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"Oh, The Things You Can Find "

Robert Koffman

“It’s high time you were shown that you really don’t know ...

Oh the things you can find if you don’t stay behind.”

Dr. Seuss from On Beyond Zebra (1955)

And so it was that the recently identified findings I brought with me to the pentagon, epidemiologic data collected downrange, would be a punch to the gut of the leader of our Navy, to our highest ranking active duty member of the US Navy, none other than the Chief of Naval Operations (CNO). Accompanied by the Navy Surgeon General, my 15 min of fame—or is that infamy-briefing the CNO and his entire court in the sumptuously appointed private “E” Ring briefing room, on the mental health status of a high risk group of Sailors, as if time stood still, grew to 30 min, 45 min, an hour, or more.

Entering the room and repeating my new mantra to myself, a meditation on selfpreservation, “please don’t shoot the messenger!” I knew the findings I carried with me, data collected and analyzed, would not be well received. Would these find- ings—unclassified health care data, gleaned from an at-risk population based behavioral health surveillance—at least in senior leadership’s mind, conjure up a failure of covenant responsibility and possibly forever contribute to for my wahrhol-esq fifteen minutes of CNO briefing fame?

The Surgeon General (SG), concerned not just for the welfare of the Sailors we identified at immediate risk, but how CNO would respond, rehearsed the brief with me, going over and over the data as we knew it, imploring me to “stay on script.” I have a habit of enriching the discussion, even more so with flag and general officers.

R. Koffman, M.D. (*)

Behavioral Health and Integrative Medicine, National Intrepid Center of Excellence, Palmer Rd S, Bethesda, MD 20814, USA e-mail: This email address is being protected from spam bots, you need Javascript enabled to view it

© Springer International Publishing Switzerland 2017 E.C. Ritchie et al. (eds.), Psychiatrists in Combat, DOI 10.1007/978-3-319-44118-4_13

On more than one occasion my naive offering of “too much information” culminated in gentle, but telegraphic, under the table kicks by lesser ranked officers reminding me to confine my digression to the topic immediately at hand.

As the Bureau of Medicine and Surgery’s inaugural Combat and Operational Stress Control Consultant, Acting Director of Psychological Health, and clinical psychiatrist, I’ve completed more deployments, both combat and peacetime, than most Navy Psychiatrists rack up their entire career. With over a quarter century of operational medicine, I knew my findings would not be contested simply from the perspective of credibility. Furthermore, the MPH on my signature line meant that it was my job to identify occupational hazards: combat missions which put those who the CNO was specifically entrusted to protect at undue risk, whether that was attributable to lack of experience, leadership, training, or equipping. Not that there is ever an “acceptable” risk of developing a condition such as PTSD following service to this great country, however we are at war, and the length of war, chronicity of exposure, periodicity and extant nature of deploying, justify the roles and responsibilities of the COSC Consultant.

Even before I finished my presentation, upon seeing the morbidity stats sampled from an entire detachment of Sailors, CNO spoke, his court listening intensely. Dropping their heads in mutual and unanticipated disgust “How could we let this happen?” CNO spoke, admonishing his court. Surveyed using the same instrument (language and ranks slightly modified for Sailors) as the Mental Health Advisory Team, or MHAT, my findings indicated profound psychological injury, far in excess of front line infantry soldiers and surpassing the psychological impact of the most intense combat exposure.

How could Detainee Operations be so traumatic? Why should a battalion of Individual Augments, typically reservists made up from a broad sampling of rates, ranks, ages, Reserve Centers, backgrounds, and military experiences be so profoundly impacted by their mission of guarding OIF/OEF detainees down range? With Post Traumatic Stress Disorder and Depression scales “off the charts,” it is little wonder that only a few months before, I received a distress call from the AO (Area of Operations). The Officer-in-Charge of a guard force of Navy reservists- turned-Individual Augments, had assumed command of battalion of reservists cobbled together, deployed to CENTCOM to replace an Army unit of MPs.

How did we get to this point? Several weeks earlier, across the pond, I was not aware that my collaboration with the Army’s Mental Health Assessment Team, well circulated in behavioral health circles and with data published in the New England Journal of Medicine NEJM [1], would offer hope to the Officer-in-Charge of a battalion of Sailors. Speaking over poor quality DSN line, after first confirming that my lieutenant and I had conducted MHAT analogous surveillance of deployed Marines and Sailors, this OIC inquired if we could conduct an immediate epidemiologic assist visit—the tactical equivalent of popping smoke, the herald of a red star cluster. What would follow would be an unprecedented expedited request for surveillance.

A subsequent series of programs and deployments to identify other at-risk populations would usher in and presage an entirely new concept in population based, preventive medicine championed throughout Navy Medicine writ large. Like an archeologist discovering artifact, now uncovered, our epidemiological findings, dusted-off and held to sunlight, contributed a critical piece of the puzzle, shameful as it be. On time and definitely on target, clinical observations from a population of guards accomplished what good science yearns to do: create hypothesis which, once tested and validated, guide efforts which improve the quality of life. PTSD underpinnings unearthed.

Before my 67 min of fame was to be over, before senior leadership could really get their arms around this concept of the unique and for the most part, preventable risks incurred by the Individual Augment, I would be tasked by the Vice Chief of Naval Operations (VCNO) to “find it-fix it.” Much like Dr. Seuss’ Cat in the Hat intoned, it was high time our leadership was shown that they really did not know what the cost of sending ostensibly well prepared Sailors to augment Army units in order to perform what would ultimately be appreciated as one of the most injurious missions the War on Terror has produced—guarding the angriest, rageful, deceptively dangerous prisoners in the world.

To accomplish the tasking of guarding detainees, the Navy would ask erstwhile sonar techs, aviation bosun mates, structural mechanics, even yeoman (administrative staff) to leave their ships, subs, flight decks, and indestructible Steelcase desks, don Army ACUs, qualify on service weapons (M4 automatic rifle and M9 Berretta pistol), mobilize onto active duty with 180-day orders, and receive just-in-time detainee ops training. “Fall in,” was followed by, “aye-aye, sir,” over and over again ... Oh, the things you can find if you don’t stay behind ... Following my briefing to CNO, I didn’t stay behind long, either.

In their defense, senior Navy leadership, and for this matter, probably the Air Force too, knew not the perils endured by Individual Augments, much less the psychological consequences of Detainee Operations. In theory, parts are parts; TDY is TDY (or as it is called in the Navy, TAD). Why shouldn’t the Navy offer up US Navy personnel to assist the army in their effort to mend holes and patch thread-bare platoons, companies and even battalions. And holes there were: by early 2007, there were approximately 12,000 Navy personnel filling Army jobs in the USA, Iraq, Afghanistan, Cuba and the Horn of Africa. By 2008, about the time I received that sentinel call (heralded by the popping of smoke) more than 10,000 “sandbox sailors” (the pejorative moniker this group of dedicated Sailors were sometimes called) found themselves in receipt of IA orders. The utilization and demand for IAs could not be understated. Quite stunningly, according to the Defense Technical Intelligence Command, DTIC, since 9/11, the total number of sandbox sailors deployed throughout theater, actually surpassed the total number of Sailors deployed upon all Navy ships.

An Individual Augmentee is a formally defined as a US military member assigned to a unit such as a battalion or company, as a temporary duty assignment (TAD/TDY). Individual Augmentees can be used to fill shortages or can be used when an individual with specialized knowledge or skill sets is required. As a result, Individual Augmentees included members from other branches of service similarly plucked from their military family (and personal family), cleaved from the comfort and support of their organic command. The IA system was used extensively in the Iraq War, though with some criticism. Individual Augments served in vital roles, typically inferred by their more traditional Navy roles such as USMC support, maritime security, port security, cargo handling, Seabees, and even, Joint Task Forces. However, it was the not-so-traditional occupations such as, Civil Affairs, Provincial Reconstruction, and perhaps the most insidiously damaging job, Detainee Operations which garnered my concern.

Back in the dark walnut appointed conference room, crown molding abounding, underscoring the thematic importance (if not sanctity) of unit cohesion I blurted out to the CNO and his court, “With all due respect, sir, Sailors called to serve in an IA capacity, particularly Detainee OPS, are not plug and play circuit boards that can be inserted into a mission or unceremoniously extracted.” Clearly overstepping my bounds, now capitalizing on those 67 min of fame, I added, the practice of sending service men and women to Vietnam for a fixed period of time, 12 months for Soldiers; 13 months for Marines, meant that the service member deployed alone, and even more devastatingly, returned home alone! Given the enmity Vietnam veterans suffered upon returning home, no policy or practice directly under DoD control was probably more contributory to the development of PTSD—at least in this psychiatrist’s mind. “Have we not learned this lesson?” now speaking with timidity, realizing that I had definitely overstepped my bound.

From my perspective, the situation was indeed urgent, worthy of the CNO’s time and attention. At one point, more than half of all IAs were reservists, some on their second or even third mobilization. The fact is that not only would the unit to which the IA was temporarily assigned dissolve upon redeployment, but so would the active service, hence, so to, the naval identification which the mobilized reservist proudly wore. He or she would be re-introduced to a very different, now ego-alien world, where few friends, family members, or civilian co-workers could relate. War changes everything, everyone. Was I the only one who understood this seemingly trite, but never truer cliche. As the need for Navy Reservists swelled (as well as for other reservists, Air and Army Guard), so did the need for dwell time, the period of time home when one could reconnect with friends, families, and employers, to shorten.

Even though I was theoretically correct, speaking as if to not just exclaim but to educate these very senior officers, I was out of line. In my own mind, this lesson seemed to rebuke. Of course the CNO and his team care deeply about the mental health of each and every Sailor. However, we are at war. There are critical missions we must undertake. Surveying the dead pan expressions seated around the impressive expanse of the table, another swift but demonstrative under-the-table kick was warranted. To my great fortune, not only was I speaking from the walnut podium— but from the heart—the later, well beyond the SG’s reach ... I repeated my exhortation “Identified groups of Sailors performing duties as IAs in support of Detainee Operations are suffering,” pleading the four-star seated directly across from me to take action . “Oh boy, is it ever high time you were shown that you really don’t know,” I thought to myself.

As a psychiatrist, a military psychiatrist, even more so, a combat stress control/ Director of Psychological Health psychiatrist, it seemed more than intuitively obvious that the loss of one’s shipboard and sailor-centric identity (replete with loss of shipboard support system—probably the single most important life-support system a service member has), could contribute to the development of additional stress. Departing from the time honored admonition, train-like-you-fight; fight- like-you-train, the whole idea of the Individual Augment is anathema and smacks in the face of promoting resilience. After all, we military mental health types (I include the broad array of social workers, psychologists, therapists of all stripes) preach the gospel of Combat Operational Stress Control (COSC): unit cohesion is sacrosanct. It is in this collective sense of purpose, combined with competent leadership and supported by a comprable level of training, preparation, and physical conditioning that ARE the apostles in this congregation. Facilitated by unit identity, unit cohesion IS the reason young men (and increasingly now, young women) offer and sometimes forfeit their lives. It is not for God, or country, or some platitude artistically depicted in a music video; it is precisely and personally for that person on his left or her right. Protection of each other and the willingness to die for that brother or sister defines unit cohesion and underscores EVERY value, action or platitude. Traditions, rituals, and customs burnish unit pride and reinforce centuries of distinction. Wearing the cloth of his nation is intensely service-centric (to this I will add: GO NAVY, BEAT ARMY!)

If unit cohesion is inviolable, unit cohesion can be and most certainly develops within newly formed IA units, too. However, organic units/commands have the benefit of remaining intact post deployment. To be truly accurate, the need, and benefit, of mutual support, acceptance, and understanding, really begins once the mission is over. In the unkindest cut of all, once home, the opportunity to reflect upon the enormity of their contribution-inclusive of personal and private sacrifice, dramatically wanes. Overcome by events of living, looking back becomes as difficult as it does not to emotionally detach. Suppression, Repression, Denial ... you name it: defensive operations keep distant memories just that. Problematically, there is no time downrange to grieve for what was, or perhaps even more importantly, what wasn’t. Individual Augments, like reservists themselves, suffer a double dose of transition from deployment to redeployment. Alas, for most, redeployment will forever be incomplete. Unlike most of men and women seated around that table, having been a lone IA in the desert, I knew this too well.

A short digression to illustrate the critical importance of unit cohesion is warranted. From the time of Thomas Salmon, the early twentieth century neurologist who championed the foundational tenets of the treatment of “Shell Shock”: Proximity, Immediately, Expectancy, or PIEs, the deliberate intervention of keeping traumatized service members as close to their organic unit as possible providing them rest, replenishment, and rehydration (the so-called three-hots-and-a-cot) remained the dogma of managing Combat Stress.

Previously referred to as Shell Shock, Battle Fatigue, the 1000 Yard Stare, this lesson of combat stress control has unfortunately been learned, forgotten, and relearned throughout history. What’s more, practicing Combat Stress Control has been made exponentially more difficult in this now asynchronous battle sphere where classic “frontlines” do not exist. Indeed, Thomas Salmon could never have imagined the stress upon the IA.

I learned about PIES first hand during my early medical education. It was a lesson which has stuck with me throughout the many years of war this combatant has experienced and endured. In 1991, I was a young Lieutenant Commander. Though I had several overseas tours previously, they were all unit deployments in preparation for what was to, years later, arrive with the crossing of the proverbial “line in the sand.” The coalition’s buildup to the first Gulf War followed a long prelude in anticipation of Saddam Hussein crossing this line, a staging of forces which offered me the unprecedented opportunity to deploy to the Persian Gulf during as a PGY-4 resident.

Because of follow on orders to Camp Lejeune, where I was slated to become the 2nd Marine Division Psychiatrist, for the purpose of learning about this heretofore theoretical construct, Combat Stress, I wrangled my way to the Middle East for a several month-long “senior elective.” In my efforts to understand, identify, and treat COSRs (Combat and Operational Stress Reactions), I came to appreciate that because our forces remained faithful to the canon: excellent training, realistic preparation, belief in the cause, and most importantly, a strong and covenant leadership up and down the chain, resilience during combat and post traumatic growth following redeployment was ostensibly the combat norm. As for doctrine, at this point in the desert conflict, naval Combat Stress Doctrine was lacking; something my mentor and I hastily constructed immediately prior to the kick-off of the ground war.

As validation, moreover vindication, of what I traveled to the desert to learn, when the ground war began, tens of thousands of Saddam’s troops immediately abdicated their positions and surrendered in endlessly long, retreating columns causing the over-flow of hastily constructed Enemy Prisoner of War camps. As if Saddam had missed Salmon’s historical lesson (indeed, history throughout, is rife with learning and relearning Combat Stress Control) every stressor operating to degrade the strength of his Saddam’s Army was evident. And surrender they did ... given an absolute dearth of US forces seeking behavioral health assistance at my lone Combat Stress Center outpost, due in large part to the speed at which maneuver units outpaced the static positioning of the surgical companies, I volunteered my medical officer skills to staff the burgeoning EPW stockade.

What I had journeyed to the Persian Gulf to observe and study, I was serendipitously confronted—if not rewarded—with hundreds and hundreds of CO SR cases, not in our troops, but rather the enemy! As the General Medical Officer working the night shift, assisted by five Iraqi physician EPW interpreters, I observed the protean manifestations of Combat Stress; every possible presentation of conversion disorder, from pseudo seizure with “convulsion”, to hysterical blindness and paralysis. I became a believer in this condition so tactically important, wars were won—or lost—on account of it. Like Salmon, I became a believer and would soon preach the gospel!

Cleaved from their families precipitously, conscripts to Saddam’s Army (Republican Guard excluded), surrendered in droves, largely due to the stress inflicted upon them through the culmination of 30 days of B-52 raids, poor training and equipment (some soldiers wore empty sandbags as shoes), and ire and rage for Saddam and his government following payment in counterfeit dinars. Physically, the fact that the hapless combatants remained sheltered for such a long period of time, immobilized by carpet bombs overhead, subsisting on limited rations of a cup of rice and a dry cheese stick, and forced to drink incompletely desalinated drinking water (we bombed the water desalination plant, too) further set these soldiers up for flagging moral, high anxiety, and mission failure.

Differential diagnosis was challenging, given the sea of somatization. Dehydrated and suffering from circulatory collapse, as well as venous stasis (many were required to squat for hours and days at a time), swollen legs with calf pain, like pain from other physical causes, was legion and contributed to and confounded the Enemy Prisoner of War’s presentation. Was this a Deep Vein Thrombosis, the unconscious somatization of the wretched, or the conscious manipulation for an additional blanket and bottle of water? Virtually every stressor possible which could lead to the development of a Combat Stress casualty was in place.

The coalition forces fared much better. Reflecting upon Combat Stress gospel mentioned earlier, even those who fought valiantly on the so-called “Highway of Death,” our own US forces were for the most part, psychologically unscathed. Such is the power of truly understanding Combat Stress. All the electives in the world could not have instructed me more elegantly in not just what went into the making of a combat stress casualty but, for the sake of our troops, how to prevent it!

When it came time to retrograde home following the quick win of Desert Storm, I was stuck. Following this unprecedented 6 month build up, there was an impossibly long queue of physicians, nurses, medical of all types, waiting to retrograde home. Learning that I was PGY-4 resident in need of finishing my residency only angered the colonel from the G4 shop even more. “You’re a doctor, aren’t you,” the colonel inquired upon hearing my request to hurriedly depart theater in order to complete PGY-4 year ... “Yes, ma’am, but I am a resident physician”, I replied. “I need to return home to finish my residency,” I added, knowing that other mobilized and recalled physicians would understand. “You’re licensed, aren’t you”, clearly aware that her G4 shop could be in trouble if unlicensed personnel had been caring for her Marines. “Yes, ma’am,” I dutifully replied ... “You doctors—with your excuses of needing to get home to care for the sick, sickens me,” she rebuked!

Humph . I was really stuck. In just a week, I was to continue my residency as chief resident. It was only upon the colonel’s learning that under the terms of my elective, I was actually required to pay my own way to the point of embarkation that her curiosity piqued. “What kind of a residency do you need to get home to?” she asked, clearly disgusted with the litany of excuses from other doctors “Psychiatry,” I informed her. “You’re F_N crazy!” she shouted incredulously, “YOU’RE OUT OF HERE!”

Fortunately, notwithstanding this humorous digression, the breadth of my operational career bolstered my professional credibility. Two warfare devices, multiple pumps downrange, more than seven rows of ribbons on the left side of my chest—though not nearly as decorous as the CNO’s remarkable rack—underscored my credibility and subsequent clarion call for aiding IAs. Who knew projectiles not of copper or lead, but of shame and guilt . bullets with which the detainee was psychologically armed . could wound so grievously. In a population of poorly trained and hastily assembled IAs, the casualty is not the individual, but the unit. The data did not lie.

Without the will and presence of mind, the soul and psyche, even spirit cannot be armored. Chinks in this armor then appear, quite insidiously, eroded by physical threats, hurtful, racist taunts, and lurid, sexist gestures. Danger for the guard force was everywhere. Detainees who could fashion shanks from bed springs, could similarly weaponize an adrift pen or pencil. Buckets of feces mixed with vile concoctions of urine and semen were tossed on unsuspecting guards. Like snipers picking off the psychologically weakest, IAs serving this most dangerous of mission fell quietly and surely. The cumulative effect of daily exposures of 15 h—or longer-produced nonstop interactions, replete with face-to-face contact with these desperados.

Shame, like fear, disarms the limbic system, and sets in motion, the desire for retaliation and retribution. Even more alarmingly, in the post Abu Ghraib world, the Department of Defense’s pendulum swung widely the other way, from hard scrapple interrogation techniques replete with (inappropriate and illegal) highly publicized detainee abuse by a few miscreants to ICRC-monitored detainee “rights.” From senior leadership’s perspective, there must not, cannot be, any more flagrant mistreatment of the detainees at the hands of US military members.

Knowing this meant that the detainee could add to their armamentarium, the threat of uttering factitious and felonious abuses at the hands of the guard force to the ICRC (International Committee of the Red Cross). Reminiscent of the sadistically malicious, older brother who would beat the bejesus out of his whiney kid brother when mom and dad weren’t around, the detainee population continued to strike out with malice and lethality, yet feign ignorance and innocence with impunity. In the unkindest act of all (at least during this particular visit), the guard would then be reprimanded for “allowing” himself to be beaten, or herself to be sexually groped—then beaten. Assaulted during a moment of inattention, then punished for same by the leadership set up a lose- lose proposition; the rat gets shocked no matter what. The detention facility became the detainees’ new battleground. Given these dynamics, the detainee was now armed with spears capable of inflicting a new type of moral injury.

Upon arrival to this decrepit, dank, and immediately depressing facility in Afghanistan, the stench was staggering. As if not to be outdone by captive’s cacophonic chorus, a mixture of human, rodent, and only God-knows-what, excrement pervaded the fetid stink. A milieu of various body odors and fluids, admixed with mold and mildew straight from the underworld was only partially masked by air sanitizers struggling to keep up. Large industrial sized fans, Springer-esq if not for the dashed humanity, circulated stale air among the din and clamor of the imprisoned. Not only was my olfactory sense overwhelmed, but so was my sense of humanity and the dignity which previously accompanied it.

This particular facility screamed of an earlier era during a time the Soviets learned a decades-old lessons of not tangling with the Mujahedeen. More representative of a Hollywood set within the cellblock, the most intimidating “actors” on this harrowing stage seemed to play the restive part well. Milling robotically in circles, pausing only when called to prayer, their stockade seemed to limit free will as it did physical movement. Suddenly, springing to menacing animation as if from the pages of a Mary Shelly novel, a detainee would grab the bars, reaching other-worldly. Tactically aware, waiting and watching for a that precise moment of inattention, hopefully killing or at least maiming an unsuspecting guard, the prisoners were thoroughly skilled to play the part.

While there were a few Master of Arms (military police) mobilized to IA orders, the majority in this unit were Sailors from every rate in the Navy. Once assigned IA Guard Force duty, they were required to serve in the same capacity as fully trained military police. What these true patriots had in common, beside criminal justice naivety, was the willingness to fight—and if need be—to die for their country. Shared too among them, was the lack of training and staffing sufficient to endure hours upon hours, days upon days, months upon months, in this disheartening, demoralizing, dispiriting, and most perilous of all, dangerous setting.

Locked away with these heinously misbegotten souls for up to 18 h a day in an offensive, soon-be-closed facility, I could only wonder how the E3s, the most junior members of the Navy, Sailors who hadn’t even really checked into their first duty station, could/should be in receipt of such IA orders. It would be several months following this maiden visit (and several subsequent visits after that) validation of our original findings data came in the form of the CNO’s utterance, “How could we let this happen?”

Practiced in the world of military psychiatry where Combat and Operational Stress is the substrate of PTSD, once understood, Combat Stress could be managed. What my visits to this and other detention facilities taught me, was the unique kind of operational stress detainee operations imparts: an inescapable, unavoidable, and most treacherous experience of shame and guilt. Whereas guilt can be considered a feeling of remorse for oneself for an act one did—or did not—commit, shame is the pervasively negative state—an attack on one’s self—for what they experienced. And the detainees were masterful at shaming, belittling, humiliating, chastising, debasing, and of course, when given the opportunity, attacking! Even though guards may not have committed shameful acts, shame, like fear, is not rational. Rather, it is a profoundly human experience endured by the civilized, the dignified.

The emotional environment paralleled the physical environment and compounded guard force stressors. Like heavy metal exposure and asbestos exposure (another real risk accompanying this mission), the lingering impact of shame and guilt were toxic to the autonomic nervous system. Other authors have noted the relationship of Shame and Guilt to PTSD. This dysregulation markedly impacts the sufferer’s ability to process psychological traumas [2].

If I have learned one thing in my 30 odd years of active duty working directly for and with the line community is to never, ever identify a problem without also identifying a solution or solutions! (Note: The line community are those officers who command ships, fly planes, order around squadrons or battalions ... the medical corps is NOT the line, rather a Staff Corps). For the most part, providers are considered non-combatants, servants of the line, imbued with certain skills, granted certain protections under Geneva Convention. As a Staff Corps, we work for the Line Community. Hence, it did not come as a surprise to me that when after CNO heard about the morbidity statistics associated with Detainee Operations, I was asked, “So what are your recommendations, Captain?”

Fortunately, my lieutenant and I had thought this through. Given the ubiquity of the Individual Augment valiantly serving throughout the theater of operations, the solution needed to impact the thousands of other Sailors, in multiple locations, who were similarly affected. These fish-out-of-water, so to speak, needed advocates, monitors, reach-back to big NAVY. IAs could certainly be attached to Army units but not without Navy personnel providing over watch. Never again would a ships’ store keeper show up at Fort Jackson to be assigned to a Stryker platoon as a communicator, then be hastily reassigned as combat replacement for a 50 cal. turret gunner without continued surveillance.

Alas, the concept of the Mobile Care Team (MCT) was born. For the first time in Navy Medicine, covenant leadership would be defined by the ability to monitor, surveil, and track through the use of standardized inventories and instruments, realtime health outcomes of active (and principally Reserve Component) Sailors during actual combat. Moreover, this same covenant leadership would ensure that by having a suitably trained clinical/investigative team on the ground, just-in-time, hands- on care could be rendered. Sailors caring for Sailors. Imagine that. The brilliance of the concept being the mobility of the team to go where covenant Navy leadership, oversight, and authority could not. The MCT could provide not just one-on-one care, individual and group psychiatric care, but armed with real time, actionable epidemiological data, offer consultative assistance at a command level also!!

Nine consecutive iterations of the Mobile Care Team followed, surveilling thousands of deployed Individual Augments, identifying countless problems while boots were still on the ground. Preventive Medicine re-imagined. Best of all, the MCT provided direct care to hundreds of Sailors, delighted to be visited by someone who spoke Navy, looked Navy, and reassured that “big Navy” cared enough to ensure the IA was not treated as a “fire and forget weapon” ... “Oh the things you can find if you don’t stay behind”—

Acknowledgment The author would like to acknowledge the contribution of his “right hand man,” battle buddy, and collaborator, Justin Campbell, Ph.D., in the preparation of the manuscript.


  • 1. Charles W. Hoge, M.D., Carl A. Castro, Ph.D., Stephen C. Messer, Ph.D., Dennis McGurk, Ph.D., Dave I. Cotting, Ph.D., and Robert L. Koffman, M.D., M.P.H. N Engl J Med 2004; 351:13-22.
  • 2. Leskela J, Dieperink M, Thuras P. Shame and posttraumatic stress disorder. J Trauma Stress. 2002;15(3):223-6.

Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care Robert Koffman served as a Navy Combat and Operational Stress Control Consultant, Acting Director of Psychological Health, and clinical psychiatrist, with over a quarter century of operational medicine. This chapter covers events from around 2006 to about 2008.

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