Surgeons at Bethesda Naval Hospital prepared to drill a hole in Lance Cpl. Bret McCauley’s badly swollen head to relieve pressure on his brain when he unexpectedly awoke from a two-week coma.

“Hold up one finger for me,” McCauley recalls someone saying.

He held up his middle finger — “and from that instant they knew I would be OK.”

OK in the sense that he would survive severe wounds suffered when a suicide car bomber rammed his military convoy outside Fallujah, Iraq, on Sept. 6, 2004, setting off 500 pounds of explosives and killing seven fellow Marines.

But not all right when the trauma of that tragedy and other war scenes kept flashing back through McCauley’s mind like a horror movie on rewind during his recovery.

Nightmares, hallucinations, helplessness, paranoia, depression and guilt about surviving when others didn’t. McCauley said he experienced all of these mental demons and more during his struggle to get back to normal.

It is a condition known as Post Traumatic Stress Disorder, first recognized during the Vietnam War era and now diagnosed frequently among troops returning from Iraq. Head injuries, doctors say, can make the condition worse.

McCauley’s life was saved by modern military medicine and a fast-responding team of medics, nurses, doctors and pilots. They removed his spleen and a kidney in Iraq before airlifting him to a regional hospital in Germany to stabilize his wounds, then to Bethesda for additional treatment and recovery.

But the bomb blast had sent McCauley flying from the open back of a truck, striking his head hard against the ground and causing it to gradually inflate to the size of a basketball.

A tumor-like blood clot — known technically as a subdural hematoma — formed inside his head, putting intense pressure on his brain and causing him to lose consciousness.

Surgery removed the blood clot. It did not fix the mental anguish the 23-year-old McCauley, of Kokomo, Ind., said accompanied his condition. Mental anguish that eventually moved him to wonder if the military even cared about his recurrent thoughts of trauma.

Maj. Gen. George W. Weightman, medical director and commander of the U.S. Army Medical Center and School at Fort Sam Houston, Texas, said McCauley’s state of mind was predictable. He said more than one in three soldiers who come back from Iraq face post-combat mental health issues.

A primary reason, he said, is that Iraq veterans are more likely to have witnessed someone getting wounded or killed from improvised explosive devices, the weapon of choice for rebel insurgents and terrorists.

“Think about what war is,” said Weightman. “It is sending a normal person into a very abnormal situation. Death and serious injury are very traumatic things to have to deal with.”

Military procedure calls for treating Post Traumatic Stress Disorder as soon as it is recognized. And often, said Weightman, that means in the war zone. Especially when there are significant casualties such as those from a roadside explosive or car bomb.

“The farther forward you treat it, the more proactive you are, the greater the chance that patients can recover and return to their unit,” said Weightman. “We have combat operational stress control teams and we send these out with the battalions.”

Battlefield psychiatric help was not possible in McCauley’s case. He blacked out from his head wound and didn’t awaken until Sept. 20, 2004, in Bethesda hospital.

Later he was transferred from Bethesda to the Indianapolis Veterans Hospital in his home state of Indiana, allowing him to be closer to family and friends. It was here, he said, that he first talked to a military doctor about Post Traumatic Stress Disorder. He did not confide in anyone else.

Then, McCauley said, he was sent to Camp Pendleton, Calif., the home base of his Marine unit, and given the impression he was well enough to recover on his own. That’s when his misgivings began to bubble up about the military methods of treating post-combat stress. Yet, he admitted, he still didn’t say anything to anybody.

“My unit didn’t even know I was coming back,” said McCauley. “They stuck me in a room by myself, and pretty much just left me there.”

McCauley didn’t recall precisely how long his solitary recovery went on — “a month, five or six weeks … staring at bare walls” — but he said during that time he became addicted to painkillers, and continued to suffer from terrifying flashbacks.

Fellow Marines would come by his room once or twice a week, but McCauley said he never asked them for help.

“I didn’t know if they didn’t know how bad of shape I was in,” he said. “Some of that you could construe as being my fault because … being a Marine makes it a lot harder to admit that you can’t handle something.”

Marines, McCauley said, are “taught to suck it up, suck it up ... . That is drilled into us; you keep going no matter what. A little pain is normal. So we don’t say anything.”

Weightman, one of the Army’s top medical officers, said reluctance to ask for assistance is due to the stigma connected with psychiatric recovery problems in the macho culture of the military.

“We are trying to take that stigma away,” said Weightman. “If I had a sprained ankle, I would go seek care for it. So why not seek help if I’m having nightmares or I fly off the handle a lot quicker than I used to?”

The New England Journal of Medicine studied the issue two years ago, estimating that between 15 and 17 percent of U.S. soldiers who served in Iraq suffered from mental disorders but only half of them sought care upon returning home.

Brig. Gen. Michael J. Kussman, a medical doctor and a top official with the Veterans Health Administration, said the military is aware of the problem, and has made psychological rehabilitation of war-tested soldiers a primary concern.

He said poly-trauma centers to treat veterans with severe physical and mental wounds have been strategically established in Minneapolis, Minn., Palo Alto, Calif., Richmond, Va., and Tampa, Fla. Additional centers will be built, he said, as the need increases.

“We are quite prepared to take care of any veteran who comes to see us,” said Kussman.

Some of the best proven therapy, both Weightman and Kussman said, can come from talking with other soldiers who have been through the trauma of war.

In McCauley’s case, that proved to be the right medicine.

The Indiana Marine said he finally opened up to his father, Greg McCauley, about his post-combat stress. His father, in turn, called an officer he had met at the Bethesda Naval Hospital while visiting his son there. And the next morning, two Marines from McCauley’s command post were in his room to talk about his nightmares and misgivings.

“I told them I needed help,” said McCauley. “I couldn’t take it anymore.”

At first, he underwent special counseling. But McCauley said he didn’t like talking to the Navy psychiatrist because “he didn’t go through what I went through.” He said he felt better after talking it out with Marines who had been in combat.

“That’s how I found closure,” he said. “It was tough talking about it again, but it eventually got easier. It got easier and easier the more I talked about it.”

That’s the lesson McCauley would like to pass on to other soldiers who suffer from post-combat stress tied to the trauma of war: don’t internalize frustration and anger. Let it out.

“Whether they try to swallow it, it’s eventually going to come out,” he said. “Whether it’s a month later, five years later, 10 years later. Everybody eventually deals with it and the longer you wait, the worse it is.”

Eric Reinagel is a CNHI News Service Elite Reporting Fellowship recipient. He writes for The Meadville, Pa., Tribune.

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