Citation Nr: 1609455 Decision Date: 03/09/16 Archive Date: 03/15/16 DOCKET NO. 14-25 550 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a traumatic brain injury (TBI) as secondary to service-connected PTSD. 2. Entitlement to service connection for a skull defect as secondary to a service-connected TBI and PTSD. 3. Entitlement to service connection for a right eye disability as secondary to a service-connected TBI and PTSD 4. Entitlement to service connection for loss of the sense of smell as secondary to a service-connected TBI and PTSD. 5. Entitlement to service connection for loss of the sense of taste as secondary to a service-connected TBI and PTSD. 6. Entitlement to service connection for loss of the jawbone as secondary to a service-connected TBI and PTSD. 7. Entitlement to service connection for loss of teeth as secondary to a service-connected TBI and PTSD. 8. Entitlement to service connection for an injury to the roof of the mouth as secondary to a service-connected TBI and PTSD. REPRESENTATION Appellant represented by: John Worman, Attorney ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from May 1981 to February 1982 and from January 1983 to August 1997. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cheyenne, Wyoming. Jurisdiction over the claims file is currently held by the RO in St. Louis, Missouri. A claim for entitlement to an initial rating in excess of 50 percent for PTSD was addressed in a February 2012 statement of the case (SOC). The Veteran did not respond with a substantive appeal and the claim was not certified to the Board. VA has also not explicitly or implicitly waived the requirement for a substantive appeal and the appeal was closed. See Percy v. Shinseki, 23 Vet.App. 37 (2009). In April 2015, the Veteran filed a new claim for an increased rating for PTSD, but this claim has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and the claim for a rating in excess of 50 percent for PTSD is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The issues of entitlement to service connection for a skull defect, right eye disability, loss of the senses of smell and taste, loss of the jaw bone, loss of teeth, and injury to the roof of the mouth, all as secondary to a service-connected TBI and PTSD, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDING OF FACT The Veteran's TBI was incurred secondary to PTSD. CONCLUSION OF LAW The Veteran's TBI is the result of service-connected PTSD. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran contends that he incurred a TBI secondary to service-connected PTSD. Specifically, the Veteran reports that he attempted suicide in November 1998 by a self-inflected gunshot wound to the head due to PTSD and associated trauma, depression, nightmares, and marital conflict. After review of the evidence, the Board finds that service connection is warranted for the Veteran's TBI as secondary to service-connected PTSD under 38 C.F.R. § 3.310. The available medical records establish that the Veteran was admitted to a private hospital on November 9, 1998 for treatment of a self-inflicted gunshot wound to the head. The Veteran was involved in a domestic argument with his wife when he shot himself; hospital records show that he arrived at the emergency room (ER) with massive trauma to the anterior portion of his head, extreme swelling of the face, and wounds to the chin and forehead near the hairline where the bullet entered and exited his skull. A head CT showed multiple fractures to the mandible, nose, ethmoid complex, and skull. The Veteran's right pupil was nonreactive to light and he also had the traumatic loss of at least one tooth. A frontal craniotomy was performed along with a tracheostomy during the initial hospitalization. The Veteran recovered in the intensive care unit with assisted ventilation. He was discharged and transferred to the Boise VA Medical Center's (VAMC's) neuropsychiatric department on approximately November 25, 1998. A cranioplasty was performed six months later at the private hospital in May 1999 to repair a large skull defect. The Veteran reports multiple residuals from the TBI, including headaches, vertigo, and the other disabilities on appeal. The Veteran has consistently reported that his attempt to take his own life was the result of untreated and uncontrolled PTSD. He stated in a February 2009 correspondence that at the time of the November 1998 incident, his wife had recently left him and he was experiencing severe depression, nightmares, traumatic memories, and stress. The Board finds the Veteran's statements are credible and he is competent to describe his psychiatric symptoms leading up to the November 1998 incident. Although the record does not contain a medical opinion explicitly linking the suicide attempt and resulting TBI to PTSD, VA examiners in October 2009 and December 2011 discussed the Veteran's head injury in the context of his past history of PTSD manifestations. Similar observations have also been made by the Veteran's treating health care providers and recent VAMC records document the Veteran's head injury, forehead reconstruction, tongue repair, and bilateral jaw prosthesis. The October 2009 VA examiner also noted that the Veteran was diagnosed with PTSD in 1998 immediately after and in connection with the suicide attempt. Finally, the Board observes that the RO acknowledged the Veteran's suicide attempt in the April 2012 rating decision granting service connection for PTSD. The Board therefore finds that the Veteran's claimed TBI is due to service-connected PTSD and service connection on a secondary basis is warranted. The remaining issues on appeal pertain to specific residual disabilities claimed by the Veteran as associated with the TBI and secondary to PTSD; they are addressed in the remand below. The Board also finds that VA has substantially satisfied the duties to notify and assist in this case. To the extent that there may be any deficiency of notice or assistance, there is no prejudice to the Veteran in proceeding with this appeal given the favorable nature of the Board's decision to grant the claim. ORDER Entitlement to service connection for a TBI as secondary to service-connected PTSD is granted. REMAND The Board finds that a remand is necessary to further develop the record with respect to the remaining claims on appeal. The Veteran contends that the claimed conditions are all residuals of the now service-connected TBI and PTSD. He was previously scheduled for a VA examination to determine the nature and etiology of these conditions, but cancelled the examination in April 2012 presumably due to his relocation from Wyoming to Missouri. The RO asked the Veteran to provide his current address to allow for a rescheduling of the examination, but no response to this request was received. The RO then denied the claims for service connection in the April 2012 rating decision on appeal based on the Veteran's failure to attend a VA examination. The Board finds that a VA examination is necessary to determine the precise nature of any residual disabilities associated with the service-connected TBI and PTSD. The Veteran's claim file includes his current address in Eldon, Missouri, and he recently appeared for a VA examination of his knees at the Columbia VAMC in May 2015. Therefore, VA examinations should be scheduled in accordance with VA's usual procedures to determine the nature and etiology of the claimed TBI residuals. Additionally, the lay and available medical evidence establishes that the Veteran was transferred to the Boise VAMC for inpatient care in November 1998 after his initial private hospitalization for a gunshot wound. However, records of the Veteran's VAMC inpatient treatment are not included in the claims file (which only contains scant VA records from this period). These records are pertinent to the claims before the Board and must be obtained. See Bell v. Derwinski, 2 Vet. App. 611 (1992). The Veteran has also reported that he sought treatment at the "local" Vet Center after his discharge from the Boise VAMC in 1998 and attended weekly counseling sessions at that facility until sometime in 1999. A December 1998 PTSD assessment at the Boise VAMC shows that the Veteran was referred to the Boise Vet Center for counseling, and records from this facility should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's complete treatment records from the Boise VAMC dated from November to December 1998, to include all records of inpatient treatment related to the service-connected TBI and PTSD. 2. Obtain the Veteran's complete treatment records from the Columbia VAMC from March 2015 to the present. 3. Obtain the Veteran's complete treatment records from the Boise Vet Center, to include any records dated from December 1998 through 1999. If a medical release form is necessary to obtain these records, provide one to the Veteran and ask that he complete it to authorize VA to obtain these records on his behalf. All attempts to obtain the records must be documented in the claims file. 4. Then, schedule the Veteran for all necessary VA examinations to determine the nature and etiology of the claimed residuals of a TBI secondary to PTSD. The claims file must be made available to and reviewed by the examiner(s). After physically examining the Veteran and reviewing the complete claims file, the examiner(s) should identify and describe all current residuals of the Veteran's November 1998 gunshot wound to the head and TBI, to include whether he manifests a skull defect, a right eye disability (including loss of vision), loss of the senses of smell and taste, loss of the jaw bone, loss of teeth, and an injury to the roof of the mouth. The examiner should also determine whether the Veteran experiences chronic headaches and/or vertigo as a result of the service-connected TBI. The Board has determined that service connection is warranted for the TBI as secondary to service-connected PTSD. Treatment records from the private hospital that treated the Veteran immediately after the November 1998 gunshot wound establish that he incurred massive facial trauma, multiple fractures of the mandible, nasal area, and skull, the traumatic loss of at least one tooth, and manifested a nonreactive right pupil. A craniotomy, tracheostomy, and cranioplasty were performed in November 1998 and May 1999. More recent VAMC records also document a forehead reconstruction, tongue repair, and bilateral jaw prosthesis. 5. Readjudicate the claims on appeal. If the benefits sought on appeal are not fully granted, issue a SSOC before returning the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs