TRANSITION INTERVIEW #14: Dr. James Kelly, MD. Former Founding Director of the Marcus Institute of Brain Health and the National Intrepid Center of Excellence.

Caring for Traumatic Brain Injury during the Global War on Terror, the corporatization of clinical brain care, and the dangers of second impact syndrome during military service.

During my active duty, I worked with many individuals treated for Traumatic Brain Injury (TBI) at the National Intrepid Center of Excellence (NICoE). Their stories—and the life-changing impact of the protocols—stood out, especially compared to other programs.

After leaving the Navy and moving to Denver, I started crossing paths with veterans treated at the Marcus Institute of Brain Health, and their experiences echoed the same high-quality care.

Behind both of those programs is Former Founding Director, Dr. James Kelly, MD.

Earlier this year, a week after the NYT’s published an article titled, “Pattern of Brain Damage Is Pervasive in Navy SEALs Who Died by Suicide”, I had the privilege of being introduced to Dr. Kelly, who agreed to meet with me.

---

I know a dozen or so folks who’ve attended NICoE and Marcus Institute, some are close friends and they all speak so highly of the care they received, so it’s a pleasure to meet you in person.

Perhaps we start with how the idea for National Intrepid Center of Excellence came to be in the first place?  How you got involved?

The story is a bit lengthy. TBI programs existed before NICoE. One at Naval Hospital Balboa, and the one you mentioned you went to was at Portsmouth Naval.

When NICoE was ordered to become a thing, some folks within DoD took offense to it.

To have a civilian academic neurologist be selected to run it - which was by design – was a hard pill to swallow for some. But some members of Congress really didn't want the military running it.

On top of that, we were given a lot of resources, $30M dollars, and many expedited resources to get the thing up and running. We had two overnight sleep labs, every patient got an MRI scan, and a clinical workup. Everybody had access to psychiatry, psychology, neuropsychology, physical medicine, rehab, neurology, speech, pathology, and physical therapy, which was a big thing.

We had experts in alternative medicine—integrative health if you will—art therapy, music, yoga, heart math, meditation, and all kinds of things.

Special Ops guys like yourself would really lean into that side of things.

When you say, “they didn’t want military folks running the thing,” who is “they” in that sentence? Who came up with the idea?

Well, you may already know this, but in 2007, the wars were raging. People were coming back with blunt and blast-related brain injuries by the thousands. A lot of them ending up at Walter Reed.

Well, at that time, they were planning to close Walter Reed – the old hospital.

And you know how that works. No one puts any money into something that’s about to be shut down. So, as it was, brain injury care was taking place in this old rundown building, underfunded, with the staff just doing the best they could.

Well, one day, the Washington Post came out with an expose describing “Abysmal Care for TBI Patients Inside Walter Reed" on the front page, or something to that effect.

And keep in mind that this is right after the opening of  the Center for the Intrepid – a state-of-the-art rehab hospital for amputee patients in San Antonio. It was this four-story, beautiful building that was a gift from the Intrepid Fallen Heroes Fund. It wasn’t even a year old.

So, when this article comes out, Arnold Fisher, on the Board of the Intrepid Fallen Heroes Fund, got involved. Their family is responsible for the Fisher houses, as you may know?

Arnold Fisher reads this article and, in essence, says, “I’ll build a brain injury center.”

He worked with the Intrepid Fallen Heroes Fund Board, and basically got them to raise the money, build NICoE and give it to the military.

In that same year, this is 2007, Congress via the NDAA told DoD they would build a Center of Excellence for TBI and Psych Health. So, separately, the two pots of money came together.

Interesting. How did you get involved?

While all this was going on, changes were being made to what’s called the Defense Health Board, which really had not been updated since World War Two. The DHB, if you’re not aware, is an advisory committee which makes recommendations to DoD on how we should care for our service-members and advise military leaders regarding health policy.

They decided to set up these subcommittees, one of which was a TBI subcommittee. Anyway, I was invited to join and subsequently elected Chairman.

One day, I was summoned to General Lori Sutton’s office, the Brigadier General Psychiatrist. I spent a day with her, and toward the end, she asked me if I would consider helping develop and eventually run NICoE.

Good for you. And before NICoE, were you focused on trauma?

That’s right.

Civilians or were you seeing military?

A lot of athletes.

I see. That's how you got to know Scott Parker, whose wife introduced us.

Right. Not long before NICoE, I met Scott. He had persistent concussion symptoms and had run into disagreements amongst his team or with the NHL’s medical folks. I’m not really sure.

I think he was trying to decide whether he could be cleared to play, and he came to me for more of an objective, second opinion.

He could tell you the story, but I couldn't clear him. One day, he asked me, "Dr. Kelly, have you ever had a concussion.” I didn’t know what he meant. Then he says,  “Would you like one?”

He was kidding, of course.

During your time at NICoE, as you’re seeing these guys return from war, how much partnership did you have with DoD? Was your staff able to make suggestions?

We did, but we focused less on prevention and more on care. We were considered experts in treatment and recovery.

I was there from 2008 to 2015, and my job was to establish a place to care for these people.

That was the job, and we needed it running right away. So, efforts in terms of stopping these injuries upstream was a more minor part.

We completed a few breacher studies and a variety of other things.

How much depth is there in the American workforce for a place like NICoE? Are there enough folks who do this kind of work?

No. That’s a real problem. It's really a small subset of healthcare professionals. Plenty of people wanted to work there, but so much of the care was niche – then you add in the process of hiring someone at an institute funded by multiple sources.

I can imagine. That’s a great story. The speed at which things were transitioned from the old Walter Reed, Mr. Fisher stepping in to help. It’s such an asset that the previous generation never had.

One thing I wanted to ask you—from my own experience writing and talking to other vets — it seems the optionality and the abundance of new interventions has really multiplied over the last few years. From pharma, to psychedelics, to hyperbaric, and , transcranial magnets. I bet there’s a hundred others.

If  a Veteran, or any person with a history of brain injury is interested in bettering their brain health; where do you advise they get started?

The most important thing is to get the diagnosis right. You're right about the panoply of opportunities, and they keep coming.

Often their advertised as the cure for everything and so forth. But nothing's the cure for everything.

The brain has its ties to every part of the body. If  you get the diagnosis wrong, we can assume you start to travel down the wrong path, and a lot of times, that will worsen the situation.

You want to really understand the problem before manipulating the nervous system.

I think you want to start by examining what’s physical and consider this might just be a general health issue. Just because someone was affected by an IED (Improvised Explosive Device) doesn't mean they don’t have hyperthyroid or a thousand other things which are potentially unrelated.

You need a general medical evaluation and a detailed neurological evaluation to make sure you're not assuming a psychological problem. A lot of times physical problems are causes for psychological problems, but you need to know that.

About a year ago, there was 12-month period where whenever I went above 12k ft of elevation, the following day would be pretty unpleasant. Headache, lethargy, depressive mood I suppose - sort of apathetic to life in general. I know there’s research on the effects of living at altitude and brain function, hypoxia, etc., so I became interested in this topic. I wanted to know if I should stop doing this sort of thing.

So, I see this neurologist, a Physician's Assistant, and when we meet, I can tell she is rushed. She isn't rude, but I can tell she was off put by my questions. Her response is more or less, "What would you like me to do for you?"

I don't want to make excuses for her, but it was challenging for me to articulate what I wanted. I think I wanted an experts advice and education.

It seems common that when navigating TBI, Veterans especially, struggle with this phase of care - to articulate how they’re feeling in a ten minute clinic visit.

Do you have any advice for care providers and patients to solve for this?  

This is a big question, and there isn't a straightforward answer. Part of this is a result of the complexity that exists in the brain and the fact that there are many specialties within brain science. In the example you gave, certain clinicians aren’t going to have a clue how to respond to what you’re presenting. The other part is that they’re rushed.

There’s corporatization of healthcare is leading to a kind of a concussion mill approach.

You must generate enough revenue to run your practice and employ people; to do that, you must see a lot of patients.

That's really what made NICoE and places like the Marcus Institute for Brain Health special.

We need a system where a care-provider can truly hone in on what the nature of the problem is. 10-minutes is not going to work.

When I was seeing athletes, I would spend two hours minimum with a new patient. We would do a detailed history and physical examination. That’s more detailed than most people, and that's one of the things I pride myself in professionally, but it's less lucrative.

I gave a lecture to the Colorado Society of Clinical Neurologists about how you handle concussion. What do you do about persistent symptoms? About halfway through my talk on how I examine people, one of the neurologists stood up and said, “Wait a minute. We'll all go broke if we do this.”

In a way, he's right. But I said, “Well if you don't do this, you’ll miss things.”

The idea that you bring this idea to somebody, and they'll have it figured out in 10 minutes…. The table isn’t set right.

So, you would encourage a Veteran, a TBI victim, to seek out a trauma specialist?

Yes, a concussion specialist.

So, we get to 2015, and you decide to leave NICoE and return to Colorado. Was the idea for the Marcus Institute already alive at that point?

Not while I was at NICoE. By 2015, a lot had changed since the original model.

At the beginning, my selection as a non-military guy had been put in motion by Congress. They were set on the idea that we weren’t going to have military medical people run NICoE.

They're the ones who should have done a better job - was sort of the attitude.  

You can imagine it put a bit of a target on my back. Military Medicine didn’t love that idea, and little by little, things began to fade regarding who should be making decisions. We flipped from Bush to Obama, and so a lot of the administration had turned over, and new people were in position.

I was commuting on the weekends, flying back to Colorado on Friday nights, seeing patients on Saturday mornings, and we had four kids at home.

It was a lot.

Wow, that is a lot. So, you decide to leave?

Yep. So, it’s 2015, and in a way, the military is pushing me out and making me more of a consultant.

An Army officer named Marcus Ruzek was hired by the Marcus Foundation—this is Bernie Marcus from Home Depot. Bernie wanted Ruzek to help find best-in-class TBI programs and set them up for Veterans outside of the VA, outside of the DOD, and outside of the private world.

I get a call from the Marcus Foundation, and they say, “We’d like to talk to you.” So I go to Atlanta, to the foundation headquarters, and met with the folks who run the foundation. I assumed they would want me to do something there in Atlanta, at Emory or the Shepherd Center. But they asked me, “If we go through with this, where should it be?”

So we got started in 2015, but what followed was a lot of planning and negotiating between the foundation and the University of Colorado. Agreements had to be reached, and at the end of the day, we had a $30M dollar gift to make it happen.

And is there partnership with the VA Hospital next door?

No. Bernie's expectation has always been that this would be no-cost. We didn’t want it to be beholden to VA.

I see. I thought because of the proximity, perhaps it was by design.

That’s common.

In the early years, there was a bit of informal referral going on, some “you might want to reach out to the Marcus Institute” between VA and their patients, but there was no coverage of care if a VA patient attended Marcus. Nor could anyone at VA be sure that their patient would be admitted.

People came in from all over the country and all over the world.

Bernie's message all along was that this should be free. The problem is that it comes at a huge financial loss. Right? There are circumstances where patients have TRICARE, and sometimes a spouse will have private insurance, and they can contribute. But in total, what the Marcus Institute costs is covered about 15 cents on the dollar.

But the benefit is that these healthcare providers are on fixed salaries, so the “10-minute issue” we talked about is lessened or non-existent?

Exactly.

How do you see the future? Is there limited runway in terms of sustainability at Marcus Institute?

There is. Bernie hoped for a path to sustainability—that the healthcare world would see what we’re doing and come around. As the years progressed, the university has taken a different approach. This isn't a ding on them by any means, but in order to move towards sustainability, they've downsized and changed the model significantly. The clinical team is about half the size it was.

A recent New York Times Article referenced a study that you were part of, looking at Astroglia Scarring. Is that compelling to you?

There was a study this spring out of the Harvard Group, funded by the DOD, using very advanced neuro-imaging on special operators, not a huge number, but a good number, and it showed imaging abnormalities that could be detected that line up with where we see them.

You can think of it, astroglia scarring, as a star shaped cell type which nourishes the nerve cell.  So long ago, astrocyte and astroglia, which means “glue”, became the term for that type of white matter cellular tissue.  We're not entirely sure why this region is selectively damaged by blast.

At autopsy, in Dr. Dan Pearl's Defense Department lab, the brain repository has hundreds of individuals who've had blast-related brain injuries that they've been able to identify astroglia scarring, and it's not Chronic Traumatic Encephalopathy (CTE).However, they may also have CTE from blunt injuries, sub-concussive blows, and so forth. Astroglia scarring is a separate type of scarring and an inflammatory process in different areas and cell types of the brain than seen in CTE.

And the scarring is present in victims of TBI? Or it’s common in all people? 

Well, that's what we've been trying to figure out, not just at NICoE but also at Marcus Institute and other partner organizations nationwide.

It’s really tough to distinguish between the two on clinical examination of a given patient. You can get a bit of history on the patient’s exposure based on their own willingness to tell you or documentation in their health records, but proving causation has yet to be done.

And the imaging I mentioned is not FDA approved so far. So, we're talking about a low number of individuals who have had those research scans at this point in time.

CTE requires an autopsy. Do you think that will be the case forever?

It still does today. There are images that show suspicious indicators with the use of different injectable tracers, but it’s not crystal clear.

A lot of people worry when their scans appear to be positive for those indicators, but it's possible they have no clinical problem.

I might have CTE right now. That’s the problem with this whole business. We don't know what the denominator is.

I wrote an article a year ago, with three other co-authors, on this very issue. The idea is, since we don't do autopsies on very many people, largely, we have no concept of base rates in the general population.

What are you most excited about in terms of interventions?

I really think this model (Marcus Institute) is one that could be perpetuated if the financial advantages of doing so could be demonstrated.

If we could get some movement in that direction—true personalized medicine, highly detailed and specific to the individual—I think we would see advancement in overall healthcare for veterans and all people.

One of the things we were trying to figure out at NICoE, and certainly since then, is the economic cost of failed therapy—when a patient is left with persistent problems after conventional treatments.

How much avoidable spending is out there?  

If we had a way of showing the financial benefit of this kind of this interdisciplinary treatment model, that could really keep it going. That’s what buoys my spirits, when we look at the at the outcomes we've been publishing on what it is this approach has to offer and how it benefits people. The FDA would be doing cartwheels to have a drug that works like that.

Interesting. And if I'm an insurer, playing devil's advocate, I would argue that it's unclear where the crossover into elective interventions exists. Without a diagnosis, do we want to invest in something that may or may not be true?

Right. That's where the really detailed evaluation is of interest to the payer and the insurer. Eventually, you would see that this benefits both parties.

That makes a lot of sense.

While in the Navy, I got the impression that my teammates who were struggling could not always connect the start of their symptoms to a specific date. Some were never exposed to a major IED. Moreso, it was as if they'd spent too much time in the job. Too many years breaching, skydiving, high-seas boating, and so on. How much of what you saw at NICoE and Marcus would fall under this sort of patient-history?

All of it. What you’re describing can be very serious. As you know, people, too often kids, have died from second impact syndrome. What you’re talking about is either sub concussive blows or repeated mild TBI which leads to vulnerability of the brain because it's already injured and not healing.

In sports literature, we've shown that even people injured as far back as seven years ago are more vulnerable should they experience another brain injury.

Okay, I’ll ask you one more. If we zoom out, if we package what we’ve learned over the last twenty-three years of war, can we conclude that despite the efforts of our enemies – much of our own training is harmful to the brain? 

That is happening without me having to say anything. But remember, they've known this since before Iraq and Afghanistan. Since the Defense and Veterans Brain Injury Center started their TBI registry, we’ve known that 80% of injuries are not caused in conflict zones.

It did peak in 2011 and then started to fall, and it continued to fall off, but it will never be zero. The vast majority of the injuries that are in a medical registry don't happen in conflict. So yes, if we're really trying to protect our fighting force, we’ve got to look at all combat. Combat, training, car crashes, recreational activities, everything.

This was very gracious, Dr. Kelly. I can’t thank you enough for the investment you’ve made in the SEAL community and the military community at large. Thank you for that, and thank you for doing this.

---

If you’ve enjoyed this article, please hit like and leave a comment.