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Guest Perspective: Think Outside of the Box

Guest Perspective: Think Outside of the Box

Editor's Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” This series features blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.

As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).

That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.

As I walked into Mr. Smith’s small hospital room I knew this was not going to be an easy physical therapy evaluation.   Mr. Smith and his wife had been through a devastating car accident a few days earlier.  As with most high-speed, roll-over accidents, Mr. Smith had suffered many broken bones to include two broken legs, and a broken wrist and his wife sitting at his bedside was covered in bruises and had one arm in a sling.  As I stepped up to his bed, I introduced myself and stated my purpose for my visit. “Good morning, Mr. Smith, my name is Carolyn.  I’m a Physical Therapist and at your doctor’s request I’m going to teach you how to get out of that bed today, get into your car, and up the six steps into your home.” 

Mr. Smith and his wife both dropped their jaws and looked at me like I had lost my mind. (Little did they know, three tours of combat in the Army had left my mind with quite a few Band-Aids, but we can talk about that later.)  Having already been through a few surgeries, Mr. Smith’s hand and wrist on one arm was wrapped in a cast and both of his legs were fixed in full extension with external fixators from mid-thighs to mid-calves (picture a half dozen screws exiting the bones in all directions and the screws attached to a medieval-looking cage with bars that wrapped both legs).  The doctors were ready to send Mr. Smith home, as he was at least one or two weeks away from his final surgeries, which could not occur until the swelling from the recent trauma decreased enough to remove the ex-fixes and place plates along the broken bones to allow the injuries to fully heal.  Mr. Smith didn’t have a medical necessity to stay in the hospital waiting for those future operations and insurance was not going to pay to send him to a rehabilitation center until the final operations were complete and he could again bear weight through his broken limbs.  With his one good arm, he shook his fist and exclaimed, “Just how are you going to do that?”

While the three-year post-graduate doctoral program covers an immense amount of information and research for physical therapy rehabilitation, they could not possibly cover every situation and scenario one will face when after graduation.  Therefore, I, along with my fellow therapists, am quite used to “thinking outside of the box.” (Stay with me till the end and I’ll share a few secrets of the trade and how Mr. Smith safely and successfully exited his bed that day.)

As medical practitioners, it’s easy to get into routines, customary practice guidelines and well-organized treatment regimes.  I’m well aware, as with any situation or job, it can be very challenging and frightening to step outside of your comfort zone and push the boundaries. Yet, every single patient and situation is different.  Each person is unique, has a different story, and is looking to you for help. Let’s face it, sometimes you run across that unicorn; the square peg that will not fit in that round hole. 

That is why I have been asked to write to you today.  I’m here to share with you a story, my story about a life and a family that was saved by two mental health practitioners thinking outside of that box.  Those practitioners brought a soldier out of what seemed like a hopeless situation that had baffled doctors across the country for over a decade. 

As a decorated NCAA Division 1 swimmer, West Point graduate, four-time ironman athlete with a post-graduate degree, and a happily-married mother of two boys, I think most people would consider someone such as myself to be perhaps the last person one would find locked behind the doors of a psychiatric ward. 

I deployed as a civil affairs officer with a Special Forces unit in 2002 to Kabul, Afghanistan. There I helped rebuild schools and medical buildings, dodged ever-present mortar fire and suicide bombs, had weapons placed at my chest, and dealt with the inevitable loss of over a dozen comrades, this first deployment would be considered enough for anyone to endure, yet it would not be my last.  Three months after returning home from my seven-month long mission, I was lined up at the border of Iraq as a company executive officer for a combat Heavy Engineer Battalion.  My soldiers would be the first ones into battle (engineers build and clear the lanes for the armor and infantry to follow) and we would spend the next year of combat operations in Iraq building airfields, clearing roads, and working with the people of Iraq to help them get back onto their feet and rebuild their country following the initial months of destruction left behind by battles.  After a year, we returned home, and I made plans to complete my contract and move onto a career in the FBI.  Four months short of the end of my commitment, my unit was given orders to redeploy to Afghanistan and with a lack of man-power, I along with my fellow comrades were stop-lossed; meaning we could not leave at the end of our commitments and we would join the unit for another year of combat operations in the desert.  Now on my third deployment, in fact three out of the last four years of my life had been spent in a combat zone, I was considered a seasoned combat veteran, with no history of mental illness.  Yet, in the middle of a simple convoy, no different than the dozens upon dozens of combat operations and missions over the previous four years, my mind just broke.  I was suddenly paranoid, quiet, and I couldn’t function.  I don’t think anyone can prepare you for the moment your commander steps before you and asks you for your weapon.  Days later I found myself on a psychiatric ward on a US military base in Germany.  As the doors shut behind me, all my hopes, dreams and aspirations seemed lost.  I was the only woman, I was the only combat soldier fresh from a war zone still wearing my dust-covered combat uniform.  They took my shoelaces and my hair ties. The doctors drilled me: why I was there; what illegal drugs was I taking; was I pregnant and using mental illness to get out of combat, was I making it all up? I was scared and fearful of those around me.

Then just like that, within three days I was back to my normal self and begging to return to the combat zone, to return to my soldiers in Afghanistan. The doctors were baffled and kept me on observation in Germany for two weeks and then on the ward at Walter Reed back in the States.  I was told that there was no way that war did this to me, that I must have had a history of mental illness, that I was born this way, and one doctor even suggested I shouldn’t be allowed to fly in an airplane with my condition because they feared I could possibly take over the controls and try to crash the plane. Eventually after three months everyone agreed I was sane, and I was safe to myself and others and they let me return to my unit in Afghanistan in September of 2005.  I was not broken, I did not have a mental illness. This was not how my army career was going to end.  

But it happened again, this time three months into my tour, my mind traveled back to the valley and I shut down.  A few days later I found myself on the same psychiatric ward I had left just six months earlier. Just like the previous time, I was again back to my normal self very quickly. 

As my observation periods on the ward continued, I was given opportunities to leave the ward to have a meal in the hospital or meet with family and friends outside of the ward who traveled to DC to visit.  Typically, I would run across the soldiers with the physical battle scars of war. The bullet wounds, burns, and missing limbs.  I would always feel guilty and ashamed.  These soldiers appeared to have it much worse than I, and no one could see my wounds or what was wrong with me.  I now questioned and doubted myself just as the doctors had.  Why couldn’t I fix myself, why was I so weak? 

On these outings, it was hard to miss the differences in the wards.  The pleasant furnishings, pictures on the walls, vases with flowers and most importantly: visitors and family members that could stay at the bedside of their physically wounded warrior.  It was a stark contrast to the bare walls of the psych ward.  Far from warm and welcoming, families and friends were not allowed to come on to the ward or stay at the bedside of their soldier.  There was always a steady stream of actors, athletes, politicians, and our military leaders at the bedsides of the soldiers with these physical wounds. But they were not allowed on our ward.  In my case, these types of rules and policies made me feel that much less of a soldier or deserving of America’s embrace. 

I finally came home and was medically processed out of the military in 2006. I tried to move on in my life as if nothing had happened. I took a job as a military contractor in DC.  But again and again, I shut down, cyclically for a period of days to weeks, even months. Each time I found myself back in the valley again on that third tour. I couldn't work, I couldn't function effectively.  I didn’t present the typical rage that is often associated with PTSD.  I was scared, paranoid, and quiet.  I wanted to stay in my house, I didn’t want to talk to anyone, and not a single provider could tell me why or find a medication that would stop or curb my symptoms.

Always seeking distractions, I yearned to be around soldiers.  I stumbled upon a volunteer position at Walter Reed in the physical therapy department.  Over the course of a year I met and worked with a soldier recovering from his physical injuries from a roadside bomb.  I asked him how he could keep his smile and positive attitude every morning I saw him, knowing the pain he was about to endure in his therapy session.  He told me three other soldiers in his vehicle were never coming home.  He was making the best of every day and he would become a functioning member of society again. This was the day I decided to change directions.  I would help others realize their full potential after an injury or life-altering accident. In order to do so, I was going to become a physical therapist. 

I applied to and was accepted to a doctoral program at Bellarmine University in Louisville, KY in 2008 and the VA’s vocational rehab program supported my efforts. 

Both myself and my family hoped the past and my mental struggles were behind me. I was no longer at war or dealing with stressful intelligence work.  I was safe at my grandmother’s home, surrounded by family, and I was helping people in a profession that you could truly see people heal, get up and walk again.  However, life had other plans for me.  My episodes continued.  They would happen again and again, lasting longer each time. It took me five years to get through the two-and-a-half year doctoral program. But I persisted and I graduated. I stand here before you today a practicing Physical Therapist.  I met my husband, another engineer, while I was in the program. He is an amazing man and loves me with all my flaws.

To say that these episodes were a disruption in my family’s life is an understatement.  I took a job as a PRN (substitute therapist). I could fill in when the hospitals needed additional help, but I could also call in and say I couldn’t work for any length of time. While I continued to have these setbacks, I also never gave up hope that these struggles would end.  I took each mental health visit as a new opportunity to retell my story to each new provider, to learn from them, challenge them, and try their new techniques and treatments.   Furthermore, I developed a solid support network around me.  I didn’t hide the fact that I struggled.  I would explain to close friends, family and even bosses about my situation so when I did struggle they didn’t fear me.  We had a plan and everyone knew how to get me the help I needed.  Most importantly during these times, I did not push them away.  I accepted their help.

Through all the trials, medications, and mental health appointments, the doctors and I could never find a diagnosis to explain my symptoms and struggles.  In fact, for years I was prescribed the same medication over and over again by each new provider because it was in my medical record and the provider before them had used it.

The last doctor, very well meaning and whom I very much respected, told me before he retired that they would probably never know the answer in my lifetime. Rather than get angry and frustrated, I channeled any negativity into making the best of every day… I NEVER GAVE UP. 

One day my VA Nurse Practitioner, Ms. Reddington, told me about a doctor named Rif El’Mallehk (perhaps some of you have heard of him, if not, you can find over 200 medical journal articles authored by him and his research in mental health over the last 30+ years), a world-renowned and well-respected psychiatrist. My provider had just listened to him at a continuing education lecture over her lunch hour. She told me he was actually at the hospital where I worked as a physical therapist at the University of Louisville. She thought he would be interested in my case.  

So, I wrote a letter to him, summarizing everything I could as concisely as I could in one page, describing my history and struggles over the last decade. I dropped the letter off at noon in his office with his secretary.  He called me at 6 p.m. that night and said: “I know what your condition is, and even better there is a medication when dosed correctly, that can treat it.”  The doctor believed my condition was Cycloid Psychosis. A diagnosis not used readily or found in the DSM here in America.  It’s more commonly found and well-researched across the pond in Europe.  As I spoke with Dr. El’Mallehk, I realized that for the first time in over a decade here was a provider who could give me an explanation as to WHY he believed this was my diagnosis and HOW the medication would work. 

Furthermore, Dr. El’Mallehk challenged me to take part in my care and this diagnosis.  He made me think critically.  He would say: “Look at the research, look at other case studies.”  He also told me to not just accept what he had to say, but to really seek to understand for myself, and feel free to question him at any time. 

It has been two years now since I have suffered seriously from the symptoms of my condition, all because of a providers who were thinking outside of the box.  They didn’t try to place me in a category, or suggest a medication like the medical books and drug companies told him to do.  Dr. El’Mallehk and Tammy Reddington pushed the boundaries.  Now, since the publication of my book and the sharing of my story to audiences across the country, Veterans, providers, and families have come forward saying that they believe they have the same symptoms, or are treating someone who may fit this diagnosis and they want to talk to the doctor to learn more.  So, perhaps this case is not so much of a unicorn after all. 

I am not looking for sympathy here today.  I do not regret what has happened to me because I have met amazing people who have supported me in this journey of life and, of course, I met my knight in shining armor, my husband Joe. Together we are raising two very smart, wild, and crazy boys. I love my life with all of its ups-and-downs. Even after all that has happened, I would choose the same careers, the same schools, serve in the military all over again because I love our military, its mission, and the soldiers and Veterans that fill the ranks and continue to put themselves in harm’s way today for the American people. 

Since I know all of you have been waiting on the edge of your seat, let’s go back to Mr. Smith and his hospital room and what would appear as an insurmountable task at hand.  With most patients with broken legs, a wheelchair can be brought to the side of the bed, Mr. Smith could roll to his side, dangle his legs over the bed, bring a sliding board under his buttocks and bridge the gap from the bed to the chair.  He could then easily slide from the bed placed in a higher position into the chair using his one good arm to guide him.  Yet, Mr. Smith is my unicorn, his ex-fixs cross the knees so he can’t dangle his legs, and his room is so small we can’t get a wheelchair along the side of the bed.  So, what do we do? (Wait for it…) Mr. Smith is instructed to lean down on his elbow on one side (the break on the arm was at the distal wrist, therefore he is perfectly fine to weight bear through his elbow) and using his one good arm and hand to push and pull…he turns himself around so that his back is to the end of the bed and he is in an upright long-sitting position.  The footboard to the bed is removed.  The wheelchair is rolled straight to the end of the bed.  Mr. Smith, then scoots on his elbow and uses his one good arm to pull himself back into the chair.  The chair legs are brought up to support his extended legs and with the help of his wife’s one good arm and his one good arm, Mr. Smith has gotten out of bed for the first time. He realizes he’s got this, he is going to move on after this accident. He and Mrs. Smith wheel away into the sunset.  Now if you want to know how he could possibly get into his car to go home and climb the steps into his house, you’ll have to either change careers to physical therapy or join me on my next visit to another “Mr. Smith” because he is not the only unicorn.

Given, I would hope, you are in a profession that you love, I doubt you are willing to change careers. So now I challenge you to step outside of the box, push the boundaries and champion the next patient that walks into your office.  NEVER GIVE UP.

Carolyn Furdek travels the country sharing her message of hope, resilience, and a never give up attitude to audiences ranging from medical providers, students, business leaders, and Veterans.  You can learn more at http://bravo748.com/presenters/carolyn-furdek/)

Guest Perspective: Think Outside of the Box | Center for Deployment Psychology

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