Burying False Bravado in the Military
Trauma hurts. Health care providers see traumas of various kinds and at various stages every day. It never stops coming and it never gets easier. In the military, most soldiers come out traumatized in some way, not to mention the civilians affected by the horrors committed in war’s name. Trauma runs through the veins of the military, and its medical personnel work to prevent it, treat it in the moment, and provide support to survive it long after soldiers retire. To learn more about this unique circumstance, I interviewed Major James Oneal, former combat medic and current Physician Assistant in the US Army National Guard, about his decades of experience.
Seeking Meaning
James Oneal has been working as a Physician Assistant for twenty years, plus ten years’ experience as a combat medic. His work revolves around so much more than medical response. He works to build relationships, solve problems, and create accessible spaces for care with people of all backgrounds, in contexts that vary from trauma hospitals in cities to rural medicine in mountain villages.
Oneal joined the military at age 17 in an effort to escape his impending life path, and he was assigned work as a combat medic. The harsh realities of his work came crashing down a few years into his service. He shared, “During the first Gulf War, one of my friends was killed . . . He was blown up, and at his funeral, in my dress uniform, I had an epiphany… Until then it was all fun and a lot of false bravado that a lot of young enlisted men have, but when you start burying people it kind of changes your view about your role and I thought, ‘I’m not getting any younger. I need to become a PA.’” After working as a combat medic with a Marine Reconnaissance team for several tours, he achieved this goal and returned to military service ready to put his newly certified skills to use. When home between deployments, he works in a Veterans Affairs (VA) Department Clinic in a small town, serving retired veterans in their civilian lives.
Military Emergency Medicine
All kinds of military operations go beyond traditional medical environments. Beside the obvious considerations, like not having a building or running water to work with, the adaptability required of military medical personnel is astonishing. They are working in risky places, whether urban or rural, and have to be able to change at a moment’s notice. There has to be a plan for everything. For example, “what can go wrong when you’re a small team working on the ground? What’s gonna happen if there’s a big demonstration and you’re caught up in that demonstration and something goes wrong in the city, how do you move soldiers and/or injured personnel from a small area in, say, Cambodia? What’s the best hospital in Asia? And you have to treat them. It’s a challenge.”
To be prepared, teams have to be chosen in advance, and as much as can be regulated, must be. This includes everyone having the same clothing and gear, all the way down to socks and underwear. Sometimes they wear civilian clothes, but in Oneal's experience, “either way, you’re gonna stick out like a sore thumb.” As a leader, part of Oneal’s job is to memorize everything about his team: blood types, medications, allergies, and everything in between. The number of little pieces of information he described was astonishing.
After everything is in order, community development comes next. In his process, Oneal commented that he likes to do a site survey, first thing. This helps him identify a community he can return to if something happens to someone on his team. The connection often starts with relationships in the embassy, where there are other medical personnel. In one experience, he even described making small talk with someone who turned out to be married to a surgeon. You need to think about when something bad happens, what connections you will need to preserve life, limb, and eyesight for your whole team. This is of course different from the clinic Oneal works in at home, where resources and connections are known quantities.
Despite this necessary proclivity for strategic planning and community development, medical teams have a bad reputation in the military, especially in special operations. This is because medicine is very person-centered, and in special operations, the mission always comes first. Nurses, doctors, and PA’s like Oneal have high educational levels, but are not always given the full picture. In the rooms where decisions are made, when there is a choice, medics can advise when asked, but they are always reminded that they can be told “no” at any time. Because of this, there is extra pressure for medical personnel to honor the social norms at play. “People get territorial when it comes to being in charge,” Oneal observes, and for a mission to be successful for the soldiers’ well-being, medical advisors like James Oneal have to respect the territories.
Learning and Using The Culture
As a civilian, it is difficult to imagine a context as insular as the military. They control what you eat, what you wear, where you live, even your circle of friends, to a certain extent. In the military universe, social norms are rigid and difficult to change, for better or for worse. As Oneal mentioned to me, “Vets are a subculture of people.” Within this subculture, many people come from similar backgrounds: families with few prospects outside of military service. People use the military to get an education, and to climb out of their socioeconomic circumstances with everything they can. This adds further pressure to fit in, even if it causes harm in the process.
There were a few examples of what harm social norms can cause. Many people smoke in the military. It quickly becomes a social activity, and kids get hooked early on. How can you talk to someone about the long-term effects of the behavior, when fitting in right now is a key part of one’s ability to thrive socially? Oneal went on to say, “I can talk to a kid about what it’s gonna look like in 20 years if you’re still smoking a pack a day [from when] you’re 22. Will he listen? I don’t know.” These behaviors are normalized, and they continue up the ranks. Another example is Rip It, an incredibly popular energy drink found on smaller operations bases abroad. He said, “I’ve seen guys [in their 50’s] sit in a meeting and drink 2-3 of those. They’re loaded with caffeine, they’re loaded with sugar, they’re not good for you, but it’s a cultural thing… Sometimes it’s hard to fight that battle.” It starts with a pack of cigarettes or a couple cans of energy drinks, but unhealthy coping mechanisms and other shadows of service follow veterans for the rest of their lives. As Oneal made a point of telling me, at some point, “Mother Nature will come for the bill.”
When Mother Nature does come, most vets rely on VA clinics and hospitals around the nation to care for them. In these bureaucratic structures, it is clear how military culture carries over. Because Oneal is a veteran himself, he has common ground with veterans that allows him to better develop relationships with patients, which in turn allows for better care. His philosophy is that more often than not, “meds work for patients, the problem is they aren’t taking them. The reason they don’t follow your advice to quit smoking... or stop eating hamburgers three times a week is because they have a bad interaction with the provider. I think the reason [for that] is that there’s no connection, there’s no buy-in.” Veteran patients can tell he is a veteran himself, which leads to patient/provider bonding and understanding. Patients are then encouraged to follow through with treatments because although their adjustment back to civilian life has been hard, this dynamic is familiar to them. This trust is especially important when processing mental health needs, particularly the Post-Traumatic Stress Disorder that is so common in this population.
PTSD in Combat Vets
Post-Traumatic Stress Disorder affects military personnel in a way that pervades every aspect of their being. The way Oneal explained it has to do with how veterans perceive the world: specifically, their ability to appropriately analyze and respond to relationship dynamics. Take a young person, put them in combat, and how they analyze the world changes. For example, take something as simple as a staff meeting, with coffee in the cafeteria afterward. “[Veterans would be] worried that there’s a new person in [the] meeting. You don’t know who that new person is, but you’re watching them because you’re worried they’re gonna try and kill you… Typically, insider attacks are after a meeting. When you leave a meeting, you’re at your most vulnerable point for being killed.” Something that civilians see as a generally positive activity suddenly poses a threat that would not have crossed most people’s minds. There is no way for veterans to bring it up without being brushed off, because civilians see these events as some of the lowest-stakes, most universal experiences the working world has to offer.
Beyond acknowledgement of veterans’ context, the thought process that follows is starkly different from civilians’. The way Oneal explained it was, “amped up all the time, always on guard, worried that you might get shot, that you might die-- it changes how you analyze everything that comes into your life. Everything from how you get a cup of coffee to how you say hello to people at work to how you go to your desk to open up an email, so your threshold for getting worked up is much lower" and "it’s hard once that threshold has been lowered in combat and stress and trauma, to get that threshold back to what is normal.” Not only are “normal” circumstances uniquely threatening, but the process to decompress looks completely different. In this way, it is incredibly difficult to provide universal support in mixed environments. This further ostracizes veterans struggling to reintegrate into society.
Many choose to re-enlist instead of pushing through, because it is easier. No matter how difficult or horrifying it can be, the military matches veterans’ new normal, even though it is continuing their trauma. At least this way, the people around you understand why you think the way you do. At some point, Oneal says, most of his patients struggle with vices they use to fill the void. It could be alcoholism, smoking, getting in fights, or any number of other problems. Choosing to re-enlist is one more coping mechanism. At the end of the day, in the military, “even if you are a good, moral person, sometimes you will be forced to make decisions under duress. Sometimes you won’t make the right decision, and there is a price to pay for that.” It is the responsibility of military medical personnel to create spaces that encourage veterans to care for themselves even when the price feels like too much to pay. Medical veterans like James Oneal who work with veterans coming back from combat are able to provide this service best, because they provide trauma-informed care that speaks to shared experiences.
Emergency Response & Mental Health
There is a huge focus on resolving PTSD, and what it looks like to reintegrate affected veterans back into society. This issue comes from somewhere, and it is important to also acknowledge the precautions taken in the military to preserve mental health, as well as the treatments afterward. Most of these precautions are chemical. As an example, “On a flat-out gunshot trauma, you have six soldiers coming into your trauma bay, ketamine is something that they’ve started using.” It has been shown that using ketamine post-injury results in reduced PTSD, with the logic being that if a veteran does not remember what’s going on, the memories can’t haunt them in years to come. Many veterans resort to inappropriate drug use as a coping mechanism for PTSD to make the memories disappear. This method uses a drug intentionally and safely in the beginning, right after trauma, rather than opening the door for veterans to discover different kinds of drug use as retroactive coping mechanisms after returning home.
There are also a number of social needs each veteran has in instances of trauma. The environment and interpersonal relationships soldiers are able to develop can provide a support system, but they do not erase the truths of different populations targeted by military recruitment. Many people go into the military to run from the life they are living, whether it is a broken home or a poor socioeconomic situation with no clear escape route. Many of the individuals who sign up for the service already have existing, untreated mental health problems, whether anxiety, depression, personality disorders, or other illnesses. PTSD exacerbates these issues, and creates myriad harmful circumstances for veterans who experience trauma. At the end of the day, multiple people can be exposed, but after combat, those with pre-existing issues will have a lower tolerance threshold. They will also have poorer skills to seek help, and poorer support systems to help them follow through with the help they receive. The military does not have a clear system for filling these gaps, despite many of their starting populations belonging to systemically traumatized and underserved communities. There is a need to integrate preventative mental health care into emergency response more intentionally. It needs to start at the scene, as the military is trying to do with ketamine.
Conclusion
The military is a challenging environment, but it offers structure where so many young adults lack it. For Major James Oneal, it opened doors and allowed him to get an education, discover his passion for medicine, and save lives on deployments and at home. For others, it creates trauma that cannot be overcome with the resources currently available in and out of the system. Its echochamber provides a place for veterans to continue engaging with the people who understand where they are coming from, even if it furthers their trauma in the process.
Oneal recently completed what was likely his last deployment. He has worked in eight countries across Asia, and around the United States in a number of roles. Now, it is time to take the lessons learned about problem solving, emergency preparedness, and team development back home to stay. He enjoys teaching tourniquet classes to different community groups, such as police officers who missed training due to COVID regulations, and exploring other applications of his skills in civilian life. The rural town he lives in is quiet. It is isolated. It is a place to settle down, and enjoy the sunset. It is a place to find peace after a career rooted in trauma.
