Military awakening to needs of veterans with TBI, PTSD

From The Washington Post:

The 300-pound bomb blasted Marine Staff Sgt. James Ownbey's mine-resistant truck so high that it snapped power lines before it slammed to the dusty ground in western Iraq.

Ownbey (pictured), knocked briefly unconscious by the blast, awoke to suffocating black smoke and a swirling cloud of dirt. He felt for the vehicle's door, then stumbled into the sunlight where he was joined by the rest of his woozy, three-man crew. Their bodies were sore, but they looked fine.

A Marine general visiting from Washington heard about the blast and came to see the survivors. As Gen. James F. Amos laid a hand on Ownbey's neck, his aide snapped a picture, proof of the new vehicle's efficacy against insurgent bombs.

"I kind of felt separated from myself," Ownbey recalled of the aftermath of the 2007 blast. "It didn't feel like anything was real."

Two years after the explosion Amos and Ownbey met again, this time in a cramped room at the National Naval Medical Center in Bethesda. Ownbey had been overtaken by terrifying panic attacks, puzzling memory loss and strange rib-snapping coughing fits that left him hospitalized for weeks at a time. Doctors diagnosed post-traumatic stress disorder (PTSD) and traumatic brain injury, caused by battlefield concussions.

For Amos, seeing Ownbey's condition was the moment that the bloodless trauma of the Iraq and Afghanistan wars became tangible. "I thought we can't do this anymore," said Amos, referring to the military's slow response to treating PTSD and traumatic brain injury.

Ownbey's descent from dazed survivor to bed-ridden Marine exemplifies the debilitating passage of troops afflicted with PTSD and traumatic brain injury. His story also traces the military's awakening.

Senior commanders have reached a turning point. After nine years of war in Afghanistan and Iraq, they are beginning to recognize age-old legacies of the battlefield - once known as shellshock or battle fatigue - as combat wounds, not signs of weakness. Gen. Peter Chiarelli, Amos's Army counterpart, has been especially outspoken. "PTSD is not a figment of someone's imagination," Chiarelli lectured an auditorium of skeptical sergeants last fall. "It is a cruel physiological thing."

The challenge facing Amos and Chiarelli has been convincing an undermanned force that PTSD and traumatic brain injury are real injuries that demand immediate care. The generals also have run up against an overburdened military medical system that is short on doctors and reluctant to take risks with new types of treatment.

"I have been asked . . . should you have figured this out sooner?" said Amos, who was recently tapped to be Marine Corps commandant. "Yeah, we should have. But we didn't. It has been evolutionary."

Only a few weeks before the blast that injured him, Ownbey had reenlisted for another four years.

His engineer company's job was to find and destroy roadside bombs, a dangerous mission that had claimed the lives of eight Marines over two tours. The toll weighed heavily on Maj. Jeff Hackett, Ownbey's commander, who had begun to blame himself for the deaths. "I can't stand to look at myself," he confided in an e-mail to his wife.

When Ownbey arrived at his base's aide station following the blast he immediately called Hackett, who rushed to see him and the other wounded Marines. Ownbey remembers the relieved look on his commander's face.

Later that night Hackett told his wife about the apparently unscathed survivors of the massive bomb. "They are so fricking lucky!!!" he wrote.

In late September 2007, about three weeks after the blast, Ownbey returned to Camp Lejeune, N.C., after finishing his third combat deployment. This homecoming was nothing like the first two. The Ownbeys had bought a small house near the base. On the first drive home with his wife and three children, Ownbey slammed on the brakes, stopping just short of a pothole that had been repaired. "Why is that there?" he said pointing to the square of pavement, which resembled the holes insurgents use to plant roadside bombs.

"What do you mean?" his wife, Sandy, recalled asking him.

Ownbey jerked the wheel to the right and drove across a neighbor's lawn to avoid the patched pavement.

Sandy took her husband on a mountain getaway a few weeks later. After dinner and a few glasses of wine, Ownbey began rambling incoherently about friends killed in Iraq. "He was walking and talking as if he wasn't really there," she said.

Sandy called up one of her husband's close friends from his Iraq tour. Ownbey spent the next three hours talking and sobbing before he fell asleep with the phone cradled to his ear. The next day he sought counseling for PTSD.

As time passed, Ownbey's hands began to shake and he began to put on weight. Five months after the blast, he finally landed an appointment with a neurologist at the Camp Lejeune hospital. The military cannot fill its pre-9/11 quotas for neurologists, creating agonizingly long waits.

At the examination Ownbey couldn't remember and repeat three simple numbers. He was so twitchy that his doctor ordered him to stop driving.

In late 2008 blood clots caused by the blast injury, migrated to Ownbey's lungs, leaving him so short of breath that he couldn't climb a flight of stairs. He coughed so hard that he snapped six ribs. The doctors at the Camp Lejeune hospital moved him to Bethesda in February 2009.

"Every day he deteriorated for over a year," Sandy said.

In spring 2009, the top brass in the Marine Corps and the Army were seeing troubling signs that the force was starting to fray. The suicide rate in the two services was on pace to set a record. The percentage of the Army's most severely wounded troops who were suffering from PTSD or traumatic brain injury had climbed to about 50 percent, from 38 percent a year earlier.

Amos and Chiarelli ordered the military's top psychiatrists and neurologists to the Pentagon for a meeting. "We were looking for some treatments," Amos said. "Something we could do right now."

To moderate the session, the generals brought in David Hovda, a UCLA neuroscientist who had worked closely with the National Football League on concussions.

Hovda gave a 15-minute presentation on traumatic brain injury. Then the military doctors began to argue with him and among themselves, according to participants. PTSD and mild traumatic brain injury both cause a similar array of symptoms, such as migraines, sleeplessness, anxiety and memory loss. The military doctors worried that Hovda was too quick to blame repeated concussions for medical symptoms that could also be attributed to PTSD or depression.

"It's not wrong to think these symptoms could be related to concussion," said Army Col. Charles Hoge, one of the military doctors at the session. "What is wrong is to think that they are only related to concussion."

Hovda shot back that Hoge was underestimating the damage caused by repeated battlefield concussions. "I do not agree with Colonel Hoge's position at all," he wrote in an e-mail after the meeting.

Doctors say it is essential to understand what is producing the symptoms they are trying to treat. PTSD is caused by the way the brain remembers a harrowing event. Traumatic brain injury results from the jostling of the brain.

The disagreement was deeply frustrating for both Amos and Chiarelli.

"It was three hours of hell," Chiarelli said. "No one could agree on anything."

Amos and Chiarelli stormed out of the meeting angry. They worried the internal debate was slowing the effort to help suffering soldiers and Marines. At 3:51 a.m. Chiarelli fired off an e-mail to Amos and Hovda. "I am frustrated with the way we are treating, or not treating, [traumatic brain injury] and PTSD," he wrote. "There seems to be a lack of direction and so many different ideas of what right looks like."

The generals asked Hovda to invite a dozen top civilian experts on PTSD and traumatic brain injury to Washington for two days of meetings. They wanted the sessions to focus on treatments that military doctors and researchers had overlooked. To prevent the sessions from bogging down into another academic debate, Amos and Chiarelli did not invite most of the military physicians from the first session.

Amos had his encounter with Ownbey at Bethesda in late August 2009, four days before the meeting with civilian doctors and scientists. The general had been pinning Purple Hearts on wounded troops when he got word that one of the patients wanted to see him.

The Marine was so weak he could barely walk. Electrodes and wires were pinned to his bare, puffy chest. The 2007 blast had damaged Ownbey's pituitary gland at the base of his brain and his weight had ballooned to 240 pounds. He was 165 pounds before the injury.

Amos extended a hand to introduce himself.

"Sir, we've met before in Iraq," Ownbey said.

Sandy watched as the general slowly recognized her husband. Amos's face turned ashen. He hugged Sandy, and she began to cry. "We are going to figure out why this is happening to him," he said.

Amos opened the meeting with the civilian doctors on Sept. 1, 2009, by passing out the now two-year-old picture of himself and Ownbey posing in front of his crumpled vehicle. Then he handed out the snapshot of the Marine in his hospital bed.

"What can you do to help us with this now?" he asked the doctors.

By early October, Chiarelli had become obsessed with the science of PTSD and traumatic brain injury. He turned an awards luncheon in Washington for the Army's 24 noncommissioned officers of the year into a half-hour seminar on the mental wounds of war.

The Army general flashed a picture of three brain scans depicting a normal brain, a patient in a deep coma and a UCLA football player who had suffered a mild concussion. The normal brain glowed red and yellow, indicating that it was actively burning glucose. Both the concussion and the coma scans were blue, a sign that the brains had shut down to heal.

The football player's brain would only return to normal if it were given a couple of weeks to heal before it was struck again, Chiarelli said, according to a transcript of the event.

Chiarelli then explained how physiological changes caused by PTSD flooded the body with chemicals and triggered a rush of fear. "Contrary to what some believe, PTSD and traumatic brain injury are not phantom conditions exhibited by weak soldiers trying to get out of a deployment," he said.

As the months passed, Chiarelli began to refer to post-traumatic stress disorder as PTS. "I drop the D because I believe it is more of an injury than a disorder," he said. "A lot of doctors agree with me, but there are some who don't."

He sent instructions urging commanders to hold full memorial services for suicide victims just as they would for other Army fatalities. Some field commanders argued passionately against the policy, insisting that it was wrong to salute troops who had shown a lack of resolve. Chiarelli overruled them.

The best way to erase the stigma of mental illness, he insisted, would be to award the Purple Heart to troops suffering from post-traumatic stress. A 2008 study ordered by Defense Secretary Robert M. Gates had concluded that it was too difficult to prove that a soldier was suffering from PTSD. By 2010 Chiarelli countered that the science had sufficiently advanced and was worth reconsidering.

Amos disagreed with Chiarelli on the Purple Heart. "We need to keep that award as pure as we possibly can," he said.

The Marine general was never particularly captivated by the science of PTSD or traumatic brain injury. But Amos was convinced by Ownbey's suffering.

The two generals worked with the civilian doctors from the meeting they had organized in Washington to develop new procedures for treating mental wounds. To prevent traumatic brain injury, the doctors recommended new rules requiring troops who experienced a concussion to rest until a doctor cleared them for duty. After three concussions troops are no longer allowed to return to combat for the rest of the tour. "We've taken away the opportunity for Marines to say they are good to go after a concussion," Amos said, "because every Marine is going to say he is fine."

To treat PTSD, the doctors recommended therapy be delivered as soon after the triggering incident as possible. Amos and Chiarelli instituted programs to train front-line medics to spot the signs of PTSD and provide immediate psychiatric first-aid. They instructed therapists to use video conferencing to screen troops who might otherwise not get help.

The generals' goal was to fix the flawed system that Ownbey and his men confronted in Iraq and when they returned home to Camp Lejeune.

Gunnery Sgt. Christopher Wellman, who was sitting behind Ownbey when their truck was launched 30 feet in the air, estimated last month that he suffered four or five concussions during his final tour in Iraq. But he never sought medical care or skipped a patrol to rest and heal. "People were dying," he said.

He returned home and began experiencing memory problems, dizziness, nightmares and migraines. Wellman spent a year on limited duty before he made it back to his engineer unit, where he lasted three months before a routine explosion at a firing range caused him to relapse. He was medically retired from the Marine Corps this summer and began work with the Defense Department in Arlington. He stopped receiving treatment when he left Camp Lejeune.

Staff Sgt. Curtis Long, who was driving the truck, came home from Iraq angry and emotionally distant. "He told me that he had to force himself to feel something for me and our kids," said Virginia Long, his wife. "He just feels numb." She urged to him get treatment for PTSD, but he stopped after five sessions.

Last summer Long began to suffer migraines, hand tremors and a nervous eye twitch. Long's platoon sergeant pressed him to seek help from a neurologist, who said his symptoms were caused by stress. Months passed before the doctor was able to squeeze him in for a second exam.

The 25-year-old Marine sat for 45 minutes in the waiting room, then screamed at the receptionist and stormed out of the office. "I just went off on her," Long said. His wife begged him to return, but he refused.

In February Ownbey recommended his former neurologist at Camp Lejeune. More than two years after the blast, the doctor diagnosed traumatic brain injury and put Long on a weekly regimen of four therapy sessions to help him compensate for memory and balance problems.

A Navy medic who was a part of Ownbey's crew said he has suffered no long-term effects from the explosion.

Ownbey's health - though still fragile - has slowly improved. In 2009 the general had ordered Ownbey to stay in the service so that Navy doctors could figure out what was wrong with him. He recently asked Amos for permission to leave the Marine Corps later this summer.

"I can't get to a point where I can go back to combat," Ownbey said. "But I can apply myself to my family. I can get to a better way of living."

Ownbey's good friend and company commander, Jeff Hackett, retired as a major from the Marine Corps after 26 years of service.

"He looked like he was really going to miss it ," Ownbey recalled. Ownbey hugged him, and for the first time in their three years together called him "Jeff" instead of "sir."

Hackett and his wife bought a house and 40 acres of land about an hour outside of Cheyenne, Wyo. His family said he often seemed distant.

When Ownbey had reenlisted in August 2007, he suggested that Hackett don his blast-resistant suit for the ceremony, which took place outside in 120-degree heat. Hackett did it.

By 2010 Hackett's goofy sense of humor was gone. He could not stop blaming himself for the deaths of the Marines his company lost in Iraq. "I killed eight of my men," he told his sister.

On June 5, Hackett called his wife, Danelle, from the parking lot of American Legion Hall in Cheyenne. "I just want to let you know how sorry I am and that I love you," he said. He called his sister to thank her for her love and support. Then he turned off his phone.

Hackett's sister raced to his house, picked up Danelle and began searching for Hackett.

The retired Marine returned to the American Legion Hall and continued to drink. After about an hour, he pulled out a gun and shot himself.

In the front seat of his Chrysler truck, his wife and sister found an envelope on which he had scribbled "I deserve Hell."

In an interview, Danelle said she was angry at the Marine Corps for doing too little to educate her about PTSD. "The Marines want to brush all of this under the carpet," she said.

Amos called to offer his condolences on July 4. She told him about her 18-year-old son, who is headed to boot camp later this year. "He has his dad's integrity," she said. "He's going to make a hell of a Marine."

Danelle was two months behind on her house and car payments. Because her husband had killed himself, their mortgage insurance did not apply. Amos alerted a Marine Corps charity, which sent a check to help her get through the summer.

"I don't want others to suffer what my sons and I have gone through," Danelle told the general. "I want to be an advocate."

Amos promised her he would stay in touch.