Dr. David X. Cifu, the VA's director of the physical medicine and rehabilitation program likes to think of the acute and long-term TBIMS data as a roadmap for recovery.
Staff at polytrauma centers, for example, can plug in seven factors and get a patient's expected length of stay at a rate that Cifu says is about 50 percent accurate. Those might seem like lousy odds, but for a patient with a TBI, an amputation and severe burns, knowing how you compare to 10,000 people who have had similar injuries is something tangible.
It also allows hospital staff and families to begin immediately planning for that projection. If there's a setback, like a seizure or an infection, both groups can rally around the road map, using it as motivation for realigning the patient with his treatment plan. Cifu says the staff will remind a service member whose confidence or determination has flagged that pain brings recovery: "If you struggle harder, tomorrow will be better, and we're going to keep laying on more struggle."
Gaal knows this well. He was motivated, privately setting goals outside of physical therapy sessions and exercising in the gym or his room. He drew on old basketball workouts to improve his core strength. He remained a fighter, but there were often moments of despair.
One day he refused to attend a groundbreaking ceremony attended by VA Secretary Eric Shinseki on the hospital's grounds. Gaal couldn't yet independently move himself from the bed to a wheelchair and cited that as part of his reluctance. The center's program director, Pawan Galhotra, and social work supervisor, Scott Skiles, safely transferred him by the sheet of the bed to his wheelchair and escorted him out. "They pushed me," Gaal says. "They wouldn't allow me to sit around in my room and sulk about anything."
Galhotra, who came to the VA from the private sector, says this diligence is necessary: "It's very important to emphasize that because we have resources doesn't mean we can sit back and say we're resource rich. I constantly challenge the team to say how are we pushing this individual forward."
In the last fiscal year, 92 percent of the patients at the Palo Alto center were discharged to a non-institutional setting, outpacing the national average by nine points. The typical length of stay is longer than for TBIMS patients, but the VA's charges have unique injuries and also are covered by government insurance that does not set arbitrary limits on hospitalization. (The average cost of the first year's care for a polytrauma patient is $136,000.)
Where the center really shines, Harris says, is its functional independence measure (FIM) at discharge, an 18-item scale that measures rehab progress. Palo Alto's FIM is 120 compared to an average TBIMS score of 93.
Cifu acknowledges that the Palo Alto center is "ahead of the curve," thanks in part to Harris' intimate knowledge of the data. The goal, he says, is to use these means and help driven patients and their families create a new normal.
"Even when they can climb mountains, they're not exactly the same as they were before," he says. "This is not Hollywood. If you've lost a limb, you've lost a limb."
Gaal is energized by the possibilities of his future. He could play wheelchair basketball, but prefers to focus on his new passion for rowing. Though he's heartbroken at the prospect of never again leading a crew of men into combat, as an emergency services dispatcher, he'd be responsible for people's lives -- a duty he relishes.
If he's held onto anything of his former life, it's the sense of mission that guided his recovery: "My Marines have been a huge part of my way of getting through this. If I quit, what does that show them? They know me as this person before, so they're not going to see me give up."