Psychological First Aid? There’s An App For That

Written by Dr. Julie Kinn

I’m not alone in saying my heart goes out to those impacted by Hurricane Isaac. As a clinical psychologist, I have treated many children and adults who carry trauma symptoms long after danger has passed from natural or man-made disasters. We health care providers are keenly aware that disasters happen many times a year, and that those treating the survivors rarely have a surplus of resources.

To help support providers on the frontlines of care in emergencies, the VA’s National Center for PTSD and the DoD’s National Center for Telehealth & Technology (T2) have released PFA Mobile . This free mobile application assists providers in putting Psychological First Aid (PFA) into practice in the field. The app includes a brief refresher on the main components of PFA, assists with mentorship of other providers, and allows providers to self-assess and develop insight into readiness to provide PFA.

Some primary features that make the app so appropriate for disaster situations include:

 ■Easy forms for collecting data in difficult circumstances

 ■Intervention strategies tailored to unique conditions

 ■No requirement for internet or phone connectivity to run

PFA Mobile is currently available for iOS (Apple) devices and will deploy for Android devices in 2013. If you are a first responder or frontline care provider, I suggest you take it for a test drive and become familiar with this excellent resource.

Dr. Julie Kinn is a clinical and research psychologist. She leads mobile health application development for the DoD’s National Center for Telehealth & Technology (T2).

PE COACH Mobile App Supports Prolonged Exposure Therapy

By Robyn Mincher

DCOE Strategic Communications

The Departments of Defense and Veterans Affairs (DoD/VA) have released “PE Coach,” a smartphone mobile application for use with posttraumatic stress disorder (PTSD) treatment.

PE Coach is a form of “prolonged exposure” therapy available to all past and present service members — including the more than 10,000 Wisconsin Soldiers and Airmen who have deployed since 9/11 — as a way to help diagnos and treat symptoms of PTSD.

“As technology grows – our ability to find new ways to get information out to our service members and their families needs to grow as well. This new technology is another great tool for our service members and their families to use while transitioning back into their normal routines following a mobilization.” said Vicki Cushman Edgren, director of the Wisconsin National Guard Badger Yellow Ribbon program.

“In addition to our three phases of reintegration, PE Coach can be a valuable tool for our Soldiers and Airmen to use when returning from deployment and beyond. It especially speaks to the younger generation who already utilize phone apps in many other areas of their lives,” she continued.

Both the DoD and DVA use prolonged exposure (PE) therapy as an effective treatment for PTSD.

Psychologists at the Defense Department’s National Center for Telehealth and Technology, known as T2, and VA National Center for PTSD, developed the mobile app to specifically help patients with their therapy.

“‘PE Coach’ is a helpful tool that assists our service members and veterans who are between visits and in treatment for posttraumatic stress disorder,” said Dr. Jonathon Woodson, assistant secretary of defense for health affairs. “We have shared this app with our military health care providers as well, and hope that many individuals who are receiving PE therapy will find it useful.”

Prolonged exposure therapy helps a patient process a trauma memory to reduce the distress and avoidance caused by the trauma. The patient revisits the memory with a therapist and as the memory is emotionally processed, anxiety decreases. The therapy also helps the patient confront avoided situations that trigger memories of the trauma.

“We worked with a broad and diverse group of psychologists in the DoD and VA who are treating PTSD patients with prolonged exposure therapy,” said Dr. Greg Reger, clinical psychologist with the T2 Innovative Technology Applications division. “We wanted to help our patients in the therapy and make it easier for providers to deliver this treatment. PE Coach does both.”

Many psychologists who provide prolonged exposure therapy acknowledge it could be more effective if patients could better adhere to their assignments between sessions.

The patient installs “PE Coach” on their smartphone and can record the therapy session for playback between sessions. The app also provides an explanation of exposure therapy, assignments, explanations of PTSD and its symptoms, and a convenient way to write notes about typically avoided locations, situations and events for later discussions with their therapist.

Reger said that writing in a notebook in public places may make people feel uncomfortable. However, tapping a note on a smartphone is much easier and a more personal way to capture those in-the-moment feelings.

“PE Coach” will help users successfully adhere to PE treatment, which could improve the quality of treatment. Reger said it was not designed to be used as a self-help tool and should not replace professional counseling.

The Defense Department and VA released a similar mobile app last year; “PTSD Coach” is a reference tool for education, tracking symptoms, self-assessments and connections to support individuals with PTSD.

“PE Coach” is available for Apple and Android mobile devices. Find more information about the app at t2health.org/apps/pe-coach.

The National Center for Telehealth and Technology, located at Joint Base Lewis-McChord, Wash., serves as the primary Department of Defense office for cutting-edge approaches in applying technology to psychological health. More information about T2 is at t2health.org.

T2, a Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury center, designs, tests and evaluates available and emerging technologies in support of psychological health and traumatic brain injury recovery for service members, veterans and their families. To learn more, read “About T2.”

DCoE Seeks Feedback on Mild TBI Pocket Guide

By Corina Notyce, DCoE Strategic Communications

We want to hear from you! Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) encourages health care professionals to share their thoughts on the Mild Traumatic Brain Injury Pocket Guide and corresponding mobile app. Your feedback will help us make improvements to the pocket guide and other traumatic brain injury-related products.

How often do you refer to the pocket guide? What aspect of it do you find most useful? Based on your experience with the pocket guide, tell us everything from advantages and disadvantages to recommendations and suggestions for future traumatic brain injury (TBI) clinical resources and tools.

The pocket guide, developed by DCoE, is an all-encompassing, quick reference clinical guidance tool to help primary care providers assess and treat service members and veterans who have sustained a concussion. It includes a summary of the clinical practice guidelines and recommendations from the Defense Department and Department of Veterans Affairs on the management of mild TBI and provides information on treating common mild TBI symptoms; coding guidance; clinical recommendations for cognitive rehabilitation and driving following TBI; patient education materials; and additional clinical tools and resources related to TBI prevention and care.

You can also access the pocket guide from your smartphone with the free mobile app developed by National Center for Telehealth and Technology, a DCoE center. The mobile app was created to help providers conveniently access the latest evidence-based clinical guidelines for concussion care and enhance provider-patient interactions.

Hard copies of the pocket guide are available from Defense and Veterans Brain Injury Center. Call 800-870-9244 or email for details. To download an electronic version and other TBI clinical resources, visit the Health Professionals section of the DCoE website.

Take the online survey today — it only takes a few minutes. Participation is voluntary and responses will remain anonymous.

“I Was A One-Sided Person”

VA researchers join forces at the Manhattan VAMC to help a Veteran who lost his arm 40 years ago. The Gen-3 DEKA Arm System was developed for the Department of Defense which collaborated with VA Research on a VA-funded optimization study to incorporate design feedback from thirty-five volunteer amputees. The goal is to produce the world’s most advanced prosthetic arm system to help improve the lives of veterans and service members.

Looking for Uranium In All The Wrong Places

Military doctors here are examining shrapnel taken from service members and veterans, looking for depleted uranium  and other metals.

The Joint Pathology Center ’s Biophysical Toxicology and Depleted Uranium/Embedded Metal Fragment Laboratories branch is analyzing the embedded fragments and providing second opinions at military and Veterans Affairs  medical centers to treat those who had retained shrapnel.

“Our goal is to improve the care of wounded warriors,” said Army  Col. (Dr.) Thomas Baker, interim director of the Joint Pathology Center, the umbrella organization for the lab.

“We advise [doctors] how to follow up and what treatment is needed” to mitigate the potential effects of uranium and other metals, he said.

The lab analyzes all combat-associated metal fragments taken from DOD personnel that might pose a long-term health risk, such as depleted uranium, which can contribute to kidney damage over time, Baker explained.

The lab also develops laboratory capabilities in metal toxicology to support the Defense Department , The Pathology Center and VA and Army programs that require exposure assessment to depleted uranium, embedded fragment analysis and analysis of certain metal alloys, officials said.

The only one of its kind in the United States, Baker said, the lab keeps a registry of the fragments for future re-evaluation. The register now includes 600 specimens.

The lab also has the only diagnostic equipment in the nation that can detect where the uranium originates in the body, noted Dr. Jose Centeno, the lab’s director.

A wide range of materials are packed in improvised explosive devices, the doctors said.

The metal fragments and alloys the labs analyze comprise common metals and alloys of steel, aluminum, copper and brass. Depleted uranium is contained in some fragments, the doctors said, noting that shrapnel specimens are tested in triplicate for accuracy.

Concerns about tainted fragments began in 1993 following the Gulf War , when evidence arose of kidney damage from uranium, the doctors said.

For 18 years, 75 volunteers have participated in a study as part of the depleted uranium program, Baker said. All but one, an Iraq War veteran, served in the Gulf War, said Centeno, a physical chemist with a background in the toxicology of metals.

While many service members and veterans have retained fragments because of high risks removing them would pose, Baker said, some alloys such as depleted uranium are not safe to leave in the body. Because of that potential risk, DOD and VA have comprehensive programs to reach troops and veterans for testing, he added.

Baker said service members and veterans who carry shrapnel but haven’t sought medical care should seek advice from a doctor or call the Baltimore VA Medical Center , which works with the laboratories here.

“Anybody with an embedded fragment who hasn’t been followed up or hasn’t seen a physician should [do so] … and talk to them to discuss their risks,” he said.

Written by Terri Moon Cronk

From American Forces Press Service

Power Prosthetics Propel Service Members to Better Lives

By Terri Moon Cronk

American Forces Press Service

BETHESDA, Md., April 27, 2012 – Marine Corps Cpl. Garrett Carnes was on a clearing mission in Afghanistan‘s southern Helmand province in February when he stepped on a pressure plate that exploded and cost him both legs.

Two months later, the former squad leader was fitted with prosthetic legs -- one with the X2 microprocessor power knee, and the new combination of a bionic foot and ankle at Walter Reed National Military Medical Center here.

Carnes, 22, called his first steps “motivating.” The gift of being able to walk so soon exceeded his expectations. “Mentally, it feels good to get back on my feet,” he said, taking steps on a slightly elevated ramp with parallel bars to grasp. “It’s a little awkward, like a baby who’s learning to walk.”

Such steps are taken every day at Walter Reed’s prosthetics gait lab, where rapidly changing technology is giving active-duty service members the chance to walk again and, in some cases, return to duty, said Dr. Charles Scoville, chief of amputee services in the orthopedics and rehabilitation department.

First considered impossible to design, the X2 and higher grade X3 knees have provided a new way of life for above-the-knee amputees, Scoville said. New microprocessors have five sensors, compared with the original C-Leg, which had two.

Now, a combination of gyroscopes, accelerators and hydraulics provide the knee with greater stability, mobility and versatility by recognizing actions, officials said. The multiple sensors can determine when the wearer wants to sit down or go up and down ramps and stairs, all without presetting the limb with a remote device, as required by the former technology.

The first prosthetic limbs, Scoville said, had mechanical knees that were neither limber nor conducive to the warfighter. The wearer had to swing the leg outward and project himself forward to walk.

The Biom ankle -- a combination foot and ankle prosthetic that works with the X2 or X3 knee and is specifically designed for returning warfighters -- is the newest device that enables flexibility.

Scoville describes the knee and ankle/foot combination as more intuitive than older versions.

“It does the work for you,” he said. By replacing the once-rigid prostheses, the new, lighter and user-friendly limbs allow enough flexibility to stand on one leg, and step or walk backward without falling, he said.

Army Staff Sgt. Billy Costello demonstrated his knee, foot and ankle flexibility by sitting on the floor and stretching to pull his foot toward him. He also lost a leg by stepping on an improvised explosive device while on a clearance mission.

“We had just taken out 19 IEDs,” he said. “I found one more the hard way.”

Costello was another patient who progressed faster than his doctors expected. Soon to be discharged, he is an intern at the FBI Academy in Quantico, Va. and plans to enter the National Guard when he returns to North Carolina.

“I still want to support the guys,” he said, adding that he would deploy if his medical condition allows it, but quickly added he doesn’t want to be a “liability” to his unit.

“The vast majority of patients won’t return to active duty,” Scoville said. “Our goal is to bring them to their highest level of function.”

Scoville said 1,453 troops with severe limb loss have been fitted with prostheses since December 2001 and of those, some 300 service members returned to duty, with 53 redeploying to Iraq and Afghanistan.

“We view patients as tactical athletes,” Scoville said. “They don’t have an off-season and they don’t know when their next game will be."

Marine Corps Cpl. Rory Hammill plans to resume his active lifestyle once he’s discharged from active-duty. Before an accident in Marja, Afghanistan claimed one of his legs, he was a runner, snowboarder and surfer, all of which he hopes to resume he said, close to the level of ability he once had.

These service members are just a few of the 200-250 patients who are fitted with prosthetic limbs each month at Walter Reed, said David Laufer, chief of orthotics and prosthetics services. By contrast, he added, the civilian sector produces about the same number per year. In addition to limbs, the lab also creates hands that can move fingers, with such dexterity that they can operate a computer mouse and perform other daily tasks. Designing and developing hands is the lab’s niche, Laufer said, noting that work is ongoing to enable hands to act intuitively like ankles, feet and knees.

Far fewer hands are made in the lab than legs. “The standard of care is shifting,” Scofield said. “It’s made a significant impact on the wounded warriors who live with these advances. We want people to know we’re restoring their lives.”