Healing Combat Trauma

From the Canadian Side of the Street: A Military Author's Take on Veterans Suffering from War and PTSD

One of the many blessings of the new media -- social media like Facebook -- are the interesting, talented people one meets within that. One such person is Bonnie Toews, a Canadian former journalist and novelist with a longtime background in writing about the military. I forwarded her an article from the Montreal Gazette last week about social workers quitting because of burnout in Canada, meaning that fewer will be available to serve returning veterans with PTSD, and this is what she wrote on her website in response:

Outrageous failure of government assistance to returning Afghanistan vets

"It is wonderful that we celebrate the lives and courage of fallen soldiers when they are repatriated to CFB Trenton and paraded down the Highway of Heroes, but the question that is never answered: who looks out for the returning vets? Especially those whose minds, bodies and spirits have been shattered on a continual rotation of tours through the past eight years.

It is disgusting and absolutely unacceptable to hear that Canada's Veterans Affairs is cutting back on social workers because WWI and WWII vets are dying off. 

Excuse me, but Canada has a whole new generation of vets who have served in Afghanistan for eight years. By next year it will be nine years. The war in Afghanistan has lasted longer than either world war in the 20th Century and soldiers have been repeatedly rotated through three and four tours because our forces aren't large enough to handle a deployment this long and this demanding. These vets and their families need help to mend their lives back together. 

Kevin Dougherty in Montreal's newspaper, The Gazette, writes that soldiers suffering from Post Traumatic Stress Disorder can wait up to four months before seeing a social worker, a necessary step to integrate them back into society and return them to the labor market. 

Why? Because federal social workers each have a caseload of 40 clients to their provincial counterparts, who carry a caseload of 20 clients each. There are not enough social workers to contend with the need, and under such strained resources, these caregivers burn out, depleting veterans' social services even further. 

People forget that soldiers returning home are not the only victims of the wars they've fought. So are their loved ones, families and friends. They need as much social assistance as the soldiers themselves. Those coming home are forever changed. They have experienced things the rest of us can't imagine. They carry this psychological burden for the rest of their lives. 

In 1994, in Rwanda, I was briefly introduced to that world of theirs. I was one of the few North American journalists covering the massive humanitarian effort following the genocide against the Tutsis and moderate Hutus in Rwanda. One peacekeeper after another told me what they saw, incomprehensible mass slaughter with no human respect whatsoever and they were forced to observe because the UN didn't give them the mandate or size of force to quell the madness. Soldiers trained to fight and defend forced to stand down. Can you imagine the helpless rage they experienced? Yet, when I came home, I faced the same apathy from friends, co-workers and the public as they did. My husband proudly explained that I had been in Rwanda and time and time again I was asked, "Did you go there on holiday?" 

People didn't even know what was going on, and were indifferent when I chose to explain. I, like so many soldiers, learned not to talk about it because no one really cared to listen. 

This time the public must get behind their vets and demand the social services they deserve and need. This is the most important tribute we can give our returning vets for the sacrifices they've made on behalf of our country."

 -- Bonnie Toews. A longtime journalist reporting for logistics and private security magazines and now a novelist, speaks out for the victims of genocide and war, from the peacekeepers and coalition forces trying to save suppressed peoples to the children and innocent civilians caught in the crossfire of opposing powers, ideologies and cultures. Current writing "Trilogy in Treason." Member of Military Writers Society of America, American Authors Association and ACFW. Her website is linked here.

Editor's note: Find us on Facebook, here; follow us on Twitter @HealingPTSD.

Provider Burnout among Combat Stress Healthcare Practitioners

It's been interesting to follow the Tweets from the conference at Mass. General Hospital this Friday and Saturday, on the "Complexities and Challenges of PTSD and TBI." It sounds like it was a great conference. One of the items that stood out to me was the statistics being shared about provider burnout. Check these out:

"Not enough social workers, therapists, etc. to help all the people who need help."

"146,000 mental health providers in U.S. Medical Command (MEDCOM),...a huge centralized training that's re-assessed annually for improvements...now (with) significant training resources in place to help providers manage stress." 

Studies that MEDCOM has done indicate that provider "burnout" is approximately "35% among deployed psychiatrists," "20% in deployed psychologists," "15% in deployed social workers," and "26% in non-deployed." (Source: LTC Graeme C. Bicknell, PhD, LISW, LTC, MS, Deputy Chief, Behavioral Health Division US Medical Command.)

We've written about "Caring for the Caregivers" frequently on this website, most recently here, in a post entitled, "Too Long a Sacrifice Can Make a Stone of the Heart:The Tao of Self-Care." Acknowledging provider burnout is another aspect OF "caring for the caregivers." The takeaway? Combat stress injures troops AND mental health providers; servicemembers and practitioners alike need stronger support. 

(There's a great article by Charles Figley on the topic, "The Art and Science of Caring for Others without Forgetting Self-Care, linked here, suggested by one of the readers on the Facebook site for this website, which is linked here.)

Editor's note: You can follow the PTSD Conference, now over, on Twitter, @PTSDConference; and you can follow this website on Twitter @HealingPTSD.

Veterans, PTSD and Suicide: The Overlooked Element of Contagion

This is an article I'd first started writing two years ago now. I did the research, and located the main, most often-cited study's principal investigator, long since retired, and asked him to confirm whether the trend is still true, though he first published it back in the 1970s. He affirmed that it was. What it is is an important and often-overlooked "connection" that will make more sense when we start describing it. It also fits into the category of things where the information is out there, but for some reason is also strangely ignored. Another instance was a few years ago, when the military kept saying, "We don't know what PTSD is tied to"; essentially, "we have no idea." Yet at the time, and this goes back several years now, I was able to read through the existing literature and learn, PTSD is tied to combat exposure. In other words, the more combat, the greater the chances of developing PTSD. And I wrote about it, here, at the time the military was saying, in essence, we don't know what it's linked to.

So it isn't that that wasn't known...it's that no one was paying attention to what was out there. (And these days, several  years later, they ARE admitting publicly that more exposure = greater chance of developing PTSD. But it does make me laugh a little bit to hear that now, thinking, we were talking about it here well before that was being said publicly. And not because of some strange prophetic abilities on our part; just from reading the available literature, and drawing what seemed like obvious conclusions.)

There's the old saying that "those who refuse to learn from history are condemned to repeat it." Well, much of what's known about PTSD has been known for decades now, with another fair part of the knowledge base has been increasing exponentially. I read an article the other day about a Harvard-trained psychiatrist who worked at the V.A. in Boston during the Vietnam war, and was "shocked" to learn that there wasn't a single book on war trauma in the library there. Today, one would hope, that situation has changed quite a bit. 

But to the point at hand...

As I read through my Twitter feed today (you can follow us @HealingPTSD on Twitter), I noticed several suicides being Tweeted by various sources. One was that of Mel Turpin, a former All-American basketball player and NBA star, dead at 49; and then the troubling news, especially to us in the veterans community, of a Marine Corps veteran, James F. Popkowski, 37, who apparently died in a "suicide-by-cop" or armed confrontation outside the V.A. in Bangor, Maine. (See those stories linked here and here, as well as a longer quasi-obituary of Popkowski, here.) At first the headline said only "an armed man" had died in a confrontation with police near a local VA -- and as soon as I read that, I hoped -- but yet somehow knew -- that it would be a veteran, with a painful story of his own. Later the news matured to show that in fact he was a veteran, who was struggling with this illness (cancer) and its treatment. But the fact he was a veteran and committed suicide reminded me instantly of the news from the last few days, where the Seattle Times did such a good job covering the suicide of a veteran with PTSD from Whidbey Island, Orrin McClellan. (I wrote about Orrin's life and death here and here.) So many suicides in the media, and superstitious types tend to think those run in threes -- though technically McClellan's death was in mid-May, with the coverage of it in the media happening over the last few days.

I need to branch off in two different directions here, to cover this material. 

One is to talk about the V.A. suicide's statements about his own condition, because veterans with PTSD and their family members may recognize their own veterans in those words. And the other is to introduce something very different, which is the effect that media coverage of suicides has on "successful" suicide attempts by others during the same general news cycle, especially young men (who are, after all, the majority of those who serve.) 

On that second point, as the military has generally speaking tried and failed to lower the suicide rate lately, I haven't seen much recognition (OK, any) of the idea that suicides are to some degree contagious. There's quite a bit of medical literature on the subject...and it's been documented in studies around the world, starting in the 1970s, that suicides reported in the news will have a demonstrated effect on increasing suicide attempts from specific populations who hear the news. Since suicide is a broad category -- many single-car or single-motorcycle accidents are also suicides -- and the military attempts periodically to crack down on motorcycle safety, etc., it would also be wise to enlarge the conversation to not only what other methods qualify as suicides, but also to take a look at how one suicide making the news can, depending on how it's portrayed, have an effect on increasing the number of other suicides that take place in the same general time frame, especially among those prone to committing suicide, because of depression and other factors. And we haven't even mentioned yet here the effect that some prescribed pharmaceutical medications can have on increasing suicidal thoughts.

(While it's somewhat unlikely that Popkowski, in Maine, was reading the Seattle Times' coverage of Orrin McClellan's death -- one, we never know; and two, in the age of the Internet, geographical barriers have disappeared and the news is instantaneous -- especially if you include other social media, like Facebook and Twitter, which can serve as additional sources of the same news. We're so much more wired now than when these studies first started being done, so we can't assume Popkowski didn't read the Seattle Times coverage, even though it's most likely that he didn't. For the sake of this argument -- because if it didn't happen with this case, it surely does with others, let's pretend that Popkowski did spend some time over the last few days reading the coverage of McClellan's suicide on the Internet.)

There's enough material to cover here that I need to go as far as I can with it now and then circle back around to it again soon. We'll introduce the science (below) but also cover what Popkowski said about his failing health, because his words will resonate with other veterans, who struggle not with cancer but with PTSD.

According to the article in the Portland, Maine Press Herald today, Popkowski, who had undergone a stem cell transplant for his cancer back in 2003 at the National Institutes of Health, struggled valiantly with the effects of the cancer and its treatment (both difficult), as well as sleep problems, depression and the like. In a letter to the editor of the magazine "New Scientist" back in 2008 he wrote,

"Suicide is like a little devil, always on my shoulder and always tempting me. Concern for the care of my three dogs after I am gone, my dogs being the only things I feel anything resembling passion for, is the only thing I think that has kept me from pulling the trigger on the loaded pistol, which rests next to my pillow."

He continued,

"The best way to describe the mental and emotional issue is that I am numb and passionless. Nothing brings joy or pleasure. I graduated magna cum laude with a (Bachelor of Science degree) in computer info systems and business management in just three years. Now, I cannot mentally focus enough to read a newspaper."

He added,

"I have lost count of the number of sleep aids NIH and my local VA have tried. Like the anti-depressants, none have worked."

And he described leaving his bunker, in terms that a veteran with PTSD would understand, only for brief forays out to re-provision with groceries and return, if his health even allowed him that. He wrote:

"For weeks at a time I will only leave my house once, and only briefly at night, to buy groceries and other supplies. Most of the time, the only time I drag myself into the shower, is when I have to go into town to buy groceries."

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Now, we hope that no veteran ever crosses the bridge to suicide in his or her lifetime, and especially is not discouraged enough reading news of how another distressed veteran felt to contemplate it. Please use the resources at your disposal, including hotlines, buddies, and compassionate others as lifelines to not give up hope, because there IS hope, and you can get better. But for the rest of us, we need to keep pushing on with this narrative because there's something to learn here, including for decisionmakers who wonder about how better to educate about suicide prevention. This is where the element about the notoriety/publicity level of a suicide influences other at-risk populations.

To the science on this.

• Back in 1977, in the journal Science, DP Philips showed that "motor vehicle fatalities" (including "suicides by motor vehicle") increase in the time frame "just after publicized suicide stories." From the abstract: "The average increase in motor vehicle fatalities is 9.12 percent in the week after a suicide story. The more publicity given to the story, the greater the rise in motor vehicle deaths thereafter. This rise apparently occurs because suicide stories stimulate a wave of imitative suicides, some of which are disguised as motor vehicle accidents."
• In 2006, an Australian journal, Social Science Medicine, published a similar study, further demonstrating the "relationship between media reporting of suicide and actual suicide." They studied data on "4,635 suicide-related items appearing in Australian newspapers and on radio and television news and current affairs shows between March 2000 and February 2001. The study found that 39% of media items were followed by an increase in male suicides, and 31% by an increase in female suicides. Media items were more likely to be associated with increases in both male and female suicides if they occurred in the context of multiple other reports on suicide (versus occurring in isolation), if they were broadcast on television (versus other media), and if they were about completed suicide (versus attempted suicide or suicidal ideation). Different item content appeared to be influential for males and females, with an increase in male suicides being associated with items about an individual's experience of suicide and opinion pieces, and an increase in female suicides being associated with items about mass- or murder-suicide." They concluded, "Further research on this topic is required, but in the meantime there is a need to remain vigilant about how suicide news is reported. Mental health professionals and suicide experts should collaborate with media professionals to try to balance 'public interest' against the risk of harm."
  
• Versions of the original study were repeated over and over in the intervening years, and 30 years later, in 2007, the International Journal of Epidemiology published a study which showed "the influence of media reporting of the suicide of a celebrity on suicide rates," where a male television celebrity in Taiwan committed suicide, followed by a wave of somewhat "copy-cat" suicides among young men. (The "celebrity" element may initially confuse, but think of it this way -- it's a well-publicized suicide when it happens, which means it reaches most of the target audience. It also happens, according to other studies, when non-celebrities commit suicide. The distinguishing factor is how well publicized the suicide is/how much media attention or coverage is given to it. The more coverage, the more people know about it, including those in somewhat fragile populations.) Back to the study's results: "After controlling for seasonal variation, calendar year, temperature, humidity and unemployment rate, there was a marked increase in the number of suicides during the 4-week period after media reporting (relative risk = 1.17, 95% CI 1.04-1.31). The increase was in men (relative risk = 1.30, 95% CI 1.14-1.50) and for the individuals using the same highly lethal method (hanging) as the TV  actor did (relative risk = 1.51, 95% CI 1.25-1.83). However, the age groups in which the increase occurred were younger than the age of the celebrity. CONCLUSIONS: The extensive media reporting of the celebrity suicide was followed by an increase in suicides with a strong implication of a modelling effect. The results provide further support for the need for more restrained reporting of suicides as part of suicide prevention strategies to decrease the imitation effect."
• Also in 2007, a study was conducted in Taiwan around the fact pattern of the same television celebrity's suicide and published in the Journal of Affective Disorders. It attempted to define the "influence of media reporting of a celebrity suicide on suicidal behavior in patients with a history of depressive disorder," and what it found was "Among 438 depressive patients exposed to the media report, 38.8% reported an influence on subsequent suicidal behaviors, including 24 (5.5%) with a suicide attempt. The risk of such influence was highest among patients in a severe depressive state just prior to the media report (adjusted OR 7.81, 95% CI 3.28-18.59). Such influence on a subsequent suicide attempt was highest in patients with a most recent suicide attempt within one month prior to the media reports (adjusted hazard ratio 11.91, 95% CI 3.76-37.72)." The authors concluded, "This study has provided more convincing evidence suggesting negative influences of media reporting of a celebrity suicide on subsequent suicidal behaviors among depressive patients. Particular attention in terms of potential negative media influences should be paid to patients who are younger and currently depressed and have made a recent suicide attempt."
• This year (2010), another Taiwanese study took a look at suicide rates after media reporting of another celebrity suicide, this time a female singing star. Their premise was that "Suicide attempters are known to be vulnerable to the influence of media reporting of suicide events. This study investigates possible influences of media reporting of a celebrity suicide on subsequent suicide attempts and associated risk factors among suicide attempters." In their study, "Sixty-three suicide attempters registered in a surveillance system of Taipei City Suicide Prevention Center were assessed using a structured interview soon after media reporting of the suicide of a young female singing star." Their results? "Forty-three (68%) respondents had encountered with the suicide news. Among them, 37% reported being influenced by the media reporting on their subsequent suicide attempts." Most hard-hit by the news? "Men (adjusted OR 6.36, 95% CI 1.29-31.44) and younger age groups (adjusted OR 4.93, 95% CI 1.04-23.45) were more susceptible to the media reporting." And the authors concluded, "This study has provided further evidence for suicide imitation among vulnerable people encountered with media reporting of celebrity suicide, and for the need to actively restrain reporting of suicides to decrease the imitation effect."

It's also true that young men -- the dominant demographic of who the all-volunteer military is these days, though approximately 11% are women -- are more prone to suicide than other age groups. Back to the science:

• According to statistics from a fact sheet on youth and violence provided by the CDC, "In 2005, 17% of high school students seriously considered attempting suicide, and 13% made a plan about how they would attempt suicide during the 12 months preceding the survey." (The reference cited is CDC. Youth Risk Behavior Surveillance - United States, 2005.  Morbidity and Mortality Weekly Report 2006; 55 (SS-5): 1-112.)
• Similarly, according to the CDC, "approximately 14% of all deaths among children and adolescents aged 5-19 years result from suicides."  The numbers climb according to age ranges, with younger children having the fewest, and older children the most.  Suicided ages 10-14: 283.  Suicides ages 15-19: 1,700.  (The reference cited is CDC, National Center for Injury Prevention and Control, Office of Statistics and Programming. Web-based Injury Statistics Query and Reporting System (WISQARS). Online at http://www.cdc.gov/ncipc/wisqars/. Accessed September 6, 2007.)

There's more that we could talk about here -- responsible reporting guidelines about suicide, when disseminated and implemented, seem to have the effect of reducing the number of copycat suicide attempts after a successful publicized suicide (a study in Austria shows that) -- but the intended effect here, which we can elaborate on in future posts, is to introduce the idea that one publicized suicide by, say, a veteran, can also most likely encourage an increased number of suicide attempts, some of them successful, by members of at-risk populations, such as young/depressed/men. Do any of those words correlate with anyone who might be suffering from PTSD, or taking medications that might also increase suicidal thoughts? And we haven't even added into the mix the effects of alcohol, which many PTSD sufferers self-medicate with, and how that would affect suicidal thinking. There's much, much, much more to talk about on this topic -- not just here on this site but nationally -- but we hope this dense, rather convoluted post has at least gotten you thinking about not so much that we need to protect veterans with PTSD from seeing or reading the news, which might contain an item about another veteran's suicide -- but that suicides can almost go in waves (read the literature on prison populations, etc. for this), where one suicide spurs others in the same population -- because publicity surrounding a suicide has the unintended consequence of increasing suicidal tendencies in other affected people. Since many, many veterans with PTSD are to a degree on edge already...it might be good to realize the effect that reading about another veteran's demise could have on an already depressed, stressed or demoralized individual.

And since the larger goal for all of should be preventing suicides among PTSD-injured veterans, it's highly worth having this conversation.

43,000 Troops Found "Unfit to Serve": Non-Deployable but Sent Anyway?!

Several weeks ago I watched a wonderful Bill Moyers interview on PBS with Oliver Stone, noted filmmaker and Vietnam veteran. The whole interview was great, but a figure Moyers used at the beginning was just stunning -- for the implications it has for soldiers with PTSD and their families.

Moyers said:

"...I read a report based on military records which revealed that from 2003 to 2008 some 43,000 troops had been sent to Iraq and Afghanistan despite having been classified as "non-deployable" for medical reasons. In plain English, they weren't healthy enough to go, but were sent, anyway."

Yowser. It's hard to imagine a circumstance in which being considered unfit to serve for medical reasons, and being deployed anyway, improves your situation. It sounds like all it would do is reinforce the difficulties you were already having, or pile more trauma on top of the pre-existing trauma.

Additionally, troops who have fought in Iraq, when they're deployed next to Afghanistan, find that to be a completely different experience. So Afghanistan for them isn't "more of the same," it's new and different, with all the challenges that implies.

(See news report from November 29, 2009, entitled "Afghanistan, Iraq: Different Wars -- U.S. Soldiers: Afghanistan War Dramatically More Difficult, Challenging Than Iraq," linked here.)

Editor's Note: For the link to Bill Moyer's Journal and his excellent interview with Oliver Stone, shown on December 4, 2009, click here.)

Virginia Not Just for Lovers This Summer: Also for Vietnam Veterans and Their Families

The Virginia Historical Society is pleased to offer free admission for everyone this summer! From June 6 to August 30, the VHS is displaying three exhibitions about the Vietnam era. The society is offering complimentary admission as a way to honor military personnel who served in the Vietnam War and their families.

On Display / Current Exhibitions:

• Soul Soldiers: African Americans and the Vietnam Era through August 30, 2009

Soul Soldiers: African Americans and the Vietnam Era explores the issues, actions, reactions, and expressions of life and culture of African Americans as they were affected by the Civil Rights Movement and the Vietnam War. Over 160 artifacts, photographs, audio recordings, songs, oral histories, and an original documentary on display in this award-winning exhibition show how events in the 1960s helped frame African American political and social perspectives that extended beyond civil rights. The roles of Dr. Martin Luther King, Jr., Colin Powell, Jimi Hendrix, and many others are explored, as well as the 9,000 women who served as nurses and in clerical and support positions during the war. Soul Soldiers was organized by the Senator John Heinz History Center in Pittsburgh, Pa.

• Marking Time: Voyage to Vietnam through August 30, 2009

Marking Time: Voyage to Vietnam features a cache of Vietnam War soldier art of striking importance and poignancy. Soldiers and Marines on the ship USNS General Nelson M. Walker, bound for Vietnam in 1967, inscribed graffiti phrases and images on the bottom sides of canvas bunks in the troop compartments. Men wrote their name and hometown, the date they expected to leave the service, and kept day-by-day calendars to mark the progress of the voyage. Original graffiti-covered canvases—discovered in the process of scrapping the vessel in 2005—display messages of patriotism, politics, humor, anxiety, and love. Marking Time was organized by the Vietnam Graffiti Project in Keswick, Va.

• A Vietnam POW's Story through August 30, 2009

Bring Paul Home: Phyllis Galanti and Vietnam War POWs is based on the collection given to the Virginia Historical Society by Richmond resident Phyllis Galanti. Her husband, Paul, was a lieutenant commander in the U.S. Navy when his plane was shot down over Vietnam on June 17, 1966. Mr. Galanti was a Prisoner of War (POW) until February 12, 1973. Pictures, letters, pamphlets, buttons, and posters from the donated collection show Mrs. Galanti's efforts, and those of the National League of Families of American Prisoners and Missing in Southeast Asia, to publicize the plight of their loved ones and to secure their release. "I think these exhibitions will be of interest to visitors, especially those who lived through the 1960s and 1970s, because they will be able to personally relate to the topics covered in all three shows," Levengood said. "It is the perfect opportunity for parents and grandparents to bring their children and grandchildren to learn about events that had a huge impact on American society, politics, and culture—and they can see it all for free!"

The Virginia Historical Society is located at 428 N. Boulevard, Richmond, VA 23220 Tel.: (804) 358.4901. The Museum is open from Tuesday–Saturday 10–5 and on Sunday 1–5 (galleries & shop only).

The Story of Virginia, An American Experience, a 10,000-square-foot exhibition with more than a thousand objects covering all of Virginia history from prehistoric times to the present is featured in the Robins Center for Virginia History. Hours: Tuesday–Saturday 10 am–5 pm and Sunday 1 pm–5pm (Museum Galleries and Shop only). Admission: $5/adults, $4/seniors 55+ ($2/Tuesdays–galleries only), $3/children and students, free/members. Admission to the galleries is free on Sundays. For group tour information, call (804) 342-9652. For more information, please call (804) 358-4901 or visit www.vahistorical.org.

Editor's note: For further information about these and other exhibits at the museum, please click here. (And thanks, Merri, for letting me know about this!)

Upcoming Seminar on Warrior Health: PTSD, Depression and TBI

The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., presents:

A Center for Deployment Psychology Training Program:

"Addressing the Psychological Health of Warriors and Their Families: PTSD, Depression and TBI."

When: Mon 22 Jun 2009 through Fri 26 Jun 2009.

Where: The Cheyenne Mountain Resort, Colorado Springs, Colorado.

What: This intensive course, which is comprised of 4 modules, will train civilian mental health providers to better address the behavioral health needs of military personnel and their family members throughout the deployment cycle.

Who: The intended audience is civilian mental health providers who provide behavioral health care to the military population or military family members, including veterans and their loved ones.  This training is NOT intended for active duty military providers, but rather for civilian or private practice/community providers.

Supported by: Fort Carson Soldier Readiness Center, National Organization on Disability, Operation TBI Freedom and Regis University.

For more information about this upcoming seminar or to register online, click here.

The Real Meaning of Memorial Day: Remembering the Sacrifice

For the real meaning of Memorial Day, remembering the sacrifices that have been made, there's a powerful essay written by a trauma surgeon in Iraq about the tragic death of one Marine he treated that might be worth your while to read.  Beware: it's completely gruesome, and spares no detail, though is done respectfully.  And it has an even doubly tragic ending (you'll have to read it to see what it is.) If you have been to war, you might not need to read this -- you're already plenty in touch with what carnage and sacrifice are all about.  If you haven't been, though, it might be a little more eye-opening about what those who serve go through and ultimately sacrifice.

The most impressive part of the story to me, besides the great care the trauma surgeon takes with every battlefield injury, is his love and respect for those he's working for -- and on, a love and respect shared by everyone involved in the course of his workday.  The sheer magnitude of what they go through, and its power to numb the human heart and psyche, is astronomical.  The fact that they fight through for it not to numb them is even more remarkable.  It's a complex human reaction, best expressed by the doctor himself, but it's also summed up centuries ago in the following quote, which we've used before on this blog:

"Anyone who looks with anguish on evils so great must acknowledge the tragedy of it all; and if anyone experiences them without anguish, his condition is even more tragic, since he remains serene by losing his humanity." -- Augustine of Hippo, quoted in One Bullet Away: The Making of a Marine Officer, by Nathaniel Fick.

If you want to read a gory but powerful reflection on the true cost of sacrifice, read "A War Surgeon's Perspective on Memorial Day," by John P. Pryor, M.D., quoted in full on the blog, The Kitchen Table. The reflection is linked here.  It's well worth reading, though completely sobering and sad.

Editor's note: For more material along the same lines, there's an OEF/OIF memoir by another doctor who served, "On Call in Hell: A Doctor's Iraq War Story," by Cdr. Richard Jadick, which is linked here.

Feel Like Just a Number / War's Psychic Toll

The New York Times has a good op-ed piece today by Bob Herbert, entitled "War's Psychic Toll," linked here.

One point he makes, in the wake of the shooting deaths at Camp Liberty, is that:

"The fallout from the psychic stress of the wars in Iraq and Afghanistan has been vast, but there was no reason for its destructive effects to have surprised anyone. There was plenty of evidence that this would be an enormous problem. Speaking of Iraq back in 2004, Dr. Stephen C. Joseph, who had been an assistant secretary of defense during the Clinton administration, said, “I have a very strong sense that the mental health consequences are going to be the medical story of this war.”

He also further clarifies a point that a number of people have been making over the last several years, which is that an all-volunteer military concentrates the inevitable "psychic toll" of warfare into too few combatants on our side.  Herbert writes:

"Because we have chosen not to share the sacrifices of the wars in Iraq and Afghanistan, the terrible burden of these conflicts is being shouldered by an obscenely small portion of the population. Since this warrior class is so small, the same troops have to be sent into the war zones for tour after harrowing tour.

As the tours mount up, so do the mental health problems. Combat is crazy-making to start with. Multiple tours are recipes for complete meltdowns."

We've already seen, in previous blog posts, how more combat => more opportunities for PTSD. The relationship is direct.

At some point, with the same people serving multiple deployments, being injured becomes a numbers game.  And increasingly servicemembers who keep going back, if they've managed to avert injury so far, become concerned that their luck can't hold out forever.

A Recon Marine, with multiple deployments under his belt -- some would say, the toughest of the tough -- headed back to Afghanistan on Monday.  "I'm scared," he told his friends and family, unashamedly.  War is a dangerous game, and multiple deployments wreaks havoc on those who go, and those who stay behind and wait.

---
In the old Bob Seger song about working on an assembly line, "Feel like just a number," he sang, "I feel like just another / Spoke in a great big wheel / Like a tiny blade of grass / In a great big field."  Seger insists he's gonna "cruise out of this city / Head down to the sea / Gonna shout out at the ocean / Hey its me!" "I feel like a stranger / A stranger in this land," he sings.  "I feel like a number / But I'm not a number / I'm not a number -- Dammit, I'm a man! / I said, I'm a man."

I recall a conversation with another Marine, who between tours of Vietnam, had a premonition that he wouldn't survive his second tour.  What worried him even more than the dream was that everyone he knew who'd had a dream like that, and shared it with his buddies, subsequently was killed.  This Marine talked it over with his dad, a heavily-decorated Army officer, who told him, in sort, to buck it up and suck it up and go back -- because if he didn't, he'd be running from every other experience like this in his life.  Well, the premonition had a lot of weight to it -- he was shot multiple times and almost died, and took years to recover from his injuries. So we know that the Recon Marine in today's story, headed back to Afghanistan, does have something to be worried about -- even if he hasn't had a dream like this.

Ultimately, whether he and servicemembers like him think of themselves as "just a number" in the larger war machine or not, their more pressing concern, with multiple deployments in harm's way, is whether this time their number is going to be up.  And let's hope it won't be.  But of course, for society at large -- who stays behind -- the broader public health worry is that even if these warriors come home relatively "unscathed" -- in body, more likely than in mind -- their struggle with dealing with the after-effects of combat will just have begun.

Editor's note: To listen to the Bob Seger song mentioned above, on YouTube, click here.

After Combat: Looking for Health in a Handful of Pills?

From a week ago: The Savannah Morning News had an excellent article, by Pamela E. Walck, called "One soldier's struggle: Sgt. fights anger, treatment system," linked here. (There's also video, but it's not as on target as the article is.)

Sergeant John Jones, now part of the Warrior Transition Unit at Fort Stewart, Georgia, is the subject of the article, and by any standard he has a lot on his plate.

He was deployed with the 3rd Infantry Division's  2nd Brigade's 1st Battalion, 30th Infantry as a gunner, serving his second combat tour at age 29, when he was injured by an IED blast in July of 2007.  Less than six months later, doctors also discovered a brain tumor, and operated.  Since then, though the difficulties you could anticipate from those incidents alone would be enough for one person to cope with, there's been more. Symptoms of PTSD, trouble with authority both on and off the base, difficulty sleeping, the sense in Jone's own words that his personality is not what it was before, a (fortunately) failed suicide attempt, etc.  Really a painful story, of what sounds like a good man, having trouble coping with the after-effects of his injuries. The one peace in his life appears to be a rented cabin, where he goes for solace (and to fish!), yet is in danger of being taken away from him.

Walck does a great job reporting the story, and not settling for just the usual details. Through her work and Jones' own words, you're drawn into the story of what amounts to really a typically "wounded warrior." And while you find yourself pulling for Jones to survive and thrive, you can't help noticing that the "hope" held out for him is not much more than a handful of pills. Who he feels like he's lost, in his words -- echoing that of so many other combat vets with PTSD -- is "the old John," who he's now all but lost entirely. How he's going to get that guy back... is unfortunately anybody's guess. (As an additional difficulty, it's unclear whether his brain injury is making his behavioral issues worse -- it's likely that it is.) In the meantime, we can hope for peace and a healthy solution for Sgt. John Jones -- but for those who want a broader-than-usual, fully-developed "portrait" of one wounded warrior, struggling with the ravages of combat and PTSD, be sure to go here and read his story.

Violence at Camp Liberty: Shocked, Maybe, but Not Surprised

 Allow a little venting of spleen here: The violence at Camp Liberty today in Iraq, where an American active duty servicemember allegedly opened fire on others at the stress clinic, a location where other servicemembers go for counseling, killing 5 at 2:00 p.m. local time -- if we're shocked that this happened, that's okay; but seriously, America-- why are we still "surprised"?!

Here's 10 reasons NOT to be surprised, though feel free to continue to be shocked:

1.    Tours are too long, putting considerable and unprecedented strain on the all-volunteer military. The AP reports, "The U.S. military is coping with a growing number of stress cases among soldiers in Iraq and Afghanistan - many of whom are on their third or fourth combat tours. Some studies suggest that about 15 percent of soldiers returning from Iraq suffer from some sort of emotional problems." The ones who initially deployed?  Strong and willing.  But as the tours wore on, how many stayed that way?  Certainly not everybody.
2.    Resources for stress management are inadequate, and there's often peer pressure not to make use or take advantage of them -- and then the broader question: what are we really offering to help soldiers heal?  Is there anything in the conventional medical world that's actually working? There's talk therapy and there's medication, and those who follow this topic in-depth know that there are problems with either or both of those approaches.  Anecdotally, of the three combat veterans whose lives I follow most closely, all three of whom had recently pronounced substantial healing  -- two of the three who relied on the most conventional approaches -- were re-hospitalized within the past month for psychiatric reasons, each within several weeks of pronouncing how much better they were doing, thanks to their course of treatment.  (The third combat veteran, who follows a less conventional path, is actually truly doing better -- or so it would currently seem.) When it comes to combat-based PTSD, the "cure," such as it is -- is a long way off -- particularly if we only look along conventional channels.
3.    Access to firearms is...ummm...not an issue: they're everywhere.  It's war, and we're armed to the teeth.  It's part of what we do.  But carrying a weapon in a stress clinic?  Doesn't seem on the face of it to be a wise safety choice;
4.    Workplace violence is a fact of civilian life, too: OSHA reports that homicide is the fourth leading cause of workplace fatalities. On an average workday, according to one site, "three people will be murdered on the job in the U.S."  Annually, "one million workers are assaulted, and more than 1,000 are murdered." Concerns are that half these cases go unreported, so the figures might even be doubled. Mondays, in fact -- today  when the Camp Liberty incident took place is a Monday, after all -- are a prime time for incidents to take place.  Something about people stewing about their real or imaginary mistreatment over the weekend, and coming back in and deciding to "do something about it."  Read the cases: Monday is often when disgruntled American workers, at the very least, choose to settle the score;
5.    Sleep deprivation is a chronic problem in the over-extended military.  As a technique for inducing symptoms along the spectrum from abject misery to forms of psychosis, it's effective enough that it's used (by the U.S.) as a form of torture, like waterboarding. Going without sleep, which the military chronically does, puts soldiers at risk on a regular basis.  Not that there are any easy answers to this, but that needs to be taken into account. Not sleeping is very dangerous to your health: and if to yours, by extension to those around you, too. Experts like veterans advocate Jonathan Shay, M.D., Ph.D. have long warned about the dangers of exhaustion and sleep-deprivation.  It's time to pay greater attention;
6.    Talking heads and pundits attempt to minimize the problem by saying, it's only the fifth case of soldiers killing one another since the war began but REALLY -- are they serious?!  How about adding the qualifier, "known" case -- as in, proven.  (Even the New York Times said, more accurately, "The killing of American troops by their fellow soldiers is infrequent, but not unheard of.") Think of the many cases of noncombat deaths in Iraq.  How many of these, because of insufficient, inadequate, or misguided investigations -- or cover-ups -- might turn out to be soldier upon soldier violence, if we but knew the facts? A percentage of the noncombat deaths are murders, not just accidents or suicide.
7.    Felony waivers. While many -- or most -- of the military may be fine and upstanding individuals -- better, in fact, than most of their less patriotric, more self-centered peers -- the reality is, as the war continues, an increasing few who have less savory backgrounds or mental states are being given waivers and allowed to join anyway -- then deployed with the rest of the troops, and put under the same types of strain, which perhaps they don't bear very well -- or as well as their peers;
8.    If recruiter suicides are up (and they are) -- recruiters being in a good position to know the true costs of going to war on the troops -- and suicide is effectively giving up on their being a solution to one's problems -- shouldn't  this ring some greater warning bell than it has, that perhaps we're asking people to do and to sacrifice, far beyond their actual ability to?
9.    We can't discount the fact that some people are just unbalanced -- and some of the ones who are, unavoidably, also serve in the military.  The last well-publicized statistic on the subject was that roughly 10% of the (overall) population suffers from mental illness. Some of these people are in the military, and under stresses and strains greater than most of us have ever endured, some will snap.  that in itself should not really...surprise us.  It's not a diss against the military: it's a fact of life. If anything their challenges are stronger than anyone else's.
10.  Interpersonal violence and suicide are both extreme versions of "lashing out" at what's perceived to be an unjust fate.  Domestic violence rates in the military ARE worthy of some "shock 'n awe" of their own.  During the same news cycle, where the Camp Liberty incident is being broadcast across all possible news outlets, other, equally horrendous incidents are also happening among servicemembers and veterans -- horrendous to the victims and their families, as well as to the families of those who commit the crimes. Here's an example of the same from today's news cycle, though it's all been pushed off the page by the greater prominence of the Baghdad story. The Colorado Springs Gazette reports that Thomas Woolly, 24, was arrested in the shooting death of a 19-year-old woman.  As the Gazette describes, "Woolly ... was a heavy machine gunner in the 4th Infantry Division's 2nd Battalion, 12th Infantry Regiment.  Members of the 500-soldier unit, nicknamed the Lethal Warriors, have been involved in stabbings, beatings, brawls, domestic violence, shootings, at least two attempted murders and four homicides in Colorado Springs. Another soldier who served with the unit in Iraq has been accused of murder in California. The unit has also been plagued by drug abuse and suicide..."

By bringing this up -- that this violence might be "shocking," but surely shouldn't be "surprising" -- it isn't intended to single out servicemembers or veterans as "bad" -- if anything, they're under abnormally large stressors.  It is to say, this stuff happens -- not always as well broadcast as when it happens in a group.  But it happens all the same. Forgetting even Iraq and Afghanistan for the moment -- across AMERICA -- do we honestly believe that fewer than five people -- including the servicemembers and veterans involved -- had their lives in actual, mortal danger from incidents like this? (In the Woolly incident above, for example, one woman was killed, but another one was injured, according to published reports.)

Again, if we were but able to "see" across the broad expanse of all the people this affects, and into all their homes and lives, even on one given day, I think we might be quite surprised to see the continuing emotional toll and strain that combat stress and its aftermath produces. Continuing to look at incidents like whatever happened at Camp Liberty today -- as the facts continue to come out, over time -- as "isolated" incidents, instead of a very visible part of the mostly in-visible spectrum of pain and suffering -- only allows us to stay in the dark on this topic a little longer than we should. 

For the health of servicemembers, veterans and their families, it's time to start admitting what a difficult problem we have: and one that takes more than lip service, and conventional modes of treatment, to "handle" and ultimately to "solve."