All deployed personnel, medical staff included, face physical, psychological and emotional stressors, due to the ever-present dangers of living and working in an active war zone. Physical or psychological harm from the unexpected nature of mortar attacks, Improvised Explosive Devices, or small arms fire are constant threats. The indiscriminant violence wrought in modern warfare is a risk each individual had to consider at all times. These risks are highlighted in the 2008 account of an OT deployed to Iraq.

Our adjacent FOBs (Forward Operating Bases ) were hit 21 times by rocket mortar attacks today, Christmas day. We were expecting to get hit, but what do you do when you’re expecting?

The emergency room (ER) doctor, here for seven days, the father of three children, was killed along with many injured by mortar attacks that day. He was on his way back from church .

I spent most of the day at the hard shelled/concrete Combat Support Hospital, which was built to withstand a blast. Due to the number of attacks we were not allowed to remain in our living area, which was a soft-shelled Containerized Housing Unit. Eventually, we were cleared to go to the COSC clinic, which was also concrete. Some people slept in the COSC building that night.

The ER doctor died at around 11 PM, approximately 5 AM eastern time. All I could think about was the casualty officer going to his house on Christmas morning. Christmas for those kids will never be the same.”

LTC Arthur Yeager, OT, US Army, Active Duty

This testimony highlights the unpredictable environment of a deployment ; physical damage, loss of life, and the extent to which the lives of survivors are forever changed. Such stressors can significantly impact the psyche of a SM; with the effects lasting long after their return home. These persistent psychological effects may manifest as Post-Traumatic Stress Disorder (PTSD) and depression, which are especially prevalent in those returning from war.

A recent study of approximately 289,000 veterans with mental health diagnoses estimated that 21.8 % return from deployment with PTSD and 17.4 % with depression [17]. This is a stark contrast to the national averages; 3.5 % of adults in the United States have PTSD and about 6.7 % suffer from depression [18, 19].

A hazard among deployed medical SM’s, including OTs, is the potential for burnout. Burnout can manifest in forms of physical and/or psychological fatigue, loss of morale, depression, hostility, or reduced commitment. This is demonstrated by the following account from CPT Francisco Rivera while stationed at a Combat Out Post (COP) in Afghanistan (Fig. 5.2).

We arrived once again at one of the most dangerous places in Afghanistan. The COP was being manned by a Stryker Brigade Combat Team; one of the Army’s most effective fighting forces.

The Commanding Officer, other senior unit leaders and I were tasked to complete Traumatic Event Management debriefings, which were required to assess and manage emotional and physical responses of unit members when experiencing comrades killed in action (KIA).

Alpha Company had 4 KIAs, along with 12 wounded in action who sustained multiple amputations and other life threatening injuries. We conducted 11 debriefings accounting for over 100 Soldiers with a goal to help them process the trauma and constructively manage emotional reactions to these combat experiences.

A number of Soldiers were struggling with and concerned about thoughts of trying to avenge the deaths of their fellow Soldiers while on patrol off the COB. It was very difficult to encourage them to “drive on” and stay focused on their mission. Many had lost the motivation to fight or carry on with their assigned mission. Some struggled to identify with the mission and had difficulty rationalizing the worthiness of it all and risk of more loss of life. Others lacked confidence that higher command was supporting their needs.”

CPT Rivera, OT, US Army Reserves

CPT Rivera’s narrative attests to the mental and physical exhaustion SMs endure while on deployment . Factors such as suffering from injury, witnessing severe trauma or loss of life amongst friends and fellow SMs can severely disrupt one’s emotional state. Additionally, performing military operations without meeting calculable success, perceptions of neglect or lack of support from superiors despite individual efforts, sacrifices, or losses can lead to emotional collapse or burnout. Deployed OTs must be able to recognize burnout in order to rehabilitate, rejuvenate, and return a SM to duty with the capacity to independently and safely perform their mission.

When not in a deployed environment, OTs assist patients in restoring functional skills needed to return to work, daily life, leisure, and social reintegration. When deployed, OT treatment objectives predominantly focus on returning a SM to active duty. The timeline for recovery is much shorter in a war zone. If a SM displays the inability to function safely and productively in a timely manner, a medical evacuation must be considered. OTs must be cognizant of the unique physical and psychological duty requirements of a SM to alter their therapeutic treatment programs accordingly (Fig. 5.3).

Our COSC unit arrived in Baghdad in support of OIF in 2008. Our mission was to coordinate and deliver Combat Health Support to US forces in the Multi-National-Corps-Iraq sector by conserving the fighting strength, preventing injury, or evacuating COSC casualties to higher levels of medical care (Germany), if a patient’s recovery was not in a timely manner or needed more intense medical attention.

In Iraq, I was assigned as the Officer in Charge (OIC) of Restoration (a rehabilitation mission), housed in a facility created by two adjoining trailers, and co-located with the Troop Medical Clinic. My team’s mission was to restore a Soldier’s physical and mental capacity to return them to the fight.

Lieutenant Colonel (LTC) Enrique Smith-Forbes, OT, US Army, Active Duty

Preparing yourself physically and mentally when deploying to an active combat zone is critical for everyone. Therapists must adapt professionally and train to address injuries not experienced back home in a traditional hospital setting. One must be prepared to treat symptoms such as anxiety, depression, workplace violence, and survivor guilt, among others provoked by events such as combat, indiscriminant blasts, death, severe injury, unresolved problems at home, relationship constraints, or financial crises.

The urgency to return SMs to duty is driven by the need to maximize unit strength to meet the requirements of the mission. Treatment goals and priorities must shift to provide these individuals with the rehabilitation they need within a truncated time frame. This differs significantly from civilian or stateside military hospitals where a longer, more ideal rehabilitation timeline is available to maximize psychological recovery .