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The Vets First podcast is a research-based podcast that focuses on the VA healthcare system and its patients. Instead of being just another research podcast, the Vets First podcast was created with a primary focus on the Veterans and their stories. The hosts, Levi Sowers PhD, and Brandon Rea work to bridge the gap between the state-of-the-art research being performed at Veterans Affairs and the Veterans themselves in an easy-to-understand manner. Importantly, Levi and Brandon want to assist researchers around the country to better understand the needs of Veterans. In this podcast you will hear interviews from Veterans with specific conditions and then hear from VA funded researchers who are studying those very topics as well as other highlighted services the VA provides.
The Department of Veterans Affairs does not endorse or officially sanction any entities that may be discussed in this podcast, nor any media, products or services they may provide.
Announcer: Welcome to the Vets First Podcast, a research-based conversation centered around the VA health care system, its services, and patients. From Iowa city, Iowa, here's your hosts: Dr. Levi Sowers and Brandon Rea.
Levi Sowers: Welcome back to the Vets First Podcast. Today, we have Dr. Eric Singman from Baltimore, Maryland. He works as a neuro ophthalmologist at the Baltimore VA, and he has in some way or another, cared for vets and active duty military at the DOD Vision Center of Excellence for 20 years, you said, I believe?
Eric Singman: About 12 actually. I've been a neural ophthalmologist for about 30 years.
Levi Sowers: 30 years, that’s right.
Eric Singman: I've been involved with the folks in the military one way or another since the VC- since the VC started in 2011.
Levi Sowers: Awesome.
Brandon Rea: Very nice.
Levi Sowers: Well, welcome to the podcast! As always, Brandon is here with me, as well, and we’re really appreciative that you're coming on.
Eric Singman: My pleasure.
Levi Sowers: All right. So let's get down to business. You know, one of the first things we ask people is, is, you know, we really look to make researchers more human- health care practitioners more human. And so we'd like to know where like where you came from and what your history is with, like, where did you grow up at and how'd you come to the point you are now?
Eric Singman: I'm- well, I grew up in Queens, New York, and I spent most of my life, in terms of my training, in New York City. In Manhattan or Brooklyn and Queens. And when I finally finished my training, which included my M.D. and my Ph.D., which is- my Ph.D. is in vision problems associated with optic nerve damage, trauma in particular, I then went to Lancaster, Pennsylvania, where I served in private practice for 14 years. But during that time I was involved in other ventures. So I was called and recruited to help stand up the Vision Center of Excellence, the Department of Defense, VA, DC, where most of those wonderful people I've ever met and I'm still in touch with them today, I've got to consult with them at that time. But oh, even had other consulting opportunities with them later on and to do research with them, published research with them. And I focused my practice on brain injury medicine. My fellowship in Ophthalmology was in a hospital called Kingsbrook Jewish Medical Center, and that used to be called the “Hospital for the Incurable.” It was a place where patients who had very, very severe injuries, either birth injuries or brain injuries, were taken and it became a more of a rehab style hospital. But I was a wonderful place to learn and try to help patients. And so I stayed on that. When I went to Lancaster, I then was able to do that kind of work, also work in low vision. I- not many neuropathologist do low vision work. I felt it was an important skill set to develop. So I did that. And I also was the consultant for a very large rehabilitation hospital in Lancaster. They have their own dedicated rehab hospital, again able to not only grow professionally, but to help in patients who suffered from brain injury, because that's the majority of the patients there in the neuro unit were brain injury patients.
Levi Sowers: When did you really get your passion to work with people who had brain injury and vision loss?
Eric Singman: That was very early on. That was actually probably during my PhD years. I did my PhD years between my first two years and last two years of med school. The first two years are called the basic science years. The last two years are called the clinical care rotations. But I had the opportunity to work with patients and see patients who suffered brain injury, particularly brain injury that affected their vision. And I always knew I wanted to do vision. I always knew I was fascinated by vision. I always wanted to be an ophthalmologist or some sort of vision care provider. But after seeing, I guess, the hopelessness at that time, it took them 30 some odd years ago or more that these patients felt when you told them, I don't think we can do much for you. I said, There's got to be more than that. And as I started to learn the statistics involved in brain injury, how widespread it was and how much it was worsening and in which the numbers are growing, it was something I felt compelled to do. I felt a passion for it, and it just continued to grow as I had the privilege of working with patients who suffered brain injury and wanted to get better and demonstrated that they got- they could get better. Some of those patients were indeed veterans. And I tell you one thing I learned about ex-military guys and women, tough as nails. I mean-
Levi Sowers: Yeah!
Eric Singman: So you say, “Okay, I lost my arm. What's the problem? I have another one!” That's like, “No, no, no, it's- what?!” And so they were- just amazing faith and amazing courage and amazing strength. And that that said, “Okay, if you're willing to work that hard, I'm willing to work that hard with you.” And that was that was kind of the fun part of it, too. You meet people like just a perfect example is Tom Zamperini, who will be our mutual friend. I mean, it's just this guy's amazing. You just you just like, you know, you wouldn't know, talk them that you can't see. It's just it's a miracle. So. So but I wanted to do as much as possible to do more than just workarounds. And so my research in Optic nerve regeneration was, was guided towards that in the work I've done with Vision Rehab for the neuro motor, the visual auto parts of brain injury has been guided towards rehabbing things rather than just developing workarounds, which is what Low Vision does, rather developing things that might be able to get patients back functioning where they can use the tools that they have rather than find new tools because they can't use the tools they have.
Brandon Rea: So. Well, Eric, you talked about. Well, yeah, something that struck me there is we're learning as we're going to see the season with all our interviews, just the the resilience of these veterans who are having these vision issues just blows my mind. You're talking about, and I think this probably a topic that we get asked once in a while, about neurodegeneration. In terms of your research, can you talk a little more about that? Like what what what are you looking at in regards to research there? So personally, I'm not involved in the neurodegeneration research. My reaction, my research and my clinical efforts are mostly taking the patients with what they got and trying to rehab what they have. But the neurodegenerative research efforts are pretty amazing. And every year I get astounded that they're doing more things from 3D printing parts of the body, particularly the solid parts like bone, so that the infrastructure, if you will, of it can be replaced. So, for example, a brain can certainly work without a skull, but it's much better to have a skull. So a face can certainly work if it's misshapen, but it's much better for the eyes to be the way they used to in the same plane, the same platform. And so you get someone with these terrible injuries, especially theater injuries, where they're explosive injuries, and they'll come in with missing pieces of face and skull and we can reprint 3D, print the missing pieces to make them look basically like they used to look based on either old photos or mirror images of the other side that wasn't affected. And we so already that gives us platforms that we can work with. There are other exciting things. Of course, stem cell research is always exciting because there's more and more information to suggest that certainly within the next ten, maybe 20 years, we'll be able to regenerate certain parts of the brain with stem cells and and allow function to return again rather than a work around, give them back what they had. Visions are tough one visions, a tough one, partly because of the fact that the visual system spans the length and width of the brain. And as it develops by nerves growing and following certain pathways and making certain connections. And these are the longest nerves in the head, the nerves that, let's say, control the eye muscles so that you can look up, down, left and right. Those nerves actually start in the back of the head and make their way all the way forward. The nerves that actually control a little bit, the little opening in your pupil getting bigger and smaller. Those nerves start in the brain, go down the neck, down the chest, up the neck and back into the head. So some of these are very long nerves and so some of them are not made. May be harder to work with because you have to get if you make nerves regrow, they have to grow a very long distance. On the other hand, some brain structures, perhaps the visual association areas and perhaps the part of the occipital cortex that let you see those structures might be more amenable to growing because their connections in some ways are more local. Now they do have distal connections to other parts of the brain, but it's hope that maybe some of them can be grown and any part of the brain, we're hoping to do that. Obviously, not just vision, but perfect example is Parkinsonism. Parkinsonism, we know the part of the brain that gets hurt. We know why it gets hurt. We know what happens to it. And we probably I wouldn't be surprised if for that condition that has tremors and falls and people not being able to the muscles that that may be those connections are very close together. That may be a part of the brain. It's very exciting to fix. But the bottom line is neurogenic research is occurring. People are working on spinal cord research, the same thing. People are working on trying to replace the natural neural materials by the same token, people are also working say, Listen, I'm an engineer, I don't know about neural materials, I don't know about cells. I don't really care. I know that basically the human body is plumbing and wiring. Okay, I want to be straight with you. This is right. So I'm going to work on plumbing and wiring. And so they are actually making advances that in some ways even faster they're making is. And so you see people who who are using their brain energy to get an exoskeleton and make themselves walk again. Yeah, that was science fiction ten years ago. That was just a -Who are you kidding? Come on, stop it. Don't play with. It's for movies. That's Aliens. No, there are people walking up to their graduation ceremonies now with an exoskeleton they're controlling. Because the bioengineer said, “Hey, I can't deal with, you know, I can't wait for you regenerative guys to go. I'm just”- They're doing it. By the same token, artificial hearts, artificial pancreas is artificial kidney rot. The research there is exciting and it's happening. So what about artificial eyes? Well, yeah, the research there is happening to little tiny cameras that send information to an electrode array in the occipital cortex. And every year the cameras get better, and every year the electrodes get finer to give you a better pixel, just, you know, pixel number, if you will. And every year we're getting close to patients being able to see things that are valuable to them. So both tracks are going together and they're running in parallel and they're racing and the government recognizes the value of funding these. And I hope the government continues to do that and more, if you will. But what's exciting is that I have a funny feeling that these two parallel tracks will eventually find a way to meet and work together, and that's going to be super exciting. And I tell you right now, all things being the same at the speed we're working with, things like artificial intelligence where we're having computers tell us what the best options are. We're having computers determine what might be the best path to go and best success. Where we can check different theories- theoretically, rather than in the lab, I got a feeling that things are just going to accelerate.
Levi Sowers: Yeah. You know, when. When. When I found out you work on TBI and vision loss, I got really excited because we- my work focuses on TBI as at the Iowa City VA and Photophobia specifically that goes along with that after people get, you know, post-traumatic headache and things like that. And I'm trying to study the underlying circuitry of that and stimulating whether or not we can stimulate different parts of the brain to stop headache or photophobia. And, you know, this all fits together. You know, we're using machine learning to study faces- Brandon’s been really, really big on that project.
Brandon Rea: Yeah.
Levi Sowers: And all this technology is coming to bear fruit finally. Right? And what you're talking about, which is really neat and understanding these pathways in a better fashion helps people like what you're talking about. Bioengineers, target these circuits, target these brain areas that are important for this sort of rehabilitative medicine, if you will. I think it's safe to call it.
Brandon Rea: Yeah, we definitely, definitely recognize the collaborative race between the engineering aspects of looking at these things and the biological aspects of it.
Levi Sowers: You know, we've really started to embrace it. I love getting bioengineering students, for example, undergraduates. They're amazing. They think outside the box. They take their engineering prowess and apply it to our biology and it's really, really exciting.
Eric Singman: And they know math!
Brandon Rea: That's a plus!
Levi Sowers: Specifically, computer programing.
Eric Singman: Yeah, you know, I've worked with bio engineers now on a couple of different projects, and these these are students, these are grad student and so they just blew me away. I just feel like a dummy. I mean, really feeling like a turkey flying with eagles. These kids were so amazing and it was just scare the heck out of me. And you mentioned glare. That happens to be your pet subject of mine, only because of the fact that, you know, it's something you really get your teeth into because everyone gets it. I mean, I've yet to see a TBI patient not get it. And, you know, it used to be I remember everyone's getting, you know, there's there's a huge market people make money from FL41 lenses which were meant for migraine patients for fluorescent lights and that's all they were. That was the one paper that was published on it. And then, and then other people started coming. Then, I think the worst disservice that ever happened to that were there were articles written about glare where if someone comes in with sunglasses, it's called the sunglass sign. It means they're probably faking. It means they're probably in litigation. They want to just look bad. I'm thinking myself, how do you say that? How do you say that? I said, “Do you realize that? Think. Let's think like a patient for a second. Okay. Yeah, Maybe some lawyer told the patient, Look sick, or maybe I can believe a lawyer could do that. No offense. If I'm going to get canceled for this, I apologize. I have friends who are lawyers. Okay? But on the other hand, patients desperately want to have some control over their condition, even if it's grasping at straws. Are you going to take that away from them? Don't. If they say glasses make me feel a little tiny bit, but give it to them.” But the other thing about that is and this is something you know, I spoken to Randy Cardon, who's over there I am with you guys about glare and and I can tell you that that it's a toughie because I've tried- what I've done lately, me personally, is I went to noir sunglasses. You probably know them. They're online N-O-I-R sunglasses. They have a trial frame- they have a trial kit of like 40 different lenses. Another- a lot of companies have that - well, there are a couple of low vision places that have that too. Trial kits of different colors. And so I get I bought the trail kit it's like 75, 100 bucks, something like that. And I give it to my- it's on a big ring- and I give it to my patient and I say go out to the waiting area where there are windows, and just see if any color makes you more comfortable. Don't worry, if it makes you uncomfortable. These- and the nice thing about that, they come in different colors, but they also come in different densities. So I have them say, you know, I say, don't just look for the color. If you just say, oh, it's darker, it's more comfortable, be careful about that. And they often tell it. Every one of them come back to me. And so for I've done this maybe 6000 times since I bought the set, it's always a different color. But I it blew my mind. I said you would think to be always, oh, it's always yellows, always blues, always greens. It's always a different color. I mean, am I lazy and should I have already done a study on this? Yes, I should have. I'm lazy. I'm sorry. Okay? I just. It's my fault. But I. But I'd probably do it. I probably wouldn't do retrospective study to see what colors they were chosen because I tell the patients, once you find a color you like, call noir sunglasses- and I promise I don't get any money from Noir and there are other companies that sell dark glasses. I'm sure they're all perfectly fine, but call Noir and ask them because they have good customer service, and say, “All right, I like this color. I need a dark one for outdoors and a light one for indoors” and noir usually has that or can make that. And they make them all sorts of different sunglasses. So they give it to a guy who is a full military man who wants to wear something that looks like an Oakley because, you know, it has a big, you know, CDI factor. The chicks dig it factor. They'll get some. Cool. All right. Whereas if if it's one of my other patients who doesn't don't give a rat's whatever about how they look they just want no they won't be comfortable, you know. So they come in different frames of covered but they, they end up getting usually two frames, one with dark and with light, and they often really are really happy. And it was the it was one of the most least expensive, fun things I did for lab patients. The feedback I usually get is it's not perfect. Nothing is. It's more comfortable and I'm more I feel better and great because a lot of my glare patients never get completely better. Yeah, never get completely better. Many of them, I guess, adapt. Many of them learn to deal with it. Many of them have workarounds. Many of them, you know, they like working in natural light. That's a workaround. They seem to like it better than artificial light. Many of them, you know, adjust their computer screens, invert the contrast and look at white letters in a black background to the list glaring, you know, real estate on the screen. But whatever it is, it's such a pervasive problem that I love hearing that people going to And he told me it was so exciting and I would love to see studies that bear out, you know, my personal experience. That is it. It seems to be the colors all over the map. Have you- may I ask you, if your work is found are there any particular colors they seem to like or any groups that they seem to like?
Levi Sowers: There's colors that we know they dislike. Blue light typically is bad makes it worse. Red light can also do the same. And Romy Bernstein from Harvard has done a really good set of studies on green light showing the green light or different. I think colors of green are actually lower headache pain levels in people. That's pretty set- a pretty cool set of studies.
Brandon Rea: Yeah, I know anecdotally those new headlights that are like bright blue, I just find them a little more obnoxious at light- at night than the old warm ones. But I know I think it's this I think it's awesome to hear about like this is a research aspect that has a practical solution. Like if I, if yeah, like, if it helps a patient out like, I think that's great. That's, that's amazing.
Levi Sowers: You know, if we can back up a little bit, I have a couple of questions about the optic nerve. The optic nerve is the the large bundle of nerves that carries vision back to the visual cortex, the brain. And you can correct me if I'm wrong, but it's a very simple-
Eric Singman: Well, it’s close. The optic nerve goes from the eye to the thalamus, and then the thalamus sends a second sensor is a relay station from there to the brain. So really, you missed it by just- just a little bit.
[laughter]
Levi Sowers: That's why I have a Ph.D. and not an M.D.. All right. So, you know, one thing I really think about when people or- when I'm listening to the vision talks at the Vision Center, we were taught when a person suffers a TBI, whether it be a blast injury or severe trauma to the head, you know, impact what happens to these long nerves when that occurs. Because these nerves traveling from the eye to the thalamus, that's pretty long. You know, that's what what happens to these nerves when that occurs?
Eric Singman: A lot. And I'm glad you mentioned the two types of injuries because, you know, working in the military, you know, we recognize that there's blast and there's blunt and they're logarithmically different in terms of energies. So starting with blunt and in the middle is ballistic. Okay, so let's start with blunt. With a blunt injury- and we know depending on the location, let's even if the nerve itself isn't hurt directly. In fact, one of the papers I published was about indirect traumatic optic neuropathy. The energy hits the head, particularly, especially when the energy is frontal or temporal. The two things happen. We think that hurt the nerve. First, the optic nerve is, as you said, is long. It's centimeters long. And considering how small they are, that's pretty long. And the nerve has to go through a one centimeter long bony canal to get from the eye socket, which we call the orbit to the inner circle. And part of the intracranial part of the brain, there is laxity from the eyeball to the eye socket entrance of that intracranial canal of the canal. And that's important because otherwise, if there was no laxity, if it was tight, you couldn't look around. So there has to be some slack. So usually that part of the nerve because they're slack, at least with a blunt injury, is probably okay. On the other hand, that canal may not be so okay with a blunt injury. It may very well be that the entrance and exit point of the canal are deformed and that deformation might squeeze the nerve and or the blood supply to it. Just in addition, when the nerve leaves the canal to go into the brain and is attached to a structure called the optic chasm, where the two nerves meet, there's no slack there at all. And remember, when the brain gets a blunt injury, it reverberates inside the head. Yeah, because it's loose is floating in CSF. The brain can reverberate, but the nerve is attached to the skull, so it can't reverberate, it gets pulled upon. So we think there are two mechanism, a two mechanisms of damage in blunt injury deformation, the bone, which can hurt the nerve by crushing it and stretching of the nerve, both of which can damage the nerve badly. When these things happen, we know that patients can lose a little vision to all of it. We know they can get a little better, too, completely better. And all the combinations in between. We don't know why some folks lose a little and some fix a lot. We don't know why some folks get better and some don't. And we- all we do know is that we have no way to treat it. On the other hand, one of the research papers we published through the Defense Veterans Injury Registry of the Vision Center of Excellence using that big data set, which is wonderful, said that patients with traumatic brain injury generally don't suffer severe low vision. Now what I mean by low vision is not reduction of visual field, but reduction of significant loss of visual acuity. So we don't see many there's not there's really a low there's not much of a correlation between brain injury and patients who get vision much worse than 20/70 or 20/40. And that's really important because it suggests that these are guys who've been in the field helmets work. So at least to this condition of indirect traumatic optic neuropathy, where there's damage directly to the damage indirectly to the nerve to some energy process. It looks like helmets are good protection and the current helmets are good protection, which is pretty awesome.
Levi Sowers: Yeah.
Eric Singman: Now we get to ballistic injury. You guys probably know as much as I about the fact that the helmets can prevent to some extent from a glancing ballistic injury. But if it's a direct ballistic injury, depending on the size of the shell, obviously your helmet may not be able to do as much. And so a ballistic injury is may you may have to deal with penetration to the parts of the brain and that could simply cut fibers. And that's that's your end of game blast injury is a whole different ballgame helmets do not prevent against blast injury. Well again let me back up There are multiple types of breast so there's the primary blast and the secondary cordura. Right. So one type of blast injury is the blast wave.
Levi Sowers: Yeah.
Eric Singman: One type of blast injury is the blast throws some of the service personnel against a hard object. Yeah. One time a blast the next time blast as they throw a hard object against a service personnel like a rock or some shrapnel. And then there's the chemical effects of that, like the burn, and then there's the thermal other type of salt. So this is up to in every blast. But let's just talk about the energy wave. Just the energy wave. Yeah. That energy wave likely does damage on a microscopic level. Remember that a blast causes a vacuum bubble. It gets rid of all the air, everything in a certain area. There's nothing there. It's a vacuum. It's a blast that's sudden change in very, very low atmosphere. Pressure actually can remember if you take any liquid and you put it in zero pressure, it bubbles and goes into the atmosphere, vaporizes so you can get micro vaporization in the brain. And that may happen at the level the optic nerve and other brain tissues. Now, it's that doesn't happen for a long time. It's not a long process. The blast is very fast. And so there may not be a lot of it and it may be microscopic big damage that's able to be healed. But there's no question that when patients come to us with blast injury, they have global problems with protean manifestations. And the reason vision is almost always affected is because they said almost perhaps half the brain one way or another, if you counted up the cells of the fibers, is involved in vision. The optic nerves alone are a million fibers each. The frontal cortex is involved in moving your eyes and deciding where you want to move your eyes. The occipital cortex is involved in interpreting what you see and telling your brain, interpreting what you see. The other parts of the cortex are involved in making the eyes work as a team. The midbrain is all making the eyes move and work as a team. So the whole brain is so much involved in vision that these patients always come with some sort of visual problem. So in the book chapters that I wrote with Carey Balaban, who also worked with the VC with me there, in the book chapter, he wrote the textbook- I just wrote the book on vision, but that the textbook on so-called “Mild Traumatic Brain Injury.” Yeah. Talk about which by the way, one of the points of the book was there's no such thing. It's a misnomer. It's like being a little pregnant. Okay, so but we talk about how how y how widespread vision is because the brain is so much vision oriented.
Levi Sowers: That's, you know, that's that's awesome. That that's a really good description. Some of the better descriptions I've heard of a blast injury. You know, one thing I think that also is important to discuss, maybe and you can totally correct me if I'm wrong, but sheering force of that wave, right, it can shear the nerves in the brain.
Eric Singman: That’s right.
Levi Sowers: So it's like-
Eric Singman: That’s exactly correct.
Levi Sowers: And so, because the brain is more like liquid ish, if you will, than the air surrounding it. So when you get a change, a phase like that from a blast wave, it can cause damage when it changes phases. Would you be able to discuss that a little bit?
Eric Singman: To some extent, the bioengineers do a better job with it, but the brain has a couple of very interesting parts about it. First, it's inside a solid, so the skull is solid and solid transmits waves pretty well. I mean, you know, you're not going to a table and you listen at the end of a table, you hear pretty well. That's that's the basis of drums, right?
Levi Sowers: Yeah.
Eric Singman: Then you have the liquid portion and liquid transmits also through the spinal fluid. Then you have the brain tissue, which is not it's more solid than liquid, but it's definitely not solid as a rock like the skull. So you have these different phase changes as a transporting. And I've always personally wondered, you know, if you ever see shuttle light through a through air them to a let's say water in the air again and you get those refraction. I've always wondered whether the energy as it goes through the different media in some way changes and has an- there's an effect on the tissues as it does so I can't speak to that. But I've always wondered, you know, is there perhaps an underlying either protective element or a weakness to the fact that the brain is in a water bath inside a solid medium? So I've always wondered about that. But getting to your point about shear injury, certainly with ballistic and blunt, we already know that there's shear injury, so it makes sense it's going to be with blast as well. And even though diffusion tensor imaging as an imaging modality is still considered a research tool and it's not really- it's you know, even though, you know, there's some places that do it and people want to show like in court in tort cases, oh, look, this patient had an injury because the DTI is abnormal. It's not ready for prime time yet in that regard. But certainly as a research tool, it's been effective in demonstrating in certain cases that the different fiber tracks have been disrupted because of things like shear injury and the energy that goes through them. And- it's the fact that patients actually get better is a miracle in and of itself, because, you know, you with adult neural tissue, you think generally especially central nervous system, we don't think of regenerating real well. And so I've always wondered whether the healing is regeneration or simply that the tissue was strong enough not to die and just can get healthy again. Or and finally, the other point I always wonder is, you know, the good Lord has been kind to give us extra stuff to lose, like we have two lungs, but people can live on one level. We have, you know, someone could lose half their liver and still do fine. Two kidneys, right? So we've been we've been given extras, we've been given extra presents. It may very well be that brain tissue has some degree of redundancy in it. So when there is damage, we still have something we can work with and look human.
Levi Sowers: Yeah, that's an interesting thought. That's an interesting thought. I have two more questions.
Eric Singman: Maybe I'll take your time. One.
Levi Sowers: We try to aim for 45 minutes coming up on 34 here.
Eric Singman: Okay.
Brandon Rea: Well, this has been awesome.
Levi Sowers: Yeah, it's been really good. It's been a really good interview. So, you know, putting on your clinician boots for a second, what's difficult about treating TBI related vision loss versus other types of vision loss? Maybe there's no difference, but I know there's.
Eric Singman: There's a big difference. In fact, I'm going to do something. Hang on a second here. Some there's an article I just recently published last year in the Journal of JCO, Journal of Clinical Medicine, and it's entitled “From Provider to Advocate the Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement.”
Levi Sowers: I saw that paper on your pubmed.
Eric Singman: Right, it’s there on pubmed and, so, the reason that I published that paper was as a way of thanking the different brain injury organizations we have in our country who advocate for brain injury patients because it's amazing how difficult it is not only to be a brain injury patient, but to be a caregiver for a brain injury patient. And one of the things I talk about, I teach this to the residents that I am the ophthalmology resident trainers, is that, you know, brain injury, certain ophthalmology tasks or almost veterinary ophthalmology. I hate to say it that way, but if someone comes in with a cataract, I don't I mean, of course you want to speak to them, fine. But if that person doesn't speak at all, doesn't want to talk to you, doesn't even like you, you just want to see better and you examine, you see cataracts. Okay. I may not develop a great relation with this guy, but he's going to see better. We'll do a cataract surgery. He's going to see better. Okay? It's just like if your dog came to you and you notice a cataract in their eye, they don't need to say a word. They're your dog. They love you. They're still good dogs. They can see how the other, but you want the character. And so again, all my colleagues and characters, you're going to hate me for this to not show this. But. But with brain injury medicine, you have to develop a relationship with the patient because anything that can go wrong does go wrong. The you know what hits the fan with these people first, they let's just talk just briefly about the social issues with them. They often lose their job.
Levi Sowers: Yeah.
Eric Singman: So they often lose their health insurance and they then lose their income and they might lose their house. And so all of a sudden, how are they going to get and they lose their car? How are they going to get to appointments? Who's going to make their payments with no Internet access, they lose their computer, they lose their cell phone. How are they going to make appointments? How are you going to keep appointments? How are they going to communicate with the doctor? How are they gonna get tests done and how are they gonna pay to get tested? For some, life is it can be a downward social spiral. When you look at the ranks of the people who are homeless and you see the proportion that are veterans, it's horrifying because the number is way disproportionate when you see the ranks of people who go to prisons, who deal with drug and substance abuse and you see the proportion of their veterans, it's horrifying. These are people who should be given, in my opinion, if you put on that uniform and you're not decent and you're not dishonorably discharged, in my opinion, and you were honorably discharged or you were discharged from MIT, what As far as I'm concerned, I'm a taxpayer, okay? I don't like certain taxes that I paid, but there was one tax I'm happy to pay free health care for the remainder of the life of any veteran, period. Yeah, I just I've been an advocate for that. Always will. I'm on a bit and I'm a concern. I'm a fiscal conservative. Okay. I think this government spends money on stuff. That's ridiculous. Okay. You see how much elections cost? $12 billion for an election. I mean, like Mike Bloomberg spent half a billion dollars for ads to get three electoral votes. So even if they like them still, he could have half a billion dollars to watch health care he could have given for a veterans well, instead.
Levi Sowers: Yeah.
Eric Singman: So. So just the health problems. Just the social problems get in the way of the health problems. But if you have someone who at least who has a a loving caregiver, a family member or a support member. All right, you get past that blockade Job one is to teach that health care giver how to be an advocate for their patients. As I say to my patients, it takes a village for a TBI patient. And once you have that village, I try to create a network for my patients because oftentimes there isn't a vision center of excellence for them to go to. So I try to create a network for my patients of different providers, and I try to teach that caregiver how to be the guide. If you have, God forbid, someone has to go to a cancer center, the first thing they assign to you is a patient guide or a patient walk through. It's usually a nurse practitioner, nurse and advocate somebody so that that person not only understands the medical jargon, but also can explain to the patient, Well, yes, you have an ecologist, but you also see this surgeon. You have to see this endocrinologist because you'll see this doctor and that doctor, this doctor and the patient gets it and they know they have some of the contact- there's a guide. Brain injury patients deserve centers of excellence where things are under one roof. But if they can't have that, at the very least, they deserve a guide who can take them to the different providers who may not be under one roof but at least work as a team.
Levi Sowers: Yeah
Eric Singman: And so that's the second thing we do is to teach not only is to try to help the patient with the social problems, but if they have a guide, teach that guide to be an advocate. Once they have their which are two biggies, once they have an advocate, then it's the doctor's job to ask the patient everything. Because nothing is off the table. People are shocked. I ask my patients, my male patients, are you tired a lot? Are you sleeping well? How is your libido? Because neuroendocrine damage happens with traumatic brain injury and guys don't like to talk about that, but they need to talk about that because I had one patient come in because his libido was kind of down, so he started using Viagra. The only problem is he got a ischemic optic neuropathy from the Viagra. He went blind in one eye. Did the Viagra cause it? Well there- it's probably likely it's the cause of it. The research suggests that may be a risk factor for it. Okay. But he went blind in one eye because he had AD and he had AD because he had a traumatic brain injury. So it all comes back to it. Another patient, I had a traumatic brain injury and he became a couch potato when he put on £75 and he developed sleep apnea. And from the sleep apnea he developed elevated intracranial pressures from the sleep apnea. So he came in to me because he had swollen optic nerves, which happens with that. When you look at traumatic brain injury, you go back to the source. It affects every part of your body. So it's the doctor's job that if not, if you're not going to ask the patient, at least educate them. So one of the reason I wrote that article is to educate the patients and their caregivers to not be afraid to ask the doctor, even if it's not the doctor, especially. “Hey, Eric, I know you're an eye doctor, but, you know, I've been having a pain in my back. Is there someone who could talk to me like I could see about that?” That's what you want to do.
Levi Sowers: Well, it really highlights how everything- everything is interconnected. Everything works together.
Eric Singman: Absolutely.
Levi Sowers: But, Eric, I got a question then. What are you most excited about? Like moving forward with vision research and TBI? Like, what is like we kind of touched upon that earlier in the episode, but personally for you, what are you most excited about? What's been developing? What is kind of on the horizon?
Eric Singman: I'm most excited about some of the research I'm seeing that personalizes the care for our deployed service personnel who might become veterans there afterwards. And you guys both know that everyone goes through a pre-deployment physical. Right. No problem. But the pressure for a physical, we want to be as granular as possible in this, tailored as possible, but also, if it's so complex that it's inexpensive and unwieldy, we can't use it. So I'm seeing more and more devices that do rapid testing of some of the metrics we see associated with concussion and brain injury. That can be done within literally minutes. So it doesn't eat up a big part of the pre-deployment physical so that when Trooper Smith goes into battle and was exposed to blast, I have Trooper Smith's numbers of how his pupils react. How was his speed of convergence and pursuits in seconds? Those different visual more things that can be affected how his reaction time is and I know his exact name is pre-deployment when he was perfectly healthy. Now I can compare Trooper Smith not to some average. I can compare Trooper Smith to Trooper Smith before and afterwards. And I now can tell if Trooper Smith was specifically hurt compared to Trooper Smith. And I'm really excited about that because it personalizes the medicine for each individual trooper, so that I can say listen- So I don't under or overestimate the blast. Look, if I have a squad out there and there was a blast and I need that squad out there and I want to if they have a blast, do I pull every member of the squad in because I'm- of fear they got a blast injury. I mean, I'll definitely get anyone who didn't have a blast injury. But now I have a I have a need for squad out there and I'm going to send another group out there. Can do that if I could quickly and rapidly in the field with it in the hostile environments be able in austere environments be able to test Trooper Smith quickly with this little handheld device. You're okay, pal. You did good with Trooper Jones. I think you better come back with me. Look at the difference it makes. That's one of the things I'm totally stoked about because that's coming that's on the horizon. I've seen some of the injuries, I've seen some of the work, Some of it's not ready for prime time yet, but they're getting very close, certainly with the next five years.
Levi Sowers: That's awesome. All right. This is the fun part of the interview, Doctor saying that.
Eric Singman: This was fun.
Levi Sowers: I just you know, I've enjoyed the whole thing. Yeah, but this is something off the cuff. So you are excited about TBI research, but what are you excited about outside of research, outside of your career? What do you do for fun?
Eric Singman: I play bagpipes.
Levi Sowers: What?
Brandon Rea: Nice!
Levi Sowers: Wow! That’s kinda cool.
Eric Singman: Badly. I play badly.
[laughter]
Eric Singman: I don't play for anyone who actually knows how to play. But for people who don't know how to play, I sound darn good!
[laughter]
Levi Sowers: Awesome. Yeah, that's. That's- that's what it's about, man.
Brandon Rea: You have me convinced?
Levi Sowers: Yeah, exactly. You know, I have some hobbies I'm not so good at either, but people think I'm good at them.
Eric Singman: That's the whole point.
Levi Sowers: That's pretty cool. Well, hey, I really want to thank you for coming on today. It's been a great interview. You're very knowledgeable and it's really great to see someone who's passionate about treating veterans and I agree with you 100%. You know, I've had a lot of military members in my family and it's like a moral obligation to treat these people, in my opinion and we are definitely on the same page when it comes to that and that's really exciting. So anyway, once again, thank you for coming on the Vets First Podcast. It's been a really great interview.
Eric Singman: Thank you so much for having me. And please, I have a couple of people, I know them there. Just say Eric says “Hi,” they'll know who I am-
Levi Sowers: Okay. Yeah.
Eric Singman: And I just- I'm grateful. I wish you guys the best of success.
Announcer: This concludes today's Vets First Podcast. For questions or comments relating to the program, please direct email correspondence to vetsfirstpodcast@gmail.com. Thanks for listening!