Page 19 - JSOM Winter 2019

revealed a healthy appearing young man with no obvious signs during and after capture can derive from the environment or
of trauma. The ANASOC SGN believed the patient appeared from torture. Malaria, dysentery, cholera, typhoid and para-
depressed, but the linguists and CJSOTF-A SGN did not ob- sites are common in captivity, and studies have demonstrated
11
serve this finding. This disparity in clinical assessment was an increased risk of peptic ulcers, purportedly from stress and
most likely due to unspoken communication and subtle sig- an increased incidence of H pylori infection. Imprisonment
10
nals and was not due to the language barrier. The CJSOTF-A often includes physical restraints that can place repetitive con-
SGN and ANASOC SGN ordered laboratory tests as available strictive pressure on extremities, and POWs have been found
at the local clinic. These laboratory tests included urine, com- to have an increased incidence of long-term peripheral nervous
plete blood count, basic metabolic panel, malaria screening, system disorders. Other methods of confinement paired with
and typhoid screening. disruptive articular trauma may contribute to the increased in-
cidence of arthropathies and dorsopathies (Figures 1 and 2). 10
Literature Review
FIGURE 1 Liberated POW at the time of rescue from a Taliban
Reflecting on the haphazard nature of the experience, the prison.
authors sought to better understand the medical literature to
enable evidence-based screening and management of future
POWs. The majority of US medical research on war prison-
ers originates from the roughly 116,000 repatriated prisoners
from World War II, 4500 from the Korean Conflict, and less
than 600 from the Vietnam Conflict. The experiences from
1
these conflicts are varied with one study articulating differ-
ences in outcomes even between the European and Pacific the-
aters of World War II. Additionally, individual characteristics
2
of prisoners including age, education, and length of service
have been shown to affect health outcomes. One prisoner of
1
war and surgeon wrote about his experiences in a German
camp and described how different diseases resulted from dif-
ferent “psychological and physical humiliations,” a division
that serves as a suitable means for categorizing the spectrum
of unique experiences. A different author stratifies physical (Photograph by US Army SPC Edward Randolph.)
3
stressors into four subcategories: weight change, nutrition, in-
juries at time of capture, and captivity injuries and illnesses.
These divisions help frame how military medical personnel
could approach screening recently repatriated prisoners.
The psychological ramifications of war imprisonment are sig-
nificant. One author articulates the major sources of stress for FIGURE 2 Freed prisoners during a press conference at ANASOC
POWs that can lead to psychological change: cycles of anxi- headquarters.
ety and relief, starvation and inadequate shelter, and indoctri-
nation. These stressors have immediate and enduring health
4
effects. Researchers have noted an immediate presentation of
apathy that can begin to lessen within days of repatriation.
4
Often more enduring, POWs experience greater symptoms of
posttraumatic stress disorder (PTSD), and these symptoms are
dose related to the severity of experienced trauma. Finally,
5,6
there is a lifelong increased risk of suicidal ideation decades
after imprisonment. 7
The descriptions of physical stress on POWs are harrowing: (Photograph by US Army SPC Edward Randolph.)
60-mile death marches from Bataan, diets consisting of less
than 750 calories a day, and extreme cases of physical tor-
ture including repeated blunt trauma to a prisoner’s stomach
after artificial distention with water and forcing the eyelids
of a prisoner open while staring at the sun for hours. These
8
examples demonstrate the need for careful attention to diet, Management
changes in weight, and incurred injuries. In cases of malnu-
trition, historical accounts demonstrate the potential of avita- In the case of this repatriated ANASOC soldier, the CJSOTF-A
minosis including pellagra, ariboflavinosis, and beri-beri with SGN provided recommendations for vaccinations and advised
symptoms including scrotal and exfoliative dermatitis, ankle a referral for specialty and subspecialty evaluation at the na-
edema, ascites, atrophic glossitis, absence of deep tendon re- tional Army hospital in Kabul: infectious disease for endemic
flexes, optic atrophy, sensorineural deafness, and peripheral pathologies and parasites, psychology for psychological health
neuropathy. 8–10 In evaluating the severity of these symptoms, conditions, orthopedics for occult musculoskeletal injuries,
long-term measures of morbidity associated with nutrition and dermatology for pruritus within the context of long-term
correlate to overall weight loss during captivity. Injuries confinement. The ANASOC religious cultural advisor met
10
Medical Screening of a Repatriated ANASOC POW | 17