More shots rang out. "People ran and Marines began to fight. "Still in a little daze, and pain causing a haze, "I have lost all my might. "He found a spot, and while under heavy fire, "he ran back out into. "Then my mind cleared as I saw him there. "I knew he came for me. "His life for mine he was willing to trade without skipping a beat. "I couldn't let that happen, so I climbed onto my feet. "He half carried me back to the place he had found the spot. "He gently helped me down and screamed, 'Corpsmen up!' "I couldn't help but think my life I would have to pay. "Then, as if sent by God, Marines were there to save the day. "The MedEvac called and people going every which way. "I heard it over and over from my buddies, "'You do not get to die today.' "Then up the streets the Humvee roared "as they pulled up to my shop. "More Marines jumped out and began to shout, "'We are here to pick him up!'  "Upon arriving, he came to me and held my hand and said, "'Don't worry, man. "Soon you will be home free.' "My gunner from Afghanistan, a best friend he was to me. "He gave me strength while we waited there. "He helped me to the bird and covered my eyes for me. "I'd never get to repay him, "because two days later he died by an IED. "Lying in a hospital with things hooked up and beeping, "Drifting in and out of consciousness, "but not really sleeping. "Pretty soon, I was able to start accepting a phone call. "The people on the other end are the ones who are worth it all. "The ones I would take 10 bullets for "and never flinch or fall. "My family and my friends, you know I love you all. "They flew me to Bethesda where my family I'd get to see. "I'd get to hug and kiss my mom, my dad, of course, Rusty. "But upon their arrival, they got no proper greeting, "Just me being a jerk with no proper reason. "How painful it must have been to see me lying there, "And added pain of me lashing out like I didn't care. "With me every painful step on the path of recovery, "Though I am weak and they are strong "and bear my burdens for me. "I want my message loud and clear "in what I am trying to say. "If it weren't for my loved ones, I would not be here today." Thank you. [ applause ]