Nick Patton was only 11 years old when he started working on the boats and canneries of the Alaskan fishing industry. With a community of other fisherman, Nick followed the seasonal work, living on boats and in tents, even during the cold Anchorage winters.
It all ended with the smack of a crowbar.
Nick was 32 and alone on the night he was attacked, and there were no witnesses. With no memory of the assault, he has few clues to the story except for the scar on his forehead where the crowbar cracked his skull.
"First it hurt the front of my brain, because that's where they hit me. Then, the force caused my brain to hit the back of my skull, back here. Then, there was also some swelling, so that caused more damage -- way down here in my brain stem."
Nick woke up in an Anchorage hospital, but nothing was ever the same.
"I couldn't deal with society anymore. I didn't know what was real or who to trust. I ended up cutting all ties to the world."
Alcohol and drugs became his only way of coping. "If I stayed high I could deal with it."
For the first time in his life, Nick found himself unable to work and spent the next several years selling heroin, panhandling and living on the streets.
Unfortunately, Nick's story isn't unique.
News about traumatic brain injury, or TBI, has increasingly come to light in recent months, from a spate of sports-related injuries particularly among football players, to the blast injuries of veterans returning from Afghanistan and Iraq. The medical world is only beginning to connect the dots between TBI and homelessness.
Head injury hits half of the homeless According to the National Healthcare for the Homeless Council, at least half of all homeless individuals have experienced at least one head injury in their lifetime.
"Brain injury in the homeless community is a very common thing that we're just starting to learn about," said Dr. Barb Wismer, a practicing physician who serves on the board of the Council. Few formal studies have been done, but those few are sobering.
In one recent study of 904 homeless men and women in Toronto, Ontario, 53 percent reported some type of traumatic brain injury. Studies in Milwaukee and Boston offer similar statistics of 48 and 67 percent.
The Toronto study found that for those who had experienced a head injury, 70 percent had suffered the injury prior to becoming homeless. And although there is no clear cause and effect, the results suggest that TBI could be at least one contributor to some individuals' homelessness.
Symptoms vary widely and can be debilitating. Some are as dramatic as Nick's hallucinations. Others are much more subtle. Sometimes described as an "invisible disability," brain injury often causes problems with memory, concentration and thinking, as well as the ability to regulate emotion and behavior.
As a result, brain injury survivors often have a hard time doing the work they did before their injuries. Family and social relationships suffer, straining the most immediate safety net before homelessness.
The same symptoms can also create barriers for those living on the streets. Navigating shelter systems, attending to basic health and hygiene, and accessing services can be overwhelming and difficult. Controlling anger can be a daily struggle.
One of TBI's biggest dangers is that it often goes unrecognized. People with TBI often don't connect their symptoms with previous head injuries, and many health care providers, mental health workers, and case managers don't either.
Some brain injury survivors have a hard time remembering appointments, following instructions or taking medications. They may have a hard time organizing their thoughts, finding the right words, or picking up on social cues. As a consequence, these clients might be labeled as disinterested, rude or non-compliant.
Or they may be misdiagnosed. Symptoms of TBI can also look a lot like major mental illness, emotional trauma, or drug and alcohol abuse. And these conditions often co-exist and exacerbate one another. Distinguishing between them can be difficult.
This was the case for Nick Patton.
"They thought I had schizophrenia, even though the symptoms didn't start till after the injury. And that was when I was 32." (This is much later than the typical onset of schizophrenia.)
His doctors prescribed heavy antipsychotic medications to control his hallucinations, but that left him so sedated he couldn't function. And it didn't get to the root of the Nick's problem: small seizures caused by the brain injury, left completely undiagnosed.
According to Dr. Wismer, Nick's case is a prime example of why it's important to identify TBI in an individual who is homeless. Treatment for TBI is often different from traditional mental illness, including differences in medications. Some psychiatric medications have little positive effect on an individual with TBI, yet can produce very harmful side effects.
Because of its high prevalence, the National Healthcare for the Homeless Coalition recommends that homeless individuals be routinely screened for TBI during health appointments and in other service settings. For a comprehensive, standardized screen, the coalition recommends a web-based tool called the Brain Injury Screening Questionnaire. Although it only takes four minutes for the questionnaire to rule out brain injury, confirming a TBI takes about 20 minutes.
This isn't a standard practice in Portland, Ore., where busy clinics are filled with patients at risk for a whole host of health problems.
"The system isn't set up to support a really thoughtful and complete history of complex individuals," explained Rachel Solotaroff, director of Old Town Clinic. Physicians have a limited amount of time and need to address each client's most pressing health issues. According to Solotaroff, clinicians end up using a "clinical reasoning process" to determine what type of screening might be most important for a particular client. TBI rarely makes it to the top of the list.
But given the high correlation between homelessness and brain injury, some advocates think it deserves more attention.
"We have to find a way to identify brain injury on the streets," said Pat Murray, the executive director of Portland's Brain Injury Resource Community (BISC). "When we understand that this is a physical injury, we start to look at people differently. We might need to work with them a little differently. And there may be ways to help."