BVA9405222 DOCKET NO. 91-21 464 ) DATE ) ) ) THE ISSUES 1. Entitlement to service connection for post traumatic stress disorder. 2. Entitlement to service connection for left temporal epidural hematoma. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel INTRODUCTION The veteran had active service from February 1968 to January 1970. This appeal arises from a July 1990 rating decision which denied service connection for post traumatic stress disorder (PTSD). The case was remanded by the Board of Veterans' Appeals (Board) to the Nashville, Tennessee, Regional Office (RO) in August 1991 for additional development of the evidence regarding entitlement to service connection for PTSD. This appeal also arises from a March 1993 rating decision which denied service connection for left temporal epidural hematoma. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that the RO erred by failing to grant service connection for PTSD which resulted from his wartime service in Vietnam. He maintains that he was engaged in combat, was wounded, and received the Combat Infantryman Badge (CIB) and the Purple Heart. It is further contended that a left temporal epidural hematoma resulted from PTSD and combat. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for service connection for PTSD, and that the claim for service connection for left temporal epidural hematoma is not well grounded and must be denied. FINDINGS OF FACT 1. All available relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The veteran was not involved in combat during his service in Vietnam. 3. Objective demonstration of an inservice stressor has not been shown. 4. The veteran does not have PTSD as a result of his wartime service in Vietnam. 5. The veteran suffered a left temporal epidural hematoma in 1991, many years following separation from service, which was totally unrelated to service. CONCLUSIONS OF LAW 1. PTSD was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 1991); 38 C.F.R. § 3.304 (1993). 2. The claim for service connection for left temporal epidural hematoma is not well grounded. 38 U.S.C.A. §§ 1110, 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The threshold question to be answered in all claims in whether the veteran has presented a well grounded claim. That is, one which is plausible. If he has not, his appeal must fail. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet.App. 78 (1990). In February 1993, the veteran initiated a claim for service connection following a brain operation which was performed in 1991 with resulting loss of smell, taste, and vision which he contended were "due to PTSD, and combat in Vietnam." Submitted with the claim were July 1991 records from Holston Valley Hospital and Medical Center (HVHMC) which show that the veteran had a premorbid history of PTSD. The veteran had been admitted after apparently being found unconscious. On arrival, there were bilateral periorbital ecchymoses; an emergency CT scan showed a left temporal acute epidural hematoma. Medical history was significant for PTSD; no other history was available. An operative report shows that a left temporal craniectomy and evacuation of epidural hematoma was performed. A report of consultation included an impression of premorbid psychiatric history of questionable extent, which would complicate the veteran's case. The discharge diagnoses were left acute epidural hematoma, basilar skull fracture, cerebral contusion, sphenoid fracture, and post-traumatic stress reaction. On the October 1966 pre-induction examination report, the veteran reported a history of headaches and dizziness after an automobile accident. On clinical examination, the veteran was normal physically and psychiatrically, except for a hearing loss. On the February 1968 induction examination, the veteran was clinically evaluated as normal physically and psychiatrically. Medical history provided in April 1968 included being hit in the head at age nine, and having passed out, no problem indicated. On clinical examination in November 1969, the veteran was normal physically and psychiatrically. In January 1970, the veteran executed DA form 664, indicating that he had decided not to file an application for compensation at that time. DA form 1811, physical and mental status on release from active service, dated in February 1970, indicated that the veteran's physical condition was such that he was considered physically qualified for separation or for re-enlistment without re-examination. At no time prior to the filing of the claim for service connection for the left temporal epidural hematoma in February 1993, to include the filing of the service connection claim for PTSD in March 1990 or during the January 1991 personal hearing, did the veteran indicate the existence of a left temporal epidural hematoma. Rather, the record demonstrates that this condition stems entirely from a post service event in July 1991, more than 20 years following service, when the veteran was treated for skull fracture, cerebral contusion, and sphenoid fracture. Allegations that cranial disability was due to PTSD and combat in Vietnam are without foundation. Service medical records show that the veteran did not sustain a head injury during service. Private medical records from 1991 show that PTSD may complicate recovery following cranial surgery; however, they do not indicate that PTSD was a precipitating cause of the condition. Even assuming arguendo that PTSD played a role in the genesis of the head disability, as service connection for PTSD is not forthcoming, any putative causation for VA claim purposes is moot. We find that there is no plausible basis for the claim for service connection for left temporal epidural hematoma; accordingly, we conclude that the claim is not well grounded. See Tirpak v. Derwinski, 2 Vet.App. 609 (1992). Furthermore, as the claim is not well grounded, there is no duty to assist the veteran in the development of that claim. 38 U.S.C.A. § 5107(a); Grivois v. Brown, No. 92-289 (U.S. Vet. App. January 5, 1994). Conversely, we find that the veteran's claim for service connection for PTSD is well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, we find that he has presented a claim which is plausible. We are also satisfied that all relevant facts have been properly developed and that no further assistance is required to comply with the duty to assist under 38 U.S.C.A. § 5107(a). Regarding evidentiary development, the veteran reported having received treatment from 1970 to 1989 by J.J. Porter, M.D., who prescribed valium; however, he also reported that Dr. Porter's records had been destroyed in a fire. (T-11; January 1991 hearing). Service connection will be granted for a disability resulting from disease or injury which was incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110. 38 C.F.R. § 3.304(f) provides that: Service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed inservice stressor. The veteran's DD Form 214 shows that he had active service from February 1968 to January 1970, and that his military occupational specialty (MOS) was an air traffic controller. He received the National Defense Service Medal, and the Vietnam Service Medal. The veteran did not receive any awards or decorations specifically related to combat. The veteran's DA form 20 was received from the National Personnel Records Center (NPRC) in June 1990. It indicates that he served in Vietnam from November 1968 to November 1969 as an air traffic control operator with the 160th Aviation Group. In November 1992, the NPRC reported that a search for morning reports from November 1968 to November 1969 for the 160th Aviation Group had been conducted and the only information found was an extract showing that the veteran had been transferred from the 101st Administrative Company to the 160th Aviation Group in November 1968. No information regarding missing, killed or wounded in action was available. A June 1969 Army Commendation Medal was submitted in January 1991. It was presented to the veteran for meritorious achievement in ground operations from December 1968 to April 1969, and for outstanding performance during the cited period which was a significant contribution in support of the United States counterinsurgency effort in the Republic of Vietnam. Medical history provided at a pre-induction examination in October 1966 included depression or excessive worry, and nervous trouble. The physician's summary noted "nervous", no medication now. On examinations in October 1966, February and April 1968, and November 1969, the veteran was clinically evaluated as normal psychiatrically. No history, clinical finding or impression indicative of a left leg wound is contained in the service medical records. The veteran was admitted to Indian Path Pavilion (IPP) from September to October 1989 for depression, flashbacks of Vietnam experiences, erratic behavior, withdrawal and suspected psychosis. He reported that he had been a paratrooper and that he had killed several people. He could not or would not give details regarding such events. The veteran stated that he had often been at risk and was wounded in the left leg. Family members indicated that the veteran had been in need of help for a long time, but that symptoms had increased in recent months. His mother indicated that he had never seemed the same following his return from Vietnam. Discharge diagnoses included delayed onset PTSD. A May 1990 written statement from Frank Varney, M.D., indicates that he had treated the veteran since 1988 for disabilities to include PTSD. On VA psychological evaluation in June 1990, the veteran reported being involved in heavy combat for one year while in Vietnam, and participating in firefights. He related that his closest friend, named Frost, had been mortally wounded and died in his arms. Diagnoses included PTSD. A September 1990 VA PTSD program report indicates that although the veteran's MOS was an air traffic controller, he reported serving most of his time with infantry and pathfinders in Vietnam. He stated that he had been in Vietnam for two weeks and was assigned to an M-60 even though he didn't know how to use it. The veteran reported seeing extensive combat and was very specific and descriptive in his account. A summary indicated that the veteran had a history of severe combat trauma and demonstrated an almost classic picture of PTSD. The diagnostic impression was chronic PTSD. An October to November 1990 VA hospital discharge summary includes a diagnosis of PTSD. The veteran submitted a stressor statement in May 1990. He indicated being involved in constant firefights, and that many individuals in his unit were killed. The veteran reported being able to see the faces of comrades but that he had been hypnotized to forget names, and that he had held many paratroopers in his arms as they were dying and did not know their names. He reported suffering a gun shot wound of the left leg in March 1970, and stated that he had been awarded the CIB, and Purple Heart. The veteran testified at a January 1991 personal hearing that he had been assigned to the 169th Assault with a pathfinder unit upon arriving in Vietnam (T-4); that he never performed duties as an air traffic controller, but set up perimeters for the 160th Aviation Company (T-6); that he was awarded the CIB (T-9) and Purple Heart for a left leg wound (T-14); that comrades named Stevens and Moncrese had been killed (T-15); and that he was a paratrooper with the Army Rangers and that he was trained to jump while in Vietnam (T-16). An April 1992 statement from U.S. Army & Joint Services Environmental Support Group (ESG) indicates that in order to provide information as to the mortar/rocket attacks, convoy incidents, or firefights as mentioned by the veteran, additional information would be needed. The veteran should provide dates of incidents within sevens, type and location of the incident, full names of any casualties, and any other units involved. Casualty data lists include numerous "Stevens". In order to provide research concerning this casualty, more specific information must be provided. U.S. Army casualty data does not list the veteran as injured/wounded in Vietnam. Anecdotal incidents, although they may be true, are not researchable. Stressors such as the veteran holding a dying paratrooper, his assisting casualties, or that he made his own bombs, are seldom found in the combat records. In order to conduct meaningful research, the veteran must provide the "who, what, where and when" of each stressor. A February 1993 stressor affidavit from the veteran indicated "Listed below are K.I.A.'s and wounded I was accepted to, on my tour of duty." The list includes Robert Santos of the 501st Infantry, wounded in November 1968; William Stocks, 1st Battalion, 6th Infantry, 198th Light Infantry Brigade, helicopter crash; Richmond Sito, 198th Infantry Brigade, K.I.A.; Peter Roepoke, 506 Infantry, 101st Airborne Division, broken leg; James Wilson, 505th Infantry, 82nd Airborne Division, K.I.A.; Raymond Tymeson, K.I.A., U.S.M.C.; Jesus Betancourt, U.S. Army, K.I.A.; and Paul Baker, U.S.M.C., K.I.A. In Smith v. Derwinski, 2 Vet.App. 137, 140 (1992), in reviewing the legislative history of 38 U.S.C.A. § 1154, the Court stated that "...the matter of service connection is a factual determination which must be made by the Secretary based upon the evidence in each individual case..." Whether the veteran was exposed to a stressor in Vietnam, is a factual determination to be made by the Board. VA Adjudication Procedure Manual, M21-1, Part VI, provides: If the evidence shows the veteran engaged in combat with the enemy and the claimed stressor is related to combat, no further development for evidence of a stressor is necessary...If the claimed stressor is not combat related, a history of a stressor as related by the veteran is, in itself, insufficient. Service records must support the assertion that the veteran was subjected to a stressor of sufficient gravity to evoke symptoms in almost anyone. The existence of a recognizable stressor or accumulation of stressors must be supported. It is important the stressor be described as to its nature, severity and date of occurrence. As a starting point, it must be determined whether the veteran was engaged in combat in Vietnam. Although the veteran has consistently alleged being involved in combat, we find that the evidence conclusively demonstrates that he was not engaged in combat. Consequently, the provisions of § 1154(b) which provide that in cases where any veteran engaged in combat, satisfactory lay evidence, if otherwise consistent, shall be accepted as sufficient proof of service connection, are not for application in this case. Irby v. Brown, No. 93-350 (U.S. Vet. App. January 5, 1994). The veteran's MOS is not combat related. He did not receive any awards or commendations related to combat service. Although he has repeatedly referred to a wound of the left leg, the service medical records and the U.S. Army casualty data are silent regarding any injury or wound. The Army Commendation Award for achievement in ground operations, does not refer to or establish that the veteran was engaged in combat. Numerous references to service with pathfinders, paratroopers and infantry units are in stark contrast with the veteran's personnel records which show that he was assigned to the 160th Aviation Group while in Vietnam. Similarly, personnel records are at odds with his assertions that he was awarded the CIB and a Purple Heart. Testimony provided in January 1991 to the effect that without prior training the veteran had been assigned to a paratrooper unit in the Army Rangers, and the September 1990 reference to being assigned to a M-60 without training are examples of facts advanced by the veteran which fall far beyond the pale of plausibility. We find that the veteran's allegations regarding combat service in Vietnam are contrary to the documentary evidence, and lack credibility or probative value. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). At this juncture, we look to the Court for guidance. In Wood v. Derwinski, 1 Vet.App. 190, 192-3 (1991), the Court stated: We have carefully examined the record and are convinced that there is a plausible basis for the factual finding of the BVA, i.e., that there was insufficient evidence to support a finding of PTSD stemming from appellant's military service. Contrary to the contentions of appellant, the BVA was not bound to accept his uncorroborated account of his Vietnam experiences; nor was the BVA required to accept the social worker's and psychiatrist's unsubstanitated (if somewhat ambiguous) opinions that the alleged PTSD had its origins in appellant's Vietnam service. This is especially true since there was a considerable passage of time between the putative stressful events recounted by appellant and the onset of the alleged PTSD. Also, as noted by the BVA, neither appellant's military specialty (cannoneer), nor his service records, disclose that the nature of his duties exposed him to a more than ordinary stressful environment, even given the fact that service in a combat zone is stressful in some degree to all who are there, whatever their duties and experiences... Appellant now argues in his brief that, particularly because health care professionals accepted his Vietnam experiences as truthful, the BVA was required to do the same. That misconceives the role of the BVA. As all individuals in a war zone are exposed to stressful situations, corroboration of a stressor is primary to the diagnosis of PTSD. The most authoritative basis for establishing a stressor is when a veteran's military personnel records demonstrate prima facie evidence of a stressor. The veteran's military history, which shows that he served with an aviation group as an air traffic controller and that he did not receive combat or valor awards, does not demonstrate that he was exposed to more than an ordinary stressful wartime environment. While it is established that a stressor does not have to be encountered in combat; nonetheless, there must be verifiable evidence that the veteran was exposed to a traumatic event beyond the usual realm of human experience. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 247-51 (3rd ed. 1987). In this case, we are left with the veteran's ability to provide sufficient information upon which documentation of a stressor may be made. As was the situation in Wood, substantial time elapsed between the alleged stressors and the first medical evidence showing symptoms and diagnoses of PTSD in 1989. Statements from family members in September 1989 when the veteran was first hospitalized refer to a long history of mental problems, but do not indicate the presence of longstanding symptoms indicative of PTSD. The April 1992 statement from ESG indicates that the veteran's putative stressors as described in the May 1990 stressor statement were too general or anecdotal to be researchable. In response to the need for greater specificity, the veteran submitted the February 1993 affidavit which listed numerous individuals who had been wounded or killed in Vietnam; however, none of the listed servicemen were in the veteran's unit. Interestingly, the veteran stated that these were individuals who "I was accepted to", which indicates that he quite possibly did not witness any incidents involving the named servicemen. Nevertheless, the listing of servicemen who did not serve with the veteran does not constitute probative evidence. Parenthetically, the names listed in February 1993 are different from the names provided during the June 1990 VA psychological evaluation (Frost) and during the January 1991 personal hearing (Stevens and Moncrese), raising doubt as to the authenticity of any of the individuals named. The remainder of the February 1993 affidavit, like the May 1990 statement, is anecdotal and non-researchable. In summary, as the veteran's MOS did not expose him to more than an ordinary stressful environment in Vietnam, as there was a considerable passage of time between the veteran's putative stressors in the late 1960's and the onset of PTSD in 1989, and as the veteran's putative stressors are wholly uncorroborated, we are not bound to accept the recent diagnoses of PTSD which are based on the veteran's unverifiable accounts of substantial combat service. Accordingly, we conclude that the preponderance of the evidence is against the veteran's claim for service connection for PTSD. ORDER Entitlement to service connection for PTSD is denied. As a well grounded claim for service connection for left temporal hematoma has not been presented, the benefit sought on appeal is denied. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 * I. S. SHERMAN C. W. SYMANSKI *38 U.S.C.A. § 7102(a)(2)(A) (West 1991) permits a Board of Veterans' Appeals Section, upon direction of the Chairman of the Board, to proceed with the transaction of business without awaiting assignment of an additional member to the Section when the Section is composed of fewer than three Members due to absence of a Member, vacancy on the Board or inability of the Member assigned to the Section to serve on the panel. The Chairman has directed that the Section proceed with the transaction of business, including the issuance of decisions, without awaiting the assignment of a third Member. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.