Coming Home: A Field Guide (Part 8: Understanding Traumatic Brain Injury)

As mentioned before in my field guide series, Traumatic Brain Injury (TBI) is one of the three most prevalent "unseen wounds" of the conflicts in Iraq and Afghanistan – so much so, it’s often referred to as the “signature wound” of those wars. There's been a lot of discussion on what exactly TBI is and how it affects people. Even just diagnosing the issue has caused some argument in the medical community.

Traumatic Brain Injury is the result of any external force impacting someone’s skull. The injury is usually divided into three categories of intensity: mild, moderate, and severe. It is such a common of wound in the current wars because most of the combat casualties occur as a result of roadside bombs, rockets, mortars, and other improvised weapons. Generally speaking, the reason the insurgency is so deadly and hard to eliminate, and the reason they use these weapons so much, is because they don’t frequently engage our forces in traditional maneuver warfare. The majority of the deaths and injuries in Iraq and Afghanistan have come from roadside bombs specifically, because these can be hidden and sneakily activated for when our troops come upon them. Oftentimes, the IED triggerman can walk away from the blast without being noticed or observed, since they can use any electronic device to activate these bombs (or sometimes they’ll use motion sensors or pressure plates to fire them). It’s the toughest of the enemies’ weapons to counter, which is why they are so lethal and why they are still used as the main arsenal of the insurgencies today, almost ten years after the Global War on Terror began.

Revolutionary armor usage – both personal and vehicle-related – and the implementation of top-notch battlefield operating rooms and hospitals have resulted in higher incidences of TBI because, in the past, the same type of injuries would kill the soldier but now they survive. In fact, the ratio of wounded to dead for the Global War on Terror is the highest ever in the history of warfare, which is laudable, but new problems arise. These defenses protect the individual warrior’s life but, as you can imagine, the injuries resulting from a crippling concussive blast that knock someone down or against a wall cannot be protected against.

And, as you can also imagine, the psychological repercussions of a blow to the brain can be particularly harmful to the surviving veteran. Here’s a list of symptoms for mild TBI: headache, changes in sleep patterns, confusion, blurred vision or tired eyes, ringing in the ears, lack of motor coordination, dizziness, difficulty balancing, vomiting, nausea, lightheadedness, bad taste in the mouth, fatigue or lethargy, and trouble with memory and focus.

Moderate to severe TBI can result in the following symptoms: repeated vomiting or nausea, convulsions, an inability to awaken, slurred speech, dilation of one or both pupils, headache that does not go away, dysarthria (muscle weakness that causes disordered speech), weakness or numbness in the limbs, aphasia (word-finding difficulties), loss of coordination, confusion, restlessness, or agitation, deficits in social judgment, and cognitive changes.

Treatment and diagnosis is somewhat difficult, especially in veterans, because many of these symptoms overlap with combat stress and PTSD. Fortunately, this issue has earned a lot of attention and a new sense of urgency in the last few years, and there are many resources at your disposal. I will be discussing those in the next blog.

If you’ve ever come close to an explosion, vehicle accident, fall or other accident while in the military, it is your interest to at least get yourself checked. The only person responsible for your health is you. No one else is going to accept accountability.

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Just Do It

I’ve got to admit that I had some trepidation when accessing Not Alone’s E-counseling services last Wednesday. I think I’m mentally well, but until last Wednesday, I'd never actually actually sat and talked with a bona fide medical professional about my experiences in war. I think, for me, some of the anxiety about talking with the counselor was the same kind of stress people get when getting a check up for cancer. If you don’t go find out, that means there’s not problem, right?

Wrong.

I realize now what I fool I was so many years ago to never see a medical professional when it is very possible that I did have PTSD. I think about where I am now. Where would I be if I didn’t drink myself into oblivion every night for three years, and instead tried to get well?

I was also worried before doing the E-counseling that, maybe if I did talk to him, some experience I hadn’t ever processed healthily might get galvanized and I might become overwhelmingly depressed. But that’s kind of the same idea as those nightly news reports about our nation’s weakness back in the day. Remember those? Is America’s water supply secure? Shh. Don’t ask that; you’re giving the terrorists ideas. When, in reality, if the danger is there, you shouldn’t ignore it because eventually you will get burned.

As it turned out, the counselor agreed with me, that I am well. As tough as I like to pretend to be sometimes, I can’t really tell you how good that makes me feel. It’s a clean bill of health that felt amazing to have reaffirmed. (And, yes, I know the E-counseling is more informative than personal and in-depth, but I trust the man’s intuition.)

At the end of the day, if you are dealing at all – and in any way – with the trauma of war, what can it really hurt to just go explore these services and see if they can help you at all? Who knows, it really could change you for the better. What is one hour when weighed against the rest of your life?

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E-Support on Not Alone

In case you might not know, in Not Alone’s commendable effort to help a nation and its warriors and families deal with the trauma of war is not just a lofty idea that sounds nice, but won’t be put into practice. No, Sir. This place is serious. Not Alone offers many free programs that provide tangible relief for the struggles of life after war. It’s not all talk here. They want to be your boots when walking the difficult journey of returning to wellness.

Last night I went to visit the Warrior’s Group on Not Alone, to experience firsthand what the site has to offer. I do admit the interface was kind of tricky, which was frustrating, but I’m an old seadog these days (next year is my tenth anniversary of graduation from boot camp), so I imagine anybody a little bit younger (and therefore, more technologically savvy) wouldn’t have the same problems.

I spoke with a counselor named Larry, a veteran of the Vietnam War. He was quick to point out that even though he served in Southeast Asia, he never saw any combat, but the man knows his stuff. Also, he can relate. Anybody who puts their life on the line can relate to that pain in the gut, and nagging fear, of being deployed.

This warrior group was a place to start opening up and learning about PTSD, and about what to do if you're still struggling when you return home. Larry was quick to point out to me that “even if a vet doesn’t have PTSD – they have depression or guilt or whatever else – we still want them here.” In the group, you get to learn about the symptoms of PTSD and you get a gut check about your own life and mental health. Do you have flashbacks? Did you experience a traumatic event? Are your emotions numbed? Are you always on guard (hyper vigilant)?

We also talked about different techniques for remaining calm and processing emotions appropriately: meditation, guided visualization, and breathing techniques. Larry is also a big advocate of yoga, which, as wimpy as that sounds, he totally sold me on. There are a lot of parallels to military things, such as breathing techniques and firing positions, in the practice of yoga. And doing those things, as you proceed in overcoming your trauma, can help you achieve better health in a sort of familiar way.

Larry reminded me flat out: there are some things we’ve lost because of our experiences that we can never get back. Maybe that’s a marriage. Maybe it’s a job. Maybe it’s a drunken incident we’d like to undo. But the sooner we start addressing what’s wrong – the sooner we can create a pleasant future for ourselves.

It only takes one step. That one initial step.

On forced marches at boot camp, with my rifle and dozens of pounds of gear, I wanted to quit once. The burden was too much. A drill instructor sensed my feelings. He said, “Just put your chest out, and then put one foot in front of the other; the momentum of all that extra weight will keep you going.”

I think that’s appropriate for dealing with life after war. Use your burden as motivation. Once you start, I think you’ll find that you can’t stop, and wellness is the mission.

Good luck and Semper Fi.

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The Story of Steve-O

One thing that I think is crucial for maintaining a healthy mental well-being is this: coming to understand that your pain probably isn’t sacred. Personally, I am a believer that any trauma can be equal to another person’s trauma even if the situations are different. I can’t enter someone else’s head and decide how they should feel as a reaction to something that has happened to them, and they can’t do the same to me.

Yes, I got shot at. And for me, that was probably the most intense thing I’ve ever had to endure. But what about someone who has been raped? If they’ve never experienced war, that’s probably the most intense thing that they’ve ever endured so whose pain is worse? I would guess that they’re equal; really, it would just depend on the individual’s perception. I’m pretty confident that if there were a way to measure someone’s brain activity while they were enduring significant mental conflict, both situations would elicit the same sort of readings.

Simply put, trauma is trauma is trauma, and when I am feeling sad or helpless for myself, cursing the world and getting frustrated at God, I remember the story of the young Iraqi boy who lived with us, whom we nicknamed Steve-O to protect his true identity.

Steve-O’s father had been an officer in Saddam’s Army. After the U.S. had brought down the regime, Steve-O’s dad became an insurgent leader, commandeering a 40 man team, including Steve-O, who was given a rifle and told to shoot at Americans. Steve-O didn’t want to fight, however. He protested and his papa beat him; his body still bears the scars.

Finally, too overwhelmed with his predicament, Steve-O turned himself into the Americans – he also turned in his father, telling the Americans where he could be found. And, while riding in humvees in future patrols with the Coalition Forces, he pointed out the other 40 fighters when he saw them. That was an act of courage I can’t even fathom or ever truly appreciate because it just seems too insane: a 13-year-old boy (we didn’t really know Steve-O’s age; we gave him an arbitrary age and birthday, July 4^th) with the mental courage to stand up for what he believed in against the very real possibility of murderous revenge (now that he was considered a traitor)!

When he went to visit his mother a few weeks later, she said her life had been threatened also, if she didn’t turn him into the insurgents. She didn’t turn him in; she told Steve-O that he should return to the Americans. The threats became reality, unfortunately. His mother was killed. The whereabouts of the rest of his family and their fates remain unknown.

Steve-O rose above all that drama with a courage and determination that still seems unbelievable to me. He integrated with the Americans and won everyone’s utmost affection. He took to wearing military uniforms to perfect standards and he learned proficient English in just a few months. He’d never stop smiling; practical jokes were his favorite. I can’t tell you how many times I saw Steve-O run out of the building with a column of Marines chasing him after the antics he pulled. They’d tackle him playfully and rub their knuckles on the top of his head.

And his empathy for others, despite all his hardships, still humbles me and makes me feel like less of a human being. Through his resourcefulness and the networks he created for himself, Steve-O would do whatever he could for others.

On one particularly hot day, about 125 degrees according to a thermometer, Steve-O once asked me if I wanted a coke. “Hell ya, I want a coke – where on earth are you going to get that!?” I responded, outstandingly. We were on the border with Syria, and the closest other base to us, took almost four hours to travel to. Resupplies only came once every two weeks and we didn’t even get our mail often, let alone unnecessary amenities like candy or dehydrating soda. We lived in an abandoned railroad station, and there were only two refrigerators that I knew of, and one of those was broken.

Five minutes later, after rushing away, Steve-O came back with a cold Pepsi (“Coke” was just the blanket term the Arabs used for any soda). “You my saddiqi (SA-DEE-KEE),” Steve-O said to me, grinning.

“You’re my friend, too,” I replied.

I miss that boy. So much. He’s in the U.S. now, a political refugee, living with one of the Soldiers who looked after him before the Marines took over responsibility of that area of operations, and responsibility of Steve-O. His story still inspires me, and helps keep me motivated to staying well, and away from the dark place.

(It turns out by the way, that while we were watching over Steve-O in Iraq, he was becoming a national celebrity in the states. Here’s his clip from Oprah. And here’s the book that’s been written about him.)

Don’t give up, people.

~ Semper Fi ~

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The Bureaucracy Adapts (Slowly)

Thank you, President Obama for what you’ve enacted recently for the veteran community. I know in an emotional moment, I’ve criticized you harshly in the recent past, but I believe in giving credit where credit is due and, as a veteran, I just want to say thank you.

In case you still haven’t heard, via the big man's approval, the VA is easing the rules that cover the application of claims related to PTSD.

According to the New York Times, “Under the new rule, which applies to veterans of all wars, the department will grant compensation to those with PTSD if they can simply show that they served in a war zone and in a job consistent with the events that they say caused their conditions. They would not have to prove, for instance, that they came under fire, served in a front-line unit or saw a friend killed.”

The unique thing about the Wars in Afghanistan and Iraq (odd how those are flipped precedence these days, isn’t it?) that a lot of people don’t understand is that the fighting occurs in a completely organic environment; it’s always shifting and changing and there’s no respite from it. Anecdotally, I can tell you for fact, when I served at Camp Fallujah Iraq, the rocket and mortar attacks were so incessant, just stepping outside the cement housing structures we lived in to smoke a cigarette meant risking our lives. Additionally, as the majority of the casualties in these wars have come from roadside bombs, jobs like motor vehicle operator or supply and logistics are just as likely as the ground-pounding grunts to be attacked, maimed, or killed by incredible explosions. For a time, even just flying into the Iraqi combat zone literally meant risking your life.

(I will spare you some of the other stories I’ve heard about support troops being killed on base. They involve port-o-johns and mortars.)

I do worry like some of the experts quoted in this Times’ article, about fraudulent claims and making certain young veterans unnecessarily dependent on the system, but I’m happy that finally, nearly ten years after the Afghanistan War began, we’re giving recognition to the unique considerations of 21^st Century warfare.

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Book Review: Here, Bullet

I’d like to finish the week with one last review of the literature of war: Brian Turner’s widely acclaimed book of poetry, Here, Bullet. If you’re thinking to yourself what on earth could a book of poems possibly do to help someone cope with life after war then, you haven’t opened this collection. A MFA graduate of poetry before serving a deployment to Bosnia-Herzegovina and the invasion into Iraq as an infantry team leader, some of Turner’s language that he crafts in Here, Bullet still lingers in my mind daily, even years after first reading this book. It’s become a part of me in a way; the poetics are that chilling and humbling.

I had a poetry professor who told me once that a good poem is a gift; you’re giving someone an experience, an emotion, a feeling they’ve never had, and you’re giving them a resolution or clarity and calm. “Believe it when you see it,” Turner writes in the poem The Hurt Locker, “believe it when a twelve-year-old rolls a grenade into the room. Or when a sniper punches a hole deep into someone’s skull… Open the hurt locker and learn how rough men come hunting for souls."

Feel that chill up your tailbone yet? In the poem called Eulogy, Turner writes lovingly of a fellow Soldier’s suicide, “It happens likes this, on a blue day of sun, when Private Miller pulls the trigger to take brass and fire into his mouth: … no mater what blur of motion surrounds him, no matter what voices crackle over the radio in static confusion … Private Miller has found what low hush there is … there by the river.”

While many of these poems are excellent narratives and disturbing recollections of suicide bombs and battle, Turner does veer to the high-brow state of modern poetry from time to time in this collection, and those poems are especially frustrating because of their inaccessibility. But like a sporting event where it’s the highlights and best parts that bring about the win, Turner’s Here, Bullet is by far the strongest poetry to emerge from the current conflict, a title that he might not lose for a very long time.

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On Reading Literature for Getting Well

(This is an essay I wrote in college and have since revised. Reading always helped me on my path to getting well after coming home from war.)

The Power of One Book

Like Paul Baumer, the fictional main character of All Quiet on the Western Front, I was nineteen years old when I served in combat. Somehow I had wandered through a formal literary education in a middle class public school, developed a strong interest in classic film, and fought in a foreign war without knowing who Paul Baumer was. It is a shame that much of the civilized world no longer knows his story.

I would not read Paul Baumer's story as told in All Quiet On the Western Front, which is the cathartic reflections of World War I veteran and author, Erich Maria Remarque, until the age of twenty-one.

Paul could have been my buddy in Fallujah, Iraq. Under a torrent of enemy bombardment we might have nestled into the ground together like children in our mother’s chests, pleading for survival. We might have manned a machine-gun together, our bodies becoming automatons as we performed the training conditioned within us. We might have stayed up late nights conversing about the torment of war, the malnutrition, the angst of low-standing in military hierarchy – anything but the deaths of our peers and brethren.

Paul was not with me in Iraq. I was not with him in Europe. But like all stories, inspired of men who fought in war, we were ideologically linked. We did serve together. Blades have become bullets, catapults into cannons, shields into bullet-proof plates; the soldier has remained the same. The psychology of men who are dutifully tasked into the killing of other men or direct support of such cause will never change.

I am glad Paul and I got to know each other when we did. My return stateside from near daily rocket and mortar attacks, deadly roadside bombings, and the pervasive threat of death from snipers, was not a happy reunion. How does one remember to walk in an open field again and be gallant and without fear? How does one turn off a paranoid, high-intensity force within them that once guided their survival? How does one forget the faces of those that did not return and wear a smile again? How does one relate these feelings to those that did not dutifully serve?

I needed Paul. He was introduced to me by a good friend who knew of my plight.

"Take this," my good friend said after one of our drunken conversations. "Go home, and start reading it tomorrow."

Paul became my counselor and friend from the very first words he said to me. "This book is to be neither an accusation nor a confession, and least of all an adventure, for death is not an adventure to those who stand face to face with it. It will try simply to tell of a generation of men who, even though they may have escaped shells, were destroyed by the war." Paul's words were a symphony of sympathy to my burdened spirit.

We became best friends that day. I listened to his entire story.

We shared a morbid humor, one that only men who lived such lives could have. We laughed heartily and reflectively. We were unabashed to share things about ourselves with one another.

That day, we looked at each other with silent stares, our arms curled over our skulls, in prone positions on the ground as bombs fell over us. We boozed together and talked of death as our inhibitions waned.

We held hands as we returned home on a sojourn which felt like staying in an alien world. We shared ammo, food, and cigarettes. We did serve together, that day.

On my couch where I had not moved since I first listened to Paul, and the sunlight dissipated outside my patio window, I cried at the news of Paul's death. He was my best friend. He was me. He was my friends who did not make it back. He was every soldier who had ever served. I am glad I am alive to tell his story to anyone who needs to hear it – it is my new duty.

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Beware! Combat Rage

It still comes out sometimes. The combat rage. Usually at bars; other people get so plastered that they lose their filters. They will come to me with disrespect, being uncouth to one of my women friends or accosting me for no real reason. I’ve learned to be a peaceful man, but don’t doubt that beneath my wild beard and extra pounds of flab, the green, clean, killer-confident Marine still lies dormant.

You wouldn’t poke a stick against a serpent would you?

It’s the hardest part of the combat experience to erase – that warrior instinct to maim or kill at a moment’s notice. It’s part of boot camp: beat up the other Marine, knock off his helmet with your pugil sticks and get a phone call home.

It’s an aspect of weapons training: peer through your iron sites at the targets shaped like people; imagine what it’s like to violently end another human.

And it’s the most essential part of war: an explosion ignites, rack your machine gun and get ready to kill.

I used to spend a lot of times at bars because I was depressed and suicidal. Drinking allowed me to at least feel a burn, the flaming spirits torching my throat and charring my mind, which was something at least. Or maybe I’d just consume so much I’d never wake up again. That would have been fine too.

Now I drink however, because I have found a calm and joyous spirit, and I love to be social and spend time with my friends. I’ll have a few brews and laugh and watch sports. Or stay up late discussing philosophy and life and the lessons I’ve learned.

But I forget sometimes who I am really am – the warrior I was programmed to be – and the mental struggles of surviving battle that I may never entirely rise above.

A very muscular man with a shaped goatee, tried to take one of the chairs I had reserved for my friend, as I chilled with some old buddies at a bar a few days ago. He did this even though I reminded him when asked about the chair several times already, that “yes, my friend is coming. He’s just running late, man.”

“You sure you need this chair?” he asked yet again, jeering us, as he began to drag it away.

I slammed my palm against the table and leaned into him. “Take your hands off that f***ing chair.”

He stared back, deciding if he wanted to pursue a brawl. I’m sure he was way stronger than me, and maybe more trained. Who knows, maybe he was even a part time cage fighter. But I get blackout rage, this deeply ingrained caustic instinct that prevents me from feeling any pain when I’m mad. And I don’t think those who haven’t survived man versus man, life or death combat (or ever even had to consider their mortality) can really understand how that can be.

He backed off and returned to his group of friends, chair-less, and leaned against the bar. My friends stared at me awkwardly and my pulse still roared.

It was all the better for him though. I like to think of myself as a pacifist now, but I cannot shut off my nature. It’s in moments like these that the darkness returns. I pray I’m not pushed too far in these times. They are less and less frequent the further away I get in years from Iraq and war. But I know they’ll always remain.  

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