Dr. Wendy Law Takes a Detailed Case History of a Marine Sergeant

Questions about childhood, habits pre- and post-TBI, and how relationships can change are all part of taking a full case history.

NOTE: The name of the service member is not included to protect his confidentiality.

Dr. Wendy Law: Before we get started, I want to get some background information. We'll talk about what your injuries were and what brought you in today, but let me get to know you a little bit first. I need some of your history. What branch of the service are you with? Sergeant: Marine Corps. Dr. Law: What's your rank? Sgt: Sergeant. Dr. Law: Is that E5? Sgt: E5. Dr. Law: Thank you. Dr. Law: What's your primary job? Sgt: Mortarman. Dr. Law: Mortarman. Sgt: Yes. Dr. Law: And what's your current status? Sgt: Active. Dr. Law: Active. Dr. Law: How old are you? Sgt: 31. Dr. Law: What's today's date? Sgt: Today's date? I think it's the 19th. Dr. Law: What month? Sgt: August Dr. Law: What year? Sgt: 2011. Dr. Law: Thank you. You passed that test. [laughter] Dr. Law: Have you deployed while you've been in the military? Sgt: Yes. Dr. Law: How many times? Sgt: Four. Dr. Law: We'll talk more about that in a little bit; I want to get some other information first. Sort of going back a little bit — where were you born and raised? Sgt: Puerto Rico. Dr. Law: Puerto Rico. Grew up there too? Sgt: Yes. Dr. Law: When did you leave? Sgt: I joined the Marine Corps when I was over there. Dr. Law: Who were you raised by primarily in the home? Sgt: My mother and my father. Dr. Law: And what was it like for you growing up in your home? Sgt: It was awesome. Dr. Law: Okay. Sgt: I grew up — I've got an older brother, and I've got two sisters — I've got a twin sister. Dr. Law: Oh, really? Sgt: Yes, so I grew up in a family that learned how to appreciate things and learned how to earn things. Dr. Law: Okay. And then you joined the Marine Corps? Sgt: Yes. Dr. Law: How much formal education have you had? Sgt: I have two years of college. Dr. Law: Is that an associate's degree? Sgt: Yeah. Dr. Law: In what? Sgt: Theology. Dr. Law: Did you have any particular difficulties in school? Learning how to read, write, and do math? Sgt: No. Dr. Law: Were you ever diagnosed with learning disability or attention deficit — Sgt: No. Dr. Law: What did you do for recreation and fun as you were growing up? Or what did you do — what were you involved with in school? Sgt: I did all kinds of sports. I went to the beach; I did basketball; I did volleyball; I did boxing; track and field. Dr. Law: So you were very active in sports. Sgt: Yes. Dr. Law: Did you ever play football? Sgt: No. Dr. Law: Did you ever have any injuries in any of your activities where you fell and hit your head or had any — ? Sgt: Any concussion? Dr. Law: Yeah. Sgt: No. Dr. Law: Nobody ever said that you hit your head or that you had any - Sgt: Not that I know of. Dr. Law: As a kid, you never fell? Your parents didn't say that you had a problem where you didn't wake up for a while or — ? Sgt: No. Dr. Law: Usually they would have said if that had happened. Have you ever had any serious illnesses or hospitalizations? Sgt: No. Dr. Law: Prior to your injuries, of course. Sgt: Right. Dr. Law: Were you ever in any motor vehicle accidents? Sgt: No. Dr. Law: Have you ever seen anybody for emotional or behavioral problems? Therapy or treatment? Sgt: No. Dr. Law: How much do you drink? Sgt: I don't drink. Dr. Law: Not at all? Sgt: No. Dr. Law: When did you stop? Sgt: I never — Dr. Law: Never drank? Sgt: No. Dr. Law: Okay. So it's — not even when you were younger. Sgt: No. Dr. Law: Any other substances? [Marine shakes head to indicate no.] Dr. Law: Have you ever been arrested? Sgt: No. Dr. Law: Are you married? Sgt: Yes. Dr. Law: And how long have you been married? Sgt: Two years. Dr. Law: Do you have any children? Sgt: Yes. Dr. Law: How many? Sgt: Two. Dr. Law: And how would you describe your relationship with your spouse? Sgt: Outstanding. Dr. Law: Good relationship? Sgt: Outstanding. Dr. Law: Outstanding. It's a good support? Sgt: Yeah. Dr. Law: And do you have other friends and family that you have good connection with? Sgt: I have a very good support group. Dr. Law: Thank you. [papers rustling] Dr. Law: So I want to turn now to some of your deployment experiences. You said you've been deployed 4 different times? Can you tell me, in order, what the locations were? Sgt: The first time in Iraq — hit. And my second time, in Iraq. Third time, in Iraq. And my last time, in Afghanistan. Dr. Law: And how long were the first three deployments to Iraq? Sgt: Six months. Dr. Law: Each? Sgt: Yeah, 6 to 7 months. Dr. Law: Were you engaged in combat? Sgt: Yes. Dr. Law: Did you have exposure to blasts and small-arms fire? Sgt: Yes. Dr. Law: In the first deployment, did you have any experiences where you were dazed or confused after a blast or any other type of incident in theater? Sgt: Uh - Dr. Law: If you can remember back to the first one? Sgt: Not really, no. Not that I - Dr. Law: Not that you remember? Sgt: Yeah. Dr. Law: And in the second deployment to Iraq, did you have any incidents where you either hit your head or were exposed to a blast and you were dazed or confused or had a loss of consciousness? Sgt: I was exposed to a lot of blasts, but - Yes. I was — I was confused a couple times. Dr. Law: In the second one? Sgt: Yeah, reaction to the blast, yeah. Dr. Law: Confused in terms of being startled because it occurred, or were you just, sort of, your thoughts were confused? Sgt: Probably the shock — you know — the shock wave. Dr. Law: Okay. So actually the effect of the explosion and not the emotional response to it. Sgt: Yeah. Dr. Law: And how long did those symptoms last? Sgt: I don't know. Probably a couple minutes. Dr. Law: And then did you sort of just get right back up and go back in to work? Sgt: Yeah. Dr. Law: So, the second one so far — of the 3 Iraqs, the second one was the most active? Sgt: The most — no. Yes, the second one was the most active. Dr. Law: Okay. But you completed all three of your Iraq deployments. Sgt: Yeah. Dr. Law: And in the Afghanistan deployment, were you again engaged in combat activities? Sgt: Yeah. Dr. Law: And prior to being injured, when you were brought out of theater, did you have other incidents when you were exposed to blasts and had some - Sgt: Yeah, I had a small concussion. Dr. Law: Do you remember what happened? Sgt: I was in my vehicle; we ran over an IED. Dr. Law: Where were you in the vehicle? Sgt: I was in the passenger seat. Dr. Law: Front or back? Sgt: Front. Dr. Law: So you were the technical command? Is that correct? Sgt: I was the VC — the vehicle commander. Dr. Law: Vehicle commander. Sorry, that's the wrong service. The vehicle commander. And how many people were in the vehicle? Sgt: Three. Dr. Law: The driver, yourself, and another? Sgt: Yes. Dr. Law: Okay. And where were you? Were you on a convoy or on a mission? Sgt: On a convoy. Dr. Law: And where was your vehicle in the convoy? Sgt: Front vehicle. Dr. Law: Front vehicle. Can you tell me what happened a little bit more? Sgt: We were driving, and we just heard the explosion. The vehicle — the front — the window was all black, all dark. In the beginning my reaction went, like, what happened? I looked to my side. My driver — he had a pretty big concussion. And my turret gunner — I was trying to wake him up and assess the situation. Dr. Law: Did you know what was going on right away? Sgt: Yeah. After that, yes. Dr. Law: Took a few minutes — ? Sgt: A few minutes. Dr. Law: Or just a few seconds? Sgt: A few seconds. Dr. Law: So your driver was unconscious. Sgt: Yeah. Dr. Law: And your gunner? Sgt: Yes, unconscious. Dr. Law: He was unconscious as well. So you came to first. Sgt: Yeah. Dr. Law: Did you lose consciousness? Sgt: Not that I know of. Dr. Law: Okay. You were just sort of dazed and trying to figure out what happened. Sgt: Yeah. Dr. Law: Where was the explosion relative to the vehicle? Sgt: It was right on my side. Dr. Law: On your side. Front wheel? Sgt: Yeah. Dr. Law: Do you remember feeling the vehicle move from the explosion? Sgt: Uh...no. Dr. Law: What's the last thing you remember right before the explosion? Sgt: Uh...the window was all black. Dr. Law: And that was when the explosion occurred, probably? Sgt: Yeah. Exactly. With all the dirt and whatever. Dr. Law: Did you know that an explosion had occurred right then? Sgt: No. Dr. Law: Not right in that second. Sgt: No. Dr. Law: Did you hear the explosion? Sgt: Yes. Dr. Law: So after you thought about it, you realized what that was. What's the first thing you clearly remembered right after that? Sgt: Just looking at my Marines. Dr. Law: Okay. Seeing that there were people who were unconscious. Did you have any physical injuries in that blast? Sgt: No. Dr. Law: Other than the — dazed. Did symptoms stay with you afterwards for a while? Sgt: No. Dr. Law: What did you do to help your fellow Marines? Sgt: I was trying to wake them up. And I was on the radio checking on all the other — the whole convoy. Dr. Law: How big a convoy was it? Sgt: Like 5 vehicles. Dr. Law: Okay, your vehicle was the first one, so you hit the IED; the others were behind. Sgt: Yeah. Dr. Law: Did the other service members need to be medically evacuated from there? Sgt: No. Dr. Law: Okay. So they came to, and you were able to continue on the mission? Sgt: Yeah. Dr. Law: Okay. Thank you. Did you have any other blast exposures prior to your getting this final injury in which you were dazed or confused? Sgt: No. Dr. Law: So now I would like you to tell me a little bit about what happened the day you were injured. Sgt: I was leading a foot patrol, and we were clearing an area, and we had metal detectors. We were getting ready to go, and we found a couple of IEDs. As we were getting ready to go — because the area was supposed to be clear - I looked up at — looking at my Marines, and I walked probably like 8 steps. And I heard a — that's when I heard the explosion. Like I saw myself like in the air or something. Then I — my ear, my left ear — I heard like a "beeeeeee." And I opened my eyes, and I was just — I thought it was someone else, because I didn't feel any pain. You know, just looking around to see what happened. And that's when I saw my corpsmen — some of my buddies — were on top of me. Dr. Law: They were on top of you at that point? Sgt: Yeah. And that was just...trying to understand what happened. And I was just going — you know — I was — I felt very tired. Dr. Law: Sure. Sgt: And I was just — I kept closing my eyes like to go to sleep; I was tired. And then I started feeling a lot of pain, and it was so much that I just told my corpsmen that I wanted to die, just to leave me alone, I didn't want to take it. Then I remembered my buddy, and he was trying to keep me awake, and he started to talk to me about my family — my wife and my girls. And I just started praying. I wanted to go home. I wanted to live, see my family. He was just telling me that — you know — you're going to go home. You're not going to stay here. I was just fighting for my life and praying to God to give me — you know — give me a second chance to go home. Dr. Law: You had some awareness at that point of how serious your injuries were? Sgt: I didn't know how serious my injuries were, but I know — I know I was fighting for my life. Dr. Law: Okay. What's the last thing you remember? Sgt: Just talking to my buddies. Dr. Law: And then what was the next thing? Sgt: Talking about my wife and my girls. That's it. Dr. Law: Did they — do you remember being medically evacuated? Sgt: No. Dr. Law: Okay. When is the next memory you have after that? Sgt: I was looking at my buddy. Right there. The next thing I remember after I got medevaced — that I was here, in Bethesda. Dr. Law: Okay. Do you have any idea how long afterwards that was? Sgt: I think it was 4 days. Dr. Law: Okay. So you have 4 days that — nothing at all. Sgt: No. Dr. Law: And obviously they medicated you and were doing medical treatments. Do you have any idea how much blood you lost in association with the injury? Sgt: A lot of blood. Dr. Law: Yeah. Okay. And obviously they did a lot of very emergent work with you. Sgt: Yeah. Dr. Law: And since your injury, what kind of treatment did you have after you got here to the hospital? How did they work with you? Sgt: Everyday. My amputations, my wound care, my TBI. A little bit of everything. Dr. Law: Are you currently having symptoms? Sgt: Ah... ...not that I — you know — not that I — I can't describe like, "Hey, I'm going through this symptom now." Sometimes I'm in a very high good mood, and sometimes — I got ups and downs. Dr. Law: Okay. So it sort of waxes and wanes a little bit. Sgt: Yeah. Dr. Law: Have you had any problems with your thinking, that you've been aware of? Sgt: Ah...my TBI said I do. Dr. Law: What are you noticing? Sgt: I think retaining — you know — I'm not retaining — that's what they said. I don't know. I'm not retaining like I used to. Dr. Law: Do you notice that, or is it more just what other people have told you? Sgt: I notice that. I notice that. Yeah. Dr. Law: Are you doing anything to try and help with that? Sgt: I'm working on it. Yeah. I'm working on it. Dr. Law: What about concentration? Have you noticed any change in your ability to focus on what you're trying to do? Sgt: Ah... No. No. Dr. Law: So it's really more memory kinds of things? Sgt: Yeah. Dr. Law: Are you having any problems with headaches? Sgt: No. Dr. Law: How has your sleep been? Sgt: Good. Dr. Law: Yeah? No problems with sleep? Sgt: Just — you know — sometimes to fall asleep. Dr. Law: Hard to fall asleep? Sgt: You know. Like at night — like just to go to sleep. But when I'm sleeping — I sometimes — once I'm asleep, I'm asleep. Dr. Law: Okay. Sgt: Until I wake up. Dr. Law: Are you currently taking any medications? Sgt: No. Not to sleep. Dr. Law: No — at all? Sgt: Yes, I am. Dr. Law: What medications are you taking? Sgt: I'm taking Lyrica for nerve pain and Suboxone. Dr. Law: And what is your pain right now? Sgt: I'm all right. Dr. Law: Zero? On a scale of 0 to 10? Sgt: Zero. Dr. Law: Do you have any pain at all during the day? Does it come at different points? Sgt: Yes. Dr. Law: What's the worst? Sgt: The phantom pain, like, comes and goes. Dr. Law: Okay. And how has your vision been. Sgt: Good. Dr. Law: Any difficulties with blurring or — ? How's your sense of taste? Sgt: Good. Dr. Law: No problems with smell? How's your appetite been? Sgt: Very good. Dr. Law: No difficulties eating? Sgt: No. Dr. Law: Do you eat as you would normally eat before you were injured? Sgt: Yeah. Dr. Law: Pretty much? Sgt: Mm-hmm. Dr. Law: And have you ever been feeling so down about things that you thought about harming yourself? Sgt: I felt — at the beginning of my injury I felt very - I felt that — in a moment I felt that it probably wasn't worth it to live. But I wasn't going to hurt myself. I snapped out of that — you know — I've got a family. Life is good. I feel very grateful that I'm alive. Dr. Law: What about the circumstances in which you were injured or you saw other people injured? Do you ever have memories of those things coming back that you have a hard time pressing out? Sgt: No. I mean — I think about it, but I guess I deal with it. Dr. Law: Have you had any nightmares? Sgt: Yes. Dr. Law: How often do you have nightmares? Sgt: Probably once a week. Dr. Law: And they wake you up? Sgt: Sometimes. Yes. Dr. Law: So when you're having nightmares, your sleep is a little more disrupted, but most of the time you sleep through pretty well. Sgt: Yeah. Dr. Law: Do you find that you're — do you spend any time avoiding people or activities that remind you of your military experiences? Sgt: No. I wouldn't have been here. Dr. Law: Okay. I appreciate that. Thank you. If I'm understanding the main thing you're struggling with at this point is some persisting memory problems that people have said you have and that you are also aware you have difficulties with. Is that correct? Sgt: I think the most difficult thing that I'm dealing with right now is learning how to live my new life. Dr. Law: Absolutely. I'm sorry, and I appreciate that clarification. I was getting very focused on the symptoms, and you're absolutely right. And in that, from a symptom perspective, you're having difficulties with memory and that certainly is impacting things as well, but you're learning how to relive with loss of limbs and back in the community. Where are you living now? Sgt: I live in [town name] in an apartment. Dr. Law: You have an apartment. Sgt: Ten minutes from here. Dr. Law: With your wife and kids? Sgt: Yes. Dr. Law: And how is that going? Sgt: It's going great. Dr. Law: I mean, is the apartment adapted well for you? Sgt: Oh, it's not handicap-adapted. Dr. Law: So you're having to deal with all sorts of things. Sgt: Yeah, but it's temporary, while I'm here and doing my therapy in Bethesda. I'm very grateful that I'm living in an apartment with my family here. Dr. Law: Okay. Sgt: That helps a lot. Dr. Law: What are you doing for your memory difficulties? Sgt: Well, I'm talking to my therapist about that. Dr. Law: And — doing any sort of cognitive rehab kinds of activities? Sgt: No, I'm not — I'm not to rehab right now. Dr. Law: Okay. Dr. Law: So what have you been told about what's expected with your memory problems? Sgt: What I was told is that the main problems that I could be having is — you know — retaining things in my memory, like you said. They gave me a solution of things that I can do about it, so right now I'm in that phase. Dr. Law: Okay. Are you making lists or trying to find strategies? Sgt: Yes. Dr. Law: So what you've described to me — you clearly had, certainly, a concussion, minimally, with the incident that you were injured, because you weren't quite aware even that you had been hurt. So there's that period of not really processing what's going on. And you also had a concussion previously in the incident where your driver and the gunner were both knocked unconscious and you had an alteration of consciousness. So it indicates you at least had concussive injuries in your deployment experiences. I haven't seen the neuroimaging to know if there is anything that showed on there that would indicate that your brain was having any structural effects. But typically with concussion injuries, we don't expect the symptoms to persist as long as they have with you. See, the other thing you have going on is you had very significant blood loss associated with your injuries, and we know that can also impact the ability to think clearly and have memory problems. It sounds to me like you're struggling with some difficulties with memory that are a little longer than we would expect would be fully explained just by concussion. Things like sleep and other things can also contribute, so you're doing all the things you need to right now to try and figure out how to move forward with your life, which is your job at this point. That is your challenge. And I certainly would encourage you to keep working with your therapist and continue doing what you're doing as you continue recovering. Sgt: Thank you. Dr. Law: Thank you very much for coming in today. I certainly appreciate your taking the time.
Posted on BrainLine December 30, 2011.