HIDDEN WOUNDS • PART I
Soldiers’ silent war
Vets live with the devastating effects of brain injuries and stress
STORY SUMMARY »
The happy homecomings are splashed on the news. Troops fresh off the plane from Iraq and Afghanistan scoop up their spouses and children in joyous hugs.
But the story doesn't end there.
Angry outbursts. Nightmares. Thousand-mile stares. Memory lapses. Disintegrating marriages. The "invisible wounds" of war are cropping up in this newest generation of veterans, sometimes long after they come home. Left untreated, they can spiral into despair.
"For too many veterans, returning home from battle will not bring an end to conflict," said U.S. Sen. Daniel Akaka, chairman of the Senate Committee on Veterans' Affairs. "The war will follow them in their hearts and minds."
Duty in Iraq and Afghanistan exposed American troops to a constant threat of explosions from an elusive enemy. The impact of the blasts reaches beyond the horror of the immediate carnage. The trauma lingers in unseen brain injuries and damage to psyches that might not show up for months or years.
About 95 percent of Hawaii Army National Guard members have served in Iraq and Afghanistan, and officials are stepping up outreach to find and help those who might have returned with hidden brain injuries. Some symptoms -- such as irritability and impulsivity -- overlap with those of post-traumatic stress disorder.
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"Only in the last two years has there been recognition of the incidence and impact of post-concussive syndrome. It is something new in our combat experience."
Dr. Kenneth Hirsch
Manager for the Traumatic Stress Disorders Program at the Spark Matsunaga VA Medical Center
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Hidden wounds that haunt the minds of soldiers can slip by undetected.
"You know the problem with the Polynesian warrior tradition," said Maj. Gen. Robert Lee, commander of the Hawaii National Guard. "We're tough, we can take it, I'm OK, let me go home."
Trained to be stoic and self-reliant, troops returning from combat with mental or emotional problems are often reluctant to acknowledge that something is wrong.
Short fuses, sleep disruption and difficulty concentrating could be lingering effects of life in a war zone, or they could be symptoms of two deeper problems, one psychological, one physical.
Post-traumatic stress disorder, which scars soldiers' psyches, became well known after the Vietnam War. Traumatic brain injury, a physical blow to the head as from a blast, has been dubbed "the signature wound" of the wars in Iraq and Afghanistan.
On April 14 the Department of Veterans Affairs began screening Iraq and Afghanistan veterans for symptoms of traumatic brain injury -- even those coming in for a dental checkup.
VA officials said last week that of the 61,285 veterans screened so far, more than 19 percent screened positive and are being evaluated to see if the symptoms are due to brain injury or other ailments.
Previous studies have shown that up to 25 percent of Iraq veterans have developed post-traumatic stress disorder or significant symptoms of depression and anxiety.
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"Because of stigma, many people are afraid to go get help. They want to be seen as strong. They don't want to see a mental health professional."
Deputy director for education at the National Center for Post-Traumatic Stress Disorder in Honolulu
is considered a key to recovery from these invisible wounds that soldiers are bringing home from the front. But veterans often struggle on their own, unaware or unwilling to admit they need care.
"Because of stigma, many people are afraid to go get help," said Julia Whealin, deputy director for education at the National Center for Post-Traumatic Stress Disorder in Honolulu. "They want to be seen as strong. They don't want to see a mental health professional."
"They don't understand how easy it is to treat some of these problems as long as they're caught early," she said. "Getting help for those symptoms now will make a big difference."
Recognizing the problem, the Army recently launched a program to train every soldier in the force, from top to bottom, on symptoms of the two ailments.
"PTSD and mild traumatic brain injury, or concussion, are wounds of war that aren't visible, so sometimes we miss them," said Col. Elspeth Cameron Ritchie, M.D., psychiatry consultant to the Army surgeon general. "It's critically important that all soldiers be able to recognize these unseen wounds of war, both to help their buddies and to help themselves."
Previously known as "combat fatigue" and "shell shock," PTSD is a psychological condition that can develop after a harrowing ordeal, causing flashbacks, nightmares, panic attacks and hyper-arousal, or feeling "on edge."
Traumatic brain injury is a neurological condition caused when the head is hit or violently shaken, as in a blast. It can lead to post-concussive syndrome, which impairs memory, concentration and decision-making and can trigger anxiety and anger.
"Only in the last two years has there been recognition of the incidence and impact of post-concussive syndrome," Dr. Kenneth Hirsch, manager for the Traumatic Stress Disorders Program at the Spark Matsunaga VA Medical Center. "It is something new in our combat experience."
"Some of its symptoms are identical to some of the symptoms of PTSD, such as irritability and impulsivity," he said.
Unlike an open head wound, mild traumatic brain injury can play out in subtle changes that can elude observers who do not know the soldier well.
North Shore resident Ariana Del Negro says she had to advocate for her husband, Army 1st Lt. Charles Gatlin, for several months before finally getting the care he needed, in part because there was no physical evidence of his brain injury.
COURTESY ARIANA DEL NEGRO
Ariana Del Negro, right, whose husband suffered a traumatic brain injury while deployed in Iraq, flew to Washington, D.C., last month to urge the Senate Committee on Veterans' Affairs to boost support and care for wounded soldiers and their families. Here she greets Hawaii Democrat Daniel Akaka, the committee's chairman.
Post-Traumatic Stress Disorder is a condition that may develop after a traumatic ordeal that involved actual or threatened serious injury or death. |
» Nightmares, flashbacks, reliving the trauma
» Anxiety and panic
» Feeling keyed up or on-edge
» Irritability, anger
» Difficulty concentrating
» Avoidance of reminders of the event
» Feeling numb or detached
» Difficulty relaxing or sleeping
» Feeling depressed, sad, guilty
Mild Traumatic Brain Injury or concussion is caused when the head is hit or violently shaken, affecting brain function. It may have no physical signs but cause serious symptoms.
» Headaches or ringing in the ears
» Difficulty organizing daily tasks
» Impaired memory, concentration, decision-making
» Slowness in thinking, speaking, acting
» Fatigue, change in sleep patterns
» Irritability, anger
» Feeling sad, anxious or listless
» Vision problems, sensitivity to light
» Dizziness, nausea
Sources: Department of Defense Force Health Protection & Readiness; U.S. Department of Veterans Affairs
The Defense and Veterans Brain Injury Center treated 4,216 patients from January 2003 to August 2007. Of those:
Moderate to severe brain injury
Mild traumatic brain injury
Source: Defense and Veterans Brain Injury Center
"There was no swelling, no leakage," said Del Negro, a medical editor. "His CAT scans were negative." But the Army Ranger suffered from debilitating headaches, chronic vertigo, memory lapses and anxiety, and later developed a stutter.
Gatlin was less than 20 yards away when a 7,000-pound car bomb exploded on Sept. 28, 2006, in Kirkuk, Iraq. He was thrown into the air, then struck on the back of his head by the vehicle's flying engine block, before falling flat on his back on the ground.
The scout platoon leader spent three days in intensive care at Balad Military Hospital and tried to return to duty, but was sent home to Hawaii because of the mental fog of his closed-head injury. "He began to withdraw socially, avoiding public and busy areas," Del Negro said. "His time was mostly spent sitting, staring blankly. My husband is an exceptionally accomplished and strong individual, and it was very hard for me to see him struggle with simple tasks."
At Tripler Army Medical Center, she had to push for diagnostic tests and referrals to specialists, she said, and ended up getting conflicting advice. One doctor questioned whether Gatlin was simply shirking his duty.
Del Negro did her own research and eventually got her husband referred to Balboa Naval Medical Center in San Diego, where he received intensive, coordinated care and learned to compensate for the lingering effects of the blast. As a result, she said, "we managed to survive as a family." He still suffers from intermittent headaches, vertigo and memory problems but has returned to work in an administrative job at Schofield Barracks.
Del Negro worries about other military families who might not get the help they need because they lack her medical background, job flexibility and willingness to speak out. "These families need immediate access to resources, they need advocates and they need support," she said.
Surveys by the Defense and Veterans Brain Injury Center show that 10 percent to 20 percent of returning soldiers could have mild traumatic brain injury, said Chuck Dasey, public affairs officer at Walter Reed Army Medical Center, headquarters of the brain injury center.
About 10 percent to 15 percent of soldiers have developed post-traumatic stress disorder after deployment to Iraq, and another 10 percent have significant symptoms of depression, anxiety or post-traumatic stress, according to Col. Charles Hoge, M.D., director of the division of Psychiatry and Neuroscience at Walter Reed Army Institute of Research.
BY THE NUMBERS
Percentage of Hawaii Army National Guard members deployed since 9/11
Members of the Hawaii National Guard who have served in Iraq and Afghanistan
Sources: Hawaii National Guard
disorder and traumatic brain injury can be compounded with long and repeated tours of duty and exposure to multiple explosions or trauma, as in Iraq and Afghanistan. Due to better armor and advances in military medicine, more injured soldiers are surviving horrific experiences rather than dying in the field.
"In many cases it takes years for these invisible wounds to present themselves, and many service members do not immediately seek care," said U.S. Sen. Daniel Akaka, chairman of the Senate Committee on Veterans Affairs.
The Hawaii Democrat is sponsoring legislation to expand the window of time that a soldier has to seek care from the Department of Veterans Affairs to five years from two years after release from active duty. His amendment to the National Defense Authorization Act passed the Senate unanimously in July. He also is pushing to improve treatment for veterans with brain injuries.
"The VA was caught flat-footed by the large number of devastating TBIs resulting from the conflicts in Iraq and Afghanistan," he said.
Until last year there was no screening tool for traumatic brain injury on health forms filled out by returning Hawaii National Guard members, Lee said. The Guard is going back and rescreening everyone who left the force before the questions were added.
The Iraq and Afghanistan Veterans of America, a nonpartisan advocacy group, fears that many veterans are still being missed despite the VA's new screening effort.
"Only one-third of people eligible are actually using the VA," said Patrick Campbell, who served with the National Guard in Iraq and now is legislative director for the nonprofit organization. "A lot of National Guard soldiers don't think of themselves as veterans. As soon as you're not on active duty, you need to enroll with the VA."
The nonprofit group calls for mandatory, confidential counseling sessions with mental health professionals for all troops within 90 days of finishing a combat tour, not just filling out health assessment forms on paper. And it recommends regular follow-up calls.
"We know that up to one-third of Iraq and Afghanistan vets are going to have some type of adjustment problems," Campbell said. "We need to cast a much wider net to get these people into care."
The consequences of brain injuries from explosions such as the homemade bomb that struck Gatlin are more complex than the typical sports-related concussion.
"With a blast injury, it is not a single insult," Hirsch said. "There's the auditory blast, which can damage your hearing and therefore your balance system. There's the physical blast, where you're pushed. There's the heat injury if you're close enough.
"There may be a reverse blast as the air rushes back toward the point of explosion," he said. "You may be buffeted enough that your body or your head is knocked against something solid like your vehicle. There may be multiple insults from a blast injury, which is typically not the case with a sports injury. Also, you may have recurrent exposures."
Treatments for mild cases of traumatic brain injury are still being tested. Patients are taught to compensate for impairments, such as trouble remembering things, by using tools such as 3-by-5 cards or electronic memories, and establishing routines and habits to help them remember to do things, Hirsch said.
"Research has focused on the moderate to severe traumatic brain injury, but the huge majority of people we are seeing now are in the mild category," Hirsch said. "We're still starting to learn how to treat mild post-concussive syndrome."
Treatments for PTSD are better known, helping people come to grips with their emotional trauma using coping skills, in-depth discussion, therapy and group support. Medication is used to reduce anxiety, depression or insomnia.
At the Honolulu Vet Center on Kapiolani Boulevard, which offers readjustment counseling, Director Stephen Molnar takes a long view toward the fallout from the Iraq and Afghanistan conflicts.
"We're going to live with this for the next 50, 60 years," said Molnar, a Vietnam veteran who helped open the Vet Center in 1980. "It isn't just the physical injuries. It's the wounds of the heart. When this war ends, it's just the beginning of where we're going."
Tyrone Vesperas, left, a career National Guardsman, is accused of attacking his wife with a combat knife and fatally stabbing his 14-year-old son, Tyran Vesperas-Saniatan, right, when the boy tried to save her.
Big Island slaying prompts veterans to seek help for postwar stress
When Hawaii National Guardsman Tyrone Vesperas left for Iraq, he wept as he kissed his children goodbye, tenderly hanging leis around their necks.
"When he left, he was like one pussycat -- he cried, he hugged his children," said his father, Frank Vesperas. "When we gave him lei, he put them on his children."
Seventeen months after he got home from the war, Tyrone Vesperas allegedly attacked his estranged, pregnant wife with a combat knife at the home they once shared in Ainaloa on the Big Island. His 14-year-old son Tyran intervened to save his mother, and sacrificed his own life, Vesperas later told police.
Vesperas appeared in court June 14.
"My dad stabbed me in my neck," the teenager said in a frantic call to 911 on June 11, gasping for breath. "Please call police. Please come." His labored breathing then faded into silence.
What pushed Vesperas, 38, over the edge isn't clear. He and his wife had separated, and she was almost ready to give birth to another man's child. It could simply have been a crime of passion.
Public defender Michael Ebesugawa declined to say whether he would use the psychological aftermath of combat in defending Vesperas. But sudden fits of rage can be a symptom of post-traumatic stress disorder, along with flashbacks and depression.
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William "Clay" Park, veterans specialist for Helping Hands Hawaii, said a lack of emotional control can be symptomatic of post-traumatic stress disorder. "With major PTSD their coping skills just go downhill big time," he said. Park, a Vietnam veteran, counseled National Guard members on the Big Island after the Vesperas tragedy. Here he visits Sherwood Forest in Waimanalo in hopes of finding and helping other veterans.
"Why is it that this man ended up killing his son and his wife's unborn child?" asked William "Clay" Park, a veterans' specialist for Helping Hands Hawaii who spent 21 years with the Hawaii National Guard. "The anger, he couldn't control that. With major PTSD, their coping skills just go downhill big time. They can't cope."
The case shook the Hawaii Army National Guard, where Vesperas worked full time as a technician and staff sergeant. A Hilo High School graduate, Vesperas had made a career of the Guard, signing up at age 18 and recently marking his 20th anniversary on the force.
He now faces charges of second-degree murder in the death of his son, Tyran Vesperas-Saniatan, and attempted first-degree murder in the attack on his wife, Cheryl Saniatan, who was stabbed repeatedly in the abdomen and lost her baby. He is being held at the Hawaii Community Correctional Center and could face life in prison.
His father did not want to talk about the case for fear of affecting the trial, but said Tyrone was a doting father to his two children, and often surfed and played ball with Tyran.
"He loved his son. He was with his son all the time," Frank Vesperas said. "It is the last thing he would ever have done."
National Guard officials say the disaster spurred others to seek help for problems adjusting to ordinary life after returning from the war zone, from road rage and irritability to alcohol abuse and marital discord.
"The phones were ringing off the hook," said Lt. Col. Laura Wheeler, State Family Program director for the Hawaii National Guard. "I was already pretty busy. It had to take something like this to get the real hidden people out. It saddens me that it takes a tragedy for people to reach out."
After Tyran was killed, the Guard set up counseling sessions on the Big Island and held more briefings to encourage veterans of Iraq and Afghanistan to take advantage of services they have earned, such as VA health care. There is a two-year window to sign up for free health coverage with the VA, but most members had not done so yet --18 months after their return.
"Once this incident happened, I guess it opened our eyes," said 1st Sgt. Allison Yano, of the Hawaii Army National Guard in Hilo. "Help is out there if we want to go get it. A lot of people started registering. After the incident, I set up some counseling sessions for our co-workers. That seemed to have drawn more people out to open up, which was real good."
Park, who taught at the National Guard Training Institute before joining Helping Hands, flew to the Big Island to give one of the briefings -- and is glad he did. After the session a former student approached him.
"He told me, 'Whatever happened to that guy that killed his son is happening to me now,'" Park said. "He was having marital problems. He said, 'I'm not going to do something stupid, but I'm looking at getting a divorce.'"
"Soldiers are told to ease back into the system, let the family run stuff," Park said. "They had been back a year and a half, and when he started voicing his opinions, his wife would tell him, 'Yes, sir! Yes, sir!' and he would just go downhill."
Park connected him with a counselor at Helping Hands and with the local Vet Center, an informal drop-in center that provides free, confidential readjustment counseling to veterans. Park specializes in helping veterans navigate the benefits bureaucracy, and his caseload keeps growing, with calls from families on various islands concerned about their soldiers' behavior.
In August, U.S. Sen. Daniel Akaka, the Hawaii Democrat who chairs the Veterans Affairs Committee, held hearings in Hawaii on veterans' care and benefits. At the Kona hearing, Yano called for making enrollment in the Veterans Affairs health system a mandatory part of demobilization, to help ensure that those who need help get it.
"A vast majority of combat veterans failed to receive early intervention," he testified. "We are only now getting our soldiers enrolled."
Maj. Gen. Robert Lee, commander of the Hawaii National Guard, said part of the problem is that Guard members are unlikely to acknowledge behavioral health problems that they think could delay family reunions or affect their jobs.
"We want to say, 'That's OK, it's not going to hurt your career, affect your promotion and all,'" he said.
Wheeler said an array of help is available, ranging from confidential counseling to free marriage enrichment retreats that include two nights at a hotel. "We've got tons of services now. They may not be utilizing them as much as they need to."
Since 2003, when Wheeler ran a one-person office with volunteers at Fort Ruger, the Guard has opened Family Assistance Centers on the Big Island, Maui, Kauai and Oahu, and recently added a mobile team. The staff is now up to 10, offering intervention, information and referral.
"They provide support to anybody who walks in that door," she said. "They don't have to be National Guard. They could be retirees. We've had families whose soldier is active-duty on the mainland. We won't turn anybody away."
"They can seek confidential counseling if they don't want to see a military person like me," she said. "We can refer them. We can have very creative treatment plans."
"The bottom line," she said, "is safety first. We want to make sure the service member and their families are taken care of."