Integration of a Psychiatrist on a Military Physical Rehabilitation Unit
By Steven J. Davis, MD, DLFAPA
Davis is a long term member SDCMS member, currently retired.
He serves on PAVE’s Board of Directors
Reprinted from San Diego Physician Magazine, May 2014, pp 26-27
A therapy session at Walter Reed Army Medical Center (WRAMC) in Washington, DC began with: “Hey, Doc. Know what happiness is? Happiness is good health and a bad memory.” He entered on crutches with a left transtibial amputation and combat memories as a sniper. He had neither good health nor good memories. He had very little happiness.
In response to the attacks of 9-11, the United States embarked upon two wars, in Afghanistan (OEF) and Iraq (OIF). I had the unexpected privilege of working as a locum contract psychiatrist at Walter Reed from 2010 to 2012 at the height of aggressive combat when village foot patrols were at their highest. By then, we had been sending young men and women on multiple deployments for over nine years.
Whereas, in professional and popular writing, TBI and PTSD were the signature invisible OEF/OIF war injuries, at Walter Reed, the signature injury was traumatic amputation. 90-95% of amputee patients were admitted and treated at WRAMC. By the end of 2012, they had received and treated over 1700 amputee patients, generally carrying 150 active patients at any given time.
During the year 2011-2012, for the first time in military history, more than half exhibited multiple limb loss, including some triple and quadruple casualties. All required sophisticated tertiary level multidisciplinary team management. No one had been prepared for this carnage and military medical staffs at WRAMC and sister institutions were under continuous duress. Because of medical staff deployments, contractors filled the gaps.
The Psychiatric Consultation and Liaison Service (PCLS), under its chair, Hal Wain, PhD, evolved from a traditional C&L service into a bifurcated model. One arm served traditional complex medical/surgical patients while the second arm functioned as a pro-active early interventionist service committed to the support and behavioral health care for every wounded warrior and family within the first 24-48 hours of WRAMC arrival. It approximated battlefield medicine as it was not uncommon for the wounded to be only 36-72 hours removed from the originating trauma.
Hal creatively renamed the service as Preventive Medical Psychiatry and, with the support of the Physical Rehabilitation and Orthopedic Departments, I became physically embedded on the rehab floor itself (known as MATC – Military Advanced Training Center), consistent with the military field combat model of moving critical services forward. I was a constant presence and introduced my role as our name implied, Prevention is first and Psychiatry is last. Slowly, the Marines got it. I saw everyone.
PCLS interventions began on the hospital wards where grief and the miracle of survival were the earliest psychological and spiritual responses. The MATC embraced an aggressive sports medicine model and was an array of high tech weight, cardio machines and stretching mats, already familiar to these young athlete warriors. That I was physically embedded, fully integrated into the treatment team, and that I saw everyone (and their family) as they arrived on rehab, demythologized psychiatry, automated access, and mitigated stigma. I served three populations simultaneously, patient and family and staff, all staggered by challenging traumatic physical and psychological disorganization.
“Every morning when I get up I look at myself and I have no legs. I do it again when I go to bed at night. One of these days I’ll find a way to accept it… and I do, mostly.” He caressed his residual limbs through parts of the session.
On his first deployment to Afghanistan, R.S. stepped on a pressure plate IED and “woke up” in WRAMC with severe polytrauma. He suffered both L and R transfemoral amputations, an open pelvic fracture with elaborate external fixation, buttock and rectal lacerations, L orchiectomy, and multiple shrapnel pepper wounds. Extended intubation left him uncommunicative for weeks. “I want to be the first double AK to go back through Ranger training.” His was a common refrain, a longing to recover the competence he had briefly known, a wish to restore his career identity, and a wish to re-connect to his Army family. If only he could go back and start over.
Their stories of combat and trauma were molded to fit their psychological strengths, forgive their guilt for leaving their friends and the fight behind, and, in their constructions, preserve their self-esteem. It was never important that their story be fully accurate nor, given the presumed concussive neuronal effects of blast injuries, may that even have been possible. Over time, their “story” changed, but it always commemorated survival (their “alive day”) and became internalized and reorganized by its repeated retelling.
A young Marine with a high L transfemoral amputation and testicular and penile injury initially avoided talking about his injuries or the combat that led to them. Instead, he constructed his “story line” around a framework of competence and potency. He described in detail his very first combat encounter, not his last.
“Get away from me. You creep me out when you stand over me, like that.” He had a shrapnel peppered face, had high bilateral transfemoral amputations and loss of all digits except his thumb on one hand and loss of thumb and preservation of digits on the other. By any standard, he was grievously mangled. He projected how he believed he must appear to others. (Get away from me, I must creep you out. No one would want to talk to me. I’m so disfigured.)
The work could be arduous, but was continuously rewarding and inspiring. I had always understood honor and integrity, but these wounded taught me the fullness of sacrifice and brotherhood. It was their shared commonality that made the unbearable bearable. More than any staff intervention, it was love for each other (their brothers, a wounded mirror of themselves) that enabled recovery. Many not only survived, but thrived (Perhaps 20% of the recent USA Para-Olympic team were “graduates” of Walter Reed).
I kept personal notes, case vignettes, and periodically still reflect on two remarkably unique years, unknown except to those who have served during these and past periods of combat. To work alongside that dedicated and talented staff has been a career pinnacle. One Physical Therapist had remarked that “it was like working in the NFL,” nothing else in her career (or mine) would ever match the stakes, intensity, or professionalism. I was more often a quiet observer than an active therapist. I listened, bore witness, offered validation and countered with respect. They gave more to me than I gave to them.
I was an accident of place and moment in our nation’s history. A unique and unforgettable witness. I encourage you to read any account of wartime medicine.