IN THE CASE OF: BOARD DATE: 15 June 2022 DOCKET NUMBER: AR20210015735 APPLICANT REQUESTS: award of the Purple Heart for the traumatic brain injury (TBI) he sustained at Bagram Airfield, Afghanistan, in support of Operation Freedom's Sentinel. APPLICANT'S SUPPORTING DOCUMENTS CONSIDERED BY THE BOARD: * DD Forms 149 (Application for Correction of Military Record under the Provisions of Title 10, U.S. Code, Section 1552), 16 June 2021 and 1 August 2021 * Military Personnel Message Number 11-125, Army Directive 2011-07 (Awarding the Purple Heart), 29 April 2011 * Casualty Report, 11 December 2019 * Military Acute Concussion Screening, 13 December 2019 * two Standard Forms 600 (Chronological Record of Medical Care), 13 December 2019 and 25 December 2019 * Headquarters, Joint Task Force, Bagram Airfield, Afghanistan, Memorandum (Mild TBI Treatment), 22 January 2020 * DA Form 4187 (Personnel Action), 26 April 2020 * Air Force Form 3994 (Recommendation for Decoration Deployment and Contingency Operations), 26 April 2020 * Memorandum (redacted – unidentified organization) (Surgeon Medical Opinion for (Applicant)), 6 May 2020 * U.S. Army Human Resources Command (HRC) Memorandum (Award of the Purple Heart for (Applicant)), 11 May 2021 FACTS: 1. The applicant states: a. He sustained a TBI on the base attack at Camp Alpha, Bagram Airfield, Afghanistan, on 11 December 2019. He was knocked unconscious by the blast, received shrapnel wounds to his legs, and was evaluated and treated for a TBI. b. The HRC memorandum (Award of the Purple Heart for (Applicant)), 11 May 2021, stated that although he had been evaluated for and diagnosed with a TBI, he was denied award of the Purple Heart because he didn't receive treatment. However, he was treated. He had to had to spend 48 hours in a dark room with no light, no electronics, no gymnasium – just a latrine. He had food brought to him. He was also placed on restricted duty for 2 weeks and had to follow up at the clinic for a Military Acute Concussion Evaluation every day for 2 weeks until he was cleared. That is the standard treatment for a TBI. 2. His self-authored statement attached to his 15 June 2021 application states that on Wednesday, 11 December 2019, at approximately 0552 hours, he was in the "Neil Roberts Gymnasium (a garage-like structure with weights, cardiovascular equipment, and some wrestling pads)," Bagram Air Base, Afghanistan. He had just finished a jump rope activity set and was standing at the edge of a mat getting a box in place to perform box jumps when he suddenly felt a giant shove from behind him and heard a loud crack. The next thing he knew he was picking himself up off of the floor, the "gym" was filled with smoke and dust, all of the light bulbs were shattered, the ceiling fans had blown down from the ceiling, the box for his box jumps had moved approximately 5 feet, he was about 3 feet from where he had been standing, his leg was bleeding, and he heard another "boom." One of the Rangers yelled "Incoming!" and asked if he was alright because he lost consciousness briefly. He said "Yes," then he quickly ran to the bunker where there were about 5 or 6 other people, thinking it was a mortar attack. He quickly asked if anyone was hurt and realized he was alone in a bunker full of Afghanistan National Army personnel. Not knowing what was going on and also not wanting to take the chance, he ran out of the bunker and to the Tactical Operations Center for accountability. 3. Wyoming Army National Guard Orders 54-225-0001, 13 August 2019, ordered him to active duty as a member of his Reserve Component unit in support of Operation Freedom's Sentinel with a reporting date of 8 September 2019. 4. The Casualty Report, 11 December 2019, shows he was wounded in action by an enemy force on 11 December 2019. The circumstance is listed as a vehicle-borne improvised explosive device (VBIED) attack in Bagram, Afghanistan, at 0605 on 11 December 2019 and notes he sustained a TBI from a VBIED blast. 5. The Standard Form 600, 13 December 2019, notes: a. The applicant reported for evaluation for a TBI 48 hours after a blast. He complained of recurring nausea and headache. He reported he experienced confusion to possible unconsciousness for a brief period of time; he may have hit his head. b. His neurological checks were normal and the examiner noted a mild TBI. He was instructed to avoid computer and phone screens, and avoid other activities that may cause eye strain. He was instructed to return should symptoms worsen or any new symptoms occur. c. The medical examiner is not identified. 6. His Military Acute Concussion Evaluation (pages 1 through 4 of 14 pages), 13 December 2019, shows in: * item 1b (Observable Signs) – Disorientation, confusion, or an inability to respond appropriately to questions * item 1d (Was there a blow or jolt to the head?) – Unknown * item 2a (Was there alteration of consciousness?) – Yes * item 2b (Was there loss of consciousness?) – Unknown * item 2c (Was there any post traumatic amnesia?) – Unknown * item 2d (Was there alteration of consciousness, loss of consciousness, or post traumatic amnesia witnessed?) – Unknown * item 3 (Symptoms) – Headache, Nausea/Vomiting 7. His Standard Form 600, 25 December 2019, notes: a. He reported for follow up for a mild TBI he sustained on 11 December 2019. He complained of headache, worse with computer work; he was sleeping alright with Tylenol PM; and he experienced some morning nausea and some balance disorder with single leg work. b. Assessment and Plan: mild TBI; persistent symptoms, but improving. The medical examiner recommended: 1:2 ratio work-to-rest with computer work, continue the naproxen/Tylenol schedule (dispensed refills), exercise as tolerated, and follow up in 48 to 72 hours. c. The medical examiner is not identified. 8. The Headquarters, Joint Task Force, memorandum (Mild TBI), 22 January 2020, states the personnel listed (including the applicant) were seen and evaluated at Bagram Air Field. The members listed were first evaluated for mild TBI 48 hours post-injury. They were evaluated for blast-related injuries after a VBIED attack on Bagram Air Field at approximately 0600 hours on 11 December 2019. Each member was diagnosed with a mild TBI and placed on modified/light duty due to symptoms persisting longer than 72 hours. 9. The DA Form 4187, 26 April 2020, shows the Joint Task Force Commander requested award of the Purple Heart to the applicant. Section IV (Remarks) states: a. Service member meets all requirements of Army Regulation 600-8-22 (Military Awards), paragraph 2-8 (Purple Heart), 25 June 2015. b. Service member was wounded in action while satisfactorily performing duties in an area where hostile fire pay and imminent danger pay is authorized. c. Service member was wounded while in support of Operation Freedom's Sentinel. 10. The Summary of Action/Meritorious Service section of the Air Force Form 3994 (Recommendation for Decoration Deployment/Contingency Operations), 26 April 2020, states the applicant sustained a TBI while supporting (redacted). The applicant was in the (redacted) when a VBIED initiated approximately (redacted) meters from his position and consisting of approximately 6,000 pounds of homemade explosive. The applicant was shaken from his position and was concussed by the overpressure in the (redacted). The initial blast knocked him to the ground and he was pelted by glass and debris. The applicant rallied to a preplanned position with the rest of his unit and prepared to defend his immediate area. Once the threats had been cleared approximately 16 hours later, the applicant began noticing headaches and blurred vision. The post-mission medical assessment indicates that he suffered a TBI and concussion with symptoms lasting longer than 3 weeks. The applicant was placed on restricted work status for 2 weeks while he was monitored for mild TBI. In summary, due to the injury the applicant suffered, he is eligible for award of the Purple Heart. 11. The memorandum (redacted – unidentified organization) from an Army National Guard civilian physician assistant (Surgeon Medical Opinion for (Applicant)), 6 May 2020, states: a. The DA Form 2173 (Statement of Medical Examination and Duty Status) states the applicant was in close proximity of blast from a VBIED on base on 11 December 2019 and requested a determination for a diffuse TBI without loss of consciousness, initial. b. The applicant deployed in support of Operation Freedom's Sentinel on 5 October 2019 for a period not to exceed 373 days. c. Findings: (1) The Standard Form 600, 13 December 2019, indicates the applicant was in close proximity to a blast 2 days prior and experienced a brief loss of consciousness at the time of his injury. He reported his symptoms were improving. (2) The Standard Form 600, 20 December 2019, indicates the applicant continued to improve but still had tinnitus and difficulty focusing; he was returned to duty. (3) The Standard Form 600, 25 December 2019, indicates the applicant had some worsening of symptoms after returning to work. d. Remarks: The applicant suffered a TBI as a result of blast exposure while deployed. No evidence of misconduct or neglect. The diagnosis/finding of diffuse TBI without loss of consciousness was initially determined to be in the line of duty. 12. He was honorably released from active duty to the control of his Army National Guard unit on 19 August 2020. His DD Form 214 (Certificate of Release or Discharge from Active Duty) and DD Form 215 (Correction to DD Form 214) show in: * item 12c (Net Active Service This Period) – 8 months and 19 days * item 18 (Remarks) – Service in Afghanistan from 8 October 2019 through 4 July 2020 13. The HRC memorandum (Award of the Purple Heart for (Applicant)), 11 May 2021, disapproved award of the Purple Heart to the applicant. After a thorough review of the information provided and consultation with the HRC Office of the Surgeon General, the Awards and Decorations Branch Chief determined the recommendation for award of the Purple Heart does not meet the statutory guidance outlined in Army Regulation 600-8-22 (Military Awards), paragraph 2-8g, which states: "To qualify for award of the PH [Purple Heart] the wound must have been of such severity that it required treatment, not merely examination, by a medical officer." 14. MEDICAL SECTION: The Army Review Boards Agency (ARBA) Medical Advisor was asked to review this case. Documentation reviewed included the applicant’s ABCMR application and accompanying documentation, the military electronic medical record (AHLTA), the VA electronic medical record (JLV), the electronic Physical Evaluation Board (ePEB), the Medical Electronic Data Care History and Readiness Tracking (MEDCHART) application, the Army Aeromedical Resource Office (AERO), and the Interactive Personnel Electronic Records Management System (iPERMS). The ARBA Medical Advisor made the following findings and recommendations: a. The applicant is applying to the ABCMR requesting in a reversal of the United States Army Human Resources Command Awards and Decoration Branch’s denial of a Purple Heart for a traumatic brain injury (TBI). He states: (1) “I received a TBI on the base attack at Bagram (Camp Alpha) Dec 11, 2019. I was knocked unconscious by the blast, received shrapnel wounds to my legs, was evaluated and treated for TBI. (2) The purple heart denial letter stated that though I had been evaluated for and diagnosed with a TBI, I was denied because I wasn't treated. However, I was treated. I had to spend 48 hours in a dark room, with no light, no electronics, no gym, just latrine, I had food brought to me. I was also on restricted duty for two weeks and had to follow up at the clinic for a MACE exam every day for two weeks until I was cleared. That is the standard treatment for a TBI.” b. The applicant is correct. c. The Record of Proceedings details the applicant’s military service and the circumstances of the case. d. Paragraph 2-8 of AR 600-8-22, Military Awards (11 December 2006), lists the criteria for the awarding of the Purple Heart. Paragraph 2b lists the circumstances under which the injury is eligible for a Purple Heart (enemy action, friendly fire, peace keeping, etc.). Paragraph 2e states the wound and medical care requirements for the award: “A wound is defined as an injury to any part of the body from an outside force or agent sustained under one or more of the conditions listed above. A physical lesion is not required, however, the wound for which the award is made must have required treatment by medical personnel and records of medical treatment for wounds or injuries received in action must have been made a matter of official record. e. Paragraph 2g lists examples of injuries which justify the awarding of a Purple Heart, and this includes “Concussion injuries caused as a result of enemy generated explosions.” f. A casualty report shows the applicant was sustained TBI in a vehicle born improvised explosive device (VBIED) attack at 0605 hours on 11 December 2019. g. Medical documentation shows he was evaluated for TBI on 13 December 2019 for persistent TBI symptoms: “Patient complaining of nausea and headaches, recurring. Patient stated he experienced confusion to possible unconsciousness for a brief period of time and may have hit head. Patient with mild traumatic brain injury. Patient instructed to avoid computers and phone screen and to avoid other activities that may cause eye strain.” h. The applicant was re-evaluated on 25 December 2019: “Headaches 2-5{?}, worse with computer work, sleeping OK with Tylenol PM, some morning nausea, some balance disorder with single leg work. i. The provider documented abnormal ocular convergence {a TBI test} and poor single leg balance with his eyes closed. He continued the applicant’s treatment, recommending a computer work / rest cycle of 1 hour of work followed by 2 hours of rest and allowed him to exercise as tolerated. j. The medical officer in charge of a clinic on Bagram Airfield (BAF) documented his and four fellow team member’s TBIs on a 22 January 2020 Memorandum for Record: Due to mission requirements, the members listed above were first evaluated for mTBI 48 hours post injury. They were evaluated for blast related injuries after VBIED attack on BAF at approximately 0600, 11 December 2019. Each member was diagnosed with mTBI and placed on modified/light duty due to symptoms persisting longer than 72 hours.” k. These documents show the applicant received standard treatment and care for a concussive injury. From Current Concepts in Concussion: Initial Evaluation and Management; American Family Physician. 2019 Apr 1;99(7):426-434: (1) Cognitive rest: Activities that require attention or concentration (e.g. text messaging, video games, television, computer use, schoolwork) or that provoke symptoms should be limited. (2) Physical rest: Patients should avoid any physical activity that exacerbates symptoms (e.g. aerobic exercise, lifting weights, household chores, sexual activity). (3) Transition back to school/work: Reintegration should be slow and allow for scheduled breaks and additional rest periods as needed. l. His company commander summarized the events surrounding the applicant’s TBI in his recommendation for the award prepared on 46 April 2020: (1) “Second Lieutenant {Applicant}, United States Army National Guard sustained a traumatic brain injury while supporting {redacted}. Second Lieutenant {Applicant} was in the {redacted} when a VBIED initiated approximately {redacted} meters from his position and consisting of approximately 6,000 Lbs. of H.M.E. {homemade explosives}. (2) Second Lieutenant {Applicant} was shaken from his position and was concussed by the overpressure in the {redacted}. The initial blast knocked Second Lieutenant {Applicant} to the ground and he was pelted by glass and debris. (3) Second Lieutenant {Applicant} rallied to a preplanned position with the rest of his unit and prepared to defend his immediate area. Once the threats had been cleared approximately 16 hours later, Second Lieutenant {Applicant} began noticing headaches and blurred vision. (4) Post Mission medical assessment indicates that Second Lieutenant {Applicant} suffered a TBI and Concussion with symptoms lasting longer than three weeks. Second Lieutenant {Applicant} was on restricted work status for two weeks while he was monitored form TBI.” m. Army Directive 2011-07 published on 18 March 2011 addresses the requirements and procedures designed for the awarding of the Purple Heart to Soldiers who sustained a mild traumatic brain injury (mTBI) during combat. The applicant’s mTBI meets all of the required criteria outlined in this directive. Paragraph 4 of AD 2011-07 {Criteria met by the applicant’s TBI as documented in the application are underlined}: 4. Purple Heart for Concussions. When recommending and considering award of the Purple Heart for concussion injuries, the chain of command will ensure that the criteria in paragraph 2.a are met and that both diagnostic and treatment factors are present and documented in the Soldier’s medical record by a medical officer in accordance with paragraph 2.b. a. The following nonexclusive list provides examples of signs, symptoms or medical conditions documented by a medical officer or medical professional that meet the standard for award of the Purple Heart: (1) Diagnosis of concussion or mild traumatic brain injury; (2) Any period of loss or a decreased level of consciousness; (3) Any loss of memory of events immediately before or after the injury; (4) Neurological deficits (weakness, loss of balance, change in vision, praxis (that is, difficulty with coordinating movements), headaches, nausea, difficulty with understanding or expressing words, sensitivity to light, etc.) that may or may not be transient; and, (5) Intracranial lesion (positive computerized axial tomography (CT) or magnetic resonance imaging (MRI) scan). b. The following nonexclusive list provides examples of medical treatment for concussion that meet the standard of treatment necessary for award of the Purple Heart: (1) Limitation of duty following the incident (limited duty, quarters, etc); (2) Pain medication, such as acetaminophen, aspirin, ibuprofen, etc., to treat the injury; (3) Referral to a neurologist or neuropsychologist to treat the injury; and, (4) Rehabilitation (such as occupational therapy, physical therapy, etc.) to treat the injury. n. Paragraph 2-8k(3) of 600-8-22 succinctly lists the requirements for this award: “Each approved award of the Purple Heart must exhibit all of the following factors: wound, injury or death must have been the result of enemy or hostile act; international terrorist attack; or friendly fire (as defined in paragraph b(8) above) the wound or injury must have required treatment by medical officials; and the records of medical treatment must have been made a matter of official Army records.” o. The applicant clearly meets all three requirements: He sustained a concussion from an enemy VBIED attack; this injury required treatment and follow-up evaluations by a medical provider to assist with his recovery and protect him from further injury; and his medical treatment is recorded in multiple military documents. One can see how this would be analogous to a significant shrapnel injury treated with irrigation and suturing, repeated follow-ups to evaluated healing and look for infection, eventual suture removal, and return to duty. p. Based on the information currently available, it is the opinion of the ARBA Medical Advisor that the awarding of a Purple Heart is clearly warranted. BOARD DISCUSSION: After reviewing the application, all supporting documents, and the evidence found within the applicant's military records, the Board found that relief was warranted. The Board carefully considered the applicant's record of service, documents submitted in support of the petition and executed a comprehensive and standard review based on law, policy and regulations. Upon review of the applicant’s petition, available military records and medical review, the Board concurred with the advising official finding that awarding of the Purple Heart is clearly warranted. The Board found the applicant is listed on the Casualty Roster shows he was wounded in action by an enemy force on 11 December 2019. The circumstance is listed as a vehicle-borne improvised explosive device (VBIED) attack in Bagram, Afghanistan, at 0605 on 11 December 2019 and notes he sustained a TBI from a VBIED blast. Evidence shows the applicant was evaluated by a medical professional immediately following the blast and given restricted duty. The Board determined, based on regulatory guidance the applicant met the criteria for award of the Purple Heart. The Board found sufficient evidence to grant relief. 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 amending his DD Form 214 for the period ending19 August 2020 to show award of the Purple Heart. 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. REFERENCES: 1. Military Personnel Message Number 11-125 – Army Directive 2011-07 (Awarding the Purple Heart), 29 April 2011, states the purpose of this message is to inform all members of the Army (Leaders, Soldiers, and Civilians) that the Secretary of the Army has approved Army Directive 2011-07 (Awarding the Purple Heart). a. The directive provides clarifying guidance to ensure the uniform application of advancements in medical knowledge and treatment protocols when considering recommendations for award of the Purple Heart for concussions (including mild TBI and concussive injuries that do not result in a loss of consciousness). This message does not change the standards for award of the Purple Heart for concussion injuries. b. The following non-exclusive list provides examples of signs, symptoms, or medical conditions documented by a medical officer or medical professional that meet the standard for award of the Purple Heart. (1) diagnosis of concussion or mild TBI; (2) any period of loss or a decreased level of consciousness; (3) any loss of memory for events immediately before or after the injury; and (4) neurological deficits (weakness, loss of balance, change in vision, praxis (i.e., difficulty with coordinating movement), headaches, nausea, difficulty with understanding or expressing words, and sensitivity to light that may or not be transient. c. The following non-exclusive list provides examples of medical treatment for concussion that meet the standard of treatment necessary for award of the Purple Heart: (1) limitation of duty following the incident (limited duty, quarters, etc.); (2) pain medication such as acetaminophen, aspirin, ibuprofen, etc., to treat injury, such as headache; (3) referral to neurologist or neuropsychologist to treat the injury; and (4) rehabilitation (such as occupational therapy, physical therapy, etc.) to treat the injury. 2. Army Regulation 600-8-22 (Military Awards), currently in effect, provides that the Purple Heart is awarded for a wound sustained in action against an enemy or as a result of hostile action. Substantiating evidence must be provided to verify the wound was the result of hostile action, the wound must have required treatment by a medical officer, and the medical treatment must have been made a matter of official record. a. The Purple Heart differs from all other decorations in that an individual is not "recommended" for the decoration; rather, he or she is entitled to it upon meeting specific criteria. b. A wound is defined as an injury to any part of the body from an outside force or agent sustained under one or more of the conditions listed below. 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 Purple Heart 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. The key issue commanders must take into consideration when contemplating an award of this decoration is the degree to which the enemy caused the injury. The fact that the proposed recipient was participating in direct or indirect combat operations is a necessary prerequisite, but is not sole justification for award. d. Examples of enemy-related injuries which justify eligibility for award of the Purple Heart are as follows: * injury caused by enemy bullet, shrapnel, or other projectile created by enemy action * injury caused by enemy emplaced trap, mine or other improvised explosive device * injury caused by chemical, biological, or nuclear agent released by the enemy * injury caused by vehicle or aircraft accident resulting from enemy fire * smoke inhalation injuries from enemy actions that result in burns to the respiratory tract * concussions (and/or mild TBI) caused as a result of enemy-generated explosions that result in 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 e. Examples of injuries or wounds which do not justify eligibility for award of the Purple Heart are as follows: * frostbite (excluding severe frostbite requiring hospitalization from 7 December 1941 to 22 August 1951) * trench foot or immersion foot * heat stroke * food poisoning not caused by enemy agents * chemical, biological, or nuclear agents not released by the enemy * battle fatigue, neuro-psychosis and post-traumatic stress disorders * disease not directly caused by enemy agents * accidents, to include explosive, aircraft, vehicular, and other accidental wounding not related to or caused by enemy action * self-inflicted wounds, except when in the heat of battle and not involving gross negligence * first-degree burns * airborne (for example, parachute/jump) injuries not caused by enemy action * hearing loss and tinnitus (for example, ringing in the ears) * mild TBI that does not 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 * abrasions or lacerations (unless of a severity requiring treatment by a medical officer) * bruises or contusions (unless caused by direct impact of the enemy weapon and severe enough to require treatment by a medical officer) * soft tissue injuries (for example, ligament, tendon, or muscle strains, sprains, and so forth) //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20210015735 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1