Wounds Unseen Prove Just as Deadly to Troops

Wounds unseen prove just as deadly to troops


Suicides renew focus in military on alleviating toll of combat stress





12:00 AM CST on Sunday, December 4, 2005


By DAVID McLEMORE / The Dallas Morning News



Not all the wounds received in Iraq are visible. Not all the combat deaths occur on the battlefield. For Capt. Michael Pelkey, the war followed him home.


After a year in the Persian Gulf region, Capt. Pelkey returned to Fort Sill, Okla., in July 2003. He quickly immersed himself in a new job and began getting reacquainted with his wife and infant son.


Then came the terrifying nightmares of the death and destruction he had seen in Iraq – and the inexplicable anxiety he felt in the safety of home. He grew forgetful. He began sleeping with a loaded 9 mm handgun.


On Nov. 5, 2004, a week after an off-post therapist determined that he had post-traumatic stress syndrome, Capt. Pelkey shot himself in the chest and died.


"Michael wasn't in Iraq, but in his mind, he was there day in and day out," said his widow, Stefanie Pelkey of Spring, Texas. "He'd never discuss the details of his experiences in Iraq, but they changed him forever. What killed my husband was a wound of war."


Since combat operations began in Iraq in March 2003, 45 soldiers have killed themselves in Iraq, and an additional two dozen committed suicide after returning home, the Army has confirmed.


And while no one knows precisely what pushes someone over the edge, the unresolved stresses of combat on the soldier's heart and mind are a factor.


The Army surgeon general estimates that 30 percent of returned Iraq veterans showed signs of some mental stress three to four months after coming home. The 2004 Army Mental Health Advisory Team survey, while showing improved unit morale in Iraq over the previous year, also showed that nearly one in five U.S. combat soldiers had acute post-traumatic stress syndrome.


"This is the froth of the wave. The big numbers are coming," said Steve Robinson of the National Gulf War Resource Center, an advocacy organization for veterans of conflicts in the Persian Gulf region. "It took years for the severity of PTSD among Vietnam veterans to show up. If we don't give the soldiers the help they need, such as face-to-face counseling, we're cheating them of a debt owed."


Another Army study, published in The New England Journal of Medicine, found that 17 percent of U.S. combat troops, including Army and Marines, experienced major depression and combat stress, the highest rate since Vietnam.


Twenty-three to 40 percent of those with post-traumatic stress disorder sought help, according to the Army study. And some 65 percent of those questioned said they worry that if they asked for help, it would make them look weak or affect their military careers.



Taking care


The military is keenly aware of the mental health need and the potential for numbers to increase. More mental health workers are serving in line units in Iraq. Commanders of units destined for Iraq and Afghanistan are urged to give soldiers and their families information on the effects of post-traumatic stress disorder before and after deployment.


All returning soldiers go through mandatory screenings, though they vary from commander to commander. And the Army is sending more mental health teams to Iraq to work more closely with soldiers in the field.


"We recognize that it is in our best interest to decentralize mental health care. For the wounded sent stateside, it's presented as just another part of the care. We can provide some confidentiality," said Col. Lorenzo Luckie, chief of behavioral medicine at Brooke Army Medical Center in the San Antonio area and a consultant with the Great Plains Army Regional Medical Command.


For those still overseas, the Army is improving access to mental health workers and making mental health care "more visible to commanders as a source of help," he said. "We hope that leadership will present mental health care as something safe and without negative effects on career."


National Guard and reserve soldiers, who make up half the troops in Iraq and Afghanistan, show higher rates of post-traumatic stress. But once deactivated and sent home, they must fall back on the Department of Veterans Affairs for treatment. According to VA data, 9,600 of the 360,000 soldiers discharged after fighting in Iraq and Afghanistan have received a provisional diagnosis of post-traumatic stress disorder.


"We're a lot better able to assess needs now than we were for Vietnam," said Dr. Larry Lehman, chief psychiatric consultant with the Department of Veterans Affairs in Washington. "We hope to identify the psychological and social problems resulting from combat stress before they harden into mental disorders."


Critics of the VA, however, aren't convinced. On Veterans Day, retired Marine Gen. Joseph Hoar, a former commander in the Middle East, called on the federal government to strengthen its health care system for veterans.


"President Bush has consistently refused to provide enough," Gen. Hoar said. "Earlier this year, his administration admitted they were $1 billion short in funding for critical health care services. Thousands of veterans returning from Iraq and Afghanistan will require mental health care, yet the Bush administration has not taken action to deal with this emerging problem."



Lacking resources


In April, the Department of Veterans Affairs acknowledged it had underestimated medical care costs, requiring Congress to approve an additional $1.5 billion in emergency funds for this budget year.


Congressional leaders said the additional money would correct underestimations by the VA of the number of veterans seeking care, as well as increased costs of treatment and long-term care. But Congress also found that the VA had not taken into account the additional costs of caring for veterans injured in Iraq and Afghanistan.


Veterans in several states have found that Veterans Affairs had to stop scheduling appointments because of a lack of staff or a shortage of funds, said Mr. Robinson of the National Gulf War Resource Center.


"For the Guard and reserve, it's particularly bad," he said. "Their soldiers are separated from the Defense Department support system almost immediately after deployment and sent home to VA hospitals and clinics that are already overwhelmed and backlogged.


"We have to recognize the need and provide help, not wait for the veterans to ask."


U.S. Rep. Silvestre Reyes, D-El Paso, is also concerned. He cites a study in General Hospital Psychiatry that VA primary care clinics recognized less than half of the cases of post-traumatic stress distorder identified by researchers.


"Just as a bullet can destroy limbs, warfare can injure one's psyche," Mr. Reyes said. "PTSD is a serious war wound that requires serious treatment."


As a member of the House Veterans' Affairs Committee, Mr. Reyes has joined in legislation that would provide a more structured, comprehensive approach to addressing post-traumatic stress and other mental health needs, including cross-training to better screen for the disorder and the development of a joint VA-Defense Department plan to advise clinicians on state-of-the-art diagnosis and treatment.


Veterans Affairs officials said they have already placed VA liaisons in military hospitals to make the transition from one level of care to another seamless, Dr. Lehman said.


In January, the Pentagon announced it would begin health assessments of military personnel three to six months after redeployment, focusing on support to those needing assistance with post-traumatic stress disorder and psychological and social readjustment issues.


"This new initiative is designed to assist service members who have returned from areas of combat operations to ensure their health and well-being," said Dr. William Winkenwerder, assistant secretary of defense for health affairs. "We have the capacity and the desire to manage these issues proactively."


The screenings, set to begin in the spring, will include active-duty soldiers and National Guard and reserve forces returning from combat tours.



Michael's decline


Mrs. Pelkey, who also served in the Army, testified in July before the Senate Veterans Affairs Committee on how her husband wrestled with his wartime demons before killing himself.


Just before his departure for Fort Sill, he expressed concerns about emotional conflicts to a doctor in Germany. The doctor referred him to a counselor. But on-post counselors were so understaffed that they couldn't see him before he left five days later.


At Fort Sill, the pressures of everyday life – a new house, a new baby and new jobs – pushed treatment to the back burner.


And things seemed to be normal again, Mrs. Pelkey said. When the restlessness, insomnia and other early symptoms of post-traumatic stress disorder popped up, neither Michael nor his wife recognized the signs.


"We were both officers. These were things we should have known but didn't. We hadn't been made aware of what to look for," Mrs. Pelkey said in a phone interview. "There had been no debriefings for family members or forced evaluations in Germany. The post-deployment evaluation was more a check-of-the-box and move on."


At Fort Sill, Capt. Pelkey sought medical help but was discouraged that appointments were sometimes a month away. The family contacted Tricare, a program that lets military families use civilian medical care, and were told the only outside therapy available was "family therapy." They took it.


Over the next two weeks, Capt. Pelkey was told that he had post-traumatic stress disorder and that help was available.


"He was really happy," Mrs. Pelkey said. "Help was on the way."


A few days later, he was found on the couple's bed with a gunshot wound to the chest.


Three months after Capt. Pelkey's death, the Army did begin more intensive intervention for cases of the disorder at Fort Sill.


"Soldiers and families now get information on combat stress and effects before and after deployments. They learn how to prepare themselves," Mrs. Pelkey said. "But coordination in the military is horrible. Things happen at local commands, but there should be an Army-wide program that carries the weight ... from the top."


And the stigma of reaching out for help still remains a substantial barrier, she said.


"That's the biggest problem," she said. "Until the leaders – and I mean the Joint Chiefs and the president and Donald Rumsfeld – recognize PTSD as a wound of war and step up to the plate and push for more care, it's not going to filter down. And our soldiers won't let their guard down."


Mrs. Pelkey's efforts to have her husband's death recorded as a casualty of war have proved fruitless to date. The Pentagon has refused her petition, saying he died more than a year after his tour.


"PTSD doesn't always show up until a year has passed," she said. "I'm not giving up, though. I want my son to know why his daddy died. And I don't want this to happen to other military families. I don't want it to just be another suicide in the Army."



E-mail dmclemore@dallasnews.com