BOARD DATE: 26 September 2017 DOCKET NUMBER: AR20160002686 BOARD VOTE: _________ _______ ________ GRANT FULL RELIEF ________ ________ ________ GRANT PARTIAL RELIEF ________ ________ ________ GRANT FORMAL HEARING ____x____ ____x____ ____x____ DENY APPLICATION 2 Enclosures 1. Board Determination/Recommendation 2. Evidence and Consideration BOARD DATE: 26 September 2017 DOCKET NUMBER: AR20160002686 BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned. _____________x____________ CHAIRPERSON I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. BOARD DATE: 26 September 2017 DOCKET NUMBER: AR20160002686 THE BOARD CONSIDERED THE FOLLOWING EVIDENCE: 1. Application for correction of military records (with supporting documents provided, if any). 2. Military Personnel Records and advisory opinions (if any). THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE: 1. The applicant requests, in effect, correction of her DD Form 261 (Report of Investigation Line of Duty (LOD) and Misconduct Status) to show she was injured in the LOD while entitled to basic pay during basic combat training in 2012. 2. The applicant states the LOD investigation determined her head injury during basic combat training in 2012 was not in the LOD. She would like this decision investigated further. She did not have these symptoms before her head injury in 2012. She did not receive adequate medical care when she was injured. 3. The applicant provides: * letter from the Nebraska Army National Guard (NEARNG) to a Member of Congress, dated 22 December 2015 * undated letter to a Member of Congress * DD Form 261, dated 3 February 2015 * discharge proceedings * numerous medical records CONSIDERATION OF EVIDENCE: 1. The applicant enlisted in the NEARNG on 13 March 2012. On 6 August 2012, she was ordered to initial active duty for training. 2. She provided a health record, dated 2 October 2012, showing she went to the emergency room with complaints of headache and nausea after sustaining a head injury on 1 October 2012. She was marching with a heavy rucksack when she tripped and fell, striking her forehead on the ground. She denied any loss of consciousness. She was diagnosed with a superficial injury (facial abrasion). 3. She provided a radiology report, dated 2 October 2012, showing she underwent a computed tomography (CT) scan for a head injury with no loss of consciousness. The report states "IMPRESSION: Negative noncontrast CT brain." 4, She was released from active duty for training on 18 December 2012 after completing basic combat and advanced individual training. She was awarded military occupational specialty 92Y (Unit Supply Specialist). 5. She also provided: a. medical records, dated 2013, showing she was diagnosed with: * numbness and tingling * dizziness * near syncope (fainting) b. a neurological examination, dated 7 April 2014, revealing no evidence of brain injury secondary to fall, no evidence of post-traumatic vertigo, and no evidence that numbness is related to a head injury; c. a medical record, dated 10 July 2014, showing she was diagnosed with neurocardiogenic syncope (loss of consciousness for only a few seconds, common); and d. a medical record, dated 10 October 2014, showing she was diagnosed with: * syncope and collapse * migraine without aura, with intractable migraine, so stated, without mention of status migrainosus (severe migraine) 6. A memorandum from the Office of the NEARNG State Surgeon, dated 2 December 2014, states the State Surgeon reviewed her medical records and found her diagnosis of syncope and collapse disqualifying for continued service in the NEARNG as a result of a non-service connected injury/illness and enclosed an Acknowledgement of Appeal Process with a Physical Disability Evaluation System (PDES) Handout. 7. The Acknowledgement of Appeal Process, dated 14 December 2014, shows she acknowledged notification of her fitness-for-duty results and the appeal process. a. She acknowledged she understood: * her records went before a Fitness for Duty Evaluation Board and she was found medically disqualified for continued service in the National Guard * the State Surgeon recommended her separation from the NEARNG and as a Reserve of the Army * her case was not an LOD illness/injury and the board recommended separation * her records would not go before a medical evaluation board b. She acknowledged she read and understood the PDES Handout provided. c. She elected option 5, indicating "I believe my diagnosis of syncope and collapse is in the Line of Duty and will provide the supporting documentation to my Unit for LOD processing." 8. The DD Form 261, dated 3 February 2015, shows: a. She tripped and fell during a ruck march while at basic training on 1 October 2012 and hit her head. She went to the emergency room the next day due to headache and nausea. She was evaluated and diagnosed with superficial abrasion of face and released without restrictions. b. The investigating officer (IO) determined her injury was "Not in Line of Duty – Not Due to Own Misconduct" for brain injury secondary to syncope with collapse, post-traumatic vertigo and lower extremity numbness. c. The National Guard Bureau approval authority approved the findings and recommendation on 26 May 2015. 9. Her subsequent Acknowledgement of Appeal Process, dated 15 October 2015, shows she acknowledged notification of her Fitness for Duty results and appeal process. She elected option 4, indicating "I am electing not to appeal the findings of the State Surgeon for referral to the Non duty related board and would like my records processed for separation from the Nebraska Army National Guard. I understand my records will not be processed before the PDES. I will not be awarded any possible Disability Dispositions addressed in the PDES handout to include Separation with Severance Pay, Permanent Disability Retirement or placement on the Temporary Disability Retirement List if in the event the PDES finds my illness/injury in the Line of Duty." 10. A memorandum from the Office of the NEARNG State Surgeon, dated 6 November 2015, states she underwent a fitness for duty/permanent profile evaluation for her diagnosis of neurocardiogenic syncope. The State Surgeon found her medically disqualified for continued service in the Army under the provisions of Army Regulation 40-501 (Standards of Medical Fitness). This disqualification is the result of a duty-related and non-service connected condition. 11. On 10 November 2015, she was honorably discharged from the NEARNG for being medically unfit for retention. She completed 3 years, 7 months, and 28 days of total service for retired pay. 12. She provided a letter from the NEARNG Chief of Staff to a Member of Congress, dated 22 December 2015, stating: a. The NEARNG reviewed the applicant's medical documentation and LOD records for accuracy. The NEARNG Health Systems Office confirmed her medical documentation provides the necessary justification of the findings that her injury was "Not in the Line of Duty – Not due to own misconduct." b. On 1 October 2012, the applicant tripped, fell, and struck her forehead while conducting a ruck march during basic training. She did not seek medical care until the next day due to continued headache and nausea. Records indicate she was seen in the emergency room and diagnosed with a superficial facial abrasion and released without restrictions. At that time, she had a negative CT scan of the head and denied loss of consciousness. Since the incident, she has reported issues with headaches and near syncope, but no medical evidence has been presented that links her neurocardiogenic syncope or lower extremity numbness to an injury while on duty. Records indicate she has had consistent symptoms and is seeking to relate current health issues back to her initial fall and head injury during basic training. c. Between November 2013 and October 2015, she saw multiple civilian and military medical practitioners. Her medical records were reviewed by the NEARNG State Surgeon in November 2014. She was found medically unfit due to permanent limitations in multiple basic soldiering skills and physical fitness events. She confirmed she could not perform most soldier tasks and stated, "I believe my diagnosis of Syncope and Collapse is in the line of duty and will provide the supporting documentation to my Unit for LOD processing." This action triggered a formal LOD investigation and a medical IO was appointed to review her claims. d. The IO reviewed her medical records and confirmed the diagnosis of neurocardiogenic syncope. There was no indication her condition was the result of her injury during basic training and there is documentation that confirms she suffered from headaches prior to her injury during basic training. The State Surgeon reviewed the IO's findings and concurred that her condition was not in the LOD and there was no evidence that the October 2012 fall aggravated a preexisting condition. e. Her LOD was forwarded to the State Judge Advocate for a legal review. The review found the IO's findings were supported by substantial evidence. f. The National Guard Bureau determined her injury to be "Not in Line of Duty – Not due to own misconduct" for brain injury secondary to syncope with collapse, post-traumatic vertigo, and lower extremity numbness. According to Army Regulation 600-8-4 (LOD Policy, Procedures, and Investigations), paragraph 2-6c, LOD determinations must be supported by substantial evidence and by a greater weight of evidence than supports any different conclusion. Her neurology evaluation noted no evidence of brain injury secondary to fall, no evidence of post-traumatic vertigo, and no evidence that numbness is related to a head injury. g. Her appeal of the National Guard Bureau findings triggered a review by the U.S. Army Human Resources Command (HRC). HRC upheld the "Not in Line of Duty – Not due to own misconduct" determination, finding the applicant's diagnosis was not service connected or service aggravated. Army Regulation 600-8-4, paragraph 4-8e(2), states if conditions that existed prior to service (EPTS) were not aggravated by military service, the determination will be "Not in Line of Duty – Not due to own misconduct." h. The NEARNG concurs with the findings of the Nebraska State Surgeon and HRC. 13. She also provided an undated self-authored letter to a Member of Congress, wherein she stated: a. On 1 October 2012 while in basic training, she tripped and fell and hit her head on the ground. She was not wearing her helmet. She had most of her gear on and packed in her rucksack with her weapon in her hand. She does not feel she was provided adequate medical care and she has many health issues as a result. b. When she hit her head, she was not checked on by a doctor until the next night. She had to ask her drill sergeant if she could go to the hospital due to a severe headache and slight lightheadedness. According to her medical records, there were no scans or x-rays performed on her head. She was diagnosed with simple lacerations on the left side of her forehead and returned to duty. She has multiple witness statements and a photograph proving this event occurred. The left side of her forehead was cut and swollen to the point that she was not able to properly wear her military cover for a week or two. c. Approximately 25 days later in advanced individual training, her hands and feet would go numb when she ran or exercised. By the time she got home in December, she would get lightheaded and dizzy when she ran on the track. The condition has progressively gotten worse, and now she gets lightheaded when she does simple things, such as walking and lifting more than 15 pounds. She has passed out twice and has almost passed out multiple times. The condition is induced by exercise, but has also occurred during low-impact activities, such as sitting and enjoying dinner, walking the dog, and walking up stairs. d. She has been examined by two neurologists and two cardiologists, undergone multiple tests, and taken multiple medications in an effort to determine the cause. She was told she has vasovagal (also known as neurocardiogenic or cardioneurogenic) syncope and collapse. e. She was not given an LOD investigation from the military initially for this event. She applied for an LOD determination for her accident. She was denied and when she appealed the denial, her request was denied again. The LOD determination was "not in the LOD – not due to own misconduct." She believes her accident is the cause of her health problems. She is not sure why the Army is denying her injury was in the LOD when she has proof. 14. An advisory opinion was rendered by the Army Review Boards Agency Senior Medical Advisor, dated 10 April 2017, wherein he stated: a. The available records do not reasonably support post-traumatic stress disorder or another boardable behavioral health condition existed at the time of the applicant's military service. b. The applicant met medical retention standards for history of closed head injury/concussion, dysmenorrhea, and migraine headaches. c. She did not meet medical retention standards for neurocardiogenic syncope. d. Her medical conditions were duly considered during medical separation processing. e. A review of the available documentation found no evidence of a medical disability or condition which would support a change to the character or reason for the discharge in this case. f. She reported a closed head injury without loss of consciousness taking place on 1 October 2012 and she was seen on 2 October 2012 with subsequent visits for other minor conditions unremarkable during basic training through December 2012 (no headaches, nausea, vomiting, or dizziness). The first visit for numbness and tingling (paresthesias) of the lower extremities noted while working out was, 3 June 2013. There is no clear correlation between her history of closed head injury/concussion without or with a brief loss of consciousness and the onset of her symptoms diagnosed as neurocardiogenic syncope. There is an applicant and family history of migraines. In medical literature, a subgroup of syncope patients report migraine headaches immediately preceding or following syncope, and some respond to anti-migrainous prophylactic agents. 15. A copy of this advisory opinion was provided to the applicant for comment and/or rebuttal. She did not respond. REFERENCES: 1. Army Regulation 600-8-4 prescribes policies, procedures, and mandated tasks governing LOD determinations of Soldiers who die or sustain certain injuries, diseases, or illnesses. a. Paragraph 2-6c states LOD determinations must be supported by substantial evidence and by a greater weight of evidence than supports a different conclusion. The evidence contained in the investigation must establish a degree of certainty so that a reasonable person is convinced of the truth or falseness of a fact, considering all direct evidence, that is, evidence based on actual knowledge or observation of witnesses; and/or all indirect evidence, that is, facts or statements from which reasonable inferences, deductions, and conclusions may be drawn to establish an unobserved fact, knowledge, or state of mind. b. Paragraph 4-8e(2) states the doctor, during examination and treatment of the Soldier, usually determines an EPTS condition. The doctor annotates the Soldier's medical records as to whether the condition EPTS. If an LOD determination is required, information from the medical records will be used to support a determination that an EPTS condition was or was not aggravated by military service. If an EPTS condition was aggravated by military service, the determination will be "in the LOD." If an EPTS condition is not aggravated by military service, the determination will be "not in the LOD – not due to own misconduct." 2. The Medical Dictionary describes neurocardiogenic syncope as the most common reason for fainting. Neurocardiogenic syncope is also called vasovagal syncope. In neurocardiogenic syncope, blood pressure rapidly falls, and blood flow to the brain becomes very low. The person loses consciousness (passes out or faints), usually for only a few seconds. Neurocardiogenic syncope can occur suddenly, in response to a startling event or strain (a needle stick, pain, fear, cough, or defecation). It can also occur after prolonged standing, heat exposure, or exertion. Some people experience a period of ill-feeling for a few minutes before actually passing out. Neurocardiogenic syncope is common and usually does not signal any serious problem or increased health risk. However, there can be many other reasons for fainting (syncope), some of which are serious. After a fainting episode, further testing is often recommended to make sure a serious cause of syncope (such as an abnormal heart rhythm) isn't responsible. DISCUSSION: 1. The applicant requests correction of her DD Form 261 to show she was injured in the LOD while entitled to basic pay during basic combat training in 2012. 2. The evidence shows she tripped, fell, and struck her forehead while conducting a ruck march during basic training on 1 October 2012. She sought medical care for continued headache and nausea until the next day. 3. Although she contends she did not receive adequate medical care when she was injured, the evidence shows she was seen in the emergency room on 2 October 2012 and a CT scan of her head was performed with negative results. She was diagnosed with a superficial facial abrasion and released without restrictions. 4. The evidence also shows: a. In 2013, she was treated for numbness and tingling of the lower extremities following a physical workout. b. Her neurology examination in April 2014 found no evidence of brain injury secondary to fall, no evidence of post-traumatic vertigo, and no evidence that numbness is related to a head injury. c. She was diagnosed with neurocardiogenic syncope in July 2014 and diagnosed with syncope and collapse in October 2014. d. In November 2014, she was found medically unfit due to permanent limitations in multiple basic soldiering skills and physical fitness events. 5. There is no medical evidence linking her neurocardiogenic syncope or lower extremity numbness to an injury while on duty. 6. The Army Review Boards Agency Medical Advisor states there is no clear correlation between her history of closed head injury/concussion without or with a brief loss of consciousness and the onset of her symptoms diagnosed as neurocardiogenic syncope and there is an applicant and family history of migraines. 7. The LOD IO reviewed her medical records and confirmed there is documentation showing she suffered from headaches prior to her injury during basic training. 8. The governing regulation states if conditions that EPTS were not aggravated by military service, the determination will be "not in the LOD – not due to own misconduct." 9. Her DD Form 261, dated 3 February 2015, shows the IO determined her October 2012 injury was "not in the LOD – not due to own misconduct" for brain injury secondary to syncope with collapse, post-traumatic vertigo, and lower extremity numbness. The NEARNG State Surgeon reviewed the IO's findings and concurred that her condition was not in the LOD and there was no evidence that the October 2012 fall aggravated a preexisting condition. //NOTHING FOLLOWS// ABCMR Record of Proceedings AR20150000953 Enclosure 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS ABCMR Record of Proceedings (cont) AR20160002686 2 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 1 ABCMR Record of Proceedings (cont) AR20160002686 10 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 2