Citation Nr: 21006092 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 18-02 696 DATE: February 3, 2021 REMANDED The appeal for entitlement to service connection for a low back disability is remanded. The appeal for entitlement to service connection for headaches is remanded. The appeal for entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1972 to August 1975. This matter comes before the Board of Veterans’ Appeals (Board) from an October 2015 decision by the Agency of Original Jurisdiction (AOJ). Low back and headaches The Veteran contends that his low back disability and headaches had their inception during two automobile accidents during service. In a May 2014 statement, the Veteran reported two separate accidents in Kentucky while he was on leave. The Veteran reported that the first accident occurred the day after Christmas in 1973 outside of Louisville, Kentucky. He related that he had been riding in the rear seat of a vehicle which went over a thirty to fifty-foot cliff. He asserted that he was knocked unconscious, sustained a traumatic brain injury (TBI), in addition to neck and back injuries. In November 2014, he submitted two witness statements from the driver of the car and the front seat passenger attesting to the weather conditions, the date, and the accident itself. According to his statement, he was involved in a second automobile accident in February 1974, in Paducah, Kentucky. He asserts that he suffered a subdural hematoma during that accident, and received medical care at the military hospital in Fort Campbell, Kentucky. He recalled that his family members were contacted to come in case he died from the injuries sustained during this accident. Neither of these reported accidents are reflected in the contemporaneous records. However, the Veteran’s service treatment and personnel records do show an automobile accident occurring in June 1974 which occurred in Paducah, Kentucky. According to these records, the Veteran sustained a contusion and hematoma to his left abdominal wall and injuries to his lumbar area. The Veteran was treated at the Western Baptist Hospital immediately after the accident and then transferred to the hospital in Fort Campbell, Kentucky for recovery. Although records from the Western Baptist Hospital are unavailable, the records from Fort Campbell were obtained for review. There is no indication of a head injury; rather the Veteran complained of pain in his abdomen and low back. X-ray studies of his spine were interpreted as normal. After four days of observation, to include ruling out injuries to the Veteran’s spleen and gastrointestinal system, he was released to duty at Fort Hood. Unfortunately, it does not appear that the Veteran was provided with a general medical examination at separation from service, as is the usual practice. Careful review of his service treatment records shows that they appear to be otherwise complete, however, as they include the report of his entrance examination along with multiple treatment notes and the report of his hospitalization at Fort Campbell in June 1974. There was some question as to whether these automobile accidents occurred when the Veteran was absent without leave (AWOL). Indeed, the Veteran’s DD Form 214 indicates that the Veteran had a total of fifteen days lost including from December 25, 1973 to December 26, 1973, when he reports that the first accident occurred; and from June 4, 1974 through June 6, 1974. The AOJ has released several administrative decisions as to whether the June 1974 accident occurred during a period of AWOL. In the most recent decision, dated in October 2017, a panel of three VA adjudicators determined that the Veteran was NOT absent without leave from June 4th through June 6th, 1974. Thus for purposes of VA compensation benefits, any chronic injuries sustained during the documented automobile accident in June 1974, are considered to be within the line of duty. The evidence regarding these automobile accidents is scanty at best. The first reported accident in December 1973, is substantiated only by the 2014 statements of the Veteran and his two witnesses. There is no contemporaneous evidence, to include contemporaneous medical treatment reports, corroborating the accident. The second reported accident, which the Veteran has variously identified as occurring in February or June 1974, is substantiated as having occurred in June 1974. The record contains contemporaneous service personnel records regarding the extension of the Veteran’s leave and his hospitalization at Fort Campbell, selected because it was proximate to the private hospital where he was initially treated after the accident. The Veteran’s recollections appear to be less than clear. In addition to his confusion regarding the dates of the second accident, his recollection of injuries received is inconsistent with the available contemporaneous medical evidence. For instance, his recollection that in December 1973, he was knocked unconscious, sustained a TBI, along with injuries to his neck and back is not supported by the contemporaneous evidence, which is entirely negative for any physical complaints at the time. Even assuming that he did sustain such injuries, the report of a thorough medical work-up following the June 1974 accident revealed no findings involving his head, neck, or back at that time. Thus, the Board concludes that the Veteran did not sustain chronic injury involving his head, neck, or back during a December 1973 automobile accident. Similarly, the contemporaneous medical records following the Veteran’s June 1974 automobile accident do not support his current assertions that he sustained a subdural hematoma (i.e. an injury causing blood vessels in the brain to burst) and nearly died after the accident. Rather, the contemporaneous medical records show that the Veteran sustained a contusion and hematoma to his left abdominal wall and injuries to his lumbar area, which did not implicate his spleen or gastrointestinal system, and did not cause bony or other injury which would have been evident upon the X-ray study. In light of all of the above, the absence of post-service treatment records is frustrating to a full understanding of the Veteran’s current disabilities. It appears that there may be some outstanding records however, which could prove highly relevant to the analysis of this case. Following his discharge from service, the Veteran availed himself of VA education benefits from 1975 through 1980. As such he was enrolled in the VA system and records from this time period are available. Any VA medical records reflecting the Veteran’s condition subsequent to service are thus relevant and could help to fill in the missing information regarding the Veteran’s disabilities. According to a November 1976 Exchange of Beneficiary Information Form, the Veteran was admitted to the VA Hospital in Lexington, Kentucky, for treatment of abdominal pain. Any VA medical records are deemed to be constructively of record in proceedings before the Board and should be obtained prior to further review of the claims file. Bell v. Derwinski, 2 Vet. App. 611 (1992). At a minimum, the complete records of the November 1976 hospitalization should be obtained. Additionally, any other inpatient or outpatient VA medical records pertaining to the veteran should be obtained for review. PTSD The Veteran contends he has PTSD related to two noncombat traumatic experiences during service. The first involved an accident when he saw a fellow unit member crushed and killed by a truck at Fort Hood. The second involved an accident when he witnessed another fellow unit member get shot by an M50 on the tank range at Fort Hood. The Veteran has provided his recollections of the other soldiers’ last names, and also the last name of the gunner in the second incident. In an April 2017 statement, he narrowed the date range of these events to a time frame between January 3, 1974, and March 31, 1974. Recent treatment records confirm that the Veteran currently carries a diagnosis of PTSD related to traumatic childhood events. Additionally, the Veteran’s post-service history includes approximately twenty-five years of drug abuse and struggling with homelessness. However, a February 2015 VA examiner has linked the Veteran’s PTSD at least in part to the two deaths he states he witnessed. In a June 2017 memorandum for the file, the AOJ declined to conduct or request further research into these claimed stressor events, on the basis that the Veteran had not provided the full name and unit designation of the casualties. The Board disagrees with this determination. The Veteran has reported that the men killed were members of his unit, the identifying information for which is contained in the veteran’s service personnel records. He has provided the last names that he recalls, and has narrowed the date range to a matter of three months in 1974. Given the seriousness of the Veteran’s allegations; that two soldiers died in training exercises at Fort Hood, the Board is of the opinion that records reflecting these accidents should be available and a formal attempt to confirm the Veteran’s stories is warranted. The matters are REMANDED for the following action: 1. Obtain the Veteran’s complete VA inpatient and outpatient treatment records for the period from August 1975 to 2013, to include complete hospital records from the VA Hospital in Lexington, Kentucky in November 1976. 2. Contact the appropriate military history and records personnel to attempt to corroborate the Veteran’s claimed in-service stressors, including the deaths of two of his unit members. The RO should request a search into unit records for the time period in question. 3. After accomplishing the requested evidentiary development, the AOJ should review all new evidence to determine whether further development, such as obtaining additional medical nexus opinions, is necessary. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Heather J. Harter, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.