Dr. Bash: I’m good, I’m good. I was going to talk about a prototypical case that we have. We recently had a guy with a bunch of micro traumas. He was a controller under a 6-inch gun in front of a US class destroyer. You know, he has to have health care, can’t walk around, gets dizzy, and gets lost in his house. His wife does all his cooking and stuff. It’s kind of like a secret TBI because people usually look for a concussion where someone loses consciousness or has bleeding on the brain with an MRI scan or CT scan. This kind of thing can be invisible, even on MRI scans, but it causes a lot of problems with memory and concentration.
Jay: Right.
Dr. Bash: So, I think about the ideas between how to get SMCT (Special Monthly Compensation – T) because we have 100% that pays 100%, but we also have the SMCT, which is out there like an R2 level. There are a lot of little steps in between, so it’s confusing trying to figure out how to place people in those intermediate steps. Maybe Bill can help us a little with that stuff.
Discussion on TBI and SMCT
Bill: Sure, sure. Congress gave us a generous benefit for patients with traumatic brain injury. It was based a lot on testimony by victims of TBI and their spouses who testified before Congress as to the profound disability that they suffer and their severe needs. I had the privilege of actually deciding such a case for one of the individuals who testified before Congress.
Jay: No way, Bill! That guy testified?
Bill: Yeah, I’m not sure we’re speaking of the same patient, but the one I had in mind, I was able to grant the maximum benefit in that case. There were certain activities of daily living that the veteran could not perform independently because of TBI. Part of that was a rather significant impairment of his hands in coordination, lack of endurance, and so he needed help with some activities such as cooking and dressing. He also had memory problems and was reliant on GPS to get to a medical appointment or find the grocery store. He wasn’t capable of retaining that information.
Dr. Bash: Right.
Bill: The Board of Veterans Appeals had actually remanded that case for further development. As soon as the case was brought to my attention, I contacted his attending VA neurologist, who completed a VA form explaining the need for aid and attendance. Now, the veteran was 100%, and because he was 100% and needed regular aid and attendance due to TBI, he qualified for special monthly compensation at the highest possible level. It’s SMCT or section 38 USC section 1114 T. That’s where it’s in the code; that’s how it got the name. It provides the highest special monthly compensation available.
Criteria for SMCL
Dr. Bash: Can you go over that again, Bill?
Bill: Sure. SMCT is granted if a person has TBI. You got it exactly right. Now, SMCL, which stands for Special Monthly Compensation Level, is defined by 38 CFR 3.352. The specific criteria are listed there. These criteria include the inability to dress or undress, to keep themselves ordinarily clean and presentable, the frequent need for adjustment of any prosthetic or orthopedic appliance, inability to feed themselves through loss of coordination of the upper extremities or extreme weakness, the inability to attend to the wants of nature (such as loss of bowel and bladder control), or incapacity, physical or mental, that requires protection from the hazards or dangers incident to the daily environment.
These don’t have to be daily needs; they don’t have to be severe needs. You don’t have to satisfy all of them; any of them predicates entitlement to regular aid and attendance. The difference is that Congress has given us the authority to grant this at the highest level, SMCT, if it’s due to TBI.
Microtraumas and TBI Diagnosis
Jay: Bale, you mentioned the 5-inch gun or cannon. Repeated loud noises in your ears are going to do something over time.
Bill: True.
Jay: What I’m getting at is the reaction of their upper extremities. That tells you right there it could be some sort of brain issue. And you were able to prove it was a TBI, and the VA accepted that explanation?
Dr. Bash: The Navy did not recognize it. They gave him a rather vague psychiatric diagnosis. At one point, they were exploring whether or not this was a case of malingering because they didn’t quite understand what the cause of his symptoms was. They gave him this idea of amnesia of unknown cause, but he had TBI. Bill looked in the record and found some clinical notes.
Bill: Yes, there were some clinical notes and evaluations. What piqued my curiosity was the fact that shortly after exposure to that concussion blast on a recurring basis, the symptoms had an onset somewhat close to that. Today, in his VA treatment records, he has a diagnosis of TBI.
Jay: It’s a complicated issue because a lot of people get treated by nurse practitioners and PAs in the field or on ships. Unless they see someone pass out for five minutes, they don’t think about TBI. They don’t have the training to understand that this microtrauma can lead to the same kind of cascade of events in the brain that gives you just as severe mental problems as major single trauma.
Bill: Exactly right.
Chemical Exposure and Brain Issues
Jay: Could chemicals have the same effects on the brain?
Dr. Bash: Yes, they could. A classic toxin we talk about is radiation, which can affect the brain. Things that affect blood vessels, nutrition, or toxins that get across the blood-brain barrier can have similar effects.
Anoxia and TBI
Bill: For rating purposes, a traumatic brain injury means a physical disability resulting from an event of external force causing an injury to the brain. An alternative diagnosis could be anoxia. If the brain suffers from a lack of oxygen, that anoxia can produce symptoms similar to TBI. In that circumstance, if it’s service-related, it can be evaluated similarly to TBI.