The survey model

The McLennan County survey is modeled on a similar survey conducted after the 1995 federal building bombing in Oklahoma City, which left 167 dead and almost 700 injured.

Oklahoma State Health Department researchers used hospital records to catalog injuries. They tried to track down everyone exposed to the blast, including people injured but not treated at hospitals.

Subsequent research went further: Oklahoma’s State Health Department documented health effects from the blast in three phases, said Sheryll Brown, an epidemiologist with the department. Survivors were first surveyed at the four- to six-month mark. They were again questioned at least 18 months after the blast, and then up to three years after the bombing.

“The leadership of the health department was definitely behind that,” Brown said. “It became a priority.”

Oklahoma health officials also surveyed about 1,800 area doctors, including orthopedists and family physicians. They also surveyed audiologists.

Using the Texas Medical Board’s registry, The News found 432 private-practice doctors within 60 miles of West who could have treated blast injuries. There were an additional 28 neurologists and psychiatrists in the same area who could treat patients.

“We need to know about all the injuries and not just the ones that showed up at the ER,” said Dr. Bradford Holland, former president of the McLennan County Medical Society. “No one’s given really any structure to be able to report that.”

Holland, a Waco ear, nose and throat specialist, estimates that his practice has treated 50 blast survivors. About half did not go to a hospital after the blast, he said.

Some have tinnitus, or ringing in their ears. Others have permanent hearing loss, he said.

Both conditions can lead people to isolate themselves socially, suffer from depression, or turn to substance abuse to cope. “People coping with some of these injuries will still have symptoms into the next decade,” Holland said.

‘Not seeing the need’

“Trying to contact every physician in Waco? No,” Waco-McLennan County Public Health District director Sherry Williams said last year, a few months after the blast. “I guess because we’re not seeing the need for that.”

Texas health department officials noted more recently that circumstances were different in Oklahoma City: The urban area had more doctors, and the blast happened in the morning. In West, with fewer area doctors and the blast occurring in the evening, the assumption was that fewer people would go to private doctors for acute injuries.

Van Deusen, the department spokesman, said the West injury team “decided to focus its resources on the facilities most likely to have relevant information.”

McLennan County says its victim survey questions may provide details on injuries diagnosed after people were released from the hospital.

“Data from survivor surveys, once analyzed, may provide details on other injuries, possibly not included in the medical records, and/or those injuries that were diagnosed at a later date,” the county wrote.

But a copy of the survey reviewed by The News did not specifically ask whether a victim had any injuries diagnosed after leaving the hospital.

And the state said it is using data only from the original review of medical records and has no plans to continue monitoring the injured from West.

At minimum, anyone thrown off his feet by the blast may have been injured, experts say.

“It makes sense to me to try to identify everyone exposed to the blast and try to follow up,” said Dr. Jeffrey Bazarian, a professor of emergency medicine at the University of Rochester School of Medicine in New York.

Types of injuries from the West blast No. of people with injury* Laceration (cut)/ penetrating trauma (open wound caused by object piercing the body) 139 Contusion (bruise) 92 Abrasion (scrape) 91 Traumatic brain injury/concussion 53 Tinnitus (ringing in ear)/hearing problem 35 Eye injury 33 Inhalation injury (breathing in smoke or fumes) 32 Sprain/strain 30 Fracture/dislocation 21 Tympanic membrane rupture (burst eardrum) 12 Blast abdomen/acute abdomen (damage to abdominal organs caused by the blast wave) 7 Burn 6 Blast lung (lung damage caused by the blast wave)/pulmonary contusion (bruising of lung) 4 Pneumothorax (collapsed lung)/hemothorax (blood between outside of lung and chest wall) 2 Amputation 1 Compartment syndrome (swelling of muscles, cutting off blood flow, causing nerve or muscle damage) 1 Crush syndrome (release of toxins into the bloodstream after a crush injury) 0 *Some people had more than one type of injury. SOURCE: Preliminary results from the survey by Waco-McLennan County Public Health District and the Texas Department of State Health Services

The mental toll

Oklahoma City bombing researchers found that many survivors had health problems long after the blast. Almost two-thirds sought psychological counseling.

People who were hospitalized were most likely to have lingering mental problems, including emotional distress such as difficulty concentrating, trouble sleeping and trouble controlling anger, all symptoms of PTSD.

About 27 percent of those surveyed were treated by private physicians, and many suffered from the same conditions.

In other disasters, up to a third of people directly exposed, including those with no physical injuries, have been found to develop PTSD and a quarter have been found to have major depression, said Dr. Carol North, a psychiatrist at the Veterans Affairs Medical Center in Dallas and UT Southwestern.

North’s research showed that more than half of those who developed PTSD after the Oklahoma City bombing still had symptoms after seven years. Almost a third who developed major depression were still having symptoms.

Craine, the McLennan County health spokeswoman, said mental health is not the department’s focus.

The mental health authority for the county is Heart of Texas Region Mental Health and Mental Retardation, a nonprofit that receives funding from the state, the county and the United Way.

MHMR continues to offer free counseling related to the West explosion said Dana Lafayette, director of crisis services. But she said the group isn’t keeping track of the number of people with specific symptoms.

Mayor Tommy Muska said people in West are still suffering emotionally. “The mental repairing of this town, the families repairing, that’s not easy,” he said.

Muska, also a volunteer firefighter, said he sought counseling after the blast. With no official survey of mental health issues, “they are missing a vital part of the injuries,” he said. With its resources, “the State of Texas could easily come in here and do a comprehensive survey.”

The state health department said there is no plan to study long-term mental health issues. Van Deusen noted that such continuing studies of physical and mental problems is “more challenging in terms of resources and available data.”

“We don’t know of a statutory or other requirement to count and document mental health conditions and are focusing now on immediate physical injuries,” he said.

West Mayor Tommy Muska.

Brain injuries

Brain trauma is among the most common types of injury from explosions and can cause lifelong problems. But experts say sometimes symptoms don’t show up for days, weeks or even months after an incident.

The injury can occur when the head collides with an object, or simply from the pressure of the blast, said Sandra Bond Chapman, chief director of the Center for BrainHealth at the University of Texas at Dallas.

Research shows that doctors sometimes don’t diagnose them because they’re focused on visible wounds.

A team of federal and state scientists who reviewed medical records from people hurt in the 9/11 attacks found that doctors often did not diagnose a traumatic brain injury or concussion, even after writing down the corresponding symptoms in a patient’s chart.

For every two diagnosed, three were not, said Bazarian, who was on the team that performed the research.

State officials say they’re counting symptoms that are consistent with traumatic brain injuries, even if no doctor has specified that diagnosis. But if symptoms weren’t noticed when West victims were in the hospital, the survey won’t pick them up.

“We need to follow these blast victims … almost like cancer,” Chapman said. “Let’s follow you and see if you’ve stayed in remission. You never know when someone’s out of the woods.”

Leaving it to the lawyers

While the government isn’t monitoring the long-term health effects of the West blast, lawyers are. More than 200 people are suing, mostly targeting West Fertilizer Co. and chemical companies said to have made the ammonium nitrate that exploded.

Not all of those suing were injured; many are seeking compensation for property damage. The lawsuits have been put in groups that will move through the court system together, with the first trial set for January.

Within a month of the blast, out-of-town law firms had set up shop in West to provide free legal services. In November, a group of law firms sponsored a seminar on PTSD and blast-induced neurotrauma — brain injury caused by an explosion.

Clients have been evaluated by psychologists and psychiatrists for evidence of those conditions. A Virginia physician who runs a clinic specializing in brain injuries and often serves as an expert witness in litigation came to West in January.

“We’ve had virtually our entire client base evaluated for PTSD,” said Mark Underwood, an attorney with offices in McKinney and West Virginia. Of more than 130 clients, about 100 have received a diagnosis of PTSD, he said.

If cases make it to trial, some health information about West victims could become public. But that information is gathered to win lawsuits, not to inform public and health policy.

“You have lawyers deciding which data to collect, you have lawyers deciding what data to make public, and the judge chooses what comes in,” said Dustin Benham, a law professor at Texas Tech University School of Law in Lubbock.

James Wren, a law professor at Baylor University in Waco, agreed. “Just in the method and selection for collection of information, it has inherent biases built into it that are not going to make it appropriate for a long-term study,” he said.

It’s also unclear how legislators and policymakers might be swayed by injury data from those cases.

“If it’s what we’ve got, it’s what we’ve got,” said Wren. But “it’s not in the form that you’d typically like it to be in.”

Staff writer Matt Jacob contributed to this report.

RELATED STORY: Ralph Pustejovsky lost hearing in one ear when the West fertilizer facility blew up. Weeks later, firefighter Eddie Hykel lost sight in one eye. And one day, firefighter Robby Payne couldn’t walk anymore. They are among the uncounted casualties of West.

Online presentation by Paul O'Donnell and John Hancock.