DEPUTY SECRETARY OF DEFENSE 1010 DEFENSE PENTAGON WASHINGTON, DC 20301-1010 JUN 2 2010 MEMORANDUM FOR SECRETARIES OF THE MILITARY DEPARTMENTS CHAIRMAN OF THE JOINT CHIEFS OF STAFF UNDER SECRETARIES OF DEFENSE DEPUTY CHIEF MANAGEMENT OFFICER ASSISTANT SECRETARIES OF DEFENSE GENERAL COUNSEL OF THE DEPARTMENT OF DEFENSE DIRECTOR, OPERATIONAL TEST AND EVALUATION DIRECTOR COST ASSESSMENT AND PROGRAM EVALUATION INSPECTOR GENERAL OF THE DEPARTMENT OF DEFENSE ASSISTANTS TO THE SECRETARY OF DEFENSE DIRECTOR, ADMINISTRATION AND MANAGEMENT DIRECTOR, NET ASSESSMENT DIRECTORS OF THE DEFENSE AGENCIES - DIRECTORS OF THE DOD FIELD ACTIVITIES SUBJECT: Directive-Type Memorandum (DTM) 09?033, ?Policy Guidance for Management of Concussioanild Traumatic Brain Injury in the Deployed Setting? References: DOD Directive 5124.02, ?Under Secretary of Defense for Personnel and Readiness June 23, 2008 DOD Directive 5400.1], Privacy Program,? May 8, 2007 DOD Directive 5400.11-R, Privacy Program,? May 14, 2007 DOD 6025.18-R, Health Information Privacy Regulation,? January 24, 2006 DOD 8910.1-M, Procedures for Management of Information Requirements,? June 30,1998 DOD Directive 6025 21B, ?Medical Research for Prevention, Mitigation and Treatment of Blast Injuries,? July 5,2006 mpose. This DTM: - In accordance with the authority in Reference establishes policy, assigns responsibilities, and provides procedures On the medical management of mild traumatic brain injury, otherwise known as concussion, in the deployed setting for all leaders within the Department of Defense, Service members, and medical personnel engaged in ongoing DOD missions. See Glossary for de?nition of ?concussion.? if: FOR OFFICIAL USE ONLY DTM-09-033 - Standardizes te?ninology, procedures, leadership actions, and medical management to provide maximum protection of those Service members. 0 Is effective immediately; it shall be converted to a new Instruction within 180 days. Applicability. This DTM applies to OSD, the Military Departments, the Of?ce of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant Conunands, the Of?ce of the Inspector General of the Department of Defense, the Defense Agencies, the Field Activities, and all other organizational entities within the Department of Defense (hereafter referred to collectively as the Components?). De?nitiOns. See Glossary. Policy. It is policy that: The Department of Defense shall identify, track, and ensure the protection of Service members exposed to potential concussive events, including blast events, to the maximum extent possible. Leaders in the Department of Defense shall direct a medical evaluation for any Service member exposed to possible concussive events. Leaders in the Department of Defense shall identify, treat, and manage concussion in Service members by following approved clinical guidance. Recurrent concussion shall be addressed in a manner appropriate to its emerging clinical signi?cance. All individually identi?able information will be protected in accordance with Directive 5400.11, 5400.11-R, and 6025.18-R (References and respectively). Responsibilities. See Attachment 1. Procedures. Procedures following potential concussive events for leaders are located in Attachment 2. The revised Concussion Clinical Guideline Algorithms are located in Attachment 3. 3 Information Requirements. The reporting requirements in sections 2 and 3 of Attachment 2 have been assigned Report Control Symbol (RC S) in accordance with (Reference Releasability. RESTRICTED. This DTM is approved for restricted release through controlled Internet access from the Issuances Website on the SECRET Internet Protocol Router Network at William J. 111 Attachments: As stated ATTACHMENT 1 RESPONSIBILITIES l. UNDER SECRETARY OF DEFENSE FOR PERSONNEL AND READINESS The shall establish concussion management policy for the Department of Defense. 2. ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS The ASDGIA), under the authority, direction, and control of the shall: a. Advise the on the physical and medical aspects of operationally relevant concussion training standards. b. Oversee the implementation of this DTM, identify the capability gaps of current technologies and programs and, through the Defense Health Program (DHP) research, development, testing and evaluation program, budget and execute the development and ?elding of new technologies and programs to support concussion policy. c. Recommend modi?cations to this DTM based upon reporting summaries received ?om the Defense Centers of Excellence for Health and Traumatic Brain Injury d. Develop a medical quality assurance program and metrics to monitor the effective implementation of this DTM. e. Oversee the Director, in the implementation of procedures to: (1) Coordinate data analysis and promote data sharing with the Director, Defense Research and Engineering the Director of the Joint Improvised Explosive Device Defeat Organization (J IEDDO), and the Secretary of the Army in his or her capacity as Executive Agent (EA) for Medical Research for Prevention, Mitigation and Treatment of .Blast Injuries (see 6025.21E (Reference (2) Conduct comprehensive, retrospective analyses of relevant event- triggered concussion data and activities of the Services and combatant commanders and coordinate blast-speci?c data analyses with the Joint Trauma Analysis and Prevention of Injury in Combat (JTAPIC) program of?ce. 4 Attachment 1 DTM-09-033 (3) Develop event-speci?c monitoring summaries in coordination with the Services and Commanders of the Combatant Commands based on established procedures for updates to (4) Review and analyze concussion clinical algorithms to provide updates, as indicated. 3. ASSISTANT SECRETARY OF DEFENSE FOR RESERVE AFFAIRS H- The under the authority, direction, and control of the shall ensure the development of operationally relevant concussion training standards for Reserve Component members that are consistent with the policies established for the Active Components. 4. SECRETARIES OF THE MILITARY DEPARTMENTS. The Secretaries ofthe Military Departments shall: a. Promulgate Service policies consistent with this DTM and recommend suggested changes to the b. Program and budget for necessary resources to implement this DTM. c. Require the development and implementation of an effective training plan by commanders for line leadership and Service members with regard to early detection of potential concussive events. d. Require the development and implementation of, and effective training plan for, medical assets pertaining to concussion clinical algorithms in accordance with Service-speci?c policy. e. Make resources available to support the training plans. f. Develop Service reporting guidelines for potential concussive events in accordance with section 3 of Attachment 2. g. Submit tracking reports to the JTAPIC program of?ce for Service members in accordance with section 3 of Attachment 2. h. Support medical and event tracking activities and follow-up medical care for Service members. 5 Attachment 1 DTM-09-033 5. CHAIRMAN OF THE JOINT CHIEFS OF STAFF. The Chairman of the Joint Chiefs of Staff shall: a. Incorporate this DTM into relevant joint doctrine, training, and plans, as appropriate. b. In consultation with the Commanders of the Combatant Commands and the Secretaries of the Military Departments, monitor the implementation of this DTM. c. Monitor compliance with the requirements for documented tracking and reporting of Service members involved in a potential concussive event. 6. COMMANDERS OF THE COMBATANT COMMANDS. The Commanders of the Combatant Commands, through the Chairman of the Joint Chiefs of Staff, shall: a. Develop Combatant Command-speci?c procedures for Service component reporting of potential concussive events and support training programs for leaders on event-triggered screening guidelines. b. Submit tracking reports to the JTAPIC program of?ce for Service members in accordance with section 3 of Attachment 2. c. Monitor Service component compliance of reporting requirements and quality management. 6 Attachment 1 DTM 09-033 ATTACHMENT 2 l. (FOUO) MANDATORY EVENTS. Events requiring mandatory command evaluations and reporting of exposure of all involved personnel include, but are not limited to: a. (FOUO) Any Service member in a vehicle associated with a blast event, collision, or rollover. b. (FOUO) Any Service member within 50 meters of a blast (inside or outside). c. (FOUO) A direct blow to the head or witnessed loss of consciousness. d. (FOUO) Command-directed, especially in a case with exposure to multiple blast events. 2. (FOUO) SERVICE MEMBER ASSESSMENT. Commanders or their representatives are required to assess all Service members involved in a mandatory event, including those without apparent injuries, as soon as possible using the Injury/'Evaluation/Distance from Blast (I.E.D.) checklist (see Figure). Figure. (FOUO) I.E.D. Checklist Injury - Physical damage to the body or body part of the Service member? (Yesto). Evaluation - Referral for a medical evaluation based on involvement in a mandatory event or demonstration of any of the at any point, Headaches andfor Vomiting (Yest o) - Ears ringing (Yesto) A Amnesia andfor altered consciousness and/or loss of consciousness (Y eslN o) Double vision andfor dizziness (Y es/N o) Something feels wrong or is not right (Yesto) Distance or proximity to blast or damage - Was the Service member within 50 meters of blast (Yes/No). Record the distance from the blast. FOR OFFICIAL USE ONLY 7 Attachment 2 FOR OFFICIAL USE ONLY 09?033 Service members will be referred for a medical evaluation based on: involvement in a mandatory event; any ?Yes? response in screening; or demonstrationfobservation of any of the at any point. After the LED. assessment is complete, the results shall be recorded for each individual involved in the event and submitted as part of the signi?cant activities (SIGACT) report required for blast-related events or the events outlined in paragraphs La. through Id. of this attachment. 3. (FOUO) REPORTS. Minimum required data ?elds for reports to the JTAPIC are: a. (FOUO) Date of Mandatory Event. b. (FOUO) Type of Mandatory Event triggering evaluation. c. (F DUO) SIGACT number (if applicable). d. (FOUO) Personal identi?er (Social Security Number or Battle Roster Number). e. (FOUO) Unit. f. (FOUO) Combatant Command in which the event occurred. g. (FOUO) Service member?s distance from a blast. h. (FOUO) The disposition of any mandated medical evaluation (return to duty after 24 hours?). 4. (FOUO) MEDICAL GUIDANCE. All deployed medical personnel are required to use the revised clinical algorithms in Attachment 3 for treatment of concussion in the deployed setting. A summary of this medical guidance is provided in paragraphs 4a. through 4d. of this attachment. All commanders shall support the medical guidance. a. (FOUO) A 24-hour rest period for all exposed personnel involved in a mandatory screening event described in paragraphs d. of this attachment. The 24-hour rest period begins at the time of the event. Commanders may determine that mission requirements supersede individual Service member welfare in certain circumstances determined at the commander?s discretion. Each waiver will be documented in the required report described in paragraphs of this attachment. 8 Attachment 2 FOR OFFICIAL USE ONLY DTM 09-033 b. (FOUO) First diagnosed concussion: Mandatory minimum 24?hour recovery period unless clinical evaluation directs longer. c. (FOUO) Recurrent concussions (within a 12-month period): Requires longer mandatory recovery period than with initial concussive event depending on number of incidents. Recovery period includes adequate sleep (3 uninterrupted hours) and pain control. (1) (F OUO) If two documented concussions have occurred within the past 12 months, return to duty is delayed for an additional 7 days following resolution. (2) (FOUO) If three or more documented concussions have occurred within the past 12 months, return to duty is delayed until a recurrent concussion evaluation has been completed. (3) (FOUO) All sports and other activities with risk of concussion are prohibited until the Service member is cleared. (4) (F OUO) Commanders may impose more stringent requirements based on mission requirements and after consultation with medical personnel. c. (FOUO) Clari?ed guidance on documentation of a Military Acute Concussion Evaluation (MACE) to ensure that the three components that affect decisions within the clinical practice guideline (CPG) (cognitive score, neurological history and exam, and the presence of are pro?ciently documented. Documentation can be accomplished with the mnemonic (medical abbreviation for central nervous system). - (FOUO) Cognitive score (reported with 30 point score). (2) (FOUO) Neurological exam (reported as ?Green? (normal) or ?Red? (abnormal)). (3) (FOUO) reported as (none reported) or (at least one reported). (4) (F OUO) Example of summary documentation of MACE screening evaluation can be c?24i'Rede?i indicating a cognitive score of 24, abnormal neurological examination, and patient reporting presence of at least one d. (FOUO) The revised CPG provides elaborated guidance for a medic or corpsman with proper training to remotely manage concussion under the telephonic or 9 Attachment 2 FOR OFFICIAL USE ONLY DTM 09-033 telemedicine supervision of a properly privileged provider for traumatic brain injury if no red ?ags (de?ned in Attachment 3) are present. 5. (F OUO) RECURRENT CONCUS SION EVALUATION. The recurrent concussion evaluation is required for those who have sustained three documented concussions within 12 months. The purpose of the recurrent Concussion evaluation is to provide maximum protection to the Service member and preserve the ?ghting force. Results of the evaluation will be used to guide treatment in those who are and guide return-to-duty determinations in those who are not. a. (FOUO) Comprehensive Neurological Evaluation. A careful examination of the injury history will be required to make clinically sound decisions. Such information includes, but is not limited to, the level of concussion severity, the duration of and the result of sustained exertion on recurrence of headaches after 2 days of normal duty). The Neurobehavioral Inventory, Acute Stress Disorder Questionnaire, and a vestibular assessment must occur as part of this examination. b. (F OUO) Neuroimaging. Initiated according to provider judgment. c. (FOUO) Assessment. A variety of neurobehavioral assessment tools are available. No one tool is recommended over another. Rather, domains affected by concussion should be evaluated over a 4-hour period. The evaluation must include a measure of effort, including: (1) (F OUO) Attention. (2) (FOUO) Memory. (3) (FOUO) Processing speed. (4) (F OUO) Executive functioning. (5) (FOUO) Social pragmatics. d. (FOUO) Functional Assessment. A functional assessment is initiated according to the clinical judgment of the evaluating occupational therapist or physical therapist. e. (FOUO) Duty Status Determination. The neurologist, or other quali?ed licensed provider knowledgeable about concussion, will determine the return-to-duty status after reviewing the results of the entire evaluation as described in this section. 10 Attachment 2 FOR OFFICIAL USE ONLY DTM 09?033 (1) (FOUO) If the Service member is returned to duty and a subsequent concussion is sustained, the clinical algorithms should be followed. (2) (FOUO) Service members will not require another recurrent concussion evaluation unless are persistent or if an additional three concussions are sustained within a 12-month period. (3) (FOUO) Providers must be vigilant for persistent signs and of concussion with any recurrent concussion, as there is an increased risk with multiple concussions. - 11 Attachment 2 FOR OFFICIAL USE ONLY DT 09-033 (F OUO) MEDICAL ALGORITHMS Figure 1. Combat MedidCorpsman Concussiont mild Pre - Hospitai No medical of?cer in the immediate area) Wm WM may: or In mlmu a "tutu! an walnut?. mw?du mud-my Ewm me: mush-r uh; mu: km mum?! wind lenm man or mm swine mm: whim mammn a man cum-ion a War m' lull?- -M,mmrm 1. iormeuutmwuwlinnm I. 5. wm-Lwlils 5. Samara I. Mumm' Evmwhuigmrm-uot 9- mum lawman 11.6mm mutant:- WI ordilum?ndlo phat lawman? Emu-Mm . N0 .. ask-?nancial mum-mutu??: mlnl?eHr??wmr? um? WW . -murwnm ?mm val 3: mt momma] WMEEMRJ YEs-mcm minim I. -mtormum1m-mm - 1. vanigumizzinm ABM M. 2. Hum mammalian Ewan - rm mmwr?wmm? nmma pm?nmh?i'l?rmi a ?Hahn-?uff W. wider 1. Wm Inimlnof?upa. WW Wm . ?painting-pa? a Baum saw: 2. Mir-I mm S- "WWI-?ower cmmd?mmu 1cm.wmulmmr . ?Mln?umumnfm no Tam-tumult!? YES 1! I Pm? We??i?l? mm: with? vaiuumnTo ?enmfurswm -EmwtninEMRa-wum?l macrmm +131}! watts-inn mm? . . m1: comma-um Loc 5 :0 mm - mummi?ed with all La'n- mew - Pump-m Mom The goal It: to mass Mud flags qufc?y and ?a service man-aw is fauna la mqulra further consultation, the media! comm is gm almanac to further discus the Wary with a pm. FOR OFFICIAL USE ONLY 12 Attachment 3 FOR OFFICIAL USE ONLY DTM 09?033 Figure 2. Initial Provider Management of Concussionin Deployed Setting 'en?m 1. dlolning lull o1 sonar-loom?: WW .1. Prom-?M declining nourulw??i mm a. Pool nary-nuns mandatory Enron? Requiring lilacRea-Ind Anya-Moo mm "9111. willow-or rolmr 6. cum" 3? 15 AW saw ?Mr will? 50 mail? I :I'I?al armllida} 7 "animal Dolcl: or SIMON - Anyono who anal-in: I ohm am to 1113 ?ood 3.1.00 Grumman 5 minim: Corr-mud din-nod. such a: ho! not Iirnhod 1o motion exposures 5- 11:. moaning headache 11. cannot poopio ordioononml 1o Floor 12. Slumd son-r11 13. main-nu Rod ill-95' YES - 511311191131 Sonic-u WW 1. Coniuolon at noon} - 2. Unusual ooh-Viol a In-uolily - ND 4 Unlloldy on feel. 5 Vodgo?iuhon a Headache ?t any I 11m. rundown! 24 hra rut. "Ian 3. Pnonopnooa - Muss magnum-M monsoon reevaluate RTD 11 no 9. Ell-op Issues - com-lo brief nouroiogioal onrn ?ml 1 If 3 or more Gammonlod Wm? mum: In our 12 mama and My Hilary in H1- pu-t Now not had 19mm Gunmen 1. Gina shoal 11: various 12 If yes, how many? Concussion evaluation. men roionor arr-moon Enoch-Hunted. down-n! sow. con?rm Tm! 311119191114 :1 my P?lnl. it 3: sum?. mm mm? 4. 119mm? roan-ch. Management - use Owl-mill? encounter EHR manninophan 45 hr: Mora hm may not YES NewGoncusalon pm 5. Avoid 1m. narcollos o. Consioor momma-n 10111: poq H3 or ln'ii?'lpryino. 25 run P0 ?1 HS I'or porrimm humon- prom1.mo?mo no more 111111110 pills. - pm- Mm and pour r. irnpiornoni duty restrictions can a? i I a. address any map issues. Arabian Row-luau do"? Mr up in to maid-rod 'Ior 11110111111111 {2 crooks} slow medallion 9. Plin n?nagomomifappiioablo 111. Send oonauti 1o thioonoumuurmymil hr former guldnme unto-one 11 . conoioor moo-lion Io hiunorlom om Holmium i 11Doeurnunl nonunion di-annolls Rooms for Emma-1 (Quorum a Boat 1. Eur! Io 55-5515 Tami Hurt Rllo - man-age) our?; pom-111.8101} $1413 hand crank 2. Autos: hr {Manuel-no, Ferrari-11 owtionaino?ling "?1951 pno1ophobla.bailnco. . dizziness. nausea. onn?uu. ?all mm? by mam. ?mm oh 3 Ito] or Cog-1111119 Soon I: 25 MEmgnIivo mm - Conlh'lua new - Conuoor combat soon referral ?95 - Conlinua nonunion a combat . Screen rm asa won management up to 14:21 ?ay: [:on?dorlongor ilrlpioity NEB 4' Imprwino. olhorwiao mmojo i? 31 - - "Wm Consider referral to 3 "Wm ?3 '?mm'iwm? - Florian education Ihoe?l M11 SH and - Enter no]: in EMR soon as poll-ibis commu- mutation w?h feedback . Eli-'9 lo unil eomrnonoer . ETD union mm? - 550.0 ooncunion ?Jam LOG Mm? ?mum? within - 860.11 oonouaason win LOG 5 so rniuno pain 12 months. than nundatonr T-day - 1115.52} for any TBI PM ?all Mp?l?ln' noowry parlor! oymploma I: 1119 diagnosis Manama} - H3 or dooumrrlod cone-union: 0 Ensure Lh- Landauiip i1 pasl12 mom?. man rotor for recurrent oonouasion mlul?an In rent: Dom-mm ?easement ?no can I: grow byprovidors to Include a more MM amnmom, mmomonr recommendations and consideration for evacuation to a higher of care . FOR USE ONLY 13 Attachment 3 FOR OFFICIAL USE ONLY DTM 09-03 3 Figure 3. Comprehensive Concussion Algorithm Referral from Level I or II or Poly-Trauma -Con?nrt TBI evatoation -Revieuv recall-d3 -Penonrl comprehensive exern' or: or more documented in 12 months. than remnant oomsioh evaluation must take place Fm exam findings or other CT indications?? Perform CT Scan Positive CT scan -Nourost.n~pioat consult -Consider evacuation to Level Assessment -Treelrnent trial? -Specieity referral for associated it available (EMT. vision. PT. 01o) ?e-eveluate every 72 hours minimum up to 14 days Resolved? Perform enertionel Gwidar evacuation to Level IV followed by alien-ale version of MACE cognitive portion 'Evaluale for AND cognitive score 'Gomprohenolve Euro 1. Homologlc exam 2. exam 3. Other exerts as neededBalance Eaten-I indications 1. Physital evidence of Emma above the claviclea 2. Seizues 5. Vomiting 4. Headache 5. Short-term mam de?cits E. Age 3 ED Duo or alcohol i'ltolticetion 8- Cass-4mm ?Treatment Trial 1. t'ietlisvlr educational sheet with all cormsicn paiietis 2. Reduce stimulus environments 3. Avoid trol'nadol. narcotic: {or headache 4. Consider nortr'ptyine 10mg tor persistent heeded-lo days}. Prescribe no more then 10 pills. 5. implement duty restrictions 5. Sand mull to tu?her guidance 't needed Consider or evacuation to higher lavel care clinically itdicetld diagnosis in EMR sedition 9. Address any slaepissues.Arrtbien1D mg po HS may be considered for short term (2 weeks} sleep regulation Manage pain if aptpi'loabio 'Exlr?onol Testing Protocol 1. Ellat't to 65-85% Target Heart Rate hand cram. pushvupslsil-upa. or other aotiviltt. 2. Assess for (headache. vertigo. ohotophooia. balance, dizziness. nausea. timitua. visual oranges. enters) or Cognitive Score 1 25 codes 350.0 concussion wio LDC [for raw diagnosis} 850.11 concussion wi LDC 30 min [for NEW diagtosin for any TBI visit wiprintary as the clienmoia {in headache} - . I unless 2" woolen 'n the past 12 months. then mandatory 1' day rest period Positive No positive out cognitive <25? period -F'rovido education to all Consider evswathn -RTD: unless 2" Refer to Pi?hdbgi' to Level l'vr Win-?5?9" ?1 the iurtherevamtlon post 12 months. than mandatory 7 stay rest Document all encounters as soon as possible in intent: Additional resources available at Level 3 facilities allow further evaluation and more comprehensive management for those patients who present acutely with concussion endlor have persistent svntofoms. FOR OFFICIAL USE ONLY 14 Attachment 3 FOR OFFICIAL USE ONLY DTM 09-033 Figure 4. Recurrent Concussion {3 documented in 12 month span) Evaluation Algorithm 12 months? FOIFOW Connector: CPG Recurrent Cmsion Evaluation: 1. Comprehensive neurological evolution by murotogist or otherwise meli?ed provider - a review oi prior concussion history' with tours on timeline or resolution oi - Assessment of symotorns [face In race interview by - Nowhehaviorial Inventory Cited-dist - Ame stress disorder questionnaire - Vestibular Assessment 2. Neuroimegina per prouiderjudgmern 3. assessment by peydsoiogisl 4 hour battery Ihet evaluates 5 domains (Attention. Men-ion.-r Processing Epeed. Executive Function. Social Pragmatics} . mode measure oi e?on 4. chlionei assessmenl completed by Occupational Therapyithcical Therapy . Neurotom'sl (or quali?ed proulder}deten1lhes RTD status - Outcomes my home: 1. Return to CON U5 2. Outside AIDE butwithi'l theater 3. Inside JIGR but restricted to base 4. Return to full duty - Exenioml mung must be complete and negative All evaluations must be entered In EMR Mission requirements may supersede individual member wciiare in certain opera-donut environments. intent: To ensure those Service members who have sustained 3 documented concussions in a 12 month period receive a recurrent concussion eveiuetion in order to guide further treatment or guide return to dutv recommendations. FOR OFFICIAL USE ONLY 15 FOR OFFICIAL USE ONLY Attachment 3 09-033 mm Unless otherwise noted, the following terms and their de?nitions are for the purposes of this DTM. amnesia. A lack of memory. Amnesia related to trauma, such as concussion, can be either antegrade or retrograde. antegrade amnesia. The inability to form new memories following the traumatic event (typically not permanent). retrograde amnesia. The loss of memory for events that occurred prior to the traumatic event. concussion/mild traumatic brain injury. The diagnosis of concussion is made when two conditions are met. In the absence of documentation, both conditions are based on self- report information. An injury event must have occurred. The individual must have experienced one of the following: - Alteration of consciousness lasting less than 24 hours; a Loss of consciousness, if any, lasting for less than 30 minutes; I Memory loss after the event, called post-traumatic amnesia, that lasts for less than 24 hours; or I Normal structural neuroimaging. dgployed. All troop movement of Active Component and Reserve Component personnel resulting from a Joint Chiefs of Staf?uni?ed command deployment for over 30 continuous days or greater to a location outside the United States that does not have a permanent military treatment facility (?mded by the DHP). This de?nition will facilitate the capture of naval personnel a?oat should they be subjected to concussive injuries due to explosions or explosive devices. event trigger. The occurrence of one of the mandatory events listed in section 1 of Attachment 2, which directs a speci?ed leadership action such as sending the Service member for a medical evaluation. 16 GLOSSARY DTM 09-033 MACE. A three-part medical screening tool developed by DVBIC to assist clinical providers with the evaluation of concussion. This tool is available to medical personnel by emailing: info@DVBIC.org. medical evaluation or assessment. A meeting between a Service member and a person with medical training (medicfcorpsman, physician assistant, physician, etc.) to ensure the health and well being of the Service member. Components of this evaluation include reviewing a history (events surrounding injury, review of etc), a physical examination, and a review of the treatment plan with the Service member. neuroimagin-g. A radiographic imaging stud}r to evaluate the brain, to include computerized tomography scan or a magnetic resonance imaging. post-traumatic amnesia. Period of amnesia following a traumatic brain injury. 1 7 GLOSSARY