R 311717Z MAY 12
UNCLASSIFIED//
MARADMIN 294/12
MSGID/GENADMIN/CMC WASHINGTON DC HS//
SUBJ/US MARINE CORPS TRAUMATIC BRAIN INJURY PROGRAM//
REF/A/MSGID: DTM 09-033//
REF/B/MARADMIN 633-08//
REF/C/MARADMIN 184-12//
NARR/REF A IS DEPUTY SECRETARY OF DEFENSE DIRECTIVE-TYPE MEMORANDUM RE POLICY GUIDANCE FOR MANAGEMENT OF MILD TRAUMATIC BRAIN INJURIES IN THE DEPLOYED SETTING; REF B IS USMC MARADMIN 633-08 RE BASELINE PRE-DEPLOYMENT NEUROCOGNITIVE ASSESSMENTS; REF C IS USMC MARADMIN 184-12 RE REVISION TO MEDICAL READINESS REPORTING SYSTEM (MRRS) NEUROCOGNITIVE ASSESSMENT TOOL (NCAT) TRAUMATIC BRAIN INJURY (TBI) TRACKING MODULE POLICY AND PROCEDURES FOR MARINE CORPS UNITS AND INSTALLATIONS//
POC/CAPT D. A. TARANTINO (USN), DIRECTOR FOR MEDICAL PROGRAMS, 703-604-4617 (DSN 224), DAVID.A.TARANTINO(AT)USMC.MIL//
GENTEXT/REMARKS/1. THIS MARADMIN PROVIDES DIRECTION FOR THE USMC COMPREHENSIVE TRAUMATIC BRAIN INJURY (TBI) PROGRAM.
2. TBI, INCLUDING MILD TBI (ALSO REFERRED TO AS CONCUSSION), IS A LEADING COMBAT INJURY IN CURRENT CONFLICTS, LARGELY AS A RESULT OF EXPOSURE TO IEDS. TBI, ESPECIALLY CONCUSSION, IS ALSO A SIGNIFICANT ISSUE IN GARRISON, LARGELY DUE TO MOTOR AND RECREATIONAL VEHICLE ACCIDENTS (MVA), SPORTS-RELATED INJURIES AND OTHER IMPACTS TO THE HEAD. THESE INJURIES CAN HAVE A SIGNIFICANT OPERATIONAL READINESS IMPACT AS WELL AS POTENTIAL LONG TERM HEALTH CONSEQUENCES.  CONCUSSION IS OFTEN AN INVISIBLE INJURY, WITH ONLY SUBTLE MANIFESTATIONS, WHICH REQUIRES CAREFUL MANAGEMENT BY LEADERSHIP AND MEDICAL PERSONNEL. TO ENSURE OPTIMAL READINESS AND PROVIDE APPROPRIATE CARE FOR ALL MARINES, THE MARINE CORPS IS TAKING A COMPREHENSIVE APPROACH TO TBI, EMPHASIZING THE CORE COMPONENTS OF PREVENT, PROVIDE, TRACK AND TRAIN. IMPLEMENTING THIS PROGRAM IS A LEADERSHIP AND MEDICAL RESPONSIBILITY IN GARRISON AND IN THE DEPLOYED SETTING.
3. THE OVERALL LEAD FOR THE MARINE CORPS TBI PROGRAM IS HQMC, HEALTH SERVICES (HS). THE LEAD USMC REPRESENTATIVE FOR GENERAL INTERSERVICE AND INTERAGENCY COORDINATION OF TBI EFFORTS IS THE DIRECTOR FOR MEDICAL PROGRAMS, HQMC (HS).
4. EXECUTIVE OVERSIGHT FOR THE USMC TBI PROGRAM WILL BE CONDUCTED BY THE US MARINE CORPS BEHAVIORAL HEALTH AND TRAUMATIC BRAIN INJURY ADVISORY COMMITTEE, FORMERLY KNOWN AS THE BEHAVIORAL HEALTH ADVISORY COMMITTEE, TO BE CO-CHAIRED BY THE DIRECTOR, MARINE AND FAMILY PROGRAMS, MRA AND THE MEDICAL OFFICER TO THE MARINE CORPS, WITH SENIOR REPRESENTATION FROM MRA, HEALTH SERVICES, SAFETY DIVISION, MCCDC (CDI), MARCORSYSCOM, TECOM, PPO, MARFORS AND OTHERS AS REQUIRED, AND REPORTING TO THE EXECUTIVE FORCE PRESERVATION BOARD. THE USMC BEHAVIORAL HEALTH AND TRAUMATIC BRAIN INJURY ADVISORY COMMITTEE WILL OVERSEE PROGRESS IN IMPLEMENTATION OF USMC BEHAVIORAL HEALTH AND TBI PROGRAMS AND COORDINATE MODIFICATIONS AS REQUIRED. HQMC (HS) WILL CONVENE A QUARTERLY TELECONFERENCE WITH MARFOR AND MEF MEDICAL LEADERSHIP AND BUMED COUNTERPARTS, TO COORDINATE EFFORTS, SHARE BEST PRACTICES, AND MONITOR PROGRESS WITH IMPLEMENTATION OF THE USMC TBI PROGRAM.
5. THE CORE ELEMENTS OF THE MARINE CORPS TBI PROGRAM ARE: PREVENT, PROVIDE, TRACK AND TRAIN.
A. PREVENT.  THE PREVENTION OF TBI IS A CORE COMPONENT OF THE USMC TBI PROGRAM AND IS THE RESPONSIBILITY OF LINE LEADERS, HEALTH SERVICES SUPPORT PERSONNEL AND ALL MARINES.
(1) PRIMARY PREVENTION. PRIMARY PREVENTION OF TBI IS FOCUSED ON LIMITING EXPOSURE TO POTENTIALLY CONCUSSIVE EVENTS THROUGH THE PROPER PROVISION AND USE OF PPE. ON THE MODERN BATTLEFIELD, THIS LARGELY INVOLVES LIMITING EXPOSURE TO IEDS TO THE EXTENT OPERATIONALLY FEASIBLE; IN GARRISON, THIS LARGELY INVOLVES LIMITING MVA AND SPORTS INJURIES.
(A) MCCDC (CDI) WILL INCORPORATE JOINT DOCTRINE AND DEVELOP APPROPRIATE USMC DOCTRINE TO ADDRESS TBI AND LIMIT EXPOSURE TO POTENTIALLY CONCUSSIVE EVENTS TO THE EXTENT OPERATIONALLY FEASIBLE.
(B) MARCORSYSCOM WILL DEVELOP ENHANCED PPE AND VEHICULAR PROTECTION SYSTEMS TO MINIMIZE THE RISK OF TBI.
(C) SAFETY DIVISION WILL IMPLEMENT GROUND SAFETY PROGRAMS TO MITIGATE TBI RISK FROM MVA, SPORTS AND OTHER ACTIVITIES.
(D) COMMANDERS IN GARRISON WILL EMPHASIZE SAFETY PROGRAMS AND RISK AVOIDANCE EFFORTS TO MINIMIZE TBI EXPOSURE.
(E) COMMANDERS IN DEPLOYED SETTINGS WILL INCLUDE RISK OF TBI AT THE INDIVIDUAL AND UNIT LEVEL AS PART OF OPERATIONAL RISK MANAGEMENT CONSIDERATIONS.
(F) HQMC (HS) WILL DEVELOP AND PROMULGATE APPROPRIATE PUBLIC HEALTH MESSAGING.
(G) TECOM WILL DEVELOP TRAINING STANDARDS FOR TBI PREVENTION FOR THE FORMAL LEARNING CENTERS (FLC) AND UNIT LEVEL TRAINING.
(2) SECONDARY PREVENTION.  SECONDARY PREVENTION IN THE SETTING OF TBI, WHETHER IN GARRISON OR DEPLOYED, IS FOCUSED ON MINIMIZING THE ADVERSE IMPACT AFTER A CONCUSSIVE EXPOSURE HAS OCCURRED, ESPECIALLY BY LIMITING ADDITIONAL EXPOSURES DURING THE RECOVERY PERIOD.
(A) DETAILED GUIDANCE IS IN REFERENCE A. COMMENCING IMMEDIATELY ALL COMMANDERS, OR THEIR REPRESENTATIVES, WILL EVALUATE ALL MARINES EXPOSED TO A POTENTIALLY CONCUSSIVE EVENT USING THE I.E.D. (INJURY, EVALUATION, DISTANCE) APPROACH (PER REF A).
(B) COMMANDERS WILL ALSO ENSURE THAT ALL MARINES EXPOSED TO A POTENTIALLY CONCUSSIVE EVENT, WHETHER IN GARRISON OR DEPLOYED, ARE PLACED IN A 24-HOUR SIQ STATUS AND REFERRED FOR A MEDICAL EVALUATION.
(C) COMMANDERS SHOULD DIRECT THEIR MARINES TO A MEDICAL EVALUATION IN ANY OTHER CONCERNING CIRCUMSTANCE SUCH AS REPEATED EXPOSURES TO POTENTIALLY CONCUSSIVE EVENTS OR PATIENT CONCERNS OR BEHAVIORS THAT COULD BE RELATED TO A CONCUSSION OR TBI.
(D) MARCORSYSCOM WILL COLLABORATE WITH EFFORTS TO DEVELOP DIAGNOSTIC TOOLS AND EVALUATIONS USED TO RAPIDLY DETERMINE THE PRESENCE OF TBI TO AID MEDICAL PROVIDERS IN RAPID EVALUATION AND DIAGNOSIS TO GUIDE TREATMENT AND DISPOSITION.
(3) TERTIARY PREVENTION. TERTIARY PREVENTION IN THE SETTING OF TBI FOCUSES ON MINIMIZING LONG-TERM CONSEQUENCES THROUGH PROPER REFERRAL AND TREATMENT, AS DETAILED BELOW.
B.  PROVIDE. THE PROVISION OF APPROPRIATE CARE TO ALL MARINES EXPOSED TO A POTENTIALLY CONCUSSIVE EVENT OR DIAGNOSED WITH A CONCUSSION OR TBI IS A CENTRAL COMPONENT OF THE USMC TBI PROGRAM AND IS A RESPONSIBILITY OF LEADERS, HEALTH SERVICES SUPPORT PERSONNEL, AND ALL MARINES. HQMC (HS) HAS THE LEAD FOR DELINEATION OF MEDICAL TREATMENT POLICIES AND GUIDELINES. MEF SURGEONS WILL DESIGNATE A TBI COORDINATOR TO OVERSEE AND COORDINATE TBI TRAINING AND CLINICAL CARE EFFORTS WITHIN THEIR AOR.
(1) THE GUIDING PRINCIPLES FOR CARE OF MARINES WITH TBI ARE: HONOR THE WARRIOR SPIRIT; LEADERSHIP INVOLVEMENT; SENSITIVITY TO THE UNIQUE NATURE OF TBI; FAMILY INVOLVEMENT; AND A COORDINATED/ INTERDISCIPLINARY APROACH TO CARE.
(2) IN THE DEPLOYED SETTING, ALL MEDICAL PERSONNEL WILL USE THE CURRENT DOD CLINICAL ALGORITHMS FOR THE MANAGEMENT OF TRAUMATIC BRAIN INJURY AVAILABLE AT WWW.DVBIC.ORG.
(3) IN THE GARRISON SETTING, ALL MEDICAL PERSONNEL WILL USE THE DOD/VA CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF TBI, AVAILABLE AT WWW.DVBIC.ORG, AND WILL COORDINATE WITH LOCAL MILITARY TREATMENT FACILITIES FOR REFERRAL AND FOLLOW-UP CARE AS APPROPRIATE. HQMC (HS), IN COORDINATION WITH BUMED, WILL PROVIDE ADDITIONAL CLINICAL TOOLS AND REFERRAL GUIDELINES AS WARRANTED.
(4) ALL MEDICAL EVALUATIONS AND CARE WILL BE DOCUMENTED IN THE ELECTRONIC HEALTH RECORD WHEN FEASIBLE. IN THE EVENT OF A TRANSFER/PCS OF A MARINE UNDERGOING CARE/EVALUATION FOR TBI, EVERY EFFORT WILL BE MADE TO ENSURE A COORDINATED TRANSITION OF CARE.
(5) DISPOSITION. ALL MARINES EXPOSED TO A POTENTIALLY CONCUSSIVE EVENT OR DIAGNOSED WITH A CONCUSSION OR TBI WILL RECEIVE A DISPOSITION REGARDING FITNESS FOR DUTY (FOLLOWING THEIR INITIAL 24-HOUR MANDATORY SIQ PERIOD AND MEDICAL EVALUATION). FOR MARINES WHO SUSTAIN RECURRENT CONCUSSIONS ADDITIONAL MEASURES ARE REQUIRED AS DETAILED IN REFERENCE A.
C. TRACK. REPORTING, SURVEILLANCE, AND TRACKING OF TBI CONSTITUTE A CENTRAL COMPONENT OF THE USMC TBI PROGRAM AND ARE THE RESPONSIBILITY OF LEADERS, HEALTH SERVICES SUPPORT PERSONNEL, AND ALL MARINES. MRA WILL HAVE RESPONSIBILITY FOR TRACKING TBI OCCURRENCE STATISTICS.
(1) ALL PERSONNEL ASSIGNED OR ATTACHED TO USMC UNITS ARE REQUIRED TO UNDERGO BASELINE PRE-DEPLOYMENT NEUROCOGNITIVE TESTING USING THE AUTOMATED NEURO-PSYCHOLOGICAL ASSESSMENT METRIC (ANAM). THIS REQUIREMENT APPLIES TO ALL UNITS/PERSONNEL DEPLOYING OCONUS FOR GREATER THAN 30 DAYS IN SUPPORT OF COMBAT OR CONTINGENCY OPERATIONS. FURTHER DETAILS ARE IN REF B.
(2) ALL COMMANDERS, OR DESIGNATED REPRESENTATIVES, ARE REQUIRED TO REPORT THROUGH THE SIGNIFICANT ACTION SYSTEM ALL MARINES EXPOSED TO A POTENTIALLY CONCUSSIVE EVENT IN A DEPLOYED SETTING PER REF A.
(3) ALL MEDICAL PERSONEL ARE REQUIRED TO DOCUMENT ALL MEDICAL EVALUATIONS, DIAGNOSES AND DISPOSITIONS RELATED TO TBI IN THE ELECTRONIC HEALTH RECORD IN THE GARRISON AND DEPLOYED SETTING.
(4) HQMC, PPO IS RESPONSIBLE FOR THE TBI MODULE WITHIN THE MEDICAL READINESS REPORTING SYSTEM (MRRS). ALL COMMANDERS AND MEDICAL PERSONNEL ARE RESPONSIBLE FOR DOCUMENTING TBI EXPOSURE AND DIAGNOSIS DATA IN MRRS IN THE GARRISON AND DEPLOYED SETTING PER REF C.
(5) ALL MARINES AND HEALTH SERVICE SUPPORT PERSONNEL ARE REQUIRED TO COMPLETE POST-DEPLOYMENT HEALTH ASSESSMENTS AND POST-DEPLOYMENT HEALTH REASSESSMENTS, WHICH CAN IDENTIFY PERSISTENT TBI SYMPTOMS OR CONCERNS, AND TO COMPLY WITH RESULTANT MEDICAL REFERRALS.
(6) ALL UNITS ARE REQUIRED TO ENSURE A POST-DEPLOYMENT FACE-TO-FACE CLINICAL FOLLOW-UP FOR ALL MARINES DIAGNOSED WITH A CONCUSSION OR TBI DURING A DEPLOYMENT WITHIN ONE TO FOUR MONTHS OF REDEPLOYMENT (THIS MAY BE DONE IN CONJUNCTION WITH REQUIRED PDHRA). THIS CAN BE COORDINATED WITH OR FACILITATED BY LOCAL BUMED OR DEFENSE AND VETERANS BRAIN INJURY CENTER ASSETS AS APPROPRIATE. DECISIONS REGARDING CONDUCT OF POST DEPLOYMENT NEUROCOGNITIVE TESTING (ANAM) WILL BE GUIDED BY CLINICAL JUDGEMENT AS PART OF THIS CLINICAL FOLLOWUP.
D. TRAIN.  APPROPRIATE EDUCATION AND TRAINING OF ALL MARINES AND MEDICAL PERSONNEL REGARDING TBI IS A CENTRAL COMPONENT OF THE USMC TBI PROGRAM AND IS THE RESPONSIBILITY OF LEADERS, HEALTH SERVICES SUPPORT PERSONNEL, AND ALL MARINES. TBI TRAINING WILL BE INCORPORATED AND INTEGRATED THROUGHOUT ALL FORMAL LEARNING CENTERS AND CAREER PROGRESSION SCHOOLS AND AS PART OF UNIT-LEVEL ANNUAL AND PRE-DEPLOYMENT TRAINING. TECOM, IN COORDINATION WITH HQMC (HS), HAS THE LEAD FOR USMC TBI EDUCATION AND TRAINING STANDARDS DEVELOPMENT. HQMC (HS) WILL COORDINATE WITH BUMED FOR CURRICULUM DEVELOPMENT AND ADMINISTRATIVE SUPPORT TO TBI TRAINING. TECOM, WITH HQMC (HS) AND OTHER STAKEHOLDERS, WILL OVERSEE A COMPREHENSIVE APPROACH TO USMC TBI TRAINING, TO INCLUDE THE FOLLOWING REQUIREMENTS:
(1) ENTRY-LEVEL TRAINING. BASIC TBI AWARENESS WILL BE INCORPORATED INTO ALL ENTRY-LEVEL TRAINING.
(2) LEADERSHIP/COMMANDERS COURSES. LEADER RESPONSIBILITIES REGARDING TBI WILL BE INCORPORATED INTO ALL LEADERS/COMMANDERS COURSES.
(3) HEALTH SERVICES SUPPORT TRAINING. TBI TRAINING FOR CORPSMEN AND PROVIDERS WILL BE INCORPORATED INTO ALL HEALTH SERVICES SUPPORT TRAINING VENUES, INCLUDING FMTBS, AS WELL AS ANNUAL REFRESHER TRAINING. THIS TRAINING WILL INCLUDE TBI CARE IN DEPLOYED AND GARRISON SETTINGS. EACH MAJOR SUBORDINATE COMMAND WILL ENSURE AT LEAST TWO PROVIDERS AND TWO CORPSMEN ARE CERTIFIED AS LEAD TBI TRAINERS, THROUGH THE BUMED-SPONSORED LEAD TBI TRAINER COURSE, WHO CAN TRAIN UNIT-LEVEL TRAINERS TO FACILITATE/EXTEND TRAINING THROUGHOUT AFFILIATED UNITS.
(4) ANNUAL TRAINING. ANNUAL TBI REFRESHER TRAINING IS REQUIRED FOR ALL MARINES AND HEALTH SERVICES SUPPORT PERSONNEL AND WILL BE TRACKED IN THE MARINE CORPS TOTAL FORCE SYSTEM.
(5) PRE-DEPLOYENT TBI TRAINING. PRE-DEPLOYMENT TBI TRAINING IS REQUIRED AS PART OF BLOCK 1A TRAINING FOR ALL MARINES AND HEALTH SERVICES SUPPORT PERSONNEL. TBI TRAINING/SCENARIOS WILL BE INCORPORATED INTO AND EVALUATED AT APPROPRIATE EXERCISES, SUCH AS MOJAVE VIPER IN COORDINATION WITH MAGTF TRAINING COMMAND.
(6) DISTANCE LEARNING. TECOM, THROUGH THE COLLEGE OF DISTANCE EDUCATION AND TRAINING (CDET) AND IN COORDINATION WITH HQMC (HS), WILL DEVELOP AND MAKE AVAILABLE TBI DISTANCE LEARNING MATERIALS AS WARRANTED.
6. RELEASE APPROVED BY RDML M. H. ANDERSON, DIRECTOR, HEALTH SERVICES.//