Hidden Battles on Unseen Fronts

by Patricia Driscoll

  One night in late June William was with an Army convoy outside the base. He was on fire watch when insurgents attacked. He remembers heavy mortar fire and then feeling his knees give out and falling to the ground. When he came to, he had no idea he’d had his first Grand Mal seizure. For the next few days, the seizures increased in number. “I‘d twitch, black out for a few seconds, and then come to and find myself on the ground. I never knew when it was going to happen. Finally I went to my Corpsman, and I said, ‘You gotta get me out of here. I’m a liability.’” The next day William was Medevac’d to Landstuhl Medical Center in Germany.

  But despite days of tests the doctors could find nothing physically wrong with him. “They told me the seizures must be coming from deep inside my brain and there was nothing they could do.” He was sent to Camp Lejeune in North Carolina, prescribed nothing for his migraines or seizures and put to work full time as a Combat Engineer.

  Two months later William had another seizure at a party and fell to the concrete floor, fracturing his skull. His best friend, a fellow Marine, stayed with him, applying CPR until the EMS came. “I would have suffocated on my own puke if he hadn’t been there,” William says. He was flown to a trauma center in Greenville, NC, where he spent the next two days in a coma. “When I got there, he was sitting in a chair strapped down, totally unaware of what was going on, recalls Tami, “and he was like Houdini. The nurses told me he had pulled out the tube that they’d inserted to keep him breathing and had also yanked out the catheter. They finally put restraints on him and stationed a Marine in the room to help keep him under control. The nurses were great, letting me stay. About the only thing that seemed to calm him was my standing there stroking his head.”

  A short while later when orders came to transfer William back to Camp Lejeune, Tami went ballistic. “I said, ‘Over my dead body, you’re taking my kid. There’s still blood on his head; he’s only been seen by an internist, not even a neurosurgeon… I’ll get an attorney.” William was allowed to stay in the hospital and then return home to his parents’ house to recover. He was taken to a local neurosurgeon, neurologist and psychiatrist who all agreed to help him.

  On March 1, 2007, William was honorably discharged from the Marine Corps. He was given the choice of accepting 40 percent disability due to Traumatic Brain Injury or risk the 40 percent to negotiate for more. He accepted the offer. Over a year later the regional Veterans Administration would determine he was due 90 percent disability benefits for his physical injuries, TBI and PTSD combined, a monthly income that wouldn’t start for another year. For the first time since he left for the Marine Corps Recruit Depot at Parris Island at age 18, William was on his own as a civilian. He moved to Suwannee, Georgia, sharing a house with a new girlfriend, an environmental scientist he had met at a party. He got a job at the local lumberyard, bought a truck and enrolled in classes at Gainesville College. “I told myself that I could keep it together, even though I was pretty crazy at times. I thought I could outsmart my emotions.”

  But his short-term memory loss made it difficult to be on time at the lumberyard and follow through on tasks, and he lost the job. He started going to a VA TBI therapy group in Atlanta, but his symptoms got worse and his relationship with his girlfriend turned sour. “I was very childish and irritable. I had trouble being intimate with her; I would withdraw and she wouldn’t know how to bring me out of it. Then I’d get frustrated and we’d have these fights. I wouldn’t even know what they were about sometimes. I’d just fly off the handle. I’d have panic attacks. I remember we rented the Mel Gibson movie, “We Were Soldiers Once and Young,” and I had to leave because of the shooting. I freaked out over loud noises and pops. I was on antidepressants, anti-seizure drugs. She didn’t know me prior. I’d get so frustrated at the doctors for giving me one drug, then another drug, then another drug. She just couldn’t understand it all.” Their arguing escalated when William decided he wanted a dog, and soon after that they broke up.

  William rented an apartment in Oakwood, Georgia, a few miles from his parents’ house, and got himself a four-month-old Austrian Shepherd who he named Raider. He was still enrolled at the University, but was having trouble with his courses because of the memory loss. “Seems like no matter how great my notes were, I’d still forget important material.” When he sought help for his learning problems associated with TBI, the University turned him away. “When William was in sixth grade, he was always getting into trouble,” Tami recalls, “so we had him tested at the Sylvan Learning Center, and he was reading at a college level. He was just bored. It kills me that this kid who served his country and who had to fight for everything his whole life, they wouldn’t give him the tools to learn with. I was very angry that they would not accommodate him.” Soon after that, William dropped out.

  He continued to respond to local job listings and was puzzled when his application to be a security guard at a correctional facility fell through. “Maybe it’s my health record. The thing is, no one is going to make something of my life except me. When you have something like TBI that most people don’t recognize or understand, you’re on your own. You got to have patience and strength. It’s not physical strength I’m talking about that’s going to lift you emotionally.” The Armed Forces Foundation gave him career counseling and helped with rent and truck insurance.

  For a long time William searched for an alternative to the Southern Baptist church he went to throughout his childhood. “I was looking for a place where you’re not just scolded for what you’ve done all week.” He finally found a small nondenominational church where he feels comfortable. “It’s pretty low key. They use a version of the King James Bible that’s understandable. You can wear blue jeans and a collared shirt. I like the people there.”

  He keeps his hair cut like it was in the Corps. “Seems like I have to dig deep to keep my sanity. If I had longer hair I’d probably pull it out.” What does he miss the most from his TBI? “The smell of my mother’s cooking.”

  William eventually got a job with T.J. Max, but like the lumberyard, it became too much for him. He moved back in with his parents in Cummings, Georgia, and enrolled in La Nier Technical School to learn how to become a welder.

  On December 16, 2008 William was on his way to Camp Le Jeune to be re-evaluated for additional symptoms of TBI when his car broke down in Jacksonville, North Carolina. The repairs were expensive and would take a few days. With no money to speak of, and unwilling to impinge even more on his family, William was at a loss. He contacted Semper Fi and received a donation, but it only covered the cost of a hotel room for a night. Knowing that the Armed Forces Foundation has a policy of only helping veterans out once, due to the numbers of people asking for help, William didn’t contact them. He spent the next two nights in a House of Pancakes sitting in a booth until finally, exhausted and desperate, he called AFF, prepared to beg for a donation. The foundation immediately paid for his car repairs and a hotel for him to stay in until they were completed.

  MEDALS

  Combat Action Ribbon, Global War on Terrorism Expeditionary Medal, Global War on Terrorism Service Medal, 2 Letters of Appreciation, Marine Corps Good Conduct Medal, Sea Service Deployment Ribbon, National Defense Service Medal, Navy Unit Commendation.

  16

  WINNING HIDDEN BATTLES

  Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury

  By Bill Yamanaka

  I have had the privilege of working in the Office of the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness since June of 2006. My work focuses on information sharing, and this has given me the opportunity to contribute to an effort that collectively strives to improve conditions for our people who are sacrificing so much. A large part of my task had me supporting, in its formative months, the Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury. A new organization, the DCoE is leading the effort to make life better for service members who may be deal
ing with psychological health issues such as Traumatic Brain Injury or Post-Traumatic Stress Disorder.

  As a former naval officer and now an organizational communicator, what I am seeing is genuine compassion in the attitude of Department of Defense officials and military leaders. Task forces, presidential commissions and independent committees, as well as the National Defense Authorization Act of 2008, presented hundreds of recommendations to address the psychological health and TBI concerns of wounded warriors. In keeping with the intent and specific recommendations, and in charting a course for the DCoE, the emphasis for renewed efforts held steady on a continuum of care. Through the DCoE’s collaboration and what they refer to as “network orchestration,” the Department of Defense is effectively addressing the recommendations to improve the military health system.

  It is history in the making. Prior to the DCoE becoming official, the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness, Ms. Ellen Embrey, was responsible for a line of action on TBI and PTSD, reporting directly to a Senior Oversight Committee. That committee is co-chaired by the Deputy Secretary of Defense, Gordon England, and the Deputy Secretary of Veterans Affairs, Gordon Mansfield. In my eyes, it is without question that this nation’s defense leadership sincerely believes psychological health is of prime importance to overall good health in America’s armed forces. This is why the DCoE came into being.

  The line of action was referred to as the “Red Cell,” and was formed in June of 2007. One of eight lines of action to improve medical care for our troops, Red Cell worked nearly around the clock to battle an enemy that could only be seen through the effects of brain or psychological health injuries. It began with 17 representatives from the medical community of each service, and experts from the staff of Force Health Protection and Readiness. Also integral to the team effort were two officials from the Department of Veterans Affairs, as well as representation from the US Public Health Service. With a sense of urgency, they developed the plans, policies and procedures to address the needs of service members and their families affected by deployment-related brain injury and psychological health. It quickly became clear that what was needed was a national “center of centers” to identify, continue and create programs for TBI and psychological health.

  Doors to the DCoE opened on Nov 30, 2008 under director Brigadier General Loree Sutton, Medical Corps, US Army, who is also the Special Assistant to the Assistant Secretary of Defense (Health Affairs) for Psychological Health and Traumatic Brain Injury. A psychiatrist herself, General Sutton has a gift for metaphor, skillfully using words to illustrate and emphasize key messages for the DCoE. Working fast, a small support staff (initially less than ten) created a center unique within the military health care system, the core of a “continuum of care,” from initial accession to separation and discharge, for all its service members.

  The DCoE is charged with building and orchestrating a national network of research, training and clinical expertise. To do this, they integrate organizations, defense programs and other federal and civilian entities. Since its small beginnings in November 2007 the staff has grown to more than 80, and is projected to exceed 125 by October of 2009. General Sutton’s enthusiasm for service to country, and for the people who sacrifice so much in duty, has helped ensure that under her guidance the DCoE has incorporated a balanced mix of uniformed and civilian staff members, making for a diverse but talented staff.

  The mission is clear: by coordinating efforts with the Department of Veterans Affairs, the US Public Health Service, and other agencies, the DCoE is increasing the number of mental health providers working with the wounded warriors and personnel returning from Operations Iraqi Freedom and Enduring Freedom. The DCoE is also improving access to psychological health care, and trains in tandem with the Department of Veterans Affairs so that the needs of service personnel and veterans with TBI and psychological health issues are best met.

  So much of what is said in public circles would lead one to think TBI is usually of the severe variety; yet, the fact is that a TBI may range from “mild” (a brief change in mental status or consciousness) to “severe” (an extended period of unconsciousness or amnesia after the injury). TBI can also be “moderate,” a condition between mild and severe. A TBI is caused by a blow to the head or a penetrating head injury that disrupts the normal function of the brain. Not all such blows to the head result in a TBI. Mild TBI is far more prevalent, and its causes are far more often from common circumstances than war zone incidents. Sports injuries and everyday accidents at work, school or recreation often involve mild TBI instances.

  Mild TBI is also called “concussion.” Yet, although mild TBI is the most common, it is also the most difficult to assess of the three TBI conditions. It needs to be emphasized that, as with civilian circumstances, mild TBI can be difficult to identify and diagnose in the combat zone. A concussion, or mild TBI, may not be readily apparent, and there may not be obvious symptoms as found with moderate to severe TBI cases. An automobile accident or football injury could produce such a brain injury, with little or no outward signs present but clinically measurable if sufficient follow-up is carried out. Among those diagnosed with mild TBI, nearly 90 percent have no lasting residual effects. They fully recover and return to normal lives.

  Moderate TBI is clearly recognizable. It has a broad range of symptoms and signs. It may include casualties with no residual symptoms but with x-ray imaging evidence of injury, perhaps as a result of a blast incident. Severe TBI is obvious with a penetrating wound to the head. Service members with this type of injury are given immediate emergency surgical treatment and then ongoing treatment in the US at either a military medical center such as Walter Reed or Bethesda or one of four Department of Veterans Affairs Polytrauma Centers. For example, in the story of Army Specialist Walter Blackston, a relatively “normal” but very busy day turned into a nightmare due to a land mine. Both TBI and PTSD are often medical issues which manifest themselves after initial diagnoses. Specialist Blackston’s experiences lay out a process, not uncommon, that goes from battlefield explosion to head injuries and unconsciousness, to initial care, return stateside, follow-up care, then longer term repercussions of the head injuries.

  Military medicine, in collaboration with the Department of Veterans Affairs, has a strategy to improve the entire continuum of care for TBI. It involves training health providers in the latest clinical practice guidelines and giving care that is based on many proven methods. Those “evidence-based” methods of care examine clinical cases and documented treatments so that patients with TBI have the greatest chance of recovery. The shaping of that improved program is taking place today.

  PTSD is an even more common occurrence than TBI. The term is increasingly viewed as a misnomer by using the word, “disorder.” Traumatic stress causes reactions, and the impact of the traumatic stress or incident on an individual’s mental state can vary greatly. To say every case represents a “disorder,” however, can be misleading.

  As time goes on we are seeing an increasing reference to “combat stress reaction” and “post-traumatic stress syndrome” when discussing behavioral health following traumatic stress. The reasoning? People may exhibit reactions that are actually reasonable to horrific situations. It really only becomes a “disorder” if left untreated.

  Researchers from the Uniformed Services University of the Health Sciences are working on ways to prevent and treat increasing numbers of combat troops suffering from TBI and are improving methods of diagnosing and managing PTSD. The staff at the DCoE believes it is important to note that how we label people—what we say about a "condition" or a "disorder"—has a big impact on an individual’s self-perception and their healing ability.

  You can’t grasp the magnitude of the military’s response to TBI and PTSD unless you at least get a sense of how it’s addressing these profoundly significant health issues. There are six major components making up the DCoE. To begin with there’s the Defense and Veterans Brain In
jury Center which, since 1992, has made significant contributions to overall knowledge of TBI. It provides core functions for the DCoE. For example, it has a participating network of military and Department of Veterans Affairs sites, and worldwide expert contacts. They create clinical practice guidelines for the management and treatment of brain-injured patients.

  The DCoE also collaborates with the Center for Deployment Psychology of the Uniformed Services University of the Health Sciences. They train military and civilian mental health professionals to provide high quality deployment-related behavioral health services. Participating training sites involve Army, Navy and Air Force medical centers.

  The Deployment Health Clinical Center, established in 1994, developed the Specialized Care Program for those Gulf War veterans whose health concerns and symptoms presented unclear causes, often associated with the unexplained Gulf War illnesses but increasingly related to PTSD as well. These are patients who have had other treatments for PTSD (or perhaps depression) but continue to experience symptoms that interfere with functioning. It is also for patients who have no other treatment available to them. This center’s responsibilities have expanded with the wars in Iraq and Afghanistan to include clinical care for veterans of all conflicts, as well as deployment-related health research, education and training for patients and families. Here in Washington DC you’ll find them working at Walter Reed Army Medical Center helping small groups of service member patients in three-week cycles every month. Earlier in this book, Richard Gutteridge told of being admitted to the Specialized Care Program in the story about coping with PTSD.

  The Center for the Study of Traumatic Stress provides knowledge, leadership and applications in preparing for, responding to, and recovering from the consequences of war, operations other than war, disaster and trauma. Their scope reaches from laboratory to bedside, field and clinic, as well as in operations and public policy.