Four years ago I documented the following story of a soldier I followed for two years while he was on active duty in the Army and part of the Warrior Transition Battalion. After he left active duty he has been under the care of the local VA hospital. I have been able to maintain contact with him and his family. An update on his struggle will follow. The name of the soldier has been changed in this narrative, but the story is true and not uncommon.
2011
There is no better example of the soldier who is vulnerable to the ambivalent policies of the Army towards solders with behavioral health problems than the Army Combat Medic. It seems like the broken and maleficent vagaries of the Warrior Transition Battalion (WTB) system is designed to demolish the honor and pride of the Combat Medic.
As a group Medics are particularly bright, caring and conscientious. With very limited training, they take on the responsibility of caring for their fellow soldiers who have become their family as well as battle buddies. When there is a call out for a Medic in combat, it may be to save the life of your best friend. Always at the front lines, they are asked to care for injuries that would tax the skills of the most seasoned trauma surgeon; and under the most stressful and often primitive conditions imaginable. The Medic is not a certified EMT riding around in an ambulance with all the state of the art equipment and lines of communication. He is not protected from sustaining the very same injuries he is trying to treat. And the Medic does not have any preparation for the emotional trauma he will experience doing his job. Almost always, the first encounter he has with the horrific injuries of present day warfare is the very first time seeing such an injury and always is the only person in their immediate unit with any form of training , however limited that training may be. The Medic feels an unbearable personal burden and exponential measure of anguish when there is a loss of life. They feel singularly responsible for the loss and an extra measure of guilt seems to be a fundamental burden the medic always carries. Their attachment to their unit and the individual soldiers is beyond our ability to conceive and makes the Medic the most vulnerable soldier of all. Yet, if the Medic is traumatized, the first step is to separate him from his unit, his Army family, even when they return home. There, to be placed in the Army foster care system called the Warrior Transition Battalion: a cruel and unusual punishment for the Army Combat Medic.
Eddie’s Story – Part One
Eddie remembers he wanted to be a soldier in the United States Army since he was a small child. His father and a number of other relatives had been in the military. He became estranged from his alcoholic father after his parents divorced in his teen age years, but he never lost his dream of being in the Army. He is intelligent and started out in college, but in 2003 he finally fulfilled his dream and enlisted. He was directed, after being tested, into flight medic training, and Eddie was a natural, an honor graduate in every training course of his career. He felt he had found his calling, his career and – in the Army – a new family, though he remained close to his mother and his sisters. He progressed rapidly, made a mistake with a DUI, got busted and then worked his way back to E5, or Sergeant. From a primary base in Germany he had two deployments, first to Iraq from May to October 2007, and then to Afghanistan from June 2009 to June 2010. During the two deployments, he had over 125 combat related missions.
He remembers now, with vivid flashbacks every day and nightmares every night, the multiple traumatic events he witnessed and those soldiers he tried to save. It is the soldiers he could not save who haunt him constantly. It is his firm belief that he failed in his responsibilities. One soldier sustained a very high proximal leg wound involving the groin area and Eddie could not apply a tourniquet that wound stop the intra-abdominal bleeding; no amount of pressure on the area stayed the hemorrhage. As Eddie tried in vain to save this wounded soldier’s life, Eddie vividly remembers the soldier looking at him until the soldier’s vision lost all comprehension and he died. On another mission, he was the lone medic for four severely wounded Marines; one of the Marines he could not help because the Marine was literally in pieces and all he could do was try to gather all the pieces he could find and still provide what care he could to the other Marines who did survive.
But the experience that haunts him the most is the mission where he was called to resuscitate a female soldier who was involved in an explosion and it seemed she had inhaled some toxic substance and was having trouble breathing. In the course of the evacuation, as he tried to maintain her pulmonary function and ventilation, he placed a hand on her forehead, and she looked at him with hopeless, desolate fear and she then lost consciousness. He felt totally helpless as she seemed to slip away, but she still had vital signs as they touched down. He does not know for sure what happened to her after she reached a medical facility, but he has convinced himself she died. Despite his best efforts he was roundly criticized for his care in this case. And it is this case for which he still feels the most shame. It is possible to track down this female soldier and find out if she survived, but he does not want to know. Whatever the truth, Eddies is terrified of learning what happened to the soldier.
It is important to add that Eddie did not receive any counseling or validation at the time of these events, or after any other combat missions. And Eddie still has to face his greatest recovery challenge, over a year of suspended animation and isolation in the WTB; to be treated, at best, as a wayward child; told in the most derisive and mocking manner that he is a weak and useless “head case” by the “professional cadre” of the WTB. After his second deployment Eddie returned to Germany where he was seen in November of 2010, according to the medical records, for anxiety symptoms, nightmares, hyper-vigilance and heightened startle response, avoidant symptoms, difficulty concentrating, and feeling sad, helpless and hopeless. He was not diagnosed with PTSD and no treatment plan was developed, “since he was soon to leave Germany for home.” It seems in transit across the Atlantic the US Army forgot about Eddie all together and he was taken off the rolls, did not get paid and for a few days he was not even considered to be part of the US ARMY. This alone created a profound depression and paranoid state for Eddie. It took a US Congressman, contacted by Eddie’s mother, to exert the pressure necessary to get that SNAFU fixed. In the soldier’s lexicon SNAFU stands for: Situation Normal All F… up. But wait, even with the Army recognizing him as one of their own, Eddie is still hung out to dry, as a “head case” and abandoned to Bravo Company of the WTB. Now, the task is to help him gain back the sense of purpose and meaning that was taken from him by his experience in the Army.
I anguished with Eddie as his psychiatrist over the next 2 years as he struggled to find himself. The primary diagnosis was then, and remains, Posttraumatic Stress Disorder or PTSD. At first he chose to treat himself with alcohol and marijuana, which just complicated his symptoms. He was considered “high risk” because of his substance use problem, and his treatment possibilities were limited by this. It was my recommendation he be able to return to his home and family in New Hampshire and attend a community Warrior Transition program.
However, he was told (these words repeated and verified in a conversation to me by his command) “you are not a candidate to go home to your family because you are a head case.” Actually even more vitriolic and profane language was used by his WTB command to describe Eddie’s condition to me. Despite command’s judgment that he was hopeless and worthless, Eddie did stabilize as he progressed through the agonizing process of his Medical Evaluation Board. He was seen on a weekly basis by an experienced psychotherapist and I saw him at least every week for counsel and medication management. He entered a relationship with a young woman who subsequently became his wife and they have a child together. So at the time of his separation from active duty with the Army, I felt some confidence that a smooth transition to care at the VA would occur.
It was over a month before he was first seen at the VA in 2013 and even longer before he saw a psychiatrist. He called me, as did his mother, after he was seen and told he probably did not have PTSD and he should discontinue his medications. His pleas to not be taken off his medications and for the doctor to call me, were ignored. This kind of treatment of a veteran is now known to be part of the VA SNAFU, even though Eddie was listed as a medically retired and disabled veteran. A great deal of effort had been put into making his transition a so called “soft hand-off.” but for Eddie, the battle continues.
2015
Just before I left my service as a civilian psychiatrist for the Army three months ago, I received a voice mail from Eddie asking for help. I called back and got no answer and I feared the worst. His wife came to see me at my office at the Army hospital. Eddie has continued to manifest the symptoms of PTSD complicated with ongoing depression. He was constantly angry, withdrawn, feeling helpless and hopeless. In May, he went to the VA seeking help, was given sedative medication and dismissed. Fortunately Eddie did not give up and finally found a person in the VA system who listened to his anguish and got him admitted to the inpatient service. Finally, for the first time in all my five years with the Army, I got a telephone call from the VA. A very insightful and helpful social worker listened to Eddie’s story. Unfortunately I never got a call from the admitting psychiatrist. I learned about Eddie’s treatment program from his mother who came from New Hampshire. It seems the VA still does not accept the primary mental health issue is Posttraumatic Stress Disorder. The Army and the VA speak volumes about the treatment programs for PTSD. Unfortunately, there is still a stigma about the diagnosis, “just another head case” and the treatment programs are not available and accessible.
The neuropathology of PTSD has been well documented for many years, including the anatomical and neurochemical changes in the brain. There is an excellent review article on Posttraumatic Stress Disorder published in the New England Journal of Medicine in 2002 (Volume 346:108-114, January 10, 2002, Number 2). This was written by Rachel Yehuda, PhD, in response to the terrorist attacks of September 11, 2001. In regard to the events of 9/11 she stated the following:
“One could predict PTSD will develop in approximately 35% of those who were directly exposed to the September 11 attacks. In addition, many persons with prior exposure to traumatic events may have a recrudescence of PTSD symptoms triggered by news of catastrophic events and their distressing effects.”
The “35%” figure is no doubt very conservative. One of the classic characteristics of PTSD is that the people who sustain this injury to the brain do not seek help and avoid, at all costs, talking about their experience.
So why does the Army and the Veterans Administration continue struggle with the acceptance of this disorder as a real disease that profoundly effects the lives of soldiers and their families. Not to diminish in any way the profound anguish of soldiers who experience limb amputations (who also experience PTSD) but they are certainly recognized immediately in need of the very best medical care and rehabilitation. And they get it, without question. Prosthetic engineering and care for veterans of the US military are no doubt the best in the world. So why not the same level of attention to soldiers who have lost their sense of identity? I would strongly recommend the work of Edward Tick, PhD, who wrote a very insightful book entitled War and the Soul (Quest Books 2005) which states “we must see PTSD as a disorder of identity itself.” Dr. Tick makes a strong statement for PTSD as a spiritual assault on the soul of soldiers.
“For these survivors, every vital human characteristic that we attribute to the soul may be fundamentally reshaped. These traits include how we perceive ; how our minds are organized and function; how we love and relate; what we believe, expect, and value; what we feel and refuse to feel; and what we judge as good or evil, right or wrong. Though the affliction that today we call post-traumatic stress disorder has had many names over the centuries, it is always the result of the way war invades, wounds and transforms our spirit.”
Perhaps it is this language of identity and the soul that so frightens the narrow corridors of the Department of Defense, the Army and the Veterans Administration so the profound injuries of PTSD are still not fully recognized. They certainly have not been able to recognize the neuroanatomical and neurochemical changes that occur in the brain. After all, it is all about the brain. Eddie is not “just another head case.” He is a husband, father, son who has lost his sense of who he is and needs some help finding his way back.