Situational Context

I am an Army Occupational Therapist (OT). I have more than 17 years of clinical experience. I enlisted in the Army in 1999 and have been involved in some capacity, whether as a reservist or an active duty service member, since then. In 2012, I deployed to Afghanistan as an individual augmentee, which means I did not deploy as a part of a unit. Like many of my health care peers, I was needed to provide health care services that were not a normal function of the unit I was deploying to support.

I spent just under 9 months in Regional Command East, Afghanistan as the Officer in Charge (OIC) of the Concussion Care Center (CCC) on FOB Shank. I was allowed one Occupational Therapy Assistant (OTA) to help me run the center. SGT Castro and SSG Werner worked with me during the first 4 and the last 5 months, respectively. Our Concussion Care Center was one of 6 CCCs in the region. Although attached to three different commands at various times during my deployment (3rd Infantry Brigade Combat Team, 1st Armored Division (3/1 AD), the 173d Airborne Brigade Combat Team (173d ABCT), and the 30th MEDCOM), I was consistently co-located with the medical company of the corresponding support battalion (Charlie, 125th Brigade Support Battalion & Charlie, 173d ABCT) on FOB Shank.

FOB Shank had the capacity to provide Level II medical care. We treated primarily service members (Air Force, Navy, and Army), but also treated some contractors and detainees.

We were not a large medical center like that found at Bagram, but we had significant trauma surgical assets, air and ground medical evacuation assets, an outpatient clinic, an inpatient holding/treatment area, and limited radiographic capabilities. In addition to the surgeons, physicians, physician assistants, nurses, and medics we also had a physical therapist, an occupational therapist, and two clinical psychologists. US Forces shared the Forward Operating Base with international forces, including those from the Czech Republic, Jordan, and Afghanistan. Health care providers from Jordan, Afghanistan interpreters, and a few US health care providers were our closest “tent” neighbors.

The Afghanistan interpreters were courageous, hard-working, and friendly. It was not unusual for them to invite SGT Castro and I to their tent for Chai tea. I went several times with him intending to build rapport and learn more about their culture, but also realized the need to maintain an emotional and professional boundary. Although I appreciated and respected their efforts, I also recognized the inherent danger and vulnerable nature of their position. Additionally, given the cultural considerations of Afghanistan, we felt that male interaction was the most appropriate and respectful way to build professional rapport with the interpreters (all males). Since we had the capability to employ both male (SGT Castro) and female (myself) influences, we leveraged this quality, in addition to other personal and professional strengths, to care for those who were injured. Balancing each other in this way, SGT Castro and I were able to more effectively fulfill our responsibilities.

Our Concussion Care Center was initially responsible for the potential care of more than 3000 Service Members stationed at approximately 17 outposts in RC-East, Afghanistan. As the larger war strategy at that time was to train Afghanistan forces and transition security responsibilities to them, many of the outposts in our region were gradually closing or transitioning to Afghan control. The majority of our concussed patients were male, but we also treated some female Service Members. Although we were primarily tasked with concussion care, it was not unusual to also provide orthopedic/wound care services within our capabilities. In fact, Charlie, 173d ABCT supported and assisted our effort to add a small plywood room to the front of our tent so that we could also treat Service Members with orthopedic injuries which has been further described elsewhere [2].

We lived and worked primarily in a General Purpose Medium Tents, which are 16' x 32' canvas tents, built to allow heat delivery via a generator. Our tent served both as our concussion care center and our home. Like most tents on our FOB, it had plywood partitions that served to provide some privacy to those who stayed there. Our Concussion Care Center had an inpatient capacity of 12 Service Members, plus 1 Occupational Therapist and 1 Occupational Therapy Assistant. The Occupational Therapy Assistant and I lived with the Service Members we were treating. Thus, in addition to working with them during the day, we lived with their restlessness, their nightmares, their anger, their fear, their determination, their courage, and their resolve to return to their units. Their steadfast resolve to return to the fight was one of many examples of their unrelenting spirit in the face of adversity.

The unique environment afforded us opportunities for impromptu “chats.” These were sometimes as therapeutic for recovering Service Members as was the acute concussion management. At times, we simply sat quietly together outside the tent. More often, we would sit, talk, and smoke. SGT Castro was, like many of our patients, a cigar aficionado. He frequently took advantage of this commonality to build rapport with patients and other Service Members. Ironically, his love of cigars (combined with his calm demeanor and good listening skills) was an invaluable rapport- and trust-building asset. Although not a smoker myself, and not an advocate for smoking, I sometimes joined in their “smoke-shack therapy” (a term coined by a former, Army OTA) (Fig. 18.2). Considering the environment in which we lived and worked, it seemed pointless to lecture them on the long-term health risks of

Modeling a healthier version of “smoke-shack therapy,” MAJ Katie Yancosek and CPT Carly Cooper smoke candy cigarettes. Bagram, Afghanistan, 2012 (Courtesy of SGT David Price, OTA)

Fig. 18.2 Modeling a healthier version of “smoke-shack therapy,” MAJ Katie Yancosek and CPT Carly Cooper smoke candy cigarettes. Bagram, Afghanistan, 2012 (Courtesy of SGT David Price, OTA)

smoking. Rather, I (as many of my nonsmoking health care peers) decided to join them and make the most of this therapeutic opportunity.

In addition to our mission on FOB Shank, we regularly travelled to the outposts within our region to train/update the medical teams on each outpost about: (a) concussion management (Headquarters, Department of the Army, 2013), (b) the triage process to assist with evacuation decisions, (c) concussion resources in our region, and (d) expectations of recovery and return to duty. We saw this aspect of our mission as critical to the successful treatment/management of Service Members with concussions in our area. Not only was it a practical way to share this information with other commands, Service Members, and medical teams, it was essential to acknowledge that not all Service Members who needed our care would be able and/ or willing to come to our Concussion Care Center at FOB Shank.

FOB Shank (nicknamed “IDF Alley” and “Rocket City”) was an unusually kinetic environment during that period of the war. Indirect fire (IDF) in the form of mortars and rocket propelled grenades typically hit the Forward Operating Base multiple times a day. Stray gunfire also seemed to occasionally find its way through tent walls. Several people died and many more were wounded as a result of indirect fire. Some medical teams and leadership questioned the logic of sending their Service Members to our Forward Operating Base for concussive care, especially due to the fact that most sustained their injuries in blast-related incidents. We believed that our presence on other outposts in our area helped to address the fact that not all those who needed our services would come to us. We also believed that this approach would increase the ability of outlying medical teams and leadership to appropriately triage their concussed Service Members. Having the knowledge and skillset to retain and care for less severely concussed Service Members facilitated improved individualization of Service Member care and allowed outlying medical and command teams more flexibility in addressing any comorbid behavioral health concerns.

Since the Concussion Care Center admitted and assessed Service Members 24 hours a day and we had only two personnel to cover the Concussion Care Center, only one of us rotated to the outposts at a time. We tried to keep visits short (2-3 days) and stayed in touch as much as possible via phone. Given the overlapping and sometimes comorbid symptomology of concussion and post-traumatic stress, we worked closely with the Combat Stress Team. Additionally, whenever possible, we paired travel to more remote outposts with members of the Combat Stress Team assigned to the medical company with whom we were co-located. This was a practical and efficient way to visit outposts as the Concussion Care [3, 4] and the Combat Stress missions were compatible.

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