5-148
in the primary or even secondary survey!
Almost any mental disorder; consider the following:
Major depressive, bipolar, or schizophreniform disorders - severe, long-lasting conditions that will not resolve
without definitive psychiatric care, unlike battle fatigue, which will largely resolve within 72 hours with restora-
tion of confidence, reassurance, replenishment, and rest.
Brief psychotic, acute stress, or conversion disorders - temporary disturbances that may last weeks to months.
Sometimes difficult to differentiate from battle fatigue. Degree of impairment/severity of symptoms coupled
with prompt resolution suggests battle fatigue. Management principles for battle fatigue can provide support
and symptom relief.
Post-Traumatic Stress Disorder (PTSD) - also a long-lasting disorder that appears after some trauma; not
likely to occur in acute settings or immediately post-event unless there is some history of prior trauma. PTSD
has symptoms similar to those of battle fatigue; history is crucial, as is time course of illness. Someone with
PTSD may also suffer battle fatigue in an acutely stressful event.
Substance Intoxication - history will distinguish this from battle fatigue. Assess the whole unit: substance
abuse may indicate increased susceptibility to battle fatigue for individuals and units.
Plan:
Treatment guided by the acronym PIES:
Proximity: Treat service member as close to the unit as tactically and symptomatically possible. A violent,
out-of-control patient cannot likely be treated at the battalion aid station if the battalion is actively engaged
in combat, whereas one who is physically exhausted may be treated in his platoon area during a lull in
the fighting.
Immediacy: Do not delay initiation of treatment; treat as soon as symptoms are identified and tactically
feasible.
Expectancy: “This will get better. You will return to your unit.” Positively convey the expectation that this
condition will improve and that the service member will not be evacuated.
Simplicity: Keep treatment simple. Provide the “Four Rs”:
- Rest: Provide place and time for adequate rest. Consider Valium 5 mg po or Ativan 1-2 mg po or IM.
- Reassurance: Reassure service member that this condition will improve with rest and he will
soon return to his unit. - Replenishment: Food, water, hygiene
- Restoration (of confidence): Often service members will have lost confidence in themselves, their
equipment or their leadership. Work to restore confidence by keeping the service member in his military
role—do not emphasize a “patient“ role. Assign simple tasks and duties such as rehearsing battle drills,
checking weapons, etc.
Prevention: Combat resiliency, or the ability to ward off the impairing features of combat and operational
stress, is best attained through tough, realistic training, physical stamina, high morale and esprit, strong unit
cohesion, and unity of effort. This is a leadership and command responsibility, but medics play an important
role in assessing a unit’s health along these lines.
Follow-up Actions
Evacuation/Consultation Criteria: At any level of care, the provider must make a determination to HOLD,
return to DUTY, or REFER battle fatigue casualties. This decision is based on the severity of symptoms
and the tactical situation. Using the treatment principles above, 80% of service members presenting with
impairment from psychological or emotional disturbances can be returned to duty within 72 hours. Another
10% may benefit from holding and treating for up to a week. The remaining 10% likely have mental disorders
and will need referral higher for definitive care. The SOF medic’s role in those cases is to ensure safety
and stability for transport.
NOTES: Although specific to battle fatigue, these assessments and treatment principles can effectively be
applied to non-combat situations such as Peace and Peace Enforcement operations, Stability and Support
Operations, routine deployments and exercises.