Citation Nr: 21041489 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 15-34 471 DATE: July 9, 2021 REMANDED Entitlement to service connection for a chronic back disorder is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1970 to February 1977. The Veteran died in September 2018. The Appellant is his surviving spouse. In August 2019, the RO determined that she was an eligible substitute in the appeal. These matters come before the Board of Veterans' Appeals (Board) from a rating decision issued in April 2015 by the Department of Veterans Affairs (VA) Regional Office (RO). The Appellant testified at a hearing in March 2021 before the undersigned Veterans Law Judge (VLJ). The record was held open for 60 days for the submission of additional evidence. A copy of the transcript is of record. The Board notes that the rating decision of April 2015 found that the Veteran had presented new and material evidence to reopen the claims for service connection for PTSD and a back disability. However, as this new and material evidence had been provided within one year of the promulgation of the November 2013 rating decision, the Board will not conduct a new and material evidence analysis in its adjudication of the issues since. Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2011); Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011); 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.160 (d), 19.20, 19.52, 20.1103. 1. Entitlement to service connection for a chronic back disorder is remanded. 2. Entitlement to service connection for PTSD is remanded. The Veteran, during his lifetime, contended that service connection was warranted for his back disability and PTSD. Regarding his back, he provided numerous statements that he has had chronic back pains since service. For example, in an August 2014 statement, he stated that he lifted and handled bombs weighing between 33 to 500 pounds and trailer weighing 27 to 750 pounds per trailer while in service. In his September 2015 Form 9, Appeal to the Board, he specifically stated that while stationed in Guam in 1972, during the Palace Dog Campaign, he strained his back and was sent to the infirmary where he was diagnosed with strained muscles. He was given medication and aspirin and told to ice his back. As he was in a hot, humid, no air circulation "tent city," there was no ice. Immediately after service, he sought treatment for his back disability, which was unsuccessful. The Veteran's DD-214 shows that his Military Occupational Specialty (MOS) was a munitions maintenance specialist. His personnel records confirm that he had a 121-day TDY to Anderson AFB, Guam. Furthermore, he loaded and secured MK-82, MK-83, and M-117 bombs on 40-foot trailers. It was noted in his December 1972 THT, SSGT and SGT Performance Report that "he was instrumental in loading 365.5 tons of M-17 bombs and trailers for buildup." The Appellant competently and credibly testified at the March 2021 Board hearing that the Veteran had been in continuous pain and seeing a chiropractor weekly since she met him. He continued chiropractic treatment until his death in September 2018. As the Board has determined that the "low threshold" necessary to establish entitlement to service connection is met, a VA medical opinion is warranted. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Veteran was diagnosed with PTSD. He averred that it was related to stressors incurred in service. His reported stressors included his building bombs that were dropped in Vietnam and which killed thousands of people; being wrongly accused of taking illicit drugs, when he was actually on prescription medication for headache and high blood pressure, and being subsequent ostracized and demoted from Line Delivery/Bomb Dump to barrack duties because of the allegations; and being sent to Vietnam twice, in November 1972 for two days and 1975, to assist with the evacuees. The Appellant testified that the Veteran told her that he was sent to Tan Son Nhut, Vietnam, during Operation Palace Chase and Operation Palace Dog, to guard the bombs. "[H]e was scared to death, knowing that the enemy was right there." In addition to guarding and transporting bombs in Vietnam, he saw a rocket's glare, smelled napalm, and saw body bags and caskets. He also told her that he would not sleep and was put on a drug for not sleeping or for his back pain. He was prescribed Valium, Dyazide, and a blood pressure water pill. His taking of the said prescription medications led to a positive urine test, where he was accused of taking illegal drugs. The accusation caused him stress and depression, which continued after service. As to the symptoms of his disability witnessed by the Appellant, she testified that she observed, when they first started dating, "anxiety during the day and especially at night while he was sleeping." For example, when sleeping, he would "wav[e] or thrash his arms, hit the bed with his fists and talk in his sleep ... [a]nd say things such as: 'Are you packed up and ready to go?' 'Are you packed up and ready to report?' 'What's the capacity?' 'There's a field over there.'" Often times, she got up from the bed out of fear that "he might hit" her. The Veteran's service treatment records (STRs) reflect that he was seen in the Mental Health Clinic in January 1973 and October 1975. The October 1975 entry notes: "Seen at the request of .... MH file contains more info." Further, a September 1975 entry notes that the Veteran was "[t]emporarily disqualified from HRP duties ... 43 mms/cc Ltr 25 Sep 75." The Board notes that the MH file referenced in the October 1975 entry is not of record. Also, numerous entries confirm that the Veteran was seen for complaints of headaches and high blood pressure and prescribed Dyazide and other medications. In November 1975, while seeking treatment for headaches, the attending clinician noted that the Veteran had "a new job in last month as barracks chief [and was] taken off of HRP last month because of a drug problem. Off drugs completely now." During a December 1976 Report of Medical Examination, the examiner noted that the Veteran's high blood pressure was elevated in 1975 while overseas and that he had frequent trouble sleeping, occasionally. The record further contains an October 2014 letter, with a duplicate dated June 2015 from N. F., LCSW, MSW, the Veteran's treating clinician who diagnosed him with PTSD. She noted that he was receiving treatment for anxiety and depression, but many of the symptoms were attributable to generalized anxiety disorder and dysthymia, as he would often see himself the way that his Command tried to portray him. After retirement, his symptoms increased, for he did not have any external matters to focus his attention on and became more consistent with PTSD. Based on the above, the Board finds that a remand is warranted for complete service treatment records, to attempt to verify the Veteran's reported stressors, and for a medical opinion. Accordingly, the matters are REMANDED for the following action: 1. Attempt to obtain any outstanding service treatment records, to include mental health file that was referenced in October 1975 entry, from the appropriate repositories, and associate them with the claims file. The requests for records should continue until it is determined that the records either do not exist or that further requests would be futile. If such a determination is made, a memorandum documented the determination should be affiliated with the claims file. 2. Conduct appropriate research to attempt to verify the Veteran's contended stressors as outlined above in support of his claim for service connection for PTSD. The requests for records should continue until it is determined that the records either do not exist or that further requests would be futile. If such a determination is made, a memorandum documented the determination should be affiliated with the claims file. 3. Provide the Veteran's claims file to a suitable clinician to determine whether the Veteran's back disability was related to service. The Veteran's entire record must be reviewed by the examiner in conjunction with the opinion. The clinician must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's back disability began during active service, is related to an incident of service, or if he had arthritis, whether it began within one year after discharge from active service. Although an independent review of the claims file is required, the clinician's attention is called to the Veteran's statement that he hurt his back in service and had chronic back pain since service, and the appellant's assertion that the Veteran had back pain since she met him. The clinician must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such conclusion. 4. Provide the Veteran's claims file to a psychiatrist or psychologist to determine whether or not the Veteran had an acquired psychiatric disorder that was related to his service, including as due to a stressor event therein. The Veteran's entire record must be reviewed by the examiner in conjunction with the opinion. The psychiatrist or psychologist should provide opinions as to the following: a. Identify all diagnosed psychiatric disabilities during the appeal period. b. If PTSD is diagnosed, identify the specific stressor(s) and comment upon the link between the current symptomatology and the Veteran's stressor(s). The examiner should specifically discuss the June 2015 letter from a VA psychologist indicating that the Veteran's PTSD was due to the way he often saw himself the way that his Command tried to portray him. c. Determine whether it is as likely as not (50 percent probability or greater) that any identified acquired psychiatric disability had its onset during active service or is related to any incident of service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such a conclusion. 5. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Stevens, 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.