The consultation was an unusual one. A combat veteran was referred to me by another physician after the veteran had had some puzzling medical complications. The doctor was wondering whether “this gentleman’s problems might be related to his PTSD.”

Now, truthfully, if I’d just heard about this man’s symptoms in a case presentation, “PTSD” would not have been on the top of my list in (what we call in medical parlance) the differential diagnosis.

Apparently it was, though, for the veteran. For he had been the one to bring up the possibility.

When I first saw him, he appeared surprisingly chipper, given what he’d gone through medically only quite recently. He proceeded to tell me that although he was having problems remembering certain parts of his then-recent illness, he definitely recalled a time during it when he had felt “as if I were watching myself.”

“Has that every happened before?” I asked.

“Well, yes and no,” he replied. “Since I’ve been back from deployment, I’ve had some really strange experiences, but I have to say: nothing quite like this, certainly not during the day.”

“At night?”

“That’s been a different story, I’ll admit. Sometimes I’ve woken up and realized that I’d been wandering in some part of the house for who-knows-how-long, without a clue as to how I got there. And sometimes my wife says I start having these conversations with her in the middle of the night, going on and on about something or other dealing with The War, when I later can’t remember a thing.”

The man spoke with a certain assured air, if one could say such a thing about someone who was talking about being, at times, anything but assured about reality itself. He was a big guy, though in no way fat. True, he’d probably been a bit more toned, shall we say, in times gone by, but the adjective “husky” would have always been a mark of respect for him, never a euphemism. His dark hair was short, not in a military way, rather more like in the way of the decent guy next door who’d called to you over the fence some Friday evening to see if you and yours would like to join him and his for burgers and brats (and a bottle or two of Fat Tire).

“When were you over there?”

“2003, 2004. Flew over on my twenty-third birthday, flew back on my twenty-fourth.”

I looked at him and said nothing. He looked back and did the same.

I’m in fact never quite sure what to say when I find out a combat veteran took part in the initial invasion of Iraq. I only imagine, knowing that I can never begin to imagine, knowing, therefore, that anything I have to say will only be trivial, at best.

“Not good?”

He snorted, thankfully in a resigned way, rather than the disdainful way that question deserved.

“You could say that.”

“What was your MOS?” (i.e., his assignment)

“Medic.”

Once again, I’m never quite sure what to say.  As I’ve noted before (e.g., in Kilroy Wasn’t Here), when I hear that a veteran was a combat medic, I try not to react too blatantly to other imaginings of mine, imaginings of gunfire, explosions, screams, hands being held for the final time. Rarely am I successful, though.

Twenty-three, a combat medic, in Iraq.

I wasn’t successful this time either. He noticed.

“Where were you over there?” I finally asked.

“You name it.”

In spite of the relatively terse answers, he was not at all wary or distant. In a way, it was as if he’d already been through this drill many a time before, so no need to get all worked up about it, after all. But then neither was he cool nor nonchalant. Instead, he very much exuded this feel of “if you’re willing to ask, I’m willing to answer,” a certain, pleasant-enough quid pro quo, if you will–one straight out of Hell, of course.

“How many close to you did you lose?”

He looked down, again in that tired, even matter-of-fact way.

“Four I was really close to,” he replied, as if both steeling himself for inner pain, yet somehow at the same time planning to be bored by it.

“Were you with any of them when they died?”

He looked back up at me, again not indifferently, yet, what, wearily, as if one more damn trip down the back alley of unspeakable memories was simply too much to ask of him today, too much.

“One.” He sighed ever so slightly, with a been-there done-that look on his face that could only radiate to the world that he would never finish being-there, never be finished doing-that, never. “One.”

It had been an officer, a man he had deeply admired, deeply cared about. It was awful. There were plenty more awfuls, though. Over the next five, ten minutes, he recounted some of them. He spared not a detail.

Clearly he cared deeply, about everything. Clearly he was struggling to find another ounce of energy to care any more, about anything.

“I was twenty-three. I saw things no twenty-three year-old, no one should have to see. I had to put my hands where no one–twenty-three, no one–should have to put his hands.”

It was the latter image, of course, that grabbed hold of my lower spine and squeezed with a vengeance. It’s been years since I medically invaded a body, drew blood, inserted catheters, dropped a nasogastric tube. Yet the physicality of the hand inserted where no hand should go: my own body reminded me that once I had been more than close to pulsating organs–holding retractors only, of course, while others far more daring than I invaded, inserted themselves further, deeper. Yet I knew that I could imagine such a scenario–hands as strangers in a strange land–far more easily than I would like to know.

He had stopped talking. He did not appear ready to cry, to lose his composure, nothing of the kind. Yet, still, his tiredness as way of life: the façade was beginning to crack.

“What’s the greatest sadness in you?” I finally asked.

Honestly, I have no clue where that question came from. Clearly he had been expecting it as little as I had been planning it.

He cocked his head slightly, almost as if he were taking a moment to admire my chutzpah, practically radiating one of those “well, who’d a-thought” looks. After five seconds or so, he finally said:

“You know, there was once a time when a question like that would have sent me over the edge. I don’t know quite how to say this, but . . . that question makes sense to me now. You know what’s my greatest sadness? The fact that I’m never not sad, no matter how I might appear on the outside, no matter what I say, no matter that I love my family more than anything. Please understand: I have happiness. My wife, my kids, they’re wonderful, they keep me going. But it’s as if I know one truth more than any other, a truth I couldn’t get rid of even if I wanted to: although I’m happy, I’ll never be happy again.”

“I mean,” he continued, “I shouldn’t be alive. You’ve got to understand how crazy it is that I’m sitting here with you. Good men are dead, and here I am. Over there, it got to the point that I didn’t care, period, didn’t care. I’d walk into the middle of a fire fight, thinking ‘so what’? Dead, alive, it didn’t matter. If you want to know the truth, I’m still like that, basically. I don’t want to die. I’m not going to hurt myself. I want to be alive for my family. And yet I can honestly say to you: I don’t care if I’m alive or not.”

I could say that I made no effort to calm him in all this, but that would give quite a misleading impression. He was quite calm, in fact. Or rather, should I say, he was quite calm and he wasn’t even close to being so.

Yes. That’s it.  Not even close.

“You know what?” he finally asked. “I was so messed up when I got back from Iraq. I hadn’t even heard of the term “survivor guilt,” but that was all I was, survivor guilt, all day, all the time, wandering, trying to figure out how I could muster the courage to carry out the only decent act left for me to do: die. But I couldn’t even kill myself. One time I had everything in place to do just that. But in the only minutes I realistically had to carry out the plan, the means I’d chosen just wouldn’t work. I tried, and I tried, and I tried, but nothing. And then once the chance passed, the means suddenly started working again, but it was too late. It’s like I’m being kept alive, even when I don’t care one way or the other. Yet I do care. For my family, I want to live. But I don’t want to live, see? Yet at the same time, I can’t even care enough not to want to live. Is any of this even making sense?”

“Yes,” was all I could reply. For, in listening to him, it did.

“You still in the medical field?” I finally asked.

“God, no,” he answered. “I lived enough of that as it was. I can’t even imagine doing it again. No, I want to become a counselor. People say I’m a good listener. They lean on me. That’s what I want to do. Maybe that’s how all of it will make sense one day. I don’t know.”

For a few seconds I looked at him, husky, sporting his brat-and-burger haircut, his smile still discernable behind that look of indifferent confusion, confused indifference.

“You’ll be good, you know,” I told him. I meant that.

Clearly he’d not been expecting that response either.

“You speak clearly, candidly, straight from the heart,” I continued. “You’re willing to live with your own confusion. That’s key in this job, believe me. I’ll have to say one thing, though.”

With that latter statement, his indifference vanished. Only plain old-fashioned confusion remained to face the music.

“What’s that?” he asked.

“Well,” I said, “if you’re planning to make it possible for others to live better, then you’re going to have to live better yourself. Even if you think that you don’t care, that you’re really not that into living: sorry, reality check. You do and you are. Your hope, that goal of becoming a counselor who will listen to another combat vet no matter what is remembered, what is said: they betray you, the real you behind all the indifference towards the next sunrise, the next cup of coffee, the next diaper change. Hate to break the news to you, guy, but it ain’t just your family who’s keeping you alive. You are as well.”

For the first time, his eyes went into lock-down, obviously determined not to let any lacrimal material even consider escape into the light of day.

“You’re probably right,” he finally said, his every milligram of emotional fortitude on full alert.

Truth be told, though, he looked–at least to me–to be more on the relieved side than anything else. Guess it’s not so bad to be found out after all.

In the end, I told him I’d be glad to work with him. He smiled.

“You know, almost all the psychology types I met in the service were worthless, didn’t have a clue. They really thought they could slice open a huge scab on your heart, muck around there for an hour or so, and then expect you to go home and be just as fine as they were going to be that night, as if to say. ‘OK, now that you’re all ripped up and raw, see you next week and we’ll pick up where we left off.’ Nuts, totally nuts.”

I smiled back. “Me too?” I asked.

He sat back, with a smile perhaps not quite yet ready to make an offer, let alone accept one, but, at the same time, a smile not exactly ready to pack up and leave the negotiation table either.

“Maybe I should start talking with someone again,” he mused, eyes still riveted to mine, while in no way giving me the pleasure of being right about one darn thing. “Who knows? Maybe that’ll help.”

I gave him my card. He took it. We’ll see what comes of it.

I can’t remember anyone being quite so graphic with me as he’d been when describing his experiences. A reference he made to a scene near the end of Kubrick’s The Shining, as a prototype for the setting of one of his rescues, was more than apt. And if I may be so bold: the horror of Nicholson’s imitation of McMahon earlier in that film had nothing, not a thing on the horror this guy saw coming at him day after day after day.

In being so explicit, so raw, I don’t at all think that he was giving me some kind of test, as if to see how well I could “take it.” No, sadly, I fear all was just as it appeared: horror had become so commonplace for him, so sleight-of-invading-hand in its routine manifestations during combat, each of the stories was simply another day at the office, as far as he was concerned.

An unfathomable day at the office, perhaps. But he reminded me of a truth so well-known, tragically, to so many men and women who once saw what their twenty-three, nineteen, thirty-five year-old eyes should never have seen: one doesn’t to have to reach a fathom into a body, a soul to get to a horror that can leave a sadness in its wake that can become so intrinsic, one can narrate a c’est-la-vie assessment of it and almost–almost–get away with it.

No, for that, just a simple hand-length will do.