Fort Meade, MD --
When Tech. Sgt. Chris Ferrell was home from deployment he would sit in his family room in the wee hours of the morning, watching TV with his friend, Tech. Sgt. Tony Campbell, who was sprawled out in the recliner next to him.
He didn’t talk to Tony. Ever.
They would just sit there silently in the television’s blue glow while Ferrell’s wife and children slept.
They never talked because Tony was dead; cut in half by an IED in Helmand Province, Afghanistan, Dec. 15, 2009.
Ferrell was just feet away from the explosion, which also sent Tech. Sgt. Derrick Victor into a wall and Tech. Sgt. Tom Pilla through a doorway.
When not watching TV with Tony, Ferrell would desperately try to catch a few hours sleep. However, if he managed to nod off, all he could dream of was that mission or when he held another teammate, Army Staff Sgt. Glen Stivison, as Stivison’s life slipped away.
Ferrell never told his high-school sweetheart and now wife, Lauren, the details of that mission, or any of the others where he was injured or lost friends.
Nor did he share with her, or anyone else, that he was watching TV with his dead friend. He kept it all locked away. Locked away until after his second suicide attempt on the fifth anniversary of Tony’s death, Dec. 15, 2014. Then the floodgates opened.
The decorated Explosive Ordnance Disposal (EOD) technician had a mental breakdown.
Ferrell calls it the second worst day of his life, the first being the day Tony was killed.
He remembers little of the episode, except for the image of his wife on the phone with his commanding officer and some doctors, desperately pleading for them to help her husband.
It was those phone calls that transformed Ferrell’s second worst day into the most important moment of the rest of his life.
In addition to his mental state, Ferrell was suffering from insomnia, hearing loss, nerve damage and cracked vertebrae in his neck and back from two IED explosions. He was even developing a stutter because of damage to the area of his brain controlling speech.
Ferrell was ordered to report for inpatient treatment for Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI) and chronic pain at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center in Bethesda, Maryland.
Instead of relief that he might get some answers and treatment, Ferrell felt like he was marching to a firing squad.
“When I went to NICoE, I knew my career was over,” Ferrell said. “Once you go to an inpatient program, at the time that I went, you’re done… You’re broken … When I went to the NICoE, I’m thirteen years in already, I’ve got five deployments in combat. For my career, it was a death sentence, because now I’m too far gone.”
But his family’s suffering convinced Ferrell that getting help took precedence over preserving his career.
“My daughter has woken me up from naps with my hands around her neck, she’s watched me run missions in my sleep, she’s watched my outbursts that I couldn’t control. That’s nothing for a child to see,” Ferrell said. “And my wife, God bless her, she stuck through every single step of it when I told her over and over to leave, take the kids.”
The 26 stars on the tattoo covering his left arm – representing the 26 EOD teammates, special operators and friends that died in Iraq and Afghanistan – are just the tip of Ferrell’s trauma iceberg.
“You’re not prepared to work on a child for two hours that dies on you while you’re doing chest compressions. To listen to the last breath of a human body,” said Ferrell. “You eventually just start to let things layer. You bury them as deep as you can so you can keep pushing on; year after year, deployment after deployment, death after death… And once it starts layering, when one thing happens, it pushes you back to something that happened five years ago. Which is something that, in theory, you should have already been able to deal with and cope with, but you’ve never even dealt with that one. So now these traumas upon traumas upon traumas… it eventually consumes your entire space.”
After 13 years, six months, 20 days and five combat deployments worth of layers, Ferrell was retired from the Air Force – a fate he hopes to spare some of his brothers and sisters still on active duty.
“The first thing you do after you get done firing a weapon systems is what?
"You clean them,” Ferrell said. “Why do we not do that with our best weapon system, our Airmen? We send them over and over and over… Just like with your actual weapons, the more times you fire it without cleaning it, eventually it breaks down. You have to replace it.”
It is exactly this perspective that led the man who presided over Ferrell’s retirement ceremony, Chief of Staff of the Air Force Gen. David L. Goldfein, to request that he continue to serve the Air Force.
Ferrell was selected as one of a panel of five advisors to Goldfein’s Invisible Wounds Initiative, tasked with making recommendations on changes to the administrative and medical processes for service members suffering from PTSD and TBI.
It is an issue that became a priority for Goldfein after his F-16 was shot down by a surface-to-air missile over Serbia in 1999.
“General Goldfein and I, we’ve had several conversations on the way forward. Him being a guy that’s been shot down… He gets it,” said Ferrell. “One of his rescuers… on the CSAR team that came in and got him ended up in long-term care… The guy struggles; a rock star in the military and then it doesn’t translate into civilian life. He’s in a long-term care facility. So you know he cares.”
One of those initiatives is the construction of the Air Force’s own dedicated Invisible Wounds clinic scheduled for preliminary completion in 2018 at Eglin Air Force Base, Florida. The facility will be fully staffed in its temporary location until a permanent facility is completed within a few years.
Eglin was chosen as the site for this clinic primarily because the patient population adjacent to the base constitutes an Invisible Wounds ‘hot spot’ with a much higher incidence of TBI, chronic pain and PTSD. Many of the “hitters” and “ground pounders” that Ferrell went to war with are right around the corner: 6th Ranger Battalion, 7th Special Forces Group, Air Force Special Operations Command at Hurlburt Field, and the four-service EOD school where Ferrell learned his craft.
While treating all service members with debilitating PTSD and TBI will remain a priority, Col. Caesar Junker, who directs the Wounded Warrior program for the Air Force Surgeon General and is in charge of the Eglin’s IW clinic project, agrees the Air Force Medical Service must focus more on preventative care.
Junker first met Ferrell at the 2016 Warrior Games and then, at the behest of Goldfein, helped Ferrell navigate the Medical Evaluation Board process.
Junker feels that placing an emphasis on preventative Invisible Wounds treatment by actively engaging with personnel upon their return from each deployment, instead of waiting for personnel to hit the breaking point and hoping they seek treatment, is crucial to the operational readiness and personnel retention goals.
“It all really came from General Goldfein’s vision to try to de-stigmatize invisible wounds,” Junker said. “Maybe we don’t have an Airman that’s completely broke yet, but is getting there, and we can identify that Airman early in his career and tell him, ‘Listen, it’s okay to take a knee.’
“We need to try to make it easier for these guys to come forward and then work with them to get them back to duty without ruining their careers. Otherwise, they’re never going to come forward… If we’re not looking at readiness, then I think we’ve failed. Ultimately, this clinic is focusing on readiness.”
The treatment methodology employed by the TBI, PTSD and Pain Clinic at Eglin will be modeled after Intrepid Spirit centers, like NICoE, where Junker works as a physician every week.
He refers to NICoE, which opened in October of 2010 with funding from the Intrepid Fallen Heroes Fund, as the “mother ship,” as it was also the model for other Intrepid Spirit centers treating Invisible Wounds at Fort Belvoir, Virginia; Fort Campbell, Kentucky; Fort Hood, Texas; and Fort Bragg and Camp Lejeune in North Carolina.
“In our model, this NICoE model, we are using an interdisciplinary team and they’re seeing the patient all together, all at once,” Junker said.
Thomas DeGraba, chief innovations officer at NICoE, is in charge of advancing the treatment of patients who have the combined processes of TBI, PTSD, depression, anxiety and chronic pain.
“When a patient first comes in, they sit and meet with a team that consists of an internist, neurologist, psychiatrist, neuropsychologist, family therapist, and nurse navigator who is the (patient and family’s) touchstone throughout their entire four week stay,” DeGraba said.
“We’ve focused on combining conventional medicine techniques with integrative medicine techniques such as yoga, meditation and bio-feedback, which allow patients to regulate their autonomic nervous system, including their heart rate, their blood pressure and their breathing. This allows the service member to be in control of irritability or emotional response to stimuli in ways that they would prefer and in a way that is appropriate to their situation.”
Because IW patients tend to have difficulty in verbalizing their issues, their stay at NICoE invariably begins with art therapy – painting a mask to illustrate the emotions created by their injuries.
“Once those feelings have been externalized, put onto a mask, service members are able to talk about those things that are on the mask so they no longer have to just focus inward on themselves,” DeGraba said. “In front of them, in visual form, are a number of feelings that would take many, many, more words to express.”
Art therapists then relay the identification of emotional triggers illustrated on the PTSD patient’s mask to the behavioral therapists, social workers and psychologists, giving them the ability to develop a treatment plan tailor-made for that patient.
Often, a patient, like Ferrell, arrives at NICoE suffering from both PTSD and TBI.
The thought process held for many years by the medical community was that an injured brain cannot heal itself, according to DeGraba. It was also held that there was no process for military personnel with a traumatic brain injury to get back to their functional and personal interactions, much less back to active military duty.
It is now known that the brain has plasticity, the ability to repair itself by establishing new neural pathways.
One technology NICoE is researching is magnetoencephalography (MEG) – a scan that establishes which areas of the brain have been damaged. Unlike its cousin, the more commonly used electroencephalography (EEG), the MEG brain scan can see changes in structures residing deep in brain tissue.
By measuring minute activity in magnetic fields generated by the cerebral cortex while resting, while thinking and while engaged in some particular task, deficits in the brain can be measured. It is hoped that the technology will soon be used to fine tune TBI diagnoses and suggest treatments.
“Basically what we’re trying to do is make a map of connectivity with TBI, and a map of the spectrum of brain oscillation frequency,” said Navy Cmdr. John Hughes, director of the MEG Laboratory at NICoE. “How does the spectrum of the patient with the TBI or group of patients with TBI, differ from a group of healthy patients who haven’t experienced TBI? How can we manipulate these oscillations with other types of therapies? Alternative therapies, things like meditation or neurofeedback? That’s the goal.”
NICoE is also using virtual reality in the form of the Computer Assisted Rehabilitation Environment (CAREN) Laboratory, which consists of a wrap-around video screen and a motion platform, to help detect brain and inner ear damage.
A TBI patient is attached to a safety harness and then walks on a treadmill embedded in the motion platform. The patient will then navigate virtual scenarios projected onto a wrap-around screen, such as walking along a cobblestone path or crossing an unstable rope bridge, which is synchronized to the motion of the platform. Motion capture cameras track the patient’s movements via reflective markers that are applied to the patient. This is the same technology used in Hollywood to recreate the motion of a live actor in a computer-generated character.
Sarah Kruger, a biomedical engineer at NICoE, uses the virtual scenarios in the CAREN lab to assess the physical deficits of patients with traumatic brain injury and supplies physical therapists with data to see if treatment is working. The lab can also convince patients to pursue treatment that will help them navigate the real world.
“Say a physical therapist identifies that there is some drift while the patient is walking; that they have vestibular inner ear deficits (adversely affecting the patient’s sense of balance). But the patient isn’t really interested in learning the new exercises. So we bring him down here to the CAREN, and the gentleman almost steps off the treadmill during one of the scenarios… So that to him is a light bulb moment,” said Kruger. “It is more than just drifting a couple inches, he is drifting feet. He leaves the room with the therapist talking about, ‘Hey those exercises you gave me, how can I do those?’ and ‘Can we come back down to see if I can make improvements?’”
The system can also be used to assess auditory and visual deficits by having the patient turn in the direction of sounds as they walk and reach for objects on the screen.
Junker says that the IW clinic at Eglin will utilize virtual reality not only to treat TBI, but also to enhance one of the common evidence-based treatments for PTSD, Prolonged Exposure (PE), by employing all of the patient’s senses.
Traditional PE teaches the patient to gradually approach trauma-related memories, feelings and situations they have been avoiding during repeated discussions with a therapist. By confronting these challenges repeatedly in a safe environment, patients usually experience a decrease in PTSD symptoms, like irritability, emotional outbursts, nightmares, flashbacks and hyper-vigilance, a mental state where everyday objects or situations are perceived by the brain as a threat, producing high levels of anxiety.
Junker wants to go a step further by actually placing the patient into a virtual recreation of the traumatic event and employ all of the patient’s senses.
“What we do is recreate the situation that they were in when they were exposed to the trauma,” Junker said. “The individual gets onto a platform where they are seated in a mechanical chair where you can feel vibration … you can actually have smells of dust, cordite… and they are wearing (virtual reality) goggles.”
Junker has been working with the Medical Virtual Reality department at the Institute for Creative Technologies at the University of Southern California to make the event recreations as lifelike as possible. Even utilizing 3-D imaging technology to make digital images of the actual people the patient was with during the event.
“Say they were in a Humvee. You can be seated in the driver’s seat, maybe you were in the passenger’s seat, or maybe you’re up on the turret… we actually even create (three-dimensional) avatars to look like the individuals that you were with in the trauma. We then recreate the trauma, slowly.”
The goal is to allow the patient to experience their reactions to the event and then discover what events or situations in their current life trigger the same responses.
“We’re already using a lower version of this virtual reality PTSD treatment, but the one that we are going to have at Eglin is going to be much more advanced,” Junker said.
Once emotional triggers are identified, the patient is taught to recognize the first signs of an impending exaggerated or inappropriate response to normal life situations, according to DeGraba.
“If you understand the neurological and the physiological response to a particular stimuli, a particular trigger, or a particular demon that these service members experience, then we’re able to have them utilize relaxation techniques at the time and at the moment in which they feel those triggers beginning to rise… allowing them to stay in control of their situation, be able to, by themselves, reset their response to their world around them,” DeGraba said.
Some of these therapies will not even require the patient to be on site. The new clinic at Eglin will feature a more robust use of the Air Force Telehealth system, according to Junker.
Airmen who can’t travel to Eglin will be able to remotely access therapists by computer. Also, mental health practitioners anywhere in the world will be able to consult with health providers at Eglin to develop treatment plans for their patients.
A 30-year-old Airman attached to an Army unit who was able to return to flight status after treatment at NICoE believes that before personnel can feel safe seeking treatment for their invisible wounds, there needs to be administrative changes to the waiver requirements for certain career fields.
While receiving treatment at Walter Reed Medical Center for a gunshot wound he suffered on a mission in April 2016, the Airman decided it was time to address an ongoing issue that had plagued him after multiple TBIs suffered in combat.
“I was only sleeping for maybe two hours a night. I have sleep apnea, most likely from a blast to the head. Obviously sleep affects a whole plethora of things,” said the Airman.
Despite fears he could be medically separated from his career field, the Airman reached out to Junker to discuss being admitted to the program at NICoE while he recovered from his gunshot wound.
“Something had to change. I couldn’t go on just sleeping two hours a night,” said the Airman. “My main concern was getting a diagnosis that would preclude me from ever doing the job again.”
During his four-week stay at NICoE, clinicians performed sleep studies and blood work and gave the Airman recommendations for altering his sleeping position and a mouth-guard to improve his breathing.
Still, his doctors at NICoE and at his duty station had to submit waivers for him to be able to remain on flight status. His career field has medical restrictions similar to aircraft pilots, even though he does not fly a plane or helicopter. For a pilot, a diagnosis of TBI-induced sleep apnea could be a career killer depending on the severity.
“You are very restricted as to what issues you can have and remain on flight status,” said the Airman. “It makes no sense that you have guys in a career field where they don’t fly aircraft but are more prone to TBIs having the same status restrictions as a pilot who is less likely to have TBI in the first place.
“It (his treatment at NICoE) was a success for me because I got all my waivers and got back to my job. Other guys ask if I think they will get to stay where they are if they do it (go to NICoE for treatment) and the truth is, I don’t know.”
However the Airman sees it as a positive that the Air Force is actively engaging personnel with Invisible Wounds to get their input on the administrative process behind utilizing a clinic like NICoE or the IW clinic at Eglin.
“I just met with the Surgeon General (Lt. Gen. Mark A. Ediger) and his staff and we discussed rewriting the medical flight status requirements for my career field … if you have a career field that is prone to TBI and you medically retire them based on the same restrictions for pilots, then you are going to be combat ineffective,” said the Airman.
Ediger concurs that easing the fears of medical separation is key to getting IW patients to come forward and get treatment early.
“I think there is still a lot of concern among service members about being identified and a lot of that concern I think is about the potential of being removed from their occupation in which they’re serving,” he said. “But the fact is, with our current treatment, we have a significant success rate and the majority of airmen who undertake treatment return to full duty… We are working to let folks know that trained assets have a very high likelihood of waiver approval. ”
According to the Air Force Medical Service, over the past two years, 91 percent of medical waivers for Battlefield Airmen have been approved. Reviews conducted as part of the CSAF’s IW Initiative have already led to two waiver guidelines for Battlefield Airmen being updated. Additionally, career field managers are working with the medical standards team to improve and speed up the process for medical waivers.
The AFMS will soon be publishing a paper addressing common waiver concerns of Battlefield Airmen.
Still, those numbers account only for those who come forward for treatment.
“We know that concern is there and so as we move forward and gain capability, we need to go about it in a way that will actually engender confidence among service members so they’re comfortable coming forward,” Ediger said.
Junker emphasizes that outreach and IW education for operational commanders will help get out the word that seeking treatment for PTSD and TBI is not necessarily a career ender.
On the medical side of the equation, the U.S. Air Force School of Aerospace Medicine is currently changing its IW curriculum to ensure flight doctors better understand the operational challenges of Battlefield Airman and the sometimes complex diagnoses of PTSD, TBI and related disorders in those career fields.
“It really makes me happy that these are the treatments that are going to be given to others,” Ferrell said. “Because for the longest time, people didn’t even know about them… You don’t know what you don’t know. Now that we are going to be able to have a facility like that to care for our warriors, it’s going to do nothing but amplify our Air Force.”
Slowly, Ferrell has begun to adjust to the slower pace of civilian life. The guilt he feels at being the one who made it home alive is even starting to ease as he discovers a new mission in life.
He and his family will soon move to New Mexico, not only for Ferrell to start a new job, but also to be closer to his brother-in-law, a firefighter and emergency medical technician struggling with his own mental trauma.
“You have to get out of your own bubble. And as I’ve started going through all my therapies, I’ve started to realize there’s other people that are just like me. They don’t necessarily have to have been in combat. Trauma is trauma, regardless of which profession it is,” Ferrell said.
“My brother-in-law… he saves lives every single day and that’s what he craves. But he struggles… When you have a patient die on you, how do you deal with that? It’s the same trauma that you experience if you lose your brother or your sister in combat, exact same trauma. So I figured, all this therapy that I’ve been through, that I’ve been taught, if I can help him through his own kind of therapy, it helps him become a 30-year battalion chief compared to a 13-year firefighter who can longer do the job.”
