This document provides an overview of a presentation given by William A. Duncan to the Independent Football Veterans Conference in Las Vegas on April 21, 2012. The presentation discusses using hyperbaric oxygen therapy (HBOT) to treat mild traumatic brain injuries and other conditions in athletes and military veterans. It summarizes research showing that HBOT can help repair brain tissue by restoring metabolism, reducing inflammation, and promoting growth and healing. Specific examples are given of HBOT helping conditions like concussions, PTSD, and non-healing wounds. The presentation promotes further applying HBOT through organizations like IHMA and IHMF to help injured athletes and veterans.

1. IHMA & IHMF: Sister Organizations Translating
Science into Medical Practice and Public Policy to
Create Healthcare Solutions for the 21st Century
Using Aerospace Medicine in 21st Century Medical Practice
Presentation to:
Independent Football Veterans Conference
Las Vegas, Nevada
April 21, 2012
Practical Hyperbaric Medicine for Athletes &
Recovering Athletes
Using the Principles of Translational Medicine
William A. Duncan, Ph.D.
Vice President for Government Affairs, IHMA
Vice President of Development, IHMF

2. Football is Dangerous!
“We Might
Have to Do
Away with
Football”
Statement from a U.S. Congress member

3. Fact: Many Sports are Prone to Head Injury
Do we do away with all of them?
• Soccer
• Cheerleading
• Snow Boarding
• Skiing
• Rugby
• Horse Sports
• Prize Fighting
• Rodeo

4. America’s Heroes Answered Our Nations Call
Military Medicine Reports 40% have been exposed to blast and RAND reports
Over 1/3rd have Suffered Traumatic Brain Injury and/or PTSD
• Brian Schiefer is an American Hero
• Joint Terminal Attack Controller (JTAC)
• 3.5 years to train
• One in 1,000 USAF Personnel Qualify
• Worth $5 million
• After 3 Deployments of over 20 months to Iraq and
Afghanistan, Brian was injured during a pre-deployment
training exercise at Fort Irwin, CA that left him paralyzed.
• He was not evaluated for a brain injury until almost a year
and a half after his accident even though incurring a skull
fracture to his temporal lobe which resulted in a loss of
consciousness.
• He was treated with the NBIRR-01 protocol, 80 treatments,
and his recovery has permitted him to regain his life and be
productive again.
• Brian joins many active duty war veterans who were able
to continue their careers in the military, and those who Brian Schiefer, USAF.
have returned to civilian life with great improvements in Many millions of tax dollars have
their quality of life and restored productivity. been saved because of
• See Brian’s Story at www.HyperbaricMedicalFoundation.org hyperbaric oxygen therapy!

5. Marine: Battle of Fallujah
Never Unconscious
Prior to 40 HBOT Treatments
Source: Patient’s Family

6. Football Player’s Brain: Avg 200
Concussions Before NFL Play
NFL Player & Combat Injuries
Similar Images of NFL Player Before & After
• The Damage from Multiple
Concussions in Sports is very similar
Before
to the Marine from Fallujah
HBOT
• Published Reports Estimate the
Average NFL Player has sustained 200
concussions before starting to play
professional football!
• This indicates a tremendous
biological reserve capacity in these
professional athletes brains!
• These athletes likely have “Genius After
Level” Reserve Capacity! HBOT
• (Discussion on Reserve Capacity: The
Oxygen Revolution-Harch-2010)

7. All of These Situations Can Lead to
an Untreated Brain Insult
• Plus Falls A 9 Mile Per Hour
Motor Vehicle
• Motor Vehicle Accidents Collision Can Leave
• Victims of Crime a Residual Brain
• Injury
Domestic Violence (UCLA Research)

8. Results of Untreated Brain Insults
• 50% Future Lifetime • Incarceration
Loss of Income • Anger Issues (including
• 45% Unemployed two Road Rage)
(2) years post injury • Sleep Disorders
• Early Retirement • Depression
• Early Onset Dementia • Compulsive Gambling
• Homelessness • Dysfunctional Family
• Substance Abuse Life
• Costs Society $60,000 • Suicide
Per Year!
One [Brain Injured Person] effects 40 others around them!
Alcoholics Anonymous Big Book

9. “Recovery” does not mean
“healed without residual effect”

10. Acute Injury? Minutes Matter
71.3 m
12.8 min
5.2 min

11. Current Reimbursed Largely Ineffective
Drug Treatments (Symptom
Management)
Suicides now exceed losses from combat casualties!
There is no drug currently approved by the •
•
Psychiatry (Con’t)
Antidepressents (All Black Label Warning Suicide)
FDA to treat TBI. The only drugs approved for • Celexa
PTSD are Zoloft and Paxil. All other treatment • Lexapro
with drugs for these conditions is off-label and • Prozac
All in Red carry a black label
intended to treat symptoms. In fact, a significant • Luvox warning for suicidality in
percentage of psychiatric medications are • *Paxil
those under age 25!
prescribed off-label. Further, the use of • *Zoloft
• Cymbalta
antipsychotics in these patients is often as a • The Veteran Suicide Rate is
Effexor
chemical restraint. • Wellbutrin
• Remeron
120 per week! (CDC Numbers)
The following list of drugs are FDA approved for • Desyrel
psychiatric and neurologic disorders. The great All in Red Fail to beat
majority of these drugs have been and are • Antimanic
Placebo yet Millions Spent!
currently prescribed by DoD Medicine off-label for • Tegretol
TBI/PTSD in the service members Dr. Harch has • Lamictal (Journal of Clinical Psychiatry, Nov 29, 2011)
treated with HBOT 1.5 in New Orleans. • Eskalith
• Topamax
Neurology: Psychiatry • Depakote
Alzheimer's Anti-anxiety •
• Ebixa Lectopam • Antipsychotics August 2, 2011: $717 million
• Klonopin Tranxene
• Clozaril spent by VA on Drug that does not
• Zyprexa
• Neurontin Valium • Seroquel
work!!!
• Lyrica • Risperdal DoD Could have repaired 176,000
• Geodon themselves w/ O2!
• Topamax • Abilify “Antipsychotic Doesn’t Ease Veterans’
• Dalmane
*FDA Approved for PTSD Post-Traumatic Stress, JAMA Published
• Symmetrel Study Finds” - NYTimes.com

12. Non-Healing Wound of the Foot
Diabetic Foot Ulcer: This Wagner Grade III was present for one
year and unresponsive to conventional therapy.
1 Day Prior to Scheduled Amputation 26 HBOT Treatments
Hyperbaric Oxygenation prevents
75% of amputations in diabetic patients.
Therapy approved by CMS for Medicare
upon application by IHMA to CMS for
coverage, 2003.
These photographs are the property of Kenneth P. Stoller, MD, FAAP
Permission given by Dr. Stoller to the IHMA to publish on this CD (2004)
Copyright retained: Kenneth Stoller, M.D.,
50 HBOT Treatments 2010 & IHMA

13. Solution?
Biologically Repair the Brain
Case Published in: Cases Report June 2009 http://casesjournal.com/casesjournal/rt/suppFiles/6538/31370

14. Brain Insults often Result in a 50%
Decrease In Brain Metabolism
HBOT Restores Brain Metabolism
Case Published in: Cases Report June 2009 http://casesjournal.com/casesjournal/rt/suppFiles/6538/31370

15. Solution: It’s Just Oxygen!
Oxygen is being used to repair an injury caused by a lack of oxygen!
• O2 used in 5,769+ cellular processes Pressure causes
• HBOT activates 8,101 Genes! oxygen to
– Down Regulates Inflammation Processes
– Up Regulates Growth & Repair Processes saturate tissues
– Normobaric O2 does not! at 7x to 12x
• Simple: Lack of oxygen is bad normal breathing.
• We know how it works
– Acutely stops swelling/reperfusion injury
– Restarts stunned cellular metabolism
– Regrows Blood Vessels
– Activates Stem Cells 8x Normal
• No wound can heal without oxygen
– Wounds that have not healed do
– Wounds heal 50% faster with less scar tissue
– Broken bones 30% faster & 30% stronger
• Placebos have to have the potential of HBOT is FDA-approved & available &
being inert. Saturating injured tissue with oxygen On-Label for neurological conditions &
has never been shown to have a placebo effect! non-healing wounds!

16. Results Speak for Themselves
• NBIRR-01 Begins Enrolling Patients March 2010. Preliminary Results from multi-site study support
Harch’s Findings.
• LSU Pilot Published in the Journal of Neurotrauma, J Neurotrauma. 2011 Oct 25. A Phase I Study of Low
Pressure Hyperbaric Oxygen Therapy for Blast-Induced Post Concussion Syndrome and Post Traumatic
Stress Disorder PMID: 22026588
– Subjects as a group showed significant improvements on most measures of intelligence, function
and quality of life
– All subjects received 1/2 the clinically recommended protocol being used in NBIRR-01 (
NCT01105962)
– Nearly 15 point IQ Increase (average) (Difference between a high school dropout & a college
graduate)(14.8 P<.001 )
– Post-Concussion Syndrome (PCS): 39% Reduction in PCS symptoms (p=0.0002); 87% substantial
headache reduction
– 30% Improvement in PTSD (20 points of a 62 point scale; a patient must score 50 on to have PTSD
“diagnosis”)
– 51% Reduction in Depression Indices with Large Reduction in Suicide Ideation(p=0.0002)
– 64% had a reduced need for psychoactive or narcotic prescription medications
– 92% reported sustained improvement 6 months post treatment
– Functional Improvements: Cognitive 39% (p=0.002); Physical 45% (p<0.001); Emotional 96%
(p<0.001)
• Significant Reduction in Anger Issues!
– Placebo Effect Ruled Out! Results too great to be placebo effect and neurological imaging is
inconsistent with a placebo effect

17. HOPS: Translating Known Science
into Medical Practice
• Athletes (Professional & Amateur) have four basic problems
– Acute Untreated Brain Insults
– Chronic Untreated Brain Insults (prior injuries)
– Blunt Trauma Injury & pulled Tendons
– Need for Recovery After Strenuous Training
– Injuries that may require surgical intervention
• IHMF’s Hospital Outcomes & Profit System (HOPS), creates a
system that enables acute delivery of consistent HBOT
protocols for all indications.
Hyperbaric Medical Protocols Currently
Exist for ALL of these Challenges

18. As A Professional Football Player
Step 1
• Step 1: Reset the Brain’s Reserve Capacity & Function
– 80 HBOT 1.5 NBIRR-01 Protocol Treatments & Evaluate
– Reserve Capacity Detailed in Harch’s Oxygen Revolution,
2nd Edition, pages 120-128
– NFL Players have Genius Level Reserve Capacity
• Reportedly NFL players have sustained, on average 200
concussions BEFORE they start playing pro ball.
• Top 1% of High School to College Ball, to 1% of College
Ball to NFL
• Olympic Level Athletes
• Recover Reaction Time, IQ, Executive Function, Memory &
Processing Speed

19. As A Professional Football Player
Step 2
• Receive Acute HBOT Treatment for any NEW
Concussions Using the IHMF’s Acute Brain
Insult Protocol (NBIRR-11)
• Receive Acute “Sports Injury or Falls” HBOT
Treatment for Concussions (NBIRR-11), Blunt Trauma
(ACTS-08) or Spinal Cord (Acts-11) or Fracture Protocol
(ACTS-09) (Combined as ACTS-05 & ACTS-01 Respectively)
• Have Pre-Post Surgery (ACTS-06) for any
surgical interventions or repairs

20. Returning Athletes to Competition
• U.S. Olympic Team
– Treated at San Diego
IHMF-NBIRR Site
– Sports Injuries
– Concussions
– Summer & Winter Sports
• U.S. Navy SEALs &
SOCOM Members
– Treated for Fractures
– Treated for Knee
Replacement
– Treated for TBI and PTSD

21. Fractures
• Air Force Research
Demonstrated that Fractures
heal 30% faster and 30%
stronger when Hyperbaric
Oxygen is used.
• Shorter back to work time
• Stronger Fusion
• Cost Effective through
reduced down time
The effect of hyperbaric oxygen on fracture healing in rabbits, completed 2003. J Wright

22. Is Hyperbaric Medicine Safe?
Source: “HBOT for TBI” Consensus Conference, December 2008
• Treatment involves • The DoD White Paper
simply breathing pure stated: “side effects are
oxygen under pressure uncommon and severe or
permanent complications
(often while sleeping or
are rare…” (White Paper for
watching TV). the HBOT in TBI Consensus Paper,
• Ten thousand plus 12/08)
• The DoD After Action
similar treatments are
Report stated: “safety of
given every day at the treatment is not an
1,200+ locations issue.” (After Action Report HBOT in TBI
nationwide for other Consensus Conference, Defense Centers of
Excellence, 16 Dec 2008)
indications.

23. Examples: HBOT is Synergistic
with Other Treatments
• Drug Protocols • Cognitive Rehabilitation
– Patients in the LSU Study – Treatment Cannot Begin
were on no medication or until a Patient can Sleep
less medication Through the Night
– Medication was now more – HBOT Repairs Sleep Cycles
effective at controlling and most Patients can begin
symptoms sleeping at 10 HBOT
• Nutritional Programs Treatments
– NBIRR Nutritional Program – When Brain Tissue is
reduced Aberrant Violent Recovered, it is somewhat
Behavior in Felons in 30 RCT disorganized!
Studies by 39-41% • Acupuncture
– Harch did not use NBIRR • Bio-Feedback
supplement in his study • Counseling & Coping Skills

24. 24
Image Courtesy of Dr.

25. Retired NFL Player: Age 58
Pre-Post HBOT 1.5
4+ NFL Players now treated with similar results
Source: MicroCog Assessment-- Independent Evaluation by Amen Clinic. NBIRR Subject Courtesy of Dr. Stoller

26. Example of TBI impact assessment in NFL Player
Enlarged Fiber Tract showing
• NFL football player with fibers from concussive event
concussion
• Loss of about 2% of the
fiber tracts in the region of
the corpus callosum.
Courtesy Dr. Walter Schneider,
U Pittsburgh [fMRI photo]
Area of Tissue change Fibers passing through areas

27. Severe TBI Patient: Whole Brain CT Perfusion Pre & Post HBOT
Pre HBOT – 10/16/09 Post HBOT – 10/28/09
Images Courtesy of Dr. Germin, Las Vegas

28. IHMF’s National Brain Injury Rescue and Rehabilitation Project
NBIRR-01: Mild-Moderate TBI Ages 18-65
• 1,000 patients with mTBI • All participants have
and/or PTSD ANY CAUSE improved
• 17+ centers • Most improved in every
• All receive HBOT measure
• Early results encouraging • Most improved
• 35 participants in treatment substantially
(Mar 2011) • No participants worsened
• Results are durable
Many are U.S. War Veterans who have had to be treated
“for free” by the clinics as charity cases!
NBIRR Study, see: http://www.clinicaltrials.gov/ct2/show/NCT01105962

29. John Eisenberg Treatment Registry (JETR) Provides Structure for
the NBIRR-01 HBOT 1.5 TBI/PTSD Study &
Is a Clinical Research Platform for Translational Medicine Powered by CareVector®
• Platform Follows FDA-Devices
Methodology for Medical Evidence
–
IRB Workflow
Supports Multi-Site World-Wide Studies
– Online Data Entry Forms
– Security Roles protect patient privacy
• Site Records all DoD ANAM Test Scores Identify
& all Other Diagnostics Patient
• Screening &
Web-based Reporting & Analysis Capture Demographics
– 3rd Party Payer/Policy Auditing as Requested
– Analysis Tools Available to Auditors Pre-Rx Exam
– Permits CMS “Coverage with Evidence” Rules & Testing
• All Patients get Real Treatment No Placebo!
• NO BARRIER To 3rd Party Reimbursement Treatments
– (40 HBOT)
Normally “Study” treatments are not
reimbursable because of placebo (no) Post-Rx Exam
treatment provided. This study design permits & Testing
3rd party payers to pay for treatment and have
it tracked for analysis and rapid proofing. Analysis &
– Willing to only be paid when the treatment Reporting
works under the rules of HR 396, TBI
Treatment Act Patient
• Evidence-based Medicine Rules & Bayesian Follow-up
Analysis Permits
– Rapid Publication & Potential FDA Marketing JETR is a Tool Permitting Practitioners to Proof
Approval Off-Label Uses for FDA-approved or cleared
– Rapid 3rd Party Payment for New Indications Drugs & Devices & Build Treatment Protocols

30. AK
Nationwide Location of Clinics participating in N-BIRR HBOT 1.5 Study
Sponsor: International Hyperbaric Medical Foundation
See: http://www.clinicaltrials.gov/ct2/show/NCT01105962
This is a Multi-Center Study
Locations of Clinics
participating in N-BIRR
HBOT 1.5 Study
Sponsor: International
HI Hyperbaric Medical
Foundation
WIRB-Approved Active Clinics See:
http://www.clinicalt
Clinics available to join rials.gov/ct2/show/
WIRB-Approved Clinics on standby NCT01105962
Warrior Transition Units in US
PR

31. Pre-Deployment Post-Deployment 40 HBOT 1.5s 80 HBOT 1.5s

32. Figure 1:
The passenger side of the M915 truck showing
the damage caused by the IED.
Conclusion by article authors:
Several aspects of these two cases demonstrate the efficacy of HBO for the airmen treated.
Although both airmen had stable symptoms of mTBI/post-concussive syndrome, which had not
improved for seven months; substantive improvement was achieved within ten days of HBO
treatment. The headaches and sleep disturbances improved rapidly while the irritability,
cognitive defects, and memory difficulties improved more slowly.
Fortunately both airman had taken the ANAM and presented objective demonstration of their
deficits from TBI and their improvements after HBO treatment. Both airmen, who were injured by
the same blast sitting side by side, had similar symptom complexes of TBI and improved at similar
rates after initiation of HBO treatment. Neither airman had any other form of treatment for TBI.
It seems unlikely to the authors that any explanation other than the HBO treatments can be
offered for their improvements.
“Case report: Treatment of Mild Traumatic Brain Injury with Hyperbaric Oxygen:
Colonel James K. Wright, USAF, MC, SFS; Eddie Zant, MD; Kevin Groom, PhD;
Robert E. Schlegel, PhD, PE; Kirby Gilliland, PhD”

33. ANAM Scores - pre-injury, post-injury, after HBOT
Budget Savings from Restoring 4 Military Personnel to Duty: $11.2 million
Long Term Additional Savings: $4 million ($15.2 million) Cost? $100,000
100%
50%
0

34. ANAM – CNSVS Comparison
Consistency Between Two Neuropsych Tests
Executive Function is a Measure of
the Person’s Ability to Function,
and Manage Their Daily Affairs
Change in ANAM Percentiles Improvement in Percentile CNSVS Scores
45.0 30.0
40.0
25.0
35.0
Percent Change
30.0 20.0
Percent Change
25.0
20.0 15.0
15.0
10.0
10.0
5.0 5.0
0.0
Δ Simple
Substitution -
reaction Time
Mathematical
Δ Matching to
Substitution -
Δ Simple
Reaction
Δ Procedural
Reaction
0.0
Time ®
Processing
Time
Learning
Delayed
Δ Code
Δ Code
Sample
Neurocognitive
Composite
Verbal Memory
Visual memory
Psychmotor
Reaction Time
Attention
Flexibility
Processing
Funtioning
Cognitive
Complex
Executive
Memory
Speed
Speed
Δ
Index
ANAM Test
N=26 All Patients completed at least 40 HBOT 1.5 treatments
Confidentiality Statement applies.

35. Physical Symptoms Questionnaire
Eliminated or Reduced Need For Pain or Sleep Medication:
Government Cost Savings as well as Quality of Life Improvement:
55% no drugs in Harch Pilot study. 45% reduced need for drugs!
Confidentiality Statement applies.

36. PHQ-9 Components 7-9
worse
Suicidal
PHQ 9 (7-9)
thoughts
Reduced!
1.6
1.2
Score
0.8
0.4
better
0
7. Pre HBOT 7. Post HBOT 8. Pre HBOT 8. Post HBOT 9. Pre HBOT 9. Post HBOT
Trouble Trouble Moving or Moving or Thoughts that Thoughts that
concentrating concentrating speaking so speaking so you would be you would be
on things on things slowly that slowly that better off dead better off dead
other people other people or hurting or hurting
could have could have yourself yourself
Pre HBOT “If ANY drug reduced or eliminated suicidal
thoughts, it should be fast-track researched
Post HBOT and adopted immediately!”
Confidentiality Statement applies. James Wright, M.D. (COL, MC, USAF, Ret.)

37. FDA Cleared HBOT Indications
HBOT as used by the team is currently in use for 13 FDA-cleared indications (which means the
manufacturer or practitioner can advertize those indications) by hundreds of physicians at
nearly 1,000 locations across the nation, delivering approximately 10,000 treatments per day.
The thirteen accepted indications for HBOT treatment include:
1. Air or gas embolism.
2. CO poisoning, CO poisoning complicated by cyanide poisoning (Neurological)
3. Clostridial myositis and myonecrosis (gas gangrene)
4. Crush injury, compartment syndrome, and other acute traumatic ischemias
5. Decompression sickness (Neurological)
• Arterial Insufficiency: (Non-Healing Wound)
Enhancement of healing in selected problem wounds (includes uses like Diabetic
Foot Wounds, Hypoxic Wounds, and other non-healing wounds, etc.)
7. Exceptional blood loss anemia
8. Intracranial abscess (Neurological)
9. Necrotizing soft tissue infections
10. Osteomyelitis (refractory)
11. Radiation tissue damage (soft tissue and bony necrosis) (Non-Healing Wound)
12. Skin grafts and flaps (compromised) (Non-Healing Wound)
13. Thermal burns[1]
[1] Hyperbaric Oxygen Therapy: 1999 Committee Report. Editor, N.B. Hampson. Undersea and Hyperbaric Medical Society, Kensington, MD. See also:
Harch PG. Application of HBOT to acute neurological conditions. Hyperbaric Medicine 1999, The 7th Annual Advanced Symposium. The Adams Mark
Hotel, Columbia, South Carolina, April 9-10, 1999; and Mitton C, Hailey D. Health technology assessment and policy decisions on hyperbaric oxygen
treatment. Int J of Tech Assess in Health Care, 1999;15(4):661-70.

38. HBOT:
MECHANISMS OF ACTION
HBOT’s mechanisms of action are well known and well
characterized both in scientific literature and in clinical practice.
Translational Medicine Methods are Necessary to make these
treatments for these conditions ROUTINE!

39. HBOT: It’s About Oxygen Saturation
The body’s liquids are saturated with more oxygen, helping areas with compromised circulation.
Before HBOT After HBOT
Image Courtesy of Dr.

40. HBOT: Its about the Mitochondria
Image Courtesy of Dr.

41. HBOT: It’s About Your Own Stem Cells
In humans, HBOT at 2.0 atm and 100% oxygen for 2
hours per treatment for 20 treatments increased the
number of circulating stem cells in the blood by 8-fold
Thom et al., 2006
Am J Physiol Heart Circ Physiol 290:1378-86
Image Courtesy of Dr.

42. HBOT works at the DNA level
• Decreases hypoxia-
inducible
factor-1α (hip-1α) &
multiple genes
related to apoptosis
• Inhibition of
apoptosis
(programmed cell
death) by HBOT
Zhang, JH et al. Neuroscience and Critical Care Yin, W Brain Res 926: 165-171
translates into brain
Badr et al 2001 brain Res 916: 85-90 Atochin, DN 2000 UHMS 27: 185-190 tissue preservation
Image Courtesy of Dr.

43. Micro Air Embolism Contribution to Blast-Induced Mild Traumatic Brain Injury
Reimers, SD1; Harch, PG2; Wright, JK3; Slade, JB4; Sonnenrein, R1; Doering, ND1
1
Reimers Systems, Inc., Lorton VA; 2 Clinical Associate Professor and Director; Wound Care and Hyperbaric Medicine Department, LSU School of Medicine, New Orleans, LA; 3Col., USAF MC (ret.), Butte MT; 4Baromedical Associates, Doctors Medical Center, San Pablo CA
INTRODUCTION Fig. 1: Blast Waves Are More Than Simple Shock Waves, Duration Makes a Difference
RESULTS (CON’D)
Massive air embolism (AE) from lung disruption is the accepted principal etiology of mortality in • In hemodialysis, CNS abnormalities attributed to microbubbles have been correlated with the
blast injury (White et al., 1971; Sharpnack, Johnson & Phillips, 1990). For sub-lethal blast injury, duration of dialysis treatment. Barak & Katz (2008) attributed the abnormalities to
air embolism has been ignored, considered innocuous or believed to have not occurred. The microbubbles and stated “a small quantity of microbubbles may be clinically silent, while
high incidence of post-concussion syndrome (PCS), neurocognitive deficits, and mental health recurrent exposure has a slow, smoldering, chronic effect” (p. 2921)
issues resulting from sub-lethal blast injuries in U.S. Iraq and Afghanistan War veterans has Recent Combat Medical Literature
vexed military authorities and medical specialists. We propose that micro air embolism is a • Bauman et al. (2009) provides a summary of the test conditions and initial results from the
heretofore unappreciated etiologic factor. PREVENT (Preventing Violent Explosive Neurotrauma) research program being conducted
by DARPA. In the tests reported (swine model), the thorax and upper abdomen were
protected to minimize the possibility of brain injury by indirect pathways. Some neurological
MATERIALS AND METHODS damage was observed, and its significance is still being determined. However, the test
conditions are of interest as they are also ones where lung injury can readily occur. Point C
Materials and Methods: Using PubMed, PsychInfo, Google Scholar, Sci.gov, and PubCrawler, a on Fig. 1 represents a typical Friedlander wave reported for the blast tube. Test set-ups were
systematic review of the literature was conducted identifying published papers in the following built to simulate exposures in the crew compartment of a Humvee with a blast under its floor
domains: biodynamics and physics of blast overpressure; primary blast injury; microbubbles in and an open gunner port and in semi-confined space (open top room with dimensions as
systemic circulation from diving and iatrogenic causes; neurological problems and microbubbles. shown in Fig 1). In both cases the overpressure durations from a moderate sized charge
When necessary, key documents were obtained from U.S. Government archives. Reference were reported to be about 4 ms. The overpressure data was reported in general form only
lists of articles were also scanned. Papers with both significant and null findings were included. without numerical values. However, at 4 ms duration, the pressures required to produce lung
injury are not large. In situations where the Humvee or building were to be fully closed, both
RESULTS the magnitude and duration of blast overpressures can be expected to be greater.
(Note 7) • Buamoul (2009) reports results from a computer model developed by Defence R & D
Blast-induced AE Canada (CRDC) for estimating the blast damage to the lungs of sheep and humans. He
• For mammals that die promptly from either air or underwater blast, air embolism has long reports the intra-thoracic pressure range currently accepted as the “threshold” for lung
been recognized as the primary cause of death (Desaga,1950; Shapnack, Johnson & Phillips, damage is 70 kPa (695 cmH20) to 110 kPa (1,091 cmH20), which corresponds roughly to
1990; Richmond & Damon, 1991). Lung disruption is proportional to both magnitude and the intra-thoracic pressures predicted by the model at exposures near the lung damage
length of blast overpressurization (Buamoul, 2009) with disruption beginning to occur at threshold line on the Bowen charts. The intra-thoracic pressures produced by even moderate
Notes to Fig. 1
modest overpressures easily within the range of pressures experienced by U.S. combat 2.Figure is based on the survival curves for a 70 kg man where the thorax is near a surface against which a blast wave reflects at normal size blasts can be very substantial (Fig. 3). They also vary widely with both time and location
troops from improvised explosive devices (IED) (Fig 1 & 3). incidence (Bowen, Fletcher, & Richmond,1968). data shown is for a single reflection where the total overpressure is ~2x incident in the lung, suggesting that opportunities for localized AE may be plentiful. The model also
• The disruption threshold is lowered by exposures near reflective surfaces, exposures inside pressure. Total pressures can be up to 8x incident pressure if circumstances are right (Richmond & Damon,1991). In free field exposures indicates that complex (multi-peak) blast waves can produce higher lung pressures, and
(no reflections) the damage thresholds are approx. 2x those shown. When used, free field pressure data values are plotted at 50% of
structures that impede dispersion of the blast gases, and by longer exposure times. It is therefore greater risk of lung damage than do single peak, classic Friedlander waves of the
actual.
further lowered by repeat exposures in less than 24 hours (Stuhmiller, Phillips & Richmond, 3. “Short” and “Long” refer to the ratio of the length of the overpressure region to thorax dimensions. Long blast waves produce much same impulse value.
1990). greater chest compression (White et al., 1971). • Recent work by Yang et al.,1996 (sheep model) suggests the lung damage threshold
• Benzinger (1950) concluded that because symptoms were only present when a blast hit the 4. Repeat exposures in less than 24 hours, lower the lung damage threshold (Stuhmiller, Phillips & Richmond 1990). pressure may be as much as 75% lower than the Bowen charts (Fig 1) indicate when
5.The lung damage threshold curve is based on an estimated damage threshold of 20% of the 50% mortality level (White et al., 1971).
thorax, air embolism must originate in the thorax and becomes effective when it travels to the the threshold pressure is taken as the lowest pressure at which lung tissue damage
Recent data (Yang et al., 1996) suggests the threshold pressures for lung damage may be lower (circa 50%) than those shown.
brain. Benzinger also found that small amounts of air in arterial circulation could readily 6.Blast waveform is also important. However, that is beyond what can be addressed in this poster. is observable by light and/or electron microscopy.
reproduce neurologic symptoms seen in blast injury to dogs and humans. Only 1 cc of air 7.A = shock wave period, B= period where expanding blast gases maintain compartment pressure a wave speed of Mach 1. Most blast
1. Based on • It is well established that AE is a possible/probable sequelae of exposure to air blast.
injected into the pulmonary veins of a dog was sufficient to reproduce the waves are faster (up to Mach 2+) increasing the
wave length for the same time.. • It is also well established that microbubbles are harmful to brains, and that symptoms may
electrocardiographic changes seen in blast-injured dogs (Phillips & Richmond, 1990). not manifest immediately.
• Maison (1971) outfitted a dog with a Doppler bubble detector on the carotid artery, exposed Fig. 2 Blood Velocity & Embolus Indications Following Canine Exposure to LD50 Air • Blast overpressure exposures typical of the current wars in Iraq and Afghanistan,
the dog to an LD50 air blast, and subsequently observed bursts of Doppler deflections going Blast particularly blast exposures in confined spaces, are sufficient to create risk of lung damage.
up the carotid correlating with respirations for approximately 30 minutes post-blast. The dog’s Quickly repeated exposures increase the risk.
carotid blood flow was observed to temporarily drop to near zero following each group of • It is reasonable to expect that the degree of blast-related AE is a continuum ranging from no
echoes, possibly indicating reduced blood velocity due to temporary distal occlusions (Fig. 2). bubbles, to a few microbubbles to massive amounts depending on the exposure.
The dog initially showed severe respiratory distress, but recovered. Postmortem exam • The blast-related intra-thoracic pressures can be very substantial (Fig 3). The range
showed evidence of residual lung hemorrhage, but no other damage. Maison concluded that customarily accepted as the threshold for lung injury is 7 to 11 times higher than the 80
the bubbles were “clinically silent”. mmHg (10.7 kPa) differential known to produce disruption of aveolar-capilary boundary
• A conceptual model of how AE sequelae to blast exposure occurs, confirmed with rabbit tissues in slowly varying pressure environments such as diving (Neuman, 1997).
model data, can be found in White (1971). Any fast-rising blast pressure wave long enough • Work by Yang, et. al (1996) suggests that lung tissue damage, and the concurrent
to produce significant chest compression is likely to produce some AE. possibility of transient microbubble release, can occur at lung damage levels insufficient to
• Goh (2009) and Mayo & Kleger (2006) in separate articles regarding civilian blast casualty produce clinical blast lung and at overpressures substantially lower than indicated by the
management advise that AE is a possible complication of exposure to air blast. However, widely-used Bowen charts.
neither author addresses the possibility of neurocognitive sequelae from AE. • The CRDC model confirms suggestions from prior efforts that complex blast waves typical
• Protective vests reduced mortality & neural fiber degeneration in rats exposed to air blast of confined space exposures are more likely to be damaging to lungs than are the simpler
(Long, et.al., 2009) waveforms typical of free-field blasts.
Evidence that microbubbles are NOT harmless • Blast related bubble production, when it does occur, has been shown to be transient, lasting
• Microbubbles were first recognized as a medical hazard in open-heart surgery decades ago only 15 minutes to 3 hours for significant AE (Mayo & Kluger, 1996). The duration of
(Barak & Katz 2005). Air emboli from various sources in the extracorporeal circulation (ECC) microbubble production can be expected to be shorter still making them hard to detect.
set and tubes can drift into the aorta and systemic circulation, carrying microbubbles to the • All recent publications that we found, including a recent review article (Cernak & Noble,
brain. Clinical results of this unwanted event include major and minor neurologic injury, Fig. 3 . Lung Injury Prediction from CRDC Model
2009), were silent on the possible role of microbubbles as a mechanism for blast-related
neurocognitive deterioration and an overall general decline in patient health (Barak, Nakhoul brain injury.
& Katz, 2008; Shaw et al., 1987). The degree of decline in cognitive performance has been • When all the factors that may favor microbubble production are considered, it is difficult to
correlated to the amount of air emboli delivered during the ECC (Deklunder et al., 19981,2). expect they do not occur.
Patients with neuropsychological deficits 5 to 7 days after coronary bypass graft surgery • Undetected arterial microbubbles have the potential to significantly confound research into
averaged nearly twice the number of emboli compared to those without deficits (Stump, et al., other mechanisms of blast-related brain injury. In research studies where there is a
1996). possibility of microbubble production, monitoring for their occurrence is
• In mechanical heart valve carriers, bubbles are chronically delivered into the arterial system at recommended.
variable rates, which can rise as high as 800 per hour in the cerebral circulation. Patients with
The contribution of micro air embolism to blast-related brain injury may
these devices have been found to have impairment in episodic memory and deficits in
working memory (Deklunder et al., 19981,2). Notes to Fig 3.
be significantly greater than has been previously believed.
• Multiple brain lesions in divers with no reported history of neurological DCS have been found 2.Data shown are peak intro-thoracic pressures and lung
damage estimates for a complex (2-peak) wave with a
Available literature suggests that transient AE from primary blast exposure is possible, perhaps
to be strongly correlated with patent foramen ovale of high haemodynamic relevance. This probable, at sub-lethal overpressures similar to the overpressures experienced by U.S. combat
total impulse considered “threshold” for lung damage in a
finding lead the authors to a hypothesis that the brain lesions were the consequence of free field (Point D in Fig. 1) Veterans. Arterial microbubbles have been shown to be neurologically harmful and may
subclinical cerebral gas embolism (Knauth et al., 1997). 3.Data from Yang, et.al (1996) suggests the threshold for contribute to the high incidence of post-concussion syndrome in blast injured veterans. Current
• A review of 140 cases of delayed DCS treatment (avg. delay 93.5 hrs) reported findings of “Trace” damage may be significantly lower that assumed
research efforts are almost exclusively focused on the direct cerebral effects of blast waves. The
neurocognitive symptoms including severely reduced executive function, apathy and by the CRDC model.
AE pathway deserves prompt and thorough investigation.
antisocial behavior in 49% of the patients. 100% of the neurocognitive symptoms resolved
Copyright: Reimers Systems, Inc. 2011, All rights
with hyperbaric oxygen therapy. (HBOT) (Cianci & Slade, 2006).
reserved.

44. Types of Hyperbaric Chambers

45. HR 396: TBI Treatment Act
• Subject must have TBI or PTSD and be a Veteran under 66
• Voluntarily Treated by Civilian Physician
• ANY FDA-approved or Cleared Treatment (Any Purpose)
• Must Improve to be Paid
– Neuropsych Testing (IQ, ANAM, CNS Vital Signs, etc.)
– Standardized Instruments (PCS, PTSD, Depression Scales)
– Neurological Imaging (Functional MRI, SPECT, QEEG)
– Clinical Examination (Coma State, Gate & Balance)
• Must be Enrolled in IRB-approved Study
• No Discrimination Against Practitioner for Any Reason
• Paid 30 days after presentation of valid bill to MM or VA
• Other necessary protections for the treated veteran

46. HR396: TBI Treatment Act (Con’t)
• Changes Focus from “Bureaucratic Decision” on Health Care
Coverage to:
– “What Actually Worked for the Patient?”
– ALL TREATMENT MODALITIES INCLUDED
• Outlines a “Rational” Way of Determining What Works and
What Doesn’t
• HC Provider is ONLY paid if the treatment works (True Pay for
Performance)
• All data is collected under OHRP Rules for Patient Protection
• Provides Valid Evidence-based Medicine data very
inexpensively! (10% of the cost of Standard NIH-funded
Study!)
• As a Principle of Federal Law, the Bill Radically Alters the
Ability of Patients to get Effective Treatment!

47. Case Presentation
Traumatic Brain Injury from Child Abuse
It is NEVER 48 y. male 45 Years After
Too Late! Injury!
Scan #1 Scan #2
Image Courtesy of Patient & Dr. Harch: 2002 IHMA Congressional Testimony

48. Own Your Own Future: Act Now!
• If you or a loved one have a history of TBI or
PTSD, and are between ages 18-65, enroll in
NBIRR and get treated NOW!
– $350 million treats all 14,000 living retired players
– Insist HBOT be covered by workers compensation
– Insist HBOT be covered by the “88” Plan
– Provide funds to a charity of your choice who will
pay for HBOT for retired football players & others
– The IHMF: Fund for Veterans and Football Players
• Write Congress about HR 396, the TBI
Treatment Act, at the IHMA website:
www.HyperbaricMedicalAssociation.org

49. THERE IS NO “I” IN TEAM!
• Unite and Change Treatment of Brain Injury
Forever!
• Save Football, Soccer, Sports for our Youth,
and help Athletes Recover from their Injuries
• Donate to the Independent Football Veterans
to help sustain those you enjoyed watching
in your youth.
• IHMF to get real treatment for Athletes with
Brain Injury!