Coming home: The Army's fatal neglect

Forty-year-old Waltz, a member of the 3rd Battalion, 29th Field Artillery Regiment, had overdosed on painkillers. He needed the drugs to feel better. His body was falling apart. So was his mind. Waltz had “chronic” PTSD. Not only had a bomb exploded near him during his second tour of duty in Iraq, he had been ordered to pick up the body parts from other soldiers killed in the same explosion, according to his wife, Renea. He struggled with thoughts of harming himself. But he didn’t want to kill himself, because he didn’t want to leave his family behind.

When he died, it wasn’t a suicide. Waltz lost his life after Dr. Scot Tebo, a captain at Evans’ DiRaimondo clinic, prescribed methadone for Waltz’s chronic back pain. According to medical records, Waltz was already taking a powerful pain reliever, morphine. The combination of the drugs made a lethal cocktail. The local coroner ruled Waltz’s death a result of “mixed drug intoxication,” a medical accident.

In response, Fort Carson launched a “risk management” review, but nearly two years later still refuses to release the results, including whether any health workers were disciplined, saying the findings are protected under federal health privacy law.

Salon has learned, however, that Tebo was deployed to Iraq in 2007 to provide care for troops.

Sgt. 1st Class Kenneth P. Lehman
Lehman, a Green Beret, had served three overseas deployments — one of them in Iraq — before he was thrown from his all-terrain vehicle during a training exercise at Fort Carson in September of 2006, cracking his Kevlar helmet and causing bleeding inside his skull. He spent time in a Colorado Springs hospital and then was sent to the Veterans Affairs polytrauma unit in Palo Alto, Calif., as part of a medical boarding process that he and his parents expected meant the end of his military days — a retirement and a thank you from Uncle Sam, with benefits.

As his father, Paul Lehman, of Franklin, Penn., recalls, his son was proud to have served his country and wanted to keep doing it, but felt he could no longer live up to the Special Forces’ rigorous standards. His son suffered from memory loss, often not remembering what he’d done earlier in the day.  He even had to turn his head sideways just to read a menu because of brain and vision issues: “He just wasn’t the same after the accident.”

In January 2007, Lehman was still grappling with post-concussion syndrome, a form of traumatic brain injury that gave him headaches, made it difficult to concentrate and even caused emotional turmoil. A friend said Lehman would forget medical appointments. He was seen wandering around Fort Carson lost, although he knew the post well. A doctor at Evans noted that Lehman struggled to see, suffering from double images in late January 2007, according to his medical records.

Yet Douglas McNinch, an Evans neuropsychologist, determined on Feb. 1, 2007, that although Lehman “still has some minor cognitive problems” he could be returned to the war in Iraq.

The threat of a looming deployment sparked a deterioration in Lehman’s condition that the Army missed again and again. Days later, on Feb. 10, 2007, Lehman was rushed to a clinic after his roommate found him lying unconscious on his couch next to a bottle of Valium, prescribed to him for stiffness and head pain. The clinic concluded that Lehman did not attempt suicide, after speaking with Lehman and a “psychologist who feels that the patient was never suicidal and feels that this was somewhat of a confusing episode.” Lehman also told a counselor he was eager to go to Iraq.

But his friends and family say the Army dropped the ball. Lehman privately complained about the care he was receiving and was probably telling people at the clinic what they wanted to hear. He didn’t want to appear weak; he was a Special Forces soldier. Yet the incident unmasked new problems. Lehman, who had been exposed to combat and lost friends, now had “chronic” PTSD and depression.

By November 2007, he was again admitted to a clinic, this time after a clash with an ex-girlfriend. He said he had taken “a bunch of Valium to go to sleep,” Dr. Mary Zesiewicz wrote in his medical record. Lehman again denied it was a suicide attempt, she wrote. He was released.

On Jan. 30, 2008, Lehman was at Evans. He had to discuss issues surrounding his brain injury, his medical records say. While there, he told Robert M. Lee, a mental health assistant, he was having personal and legal problems. Lee described Lehman as “frustrated,” “depressed,” “fearful” and “anxious.” Again Lehman denied that he was suicidal and was told to return for follow-up on Feb. 1, 2008. Strangely, records for that meeting show Lee noting a vast change in Lehman. He was now in “very good spirits,” “happy” and “pleased,” according to his records.

The next day, Feb. 2, 2008, Lehman would finally succeed at killing himself, using his medical knowledge. He went into his barracks bathroom with a syringe filled with Lidocaine. He released the anesthetic into his body. Then, using a surgical blade, he cut deep into his left wrist, holding his arm over the bathtub.

Fellow soldiers discovered his body and called for paramedics. It was too late. The 31-year-old Lehman was pronounced dead at Evans hospital, where he’d been one day earlier.

Lehman’s suicide was a series of missed chances. He was too tough a case for the psychological workers who served him.

“He just never seemed to get the care he deserved,” his father says. “I feel Evans never took a good look at what was really going on with him.”

Moreover, the final entry in Lehman’s medical record appears suspicious to the Lehmans. Their son’s upbeat perspective on Feb. 1 wasn’t added to his medical record until Feb. 4, two days after he died.

It is common practice for military health workers to enter information within 72 hours of a medical appointment, according to experts. The Lehmans, however, say their son’s medical record shouldn’t have been touched, especially since their son had been to the clinic before his death. They feel there should have been an investigation into whether their son received adequate psychological care. The Army’s Criminal Investigative Division launched a routine suicide inquiry following Lehman’s death, but so far has withheld its conclusions from the Lehmans.

The couple now want an independent probe by Congress regarding their son’s case.

“I think they’re going to have to clean house and get rid of all these quack doctors they’ve got working there [at Evans],” says Paul Lehman. “[The] Army let Ken down,” adds his wife, Kelly.

Staff Sgt. Chad Barrett
Linda Helton feels the same way about the death of her son, Chad Barrett, who committed suicide on the same day as Ken Lehman. “It’s just so difficult to talk about,” she says, weeping. “We all loved Chad.”

Five weeks after Fort Carson sent Barrett to Iraq with the 4th Infantry Division, he swallowed a lethal combination of prescription antidepressants and sleeping pills.

Barrett, 35, was suffering from acute PTSD, a traumatic brain injury and had trouble sleeping after two tours of Iraq, according to his medical records. And, as a third tour loomed, it seemed, he was on his way out of the Army after 11 years of service. Officials had begun the process of formally retiring him because of his PTSD, according to his medical records. In 2007, he had attempted suicide. A commander wrote: “[A]ll specialists and command agree it is time for Chad to be removed from the United States Army.”

Yet Chad’s wife, Shelby Barrett, claims her husband didn’t want to let his buddies down. So she and her husband met with commanders and convinced them to change their minds. Doctors and commanders halted a medical evaluation process meant to determine Barrett’s level of disability for retirement — a process that mandated Barrett receive “no assignments remote from definitive psychiatric care.” Instead, he would go to Iraq to serve as an overnight radio operator.

Before Barrett was deployed on Christmas Day, 2007, Dr. Jonathan A. Olin, an Evans hospital psychiatrist, concluded Barrett had “no suicidal intent.” Along with his gear, Barrett packed up eight active prescriptions, including Klonopin for his anxiety and Ambien to help him sleep.

Only weeks after arriving in Mosul, dark thoughts crept into his mind. There were heavy losses among his comrades and he told his parents in an e-mail that he had reached the breaking point: “I can try to play tough all I want, but I know that I am not and that I need help.”

His parents encouraged him to find help, but he wrote that he wasn’t sure where to turn. The Army only wanted “the correct number of people on the ground … no matter what the cost,” he wrote just hours before he killed himself, adding, “Well everyone will find out the cost soon enough.”

After receiving the e-mail, Barrett’s family tried to reach the Red Cross to get them to intervene. It wasn’t easy; many hours passed. Finally, Helton got a message through. It was relayed to Barrett’s superiors at 7:55 a.m. on Feb. 2, 2008. But by the time superiors tracked down Barrett at 8:30 a.m., his roommate and medics were already in the throes of trying to save his life.

“Next thing I knew I was getting a call that Chad was gone,” Helton says, adding, “Why didn’t the Army do more to watch him? They knew he had troubles when they sent him; they should have never sent him.”

Barrett’s note, on yellow legal paper, was simple. On the outside it was marked, “THOUGHTS IN MY HEAD.” On the inside, Barrett wrote a long list of one-line statements: “Lost,” “Hopeless,” “Anger,” “Sadness,” “Wanting to cry,” “No reason or purpose in life … Failed as a soldier … Wanting to die … Command will get rid of their problem soldier …”

The Army’s Criminal Investigative Division conducted an inquiry, but not to investigate whether the care system had failed Barrett, as Helton had hoped. Instead, in a finding that Helton calls an insult to her son’s memory, investigators concluded that when Barrett killed himself, he broke military law because he did not take his medication in the prescribed dosage. In other words, had Barrett lived, he could have faced a court-martial for “wrongful use of a controlled substance.”

Helton also wonders whether some of the drugs the Army prescribed to her son made him feel suicidal. For example, Barrett was prescribed Clonzepam and Topiramate. Both include warnings that suicide could be an adverse reaction.

After his 2007 suicide attempt, Helton argued that prescription antidepressants could be the cause. While on the drugs, Barrett seemed confused, she says: “It didn’t even sound like my son.” When Barrett was taken off the drugs during hospitalization at a clinic, he returned to his good-natured self, she adds.

Still, Barrett found it tough to adjust to life after war. “He had nightmares,” Helton says. “He told me, ‘I don’t know how to turn it all off.’”

Army care, particularly at Fort Carson, she says, should be investigated. But it seems that nobody cares. “It’s hard to get people involved when you are fighting an Army,” Helton says. “The Army said it would be there for my son in his time of need. But they weren’t. His life is truly a great loss.”

Now Needham is gone too. He died on Feb. 19, about 10 days after back surgery at a Veteran’s Affairs hospital in Tucson, Ariz. The circumstances surrounding Needham’s death are unclear. According to his father, Mike Needham, an older brother discovered John Needham slumped over his bed at his mother’s house in Arizona, his face blue. Efforts by his brother, and then rescuers, to revive him were unsuccessful.

Needham, a tall, blond, sturdy California surfer and house painter, was deployed to Iraq in 2006. Not long after arriving, his life turned into a blur of roadside bombs, bloodshed and confusion. He was knocked unconscious by a grenade, suffering a brain injury. Shrapnel ripped into his legs. His back eventually gave him problems. He got a Purple Heart.

The damage to Needham wasn’t just physical. He also suffered from mental wounds. In Iraq in September 2007, when the carnage he had witnessed and participated in became too much, Needham pointed a pistol at his head and pulled the trigger. It would have ended there if a friend had not leaped forward to push the gun aside. The bullet hit a wall. Needham, who had a clean bill of health when he entered the Army, was shipped home.

When de Yoanna met him briefly in the airport in Colorado, Needham seemed nervous. He’d spent several weeks receiving care at Walter Reed Army Medical Center. Back at Fort Carson in Colorado Springs, Needham complained about punishment instead of treatment for his mental issues. His commanders threatened him with charges for discharging his weapon in his suicide attempt. Superiors also harassed him for falling asleep while heavily medicated. He was called a pussy. Though he had been diagnosed with post-traumatic stress disorder, Needham was punished for showing symptoms: failing to appear in formation, insubordination to superiors, and other problems.

With the advocacy of his father and others fighting behind the scenes, the charges against Needham disappeared and in July of 2008, the Army had washed its hands of him. He received an honorable discharge and a partial disability — but his benefits didn’t provide full access to mental health treatment, a critical gap in his care.

Had he received such care, things might have been different just weeks later. In September 2008, Needham made headlines across the country after allegedly beating his girlfriend, 19-year-old aspiring model Jacqwelyn Villagomez, to death in his San Clemente, Calif., condo.

After 10 months in a maximum-security jail cell awaiting trial, Mike Needham raised the $1 million needed to bail his son out to prepare for the murder trial.

Based in Colorado, de Yoanna traveled to California last summer and spent several days with Needham — part of Salon’s ongoing effort to understand veterans struggling with the hidden wounds of war.

Needham told de Yoanna during that visit that he couldn’t provide specifics about his case, fearing any statements he made to the press might become ammunition for prosecutors. He emphasized, however, that he was “not the murderer” authorities and the press had made him out to be. Looking over the crashing waves he loved to surf, the war veteran also said he had become an outcast and wanted to leave his home and live somewhere on the California coast where nobody would know him.

So he lived in the present, often on the beach. He surfed some, hoping the ocean would restore his body, but the pain in his lower back persisted.

After a first V.A. surgery on his back in Los Angeles that did not go as planned in late November, Needham struggled with severe pain. He developed an addiction to painkillers and was hospitalized in Long Beach in the following weeks to deal with it. Then his family brought him to Tucson, hoping the V.A. hospital near his mother’s home would do better. There was another surgery a few weeks later and one more — Needham’s third – earlier this month. Each was an effort to repair Needham’s deteriorating lower back.

Though Needham had a serious infection after his last surgery and a “tumor the size of a grapefruit” on his back, according to his father, he was only cared for by a visiting nurse while staying at his mother’s home at the time he died.

Autopsy and toxicology reports are being completed; medical investigators did not return a call to Salon by deadline.

Needham’s father feels the Army and perhaps the V.A. let his son down. “He never got correct care in the Army and, in my opinion, never got correct care from the V.A. either,” Mike Needham said. “What if they helped him when he first struggled after the explosions in Iraq? Instead, they sent him into battle day after day and harassed him when he struggled. As for the V.A., I think they’re the medical authority and responsible. I question why he was on outpatient status with a tumor the size of a grapefruit on his back.”

Mike Needham plans to join with family and friends in a small private ceremony to scatter the ashes of his son at the beach where he loved to surf. “That’s our spiritual altar — the ocean.”

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According to the report, “Survey data from this investigation suggest a possible association between increasing levels of combat exposure and risk for negative behavioral outcomes.” The study also says that “combat intensity/exposure . . . may have increased the risk for violent behaviors” and that its “findings are consistent with recent research on combat exposure and subsequent behavior outcomes among Soldiers.”

Salon’s Coming Home series showed that soldiers who returned from combat duty with symptoms of stress were often ridiculed or otherwise discouraged from seeking help, were overmedicated or misdiagnosed, or chose to self-medicate with drugs and alcohol. Many had been deployed even though they were already displaying signs of combat stress. Additionally, some of the soldiers involved in violence against themselves or others had preexisting conditions that should have disqualified them from service, but were allowed into a military hard-pressed for new recruits via waivers.

The 126-page report issued by the Army Wednesday — an epidemiological study, or EPICON in military lingo — focused largely on 14 of the Army post’s soldiers allegedly involved in murders since 2005. Ordered by Fort Carson commander Maj. Gen. Mark Graham in the wake of the slayings, it is studded with statistical evidence that buttresses Salon’s investigation. The numbers point to a link between violent behavior and substance abuse, repeated deployments, exposure to combat and enlistment waivers. In addition, many of the 14 soldiers allegedly involved in murders witnessed incidents described in the report as War Crimes. Five either heard of or witnessed the “murdering/killing” of non-combatants; three, “detainee abuse;” and, two, “fabricating evidence to justify attacks or criminal acts.”

Yet the Army officials presenting the report denied that it established any cause-and-effect relationships. Eric Schoomaker, the Army’s surgeon general, waved his hands across his chest under clear blue skies during the outdoor press conference, dismissing the notion that the report proved a tie between soldier-involved killings and the horrors those soldiers experienced in the war.

“While this is probably the most intensive and in-depth investigation on the clustering of violent-on-violent crimes in the Army that we’ve ever seen or are aware of,” said Schoomaker, “it is still in many respects preliminary.”

Without causation, there is no way to establish how the murders could’ve been prevented. “We would all like to look back at the cluster of misconduct and criminal activities,” said Schoomaker, “that resulted in devastating human tragedies here in Colorado and be able to say, ‘This is the reason they happened and we know exactly what could have been done to prevent them,’ but that’s rarely the way things work when dealing with human behavior.”

Without causation, there is also limited accountability. While commanders were blamed for standing in the way of soldiers receiving mental health and substance-abuse care, Lt. Gen. Michael Rochelle, the Army’s director of personnel, said the report “was not a tool that was intended to be used to either fix accountability or to be used for any sort of disciplinary action that may follow.”

Schoomaker, Rochelle and Maj. Gen. Graham, who was also on the podium Wednesday, were able to deny cause-and-effect because of caveats in the study. The authors of the report, a 24-member team assembled the Army’s Center for Health Promotion and Preventive Medicine, issued recommendations to stop the belittling of soldiers who seek mental health care and to identify units with high exposure to combat. They stopped short, however, of positing causation, saying that “”the cross-sectional nature of the study does not allow for making causal inferences.”

Thus Schoomaker could say, truthfully, “It’s pointing the finger to levels of causation, but we don’t know direct causation yet. … I’m very reluctant to put cause and effect there. In fact, the authors [of the report] are very careful to say these are correlations … not necessarily one causing the other.”

Yet Schoomaker also seemed to place some blame on the soldiers themselves for failing to seek help. He suggested that units where the soldiers were more willing to get help were less likely to be plagued with violence. The study, he noted, analyzed two brigades at Fort Carson, the 4th and the 3rd. “What did seem to differ between the two was the willingness and ability of those soldiers within the unit where crimes were committed to seek and get effective care for emerging behavioral health problems — alcohol and drug problems — and prompt attention to misconduct.”

But Schoomaker also claimed that the experiences of the 4th and 3rd Brigades in combat were “similar.” That’s not what’s indicated in the report — the 4th Brigade, where the murder suspects were clustered, had eight times more combat deaths than the 3rd. Moreover, the report indicated that the Army itself played a role in denying care to the soldiers — half, some with suicide issues, were sent back to Iraq “early,” according to the report.

U.S. Senator Mark Udall, a Colorado Democrat, who met on Tuesday with Schoomaker, issued a statement following the release of the report, noting it raises “serious questions about whether the military is doing enough to help service members transition from battle back into civilian life.”

“This is a matter of life and death, for our service members – and civilians,” Udall stated. “We must do everything in our power to ensure that the military is providing all necessary treatment and support to protect our service members, their families, and our communities.”

That could be a long road. The report indicated that “overall staffing” for behavioral health at Fort Carson’s Evans Army Community Hospital between 2006 and 2008 was just 65 percent of authorized positions.