Is the war ever over?

Sept. 11 brought back devastating memories the patient had repressed for 30 years.

By Marc Ringel, MD
Family Physician/Greeley, CO

Poor intelligence information had doomed the small unit's mission from the start. Instead of sneaking in behind enemy lines, killing their targets and getting out, the soldiers ran into a concentration of Viet Cong, who surrounded them. A few of the Americans were killed as they fought their way out of the circle of fire. The survivors ran for their lives, pursued through the jungle by a seasoned enemy. They still had a day of slogging and bushwhacking before they would arrive at the helicopter pickup site.

The second-in-command had sustained a moderate shrapnel injury to his leg. The wound wasn't life-threatening, but the lieutenant would slow them down, jeopardizing the whole unit. The commander and his second-in-command lingered behind while the rest of the men moved on. The two officers smoked a cigarette. Then the commander shot his comrade in the head. The rest of the unit made it out safely.

That commander is now my patient. He told me about his Vietnam experience in bits and pieces, beginning on Sept. 12, 2001. What I heard, I believe, just scratches the surface of what this man saw and did in two tours of duty as a member of the elite special forces in Southeast Asia. He had buried the pain and horror ever since, far from his conscious mind. Today he's a successful, respected professional in our community, known for his compassion and fairness.

My patient's uneasy truce with his military past was broken on Sept. 11, when his brother-in-law, who worked on an upper floor of the World Trade Center, phoned him and his wife. He'd survived, he told them, because he headed down the stairs immediately, remembering the 1993 bombing. Running down the stairwell was like descending into hell, he said. He'd dodged flying debris, ran past incinerated bodies, and smelled the unforgettable odor of burning human flesh.

For days after hearing his brother-in-law's tale of terror, my patient was unable to sleep, cried without warning, started at any unexpected sound, and was unable to work. He couldn't take his mind off the horror replaying itself in his brain.

When I saw him, he was a mess. He talked and talked, and I listened. I asked him if he felt guilty about all the lives he had taken in Southeast Asia. He said, "No. There was a job to be done, and I was very good at it. We were fighting a war." But the death, misery, and fear had caught up to him. He'd repressed it all for more than three decades. Then airliners rammed into buildings, a loved one nearly died while dodging explosions and burning bodies, and the emotional dam broke.

I prescribed a benzodiazepine to help him through the next few days. He returned to my office several times, and we talked for hours. He calmed down and returned to work, but I still suggested counseling. He said, "Repression's worked 'til now. If I have a breakdown every 30 years, I'll have one more in my whole life—max. I can deal with that."

By now, most of us have stopped mentally replaying images of the airplane crashes and crumbling buildings we witnessed in September. But for the first months after the tragedy, nearly every American suffered some degree of post-traumatic stress disorder (PTSD), a condition that has afflicted humans for much longer than the 20 years it has been listed in the DSM. Civil War combat veterans suffered from "nostalgia," World War I and World War II vets from shell shock and combat neurosis, respectively, but these labels are all synonyms for the same syndrome.

Getting people to describe the event in detail and their reactions to it is standard treatment after horrific incidents. Talking things out always seems to help, but debriefings don't immunize against PTSD, nor do they make it go away faster.

The most familiar PTSD sufferer in our society is still the Vietnam combat vet. I ask every male patient in his early 50s what he did about the draft; it is a defining issue for my generation. If he saw combat, I enter "Vietnam combat vet" on his chronic problem list; it is just as crucial to keep in mind as glucose intolerance or family history of colon cancer.

If I needed formal proof of that importance, I've gotten it since September. The Vietnam combat vets in my practice are productive, respected men who made peace with civilian life years ago. Yet each has suffered in the wake of the terrorist attacks. Images of violence and the specter of a drawn-out overseas conflict have provoked flashbacks to Vietnam battle scenes and to the feelings of isolation they experienced upon returning to America.

The former commander seems okay now. His marriage and job are going well. He's taking care of himself, spending more time at his hobbies. I don't blame him for not wanting to confront the source of his pain, once again buried deep in his psyche. But "Vietnam combat vet" will remain on his chronic problem list.

What really scares me—especially as the father of three teenagers—is that we'll create a generation of men and women with "Afghanistan combat vet" on their chronic problem lists.

 

Marc Ringel. Is the war ever over?. Medical Economics 2002;2:36.