“Fine.”
“Fine as in good or do you have any issues? Ever feel dizzy or off-balance?”
“Balance is perfect. I do feel dizzy at times. More recently. Usually, when I wake up. It can take a good hour or two for it to go away. Other days, I wake up and I’m fine.” Dr. Elm’s eyebrow raised slightly as he took notes on a pad.
“Have a seat. I’d like to check your reflexes.” Hal did, and the doctor lightly tapped his knee cap with a rubber hammer. Then tapped the other side. Hal’s reflexes were normal. “Sit back, Hal. Relax. I’ll be back.”
Hal eased into the deep-backed couch that felt like falling into a fluffy cloud wrapped in paper-thin soft leather. He looked at the book-lined walls as Dr. Elm grabbed a clipboard from his desk. Elm returned and sat in a chair before Hal that matched the couch. “So, how do you feel, Hal? I mean about life?”
Hal’s eyebrows furled for an instant and he eased back into the couch even more. It was such a broad question. He didn’t know where to start. “I feel good about life. I’m happy. Enjoy my job. Enjoy living on base and the lifestyle.”
“Have you noticed any recent changes in mood?”
“Yeah, since this whole… episode started. I have to admit, it has gotten me down.”
“We’ll address that in detail in a bit. For now, I’d like to focus more on the general. I have a list of questions here called the MMSE-Mini-Mental State Examination. It’s a standard list. You may find the questions very simple. Try to answer each as you would answer any question, not rushed, but not taking too long either. Here goes…”
Dr. Elm asked Hal several basic questions to get a baseline on his mental state. Making sure he knew the date, year, month, season, then location, country, state, city, clinic and office floor. Hal answered each with no abnormality.
“Apple, bicycle, basketball,” Dr. Elm said. “Please repeat these objects back to me.” Hal did. “Now count down backward from one-hundred, going by sevens.”
“93, 86, 79…” Hal said. It took him a little longer than Dr. Elm expected. He made a note of it.
“Now spell WORLD backward.”
“D-R, D-L-R-O-W,” Hal said. Dr. Elm took a note of his flub.
“Please repeat the three objects I just named to you.”
“Hal struggled to remember. “Basketball… apple… and truck?”
“Bicycle,” Dr. Elm said, making a note. He continued with the test, asking more questions, and had Hal fold a piece of paper and draw geometric shapes per his instructions. Hal sat silently as Dr. Elm tabulated the results with a scoring sheet on another page. He set the pages aside. “Do you have any difficulty thinking, reasoning or remembering? For example, when you carry out typical daily tasks like banking, shopping, eating or getting dressed?”
Hal pondered for a while. Sincerely thinking about it. “No. Not that I’m aware of — with daily tasks. I have noticed changes in my memory. It’s not that I’m forgetting things, I’m not. I’m remembering things that I’ve never done before. I know that sounds a lot like forgetting, but I have memories of things that seem random, like I’ve never been to the places of my memories.”
“Will you give me an example?”
“Yeah — I have plenty. Images from combat. The dreams and flashes of visions or whatever you call them, during the day. I have no memory of nearly all of them.”
“Do you ever have any thoughts of hurting yourself?”
“No,” Hal answered sternly. Looking at the doctor like he was insane.
“Do you drink alcohol?”
“Who doesn’t on an Air Force base?” Hal asked, joking.
“Has this recent episode made you feel angry, resentful or hostile?”
“Yes, it has.” Dr. Elm makes a note.
“What?” Hal asked. “What did you write?”
“These symptoms are also caused by alcohol dependence.”
“I’m not an alcoholic!” Hal said. Raising his voice.
“That’s what most people say who suffer alcohol dependence.” He scribbled again. Noting Hal’s raised anger.
“I’m not,” Hal said more calmly. “I control my drinking. I rarely drink during the week and only have a few on the weekend.” He expected the doctor to scribble that in his notes, but Dr. Elm just stared at Hal calm and cool.
“Were you drinking before you had these dreams or visions?”
“No. Well, yes, one time that I know of. Most happen at night and I made it a point to not drink before I went to sleep to see if it was causing them.”
“And?”
“I still had the dreams?”
“Would you call these dreams hallucinations?”
“No. I didn’t imagine them. I don’t know what to call them.”
“Then, how do you know they aren’t hallucinations?” Dr. Elm makes more notes.
“Because they happen… when I’m asleep.”
“You said you have some during the day too, when you’re awake.”
“Yeah, but I don’t see things or imagine things that aren’t there. They’re flashes in my mind. Like a daydream. Not a hallucination.”
“It’s fine. I understand. There’s no need to get worked up. I’m just asking questions.”
Hal shook his head in frustration and nearly apologized, but bit his lip instead.
“Why don’t we take a short break? I just have a few more questions.”
“I’m good, doc. I’d rather we just plow forward and get it over with.”
“Fine. So, when you have these dreams, what exactly are you seeing?”
“Combat. Explosions, muzzle fire. Buildings, landscapes, people’s faces. Nobody I know, but they seem familiar. I see their faces at the moment they’re shot. And it seems like I’m the one shooting them.”
“Tell me about some of the most distinguishable things you remember.”
“Turbans men wear… Specific weapons… Middle Eastern men… Mexican-looking men.”
“Mexican?” Dr. Elm asked, surprised. Making a note. “What happens when you wake up from these dreams? Are you alarmed or frightened?”
“No. I feel like I’m waking up in a foreign place, even if I’m at home. I feel sore all over — aches and pains. Rashes at times, marks on my neck, face and arms. Dizzy sometimes.”
“These marks — what happened to them? Will you show them to me?”
“They’ve gone away. They don’t last longer than a day. I’ve never bruised easily.”
Dr. Elm scribbled on his pad. “I read your file. You served in the RPA program at Creech.”
“Yes, sir.”
“Are you aware Creech has the highest rate of PTSD cases in the entire Air Force?”
“I didn’t know that.”
“And you served there fourteen years. Do you believe it’s possible that these symptoms are a form of PTSD?”
“You’re the doctor. Why are you asking me?”
“Have you had PTSD before?” Dr. Elm asked.
“No.”
“How often do you think about your late wife and child?”
Hal looked at him oddly, wondering how he knew.
“It was in your file. From a Creech assessment. It doesn’t say how they were…”
“Killed.” Hal finished his sentence. “By a drunk driver. And yes, I think about them every day. And I thought about them every day before I started having these symptoms.”
Dr. Elm flipped through his notes. “That’s all I have for today. It will be some time before I can determine a complete diagnosis. Your symptoms are pointing to any number of psychological disorders: PTSD, anxiety disorder, conduct disorder, Alzheimer’s Disease… It’s too early to rule any one of these out. The next step is to see what’s going on in your brain, so I’m going to order a CT scan and MRI. I’m also going to refer you to a neurologist, after you get the CT and MRI. They’ll be able to tell if there are any abnormalities in your brain itself. After you complete these, come back and see me.”