Pec11 chap 41 the combat veteran

Prehospital: Emergency Care
Eleventh Edition
Chapter 41
The Combat Veteran
(PTSD)
Copyright © 2018, 2014, 2010 Pearson Education, Inc. All Rights Reserved

Learning Readiness
• EMS Education Standards,. Special Patient Populations
• Chapter Objectives, page 1145
• Key Terms. Page 1145
• Purpose of lecture presentation versus textbook reading
assignments.

Post-traumatic stress disorder (PTSD) is a mental disorder that can
develop after a person is exposed to a traumatic event, such as sexual
assault, warfare, traffic collisions, child abuse, or other threats on a person's
life.[1][6] Symptoms may include disturbing thoughts, feelings, or dreams related to
the events, mental or physical distress to trauma-related cues, attempts to avoid
trauma-related cues, alterations in how a person thinks and feels, and an
increase in the fight-or-flight response
These symptoms last for more than a month after the event Young children are
less likely to show distress, but instead may express their memories through play
A person with PTSD is at a higher risk of suicide and intentional self-harm. Most
people who experience traumatic events do not develop PTSD. People who
experience interpersonal trauma such as rape or child abuse are more likely to
develop PTSD as compared to people who experience non-assault based
trauma, such as accidents and natural disasters About half of people develop
PTSD following rape. Children are less likely than adults to develop PTSD after
trauma, especially if they are under 10 years of age. Diagnosis is based on the
presence of specific symptoms following a traumatic event.

Anyone is at risk who have suffered a
Traumatic Event

Setting the Stage (1 of 4)
• Overview of Lesson Topics
– Recognizing the Patient with PTSD
– Introduction
– The Psychophysiology of Stress Response
– Combat Veterans
– The Nature of PTSD

– Associated signs and symptoms of PTSD
– Alcohol and Drug use
– Danger to self and others
– Signature wounds of Combat Veteran
– TBI Versus PTSD signs and symptoms

– Vagus Nerve Stimulator
– Terminally Ill Patients
– Renal Failure and Dialysis
– Gastrointestinal and Genitourinary Devices
– Intraventricular Shunts
– Terminally Ill Patients

Clues to Help Identify a Combat Veteran
• Military-style haircut
• Military clothing, such as combat boots
• War memorabilia, such as photos showing battle gear
• Photographs of other soldiers, combat buddies
• K.I.A. bracelet (commemorating a person killed in action)
• Tattoos
• Combat patches
• Commendation awards
• Country flag
• Veteran license plate
• Military vocabulary/demeanour/bearing
• Respect for authority
• Reluctance to seek assistance

Case Study Introduction (1 of 2)
You and your partner are dispatched Code 3 to a local residence for an “injured
person.” While en route, you receive additional information from dispatch that
your patient is a 34-year-old male with a possible broken right hand. You are
told that the police department is also responding to the same address. Your
crew is then asked
to stage upon arrival so the police can secure the residence.
Your alarm room states that you will be assigned a fire engine with ALS
capabilities. Upon arrival, you notice several police vehicles that line the street.
You stage at the corner and await confirmation that the scene is secured. You
document your “on scene” time and the reason for your delayed patient
contact. After approximately three or four minutes, a police officer signals at
you to approach the scene, while waving the “code 4 scene is safe” hand
gesture. Simultaneously, you tell your
dispatcher a police officer has cleared you to enter the scene and that it is
secure. The alarm room acknowledges as you don your personal protective
equipment, grab your EMS equipment and the gurney, and proceed to the front
door.

Case Study (2 of 2)
• What are the first actions the EMTs should take?
• What is your primary responsibility when entering this scene?
• What will you look for in your primary scene survey to identify any safety
issues or nature of illness or mechanism of injury?
• Is there any pertinent information that you can gather from the police or other
bystanders prior to patient contact? What other resources may be
• required to successfully mitigate this situation.

Introduction (1 of 3)
As an EMT, you will almost inevitably encounter a returning
combat veteran. The term returning does not
necessarily mean that he just arrived from combat. The
veteran may have been back for weeks, months, or
years. Although veterans make up less than one percent
of the population, the effect of their combat traumas will
often present to EMS in a way that other patients will
not. The etiology of this unique presentation is posttraumatic
stress disorder (PTSD), which develops
from the extreme stress of combat.

Although PTSD is a relatively new term, the condition
and how it affects people have existed for as long
as there has been war. It is even mentioned in the Bible,
when Jeremiah laments his flashbacks as he recalls the
trumpets of war. During the American Civil War, the
condition
was called “soldier’s heart,” or “nostalgia.” During
World War I, physicians referred to it as “shell shock” and
then renamed it again during World War II and Korea, in
which it became known as “combat neurosis.” The condition
known as PTSD was not recognized during, but
only after, the Vietnam War. It was then called “delayed
stress,” because war veterans began to experience issues
related to combat long after the war’s end.

PTSD does not indicate a “weak mind” or any sort
of predisposing flaw in one’s personality. Anyone, anywhere,
and at any time will predictably exhibit these signs
and symptoms if they have undergone a trauma that was
sufficiently dangerous or stressful. There is debate among
professionals as to whether or not PTSD is even a
“psychiatric”
condition. Some people, including portions of the
military, assert that PTSD is “weak” or “mental,” when it is
not. PTSD happens when normal people are exposed to
abnormal stressors or dangerous conditions.
Many combat soldiers exhibit a facial expression that
has been termed “the thousand-yard stare” (Figure 41-1
page 1146) that is a response to abnormal stressors or
dangerous
conditions.

Recognizing the Patient with PTSD
• Any number of combat situations or medical and
traumatic conditions can result in PTSD
• It is not only the Combat Veteran that can be afflicted
with PTSD, but anyone going through a very traumatic
experience, even your work companions in the EMS
world
• Impairments can result from aging, birth defects, chronic
illnesses, traumas, abuse, neglect, and other causes.

The Nature of PTSD(1 of 8)
PTSD is a collection of signs (what the EMT observes about patients) and
symptoms (what the patients experience and may tell the EMT). The
pivotal feature of this disorder is what happens when a normal individual
is exposed in any way to an abnormal event. It is abnormal because it
signals actual or perceived immediate death, serious injury, or horrific
trauma. It is also considered abnormal because there is sustained SNS
activation, and memories of the trauma linger and are disruptive to the
person.
PTSD has four essential features and numerous associated aspects. The
four features are response, reliving, avoiding, and anxiety/anger.

1. The veteran’s response involves feelings of anger, fear, horror, and
helplessness.
2. The individual relives these events by way of flashbacks, unwanted thoughts,
or nightmares. These episodes are painful and uncontrollable, lasting seconds
to hours, and can occur even decades after the combat exposure.
3. The person avoids anything that even reminds him physically or emotionally
of the trauma. This “emotional anesthesia” protects the individual from having
to repeat the trauma. This could include avoidance of involvement with people,
crowds, war movies, loud noises, diesel fumes, or any intimate, sexual, or other
interpersonal interactions.
Any event or circumstance related to the original trauma can trigger this re-
experience. For example, snow is a reminder of Korea. A palm tree is a
reminder
of Vietnam. Even the Arizona desert looks like Afghanistan. Driving along any
road means needing to watch for improvised explosive devices or stalled cars
reminding of accidents re-visited.. The number and types of triggers are
endless. One hundred percent of PTSD Patients will at some point have
flashbacks and a sleep disturbance, usually with nightmares. The person may

The key to understanding the person’s avoidance
of any situation that may cause reliving the trauma is
grasping the personal pain to the Patient and his fear
that it will become personally overwhelming (again)
and that he/she will “freak out.” In its extreme, a flashback
can resemble a psychotic episode but should be
approached differently by clinicians.

4. The person might display anxiety or anger. The nervous system’s arousal
caused by the trauma can result in a “fight or flight” response that is so extreme
the veteran is simply not able to suppress it. The traumatic event is perceived
as immediate, even though it may be months or years later. Because of this,
the EMT will observe a hypervigilant or exaggerated startle response on the
part of the veteran to any threatened or perceived danger similar to his
response to the original event. The veteran spends much of his time in this
state of perceived imminent threat. It is
constant and painful. This is why alcohol or drug use is a common way to
attempt to calm these demons. Suicide is a way to permanently end the pain.

The Nature of PTSD (5 of 8)
Associated Signs and Symptoms of PTSD
• Guilt (guilt for what I did, guilt for what I did not do), shame, avoidance of
others, depression, paranoia, hostility, feeling they will not live much longer,
agitation,
and anger are all common among combat veterans. The level of frustration
and
anger cannot be overstated; these emotional states can be overwhelming
to the
patient as well as to the EMT
Alcohol and Drug Use
Drug or alcohol dependence or abuse is notorious for its high level of denial
and minimization among veterans. As a result of SNS activity, the veteran is
always in
a heightened state of awareness; drugs and alcohol are used to suppress the
SNS activity and slow the body down. Sometimes vets feel that turning to
these substances is the only way they have to stop or dull the mental and
physical pain.

Danger to Self or Other
Part of any scene assessment is the evaluation for potential violence, known
as danger to self or other (DTSO). It is a myth that combat veterans are more
dangerous than others. Research of combat veterans makes clear that they
are no more likely to commit homicide or assault than their noncombat peers,
the previously mentioned era veterans. However, their suicide rate is more
than
30 percent above that of their noncombat peers, a rate that is rising
drastically for reasons that are not entirely clear. Almost certainly, one factor
is the nature of their
return from a war that can often be seen as unpopular and difficult to
understand. Returning combat veterans are much more likely to harm
themselves rather than others because their anger is directed inward. The
suicide rate for combat veterans is 18 per day and increasing.

Factors in Assessing Danger to Self or Others(1 of 3)
• Ensure your own safety first. You will do no one any good if you yourself are
not physically safe.
• Involve others whenever you can. This would be family, friends, clergy, or a
neighbor. This includes the patient: “How do you want me to help you?” “Is
there someone who knows you that I can talk to?” “What is it you need right
now?”
• A past history of violence is one of the better predictors of future violence.
“Has this happened to you before?” “What was the outcome?” Similarly, a
history
of the use of deadly force increases the risk of deadly force now.
• Talking about suicide or homicide will not increase the likelihood of it
happening. In fact, your concerns will be welcomed. This might be the only
time that the patient will reach out to others, so be specific.
• Get rid of any possible weapon. Veterans are, by definition, trained to use
violence as a solution to problems, so violence already has a higher
probability of use in any given situation. They are also resourceful. They have
been trained to improvise weapons in precarious situations. The lethality of
the weapon involved is a factor. Higher risk weapons are those that are easily

• If your patient is tense, agitated, yelling and pacing, has had no sleep, or is
intoxicated or high, then you, the EMT, will need to take action to ensure
scene safety.
• Take care with physical restraints. Any physical restraint will only escalate
the situation. Straps, handcuffs, or even seat belts can aggravate a patient.
Chemical restraints should always be an option, which would require an
advanced life support response.
• The “gut test” or the “orientation reflex” is unscientific, nonempirical, and
unresearched, but never to be excluded in one’s assessment of violence. It is
that
sinking feeling one gets just below the sternum that is outside one’s
consciousness and control and appears suddenly. It is the body’s way of
saying “There is danger
here,” and one must pay attention to it. The body’s personal radar has just
noticed that there is a need for fight or flight. Think of it as one of the body’s
survival
instincts, because that is exactly what it is.

• The “suicide formula” is this: pain or emotional turmoil that is believed to be
unchangeable, unending, and unbearable. Suicide risk increases with any
recent
loss someone has experienced, such as divorce, death of a friend, or loss of
a job or house. The loss has to be significant to the vet, so do not judge the
severity by any other values. It also increases with the presence of chronic,
unending, unbearable and untreatable pain that cannot be helped by any
means. The fact of previous
suicide attempts should be a very large red flag for the EMT. A very specific
plan increases the risk of suicide. In the end, if a person has decided to
commit suicide, that person will find a way to do it.
• “Anniversary reactions” can cause an acute level of stress or increase
existing stress, which will increase the risk of violence. The calendar date on
which a friend died, a close battle occurred, or the date of serious injury is an
anniversary date. A veteran can have one or as many as seven or more
critical anniversary dates.
• Know that the following is a MYTH: “When someone talks about suicide, it
means they are not really serious; they just do it to be dramatic or get
attention.”

Signature Wounds of the Combat Veteran
War and traumatic Events, brings physical scarring and pain of all kinds. As
advances in weaponry and treatment of combat injuries progress, soldiers gain
advantages when it comes to surviving battlefield wounds. Before the conflict in
Vietnam, combat personnel were likely to die of seemingly minor wounds that
became infected. Since the use of medevac helicopters, the likelihood that a
soldier could
survive an injury greatly in creased. As a consequence, there was an increase
in amputations and an increase of survival with other debilitating injuries.
The “signature wound” of Vietnam was a gunshot wound to the chest because
of the prevalence of face to-face firefights, in civilian street it may be the death
of a child in a MVA. Tragically, the signature wounds of Iraq and Afghanistan
are those caused by improvised explosive devices (IEDs). An amputation is an
indication that one may have seen combat, as is a traumatic brain injury (TBI),
a mild concussion. In these days of terrorism attacks the causes of these
traumatic Events are becoming more prevalent in ordinary life styles, therefore
PTSD is not just a symptom of the Combat Veteran but to all.

Signature Wounds of the Combat
Veteran
TBIs are defined as an alteration in brain function or other brain pathology
caused by an external force such as concussion. Because of the
prevalence of IED
explosions , TBI/concussion is a signature injury associated with those
conflicts. Since 2000, some 300,000 patients have been diagnosed with
TBI/concussion resulting from an IED. Generally, such patients are
identified early on, but some with TBI go undiagnosed. The EMT will be in a
position to help identify these undiagnosed patients.
The signs and symptoms of TBI are urgent in nature, but there are some
disease processes that will not show up until later. High cholesterol,
hypertension, and diabetes are examples of other issues patients may
eventually experience. Inexplicably, a full 50 percent of patients with PTSD
also are later diagnosed with Type II diabetes.

Persons With PTSD May Have Numerous Symptoms But
Can Participate In Normal Activities With Help From The
Right Back Up From Family And Friends
(© Jotl/Science Source)

TBI Versus PTSD: Signs and Symptoms
The signs and symptoms of PTSD and TBI overlap considerably. At the
scene, it is preferable to use the word “concussion” as opposed to “traumatic
brain injury” because of the emotional impact of the latter on the patient.
When collecting a history related to the event, a loss of consciousness (LOC)
is no longer required to make a diagnosis of concussion. The patient may
deny a brain injury event because he never experienced a loss of
consciousness. However, it is very likely the patient will have already been
diagnosed, following return from traumatic duty, as having a traumatic brain
injury. It will not be the responsibility of the responding EMT to make a
determination of the presence or absence of traumatic brain injury related to a
traumatic event. However, when you are considering the presenting signs and
symptoms in your assessment, it is important to understand the difference in
presentation between PTSD and TBI so that if the latter is the suspicion,
proper acute
care can be sought for the patient

TBI Versus PTSD: Signs and
Symptoms
PTSD and TBI are not mutually exclusive diagnoses; both can and often do
occur in the same person. In fact, TBI increases the likelihood of PTSD. This
fact should help the EMT decide what actions to take regarding patient care
when there is a suspicion of PTSD, especially if the patient has a history of TBI.
PTSD may not require any action on the EMT’s part other than transportation
to an emergency department for a referral or consultation with a mental health
professional. By contrast, a patient with TBI will likely already have been
diagnosed and almost certainly will have been under the care of a physician for
the condition. Problems in patient care can arise when the veteran
goes undiagnosed or misdiagnosed. In the patient’s history since combat, a
TBI could have been overlooked because it was mistaken for PTSD, since the
two conditions
present so similarly. A patient who presents with signs and symptoms of a TBI
that has been overlooked requires emergency care, whereas PTSD requires
assessment and treatment by a mental health professional. PTSD might not
need the attention of a neurologist or imaging studies, but a TBI will.

The following are key points to follow when arriving on scene and providing
assessment and emergency care to a combat veteran and Patients:
1. DO NOT ask the veteran if he has ever killed anyone. Ever.
2. Veterans are used to structure. Provide your patient with organization and
limits.
3. Remind the patient who you are. You are there to assist him with any
needs or concerns he may have.
4. Reassure the patient in a calm, firm voice. Be soothing, but be in charge.
5. If you, yourself, were in combat, tell the combat veteran just that. If not, DO
NOT say, “I understand,” because you don’t.
6. Anything you do with a patient can build rapport. Casually talking about
news, weather, or sports can go a long way.
7. Combat vets have an “invisible disease” and are facing a new and different
“battle” at home. This patient will be reluctant to talk to you about PTSD and
might not even be aware of just how much he has been impacted by it. Part
of this is human nature, but part of it is the stigma some of the military and
companies holds toward its people who are “mental.
Assessing and Providing Emergency Care to PTSD
Patients:
Recommendations for EMTS

8. Focus on what the combat veteran wants from the encounter with EMS as
well as what you assess as appropriate. Maybe all the patient wants to do is
get
something off his chest and be able to sleep tonight.
9. Do not assume PTSD, but be sure that you do not rule it out in your
assessment. If it does not exist in its full-blown form, there is a part of it
always present.
Remaining aware of it will add another dimension to your patient care.
10. Regarding weapons, the correct question to ask the combat veteran is
not “Do you own a weapon?” but rather, “How many weapons do you own
and are they secure?” Confirm that weapons are secure before you start.
11. Do not bang on the door and do not crowd the Patient. Respect his/her
personal space. Limit the number of people involved and, if you need to, get
the patient to move to an area that affords more privacy and quiet. Keep
your line of sight to the doorway clear. Try to keep the general “buzz” down.
Do not do anything to the patient without first explaining your actions.
Patients:

12. Diesel fumes, dust, and helicopters are a trigger for combat vets. Tanks,
vehicles, and other heavy machinery use diesel fuel in combat. These
fumes are
ubiquitous for EMTs but will immediately remind the veteran of combat.
13. Combat vets have trouble asking for help. Part of this is due to the
military ethos “Don’t quit, handle your mission, don’t leave anyone behind.”
You will
help things if you give the veteran permission, “I’m here to help you and to
understand what’s going on—it’s okay to talk to me.”
14. Even though the current situation may not be directly related to PTSD,
this may be the first time this patient has asked for help. Slow things down,
and plan on taking the time to listen to your patient.
Patients:

Summary
PTSD involves an intense emotional and physical response to abnormal
trauma. It is a condition that affects normal people exposed to abnormal
stressors or dangerous conditions. The four essential features are visceral
responses to trauma, reliving the trauma through flashbacks and
nightmares, avoiding
the smallest reminder of the trauma, and a predominate demeanor of
anxiety and anger. Additional associated features will include guilt and
shame, complaints of physical pain without clear origin, and depression
and suicidal ideation.
The EMT should also consider that the signs and symptoms of PTSD and
TBI are similar but do have their differences. A TBI or mild concussion
occurs in combat vets principally because of IEDs. In addition to many of
the symptoms of PTSD, TBI signs and symptoms include sensory
dysfunction, disorientation, confusion, headaches, and memory problems.
The returning combat veteran is a patient who will require very specialized
attention by the EMT. It is important to
remember that the trauma this patient has incurred is mental as well as
physical. The pain that the patient feels is very real, and it is not the EMT’s
job to qualify or dismiss any pain that seems to be unfounded. Although
the returning veterans are a small percentage of possible patients, once
identified they will present the
EMT with challenges that will not apply to other patients.

Be prepared to take time and listen to the concerns of the vet. These
patients might ask for assistance only once, and if they do, the EMT
must understand what they had to go through to get to the point where
they could ask for assistance. It must also be understood that there are other
resources available to the EMT to further assist in the treatment of the combat
veteran patient.
Combat veterans have made countless sacrifices for
their country, their family, their health, and other aspects of their lives. The EMT
must recognize this when dealing with these patients and give them the care and
respect that they
deserve.
Summary cont’d

Case Study Follow-up
Scene Size-up
Your crew has been called to a residence for an injured
person. After the house has been cleared by police for
any obvious threats, you make primary contact with your
patient in his living room. Around the room you notice
some military items. You spot a black bracelet on the
patient’s wrist that appears to be a killed-in-action “KIA”
bracelet. You notice that the patient seems to be a bit
“on-edge” as you and the ALS fire crew approach.
Primary Assessment
The patient is a 34-year-old male, approximately six feet tall
with a muscular build. He appears unkempt, and you smell
alcohol on his breath as he speaks. He says, “My hand
hurts but it’s nothin’ I can’t handle, doc . . . I’m good to go.”
When asked about the pain, he states, “It’s like a 4 out of
10.” You note that his right hand is swollen with an obvious
deformity to the tarsal and metatarsal region. The police are
in the kitchen taking a statement from the patient’s wife.

Secondary Assessment
You begin your history taking by asking the patient what happened this
afternoon. He replies, “You know, doc, she just doesn’t get it. I’ve told her at
least a dozen times
not to sneak up on me while I’m reading . . . or any other time for that matter.
She knows I’m having a hard time right now.” You notice a bottle of whiskey
that is almost gone sitting by your patient’s side. You inquire about his alcohol
usage today, and the man states that he has only had about half of the bottle
this afternoon.
As your partner and the fire crew stabilize the patient’s hand, you make your
way into the kitchen to get information from the man’s wife. She tells you that
the man is a combat veteran and has had some “adjustment issues” since
returning home about six months ago. She says he had seen some heavy
fighting and had lost several
men from his unit. She also states that they have been arguing lately and that
today’s incident resulted in him hitting the wall with his fist after she startled
him while he was reading. She denies any physical abuse and tells the police
that she will not want to press any charges against her husband. As she is
saying this, she begins to sob and says, “He’s just so different. He’s not the
same person I married. He
drinks all the time, he yells at me, and he has horrible nightmares that scare
me in the middle of the night. Just last week, he got a speeding ticket and
another citation
for reckless driving. He never used to do that.” You acknowledge the wife’s

Returning to the patient’s side, you ask the patient if there is anything that
you or your crew can do for him besides treating his hand. The patient says
that he doesn’t understand why he is angry all the time, and that he wants
to stop fighting with his wife. He points to the bracelet on his left wrist and, in
a statement full of
heartfelt grief, declares, “This isn’t what he would have wanted me to do. I
let him down. He was my responsibility and I let him die in my arms.” As you
are obtaining a set of vital signs, you make a note that the patient’s hand
appears to be heavily bruised and severely deformed and that he should be
evaluated by a physician at the hospital. The vital signs come back stable,
and you bring your gurney forward. The man begins to cry and tells you that
he is sorry that you have to see him in his current condition. He apologizes
to his wife as you load him into the ambulance.

Transport and Follow-up
As you secure the gurney in the patient compartment, your partner returns
to the patient’s wife to see if she has any further needs or requests. Your
partner tells you the man’s wife stated that she doesn’t know what to do to
help him. He says that she seemed very distraught by the fact that her
husband is in pain all the time, and she also said that she feels “very
helpless.” Using your knowledge of the community resources division of
your local fire department, you know that
there is a crisis response (CR) team that is available for incidents like this.
You calmly ask the patient if he would like to speak to someone about this
other than the ER physician. He states, “I’m not crazy, doc. I’m NOT! I
don’t want to talk to anybody about my dreams. They wouldn’t
understand.” You politely explain to the patient that the CR unit is a great
resource and that he would have to talk to them only about whatever he
wants. You also assure him that the CR staff are not there to judge or
criticize him, but to assist him by listening to his concerns and helping him
find the appropriate resources so he can stop fighting with his wife.
Finally, he nods his head in agreement and you call your alarm room to
have the CR unit meet you and your patient at the hospital. Leaving the
patient in the care of your partner, you tell the patient’s wife your plan and
you ask if she would like to accompany you to the hospital where she
could also speak with the members of the CR crew. She agrees and tells
you that she will follow in her car after the police leave.

Reassessment
En route to your base hospital, you are reassessing the patient’s vitals when he
looks at you and says, “Thanks doc. You know, since I’ve been back, nobody
has offered
to do anything for me. Hell, other than my wife, you’re the only one that has
even tried to listen. We lost a lot of guys over there and I miss ‘em a lot. Nobody
gets it, nobody wants to listen, and they just think I’m a drunk or I’m tired or
crazy.” You reply by thanking your patient for his service to his country, and you
express your sincere sympathy for the loss of his fellow servicemen. He nods
his head in acknowledgement. You arrive at the receiving facility and transfer
the patient to the hospital cot. As you give your report to the attending staff, the
CR unit arrives and you introduce their crew to your patient. He acknowledges
them and thanks you again for your help.
You and your partner return your unit to a ready state for the next call.

In Review
1. What is the EMT’s primary responsibility?
2. The knowledge of PTSD from this chapter has wider applicability to
patients other than combat veterans. Who might those be?
3. EMTs are exposed to trauma due to the very nature of their work. What will
you do if or when you start to develop symptoms of PTSD?
4. PTSD can be missed as a problem. What are some reasons for that?
5. What are the four main features of PTSD?
6. Which symptoms are similar between PTSD and TBI?
7. Which symptoms differ between PTSD and TBI?
8. Since 2000, how many service members have been diagnosed with a TBI?
9. What percentage of vets use drugs or alcohol to help them cope?
10. Is there a cure for PTSD?
11. What is the definitive treatment for returning combat veterans suffering
from PTSD?
12. What is the definitive treatment for returning combat veterans suffering
from TBI?
13. What other resources does the EMT have available to assist
in treating the veteran patient?

14. What are some other disease processes that might be
found in the veteran patient more often than in the general
population of the same age?
15. What is the suicide rate for returning combat veterans?
16. Unfocused pain is common in the combat veteran. Name
three other types of patients who may have the same
signs and symptoms as the returning veteran.
17. What are some “triggers” that may exacerbate a situation
involving a veteran?
In Review

Critical Thinking
You are called by the police for a person behaving strangely. You arrive on
the scene and find a young male, approximately 23 years of age, hiding
behind a garbage dumpster near a crowded street corner in the city. The
patient appears
to be very anxious and scared. He has a military haircut and a
recognizable KIA bracelet on his left wrist. He is mumbling something
about hearing an RPG (rocket propelled grenade).
1. What characteristics of the scene imply the patient is
potentially
a returning combat veteran?
2. How would you manage for scene safety? What are your
concerns for keeping the scene safe?
3. How would you approach the patient?
4. What characteristics would you notice during your assessment
that would make you suspect the patient is suffering
from PTSD or TBI?
5. What emergency care would you provide to the patient?
6. What additional resources would you contact to assist
with this patient?

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Pec11 chap 41 the combat veteran