When War Comes Home


June 28, 2006, Iraq. As the Humvee passed through the streets, Command Sgt. Maj. David Allard spotted the Taliban in their distinctive cloaks. Nothing unusual about that–yet something told Allard to look back. He shifted his weight forward and turned his head just in time to see the Taliban aim
the improvised explosive device. “Punch it!” David urged the driver. Seconds later the IED exploded right behind Allard, narrowly missing his spine.

April 24, 2008, Nashville. Command Sgt. Maj. David Allard rounds his ninth lap on Peabody College’s tranquil green campus. Physical therapist Lisa Haack stops him mid-jog to check his vitals. Heart rate 140. Headache and dizziness at level 4. Cause for concern.

Same war, different fight.

An hour’s drive northwest of Nashville, the sprawling Fort Campbell U.S. Army installation, which straddles the Tennessee-Kentucky line, is home to the 101st Airborne Division. Most of the division’s 26,000 enlisted men and women are infantry. They are front-line soldiers, prime candidates for the signature injury of the U.S. war in Afghanistan and Iraq: traumatic brain injury as a result of improvised explosive devices.

An estimated 11 percent to 20 percent of returning U.S. combat troops suffer from traumatic brain injury (TBI). Soldiers on a tour of duty in Iraq may have experienced dozens of improvised explosive devices (IEDs), and although not every blast injury is fatal, the residual damage is real.

It has been just more than one year since the Vanderbilt Bill Wilkerson Center’s Pi Beta Phi Rehabilitation Institute saw its first patient with TBI as a result of an improvised explosive device detonated in Iraq. Vanderbilt is one among only a handful of civilian agencies across the country treating soldiers, and Fort Campbell has quickly come to depend on the expertise of Pi Beta Phi, which provides rehabilitation for neurological impairment with a special emphasis on traumatic brain injuries.

Fort Campbell has its own hospital, Blanchfield Army Community Hospital–but the 66-bed facility can offer nothing like the wealth of resources down the road at Vanderbilt. According to Sandra Schneider, director of the Pi Beta Phi Rehabilitation Institute (PBPRI), Fort Campbell initiated the partnership when it asked the Brain Injury Association of Tennessee what programs were available. The PBPRI is known for its strong brain injury program, which works with an array of specialty clinics like the Vanderbilt Sleep Disorders Center and the Vanderbilt Headache Clinic. In addition, PBPRI has on-campus resources in the Vanderbilt departments of neurology, trauma and internal medicine.

“In the Army, soldiers have learned that ‘pain is weakness leaving the body.’ It’s ingrained in them, so it’s very hard for them to admit they need help.”

~ Andrea Ondera, physical therapist

Now entering its third decade, the PBPRI has a long history of treating mild to severe brain injuries. But last year, in taking on this new group of patients with injuries unlike anything its therapists had seen before, the PBPRI was navigating uncharted territory.

“In April 2007 we started to receive our first referrals because there was nothing in place to treat them at Fort Campbell,” says Schneider, who is also an associate professor of hearing and speech sciences. “Families and friends of the soldiers would say that their soldier just didn’t seem the same. The soldiers themselves would complain of sleeplessness, headaches and dizziness. We knew we were seeing a new phenomenon.”

What made the brain injuries so distinct from other “traditional” TBIs was the presence of post-traumatic stress disorder (PTSD). The combination of TBI and PTSD created a treatment conundrum.

“Most all the soldiers sent to us who have been in a combat zone have PTSD,” says Schneider. “In treating most patients with mild traumatic brain injuries, we work on memory deficits. Sometimes, however, as the soldiers share their stories with the therapist, their memories are just too painful–and those memories triggered PTSD. These are, after all, individuals who were almost killed by blasts and sometimes watched soldiers in the same vehicle lose their lives.”

The uniqueness of these soldier patients–their injuries and their road to recovery–has prompted the Pi Beta Phi Rehabilitation Institute to customize treatment regimens. PBPRI staffers found that even some of the tools often used to treat traumatic brain injuries might dredge up disturbing recollections. Personal digital assistants like PalmPilots help TBI patients compensate for memory loss by using the electronic devices to make lists, record directions and take notes. But for some soldiers, PalmPilots are too much like the devices used to detonate an IED. Even seeing the PalmPilot can send them into combat mode.

“Many aspects of ordinary daily life can be extremely stressful to a returning soldier,” says Jenny Owens, PBPRI occupational therapist. “More than one soldier has told us of being somewhere like a mall with his family, hearing a loud noise like a balloon popping, and diving to the floor with his family to take cover. The experiences of war are so fresh that they see potential threats everywhere.”

For Kristin Hatcher, speech pathologist, the soldiers’ unpredictable behavior makes treatment challenging. “These individuals are hyper-vigilant to everything going on. You never know what’s going to disrupt,” she says. “We’ve learned to watch for fire drills, audiovisual speaker noise–anything that’s going to send them into combat mode.”

War at Home

“Every single one of these guys wants to go back,” says PBPRI Director Sandra Schneider. “They feel an obligation to their units.”
Photo by Neil Brake.

Counseling is therapeutic and has become a critical part of the soldiers’ treatment, yet PBPRI therapists have learned that the emotions counseling unearths can cause agitation.

“Sometimes, particularly after their vestibular/PT treatment, the soldiers may be dizzy or have headaches, and are unsafe to drive back to Fort Campbell. We have learned to schedule that therapy first or give them breaks to avoid putting them in an unsafe situation,” says Dominique Herrington, clinic coordinator. “The traffic and distance they travel to our facility already provide a level of stress that we don’t normally see in civilian patients with brain injuries.

“Think of the typical personality of a soldier: aggressive, adventurous. They may be off the battlefield, but they’re still engaging in risky behaviors like extreme sports.”

Some of the anxiety stems from the soldiers’ frustration at being back home, points out Anita Zelek, social worker and case manager with Pi Beta Phi. “Anyone with PTSD experiences anger, but for these soldiers there isn’t one specific event that is now emotionally over–like a car wreck, for instance. These soldier patients are still living the war. They know the war is continuing without them and that their buddies are still in Iraq. It’s so difficult to move on.

“The soldiers experience great anxiety because they define themselves as soldiers,” adds Zelek. “So they think, ‘If I’m not a soldier, then what do I do?'”

War at Home

David Allard works out as part of his therapy with therapist Lisa Haack at Pi Beta Phi Rehabilitation Institute. Therapy can run as high as $50,000 per soldier, and insurance usually pays only part of the cost.
Photo by Neil Brake.

The Soldier Mentality

One would think that a soldier narrowly escaping death would never want to return to war. Ironically, though, the desire to go back to Iraq is a prime motivation. The soldiers feel an obligation to their unit, making them some of the most committed, driven patients Vanderbilt has ever seen.

Case in point: One of Hatcher’s patients had witnessed 32 IED blasts and wanted to get better so he could redeploy. “How do you prepare someone to return, with such deficits?” she asks.

This is not a rhetorical question. PBPRI staff must prepare soldier patients not only for ordinary daily activities, but for a return to the frontline. In occupational therapy, for instance, Owens works with patients to maximize independence in daily activities. Previously, she had never rehabilitated anyone to return to a dangerous situation. Now she prepares soldiers to continue being scouts.

“Scouts are the first soldiers to enter a building and clear it, so they must be watchful for any signs of IEDs or other dangers,” Hatcher explains. “For these soldiers I tailor occupational therapy to their duties–giving them maps to identify the best routes.

“We go on ‘missions’ where we follow a route, making sure the soldier is attending to landmarks, signs, etc. Even counting the
number of trash cans can simulate the type of attention to detail that is needed in war.”

In the arena of physical therapy, Lisa Haack is not just rehabilitating a patient back to normal conditions. She is rehabilitating soldiers to return to 100-degree heat with 90-pound packs–an enormous hurdle for patients like David Allard with constant headaches.

Warriors in Transition

Although he’s working on building endurance, David Allard is not returning to Iraq. Through the course of his therapy at Pi Beta Phi, he not only improved physically, but made an enormous psychological leap. A 24-year veteran of the Army, David realized his injuries could make him a liability for men in his command. Rather than redeploy, David answered the military’s call to set up a Warrior Transition Unit (WTU) at Fort Campbell.

Established in August 2007, the WTU is Fort Campbell’s response to the TBI phenomenon in soldiers returning from duty. Currently, more than 700 soldiers are in the WTU. The partnership among the Department of Defense, PBPRI and Fort Campbell has grown as the three work together to rehabilitate injured patients.

“We know anecdotally that there are Vietnam vets who are homeless because they are still dealing with PTSD,” says Schneider. “Currently, data shows there are 1,600 homeless individuals who served in the Iraq war. The Army has recognized the significance of doing something now to help returning soldiers. No one can wait 15 years to figure out what’s needed.”

In addition to the jobs for which they’re trained, each PBPRI therapist finds herself in the unfamiliar role of advocate. The number of case managers at Fort Campbell has increased from three to 28, but more are needed. At Vanderbilt the therapists must work within the system to get the treatment the soldiers need through Tricare, the insurance plan for the U.S. Department of Defense. Although
Vanderbilt commends both the Department of Defense and Tricare for funding most of the soldiers’ needs, there are still gaps.

Take Spc. Juan Zapata, for instance. He was patrolling the streets for insurgent activity when he suffered a blast injury. He served another six months before leaving Iraq in November 2006. He returned home shell-shocked and suffering from multiple vision problems due to his concussion.

Post-trauma vision syndrome caused photophobia, or light sensitivity. Driving at night has been compromised for Zapata, and headaches are relentless. In addition, he has an accommodative dysfunction–meaning it’s difficult for his eyes to shift focus. Arguably one of Zapata’s greatest challenges, though, is his difficulty in orienting.

When therapists told one soldier to bring in his medications, he brought a tackle box–full of his more than 35 pills a day.

“Because of visual-spatial deficits related to post-traumatic vision syndrome, he has navigational problems,” says Owens. “This is a tough blow for an individual with such a talent for navigation. He had built a career in the Army around those skills.”

Fighting the System

In November 2007–more than a year after sustaining his TBI–Zapata saw a Fort Campbell doctor who referred him to Vanderbilt for speech and occupational therapies. Applying a team approach to patient care, Vanderbilt recognized that Zapata also needed a physical therapy consultation because he suffered from vestibular/balance dysfunction. With his extensive vision issues, Zapata also needed to see a behavioral ophthalmologist. Because he didn’t have a case manager, the PBPRI team had to navigate the bureaucracy themselves to get Zapata the treatment he needed.

“The Tricare worker said Juan needed to see someone on base–but those specialized services don’t yet exist,” explains Anita Zelek. “It took several months of making calls before we got the insurance company to agree to cover the other services for Juan.”

Vanderbilt also was able to refer Zapata locally to obtain eyeglasses with special prisms in them.

Although Zelek and others at Vanderbilt often are able to help soldiers like Zapata get the services they need, they sometimes hit roadblocks. BlueCross BlueShield of Tennessee, for instance, does not recognize cognitive therapy as a service, although the company does in other states. All payers will, however, cover medications. That’s why over-medication is a real problem. When Pi Beta Phi therapists told one soldier to bring in his medications, he brought a tackle box–full of his more than 35 pills a day.

“With TBI patients, memory’s an issue, so often these patients can’t remember which medications they’ve taken,” notes Schneider. “This can lead to accidental overdoses.”

When the War Becomes Personal

Soldiers come to Vanderbilt only after they’ve fought their own private war–a war in which they deny their symptoms, deny anything is wrong.

“In the Army the soldiers have learned that ‘pain is weakness leaving the body,'” says Andrea Ondera, PBPRI physical therapist. “It is ingrained in them that ‘pain reminds you you’re alive,’ so it’s very hard for them to admit they need help.

“We validate for them that what they feel is real–and that physical reasons are behind those feelings.”

As demand for its services has increased, PBPRI is growing accordingly. And staffers have traveled to Alabama, Illinois, Nevada and North Carolina to share what they’ve learned with medical and rehabilitation professionals elsewhere.

War at Home

Juan Zapata performs an eye test with therapist Jenny Owens. Post-trauma vision syndrome has caused Zapata to experience light sensitivity and relentless headaches.
Photo by Neil Brake.

“Training others is the best thing we can do,” Schneider says. “We owe these soldiers the best of the best. I could spend every waking hour dealing with our military obligations–and I would do anything in the world for them.”

For the dedicated professionals at PBPRI, this war has become intensely personal. In the face of each soldier, the therapists see their brothers. Sons. Friends. Soldiers come to depend on the Pi Beta Phi team as therapists, advocates, confidants and friends. The therapists receive e-mails from soldiers who have redeployed. The younger therapists, all contemporaries with soldiers, share a common generational bond. And each of the team members at Vanderbilt feels rewarded beyond measure.

“I feel I’m serving my country,” says Haack, age 33. “Some people may build up a tolerance to what’s going on over there, but not us. Our soldiers show us the shrapnel that came out of their heads; we hear the stories and relive those experiences with them.”

David Allard, conscientiously pursuing his treatment, leads by example. He has even adapted a war tradition for the Warrior Transition Unit and Pi Beta Phi. “In the Army you get a coin for excellence, and you have to carry it on you at all times,” he explains. “I’ve given coins to my therapists. They’ve earned them. They’d best not forget them.”

On the coin is this inscription: I am a warrior in transition. My job is to heal as I transition back to duty or continue serving the nation as a veteran in my community. This is not a status but a mission, because I am a warrior and I am Army strong.

The therapists at Pi Beta Phi Rehabilitation Institute are not likely to forget–or to leave their coins behind. Like the soldiers they treat, their work is a mission.