you can watch the rest on the website c-span.org. we leave it to take you bye to capitol hill for a hearing on traumatic brain injuries in the u.s. military. you're watching live coverage of the senate armed services company hearing on c-span3 .

. okay. i just got started here. service members put their lives and their health on the line when they put on their uniforms. in return we have a profound responsibility to make sure that the nation is doing all that it can to keep them safe, to prevent battlefield and training casualties and to provide the best possible care. we are holding this hearing.

are we there? good. we are holding this hearing because dod is not meeting the responsibilities when it comes to traumatic brain injuries and other injuries that result from firing weapon. injuries from blast over pressure, the pressure that is caused by a shock wave that exceeds normal atmospheric values have been the signature with wounds of the war with iraq and afghanistan. but, there are also injuries incurred in training here at home. they are invisible but effect thousands of service members, 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 service

members nearly 50,000 times. the more we learn, the more we come to understand that blast exposure is an ongoing threat to individual service members, the moral and readiness of our entire force. i appreciate the support that i have had on this issue from ranking member scott, from senator ernst and other members of this committee. i secured a long-term study of blast overpressure injuries in 2018, national defense authorization act and i worked with senator ernst to introduce blast overpressure and secure additional requirements to track blast overpressure injuries in the fy, twoant20, nda. dod is working to implement this legislation but we have still have significant problems. last year, the "new york times"

reported on heightened brain injury risk for u.s. troops fighting isis. four artillery batteries assigned to the region assigned more weapon 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 at least one member that committed suicide. these deaths are a tragedy. ryan, a navy seal deployed to iraq and afghanistan, subjected to blasts from his own weapon over the course of his career. and later died by suicide. his father, mr. frank warkan is here today to discuss the harm that blast overpressure caused to the soldiers and their families. even when dod made policy

changes, the changes were not evident on the ground. weapon known to deliver shock waves, well above safety thresholds were still widely used. training did not involve basic safety measures and special operation forces were not issued blast exposure gages, the gages that are needed to track the threat they faced. so, dod, and congress, both have a lot to do. here is my agenda to address this problem. first, we need to establish mitigation strategies specific to the service 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 service members and integrate these logs into their va and dod health care records. third, the department of defense should partner with

innovative evidence-based programs like home base, to help service members get the care they need. and i am going to have to brag here for just a minute. homebase is a nonprofit organization founded by massachusetts general hospital and the boston red sox to take care of the invisible wounds of veterans, service members, military families and families of the fallen. homebase has clinics in massachusetts and in florida, ranking member scott states. homebase has a brain health and trauma program specifically designed for special operations, veterans and service members where it has been leading innovative treatments for veterans with co- occurring substance abuse and mental health conditions. as we work through this year's ndaa i want to support this program's work. and i appreciate the doctors from homebase joining us today.

one more item. we need to make sure that dod sets a threshold on the maximum number of rounds that service members can safely fire and this includes consideration of exposure over an extended period of time. dod must do its part and congress must do our part. so, to our witnesses, welcome, and thank you for appearing. we are going to have two panels today. the first panel will consist af outside witnesses to provide their perspective on where dod and the services are falling short, on protecting service members from blast overpressure. professor of policy analysis at the party rand graduate school. chief of traumatic brain injury and health and wellness programs at homebase, and frank

larkin, chief operating officer, troops first foundation and lead of the national warrior call day initiative. the second panel will consist of officials from department of defense and walter reed is tackling this issue. we will have secretary of defense of health affairs. kathy lee, director of war fighter brain policy at dod, and captain carlos williams, director of the national intrepid center at walt walter reed. >> i want to thank senator warren, chairwoman of the committee and subcommittee. and thank her for caring about this issue and for taking this job so seriously. chairwoman, warren, thank you for holding this hearing.

it is one of the most common injuries sustained by service members. in 2022, 20,000 military personnel were diagnosed. 20,000 members of our military diagnosed with a traumatic brain injury. over 84% classified as mild that is known as a concussion. if any of us, when you raise kids and they have a concussion, it scares the living daylights out of you. missing from this day, service members exposed to low-level blasts that do not diagnose as a concussion, repeat exposure to low-level blasts can cause similar services of severe cases of tbi. we know low-level from firing

explosives can cause concentration, memory, headaches, and decreased hand- eye coordination, each issue can be serious and disrupt a person's life. there remains a great deal of exposure to the blasts that we do not know. health care providers can treat those exposed to blasts where necessary. we have actually taken action to do that in the 2018 national defense authorization act. congress required, required the department of defense to conduct a medical study on blast overpressure exposure. the final report on the study, this hearing presents an opportunity to look at the work. legislation required the study that follows individuals over an extended period of time to include three specific elements. first, the department was to monitor and record and blast pressure exposure.

the second in the study was to assess it including blast exposure, history and to a service member's medical record. the last was to review the safety precautions of heavy weapon training in research to blast exposure. in reviewing the final report submitted this past december it is clear they have more work to do. monitoring and record blast exposures for military personnel. only a few 100 soldiers and marines were fitted with devices. while the department report does say it may be feasible to record blast information in a service member's medical record. now i would like to learn more how the department plans to conduct the business case analysis. it is an important issue that i believe the department is committed to getting it right and tbi center of excellence

and brain health initiatives are excellent initiatives that i hope will provide the military with the information better to understand the effect of repetitive blast exposure. the exposure to low-level blasts will be a risk for many of our combat troops, but, if we can do better, if we can better quantify the type and number of blasts that have the potential to cause significant perhaps permanent injuries, then, we can use that information to make better decisions how best to accomplish a particular mission. i would like to hear from the witness what congress do to ensure the department of defense has the resources it needs to conduct the plan and where we can had help. it is about the well being of the individuals willing to put on the uniform that are closest to the frontline of combat and every service member diagnosed with tbi. we owe it to them to ensure and their families to ensure when they go in harm's way they are well trained, have the right

protective equipment and utilizing the manner chief objective with an understanding of the risk involved. i want to thank you for all of the witnesses for being here today and look forward to your testimony and again i want to thank 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 dr. samantha mcber flrks ie. i am mcbernie. my research at rand and the university of california berkeley and the university of southern california has focused on traumatic brain injury. impact and blast overpressure. today, i would like to speak to you about repeated exposure to low-level military blasts that

are low-level blast exposures experienced while fulfilling military occupational duties. evidence suggests they are exposed to the blasts in blast overpressure or the pressure wave that emanates from the source of the explosion. it can cause subconcussive injuries that are not detectable and would not qualify as a tbi. exposure to blast overpressure can occur in combat and training as has already been mentioned. during training t can be breaching exercises and the firing of increasingly powerful weapon systems, such as the coilless rifle and the at-4. to provide perspective on the level of exposure some service members have, one study found up to 32% of blasts experienced by breaching instructors exceeded the recommended exposure limit. studies shown that the effect of repeated low-level blast exposure can cause symptoms similar to tbi. while a variety of effects have

been linked to low-level blast exposure as senator warren and scott have mentioned, there remains a lack of evidence linking repeated exposure to injury. one reason for this is the difficult of diagnose. the very nature of low-level blast exposure and the fact that it is not one single event that causes an issue but rather a cumulative effect of repeated effects over time. symptoms typically do not manifest immediately that makes it unlikely that repeated exposure is identified as the cause. injuries vastly under reported among service members, exceeding the issue of proper diagnose further. there is also a lack of research about the military occupational specialty at greatest risk to low-level blasts. there is no doubt certain occupational specialties are

more exposed there is little data to support it. little understanding of direct impact of low-level blast has on the health of service members in different occupational specialties f it is perfectly effective but can not be delivered in time it is not useful. this quote from a 2019rand report perfectly describes the current state and the reason many of us are here today. as a research community we clearly see the additional research needs to be done. however, there are steps that the dod can take now to better protect service members against blast-induced injury. i highlight four in my written testimony and i would like to bring your attention to one of them. the maintenance of blast records t should include number of exposures, the context of each exposure and any physical or mental or emotional effects. this would allow the dod to better track the frequency and

high risk occupational specialties, and determine the connection between exposure and health outcomes and develop strategies to mitigate exposure and training environments ultimately these records can be used to develop an index score to gauge the health risk. as our weapon systems continue to be advanced and increasingly powerful, low-level military occupational blasts will remain an enduring challenge for service members. addressing the repeated exposure to the blast has action and collaboration between the dod and the research community. by implementing 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 your questions.

i am here to talk about traumatic brain injury care and exposure. my career has been centered around the lives of people with traumatic brain injury. the department of harvard medical school general hospital and brigham and women's hospital and to the staff, 15 years i served as the homebase program directing the brain injury program. i actually see the patients as well as do the research. blast overpressure as we just heard is a sudden onset of a pressure wave from explosions for training and deployment and

breaching buildings and from impro vised explosives. tbi can have a wide range of effects, sometimes appear immediately they may take weeks to occur. 40% of brain injuries later screened positive for psychological health conditions. our research noted elevated 10- year rift of hypertension, cardiac disease, hor 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 poly-trauma 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 from north carolina. the combat program is highly efficient and compressed into five-day model of care. patients see a minimum of 9

providers. this may expand grossly related to diagnosic and images and other studies. in summary we are grateful for the support of congress, especially chairwoman warren has shared this program. and partnership and support provided. the program is successful and the demand for care is growing at a steady pace. based on my experience in the field and treating patients at homebase, i would recommend the department of defense consider the following options. invest in a developed tool to measure the funding [low microphone ]

. >> thank you for the opportunity for allowing me to testify. i am happy to answer questions [low audio ] . as a former navy seal we

are starting the day . >> subtuggeds by traumatic brain injuries. the decision for injury for the past 20 years fighting the war on terror

following the combat for iraq and afghanistan, that manifest in difficulty sleeping, nightmares, anxiety, hypervisual. he stopped smiling. he sought help but it was 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 after he was honorably

discharged from 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 later we learned he had undiagnosed brain injury related to repeated blast exposure. he was hurt, not crazy. he was right all along. our medical enterprises could not and still can not see it in living war fighter roar veteran. they are hurt, they are not broken. they break when they are cut away from their teammates, they try, they are betrayed by the

units they given it all. they spent $3 billion on mental health substance abuse, suicide prevention, ptsd and other war fighter assistance programs, i give them a d plus, c minus, at best, for the lack of measurable impact for those that need answers. those with the deck plate dirt level, war fighters we promised to take care of and not leave behind. blast exposure is the key threat to warrior brain health and represents significant national security threat to our force readiness and resiliency. however, whatever solutions we come up with, it can not impact our operational effectiveness or legality on the battlefield. we need to do it smarter and take down the risk on the front end. thank you for the opportunity to be the voice for people like ryan. >> thank you, i appreciate sharing your story, i am sorry

for your loss and sorry for the treatment that your son ryan received. i think you said it right, they are considered the signature wound of our wars in iraq and afghanistan. while improvised explosives may of caused some of the injuries a medical research study found for troops with mild traumatic brain injury, quote, the most important cause of brain injury was the long-term exposure to explosive weapon. in 2011, the defense advanced research projects agency determined that 75% of the troops blast exposure in afghanistan was coming from their own weapon. the effects of blast overpressure are terrible including memory loss, increased risk of dementia and substance abuse problems, but, despite the severity of the

impacts on service member's health, when these problems are diagnosed, blast exposure is rarely identified as potential cause. dr. mcbernie, you studied this issue for 15 years now, why is it so difficult to detect when blast overpressure is causing the types of symptons we are talking about here in our service members? >> that is a great question, senator warren, a question that so many people within the research community are committed to answering. it really comes back to the nature of the injury itself. we are not looking at an injury that is caused by one isolated event. the fact that it is caused by repeated exposure to very low- level blasts that perhaps might happen in the course of an entire military career really complicates injury recognition. add to that the fact that

symptoms typically do manifest immediately and it becomes difficult to link symptoms to repeated exposure. it is an important point. and, so, i just want to pick up and see where we can take it forward. we need to know how often i take it from your testimony, we need to know how often a service member has been exposed to blast overpressure to give medical personnel the information that they need to identify and treat the under lying cause of their symptoms. now, so far the dod only has blast exposure data for a total of 500 service members. we are missing data, obviously,

for a whole lot more. thwacking it through brain injury logs for all service members would be a good start but we -- need to pay attention to those that are in blast exposure. training instructors they are more likely to be exposed to blasts during training or operations. the marine corp found that the artillery community is also at particularly high risk. and, that high rates of exposure could lead them, quote, to suffering injuries faster than combat replacements can be trained to replace them. so, doctor, i wanted to give you another chance, does dod currently have the strategies it needs to mitigate the risks

from blast overpressure that are specific to each of the military occupational specialties that are most likely to be exposed? >> i can't say i am aware of any of those strategies. and in addition to that a lot of the folks whom i interact on a very regular basis with boots on the ground in the communities at risk of exposure are unaware of said strategies. >> okay. so, anything more you want to say about what dod should be doing in its space? i want to make sure i am giving you a chance here. >> no, thank you, senator, mr. larkin and i were discussing it. if i can choose a key takeaway it would be not letting perfection interfere with progress. everyone here is looking for the right solution and what we really want to be sure of is that we don't wait too long to implement what we think is a perfect solution. there is a lot of research that

still needs to be doing, i am always a supporter of more research but we can be looking to implement solutions, study solutions while implemented. >> so, so let's focus that for just a second. just a little bit more. about the idea of collecting the data as we go along so at least it is a first step in getting the information that we need. i understand the gap that the dod needs to fill. and i understand it is more challenging to limit service member blast exposure during combat but no excuse to expose them 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 to service member's 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 dod can take to get more data and to understand it over time but more importantly, a number of steps they can take right now in terms of treatment. i talked long enough. i will come back to you later on this. senator scott? >> first, i can not imagine, i can not imagine losing one. thank you for your service,

your son's service. i just hope, as a result something good happens out of it, somebody, it prevents something else from happening. can you explain, can you explain, the blast, what does it do to the brain? let's say i shoot a shotgun or any of this stuff. what does it do? how does it impact my brain? >> well, i think to my colleagues good point, perfection is the enemy of the good and you can criticize all of the models but we know these subconcussion injuries do a number of things. they impact areas of the brain gray matter, white matter interfaces, they probably have a vascular assessed. more likely long-term there is possibly a premature aging effect to the brain itself.

with multiple repeated blasts, exposures or certainly with traumatic brain injury. so, lifelong exposure, getting that quantity that senator warren talked about, it is critically important. we need to know, in who? how much? what were they doing? and what actually happened to the symptoms of the person and track that carefully. >> so, right now you can get a glucose monitor and put all of your data in there and pretty fast you can get a correlation, right? so, have you had any opportunity to take -- because we know if you join the service we know what flash you will have in boot camp if you are enlisted and is there anybody doing anything to just say, that we put all of the data in on something and just look at the model over a period of time? >> i think there are a number of groups including our own

looking at blood based bio markers, neuroimaging, all of those are critical as we understand the exposure and the diagnose. but we want to know how those things and specific lifelong exposures impact the symptoms of the person. because, there is not a 1-1 relationship there is a relative relationship. >> so, if you had, if every service member had the data of, you know, just start today. anyone new joins boot camp and starts going through training, if you kept, had the data and you had that in front of you, then over time you can do predictive analysis of where the problems are, right? >> right. >> and i think that -- to the point that was just raised. i think there are action steps now and that we have, we are compelled very much so, to make this a living learning

environment and continue to collect data and perhaps change policy changing how we treat people as we understand more over time. >> you don't have enough information today exactly on what happens as all of these blasts happen. what you have is that you will see the result. you see over a period of time this is what happens, that is what you have so far, right? >> i think that is right. i think, senator, what we have and thank you for the excellent question, is a series of smaller studies that slow changes in your imaging, changes in blood based biomarkers, representatives of injury of the brain. but, how it is going to behave in a large population of people is one thing. how it will behave in bobby or sue, is a very different thing. >> right. okay. and, how, so, dr. mcbernie how

hard would it be to put up a program, it would not be that hard, wouldn't it? >> it is a great question but i find myself unqualified to answer. >> we do it with other things like glucose monitors, right? >> hmm. >> if you gave service members they all have cell phones, right, you have an app, every time you have exposure, okay, you put this in. you put in exactly what you did and what you shot. some people are not going to do it well like no one follows your health or take their medicine but it would not be that hard to do, right? we have all of this stuff on sugar levels, why wouldn't that be the simplist thing to start doing and then, then you could start seeing, if you had all of that data you can do a predictive analysis even short term problems, you know, might take time for a 20 year

problem, right? >> yeah. i think following people over a decade will be valuable. i think we will see certain markers and certain things change early on. we have to remember that it is not an uncomplicated story. even the blood based biomarkers or other things as imaging has a lot of variation. you know, the brain i think my colleagues would support me. is an incredible structure but it is a bit of a black box, still within science. and understanding how different networks relationships and how the nodes connect and how one space effects another, that is a challenge. >> you would know the results, even though you don't know why you can over time predict what is going to happen? >> if you are looking for systemic, senator, prediction? i think with a large enough data set you can draw some

strong relationship. >> right. >> and then very quickly come back and say, what we, we know this, if you have this much, you know, the odds are -- you can go get a blood test for cancer now and it is predictive of if you will end up with cancer, is it perfect? no. it depends on the cancer. so, it seems like this would be pretty easy to do and it should not be that hard. >> so, senator, i would agree with you but i would bring up the issue that we are all individual and different people and, these types of injuries effect them in a different way. it is effective by who you were beforehand, the exposures and then the treatment that you had afterwards that produces the fact that are not easy to put in the box. >> okay. senator?

[low audio ] there are a lot of service members exposed to ied in the tenure of afghanistan and iraq. are you tracking the service members? most of them are probably in veteran service. are you tracking them for exposure to blasts and what is happening to them? anybody? so, i used to be in the senior of the defense, and i can tell you that it was a concern as far back as 2008, 2009 that these blast exposures were creating a unique health risk for our warriors. >> okay. >> we gotten to the point where we up armored and created new vehicles that were surviving the blast but what got in the vehicle and what got out of the vehicle were two different

states. it alerted us to the fact that there were things, the blast effect was having an effect on the human body that needed to be studied and researched. as far as having a handle on it, unless there was a catastrophe injury and usually one that was visible at the time, a lot of the phobes came out of the vehicles and they looked fairly normal. and it was not until time evolved that we started to see the behavial behavioral changes. i have no knowledge if anyone collected the data and did anything with it. >> i think that is an important kind of follow up as we try to understand what the impact of these blasts are, long-term, also, i would think that, i mean, it is bad enough there is traumatic brain injury that needs to be followed up on, but i think a lot of them might

develop conditions such as ringing in the ears? yes? doctor? >> thank you very much senator for the excellent point. we have it such as ringing in the ear, chronic headaches, and it is a big driver that drives not only a headache but invades behavior. >> yes. >> people who are in pain do not behave the same way and they do not perform the same way. so, what i am saying is that blasts have a multi-system effect. the brain is our principal and driving concern but it has effects in things that are linked to the brain, linked to the behavior that we need to know more about.. well, tenitis does not cause pain but it is

annoying. and there seems to be no cure for these conditions. i am interested to know what breakthroughs there are i know that tinnitus the disease and is that something that you are also studying, tracking? >> all i can tell you senator is that i have it. it does not go away >> i know. >> i have to live with it. >> me, too. it is very annoying. sometimes it is so loud that it is, it interfering with sleeping. so, that is, i think there are a lot more of our service members who endured or are enduring those conditions that we have to pay attention to.

one more question. 2023rand report noted there is a critical gap in effective ppp and that most models represent the average human male. so, it is that and this is for dr. mcbernie. it is important that we provide protective equipment to all of our service members. how can we make sure this type of protective equipment is also it is appropriate for woman, is that happening? >> it is a great topic, it is happening, it was from the last meeting we had on blast induced injury. we were happy to learn there is quite a bit of research being done in the community to make sure that the average male, specifically many cases the average caucasian male is not the only subject used to test equipment. >> yes. that is very important, thank you, thank you, madam chair.

>> thank you. senator ernst. >> thank you very much. and, good afternoon. and i would like to thank you, chairwoman, for the invitation to participate in this subcommittee today. it is a very important discussion that we are having. about the impact on our service members and their families. and, traumatic brain injuries can arise not only from the combat deployment but also from the routine training exercises that our men and women go through every single day. even when they are adhering to safety standards and guidelines, firing heavy weapon just as you stated mr. larkin, can create the long-term effects. other types of training sessions and preparation for combat deployments, many of these things can potentially lead to cognitive impairments, i understand you shared the

story about your son ryan, i want to thank you very much for your service as a navy seal and your son's service as a navy seal. it was through mr. larkin, through frank sharing his son's story with me many years ago that i finally understood the need to be involved with traumatic brain injuries. so, thank you for sharing the story that is difficult to tell but is to important for every -- every man and woman putting on the uniform. did you share with the committee how your son ryan had traumatic brain injury? >> thank you for the question, and thank you for your comments.

ryan had expressed his desire that if anything ever happened to him he wanted his body and his brain donated for traumatic brain injury research. that was done and his brain was donated to an activity at walter reed that post mortum analysis revealed he had an undiagnosed microscopic level brain injury that was uniquely aligned with blast exposure. they only see this pattern of injury with blast exposure. and, if we had not gotten that finding the narrative that the navy built around ryan and his struggle and his subsequent passing would of continued on, would of continued to have damaged his reputation but this finding was indisputable that

he was injured. he was not in his terms, crazy >> exactly, mr. larkin. i just want so many to understand that so many of these injuries go undetected through c t-scans and mris i am grateful he chosen to do that because you would not of known about the injuries otherwise. but then for you and dr. suavant. is the psychological metrics test that is used by the dod an accurate method of detecting those changes in cognition that will lead to a diagnose? >> senator, thank you for the excellent question. i think that we are searching for a gold standard.

a number of these measures including the anam have flaws in them. everything from the way they are administered to challenges on consistency and behavior. within the individual and external to other individuals. so, while it is an interesting screening tool it is far from perfect. >> yes. >> i hope we continue to work towards alternative or ways that we find that gold standard and it is something that this committee is going through. and the devices as well that can help with the diagnose and tbi and blast exposure. all of these things require research, development recommendations. are you confident that we can get to a point where you are able to make are recommendations and to

congress, to dod that will provide a path forward? any thoughts? >> thank you senator for your excellent question. i would say, and i think my good colleague said this before, perfection is the enemy. there are things we know to do now and as we learn more we should do better. and i think if we act and think our responsibilities to make it a dynamic learning positive environment for our service members, we can do things now while evaluating data and really making positive changes in the future. i think we are going to learn that there is a lot more of that microscopic injury than we ever believed and in certain people it will have significance over time >> i believe you are absolutely

correct. i think there are more service members that have had these injuries to their brain. i was reminded of this quote not too long ago, a old one, forgive me. if the human brain were so simple we could understand it we would be so simple we couldn't. let that sink in. i think we will all be striving to find the answer that we need when it comes to traumatic brain injury. we may never reach that 100% solution just because of the dynamics of this incredible organ. it does not mean we should just let it go. there are disruptions to families just as we heard from mr. larkin. it is national we not only

learn to prevent it, if it does occur if we can not prevent it, we need to find ways to treat it and mitigate the impact to our families. so, thank you again, chairwoman i appreciate the opportunity to be here today. >> i just want to say a special thank you to you senator ernst. she is not on this subcommittee. and like many in the senate she has an absolutely packed schedule. she has been engaged for years now on the issues around traumatic brain injury and working towards changes in the law both to the documentation that will lead us to better diagnosis and also for the resources to begin treatment now for those that need it and she wanted to be here with us today and i appreciate your coming in and doing this. thank you >> thank you. senator cane? >> thank you, chair warren and the subcommittee for having

this hearing. i am going to ask the same question of both panels, i just have one question and love to get your take and i will ask the same question to the second panel. we are not the only country that employs weapon that have these effects on service members brain health. what have we learned or what can we learn from the experience of other nations and their militaries either about strategies to prevent or strategies to treat? >> senator, again, in my role as a senior leader of the joint ied organization and dod back during the height of iraq and afghanistan this was not a u.s.- only problem. you know, we were very much in the trenches with our nato allies, partners who are all experiencing the same challenges with maneuvering on the battlefield because the ied paralyzed our movement and the ied was the weapon system the

enemy used against us that literally brought home all of the casualty and fatalities of those two conflicts and africa. you know, if we don't bridge communications with those countries as we try to solve this problem, we are missing a big part of it. they have a great data, they are as concerned about what we are talking about as we are i think that really, we need unsolicited, we need a task force to bring together the government, industry, academia and our foreign partners for a unity of effort to mass the data, intellectual capability and technology to solve this. we can solve it. it is just that we are, we have different efforts going on right now, they are not

coordinated, we are handicapped by a lack of data sharing. >> even within our own family, i know this panel has dod but not va. i know it is a high priority. sharing within our family but with our allies who have the same experiences really is important. thank you, doctors do you want to add to that at all? >> sure, thank you for the question senator, it is an excellent one. one consideration that i know some of our allies are considering at this time and it was published in a report in 2018 by the center for new american security. it is reviewing and updating firing limits for a lot of the weapon systems. those firing limits have not necessarily been revisited in some time and so, in my written testimony there is a direct quotation from that report in 2018. the details exactly what information to revisit in these

weapon systems manuals. and, perhaps consider updating to really get at mitigating exposure our service members experience in training in particular. >> thank you. thank you. >> senator, thank you for the great question. i agree with the comments of my esteem colleague. i would add one other thing. you are completely right there is power in numbers. there is power in togetherness. there is power in the opportunity to discover and serve our allies throughout the world. so, i would advocate for a common data elements, common data sets that go across our allies as we think about these kinds of exposures and the kind of long-term immediate what does somebody feel now and what are they experiencing years later. those kinds of things would be incredibly important and doable in many other health systems. >> thank you very much. i yield back.

>> thank you. >> thank you, madam chair. thank you and senator scott for holding this hearing, it is an important one. i want to thank the witnesses for their attention to these really important issues for our military. so, i got here a little bit late. if this has been discussed bear with me. i want to dig into this "new york times" article from september of 2023 entitled secret strange new wounds from the pentagon. this was about the marines in syria deployed in syria in 2016 and 2017 and they returned and struggled with ptsd issues and health issues and it was not

from direct combat. they were in combat but it was primarily from their peers really significant amount of firing pellets around. and, kind of the senator's point, we had military memberses in different wars, vietnam, korea, world war ii, of course, firing thousands and thousands of rounds. but these marines seem to have struggled. have either of you read this report? okay.

>> and senators warren and ernst and tillis relating to tba. this is a different tb -- to tbi. this is a different tbi. sometimes i worry, i just retired from the marine corp myself, i love it, but like all big organizations they can be bureaucratic and i am not sure these marines were treated very well. i am wondering from your experience. maybe we will start with you, doctor, what is your assessment of that report, well done reporting in my view from the "new york times" and what do you think the next step should be? obviously we will ask the government witnesses in the next panel on this topic, but i just like to get your

assessment from this particular episode. a lot of my constituents in alaska wrote, read this article and were quite disturbed by it. we don't even have a big marine corp press nens my state but a big army and air force presence. i would like all of you to just comment on what your thoughts were and then what we can do, you know, marines have not seen this, you can see how they can overlook it. i think it needs a deeper dive that the military has given it what are your thoughts on it? >> senator, thank you for the excellent point and question. the cover up of things and some made it more public in some

way. it talked about many of the long-term things that are seen clinically. in its population of people. they are the 1% of the 1%. they are the fittest, the swiftest, and yet, they are seeing clinically apparent problems. also in many ways the most resilient. selected many times. that raises for me some real concerns, it may be are related to the density of the exposure. maybe related to the lifelong exposure. it may be related to a global element of that kind of stress for a significant period of time. so, i think, we need to learn a

lot more about the long-term issues here and the short term ones and i think part of the way to do that is better quantifying the exposure and the person over time. absolutely. and thank you for raising this. i thought that "new york times" article was very well written and investigated. >> just for the record i don't believe everything that the "new york times" writes, and so -- [ laughter ] -- senator warren might, no, just kidding. so, i am sure the marines have points in there, that were probably not reported not saying it was a perfect piece but it raised an important issue. these young men, these are the best that we have in america, and we certainly, you know, need to take care of them.

>> absolutely. agreed. i think the takeaway for me when i read that article there is a culture that is pervasive across the dod, unfortunately, that really contributes to this under reporting 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 under reporting of traumatic brain injury, there are a variety of reasons that service members don't report injuries, but, fear of negative repercussions on their military career a huge one. so, i think when i read that "new york times" article and the series of articles, that is really what came to my mind is a culture that needs changing if we hope to improve this >> yep. >> and mr. larkin, really quickly, sorry madam chair. you know, i don't know if you have a view on this, we have had many wars with many

thousands and thousands of artillery rounds fired. i had an 81mm mortar, my marines we fired, you know, all kinds of 81mm mortar. not as big as these but it is a big mortar. you know, you feel it when you are firing those and your ears hurt if you don't have ear protection on because it is so loud. what is your sense on how we plead to look at this? that article but compare it to other wars where we had shot thousands and thousands and thousands of rounds. >> so, you know, if i am going to put my money it will be on the preventive end as much as we can to buy down these injuries. but i completely agree with dr. mcbernie. the issue here is trust. you will not get reporting unless there is trust built between that operator or that warrior and the system. we have collected blast data

on, in a variety of different efforts. >> on artillery, too? >> well, just in, you know, variety of different settings with blast gages and so forth have been warn by our warriors. we have no idea where that data has gone. so, again, it never comes back to the war fighter like one would for radiation. so, they say, we wear these things but we don't hear anything back. one of the things and it might be a novel idea that i offer is, when we acquire weapon systems munitions why don't we ask the manufactures to provide us with blast overpressure data according to strict criteria that they all have to follow that ultimately will craft training proatso protocols.

but, again, we have been calling this by a different name coming off of the battlefield helping with diagnoses and we are now biological injury caused by blast overpressure. thank you, thank you, thank you. i have another round of questions that i wanted to do, i know senator scott does, if anyone else does we are glad to do it. i want to pick up on what mr. larkin was talking about, that was trust. that, service members who were effected by blast overpressure are not getting the help they need. and the question is, why not? and it gives us on the ground look at if people are

experiencing marine corp officers was quoted in this story saying that he was experiencing severe headaches and small seizures but would not be acknowledged because there was no documentation that he was exposed to anything serious. now, we talked about the importance of record keeping and how that, that could fundamentally change what happens in this area. i want to talk about where we are right now in the consequences of the failure to diagnose early and what that means. mr. larkin, you are the one focused on this more than anyone, i think you said in your written testimony that you estimate that about 80% of your son's exposure occurred during training. is that right. that is what i understand with

. and trained combat and confirm that the maturity of the exposure. >> so, we know about what happened to ryan because you donated his brain postmortem. they were able to do an analysis, can you speak to what happened when ryan was still alive and if you and your family got the appropriate support that ryan needed as he clearly demonstrated that he was in increasing trouble? >> so, one thing that i can share about ryan is after he passed what we found on his computer were, he downloaded numerous studies on blast exposure and tbi and researching the medications he got. so he was locked on this. i did not like what he did, i

did not support what he did but i have grown to understand why he did it. it was for his teammates, he was going to prove something was wrong. when he went to get help he did it more for his teammates than himself. but, again, you know, we did not know what we didn't know. i think a lot of people are trying to do their best for him. the best that they could but all of the wrong way because we lack the science, we lacked the knowledge. tbi was not mentioned. very little, not taken seriously because they could not see it. we still can not see this level of injury in a living operator, a living war fighter. again, within the medical enterprise if you don't have a blood marker that alerts you, you know, just like a heart attack, we look at heart

enzymes saying there is heart damage and ekg, something is wrong in the heart, we don't have that right now of it. it handicaps our ability triage the folks early on in the evolution to your point. that, that and the opportunity here, i don't know if my colleagues would agree with me but the opportunity is to get it early not a catastrophic point. >> so, let me pick up on this, i understand this is hard to diagnose and that we collect data that will make it one way, i understand we would like to start as early in the process as we can. but another feature that we have control over right now that when someone has any concerns, who is the advocate to make sure they get the health they need? my sense of this is that it is

just a patchwork. you go here, you get sent there and then you end up some place else. the patient is put in a position of having to advocate for a diagnosis that it is not the patient's 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. i just want to know if you can speak just a little bit to the notion, starting now before we have perfect information 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 that will advocate and get them to the best treatment that we can.

can you speak to that mr. larkin? >> yes, the number one word that i would pick out is listen, the system needs to listen to the folks as they step forward. you know, and we need to understand this is a, this is a leadership problem. we need to educate leadership as to what is going on here so they can properly usher these folks down the right paths so that we can stop their injury process and we can start a level of treatment that one size fits one, not one-size- fits-all. that is precision medicine. as the science develops, as our medical capabilities develop we will get better and better at doing that. but, again, ryan became disenfranchised. he became, it was a system he depended on, a system that i depended on, this was my community, too. this is why i am here today.

i realize it is not a perfect world but, you know, the ultimate grader of what we do or not do are the veterans, the war fighters and their families. are we doing the right thing for them? >> i very much appreciate that and appreciate your comments here. if i can i want to go to the treatment part of this. doctor, you work at homebase, they try to be the one place that brings people in and give them response. it is on site for our service member. you are on the frontlines, you see people with tbi every day. can you talk just a little bit about how homebase organized itself and what you are seeing and what kind of needs you have? >> senator, thank you for the excellent question. you know, i think we see

ourselves as a partner with dod. and that we 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. someone is not just a psychological illness but we bring multiimspecialists to bear on this person for a very intense evaluation that might take, as i said, months or years and it is standard environment and try to emerge them in a team-based behavior where we listen to the patients and we develop a program programattic plan. let's treat their symptoms and get them relatively well. >> i am so proud of the work that homebase does. really want to underscore the importance. there is help, there are things

we can do. and i take if i can just have you under score it again, dr. zafonte, you return people to active duty military service. can you say a little more about that. >> i am 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, that is what they want to do. they want to be well and go back to their teammates and contribute at a very high- level. and indeed that is the goal. the goal is being able to give people agency over their own health again. that is what we do. very high rates of return. large numbers of people still waiting for service which we hope to provide. and i think that we see this as

a means of enhancing programatic excellence and serving as the bridge for people who need help. >> i appreciate the work that you do. thank you. senator scott? >> thank you, chairwoman. >> nfl some are wearing a q collar, can you tell me how it works and what you think of it? >> thank you very much, senator for that excellent question. it is an area of debate that is certainly of interest in the field of traumatic brain injury. the theory behind the q collar is that compression here at the neck would result in less force shaking of within the brain.

rolling back injury, i believe, unless there is more data is unclear in sport-related injury it received preliminary approval. the enthusiasm is modest. >> okay. knowing what you all know now, services of service. so, if you had a child or grand child that is 18 years old and wants to be a war fighter and enlisted in the whatever, what would your advice be to them? >> is not enlisting an option? i mean it as a serious question traumatic injury is such a huge risk of getting this injury and as we have heard today detection of this injury, treatment of this injury is not guaranteed. i would, in sitting here, i now

have a 14-month-old daughter, this question is very relevant. i would strongly urge her to reconsider her decision and unfortunately that is a decision that i know many veterans that i know asked their children to reconsider as well. >> so, ryan is here with me today in spirit. much of what i am saying is him talking through me. he would tell you that he loved being a seal. he would not trade anything. just that we have to do it better. i will say that my own naval special warfare community, the seal community, ryan's story deeply effected them. they have moved aggressively to try to make a difference along with the parent command so com right up to the commanding general. they are leading the way in my

opinion within the department of defense. and very often and what they do the forces follow. so, thanks, ryan. >> dr. zafonte. >> certainly i think this is a point of great debate. but i guess what i would say and we see this in contact sport, we see it in the military. the first thing we can do is know what we know to do now, eliminate unnecessary exposure. rules changes in sports have made a big difference. i believe we can eliminate unnecessary exposure in this population of people where there is not a lot of return on investment either to their training or for their long-term health or for their team members. that would be an awfully good

place to start in enhancing health. >>if we thank god every day someone is willing to put on the uniform. if we get to the point where people say there is too much risk say good-bye to all of our liberties, i hope we get to the point where nobody would say you should not go in because of the risk. thank you. >> senator kane? >> just a closing comment on that question, senator scott, thinking about what you would say to your kid. one of my three kids is a marine who was 8 year commander now a marine reservist, thinking about him and how he would answer that question. let me recount an amazing story that i heard from doug wilder, former governor, he was drafted into the military in the korean war. the military, like society at that time, was with a lot of

racial prej deist, a, doug is a guy to stand up for himself. he had a commanding officer that said i want everyone to be treated fairly and he believed as others in his unit in the middle of really difficult battle circumstances the african americans in the unit was not being treated well. they all agreed they were going to talk to their co and pass that on and when they all stood up to do it they all just said to doug, okay, you do it. so, he laid it out, his concerns about the way that they were being treated and his commanding officer said, you have 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 did not change for three to four weeks and all of a sudden one day, everything changed. because, he did what he was supposed to do, he stood up and he said there is not right and we are a unit and if we make changes things can be better.

and so i would hope that people grappling with the decision, maybe your daughter might be in this decision, people grappling with the decision will realize things do not just get better by themselves, things change taking people of all levels from the private first class all of the way up to 4 star standing up saying we will be better if we make these changes. and i think a lot of our young people, well, people of all ages but young people have a lot of wisdom to offer. i hope they say i will do it and i am committed to speaking up if i see areas where we can be better. thank you. >> thank you, senator kane. i call on you as we do the mdaa to tighten up the rules and 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. i would like to call up the

second panel. thank you.

. all right, are we ready? secretary lopez, if you can give us an opening statement, please. >> chairwoman, senator scott, we are pleased to represent the office of secretary of defense to want department of defense's commitment to address brain health issues and initiatives. we are honored to represent the dedicated military and civilian medical professionals in a military health system providing direct support to our combat commanders and delivering or arranging health care for our 9.6 million beneficiaries. we will inform the committee about the departments initiatives who understand the causes and impact of brain injuries and blast exposures, support ongoing training of medical professionals, inform the development of protocols

and improve cognitive and physical performance of our service members. the department of defense primary missioning is to defend the nation. fulfilling this mission means war fighters need the ability to make expedient decisions on the battlefield, promoting brain health enables our effectiveness of the fighting force operationally and impact on all of the form. it is the top thing for dod and our service members. in support, the dod established a joint effort between the operational and medical forces called the war fighter brain health initiative. this initiative was finalized in 2022 and qualified policy and direction in support of unified efforts across the

military to address tbi and blast overpressure. the war fighter brain health initiative focusing on cognitive and known brain threats in military environments, and methods to detect brain injuries. it is an important organizing function for our department- wide efforts to address brain injury and related diagnosis such as ptsd and suicide. between 2000 and 2023485,553 service members were diagnosed with tbi. the numbers grew from just above 10,000 for year in 2000, to a peak of 3,000 for year in 2011. the dod responded to this increasing rate of tbi in

combat during operation iraqi freedom and "operation enduring freedom" through rapid expansion of tbi. care and research to support military forces around the globe. we recognize, however, that more research on the inside is needed in both the care and research to better understand the risk, how to protect war fighters and how to treat brain injuries more effectively. our strategic approach is involving policy, coordinate clinical changes, and gap- driven research investment. we look at how to refine for brooder effectiveness. when they do not work, as expected, we review why and notify them to invest in research to advance alternative

solutions. with that overarching policy mind set we hope to discuss actions, research findings under impact on our current approach as implemented within the dod, tbi. we do this not because we believe it is a foolproof solution but through shared knowledge. we know there is still much to learn about the brain. and not everybody responds in the same way to similar exposures or injuries. we seek to integrate solutions for the future as we provide recommendations to inform and effect change to safety, and policy. this mission is both personal and professional. as providers, researchers and military leaders we are committed to mitigating the

risk of and improving the treatment for exposures for tbi. we appreciate your continued support of military medicine and inviting us to be here with you today to discuss the important issues surrounding the brain health of our war fighters. we thank senator warren, senator scott, and members of the subcommittee for leading continued congressional attention on blast exposures and brain injuries and we look forward to your questions. >> thank you very. , i appreciate it dr. martinez. i appreciate that dod has begun to take steps toward mitigating the risks associated with traumatic brain injury. starting this year new troops will be given regular cognitive assessments to monitor potential impacts on blast exposure on their brain health. it will help medical providers recognize brain injuries and changes in cognitive function more quickly and help service members get the clinical help

that they need. i am glad that dod is taking this critical step. it is important that we do it right. williams, your section works with service members with tbi and other invisible wounds of war. as you know, one of the -- and we discussed it here reportedly today, one of the most significant way that troops are exposed to blast overpressure is through training. to ensure that we are accurately monitoring the impact of blast exposure on service member's brain health, would it be helpful to give a cognitive test before the service member begins training and firing weapon? >> thank you senator for the question and thank you for the opportunity to talk about this important issue. absolutely, yes. let me start by saying yes, critically important.

baselining is something that we utilize in all aspects of medicine for surveillance, utilize it prior to treatment, prior to what we know cause risk. so, we have moved to now, this year, we hope to move to all members once they join the military, before they start their training they get cognitive testing. they get cognitive testing because we know the highest risk of tbi in the military are in the training environment. >> yes. >> it would be valuable to use the same precision medicine we have been using with tbi. >> okay, so, baseline assessment is not starting until after training then it is not an accurate measure of the service member's brain health changes over time, we will miss the front end of this and as we have talked about the importance of isolating the problem early is absolutely critical. so, to make sure that we are able to detect signs of cognitive decline due to blast

exposure we got to do this assessment before the training starts. second thing, we also need to do regular tests of service members cognitive health after the baseline assessment. while special operations command will conduct the tests every three years, dod is currently planning retest troops only every five years. dr. martinez you are responsible for assessing the effects of and improving how dod tracks blast 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? >> ma'am, as a department we are looking into this. i think if there is value to doing it every year, we don't

know. maybe three years, maybe five years, i am not looking at 10 years research, i am looking for short term research to figure out the best frequency of doing the test. and not only that, what other testing should we have to assess the condition of the soldiers, service members >> i just want to say i feel a little frustrated here that special operations command already clearly says five years is not enough, they are at three and frankly, until we have better data i don't know why we wouldn't be saying let's do an annual test and see what we can detect? if the data shows us that three years is often enough intervalto be able to detect changes, that is fine. but it seems to me, given what else we know and given how catastrophic the implications of untreated tbi can be, that

we ought to be errorring on on the side of, waiting five years is not often enough. another way that dod needs to show that it is serious about protecting service members from blast overpressure is by establishing effective weapon use safety limits. we have some conversation about this earlier. in 2022, dod directed the services to establish a maximum allowable number of rounds for service members to fire to mitigate blast overpressure injury risk. now, good start but i see two problems with this. first, limits do not include brain injury risk. blast experts raised concerns that this means our current safety thresholds are built on things like whether or not it

is likely to cause your eardrum to burst. they are very old guidelines and they are not about traumatic brain injury. you are in charge of overseeing dod war fighter brain health policy. why is it important that dod establish a maximum allowable number of rounds for service members to fire that takes into account brain injury as well as injury just to the ears? >> senator warren thank you very much for the question and having us here today to talk about brain health and blast overpressure and traumatic brain injury. this is san excellent question. it is imperative that we have allowable number of rounds for all of the weapon systems that are commonly used to avoid unnecessary blast exposure in our service members. we believe that this also gives us an opportunity to be able to ensure the usage is correct,

the position, crew position, proximity all of those pieces can come together. our policies are moving in that direction to be able to look at the brain. as you mentioned historically it has been through ear and lung. however, we are looking at what the brain effects are and we will follow suit with our policies as such. >> so, again, i want to say i feel a little bit of frustration here. i appreciate that you are working on establishing these limits but we got to get it off of the ground now. we know enough to start moving in the right direction. my office has heard stories of service members having to take their own initiative in setting limitations for their troops, we have training instructors who just say i decided that is enough. and, that is not enough to get this job done. so, again, i urge you, better to make your best estimate and

get started on forcing these weapon manufactures to start collecting this data so they would be able to give us limits on how they can be used. one more concern here. it is how we measured the weapon used safety limits. dod's own studies found it took 72-96 hours to resolve service members cognitive deficit after firing heavy weapon, that is about how long it appears before people are back to their original steady state. but, dod guidelines say they are only going to test for the first 24 hours. mrs. lee could service members benefit from establishing weapon used safety limits for longer periods of time like 72 hours? >> yes, ma'am. we are looking to expand that time frame so we allow for those differences that are

coming up with blast overpressure. so, that is, again, where our policy, the direction that our policies are headed so that we can cover that time period. we are firmly committed to early detection and provide the opportunity to treat and that maximizes our outcome. >> well, i hope do you this soon. the department of defense inspector general has raised concerns that military health system providers are not consistently providing a 72 hour follow up appointment for patients with mild tbi. so, clearly a longer time frame is something that dod itself recognizes it is important and that we need to get done. look, i get it. this is hard. i am grateful that you are doing the work you are doing. i want to be a partner but a partner that urges you to move faster and deliver more for our service members as quickly as possible.

we need to do better for our troops and we need to do it right now. senator scott? >> i will ask you the same question, what would you tell your son or daughter, 18 years old to enlist, what would you tell them today, based on what you know? i have three kids, two in, i am proud of the service and tell my grandkids i have eight of them. there is a great opportunity in the services. it is important for the service, even for a short time it makes a big difference, i don't care who you serve or how you serve it is critical. now, they need to understand

that this is a risky business. i am proud, i tell my grandkids if there is something that triggers them to serve, go fetch. go do it. >> thank you for the question, sir. >> i don't have any children but i have many nieces and nephews i encouraged. it has been a great opportunity in my lifetime to serve in uniform. i would not change that requirement or request for anyone. i would tell them to follow their heart and encourage them to know that they are at risk to the job and our job is to make sure that the people who you are entrusting your life to have a responsibility to care for you. no different. the reason why i am here today is we want to make sure that

our men and women in uniform knows we are caring for them in every possible way. >> yes, hi, so i have five children and one grand child and i would absolutely say to support and defend our homeland. and joining our services, one of them is a marine. and through that service it is about the trust. i have seen working in this environment in the last 20 years, especially around traumatic brain injury relm you really do need to be credible and have integrity based on that trust and ensuring we are going to do right by you. we are a family with we will do right by you. mr. well la -- mr. larkin is part of our team. >> now, the department plans to conduct a business case

analysis and review lessons learned to form its way for blast monitoring, who is conducting the analysis? when do you expect it to be completed? what factors are included in the analysis. >> sure, do you mind if i defer . >> okay. so, the business case analysis kick off meeting was the 14th of february, conducted by a contract service. we are expecting the result in september of 2024. we are looking at, we have an extensively involved military department in this. so that the outcome that comes, the out come and recommendations will be able to be implemented by the military departments both the service communities and the operational communities are heavily invested in this. so that we can review the necessary resources, the, and look at how to establish a standardized monitoring program throughout the force. >> when do you think it will be

completed? >> it will be completed in september. >> september. >> okay. >> the fiscal year 2023 authorized but did not require the director of defense to have a pilot program to monitor blast exposure to the use of commercially available wearable sensors do you plan to do it? and do you have any sensors in mind that you think are working? >> so, yes, sir. so, we are awaiting the bca results, business case analysis results in september to make a decision on whether or not the pilot that could be the segue from 734 work into a full blown monitoring program throughout the department. so, again, those decisions will be probably made in the september 2024 time period. in terms of blast sensors we have various communities to include the special operations command who have been looking

at, right now, the three commercially available products. those decisions are right now living in the acquisition world as they are doing suitability and fielding exercises. and, based on the requirements of each individual community. >> good. >> also, the fiscal year 2023 required report describing strategy and implementation plan for the war fighter brain health initiative, i guess this was due at the end of last year, so, is that different than the others? >> that is the strategy and action plan with five lines of effort. i believe that is headed over your way right now. >> okay. thank you. can i just ask one more question. that is seven months before that, what are you going to do over the next seven months? >> that is to me? >> so, in the original memo that was produced before we had

finished section 734, the assistant secretary readiness put out a guidance memo, before we 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, we sent the memo out, included in the memo are six actions to try to avoid unnecessary blast exposures, what we are doing in the meantime is updating that memo with more data that we have from our research studies and from the blast community of researchers so that we can provide more direction and guidance to the military departments on how they can have safer actions out in the operational environment and training environment. >> i appreciate that. and how are you going to make sure it will be on the ground level. we make policy changes that we all talk to each other up here and in the abstract and down on the ground nothing has changed,

dr. martinez? >> ma'am, the first issue is that it is a joint effort between the operational forces and we in the medical side. so, medical leadership and the operational leadership. if we don't work it together it will not pan out. so the way we exercised that at dod is safety oversight council. meeting with all of the services and laying out the guidance and we rely on the service to then push it down. it is an issue of policy for services, issue of training for the services, it is an issue of equipping in the services. we will give them the medical guidance, the best knowledge that we have but it has to be exercised by the line. i went over to fort campbell . >> okay. >> and i talked to the ceo of fort campbell and i told him, it is simple. less is better and less often the better. so, really look at it and pay

attention to that. >> right. right, captain williams did you want to add anything on that? okay. good. senator scott? >> have you guys ever had a glucose monitor? you know how they work. so i can put on this monitor, i can put in my exercise, i can put in my food, and i can just do it myself i can track to see, you know, how i feel, when my glucose goes up. why don't we have something simple people can do on their own? if i knew, gosh, i get headaches, i can not do this any more. i -- i mean the technology it is so simple. i mean, you go to it and why

don't we go to it and monitor that stuff. do we know that. we have it with the threshold. now -- no audio. >> i put that information in there here is what i noticed. i get this number of blasts i can not sleep. then i start saying to myself, okay, i will not do that. i am not doing that to myself anymore. i am in a dark place. you know, i, you know, this has happened to me? i am not an expert on this. i mean, you think, we are all, we are all going to be better

if we self-monitor ourselves, right? rather than a top down program that tries to tell us everything. and even the thing, glucose, i mean, your body will be different than my body. it will be different than yours. put in the information give it to everybody. and you can connect. you can say i will allow this person to connect. there is a company out there that allows people to do that. called levels, they are doing a. they are doing i think, 50,000 people or so on a study where they are doing it on their own as a private sector. everyone putting their own data in there. >> what you are speaking about is really and truly precision medicine and targeted therapy to the individual. it is variable for each

individual for tbi so, one of the things that they said was dod needed to partner with private industry and private organizations to improve research and improve treatment. that is one of the things we want to look at. what type of modalities are out there to focus on their own symptoms, we have to know what the baseline is first for that individual. feedback is something that we do, we help patients understand how to control their own individual symptoms. but, each person is different that will be a as we continue to research i think we can get there soon. >> so that is a big government answer. i am not saying you are wrong but i believe i will do a better job of monitoring my health than anybody else will

do for my health. i don't care what the study. if i sort of, personally, if i eat something and i don't feel good i am never touching it again. period. these are smart kids going into service and i mean, just look at sports, all of them are getting smarter. i am not going to do this to my brain. i just think we should do all of the things you are doing but it is simple to set up a program to give, you know, let that person monitor themselves. their body will be different. your blood glucose level will be different than mine, i guarantee it. >> i always listen to the patient and the parents. but, i do want to say, though, i agree with you. i think as a medical professional and researcher we want to come up with a pathway forward for the patients to

monitor their own. so, that means we need to come up with baselines, with normals, which we don't have at this point in time for tbi in general. when we move towards blood bio markers and moving towards concrete evidence i think we can come up with the tools that you are talking about, a lot of patients can monitor. >> thank you. >> thank you. >> good? >> so, i want to thank you all for being here. >> thank you, absolutely. absolutely. >> thank you all for being here. so, north carolina university is including east carolina university, chapel hill and health care providers prioritized research care and support for service members and veterans diagnosed with tbis. able to see that when i was in the state last week. so, again i appreciate this hearing. further understanding, the cause of tbi will cigly

significantly improve their care. dr. martinez, blast exposure, members ever the armed services that you published in december, one of the key findings is greater likelihood of tbi. can you explain what you mean by greater likelihood and what percentage of people were exposed to what level of blast are likely to develop tbis. >> i will defer for that answer. >> certainly.. >> the study you are referencing where we looked at monitoring and documenting blast exposure and then also offering a review of weapon systems which we cottified as 16 weapon commonly used and went deep to figure out what all of the safety regulations

were about those and under the safety looking at all of the blast overpressure stuff, and in the report we were able to, we reviewed 40 studies, 26 of the studies funded by the department of defense. we looked at what type of effects happened when you are doing blast overpressure. and then where do you have concerns about traumatic brain injury, and most of the areas that we found correlations were in the neurocognitive, thinking areas, and also in health care utilization areas, we, we looked at blood biomarkers and proteins to see if there were any correlations and we believe that will bear fruit. right now there is no clear trend in that regard. so, we are relying on the symptom reporting as being the most indicative of someone that would of had brain injury and

early detection of that like their balance and their eye movements and their thinking skills and sense of reporting. >> thank you for that. dr. williams, what recommendations would you make to diagnose and treat military personnel who are reportedly exposed to low-level blasts? >> thank you for the question, senator. as we spoke earlier in terms of baselining early. it has been stated several times, when you know better you do better. one of the most important things we can do is baseline our members the moment they come in the military. that means before they start the military training. and, that allows us to follow them over time. i admit we have to find the right baselining tool, right now we use anam and it focuses on cognitive and that is appropriate but we can do more, we can do better and our goal is to, again, start early to continue to monitor. >> thank you. so, proud home of the kings

special warfare center and school at fort liberty, research suggest high blast in training and combat and other military personnel and has a elevated risk of blast exposure related to brain injury. does it track with your research? >> absolutely. >> all three of you? >> good. okay. thank you. >> we certainly need to conduct more research we have to do a better job protecting our service members with what we know today. that lines up with, dr. williams, with what you were just sharing, i am concerned the department is not moving quickly enough to detect the risks. there are tested, fda-approved devices that can limit tbi, neck collars used by special operators just like you see in the nfl, and i am hearing, however, they are still years of dod testing that needs to be tested before they can be fielded for the brooder force, for the panel, for each of you, why are we not expanding the wearable devices now to keep

our war fighters safer from head trauma and pressure protection rather than waiting for testing to be completed within the department? and how can we expedite the use of the devices? >> you know, i would start with a simple answer. do no harm. we need more of them to determine if they do harm in the operational setting. >> even, doctor, if they are already fda approved devices? >> i totally understand. fda approval is not tested in our population. that is a different story. we realize now that a lot of times research is being done and not inclusive of operators. we will do no harm to that general population and especially high-level operation we are caring for. our goal is to make sure we do no harm in that population. >> think you protective respect we may have to look at the data

and the science if it's sound. even in our sent the setting we will adopt it. if we make a difference we will. and we put them to our internal processes. and that's with every inch of bashan we do with our patients >> the jugular vein compression devices you are speaking that have mainly been studied and had an impact in the sports can unity so there's different mechanism of energy is worth a look and definitely worth more than a look. looking to do more research to make sure it's safe and effective in both military population and pressure blast pressure as a mechanism. >> think of. >> thank you, senator. i want to thank you all and all of our witnesses for being here today. i want to thank you for the work you do every day.

my takeaways from this are that the department of defense needs to do better. we need to identify those who are most at risk for tbi because the particular work they do and we need to collect better data. and we need to do all of this on a much faster timetable. congress also needs to do better. we need to make sure you have the resources to do your work and we also need to make sure that those who are treating tbi like homebase, have the resources they need. it is shameful that their active duty military who have what appears to be tbi and they cannot be treated because the resources simply are not there is a waiting list at a place like homebase is our failure. we need those resources and we need the capacity to be able to treat those who have suffered brain injuries because of their service to our nation. we owe them and that to our

servicemembers. again, thank you all for being here. i want to thank the senators who have been here and i want to thank my partner, senator scott, in this and this will be an issue we take up during the next round of nda eight negotiations. thank you. inutes.

>> madame speaker. >> mr. president