The title of this diary is also the title of a training seminar produced by the Citizen-Soldier Support Program (CSSP), the Veteran's Administration (VA) and the North Carolina Area Health Education Centers (AHEC). The phrase itself was taken from a talk by Marine Corps General Robert Magnus, as he discussed the difficulties of addressing health issues for troops subject to combat deployment. I attended this all-day seminar Friday in Florence, S.C., sponsored by the PeeDee AHEC, and I'm going to share with you some of the things I learned during this incredibly compelling and enlightening training session.
Some reading this may know the primary instructor of this course, as he is an Associate Clinical Professor at Duke; but he's also been a psychiatrist with the VA for 25 years, and coordinates mental health services for the 3-state area of NC/SC/VA. I'd met and spoken with Dr. Harold Kudler a few times before this and found him to be very engaging and intelligent, so I kind of figured this would be a good class. It was much more than that, and both the VA and Duke are lucky to have Dr. Kudler on their staff.
I've talked about Post-Traumatic Stress Disorder (PTSD) in some previous diaries, and I'm going to touch on that again later in this one, but I wanted to get a little deeper into the causes and effects of Traumatic Brain Injury (TBI).
The brain is (of course) an incredibly complex and vital organ. While the skull provides a great deal of protection for the brain, the brain itself is mostly a free-floating mass of non-muscular tissue and fluids. As such, it is prone to "shift" inside the skull if the head is subjected to abrupt movement or impact with a solid object. Speed that up to an automobile collision or the impact of a high-velocity piece of shrapnel, and the brain is likely to suffer damage. An injury of this nature is not exclusive to combat situations; this can and does happen to people here at home in car accidents and such. But it's not just these "direct impact" events that cause these injuries in Iraq and Afghanistan.
While it's not something we generally pay much attention to, we live in a pressurized environment, to which our bodies have adapted. Every step we take we are literally swimming through molecules of oxygen, nitrogen, carbon dioxide, etc. The blast from an Improvised Explosive Device (IED) produces a pressure "wave" that is massive, and that wave washes across everything in its vicinity. While most of the vehicles we now use in combat zones have been up-armored and can protect the troops from much of the projectiles and fragments from these bombs, that pressure wave is unstoppable. It goes right through the vehicle's armor, right through the soldier's helmet, right through the soldier's skull, and into the soft tissue of the brain. It actually tries to carry the brain with it, but the skull won't allow that.
TBI can produce instant death, a persistent vegetative state, a high loss of function, and other very notable effects. But something like 80% of those suffering from this type of injury have what is called "Mild" TBI, which can be almost impossible to detect through normal testing or standard observational techniques. While they are (often) able to function at a relatively normal capacity, many of these folks suffer from memory problems, anxiety, sleep disorders, depression, ringing in their ears, dizziness, attention deficit, headaches, confusion, sensitivity to bright lights or loud noises, blurred vision, lethargy, etc.
For a large percentage of those suffering from mild TBI, these symptoms usually fade after a few weeks or months have passed. But during that time, and especially for returning National Guard and Reserve troops, living with those effects can be devastating. Trying to become a father or mother again, dealing with all the financial and home maintenance issues, trying to reintegrate back into their civilian job, being isolated from the structural life of the military, etc. When you're hitting on all eight cylinders, these things can be almost too much. You try to do that with TBI (or PTSD), and you're skating on thin ice.
I'm going to take a short break here and tell you a funny story. My first few days in the Army were spent at Fort Jackson, S.C., where they cut all my hair off, poked me with countless needles and issued me a duffelbag full of strange green clothing. Because I had a few years of college under my belt, I went in as an E-3 Private First Class (PFC). When it came time to catch a chartered bus to Fort Benning, GA, I was placed "in charge" of the troops making this short journey. A few hours into the trip, we pulled into a rest stop and I gave everybody ten minutes to stretch their legs and hit the bathroom. Well, one guy didn't come back.
After crawling under a restroom stall door and "coaxing" him back to the bus (no visible injuries, except maybe the wide-eyed look of fear and betrayal), all was well again. Evil Steve occasionally has his uses. After this, I instituted a New Rule: the guy sitting beside you is your buddy, and each person is responsible for his buddy's well-being and behavior. Any violations of the "Buddy System" would be met with "Dire Consequences". Luckily, nobody asked me what those consequences would be, because I didn't have a clue. But it worked well for the rest of the trip.
I actually did have a reason for telling that story. The average (non-military) person is liable to believe that there are a handful of high-level officers who make all the decisions and issue orders, while the rank and file merely follow them like automatons. In reality, responsibility is delegated down throughout the ranks, with relatively low-ranking enlisted folks making a wide range of decisions based on a sometimes painfully vague "mission" from above. In combat situations, that responsibility translates to life and death decisions concerning the troops under your leadership. When nearly every day produces dangerous situations that call for these split-second judgment calls, it is inevitable that eventually, the death or serious injury of a troop (and friend) will rest upon your shoulders, and you will carry that knowledge for the rest of your life.
Which leads me to two other speakers at this seminar. Robbie and Holly Mullis (husband and wife) are both Staff Sergeants in the North Carolina National Guard, and I will refer to them by first name so as to not get them confused. Robbie's first deployment to Iraq came when Holly was pregnant, so he missed the birth of his daughter. They both struggled through many of the issues that other couples do during deployment, and when Robbie returned home, they both suffered as he attempted to reintegrate into a normal civilian life.
The second time around, they both deployed to Iraq, and actually lived together at the Forward Operational Base (FOB) their unit operated. Some reading this may think this is ideal, but as Holly explained to us, it presented a whole new set of issues. Before, when she was back home waiting for his return, she didn't really know what he was doing. But once there in the combat zone, she knew all too well where he was going each day and just how dangerous these missions were. See, Robbie was in charge of providing security for convoys, which meant he was escorting a bunch of high-value targets through a no-man's land of rocket attacks, sniper fire and (worst of all) IED ambushes.
Even when they weren't under attack, the stress level was extremely high. An attack was almost always, "imminent", in other words. Then came the inevitable. The IED exploded up through the floor of his vehicle, killing two of his troops (and good friends). Robbie sustained a serious head wound from shrapnel, and to this day, he has to wear a hearing aid to suppress the constant ringing in his ears. He survived the attack, but that carries its own set of problems. Why me? Why did I get to come home, while my friends did not? And the story doesn't end there.
In the last few years since their return from the hell of combat, Robbie and Holly have lost more former comrades (and friends) to suicide than the ones who died in Iraq. One of them even shot and killed a deputy sheriff before turning the gun on himself. For many of these folks, the war stays with them until they can't take it anymore. Their family life crumbles around them, they lose their job, they fall into drug and alcohol abuse, and some seek the final release of their pain by taking their own life.
I know that many reading this have been against the war in Iraq from the beginning, and these tragedies are viewed as just one more reason for us to get out. I understand that, and for the most part agree wholeheartedly. But we're also prone to view this war in the abstract, looking at numbers and statistics and such. Well, these folks are not statistics, they're people. They're not eggs that get cracked in the preparation of an omelet we're not even sure we have an appetite for. These men and women are the best of us, and their families are our families. We must never forget this.
In closing, I want to reach out to those providers reading this. Social workers, psychologists, psychiatrists, GP's, nurses, etc. Please get involved and learn more about PTSD and TBI. Attend these trainings either in person or online through ahecconnect. It is imperative that we build a community-based network of providers that can recognize and treat these unique combat-related ailments. You should also seriously consider enrolling in the TRICARE system, so that the cost of any treatment does not get in the way of these folks seeking your help.
Thank you for taking the time to read this. I hope it has helped you to better understand these important issues, and maybe inspired you to learn more.
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