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UN-Diagnosed TBI while on Active Duty

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FC1

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In 1990 I was in a high speed MVA which resulted in me being conscious for approx 2 hours and the vehicle had to be cut from around me to extract me from underneath a semi trailer which jack-knifed in front of me on an icy bridge.  I was taken to a civilian trauma center and the doctors and nurse asked if I remember what happened, what day it was, where I am which I had no idea.  The nurse told me her name and came back a few minutes later and asked if I remembered her name which I didn't.  It took several times over several hours of her telling me her name before I remembered it....

Fast forward to 2019 I file for the following disabilities:

PTSD:

I filed a claim for PTSD and TBI from the car accident in 2019.  The PTSD C&P VA psych said I have diagnosed panic attacks, anxiety, and depression...but not PTSD.  I didn't have painic attacks, anxiety or depression before the car accident or 20 years of military service.  I have been diagnosed with PTSD from two separate civilian doctors which I submitted the health records and civilian diagnosis results with my PTSD claim but was shot down.

Service connection for post traumatic stress disorder with panic attacks and depression.  Service connection may be granted for a disability which began in military service or was caused by some event or experience in service. (38 CFR 3.303)
Service connection for post traumatic stress disorder with panic attacks and depression is denied since this condition neither occurred in nor was caused by service. (38 CFR 3.303, 38 CFR 3.304)
Your service treatment records do not contain complaints, treatment, or diagnosis for this condition.
We did not find a link between your medical condition and military service.
The VA medical opinion found no link between your diagnosed medical condition and military service.
The examiner diagnosed you with unspecified anxiety disorder, however the examiner did not link your diagnosis to your motor vehicle accident during service.

Favorable Findings identified in this decision:
Medical records show a diagnosis of unspecified anxiety disorder.
A stressor is conceded based on motor vehicle accident in service.

I guess almost dying and being permanently injured an motor vehicle accident doesn't cause PTSD, anxiety, depression...just ask my wife who has to practically beg me to get in a car and drive any where.

 

I also broke my left collar bone from the seat belt restraining me.  The VA gave 20% for the broken collar bone but denies my left shoulder pain is military related even though I went to medical several times and complained of AC joint shoulder pain which is clearly stated in my medical records.  I also had my knees hyper-extended by the dashboard collapsing on my knees for about 45-60 minutes before the fire department was able to cut the roof off, pry the door open and jack up the dash board.  The VA granted me 10% for my left knee because I reported left knee pain about 1 year after the car accident.  Now my right knee has pain and will dis-locate and pop back in while walking.

VA Results:

Left Clavicle:

Evaluation of residuals, left clavicle fracture (non-dominant) currently evaluated as 0 percent disabling.  The evaluation of residuals, left clavicle fracture (non-dominant) is increased to 20 percent disabling effective September 27, 2019. (38 CFR 4.1, 38 CFR 3.400)  The effective date of this increase is September 27, 2019, which is the date we received your "intent to file" communication. When an increased evaluation is granted based on VA medical evidence showing an increase in disability after the date the claim was received, and the claim was received within one year of the “intent to file,” the effective date is the day VA received the “intent to file.” (38 CFR 3.155) (38 CFR 3.400)  We have assigned a 20 percent evaluation for your residuals, left clavicle fracture (claimed as left broken collar bone) based on: 
• Painful motion of the shoulder. (38 CFR §4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint.  Since you demonstrate painful motion of the arm at the shoulder, the minimum compensable evaluation of 20 percent is assigned) The provisions of 38 CFR §4.40 and §4.45 concerning functional loss due to pain, fatigue, weakness, or lack of endurance, incoordination, and flare-ups, as cited in DeLuca v. Brown and Mitchell v. Shinseki, have been considered and applied under 38 CFR §4.59.  A higher evaluation of 30 percent is not warranted for limitation of motion of the arm unless the evidence shows:
• Limited motion of the arm to 25 degrees from the side. (38 CFR 4.69, 38 CFR 4.71
A noncompensable evaluation is assigned unless there is a malunion or nonunion of the clavicle or scapula. (38 CFR 4.31, 38 CFR 4.71a)

Left Should AC Joint/Rotator Cuff:

Service connection for left shoulder rotator cuff (non-dominant) as secondary to the service-connected disability of residuals, left clavicle fracture (non-dominant).  Service connection may be granted for a disease or injury which resulted from a service-
connected disability or was aggravated thereby. The evidence does not show that left shoulder rotator cuff (non-dominant) is related to the service-connected condition of residuals, left clavicle fracture (non-dominant), nor is there any evidence of this disability during military
service. (38 CFR 3.303, 38 CFR 3.306, 38 CFR 3.310)  The evidence does not show that your condition resulted from, or was aggravated by, a service-connected disability. (38 CFR 3.303, 38 CFR 3.304)
The medical examiner stated that your symptoms are subjective only. Objective exam is normal for a rotator cuff tear. There is no objective evidence of a chronic rotator cuff condition. A nexus has not been established.
Favorable Findings identified in this decision:  The claimed primary disability is service-connected.

 

The TBI C&P VA doctor reviewed my records from the civilian trauma center and said "You have a Moderate TBI."  The VA rating "specialist" said the opposite.

Traumatic Brain Injury:

Service connection for traumatic brain injury.  Service connection may be granted for a disability which began in military service or was caused by some event or experience in service. Service connection for traumatic brain injury is denied because the medical evidence of record fails to show that this disability has been clinically diagnosed. (38 CFR 3.303)  While your service treatment records reflect complaints, treatment, or a diagnosis similar to that claimed, the medical evidence supports the conclusion that a persistent disability was not present in service. (38 CFR 3.303)  The VA medical opinion found no persistent disability as the traumatic brain injury has resolved.  The examiner stated that there is clear documentation objectively from medical personnel that this veteran suffered a moderate TBI on December 15, 1990 at age 20 years old while active duty USN. The ER notes state a diagnosis of "closed head injury." Additionally the subjective statements by the veteran are consistent with the objective medical record and also by his statements alone establish that a TBI occurred. However, the medical records in 1995 and 1999 showed "no residual problems". Therefore, service connection for traumatic brain injury is denied since this condition has resolved.
Favorable Findings identified in this decision:
The evidence shows that a qualifying event, injury, or disease had its onset during your service.

 

My medical records show a TBI happened but the VA is judging their finding on "ANNUAL" physicals I received in 1995 and 1999....I'll let that sink in for a minute...annual physicals from 1995 and 1999...I have annual physicals every 4 to 5 years.  Not once in 22 years of military service did any medical professional ask about my unconscious episode and if I have any residuals....because TRAUMATIC BRAIN INJURY WAS NOT DEFINED BY THE VA AND DOD UNTIL MAY 2007.

How am I suppose to know the symptoms or any military medical professional is suppose to know what to look for?

To get diagnosed at a civilian facility it will cost me $1500 because of my insurance minimum has not been met this year.

I am seeing a civilian psychologist to help with PTSD, anxiety, and depression and paying for it out of pocket.  He recommenced I get a neuro-psych exam.

Does the VA do neuro-psych testing for veterans who slipped thru the cracks of the medical system?

 

The symptoms I am experiencing are like a checklist for TBI.  This list of symptoms is from the Mayo Clinic website.

Physical symptoms

  • Loss of consciousness from several minutes to hours  - UNCONSCIOUS FOR APPROX. 2 HOURS AFTER THE MVA
  • Weakness or numbness in fingers and toes - HAVE TINGLING IN FINGERS AND TOES
  • Loss of coordination - EYE HAND COORDINATION IS HORRIBLE.  I DID A COGNIFIT ONLINE TEST AND I HAVE THE BRAIN OF SOMEONE 10 YEARS OLDER THAN I AM
  • Headache - HAVE MIGRAINES WEEKLY WITH EYE SIGHT PROBLEM (TUNNEL VISION)
  • Nausea or vomiting - SOMETIMES HAVE STOMACH PAIN
  • Fatigue or drowsiness - ALWAYS TIRED NO MATTER HOW MUCH SLEEP I GET
  • Problems with speech - SPEAK SLOWLY, HAVE TROUBLE THINKING OF WORD AND RELATING THEM TO OBJECTS
  • Difficulty sleeping - ALWAYS HAVE TROUBLE FALLING ASLEEP AND STAYING ASLEEP
  • Dizziness or loss of balance - STAND UP TOO FAST AND I GET DIZZY

Cognitive or mental symptoms

  • Profound confusion - HAVE DIFFICULTY UNDERSTANDING/INTERPRETING WHAT SOMEONE IS SAYING
  • Agitation, combativeness or other unusual behavior - HAVE LOST OR LEFT 11 JOBS IN 10 YEARS, I BECOME ANGERED EXTREMELY EASILY 
  • Slurred speech - COULD NOT SPEAK CLEARLY FOR SEVERAL YEARS AFTER THE ACCIDENT
  • Memory or concentration problems - CAN'T REMEMBER LISTS OF THINGS THE WIFE WANTS ME TO GET AT THE GROCERY STORE, SHORT TERM MEMORY IS HORRIBLE
  • Mood changes or mood swings - 2 CIVILIAN DOCTORS, VA C&P PSYCH, MY CIVILIAN PSYCHOLOGIST HAVE DIAGNOSED ME WITH ANXIETY AND DEPRESSION
  • Feeling depressed or anxious - 2 CIVILIAN DOCTORS, VA C&P PSYCH, MY CIVILIAN PSYCHOLOGIST HAVE DIAGNOSED ME WITH ANXIETY AND DEPRESSION
  • Loss of Interest - I GAVE UP ON MANY OF THE HOBBIES I USE TO ENJOY

Sensory symptoms

  • Sensory problems, such as blurred vision, ringing in the ears, a bad taste in the mouth or changes in the ability to smell - VA RATED ME AT 10% FOR TINNITUS, I ALSO HAVE MIGRAINES AND TUNNEL VISION
  • Sensitivity to light or sound - NUMBER ONE REASON I LEAVE JOBS IS THE NOISY WORK ENVIRONMENT WHICH TRIGGERS MIGRAINES

MY QUESTION IS SHOULD I SPEND $1500 OUT OF POCKET TO GET DIAGNOSED WITH A TBI THAT HAPPENED BEFORE THE VA AND DOD EVEN DEFINED WHAT THE SYMPTOMS OF TBI ARE?  I THINK THE VA SHOULD BE RESPONSIBLE FOR THE TESTING.  THE VA ACKNOWLEDGES THAT ACCIDENT HAPPENED, ACKNOWLEDGES I WAS UNCONSCIOUS FOR OVER 1 HOUR BUT CANNOT TEST ME FOR A TBI?

Edited by FC1
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Given your TBI and or PTSD, you probably should get (professional) help, if you are denied.  This mean an attorney or non attorney practioner.   That is, unless your wife or another friend can help you.  VA is tough.  Many times a Veterans "last battle" is with VA.  

Edited by broncovet
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Good for you ocean bound.  VA hornswaggles Vets this way.  You need an IMO because VA does a lousy c and p exam, but Vets cant afford 2 grand for an IMO.  Some attorney's may "up front" the cost of an IMO if they think it will be a winner.  Glover Luck upfronted my IMO, and it worked llke a charm.  I paid it out of retro.  I think it was only 500 bucks.  

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On 3/16/2020 at 9:57 AM, broncovet said:

 VA hornswaggles Vets this way

This is true. I had a VA Neuro Psyc test completed weeks ago, the VA PhD was trying to do what ever it took to skew my numbers over three visits, and my results were the same as the same day visit private exam I paid for two and half years ago.

So now it means that my numbers are "locked in" and will only help the Neuro surgeon opinion after I have my two remaining main IMO/IMEs completed. I should be able to obtain one of the two next month, as for the two of two not sure. Once I get that I can focus on the private board certified Neuro surgeon IMO which will cost 3500.

Edited by Oceanbound
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