[Congressional Record Volume 150, Number 83 (Wednesday, June 16, 2004)]
[Senate]
[Pages S6886-S6888]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRAHAM of Florida:
  S. 2524. A bill to amend title 38, United States Code, to improve the 
provision of health care, rehabilitation, and related services to 
veterans suffering from trauma relating to a blast injury, and for 
other purposes; to the Committee on Veterans' Affairs.
  Mr. GRAHAM. Mr. President, today I introduce legislation to establish 
a Department of Veterans Affairs War-Related Blast Injury Center. The 
need for this type of research and treatment facility has become 
especially pressing in light of the staggering number of veterans 
returning from the battles raging abroad.
  Blasts from such weapons as artillery, mortar shells, and roadside 
bombs--improvised explosives that blow debris such as broken glass, 
nails, and gravel upward into the face--have become the most common 
mechanism of injury in modern warfare. The resulting injuries include 
those to the lungs, inner ear, limbs, and, quite commonly, the head. In 
addition to the serious physical wounds, deep psychological wounds also 
result, including post-traumatic stress disorder.
  Despite the fact that injuries from explosive devices currently make 
up the majority of combat casualties and the most severe, there has 
never been an established medical program to evaluate, treat, and track 
the short- and long-term consequences of these specific injuries. This 
bill is an important first step toward correcting this deficiency. It 
establishes at least one War-Related Blast Injury Center within VA that 
would provide comprehensive and specialized rehabilitation programs, as 
well as targeted education and outreach programs and research 
initiatives.
  The Center would be formed from a collaboration between the 
Department of Veterans Affairs, (VA) and the Department of Defense, 
promoting cooperation between the two agencies to reach their 
respective goals regarding the care of our military personnel. One of 
the Center's main purposes would be to fill in the gap that now exists 
in the evidence base for treating victims of blast injuries. Through 
its specialized evaluation and treatment of the polytrauma that results 
from blast injuries, the Center would facilitate the identification of 
trends in those suffering from this trauma and go a long way in 
determining innovative, more effective treatment approaches.
  In addition to its comprehensive rehabilitation program and the 
conduct of research, the Center will also provide education and 
training to health care personnel across the care continuum, including 
first responders, acute-care providers, and rehabilitation staff. It 
will also develop improved models and systems for the furnishing of 
blast injury services by VA.
  While my legislation does not designate a site for the Center, I 
mention with pride the work being done at the Tampa VA Medical Center 
(VAMC) in Florida. The Tampa VAMC has an exceptional Physical Medicine 
and Rehabilitation (PM&R) Service that serves the largest number of 
veterans in the Nation. The Spinal Cord Injury, Amputee, and Traumatic 
Brain Injury Programs are not only VA's largest, but they have also 
been recognized as providing the highest quality of care in VA by their 
designation as Clinical Centers of Excellence. The PM&R Service 
utilizes an interdisciplinary team for patient care that includes 
physicians, therapists, audiologists, neuropsychologists, and social 
workers. Among them, this wide-ranging medical staff has access to a 
broad spectrum of medical and support services to best treat their 
patients.
  In addition, this outstanding hospital serves as one of seven lead 
centers comprising the Defense/Veterans Brain Injury Center, a 
cooperative treatment and research program in traumatic brain injury. 
It also established a Gulf War Program in 1999 and in the past year 
created a Blast Injury Program. For all these reasons, the Tampa VAMC 
would serve as an excellent site for a War-Related Blast Injury Center.
  An April 2004 article in The Washington Post detailed the experiences 
of combat surgeons in Iraq currently caring for the heroic men and 
women serving there. These doctors described their experiences treating 
an overwhelming flow of soldiers with wounds that probably would have 
been fatal in previous wars. Increasingly, these wounds involve severe 
damage to the head and eyes and often leave soldiers brain damaged, 
blind, or both. This article paints a clear picture of the injuries our 
soldiers in Iraq are subjected to and must deal with upon their return. 
I ask unanimous consent that the text of The Washington Post article be 
printed in the Record following this statement.
  In addition, a recent update by VA's Physical Medicine and 
Rehabilitation National Program Office revealed over a 60 percent 
increase in rehabilitation patients in 2003 compared to 2002. This 
means that there were 215 additional brain injury patients and 423 more 
amputee patients. This sizable increase speaks to the great need for 
the War-Related Blast Injury Center.
  This past April, more than 900 soldiers and Marines were wounded in 
Iraq, more than twice the number wounded in October of last year, the 
previous high. On May 2, in a tragic event that hit close to home, 5 
reservists from the Jacksonville-based Seabee battalion were killed in 
a mortar attack in Iraq and an additional 30 suffered injuries 
resulting from the blast. The Jacksonville-based Seabees were in Iraq 
to do humanitarian work such as fixing electrical and water systems and 
sewage problems. These brave men epitomized American courage and 
selflessness. A War-Related Blast Injury Center would serve to care for 
servicemembers like the Seabees who suffer this type of horrific wound.
  After all that these courageous, selfless soldiers sacrifice and 
suffer in battle, we owe them a place where they may receive the 
treatment necessary to mend their wounds, both physical and mental.
  I ask unanimous consent that the text of the bill be printed in the 
Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

               [From the Washington Post, April 27, 2004]

 The Lasting Wounds of War; Roadside Bombs Have Devastated Troops and 
                         Doctors Who Treat Them

                             (By Karl Vick)

       The soldiers were lifted into the helicopters under a 
     moonless sky, their bandaged heads grossly swollen by trauma, 
     their forms silhouetted by the glow from the row of medical 
     monitors laid out across their bodies, from ankle to neck.
       An orange screen atop the feet registered blood pressure 
     and heart rate. The blue screen at the knees announced the 
     level of postoperative pressure on the brain. On the stomach, 
     a small gray readout recorded the level of medicine pumping 
     into the body. And the slender plastic box atop the chest 
     signaled that a respirator still breathed for the lungs under 
     it.
       At the door to the busiest hospital in Iraq, a wiry doctor 
     bent over the worst-looking case, an Army gunner with coarse 
     stitches holding his scalp together and a bolt protruding 
     from the top of his head. Lt. Col. Jeff Poffenbarger checked 
     a number on the blue screen, announced it dangerously high 
     and quickly pushed a clear liquid through a syringe into the 
     gunner's bloodstream. The number fell like a rock.
       ``We're just preparing for something a brain-injured person 
     should not do two days out, which is travel to Germany,'' the 
     neurologist said. He smiled grimly and started toward the UH-
     60 Black Hawk thwump-thwumping out on the helipad, waiting to 
     spirit out of Iraq one more of the hundreds of Americans 
     wounded here this month.
       While attention remains riveted on the rising count of 
     Americans killed in action--more than 100 so far in April--
     doctors at the main combat support hospital in Iraq are 
     reeling from a stream of young soldiers with wounds so 
     devastating that they probably would have been fatal in any 
     previous war.
       More and more in Iraq, combat surgeons say, the wounds 
     involve severe damage to the head and eyes--injuries that 
     leave soldiers brain damaged or blind, or both, and the 
     doctors who see them first struggling against despair.
       For months the gravest wounds have been caused by roadside 
     bombs--improvised explosives that negate the protection of 
     Kevlar helmets by blowing shrapnel and dirt upward into the 
     face. In addition, firefights with guerrillas have surged 
     recently, causing a sharp rise in gunshot wounds to the only 
     vital area not protected by body armor.
       The neurosurgeons at the 31st Combat Support Hospital 
     measure the damage in the number of skulls they remove to get 
     to the injured brain inside, a procedure known as a 
     craniotomy. ``We've done more in eight

[[Page S6887]]

     weeks than the previous neurosurgery team did in eight 
     months,'' Poffenbarger said. ``So there's been a change in 
     the intensity level of the war.''
       Numbers tell part of the story. So far in April, more than 
     900 soldiers and Marines have been wounded in Iraq, more than 
     twice the number wounded in October, the previous high. With 
     the tally still climbing, this month's injuries account for 
     about a quarter of the 3,864 U.S. servicemen and women listed 
     as wounded in action since the March 2003 invasion.
       About half the wounded troops have suffered injuries light 
     enough that they were able to return to duty after treatment, 
     according to the Pentagon.
       The others arrive on stretchers at the hospitals operated 
     by the 31st CSH. ``These injuries,'' said Lt. Col. Stephen M. 
     Smith, executive officer of the Baghdad facility, ``are 
     horrific.''
       By design, the Baghdad hospital sees the worst. Unlike its 
     sister hospital on a sprawling air base located in Balad, 
     north of the capital, the staff of 300 in Baghdad includes 
     the only ophthalmology and neurology surgical teams in Iraq, 
     so if a victim has damage to the head, the medevac sets out 
     for the facility here, located in the heavily fortified 
     coalition headquarters known as the Green Zone.
       Once there, doctors scramble. A patient might remain in the 
     combat hospital for only six hours. The goal is lightning-
     swift, expert treatment, followed as quickly as possible by 
     transfer to the military hospital in Landstuhl, Germany.
       While waiting for what one senior officer wearily calls 
     ``the flippin' helicopters,'' the Baghdad medical staff 
     studies photos of wounds they used to see once or twice in a 
     military campaign but now treat every day. And they struggle 
     with the implications of a system that can move a wounded 
     soldier from a booby-trapped roadside to an operating room in 
     less than an hour.
       ``We're saving more people than should be saved, 
     probably,'' Lt. Col. Robert Carroll said. ``We're saving 
     severely injured people. Legs. Eyes. Part of the brain.''
       Carroll, an eye surgeon from Waynesville, Mo., sat at his 
     desk during a rare slow night last Wednesday and called up a 
     digital photo on his laptop computer. The image was of a 
     brain opened for surgery earlier that day, the skull neatly 
     lifted away, most of the organ healthy and pink. But a thumb-
     sized section behind the ear was gray.
       ``See all that dark stuff? That's dead brain,'' he said. 
     ``That ain't gonna regenerate. And that's not uncommon. 
     That's really not uncommon. We do craniotomies on average, 
     lately, of one a day.''
       ``We can save you,'' the surgeon said. ``You might not be 
     what you were.''
       Accurate statistics are not yet available on recovery from 
     this new round of battlefield brain injuries, an obstacle 
     that frustrates combat surgeons. But judging by medical 
     literature and surgeons' experience with their own patients, 
     ``three or four months from now 50 to 60 percent will be 
     functional and doing things,'' said Maj. Richard Gullick.
       ``Functional,'' he said, means ``up and around, but with 
     pretty significant disabilities,'' including paralysis.
       The remaining 40 percent to 50 percent of patients include 
     those whom the surgeons send to Europe, and on to the United 
     States, with no prospect of regaining consciousness. The 
     practice, subject to review after gathering feedback from 
     families, assumes that loved ones will find value in holding 
     the soldier's hand before confronting the decision to remove 
     life support.
       ``I'm actually glad I'm here and not at home, tending to 
     all the social issues with all these broken soldiers,'' 
     Carroll said.
       But the toll on the combat medical staff is itself acute, 
     and unrelenting.
       In a comprehensive Army survey of troop morale across Iraq, 
     taken in September, the unit with the lowest spirits was the 
     one that ran the combat hospitals until the 31st arrived in 
     late January. The three months since then have been 
     substantially more intense.
       ``We've all reached our saturation for drama trauma,'' said 
     Maj. Greg Kidwell, head nurse in the emergency room.
       On April 4, the hospital received 36 wounded in four hours. 
     A U.S. patrol in Baghdad's Sadr City slum was ambushed at 
     dusk, and the battle for the Shiite Muslim neighborhood 
     lasted most of the night. The event qualified as a ``mass 
     casualty,'' defined as more casualties than can be 
     accommodated by the 10 trauma beds in the emergency room.
       ``I'd never really seen a `mass cal' before April 4,'' said 
     Lt. Col. John Xenos, an orthopedic surgeon from Fairfax. 
     ``And it just kept coming and coming. I think that week we 
     had three or four mass cals.''
       The ambush heralded a wave of attacks by a Shiite militia 
     across southern Iraq. The next morning, another front erupted 
     when Marines cordoned off Fallujah, a restive, largely Sunni 
     city west of Baghdad. The engagements there led to record 
     casualties.
       ``Intellectually, you tell yourself you're prepared,'' said 
     Gullick, from San Antonio. ``You do the reading. You study 
     the slides. But being here . . . .'' His voice trailed off.
       ``It's just the sheer volume.''
       In part, the surge in casualties reflects more frequent 
     firefights after a year in which roadside bombings made up 
     the bulk of attacks on U.S. forces. At the same time, 
     insurgents began planting improvised explosive devices (IEDs) 
     in what one officer called ``ridiculous numbers.''
       The improvised bombs are extraordinarily destructive. 
     Typically fashioned from artillery shells, they may be packed 
     with such debris as broken glass, nails, sometimes even 
     gravel. They're detonated by remote control as a Humvee or 
     truck passes by, and they explode upward.
       To protect against the blasts, the U.S. military has 
     wrapped many of its vehicles in armor. When Xenos, the 
     orthopedist, treats limbs shredded by an IED blast, it is 
     usually ``an elbow stuck out of a window, or an arm.''
       Troops wear armor as well, providing protection that 
     Gullick called ``orders of magnitude from what we've had 
     before. But it just shifts the injury pattern from a lot of 
     abdominal injuries to extremity and head and face wounds.''
       The Army gunner whom Poffenbarger was preparing for the 
     flight to Germany had his skull pierced by four 155mm shells, 
     rigged to detonate one after another in what soldiers call a 
     ``daisy chain.'' The shrapnel took a fortunate route through 
     his brain, however, and ``when all is said and done, he 
     should be independent. . . . He'll have speech, cognition, 
     vision.''
       On a nearby stretcher, Staff Sgt. Rene Fernandez struggled 
     to see from eyes bruised nearly shut.
       ``We were clearing the area and an IED went off,'' he said, 
     describing an incident outside the western city of Ramadi 
     where his unit was patrolling on foot.
       The Houston native counted himself lucky, escaping with a 
     concussion and the temporary damage to his open, friendly 
     face. Waiting for his own hop to the hospital plane headed 
     north, he said what most soldiers tell surgeons: What he most 
     wanted was to return to his unit.

                                S. 2524

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. CENTERS FOR RESEARCH, EDUCATION, AND CLINICAL 
                   ACTIVITIES ON BLAST INJURIES OF VETERANS.

       (a) In General.--(1) Subchapter II of chapter 73 of title 
     38, United States Code, is amended by adding at the end the 
     following new section:

     ``Sec. 7327. Centers for research, education, and clinical 
       activities on blast injuries

       ``(a) Purpose.--The purpose of this section is to provide 
     for the improvement of the provision of health care services 
     and related rehabilitation and education services to eligible 
     veterans suffering from multiple traumas associated with a 
     blast injury through--
       ``(1) the conduct of research to support the provision of 
     such services in accordance with the most current evidence on 
     blast injuries;
       ``(2) the education and training of health care personnel 
     of the Department; and
       ``(3) the development of improved models and systems for 
     the furnishing of services by the Department for blast 
     injuries.
       ``(b) Establishment.--(1) The Secretary shall establish and 
     operate at least one, but not more than three, centers for 
     research, education, and clinical activities on blast 
     injuries.
       ``(2) Each center shall function as a center for--
       ``(A) research on blast injury to support the provision of 
     services in accordance with the most current evidence on 
     blast injuries, with such research to specifically address 
     injury epidemiology and cost, functional outcomes, blast 
     injury taxonomy and measurement system, and longitudinal 
     outcomes;
       ``(B) the development of a rehabilitation program for blast 
     injuries, including referral protocol, post-acute assessment, 
     and coordination of comprehensive treatment services;
       ``(C) the development of protocols to optimize linkages 
     between the Department and the Department of Defense on 
     matters relating to research, education, and clinical 
     activities on blast injuries;
       ``(D) the creation of innovative models for education and 
     outreach on health-care and related rehabilitation and 
     education services on blast injuries, with such education and 
     outreach to target those who have sustained a blast injury 
     and health care providers and researchers in the Veterans 
     Health Administration, the Department of Defense, and the 
     Department of Homeland Security;
       ``(E) the development of educational tools and products on 
     blast injuries, and the maintenance of such tools and 
     products in a resource clearinghouse that can serve as 
     resources for the Veterans Health Administration, the 
     Department of Defense, the Department of Homeland Security, 
     and other departments and agencies of the Federal Government;
       ``(F) the development of interdisciplinary training 
     programs on the provision of health care and rehabilitation 
     care services for blast injuries that provide an integrated 
     understanding of the continuum of care for such injuries to 
     the broad range of providers of such services, including 
     first responders, acute-care providers, and rehabilitation 
     service providers; and
       ``(G) the implementation of strategies for improving the 
     medical diagnostic coding of blast injuries in the Department 
     to reliably identify veterans with blast injuries and track 
     outcomes over time.
       ``(3) The Secretary shall designate a designate a center or 
     centers under this section upon the recommendation of the 
     Under Secretary for Health.
       ``(4) The Secretary may designate a center under this 
     section only if--
       ``(A) the proposal submitted for the designation of the 
     center meets the requirements of subsection (c);

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       ``(B) the Secretary makes the finding described in 
     subsection (d); and
       ``(C) the peer review panel established under subsection 
     (e) makes the determination specified in subsection (e)(3) 
     with respect to that proposal.
       ``(5) The authority of the Secretary to establish and 
     operate centers under this section is subject to the 
     appropriation of funds for that purpose.
       ``(c) Proposal Requirements.--A proposal submitted for the 
     designation of a center under this section shall--
       ``(1) provide for close collaboration in the establishment 
     and operation of the center, and for the provision of care 
     and the conduct of research and education at the center, by a 
     Department facility or facilities (in this subsection 
     referred to as the `collaborating facilities') in the same 
     geographic area that have a mission centered on the care of 
     individuals with blast injuries and a Department facility in 
     that area which has a mission of providing tertiary medical 
     care;
       ``(2) provide that not less than 50 percent of the funds 
     appropriated for the center for support of clinical care, 
     research, and education will be provided to the collaborating 
     facilities with respect to the center; and
       ``(3) provide for a governance arrangement among the 
     facilities described in paragraph (1) with respect to the 
     center that ensures that the center will be established and 
     operated in a manner aimed at improving the quality of care 
     for blast injuries at the collaborating facilities with 
     respect to the center.
       ``(d) Findings Relating to Proposals.--The finding referred 
     to in subsection (b)(4)(B) with respect to a proposal for the 
     designation of a site as a location of a center under this 
     section is a finding by the Secretary, upon the 
     recommendation of the Under Secretary for Health, that the 
     facilities submitting the proposal have developed (or may 
     reasonably be anticipated to develop) each of the following:
       ``(1) An arrangement with an affiliated accredited medical 
     school or university that provides education and training in 
     disaster preparedness, homeland security, and biodefense.
       ``(2) Comprehensive and effective treatment services for 
     head injury, spinal cord injury, audiology, amputation, gait 
     and balance, and mental health.
       ``(3) The ability to attract scientists who have 
     demonstrated achievement in research--
       ``(A) into the evaluation of innovative approaches to the 
     rehabilitation of blast injuries; or
       ``(B) into the treatment of blast injuries.
       ``(4) The capability to evaluate effectively the activities 
     of the center, including activities relating to the 
     evaluation of specific efforts to improve the quality and 
     effectiveness of services on blast injuries that are provided 
     by the Department at or through individual facilities.
       ``(e) Departmental Support on Evaluation of Center 
     Proposals.--(1) In order to provide advice to assist the 
     Secretary and the Under Secretary for Health to carry out 
     their responsibilities under this section, the official 
     within the central office of the Veterans Health 
     Administration responsible for blast injury matters shall 
     establish a peer review panel to assess the scientific and 
     clinical merit of proposals that are submitted to the 
     Secretary for the designation of centers under this section.
       ``(2) The panel shall consist of experts in the fields of 
     research, education and training, and clinical care on blast 
     injuries. Members of the panel shall serve as consultants to 
     the Department.
       ``(3) The panel shall review each proposal submitted to the 
     panel by the official referred to in paragraph (1) and shall 
     submit to that official its views on the relative scientific 
     and clinical merit of each such proposal. The panel shall 
     specifically determine with respect to each such proposal 
     whether or not that proposal is among those proposals which 
     have met the highest competitive standards of scientific and 
     clinical merit.
       ``(4) The panel shall not be subject to the Federal 
     Advisory Committee Act (5 U.S.C. App.).
       ``(f) Award of Funding.--Clinical and scientific 
     investigation activities at each center established under 
     this section--
       ``(1) may compete for the award of funding from amounts 
     appropriated for the Department for medical and prosthetics 
     research; and
       ``(2) shall receive priority in the award of funding from 
     such amounts insofar as funds are awarded from such amounts 
     to projects and activities relating to blast injuries.
       ``(g) Dissemination of Information.--(1) The Under 
     Secretary for Health shall ensure that information produced 
     by the centers established under this section that may be 
     useful for other activities of the Veterans Health 
     Administration is disseminated throughout the Administration.
       ``(2) Information shall be disseminated under this 
     subsection through publications, through programs of 
     continuing medical and related education provided through 
     regional medical education centers under subchapter VI of 
     chapter 74 of this title, and through other means. Such 
     programs of continuing medical education shall receive 
     priority in the award of funding.
       ``(h) Supervision.--The official within the central office 
     of the Veterans Health Administration responsible for blast 
     injury matters shall be responsible for supervising the 
     operation of the centers established under this section and 
     shall provide for ongoing evaluation of the centers and their 
     compliance with the requirements of this section.
       ``(i) Authorization of Appropriations.--(1) There are 
     authorized to be appropriated to the Department of Veterans 
     Affairs for the centers established under this section 
     amounts as follows:
       ``(A) $3,125,000 for fiscal year 2005.
       ``(B) $6,250,000 for each of fiscal years 2006 through 
     2008.
       ``(2) In addition to amounts authorized to be appropriated 
     by paragraph (1) for a fiscal year, the Under Secretary for 
     Health shall allocate to each center established under this 
     section, from other funds authorized to be appropriated for 
     such fiscal year for the Department generally for medical and 
     for medical and prosthetics research, such additional amounts 
     as the Under Secretary for Health determines appropriate to 
     carry out the purpose of this section.''.
       (2) The table of sections at the beginning of chapter 73 is 
     amended by inserting after the item relating to section 7326, 
     the following new item:

``7327. Centers for research, education, and clinical activities on 
              blast injuries''

     .  (b) Designation of Centers.--The Secretary of Veterans 
     Affairs shall designate at least one center for research, 
     education, and clinical activities on blast injuries as 
     required by section 7327 of title 38, United States Code (as 
     added by subsection (a)), not later than January 1, 2005.
       (c) Annual Reports.--(1) Not later than February 1 of each 
     of 2006, 2007, and 2008, the Secretary shall submit to the 
     Committees on Veterans' Affairs of the Senate and House of 
     Representatives a report on the status and activities during 
     the previous fiscal year of the center for research, 
     education, and clinical activities on blast injuries 
     established under section 7327 of title 38, United States 
     Code (as so added). Each such report shall include the 
     following:
       (A) A description of the activities carried out at each 
     center, and the funding provided for such activities.
       (B) A description of the advances made at each of the 
     participating facilities of the each center in research, 
     education and training, and clinical activities on blast 
     injuries .
       (C) A description of the actions taken by the Under 
     Secretary for Health pursuant to subsection (g) of that 
     section (as so added) to disseminate information derived from 
     such activities throughout the Veterans Health 
     Administration.
       (D) The assessment of the Secretary of the effectiveness of 
     the centers in fulfilling the purposes of the centers.
                                 ______