[inaudible [inaudible conversations] the hearing will i welcome you all. [inaudible] we have a profound responsibility to do all that we can do. [inaudible] that could be trouble. All right. Can we get the rest on record as i get started here quick servicemembers put their lives and their health on the line when they put on theirand in return they have a profound responsibility to make sure that the nation is doing all that it can to keep us safe, to training casualties and provide the best possible care for those who are injured. We are holding this hearing because dod is not meeting its responsibility when it comes to traumatic brain injuries and other injuries that result from firing weapons. Injuries from the pressure thats caused by a shockwave that exceeds the normal atmospheric values have been signature with wounds of the wars in iraq and in afghanistan. But there are also injuries incurred in training home. They are invisible but they affect thousands of Service People causing headaches seizures hallucinations and ultimately significantly increased risk of depression and suicide. Over the course of just three months in 2023 dod provided tbi treatment to servicemembers nearly 50,000 times. The more we learned the more we came to understand blast exposures and ongoing threat to the health of individual servicemembers and to the wellbeing and morale and readin of ourir the support ive had on this issue from Ranking Member scott senator ernst and senator tillis and other members of this committee. I secured a longterm study of the blast pressure and injuriesin 2018 the National Defense authorization act and worked with senator ernst to introduce legislation on blast overpressure and secured additional requirements to track blast overpressure injuries in fy2020 in daa. D. O. T. Is workingov to implement this legislation but we still have problems. Last year the new yorkve times reported a heightened brain injury risks for u. S. Troops in syria fighting isis. For artillery batteries assigned to the region fired more weapons than any military american artillery since the vietnam war. The result was that each of these units had members with serious blast overpressure injuries and each had a least one member that committed suicide. These deaths are tragic. Ryan and navy s. E. A. L. Deployed to iraq and afghanistan was subject to significant blast from his own weapons over the course of his career and later died by suicide. His father mr. Frank larkin is here today to discuss the harm that last overpressure has caused servicemembers. The times reveals that even whend made policy changes to address risks those changes were not evident on the ground. Weapons known to deliver shockwaves well above 50 threshold were still widely used. Training does not involve basic Safety Measures and special operations were not issued blast exposure gauges needed to track the threats. Dod and congress both have a lot to do. Its my agenda to address this problem first. We need to establish mitigation strategies specific to the servicemember roles that are most at risk for blast overpressure. Second, we must require dod to create last exposure and traumatic brain injury laws for all servicemembers and to integrate these laws into their pda and dod health care records. Third, the department of defense should partner with innovative evidencebased partners like home base to help servicemembers get the care they need and i am going to have to here for just a few minutes. Home base is a Nonprofit Organization founded by Massachusetts General Hospital and the Boston Red Sox to take care of the invisible wounds of veterans, servicemembers military families and families of the fallen. The home base at clinics in massachusetts and in florida. Ranking member scott town. It has a brain health and Trauma Program specifically designed for special operati servicemembers were its been leading innovative treatment for veterans with cooccurring Substance Abuse and Mental Health issues but as we work through the ndaa i want to support those programs work and i appreciate home base doctor joining us today. We need to make sure the dod number of rounds that our servicemembers can safely fire and this includes consideration of exposure limits over an extended period of time. Dod must do its part and Congress Must do our part. So to eyewitnesses welcome and thank you for appearing. We are going to have to panel today are the first panel will consist of outside witnesses to provide their perspective on dod and overpressure. Dr. Samantha mcbirney and frank larkin chief operating officer of Troops First Foundation and leap at the National Warrior initiative. The second panel will consist of officials from the department of defense and walter reed to hear hoodtackling this. We will have dr. Last year martinezlopez assistant secretary for Health Affairs cathy lee director of policy at dod and Carlos Williams the director at walter reed. Ill turn to mr. Scott for his opening comments. Verso want to thank senator warren and her subcommittee and thank you for caring about this issue and for taking this job so seriously. Suchis an important topic. Tbi is one of the most common injury sustained by american servicemembers. In 2022 more than 20,000 military personnel were diagnosed with tbi. Think about that for a second. In 2022 there were more than 20,000 members of the military diagnosed with a traumatic brain injury. The vast majority you are 84 were classified as mild which is more commonly known as a concussion. Many of those who have raised kids and they have a concussion that scares the living daylights out of you. Servicemembers are forgot exposed to lowlevel blast that typically result in a clinically diagnosed concussion but but this is concerning because repeat exposure to lowlevel blast me cause similar symptoms. Lowlevel blast exposure from firing heavy weapons may cause a variety of symptoms including concentration memory problems irritability headaches increased handeye coordination. Each of theseen issues alone can be serious and disruptive someones life. Unfortunately remains a great deal of exposure that we do not know. Our researchter data requires military to mitigate the frequency of blast exposure where possible and treat those exposed to blast where necessary. We have taken action to do that. The National Defense authorization act congress requires the department of defense to do mental study on blast overpressure. The Committee Received a final reporter the study of the hearing present an opportunit the quality of the departments work. The legislation requires the study of specific individuals own extended period of time to include three elements. The department wants to the monitor recorded and analyzed data on blast pressure exposure for any servicemember likely to be exposed to a blast in training or combat. The second study was to assess the feasibility and advisability including blast exposure and history of the servicemembers medical record. Er and review precautions of heavy weaponsfe training and hemerick in their ports its clear the Department Still has more work to do. Particular its ability to monitor mccord blessed exposures for military personnel. Only a few hundred soldiers and marines were fitted with wearable devices that seem to suffer from Quality Control issues. While the departments report does say itt may be feasible to record blast exposure information servicemembers medical records is required to determine the way forward. In this hearing is like to learn more about how the Department Plans to conduct its Business Case analysis. This important issue up with the department is committed to getting this right and i believe the tbi center of Excellence Health initiatives arecellent initiatives that i hope will provide an military with information needed to better understand the effects of repetitive blast exposure. We must remember exposure to lowlevel blast could create an unnecessary risk or combat troops. We can do better but you better quantify the type of blast that could cause signature significant perhaps run it entry and we can make better decisions about how best to accomplish that particular mission. I want to hear from the witnesses what congress can do to ensure the department of defense has the resources it needs to conduct its work in where we canfe help. This is aboute the wellbeing of individuals in uniform. They are closest to the front lines and every servicemember diagnosed with tbi. We owe to them to ensure when they go into harms way they are welltrained have the right protective equipment achieves an objective with the understanding of the risk involved. Thank you to all the witnesses were being cared and i look forward to your testimony. I want to thank warren for convening this hearing. Chairwoman warned Ranking Member scott a members of the committee that afternoon and thank you for the opportunity to testify today. My name is dr. Beyer and im a bio engineer at the corporation. A researcher last 15 years not only a at but also the university of californiaberkeley and the university of Southern California and focused under dramatic brain injury today as a result of the impact in blessed overpressure. Today ies would like to speak with you about repeated exposure to lowlevel military occupational blast which are lowlevel blast exposures experienced while fulfilling occupational military duties. Evidence suggests servicemembers are exposed to these blast in the form of last overpressure where the pressure waves in an explosion. Theat pressure wave can cause concussion injuries which are not immediately detectable and did not qualify as tbi. Sure to blessed overpressure can occur both in combat and training as its been mentioned. During Training Exercise in the firing of increasingly powerfulul Weapons Systems. To provide some perspective on the level of exposure some servicemembers have one study found up to 32 of blast experience by instructors ask seated the recommended exposure. The cumulative effects of repeated lowlevel blast exposure can cause its similar to tbi but what variety of effects have been linked to lowlevel blast exposure as senator warner and senator scott have already mentioned there remains a lack of Scientific Evidence linking repeated exposure tone injury. One reason this is the difficulty of diagnosis. The very nature of lowlevel blast exposure is the fact its not one single event keynote of effects of repeated exposure over time. Symptoms typical manifest immediately whichms makes it unlikely that repeated exposure to lowlevel classes identified as the cause. Additionally injury is vastly underreported only obfuscating the issue of proper diagnosis. Theres also a lack of research occupational specialties at greatest risk of exposure to lowlevel blast. While theress no doubt certain occupational casualties or more expose and others are so research to support these hypotheses. There remains a lack of understanding of the direct impact of repeated exposures to lowlevel blast have on the health of servicemembers and occupational specialties. It cannot be delivered in time then its not useful. This go back from a 2019 report perfectly describes the current state and the reason many of us are here today. As the Research Committee we see th to be done however there are steps dod can make out of that affects servicemembers against blastighlight for recommendations in my written testimony in a bit like to bring your attention to one of them here. The creation and maintenance of blast exposure records previous record should include a number of exposures the context of each exposure and any mental or emotional ethics resulting from the exposure. This would allow the dod to better track exposure frequency among highrisk occupational ies, determine the connection between exposure and Health Outcomes and develop strategies to mitigate exposure ing environments. These records could be used to develop combat readiness and health risks. As their Weapon Systems continue to become more against an increasingly powerful lowlevel military occupational blast will remain at challenge for servicemembers. Addressing the issue of repeatedng exposure to blessed necessitate actionth and collaboration between dod and the community. Continued Research Efforts to close a substantial knowledge gap the dod has made significant strides to protecting the health and wellbeing of her servicemembers. Thank you and i look forward to your questions. Good afternoon chairwoman warren and Ranking MemberScott America the committee. Im honored to provide testament today entremed a brain injury and blast exposure. My career is centered around improving the lives of people with traumatic brain injury. He currently serves president spalding chair of the Rehabilitation Department at Harvard Medical School chief of the department of physical rehabilitation at the General Hospital in brigham and Womens Hospital and for the past 15 years excerpt as a Home Based Program directing its program. I actually do the research. Last overpressure is the sudden onset of the pressure wave from explosions occurring with ent in reaching buildings and improvised explosive devices. The bigger the explosion the more damaging the pressure wave. Tbi can have a wide range of physical and physiological effects that sometimes appear immediately. Others take days or weeks to occur. If since 2,004,000 u. S. Servicemembers experience at least one brain injury and 40 of those screened positive for comorbid Psychological Health conditions. Our own research has noted an elevated 10 year risk of hypertension cardiac disease endocrine or hormonal dysfunction and behavioral concerns such as depression even among the youngest ofie pat home base is located in massachusetts and which im proud to say as a native locations in florida in arizona offering one of the oldest and most impactful privatesector programs in the nation. For 15 years we service and a debater for innovative clinical model and research. To leverage the burgum Health System. Home base bridges the gap between research and clinical work. In 2018 home base was approached by the, negative social warfare with the problem facing navy s. E. A. L. S. But we quickly developed a conference of brain injury program. This program was named combathealth Treatment Program modeled after existing programs will be developed to provide integrated multidisciplinary specialist treatment, evaluation and care coordination for veterans and activeduty operators. Ve home base is treated nearly a thousand special operators there are program. 71. 9 of combat participants are activeduty and the overwhelming majority returned to duty so we are keeping the fighting force active. We currently have 178 active duty special operators waiting to be screened for combat and operators in 47 states, the district of columbia, puerto rico including 53 patients from massachusetts, 50 from florida six from connecticut, 22 from hawaii for from illinois, one from alaska and 54 from north carolina. Ombat program is highly efficient and preston to five day models. Patients a minimum of nine providers related to pertinent diagnostic imaging and other studies. We are grateful for the support especially chairwoman warren has shown this program the partnership and Financial Support provided. The program is successful and demand for care is growing at a steady pace. Treating patients at home base i would recommend the department of defense consider the following options. Invest and develop tools to measure [inaudible] funding, and sure all the traumatic brain injury get care. Develop novel the impacts the Health Effects and innovative measures. I also recommend the department of Homeland Security should develop on the multisystem advance and research for repeated brainies. Thank you for the opportunity to testify on this very important topic in your commitment to supporting us. Im happy to answer questions. Thank you dr. Zafonte. Thank you for the opportunity to testify. Where a voice for all those who wear the uniform. Wounds that transcend mental physical and spiritual wounds and knott [inaudible] [inaudible] following the combat for iraq and afghanistan, that manifest in difficulty sleeping hypervisual. He stopped smiling. He sought help but not what he needed. When the condition became complicated and the proposed solutions did not work, it pushed him out. It created more deep wounds. Year [inaudible] the navy he ended his life. He said something is wrong with my head. No one is listening, they keep telling me i am crazy. These are medications that were provided but did not help. It did not get to the root cause of the challenge [no audio ] no audio ] he was given 40 different medications. He never received a clinical diagnosis. He made me promise if anything ever happened to him he wanted his body donated to the tbi research. He then turned to me, no, dad, it will take more guys to kill themselves before the system wakes up and sees the problem. His body was donated. Two months we learned he had undiagnosed brain injury related to repeated blast ex [inaudible] died from his injuries suffered both in training for combat and combat operations. He didnt just die right away. These ones are hurt. They are not broken. They br