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Stress, Redeployed

Stress, Redeployed Even though he is dressed in civilian clothes, his demeanor and his close-cropped hair suggest allegiance, routine, strength. His presenting to the VA Deployment Health Clinic is courageous, a humble call for help contrary to, or at least not routine in, military culture. Why else would he have come? He enters, respectfully, and chooses the chair facing the door. “How did you find out about our clinic?” “A buddy from my unit told me about you. He was having nightmares.” His physical assurance is betrayed by a quiet unease, a quick scanning of the room, a set jaw. “And my wife wanted me to come in.” He tells us his story in the language of the military: unit number, location in-theater, duration of deployment, MOS (military occupational specialty). He describes how he spent most of his time: out on patrols in Humvees, in and around Fallujah. Daily indirect fire on his FOB (forward operating base) from mortars and rocket-propelled grenades, direct fire at least once or twice a week. Three blast incidents: two IEDs (improvised explosive devices) and one VBED (vehicle-borne explosive device). “I saw my best friend lose his leg and a kidney to a car bomb.” “Were you injured?” “Scratches and bruises, hurt my back a little.” “Purple Heart?” “You don't chase a Purple Heart for scratches and bruises. My friend lost his leg and a kidney . . . that's a Purple Heart.” His unit is scheduled to be redeployed to Iraq in a few months. His desire to return to the fray is bold and confident: “I’m going back.” The three words speak volumes: heroism, resignation, family conflict, devotion, compulsion, determination, ambivalence. What will happen to him if he goes back there? We are concerned, even judgmental, but we judge with straight faces. Or so we hope. As clinicians, we are trained to walk a fine line between empathy and objective assessment, between taking charge and stepping back. Maintaining too much distance risks detachment and failure; taking too much initiative risks disapprobation and failure. The straight face is that fine line, tenuously balancing our own tangle of mixed emotions and inclinations. What about his life after the war? What about his family? “I’m having trouble sleeping . . . having sweats at night and bad dreams sometimes. I find myself snapping at my wife over minor things. I get angry in a second, for no reason. I keep seeing the fireball. I’m always on guard, even when I’m at the grocery store. I hate going under bridges, and a backfire is enough to make me swerve off the road. I can't stand being stuck in traffic.” Trained in occupational and environmental medicine, we search for grounding in familiar models and paradigms. It's like an allergy. Well, not exactly, but he's “sensitized” to something, and he “hyperreacts.” His cortex, his limbic system, his autonomic nervous system conspire against him. Perhaps it's even leading to chronic physiological change, in his neurotransmitter mix, in his neuroendocrine receptors, perhaps even in the neuroanatomical fabric of his hippocampus. Could it be, as with occupational asthma, that if he continues to be exposed to and to experience these hyperreactive responses, he’ll become irreversibly impaired? It certainly seems possible. We know that more trauma can lead to more posttraumatic stress disorder (PTSD). He's primed with “antibodies” to triggers, reminders of the environment in Iraq. What was the “allergen”? The sight of the fireball? The smell of the ignited explosives and fuel? The impact of the blast wave? The sound of his friend moaning, dragging his mangled leg from the flaming wreck? Can we identify the trigger(s)? Why do so many of those returning from Iraq and Afghanistan come home with PTSD or related mental health conditions? Why not fewer? Why not more? Which of the combat stressors are the most potent “sensitizers”? How could anyone escape sensitization to such toxic experiences? What could be protective . . . what armor, what strategy, what training technique? In earlier wars, many if not most combatants held as prisoners of war ended up with PTSD. Is torture the “allergen”? Solitary confinement? Threat of death? And then there are those who handle bodies and body parts, most of whom end up with PTSD. How can anyone be “desensitized” after that? We snap out of our search for an explanatory model and back to our patient. He remains seated, respectful, somehow holding it all together during the silence. Anywhere in Iraq, on any road, any forward operating base, any town or village, even in the Green Zone in Baghdad, there is risk of indirect fire from mortar or rocket-propelled grenade, direct fire from any passing vehicle or building, or the ever-present explosive devices buried under roads, hidden in buildings, transported in vehicles, or strapped to the bodies of those around you. The greatest risk in this war is that ever-present threat of injury or death, day in and day out, in your bunk, in the chow hall, in your Humvee, coming or going, anywhere, anytime. Psychological trauma is not, of course, an “allergen” in the classic sense. And though it is toxic, standard toxicological models also fall short. How do we quantify, qualify, and mediate the toxicity of psychological trauma, with a hope to prevent and protect? What is the NOAEL (no observed adverse effects level) in hours for direct fire? Or the PEL (permissible exposure level) in months for daily indirect fire? What about the TLV (threshold limit value) of hours spent patrolling on IED-laced roads? Or is there no threshold at all, no safe level for susceptible individuals? We realize, not without some frustration, that these concepts do not directly translate to this context. In spite of the tremendous morbidity associated with this exposure, war doesn't fit neatly into our standard medical paradigms. And yet it is so clearly toxic to those who experience it. Through whatever model we filter our interpretations, we witness a devastating, maladaptive response, not unlike that seen in allergy or autoimmune disease. The physiological responses meant to be protective at war—the hypervigilance, hyperarousal, the emotional numbing—become themselves a disease at home. “So what are the pros and cons as you consider redeploying?” He replies, “In many ways, it seems easier over there than here. Nothing seems to be going that well since I got back. At least there you know what the dangers are, what you have control over and what you don’t.” Maybe he's right. Maybe the constant, tangible threat is easier to manage than the more diffuse and diluted fear of the “foreign-looking” cab driver or “unusually dressed” passenger on the bus. Maybe it is simpler, more streamlined, to live in constant fear. But we know too well the risk of the “anaphylactic” hit. He is primed for autonomic overload, the anxiety that won't subside, the depression that is too heavy to bear, the nightmare that won't go away. What if the next trauma leads to an irremediable arousal? Then what do we do? Then what do we say to him, to his wife and his kids? His deliberations are agonizing, herculean. “If I don't redeploy with my unit, I would never feel OK about myself again. These are the people I feel closest to in the world. Even more so than to my wife and kids in some ways. We’ve faced death together. I trust them more than I can imagine ever trusting anyone again.” Imagine your half dozen closest friends going off together to do something very important, something that you all believe in, with injury and death a possibility for all. Would you let them leave without you? “I know that going back over might make my symptoms worse. I want to be the best father that I can be, and I know this may make it harder for me to be a good parent down the road. I know it's going to be hard for my wife and kids. But I’d be a worse father and husband if I didn't do what I believe is right. My wife knows that, and as difficult as this all is for her, she supports me doing whatever I need to do.” If, as Paracelsus first said in the 16th century, “the dose is the poison,” many of the returning soldiers are at tremendous risk. So naturally hopeful to avoid sustaining the deadly hit of bullet, blast, or shell fragment, they may easily ignore the more insidious, chronic wound that is PTSD. From our safe distance, it's easy to oppose or support the war in Iraq, not having been there, not having smelled the war, not having seen it or struggled to bear the conflicting feelings that are its fabric. But once you have been there and the war is inside of you, things are not so clear-cut, so black and white. It is no longer about politics or policies. It is about the complexity of human existence, the primacy of friends and family, the immediacy of struggling to survive, the ephemeral nature of life itself. In the core of each one of these veterans, with a visceral intensity set in motion by their gut-wrenching and mind-altering experiences in Iraq, we see the fervent hope that this will somehow work out well—for them, for their buddies and families, for their country, for the people of Iraq, for humanity. And we, as medical practitioners who have not been there, armed with only our imperfect paradigms and our flawed analogies, must tend to our most basic responsibilities as physicians: to treat disease with sincere appreciation of the one we are treating, to educate, to inform, to support, and to advise. Not empowered to determine whether or not a vulnerable soldier returns to combat, we can only be fully honest in our appraisal and candid in our recommendations. Most important of all, we must have faith in and be hopeful with the one who stands before us . . . loyal, suffering, and in need. Back to top Article Information Acknowledgment: We would like to thank Carey Jackson, MD, Dennis Shusterman, MD, MPH, and Tim Takaro, MD, MPH, for helpful comments on our manuscript. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Stress, Redeployed

Carlsten, Chris; Hunt, Stephen
JAMA , Volume 298 (1) – Jul 4, 2007
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Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.298.1.18
Publisher site
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Abstract

Even though he is dressed in civilian clothes, his demeanor and his close-cropped hair suggest allegiance, routine, strength. His presenting to the VA Deployment Health Clinic is courageous, a humble call for help contrary to, or at least not routine in, military culture. Why else would he have come? He enters, respectfully, and chooses the chair facing the door. “How did you find out about our clinic?” “A buddy from my unit told me about you. He was having nightmares.” His physical assurance is betrayed by a quiet unease, a quick scanning of the room, a set jaw. “And my wife wanted me to come in.” He tells us his story in the language of the military: unit number, location in-theater, duration of deployment, MOS (military occupational specialty). He describes how he spent most of his time: out on patrols in Humvees, in and around Fallujah. Daily indirect fire on his FOB (forward operating base) from mortars and rocket-propelled grenades, direct fire at least once or twice a week. Three blast incidents: two IEDs (improvised explosive devices) and one VBED (vehicle-borne explosive device). “I saw my best friend lose his leg and a kidney to a car bomb.” “Were you injured?” “Scratches and bruises, hurt my back a little.” “Purple Heart?” “You don't chase a Purple Heart for scratches and bruises. My friend lost his leg and a kidney . . . that's a Purple Heart.” His unit is scheduled to be redeployed to Iraq in a few months. His desire to return to the fray is bold and confident: “I’m going back.” The three words speak volumes: heroism, resignation, family conflict, devotion, compulsion, determination, ambivalence. What will happen to him if he goes back there? We are concerned, even judgmental, but we judge with straight faces. Or so we hope. As clinicians, we are trained to walk a fine line between empathy and objective assessment, between taking charge and stepping back. Maintaining too much distance risks detachment and failure; taking too much initiative risks disapprobation and failure. The straight face is that fine line, tenuously balancing our own tangle of mixed emotions and inclinations. What about his life after the war? What about his family? “I’m having trouble sleeping . . . having sweats at night and bad dreams sometimes. I find myself snapping at my wife over minor things. I get angry in a second, for no reason. I keep seeing the fireball. I’m always on guard, even when I’m at the grocery store. I hate going under bridges, and a backfire is enough to make me swerve off the road. I can't stand being stuck in traffic.” Trained in occupational and environmental medicine, we search for grounding in familiar models and paradigms. It's like an allergy. Well, not exactly, but he's “sensitized” to something, and he “hyperreacts.” His cortex, his limbic system, his autonomic nervous system conspire against him. Perhaps it's even leading to chronic physiological change, in his neurotransmitter mix, in his neuroendocrine receptors, perhaps even in the neuroanatomical fabric of his hippocampus. Could it be, as with occupational asthma, that if he continues to be exposed to and to experience these hyperreactive responses, he’ll become irreversibly impaired? It certainly seems possible. We know that more trauma can lead to more posttraumatic stress disorder (PTSD). He's primed with “antibodies” to triggers, reminders of the environment in Iraq. What was the “allergen”? The sight of the fireball? The smell of the ignited explosives and fuel? The impact of the blast wave? The sound of his friend moaning, dragging his mangled leg from the flaming wreck? Can we identify the trigger(s)? Why do so many of those returning from Iraq and Afghanistan come home with PTSD or related mental health conditions? Why not fewer? Why not more? Which of the combat stressors are the most potent “sensitizers”? How could anyone escape sensitization to such toxic experiences? What could be protective . . . what armor, what strategy, what training technique? In earlier wars, many if not most combatants held as prisoners of war ended up with PTSD. Is torture the “allergen”? Solitary confinement? Threat of death? And then there are those who handle bodies and body parts, most of whom end up with PTSD. How can anyone be “desensitized” after that? We snap out of our search for an explanatory model and back to our patient. He remains seated, respectful, somehow holding it all together during the silence. Anywhere in Iraq, on any road, any forward operating base, any town or village, even in the Green Zone in Baghdad, there is risk of indirect fire from mortar or rocket-propelled grenade, direct fire from any passing vehicle or building, or the ever-present explosive devices buried under roads, hidden in buildings, transported in vehicles, or strapped to the bodies of those around you. The greatest risk in this war is that ever-present threat of injury or death, day in and day out, in your bunk, in the chow hall, in your Humvee, coming or going, anywhere, anytime. Psychological trauma is not, of course, an “allergen” in the classic sense. And though it is toxic, standard toxicological models also fall short. How do we quantify, qualify, and mediate the toxicity of psychological trauma, with a hope to prevent and protect? What is the NOAEL (no observed adverse effects level) in hours for direct fire? Or the PEL (permissible exposure level) in months for daily indirect fire? What about the TLV (threshold limit value) of hours spent patrolling on IED-laced roads? Or is there no threshold at all, no safe level for susceptible individuals? We realize, not without some frustration, that these concepts do not directly translate to this context. In spite of the tremendous morbidity associated with this exposure, war doesn't fit neatly into our standard medical paradigms. And yet it is so clearly toxic to those who experience it. Through whatever model we filter our interpretations, we witness a devastating, maladaptive response, not unlike that seen in allergy or autoimmune disease. The physiological responses meant to be protective at war—the hypervigilance, hyperarousal, the emotional numbing—become themselves a disease at home. “So what are the pros and cons as you consider redeploying?” He replies, “In many ways, it seems easier over there than here. Nothing seems to be going that well since I got back. At least there you know what the dangers are, what you have control over and what you don’t.” Maybe he's right. Maybe the constant, tangible threat is easier to manage than the more diffuse and diluted fear of the “foreign-looking” cab driver or “unusually dressed” passenger on the bus. Maybe it is simpler, more streamlined, to live in constant fear. But we know too well the risk of the “anaphylactic” hit. He is primed for autonomic overload, the anxiety that won't subside, the depression that is too heavy to bear, the nightmare that won't go away. What if the next trauma leads to an irremediable arousal? Then what do we do? Then what do we say to him, to his wife and his kids? His deliberations are agonizing, herculean. “If I don't redeploy with my unit, I would never feel OK about myself again. These are the people I feel closest to in the world. Even more so than to my wife and kids in some ways. We’ve faced death together. I trust them more than I can imagine ever trusting anyone again.” Imagine your half dozen closest friends going off together to do something very important, something that you all believe in, with injury and death a possibility for all. Would you let them leave without you? “I know that going back over might make my symptoms worse. I want to be the best father that I can be, and I know this may make it harder for me to be a good parent down the road. I know it's going to be hard for my wife and kids. But I’d be a worse father and husband if I didn't do what I believe is right. My wife knows that, and as difficult as this all is for her, she supports me doing whatever I need to do.” If, as Paracelsus first said in the 16th century, “the dose is the poison,” many of the returning soldiers are at tremendous risk. So naturally hopeful to avoid sustaining the deadly hit of bullet, blast, or shell fragment, they may easily ignore the more insidious, chronic wound that is PTSD. From our safe distance, it's easy to oppose or support the war in Iraq, not having been there, not having smelled the war, not having seen it or struggled to bear the conflicting feelings that are its fabric. But once you have been there and the war is inside of you, things are not so clear-cut, so black and white. It is no longer about politics or policies. It is about the complexity of human existence, the primacy of friends and family, the immediacy of struggling to survive, the ephemeral nature of life itself. In the core of each one of these veterans, with a visceral intensity set in motion by their gut-wrenching and mind-altering experiences in Iraq, we see the fervent hope that this will somehow work out well—for them, for their buddies and families, for their country, for the people of Iraq, for humanity. And we, as medical practitioners who have not been there, armed with only our imperfect paradigms and our flawed analogies, must tend to our most basic responsibilities as physicians: to treat disease with sincere appreciation of the one we are treating, to educate, to inform, to support, and to advise. Not empowered to determine whether or not a vulnerable soldier returns to combat, we can only be fully honest in our appraisal and candid in our recommendations. Most important of all, we must have faith in and be hopeful with the one who stands before us . . . loyal, suffering, and in need. Back to top Article Information Acknowledgment: We would like to thank Carey Jackson, MD, Dennis Shusterman, MD, MPH, and Tim Takaro, MD, MPH, for helpful comments on our manuscript.

Journal

JAMA – American Medical Association

Published: Jul 4, 2007

There are no references for this article.