ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS IN THE CASE OF: BOARD DATE: 15 March 2019 DOCKET NUMBER: AR20180016185 APPLICANT REQUESTS: award of the Purple Heart (PH). APPLICANT'S SUPPORTING DOCUMENTS CONSIDERED BY THE BOARD: * DD Form 149 (Application for Correction of Military Record) * Standard Form (SF) 600 (Chronological Record of Medical Care), dated 27 November 2012 * SF 600, dated 3 December 2012 * SF 600, dated 4 December 2012 * SF 600, dated 14 March 2013 * SF 600, dated 22 April 2013 * SF 600, dated 8 May 2013 * SF 600, dated 20 May 2013 * DA Form 199 (Informal Physical Evaluation Board (PEB) Proceedings), dated 1 August 2017 * DA Form 5892 (PEB Liaison Officer (PEBLO) Disability Compensation Worksheet), undated * memorandum, U.S. Army Human Resources Command (USAHRC), Fort Knox, KY, dated 24 April 2017 * memorandum, LTC (Ret.) D____ S. M____, MD, Defense Health Agency, Fort Belvoir, VA, dated 10 October 2017 * memorandum, CSM J____ C. M____, 1st Capabilities Integration Group (Airborne), Alexandria, VA, dated 1 November 2018 FACTS: 1. The applicant appeals the USAHRC denial of his award of the PH. He has provided additional statements from LTC (Ret.) D____ S. M____, MD, and CSM J____ C. M____, showing a diagnosis of a qualifying injury from qualifying combat actions during Operation Enduring Freedom (OEF) in Afghanistan. 2. He enlisted in the Regular Army on 2 February 1995 and served in Afghanistan from 28 January 2010 through 4 March 2010. 2. He provided SF 600 documents dated: a. 27 November 2012, showing treatment at Fort Belvoir Traumatic Brain Injury (TBI) behavioral clinic. It stated patient sustained multiple mild TBI (mTBI) injuries. The most significant occurred during deployment in August 2010 status post improvised explosive device (IED) blast. b. 3 December 2012, showing treatment at Fort Belvoir TBI behavioral health clinic for sleep and nightmares. He reported with a history of multiple TBI documented in the TBI intake. He related a significant TBI injury two years ago which was his seminal event, leading to chronic headaches, worsening of his sleep symptoms, and a definitive change in his ability to express speech. This combat related blast and the events of that day, included 5 IEDs that hit his vehicle in the "big tiff" as a Special Forces deployed Soldier. His physical injuries and TBI resulted in his theater extraction and return to continental United States. c. 4 December 2012, showing follow-up outpatient treatment at Fort Belvoir TBI behavioral health clinic. d. 21 December 2012, showing treatment for late effect of intracranial injury, cognitive disorder not otherwise specified. He was prescribed prazosyn. e. 14 March 2013, showing follow-up outpatient treatment at Fort Belvoir TBI behavioral health clinic for mTBI with neuropsychological interview and evaluation. History indicated mTBI was related to the Global War on Terrorism with highest level of severity of mTBI (Glasgow Coma Scale 13-15). f. 22 April 2013 and 6 May 2013, showing follow-up outpatient treatment at Fort Belvoir TBI behavioral health clinic for mTBI. g. 20 May 2013, showing an assessment that he met the criteria for chronic post- traumatic stress disorder manifested by intrusive nightmares and recollections of life threatening combat events spanning 14 years in Special Forces duty in hazardous duty areas. 3. He provided DA Form 199, dated 1 August 2017, showing a PEB finding that he was physically unfit and recommended a rating of 10 percent. The Board found the disability disposition was based on disease or injury incurred in the line of duty in combat with an enemy of the United States and as a direct result of armed conflict or caused by an instrumentality of war and incurred in the line of duty during a period of war. 4. On 24 April 2017, USAHRC denied his request for award of the PH. In rendering its decision, it stated the injuries received on 25 February 2010 did not meet the statutory guidance outlined in Army Regulation 600-8-22 (Military Awards, paragraph 2-8e. The lack of supporting medical documentation at or near the date of enemy action reflecting a diagnosis or indication of a qualifying injury makes it impossible to connect an injury to the incident. 5. He provided a memorandum from LTC (Ret.) D____ S. M____, MD, dated 10 October 2017, wherein he stated: a. During a troops in contact incident while conducting combat operations in support of OEF in Afghanistan, (Applicant) sustained injuries after a close detonation of a large road side bomb. These injuries included calf muscle tear, moderate TBI, autonomic nervous system disorder, jaw dislocation, nasal cavity and sinus injuries and hip joint injury. Although most of the initial combat theater medical documentation of his injuries has been lost, I was his treating physician upon his immediate redeployment from Afghanistan in 2010. His only recoverable documented treatment in theater was from an experienced Special Forces medic. b. He has had extensive work ups a Walter Reed Army Hospital and the National Intrepid Center of Excellence without resolution of his moderate TBI, mental fogging, decreased concentration, word finding, and cognitive disorder. His perpetual right pupil fixed dilation since the incident has not been medically explained but is a persistent manifestation of the lasting damage to his nervous system and brain. (Applicant) definitively suffered significant and lasting injuries that were the direct result of classified military operations sustained in a combat theater as a direct result of enemy contact. c. This memorandum serves to explain that due to the high security classification of his mission, at that time, there were no medical notes placed in the Theater or AHLTA electronic medical systems until follow-up commenced after deployment. 5. His DD Form 214 (Certificate of Release or Discharge from Active Duty), dated 20 February 2018, shows he was honorably retired by reason of disability, permanent (enhanced). 6. He provided a memorandum from CSM J____ C. M____, dated 1 November 2018, wherein he stated: a. He personally recovered (Applicant) from the airport when he redeployed from Afghanistan. Over the next several years he escorted and supported (Applicant) though dozens of medical appointments, surgeries, and psychological consultations. b. There were numerous appointments and evaluations before the true nature of (Applicant's) [injuries] were revealed and attended to. The unique nature of how Special Operations Forces operators deploy also contributed to the lack of documentation accompanying (Applicant) upon his return from his combat deployment. In 2010 it was customary to conduct self-aid and return to home station for follow-up medical treatment if needed. 7. Army Regulation 600-8-22 provides criteria for award of the PH. It stated a wound is defined as an injury to any part of the body from an outside force or agent sustained while in action against an enemy or as a result of hostile action. A physical lesion is not required. However, the wound for which the award is made must have required treatment, not merely examination, by a medical officer. a. Additionally, treatment of the wound will be documented in the service member’s medical and/or health record. Award of the PH may be made for wounds treated by a medical professional other than a medical officer provided a medical officer includes a statement in the service member’s medical record that the extent of the wounds was such that they would have required treatment by a medical officer if one had been available to treat them. b. An example of an enemy-related injury which clearly justifies award of the PH includes mild traumatic brain injury or concussion severe enough to cause either loss of consciousness or restriction from full duty due to persistent signs, symptoms, or clinical finding, or impaired brain function for a period greater than 48 hours from the time of the concussive incident. c. An example of an enemy-related injury which clearly does not justify award of the PH includes mild traumatic brain injury or concussions that do not either result in loss of consciousness or restriction from full duty for a period greater than 48 hours due to persistent signs, symptoms, or physical finding of impaired brain function. BOARD DISCUSSION: After review of the application and all evidence, the Board determined there is sufficient evidence to grant relief. The applicant’s contention and medical documentation were carefully considered. Based upon the preponderance of evidence, the Board agreed the information provided and the witness statements substantiate his entitlement to the Purple Heart. BOARD VOTE: Mbr 1 Mbr 2 Mbr 3 :X :X :X GRANT FULL RELIEF : : : GRANT PARTIAL RELIEF : : : GRANT FORMAL HEARING : : : DENY APPLICATION BOARD DETERMINATION/RECOMMENDATION: The Board determined the evidence presented is sufficient to warrant a recommendation for relief. As a result, the Board recommends that all Department of the Army records of the individual concerned be corrected by awarding him the Purple Heart for wounds caused by the enemy on 25 February 2010, and adding the Purple Heart to his DD Form 214. 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. ADMINISTRATIVE NOTE(S): Not Applicable REFERENCES: 1. Army Regulation 600-8-22 (Military Awards) prescribes Army policy, criteria, and administrative instructions concerning individual and unit military awards. a. It states the PH is awarded for a wound sustained while in action against an enemy or as a result of hostile action. The PH may be awarded for concussion injuries caused as a result of enemy generated explosions: mild TBI or a concussion severe enough to cause either loss of consciousness or restriction from full duty due to persistent signs, symptoms, or clinical finding, or impaired brain function for a period greater than 48 hours from the time of the concussive incident. When contemplating this award authorization officials must take into consideration the degree to which the enemy caused the injury. Substantiating evidence must be provided to verify that the wound was the result of hostile action, the wound must have required treatment by medical personnel, and the medical treatment must have been made a matter of official record. b. A physical lesion is not required. However, the wound for which the award is made must have required treatment, not merely examination, by a medical officer. Additionally, treatment of the wound will be documented in the service member’s medical and/or health record. Award of the PH may be made for wounds treated by a medical professional other than a medical officer provided a medical officer includes a statement in the service member’s medical record that the extent of the wounds was such that they would have required treatment by a medical officer if one had been available to treat them. c. An example of an enemy-related injury which clearly justifies award of the PH includes mild traumatic brain injury or concussion severe enough to cause either loss of consciousness or restriction from full duty due to persistent signs, symptoms, or clinical finding, or impaired brain function for a period greater than 48 hours from the time of the concussive incident. d. An example of an enemy-related injury which clearly does not justify award of the PH includes mild traumatic brain injury or concussions that do not either result in loss of consciousness or restriction from full duty for a period greater than 48 hours due to persistent signs, symptoms, or physical finding of impaired brain function. 2. Army Regulation 15-185 (Army Board for Correction of Military Records) prescribes the policies and procedures for correction of military records by the Secretary of the Army acting through the ABCMR. The ABCMR begins its consideration of each case with the presumption of administrative regularity. The applicant has the burden of proving an error or injustice by a preponderance of the evidence. //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20180016185 5 1