Identifying, Triaging and Treatment Operational Stress Disorders

INTRODUCTION

The art of war aims to impose so much stress on the enemy soldiers that they lose their will to fight. Combat stress is often the deciding factor in all forms of conflict. In each combat operation, whether high intensity full-scale combat or SASOs, we can expect individuals to suffer the effects of stress from the operation. Estimates range from greater than one stress casualty for each wounded in action to less than one for each ten wounded in action. Consider a scenario with one stress casualty for each three wounded in action (as experienced in WWII). When treated properly, approximately 90% of the stress casualties will be returned to duty within a few days. You can appreciate the importance of recognizing and treating stress symptoms. In fact, perhaps the most significant contribution the Army Medical Department can make to the combat effort will be to restore stress casualties to combat effectiveness. Each of us must know how to identify, triage and treat battle fatigue casualties.

Combat stress

Definition of Stress

(1) Stress is the body's and mind's process for dealing with uncertain change and danger

(2) Elimination of stress is both impossible and undesirable

(3) Stress can have positive and negative effects on functioning

NOTE: The positive effects of stress can enhance performance whereas the negative effects of stress can impair overall functioning.

(4) Excessive stress may lead to dysfunctional combat behaviors

(5) Controlling stress is key to controlling these resultant behaviors

Types of Combat Stress

(1) Physical (environmental and physiological)

(a) Examples of environmental stressors

(i) Heat, cold, or wetness

(ii) Difficult terrain

(iii) Hypoxia, fumes, poisons, chemicals

(iv) Ionizing radiation

(v) Physical work

(vi) Noise, vibration

(vii) Visibility

(viii) Infectious agents/disease

(b) Examples of physiological stressors

(i) Sleep debt

(ii) Dehydration

(iii) Poor hygiene

(iv) Physical fatigue

(v) Illness and injury

(vi) Malnutrition

(2) Mental (cognitive and emotional)

(a) Examples of cognitive stressors

(i) Too much or too little information

(ii) Sensory overload versus deprivation

(iii) Ambiguity, uncertainty, isolation

(iv) Time pressure versus waiting

(v) Unpredictability

(vi) Rules of engagement

(vii) Organizational dynamics

(viii) Hard choices versus no choices

(b) Examples of emotional stressors

(i) Threats to safety

(ii) Loss, bereavement

(iii) Anger, resentment, frustration

(iv) Boredom, inactivity

(v) Home front worries

(vi) Loss of faith

(vii) Interpersonal conflict

Combat stress behaviors

Adaptive behaviors

(1) Unit cohesion

(2) Sense of eliteness

(3) Alertness and vigilance

(4) Increased strength and endurance

(5) Tolerance for hardship, pain, discomfort

(6) Heroic acts and self-sacrifice

Dysfunctional behaviors

(1) Misconduct stress behaviors

(a) Mutilating dead

(b) Killing enemy prisoners and noncombatants

(d) Recklessness

(e) Alcohol and drug abuse

(f) Looting and rape

(g) "Fragging"

(h) Desertion

(i) Abuse of sick call

(2) Battle Fatigue

(a) Hyperalertness

(b) Fear, anxiety

(d) Somatic complaints

(e) Depression, indecision

(f) Exhaustion, apathy

(g) Poorer performance

Triage

DUTY category

(1) Used for soldiers who show mild battle fatigue and are expected to quickly recover

(2) The soldier must be capable of self-care and have the ability to respond if the unit comes under attack

(3) Recovery may include:

(a) Food and nourishment

(b) Fluid to drink

(d) Reassurance to the soldier

(e) The opportunity to talk about experience

REST category

(1) Used for soldiers having moderate to severe BF symptoms, or having no treatment response

(2) Requires 1-2 days of duty in the soldier's own battalion/ battery HHC

NOTE: These soldiers may be held in the BSA under the control of the FSMC or Brigade Adjutant.

(3) Monitored by the brigade CSC team (directly or supervisor's reports).

(4) If symptoms persist or worsen, category is elevated to HOLD.

HOLD category

(1) Used for soldiers who require medical observation and restoration treatment at the FSMC's patient holding area

(2) Treatment is provided for 1 day (or up to 3 days if return to duty is anticipated)

(3) Soldiers must be told that they are not patients

REFER category

(1) Used for BF and NP cases which cannot be safely held or treated in the FSMC and require evacuation to a higher echelon of care

(2) These cases may be initially triaged into this category, or may have demonstrated no treatment response

(3) Any REFER cases with good potential for RTD within 72 hours are held for treatment in the MSMC patient holding section

(4) Evacuation should only occur in nonmedical vehicles when safely possible

(5) Physical and/or medication restraints are used when necessary

Principles of combat psychiatry

Maximize combat stress prevention

(1) Primary prevention - decreases the occurrence of dysfunctional combat stress behaviors through control of known contributing stressors

(a) First time in combat

(b) Home front worries

(d) Insufficient tough/realistic training

(e) Poor unit cohesion

(f) Sleep/food deprivation

(g) Inadequate information or no clear sense of purpose

(2) Secondary prevention - minimizes dysfunctional combat stress behaviors when they first occur. Do this by training and assisting unit leaders, chaplains, and medical personnel to:

(a) Identify warning signs and symptoms.

(b) Intervene immediately.

(d) Reintegrate recovered battle fatigue soldiers into their units.

(e) Taking appropriate disciplinary action for criminal conduct.

(3) Tertiary prevention - minimizes long term dysfunctional combat stress behaviors and post-traumatic stress disorders. Do this by assisting unit leaders, chaplains, and medical personnel in:

(a) Critical event debriefings

(b) End of tour debriefings

Treat battle fatigue

(1) Proximity - treat a soldier as close to their unit and battle as possible

(2) Immediacy - treat as soon as possible

(3) Expectancy - give the soldier expectations for full recovery and RTD

(4) Simplicity - Use brief, straightforward methods to restore physical well-being and self-confidence

Defer psychiatric diagnosis

(1) Triage emergency medical/surgical conditions and then treat

(2) Treat others for battle fatigue using the PIES plan

(a) Proximity - treat soldiers as close as possible to their units and battle

(b) Immediacy - identify need for care early and treat immediately

(c) Expectancy - provide positive outlook to combat fatigue casualty. Casualty should expect full recovery and early return to duty (RTD). The most important principle in treatment.

(d) Simplicity - use simple, brief straightforward methods to restore physical well being and self confidence using non-medical terminology and techniques

(3) Non-responders should be evacuated to a higher level of care. Final diagnosis is determined at this level.

Other battle fatigue treatment principles

Initial Assessment

(1) Brief medical and mental status examination.

(2) Must differentiate between battle fatigue and more emergent illnesses.

(3) Treat battle fatigue while covertly observing for other serious conditions.

Reassure

(1) Tell the soldier that he has battle fatigue and that it is a temporary condition.

(2) Explain that battle fatigue is a normal reaction to severe conditions.

(3) Give expectations that he/she will return to duty after a short period of rest.

(4) Keep the soldier active.

Separate

(1) Keep battle fatigue soldiers separated from patients with serious medical surgical and psychiatric illnesses.

NOTE: Association with severely ill will worsen BF soldier's symptoms (called contagion).

(2) Convalescent soldiers and battle fatigue soldiers may be treated together after the contagious stage is over and return to duty is imminent.

Simple Treatment

(1) Keep treatment as simple as possible using the PIES treatment plan.

(2) Provide relief from danger but maintain a tactical atmosphere, which is not too comfortable.

Restore Confidence

(1) Keep soldiers active through structured military work details, physical exercise, and recreation.

(2) Get soldiers to talk about their experiences that led to battle fatigue.

(3) Provide a supportive environment for self expression.

(4) Reinforce the soldier's identity as a soldier, not as a patient.

Avoid Sedatives and Tranquilizers

(1) The battle fatigue soldier needs to maintain a normal state of alertness, coordination and understanding.

(2) Sedating medications may be used if sleeplessness or agitation cannot be otherwise managed.

NOTE: Remember that the soldier will think that medications are used by patients.

Evacuation and Hospitalization

(1) Evacuate and hospitalize BF soldiers only when absolutely necessary.

(2) Evacuation and hospitalization may significantly worsen initial symptoms and delay recovery.

(3) Evacuate by general-purpose vehicles not ambulances.

Unresponsive and Unmanageable Cases

(1) A soldier whose battle fatigue or neuropsychiatric symptoms do not improve or make him too disruptive to manage may be evacuated to the next echelon of care.

(2) Prior to evacuation, give the soldier a clear expectation that he will improve.

NOTE: Be careful not to let these cases become an escape route from combat.

Hospitalization

(1) Use when the battle fatigue soldier's safety is uncertain.

(2) Non-hospital environments are preferable to hospitalization.

(3) If a soldier is inappropriately hospitalized, inform him that he only has battle fatigue and that he will be returned to a forward area for treatment.

SUMMARY

We have discussed how to identify, triage and treat battle fatigue cases. The principles are relatively easy to grasp but when implemented properly they can serve as a significant force multiplier for the units that behavioral science officers support.