DO treats returning troops for TBI, PTSD
Capt. Linda J. Fuller, DO, MC, USN (Ret.) (left), says she usually sees dramatic improvement in her patients in the four weeks she spends with them at the National Intrepid Center of Excellence . (Photo courtesy of NICOE)
The patient’s symptoms were so severe that he could barely function. The combat veteran was plagued by flashbacks, depression, chronic pain, balance difficulties and hallucinations. He was drinking heavily to drown out the flashbacks and nightmares and grappling with strained relationships with his wife and children. On top of all this, he was devastated when physicians told him a war injury likely meant he and his wife wouldn’t be able to have more children.
Enter Capt. Linda J. Fuller, DO, MC, USN (Ret.), and the National Intrepid Center of Excellence (NICOE). Run by the U.S. Department of Defense, NICOE is dedicated to helping active-duty military members recover from combat-related traumatic brain injury and psychological health conditions. Patients are referred by their military physicians and come to Bethesda, Md., for four weeks of intense outpatient care with a team of health care professionals.
Dr. Fuller is an addiction psychiatrist at NICOE. She’s at ease working with active-duty military personnel, in part because she is now retired from the Navy after 27 years of service. And while many service members complete their obligations and disappear into the civilian world, Dr. Fuller’s interest in working with military personnel never left her. Today she continues to dedicate her professional life to helping the nation’s Marines, sergeants and airmen heal—perhaps because military pride and passion are in her blood.
“I’m a military brat,” Dr. Fuller says. “My dad was a Marine. He served in the Korean War and the Vietnam War and did 24 years of service in the Marine Corps. My maternal grandfather was a second lieutenant in World War I. My uncle was in the army in World War II, and my cousin served in the army in Vietnam.”
Dr. Fuller’s military background makes her indispensable, says Jeannine Mielke, PhD, a neuropsychologist at NICOE.
“She has a great sensitivity for her patients, having been in the military herself,” Dr. Mielke says. “She relates very well to our patients and brings that experience to her work in psychiatry, and she approaches things in such a calm and measured way, which makes her patients feel very comfortable with her.”
Dr. Fuller’s military service began in medical school, when she attended the Oklahoma State University Center for Health Sciences College of Osteopathic Medicine in Tulsa on a Navy Health Professions Scholarship. She then served her internship and residency in psychiatry at the National Navy Medical Center in Bethesda and subsequently worked her way up to director of the Navy’s alcohol rehabilitation department at Oak Knoll Naval Hospital in Oakland, Calif.
Dr. Fuller later completed an addiction medicine fellowship and continued her service to the Navy in Bethesda. In 1999, after completing her payback time with the Navy, she considered retiring. But a colleague offered her a sought-after position with the Navy’s formal physical evaluation board, which was part of the Navy’s disability evaluation system. Dr. Fuller intended to serve two or three years; they stretched to seven after the events of Sept. 11, 2001, moved her to stay in active duty.
“It was kind of like Gilligan’s Island,” she says. “It turned into a seven-year trip.”
After retiring from active duty in 2006, Dr. Fuller opened a private practice. She received an email in 2010 about a position at NICOE, which had just opened. She says the center’s integrated approach, along with her desire to help military personnel, inspired her to apply, and she joined the staff in December 2011.
“In my practice, I was using more complementary and alternative approaches,” she says. “I emphasized meditation and breathing exercises and really liked the holistic philosophy of NICOE. I also like the team approach and in my private practice felt isolated and missed working with a team to assist patients in achieving their maximum health.”
Many of NICOE’s patients are dealing with TBI symptoms such as bad headaches and trouble concentrating and sleeping. A lot of them have posttraumatic stress disorder after witnessing the deaths of their colleagues and friends in combat. Sometimes they are also grappling with physical injuries inflicted by guns or roadside bombs. Depression and mood disorders are common in this population, as is alcohol abuse as a way to escape physical and psychological distress.
On Mondays at NICOE, Dr. Fuller and her team meet new patients, who share their combat stories and histories of physical and psychological illness. A patient’s treatment team typically includes Dr. Fuller in addition to a neuropsychologist, neurologist, family physician, chaplain and social worker.
“NICOE is heavy on patient education and providing patients the tools to continue these practices that help to normalize their bodies.”
“Patients go through the details of the traumatic brain injuries. And oftentimes in our population, they were exposed to more than one blast,” Dr. Fuller says. “Sometimes the blast exposures were also accompanied by losses. Deaths of friends or of other members of their unit. They outline the TBI event as well as the TBI symptoms that they have struggled with.”
After learning their histories, the team helps new patients identify three or four treatment priorities for their time at NICOE, Dr. Fuller says.
The rest of the week, Dr. Fuller sees patients individually for intensive 90-minute and 60-minute appointments. A big part of her job is helping patients make lifestyle changes that alleviate their symptoms, which she does by educating patients about the physical and psychological mechanisms of their conditions.
For instance, Dr. Fuller explains to her patients with PTSD what goes on in the brain to cause them to feel constantly alert and on guard. She helps patients learn to downshift their nervous systems by using their breath to engage with their parasympathetic nervous system. She works with other team members to teach patients techniques such as coherent breathing, which settles down the sympathetic overdrive of the nervous system.
“NICOE is heavy on patient education and providing patients the tools to continue these practices that help to normalize their bodies,” she says. “Patients are able to take a look into their life and change their lifestyles and reduce a lot of their symptoms.”
In addition to educating patients, Dr. Fuller is particularly skilled at obtaining sensitive information that’s integral to a patient’s treatment, says Anthony Panettiere, MD, a neurologist and sleep physician at NICOE.
“She’s very relaxed and a patient listener,” he says. “She’s able to engender trust with the patient to coax out a lot of the nuanced history that they otherwise wouldn’t necessarily be forthcoming with.”
Patients return home from NICOE with a treatment plan. At this point, their recovery is often in its infancy. Still, Dr. Fuller usually sees dramatic improvement in her patients in the four weeks she has with them.
‘Night and day’
“In most individuals it’s like night and day,” Dr. Fuller says. “It’s like the patients are different people when they walk out of here.”
Dr. Fuller humbly credits her patients’ success to NICOE’s vision and team-based approach to medicine. But her work is instrumental to patients’ drastic changes for the better, Dr. Mielke says.
“When we see patients, they’re here for four weeks,” she says. “Through Dr. Fuller’s work in psychiatry, we often see great progress across that time.”
For this reason, patients are often highly appreciative of the staff at NICOE. Dr. Fuller reads a card a former patient recently sent her.
“It says, ‘Thank you for being so kind to me. I want you to know how much it meant to me that I was able to count on you when I needed someone to lean on,’ ” she says.
Dr. Fuller and NICOE’s staff also heard again from the war veteran who was struggling with TBI and PTSD symptoms. While at NICOE, Dr. Fuller and other physicians worked together to identify medications that stabilized his mood and anxiety and eliminated his hallucinations. He stopped drinking on his own, and then returned home to continue his treatment plan with his physician.
Twelve months later, the patient wanted to tell NICOE how far he’d come in his recuperation. He shared a video that chronicled his recovery, including the good news that his improved condition allowed he and his wife to conceive again.
Dr. Fuller compares NICOE’s interdisciplinary approach to working with patients to a gemologist examining the different facets of a diamond. With some two dozen specialists on the team, little goes unnoticed.
“It is like no other interdisciplinary evaluation that most patients have ever undergone before,” she says. “It gives me great satisfaction working with this interdisciplinary team and being able to look closely at each individual and to examine not just mental health issues but physical issues, too, and to know that we have done the best that they have probably ever experienced.”
An interdisciplinary approach to medicine is only as strong as the physicians involved. Dr. Fuller is an invaluable member of the team, says Dr. Panettiere. As a sleep physician, he assists patients with the pain that prevents them from sleeping while Dr. Fuller attends to any psychological factors keeping them awake, such as hypervigilance. Such intensive collaboration between a neurologist and a psychiatrist is rare but often necessary for successful treatment, Dr. Panettiere says.
“I’m retired Navy, and I was in private practice for four years,” he says. “I’ve never been better at treating sleep disorders than I have been at NICOE, and it’s really because of Dr. Fuller.”