PTSD: Facing the Monster

The sound of a helicopter hovering above a Boston park snapped Maj. (Dr.) Derek Speten's thoughts from a relaxing day with his family back to a trauma bay in Iraq. For Capt. Kevin Lombardo, the sight of blood on his face in a recurring nightmare convinced him his mind was still struggling to cope with witnessing a deadly rocket attack on a Humvee. Master Sgt. Justin Jordan found himself disassociating for hours and driving 20 mph on an Albuquerque interstate.
Their symptoms and triggers may vary, but all three men were among the many Air Force members who have experienced post-traumatic stress disorder after returning from deployments in Afghanistan and Iraq.

"Something's going to trigger it," said Dr. Speten, commander of the 66th Medical Group Diagnostics and Therapeutics Flight at Hanscom Air Force Base, Mass. "That trigger could be a smell or a sound. You might hear a helicopter or the backfire of a muffler and see somebody jump to the ground and lie there for a second. Other people may laugh and think it's funny, but the thing that's not funny is that person has gone back to their trauma."

When Dr. Speten first saw the two Soldiers who were brought to the Joint Base Balad hospital trauma bay after being hit with an improvised explosive device Feb. 14, 2007, he initially thought his patient's wounds weren't as severe as the other patient's. The Soldier had third-degree burns, but he'd applied tourniquets to his companion's leg to keep him alive until they could reach the trauma bay.

When Dr. Speten looked into his patient's throat, he saw the Soldier was severely burned internally. the doctor's head trauma surgeon decided the burns weren't survivable, so the patient was moved to end-of-life comfort care. While they know they're easing the patient's suffering, playing a role in end-oflife comfort care is usually traumatic for any medical professional, Dr. Speten said.

"It's psychologically devastating to most people who are involved in it because you're in the career field to save people, not to euthanize patients out in the combat zone," he said. "You want to save everybody. The problem you have is you don't get that opportunity all the time. You just have to remind yourself you're not the reason they're there."

Before the patient was moved, he told Dr. Speten he didn't want doctors to cut off his wedding ring. Because the doctor didn't yet know the severity of the injuries, his main concern was the risk of cutting off circulation and losing the finger. This would haunt him later after he returned from Iraq.

"Before I looked into his throat and saw what his airway looked like, I would've thought he was going to come out of that trauma bay," Dr. Speten said. "The guilt factor came in for me when I had to stop him in midsentence. I told him we needed to secure an airway and he could tell me everything once he woke up. The problem was he didn't wake up."

Thirteen months after Dr. Speten treated the IED victim, on March 12, 2008, Captain Lombardo responded to an attack on an armored Suburban near the main gate at Contingency Operating Base Adder in Iraq. The attack killed three of the five Soldiers in the vehicle, but Captain Lombardo, an Air Force security forces officer serving as provost marshal for the base, saved one of the two survivors. He moved Army Sgt. Joel Tavera a safe distance from the truck, put a tourniquet on his leg and talked with him for the next half-hour to keep him conscious.

Later, Captain Lombardo dealt with the aftermath of the attack, including a memorial service for the three Soldiers killed in the explosion. Several months after he'd returned to his home station at Peterson Air Force Base, Colo., he began to feel the emotional repercussions of seeing three comrades die so violently. The captain felt guilty because he wasn't able to save all five soldiers. He knew he was suffering from PTSD symptoms, but he was concerned the stigma would put his security clearance and ultimately his job in jeopardy. Recurring nightmares of blood streaming down his face, explosions and soldiers dying convinced him to get help.

"The smell, sounds, sights, touch and even taste are still there from that day," said Captain Lombardo, now the Security Forces Academy director of operations at Lackland Air Force Base, Texas. "You go from being in Iraq to the normal day-to-day setting on an Air Force base. Physically, I was fine, but I knew I wasn't as mentally sharp as I was."

Recent Air Force efforts to address PTSD include the Virtual Reality Exposure Therapy Application for Post-traumatic Stress, now available at mental health clinics at Andrews, Eglin, Elmendorf, Lackland, Langley, McGuire, Travis and Wright- Patterson Air Force bases. The virtual-reality program addresses the patient's avoidance to re-visit violent and other unpleasant memories from their trauma. In a controlled setting with a therapist's guidance, patients put themselves back among the sights, sounds and smells of the original trauma with either a scene of a foot patrol in an Iraqi city or a Humvee convoy in Afghanistan or Iraq. Therapists can add in sounds of helicopters, explosions and dogs barking and even smells such as burning rubber, body odor, diesel fuel, and weapons firing.

"The intent is to be able to utilize a variety of senses whenever you're doing the exposure," said Dr. Kellie Crowe, director of Wilford Hall Medical Center's PTSD Clinic at Lackland. One of the PTSD clinic's missions is to train psychology interns in PTSD treatment, so they can treat it at their next duty station and in Afghanistan and Iraq, Dr. Crowe said.

"Some people are unwilling or unable to do the imagining part that's necessary," she said. "The virtual reality assists those people in bringing back those senses. Avoidance is the primary symptom that maintains PTSD. This kind of puts it right there in front of them and allows the therapist to work with them to start abating that emotional distress."

Sergeant Jordan's PTSD service dog, an English bulldog named Dallas, helps him fight the avoidance behaviors he's learned are part of his PTSD. Before he became the Air Force Inspection Agency's lead checklist program manager at Kirtland Air Force Base, N.M., the sergeant worked on numerous mortuary affairs cases at Davis-Monthan Air Force Base, Ariz.

"On my last deployment, I sent 71 guys home in a box," he said as Dallas slept at his feet on the floor. "You just have to put it into a place in the back of your brain."

The one death Sergeant Jordan couldn't compartmentalize happened in September 2007 when a friend was killed in a forklift accident on base. He sought help and was treated with a form of rapid eye movement therapy. He thought he'd put his PTSD behind him after he left his mortuary affairs duties for the AFIA assignment, but within months after arriving at Kirtland, he witnessed a shooting at a building just outside the base gate. Two people were killed and four were wounded before the shooter killed himself.

"It reverted me right back to where I was, and the flashbacks were worse," Sergeant Jordan said. "I was driving home 20 mph down the highway because I was positive the tires were going to pop. It seems silly and juvenile, but you could be sitting right next to me and tell me, 'Dude, everything's going to be fine.' It wasn't going to be fine to me. This was about to happen now.

"The overwhelming thing that I think we all have in common is the unwillingness to want to have PTSD. Everyone of us expresses guilt because as young men and women, we're taught to suck it up and quit being less of a man or woman. With PTSD, that's impossible."

Just as the original traumatic events that trigger PTSD and the symptoms vary, each patient responds differently to treatment. The two most common effective types of treatment, according to a number of PTSD experts, are cognitive processing and prolonged exposure therapy. The WHMC PTSD Clinic staff predominantly has used these approaches with the approximately 170 patients who have been treated.

Cognitive processing allows patients to understand how their thoughts about what happened can intensify their symptoms. Often, this helps patients who somehow blame themselves for a traumatic event. Through exposure therapy, patients learn to change how they react to painful memories.

"Both therapies are exposure-based," Dr. Crowe said. "Prolonged exposure has the individual access the memory, both in imagining while in a session with the provider, but also in real life, where they go out and do homework assignments to start re-engaging in things they were avoiding, like restaurants and movie theaters. That allows them to build confidence in reintegrating back into the things they enjoy.

"The face of PTSD has changed so much. PTSD is treatable, and we have evidence-based treatments to support that. Generally, there's not a career impact just from seeking treatment. The career impact comes when the symptoms get out of control. It would be unfortunate for someone to get to that point when there are treatments available."

Sergeant Jordan has found that his PTSD service dog, which was trained through the Paws and Stripes nonprofit organization, helps him curtail his symptoms before they can get out of control. He received permission from the AFIA commander to bring Dallas to work each day. Dallas has her own area near Jordan's desk and will tug on his shirtsleeve several times an hour to keep him from "zoning out."

"She can sense my brain chemistry," Sergeant Jordan said. "When it changes, if I'm having an attack, she'll climb in my lap or bark at me because it scares her. She won't let me stay in that situation. A lot of times, I have to keep her calm, so I can't go to that place."

Both Dr. Speten and Captain Lombardo benefitted from cognitive processing therapy as they gradually accepted their PTSD. With Dr. Speten, the breakthrough came when he found a therapist who'd actually experienced life in a war zone. They also each found something they considered special outside of counseling that had a direct impact on their recovery.

Captain Lombardo built a friendship with the Soldier he saved and found himself inspired by Sergeant Tavera's attitude through his long rehabilitation and numerous surgeries. Through his own therapy, Captain Lombardo learned the blood on his face in his recurring nightmare belonged to Sergeant Tavera. On the day of the attack, a firefighter poured a bottle of saline over his head and hands to wash blood from his face after the sergeant was taken from the scene.

"His inspiration and fight made me realize I needed to stop second guessing myself for that day," Captain Lombardo said. "Obviously, you have that line with officer and enlisted. The line's still there with us, but it merged a lot on March 12, 2008, just as the line did between Army and Air Force. He's my new wingman, and I'm hopefully his battle buddy now."

Dr. Speten took the wingman concept to a new level after losing his patient in the Balad trauma bay. When he learned the Soldier had been an avid runner who dreamed of running the Boston Marathon, Dr. Speten decided to run the race in his honor. The doctor trained for more than a year and competed in seven smaller marathons before he finished the Boston Marathon in April 2010. Whenever training became tough, he thought of the Soldier who'd not only endured a horrific attack before succumbing to his injuries, but helped save the life of his companion by applying tourniquets to his partially severed leg.

"Whenever I thought about quitting, I just thought about what this person went through," Dr. Speten said. "Then, [my discomfort] became almost insignificant. It actually made me feel better and I think it was part of the healing process."

After Dr. Speten completed the race, he mailed his Boston Marathon jersey, T-shirt and medal to the Soldier's family. He continues to run races in honor of fallen service members and often runs with his 5-yearold son in a stroller in some of the smaller events. He believes this also has helped his recovery.

"Whenever you get deployed, your family's on the back burner, and when you come back, it's nice to be able to do something that allows you to be involved with them," Speten said. "He doesn't need to know why right now. He understands that we run, and we'll give the medals to people who are deserving of them. Every time we do this, it gets people out there to know that there are people still coming back. These are people who had goals and dreams, and they're not just going to go away. Just because that person is no longer here to compete it doesn't mean somebody else can't pick up the torch and carry it for them."

One thing Airmen returning home from deployments can learn from stories like those of Dr. Speten, Captain Lombardo and Sergeant Jordan is to be proactive about their own treatment. Active-duty members can request an evaluation at their mental health clinic and have rights to confidentiality as long as they do not pose a threat of injury to themselves or others, Dr. Crowe said.

Simply because Airmen haven't identified symptoms yet doesn't mean they escaped unscathed from trauma they experienced or witnessed. The worst thing they can do is to try to hide their challenges for fear of losing their career, family and friends. After finding the help they needed, Captain Lombardo found peace when he learned the source of the blood in his disturbing dreams and Dr. Speten is no longer afraid of helicopters.

"It's a scar," Dr. Speten said. "Somebody's put holes in me, and you can't cover them up. The holes are still visible, but it doesn't affect how I live the rest of my life."