Wed March 16, 2011
Brain Wars: How The Military Is Failing Its Wounded

Army Clarifies Purple Heart Rules For Soldiers

Acknowledging that commanders have sometimes wrongly denied the Purple Heart to soldiers who suffered battlefield concussions, the Army plans to issue new guidance to clarify when such recognition is warranted, Army officials said Wednesday.

In addition, the Army is planning to prioritize appeals from brain-injured soldiers who feel they should not have been turned down for the medal, a hallowed military honor that recognizes those injured in combat.

Gen. Peter Chiarelli, the Army's second in command, said he reviewed the Army's policies on the Purple Heart and called for the new guidelines as a result of an investigation by NPR and ProPublica. In a report published last September, we found that Army commanders denied Purple Hearts to some soldiers who sustained concussions, despite regulations that make those who suffer such wounds eligible for the medal.

"What was clear to us is that there's confusion about concussion and the Purple Heart," Chiarelli said. "There's confusion on the part of commanders, and there's confusion even on the part of doctors."

Though the new guidelines do not change the rules concerning eligibility for the Purple Heart, a modern version of an award originally created by George Washington, they add a clarity that should make it easier for soldiers to prove they deserve recognition.

To receive the Purple Heart, the Army's current regulations require that a soldier be injured by enemy action and receive documented treatment from a medical officer. The Army's official list of wounds that "clearly justify" the award includes, "Concussion injuries caused as a result of enemy generated explosions."

The NPR and ProPublica report, however, found that some senior officers and medical officials did not consider concussions serious enough to merit the award. Concussions, also called mild traumatic brain injuries, typically do not leave visible damage. While most people recover from them within days or weeks, civilian studies suggest that about 5 percent to 15 percent of victims may suffer lingering cognitive problems.

The report showed that a senior medical officer in Iraq, Brig. Gen. Joseph Caravalho, issued a 2008 memo that discouraged awarding the Purple Heart in cases in which soldiers required only "minimum medical intervention." Other senior medical officials had turned down soldiers for the medal out of concerns that giving it for concussions lessened its value when compared to soldiers who had suffered other types of injuries.

The new guidelines, which will be distributed throughout the Army, provide a checklist that makes clear that concussions requiring any sort of treatment by a medical professional—including bed rest or over-the-counter headache medication—is sufficient to meet award criteria.

The guidelines also clarify that soldiers diagnosed and treated by any medical professional, including nurses and physician's assistants, are eligible, as long as their standards of care match those a military doctor would apply.

Chiarelli said the checklist was part of an ongoing effort to ensure that soldiers, commanders and medical officers take so-called "invisible wounds" seriously. Recognizing soldiers who have suffered concussions drives home the Army's commitment to improving care and treatment, he said.

"It is very important if we're going to get at this stigma issue," Chiarelli said. The Purple Heart "shows to everyone that these hidden injuries are truly injuries that affect folks."

After the ProPublica and NPR reports, Chiarelli ordered officials at the Army's Human Resources Command to review whether Purple Hearts had been erroneously denied.

Col. Tom Quinn, the Army's director of soldier programs and services, initially reviewed nine applications from soldiers that had suffered a mild traumatic brain injury. Three soldiers had received the award. Six others had been denied or were still awaiting an answer because commanders disagreed on their cases. Four of the six clearly merited Purple Hearts, the review determined.

The results prompted Chiarelli to order a more-in-depth review this fall, a task made more difficult because the Army does not centralize the award of Purple Hearts, which are often handed out in the field.

Reviewers looked over more than 6,000 paper records, including applications for awards other than Purple Hearts. They found about 100 applications for Purple Heart concerning soldiers with concussion injuries. Some appeared to have been wrongly denied, Quinn said, but he did not have statistics.

"We determined that the guidance is not very clear out in the field and it's not being uniformly applied across the force," Quinn said. "We think some deserving soldiers may not have been appropriately recognized."

Army officials decided the most equitable way to rectify erroneous denials was to ask all soldiers who applied for Purple Hearts for concussions to re-apply.

Quinn promised the Army would move "aggressively and impartially" to resolve the requests as quickly as possible. "We don't want to miss anybody. We want to give everybody the same opportunity." Quinn said.

The new guidelines will apply only to the Army. Other military branches are reviewing their criteria, however, according to the Military Times. Currently, the Marine Corps recognizes soldiers with the medal only if they were knocked unconscious, even though the medical definition of concussion encompasses blows that leave patients dazed or confused, but conscious.

Rep. Bill Pascrell (D-N.J.), has asked the military to apply a uniform standard for awarding the Purple Heart.

Soldiers and their advocates welcomed the Army's new guidelines. The Purple Heart brings few medical or financial benefits, but is a tangible symbol of having fought and suffered for one's country. It is also the only military award that is considered an entitlement—an honor earned through individual sacrifice, rather than awarded by a superior officer.

"It's encouraging that soldiers will finally get the awards they deserve and that their injuries will be acknowledged," said Jayna Moceri Brooks, an Army wife and nurse who helped found Recognize the Sacrifice, an organization which helps soldiers with concussions apply for Purple Hearts. "It's very encouraging."

Nathan Scheller, a retired sergeant, has battled for years to receive a Purple Heart for concussions that he received in Iraq. He expressed cautious optimism that the new guidelines would help.

"It's about time," he said. "If they keep track of the system and they keep track of what's going on, I believe it will get better." Copyright 2011 National Public Radio. To see more, visit http://www.npr.org/.



The Army acknowledged yesterday that some commanders wrongly denied Purple Hearts to soldiers who suffered concussions from explosions. The Army said now, it plans to publish new guidelines that will help those soldiers receive an award that is supposed to be given to all who are injured by enemy action. Some Pentagon officials say they learned about the problem from an investigation by NPR and ProPublica.

Our story showed that some commanders do not believe that concussions, which are also called mild traumatic brain injuries, are really injuries. NPR's Daniel Zwerdling has the story, which was co-reported by T. Christian Miller of ProPublica.

DANIEL ZWERDLING: The Army's announcement should make it easier for soldiers who get concussions from explosions to get Purple Hearts. But General Pete Chiarelli says this is about more than the medal itself. Chiarelli is the number two general in the Army. He says the Army's main goal is to diagnose every soldier who has TBI, and then give them better treatment. But Chiarelli says the new guidelines on Purple Hearts send an important message to every commander.

General PETE CHIARELLI (U.S. Army): It's important to all of us. That shows to everyone that these hidden injuries are truly injuries. Those injuries must be treated, and soldiers must receive the entitlements when they suffer those injuries at the hands of the enemy.

ZWERDLING: An Army spokesman says the new guidelines are not official yet. They're sitting on the chief-of-staff's desk. He's the number one general. They're waiting for his signature. But General Chiarelli says he started looking into this issue late last year. First, he asked commanders who run the Army's awards program a simple question: How many soldiers who suffer TBIs have been rejected for Purple Hearts? Dozens? Hundreds? Thousands? And the commanders couldn't answer.

Colonel TOM QUINN (U.S. Army): We don't have a reliable database.

ZWERDLING: Colonel Tom Quinn supervises the Army's awards program -Purple Hearts, Bronze Stars, everything. You might think their files are conveniently stored on computers, and Quinn could go clackety-clack and presto, he could answer Chiarelli's question. Nope.

In other words, you have thousands and thousands and thousands of records having to do with Purple Hearts and other awards on paper, and boxes - basically - in a warehouse.

Mr. QUINN: That is a fair statement.

ZWERDLING: How long would it take you? How many man-hours would it take you to find that answer?

Mr. QUINN: I couldn't even speculate.

ZWERDLING: Weeks, months?

Mr. QUINN: I couldn't give a number. It would be a huge task.

ZWERDLING: So Chiarelli said OK, let's do a sample investigation. They pulled nine files of soldiers who got TBIs. Three of those nine got Purple Hearts, as the regulations say they should. A couple soldiers did not get Purple Hearts because their TBIs were not caused by enemy action. As for the other four soldiers, Chiarelli says they clearly deserved Purple Hearts, but their commanders didn't award them.

Gen. CHIARELLI: What's clear to us is that there's confusion about concussion in the Purple Heart. There's confusion on the part of commanders, and there's confusion even on the part of doctors. And it just really upsets me. And it's hard for me to sit here and talk to you and in some way, make you feel that your reporting brought us to this place. But it did.

ZWERDLING: And here's why some commanders and doctors have been confused: When a soldier gets a concussion, the standard treatment right afterward is simple. Doctors tell them to get some rest, and to take some over-the-counter pain pills for their screaming headaches. But NPR and ProPublica found that some top commanders have been saying: Wait a minute; if that's the only treatment those soldiers are getting, those concussions aren't really injuries; no way they should get Purple Hearts.

But today, the Army's new guidelines stress: Yes, they should. A concussion is potentially serious. Sometimes, it can cause permanent brain damage, no matter what the treatment is.

Mr. NATHAN SCHILLER (Veteran): My reaction is that pretty much, it's about time.

ZWERDLING: Nathan Schiller was injured in two explosions in Iraq. Army records document it. Now, his brain doesn't work right anymore. But commanders have rejected Schiller for a Purple Heart - twice. He says the Army's new guidelines are a step in the right direction.

Mr. SCHILLER: I want to believe General Chiarelli, that he wants to help, he wants to make a stand. But he's one person. You know, if they just make a big deal out of this for the next couple months because of what you guys at NPR are doing and things like that, and then it kind of just filters away, it'll just be like everything else. It'll just disappear, you know? If they keep track of the system and keep track of what's going on in it, I believe it will get better.

ZWERDLING: General Pete Chiarelli says he's determined to make it better. He's already spreading the word.

General CHIARELLI: Good afternoon to all of you, leaders of the brigade. I really appreciate your being here today.

ZWERDLING: One morning recently, Chiarelli had a teleconference in his office with the commanders of a brigade that's going to Afghanistan. As he talks to them, Chiarelli's looking into a big, flat TV screen - and more than a dozen commanders are looking back at him from Fort Drum in upstate New York.

Unidentified Man #1: Climb to glory, sir. Third Brigade, 10th mountain. We've got our entire team here. Our battalion commanders and sergeant majors are here along with...

ZWERDLING: Chiarelli says every time a brigade is about to deploy now, he gives them a one-hour talk about concussions - or TBIs - and other invisible injuries. His main point is, you have to treat them seriously.

Gen. CHIARELLI: Next slide, please. Now, this slide shows you the enormity of the problem. Unfortunately, soldiers affected by...

ZWERDLING: And then Chiarelli drives the point home. He gives a sermon on Purple Hearts.

Gen. CHIARELLI: I promise you I still got leaders out there - and I got leaders out there even after I talk to them like I've talked to you today - that will deny soldiers a Purple Heart when they get a concussion. You don't have to lose eyesight or lose hearing or anything else. You are diagnosed by a doctor or a medical professional. If that doctor diagnoses you with a concussion, you are - based on enemy action -you are entitled to a Purple Heart, end of subject.

ZWERDLING: Army officials say they're going to send that message to military groups and veterans organizations all around the world.

Gen. CHIARELLI: Climb to glory, climb to glory, Spark(ph).

Unidentified Man #2: Climb to glory, sir.

ZWERDLING: They want you to know: If you're a soldier or a vet and you got a concussion but you didn't get the Purple Heart, then the Army will aggressively reconsider your case - "aggressively" is their word.

Daniel Zwerdling, NPR News.

WERTHEIMER: See our original investigation, and learn about the history of the Purple Heart, at NPR.org. Transcript provided by NPR, Copyright National Public Radio.