Care of the Wounded Warrior
by Patt Maney
Issue 100 - January 30, 2008

LEADERS WANTED: Value-based leaders needed to repair confidence in Army medicine and treatment of America’s wounded warriors. Must be willing to invigorate a moribund medical and personnel bureaucracy and live “Army Values”. Successful candidates will be empowered to seek and implement innovative treatment options for a growing clientele with traumatic brain injuries (TBI) from Iraq and Afghanistan-based improvised explosive devices (IED) and provide “soldier oriented” personnel support to battlefield casualties and their families. Candor with military and civilian superiors, peers, Congress, military members and families is required.

The above help wanted ad may never be published but as a 36-plus year veteran of the Army Reserve with experience in multiple contingency operation deployments, including 17 months in Afghanistan with Operation Enduring Freedom; and being an IED casualty myself having spent more than a year and a half as an outpatient at Walter Reed Army Medical Center; I believe the ad above accurately describes a desperate need facing our Army, our nation and the growing number of TBI casualties.

Consider the following:

• February 18, 2007. After months of investigation, reporters Dana Priest and Anne Hull initiated a devastating series of articles in the Washington Post concerning housing conditions and the treatment of Wounded Warriors at Walter Reed. The series started a rash of visits by concerned senior Army and DOD leaders and Members of Congress. Commissions were formed; testimony was taken and public reports rendered. Prior to the Post series, I had been at Walter Reed for over a year. I had not been aware of the investigation before publication of the articles but I cheered them. I had spoken in detail to three senior general officers about conditions at Walter Reed with no apparent affect. I was interviewed by members of the Marsh-West Commission whose report included conditions which others and I had observed. The Army now has a new Secretary, a new Chief of Staff and a new Surgeon General. Warrior Transition Brigades were established to assist in managing Wounded Warriors. I was hopeful things would change for the better. From what I am hearing from former fellow patients, it has not.
• April 9, 2007. “The Nation” reported that 7-year Army veteran Specialist Jon Town, an Operation Iraqi Freedom veteran who narrowly survived a rocket blast two feet above his head in Ramadi, Iraq, suffering from deafness, memory failure and depression was discharged for a pre-existing “personality disorder”, at FT Carson, CO. There have been widespread complaints of soldiers who believe they are suffering from PTSD being administratively discharged without benefits based on pre-existing personality disorders rather than having their cases reviewed by Medical Evaluation Boards to determine their eligibility for statutory benefits. Mideast Stars & Stripes reported that the Assistant Secretary of Defense for Health Affairs had decided to review the 22,500 cases of soldiers who had been discharged with personality disorders. There is no evidence the practice of diagnosing combat veterans as having pre-existing conditions has ended.
• September 21, 2007. Operation Iraqi Freedom wounded veteran SGT Gerald Cassidy was found dead in the outpatient barracks for Ireland Army Medical Center at FT Knox. The Louisville Courier Journal reported on Dec 23 that “he may have been unconscious for days and dead for hours before someone checked on him.” Laura Unger of the Courier described him as a “brain-injured soldier”.
• November 22, 2007. The Associated Press reported that wounded soldiers were being billed for “unearned enlistment/reenlistment bonuses” when the separation from the Army was caused by battlefield wounds and injuries prior to the completion of their full enlistment/re-enlistment term. The Army changed its policy following the predictable public outcry.
• November 23, 2007. USA Today reported the tragic story of a Marine who survived a battlefield blast and was being separated from the Corps for a traumatic brain injury, (TBI), but that the TBI didn’t qualify for a Purple Heart notwithstanding TBI involves the medical fact of damage and destruction of tissue in the brain. The article also noted some 30,000 veterans show signs of TBI.
• November 30, 2007. DOD announced the formation of the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury in Rosslyn, VA. According to a DOD press release, the center will lead “a national collaborative network to advance and disseminate PH/TBI knowledge, enhance clinical and management approaches and facilitate other vital services to best serve the urgent (emphasis added) and enduring needs of warrior families with PH and/or TBI.” The release quoted the Assistant Secretary of Defense for Health Affairs as saying the center will develop a “national collaborative network. . . (to). . . coordinate existing (emphasis added) medical, academic, research, and advocacy efforts . . .”. According to the release, this “urgently” needed center to coordinate “existing” programs will be fully functional by OCT 2009(!). One might well ask where is the action that urgently needs to be taken.
• December 2, 2007. The Washington Post reported the tragic and ironic story of Operation Iraqi Freedom veteran LT Elizabeth Whiteside in an article whose title was taken from a comment in one of her officer efficiency reports, “A soldier’s officer”. The story chronicled Army attempts to court martial her for attempted suicide over the medical advice of her treating psychiatrist and the Surgeon General of the Army. A final decision is pending.

As the above public record demonstrates, The Army, our nation and its Wounded Warriors desperately need leaders who will take remedial action and repair the reality and confidence in Army medicine and the comprehensive treatment of Wounded Warriors to which their service and sacrifice should entitle them. But there’s more.

While TBI is often cited as the “signature wound” of the war and while it arises from the physical destruction of tissue, there is not a diagnostic code or treatment protocol for TBI. That is not the military’s fault as diagnostic codes come from a book called the ICD or International Classification Description. The US uses ICD-9. Apparently, ICD-10 includes traumatic brain injury but the US has yet to adopt that version of the international code. Nonetheless, the Assistant Secretary and the Surgeon Generals have not promulgated an agreed interim “work around” to guide TBI diagnosis and treatment. Different attending physicians use different substitutes from “closed cranial injury” to “post concussion syndrome”, making the subsequent task of locating service members and veterans with a TBI more difficult.

Similarly, the frequent cognitive difficulties resulting from a TBI are coded in the mental health manual, DSM-IV, (Diagnostic Statistical Manual), which reinforces psychological implications rather than “the fact of” a physical injury to the brain. In fact, the Army medical establishment seems to be stuck on the outdated medical theory that once a brain is injured, it will heal itself to the extent possible and there is little physicians can do to stimulate or assist its recovery. Walter Reed neurologists refer to treatment through “tincture of time” and do not routinely refer patients to Bethesda Naval Medical Center for cognitive processing enhancement therapy. Similarly, despite both anecdotal and published animal studies indicating the benefit of hyperbaric oxygen therapy (HBOT) for traumatic brain injury, Walter Reed and the DOD medical establishment do not routinely make HBOT available.

When I questioned a colonel about the lack of a treatment protocol for TBI patients, I was told Army doctors “can’t provide treatment that is not generally accepted in the medical community.” One wonders if Army Surgeon General William C. Gorgas and MAJ Walter Reed, who conquered yellow fever and enabled construction of the Panama Canal, could have survived in today’s bureaucratic medical environment that allows identification of injuries without seeking treatment modalities for those injuries. The Army and the Department of Veteran’s Affairs both have a program designed to identify 100% of the warriors suffering from TBI. While they use neuropsychological testing to help quantify cognitive loss, they do not routinely use SPECT scans to demonstrate the physical injury or HBOT and cognitive remediation to treat it. Even the Traumatic SGLI insurance which is designed to function like disability insurance as currently administered by a contractor using an insurance adjuster mindset does not compensate life-altering TBI unless physicians early on document loss of physical functioning in “activities of daily living”, not loss of mental capacity that can require constant assistance and degrade employability. PTSD is similarly not compensable by TSGLI.

The Army’s medical evaluation board process also needs updating. It is not on a war-time footing. The Dole-Shalala Commission has addressed some problems requiring Congressional action but others can be addressed within DOD and the Army. The Human Resources Command is not viewed as aggressively addressing shortcomings including a unique requirement for soldiers suffering from PTSD to obtain a letter from their commander vouching for the soldier’s claim to have suffered from a traumatic event even if the soldier has been awarded a Purple Heart Medal or the coveted Combat Infantry Badge or Combat Action Badge. The Command also doesn’t recognize the current state of psychiatry that understands prolonged exposure to a traumatic environment can create PTSD. This policy creates a hardship for Wounded Warriors who are not be fully functioning, may be heavily medicated, and creates a particular hardship on Guard and Reserve soldiers who may have served as “fillers” for active component units. The severance pay system short-changes members of the Guard and Reserve since payments are based on active federal service, not just years of membership in the Guard and Reserve, so reserve component members must give up entitlement to a reserve pension and benefits for a few months worth of active duty severance pay.

Under the current system, the Surgeon General is responsible for a warriors medical records; the Commander of the Army Human Resources Command is responsible for the integrity and conduct of the disability board and the Judge Advocate General, upon request, is responsible for providing effective representation to Wounded Warriors in determining their entitlement to federal benefits. (An Army lawyer told me I was not entitled to representation by an Army lawyer notwithstanding the clear language of the Army Regulation and the Department of Defense Instruction, DODI.). I have seen the shaken looks of many injured soldiers who believe they have been let down by the Army and Nation they love and served. Leaders, whether DOD under the current system or VA under a proposed revision of the system, are needed to purge the medical evaluation board system of widely perceived bureaucratic hostility, indifference and parsimony.

Further, the DODI, which provides guidance for the services’ medical evaluation boards, needs to be updated from one with a peacetime outlook to one that fairly deals with wartime injuries. The DODI calls for medical evaluation boards to be convened when a soldier has received medical treatment for twelve months. Perhaps an acceptable peacetime result is maintenance of a combat-ready force and avoidance or postponement of long term care. In wartime, the DODI is frequently ignored when dealing with amputations or severe burns probably because of the recognized long-term care required to treat those visible injuries. No such understanding is exhibited with TBI notwithstanding that it is a deeply serious physical injury, an invisible injury of this war.

For years, soldiers received “Army Values” cards and have been exhorted by posters and plaques to live “Army Values”, including loyalty, duty, respect, selfless service, honor, integrity and personal courage including physical or moral danger or adversity. Soldiers are told “we will never leave a fallen comrade” but that implies that we will assist fallen comrades. Wounded Warriors and our Army need leaders who will live “Army Values”. As we approach one year after the Washington Post broke its first story on care of America’s combat casualties from the Global War on Terror, perhaps this help wanted ad is not out of place at all.

In reviewing the record, I realize how extremely fortunate, even blessed, I was to have been treated by a few courageous and innovative practitioners who steered me to sometimes non-standard treatments that offer hope and which have helped. I was blessed to have a caring and knowledgeable spouse who was an effective advocate for comprehensive medical, dental, and rehabilitation treatment. I learned that we must resist the notion that nothing can be done to help an injured brain.

Announcement of plans and objectives are encouraging and satisfying. Only current action will determine the quality of the future for today’s battlefield casualties.

Leadership action is needed, not a public relations campaign or listing of plans of objectives for the future with no current reforms, if we are to fulfill President Lincoln’s commitment “to care for him who shall have borne the battle”.

Patt Maney is a retired U.S. Army Reserve Brigadier General who has served in Afghanistan.