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Introduction: The patient is a 31 year old male, single with no dependents, and no pre-existing health concerns. He is an Engineer Officer attached to REDACTED Combat Engineer Regiment. His last field posting was in REDACTED, where he was injured in an IED explosion. The purpose of this report is to assess his prospects for rehabilitation, the extent to which his ongoing concerns will interfere with the activities of daily living, and the impact his medical status will have on his current vocation.
Personal History: Kail is the eldest of three children born and raised in Toronto. His parents and one younger sister still live in the city; the remaining sister has emigrated to London, England as part of her schooling. He reports that he has been physically active his whole life in a broad array of sports, including swimming, rock climbing, running, and judo. He joined the Canadian Armed Forces directly from high school to cover his university tuition and earned a Bachelor in Mechanical Engineering before beginning his active service. Although he states it was initially not his intention to do so he chose to remain in the military after his mandatory service period had elapsed-- in his own words, "All my best friends are in the military, and I'd be hard-pressed to find a job this interesting in the civilian market."
Medical History: Prior to his injuries Kail was completely healthy, and still displays good muscle development and excellent cardiovascular endurance. He was one of four soldiers injured when the IED they were preparing to dispose of exploded unexpectedly. The blast inflicted first degree burns on his right leg, and no fewer than thirty penetrating shrapnel injuries dispersed over his body. The majority came from nails packed in the bomb, but the most severe was the result of a large fragment of the bomb's casing striking him in the pelvis. This shattered his right hip. The patient underwent emergency surgery to remove the objects and nearly died of hypovolemic shock, requiring resuscitation in the operating theatre. He was kept in hospital for six weeks out-of-country due to the onset of opportunistic infections before recovering sufficiently to be flown back to Canada. He was transferred to Sunnybrook Hospital.
Treatment: At Sunnybrook it was determined that Kail's right hip was not healing, so once his other injuries had mostly healed he underwent scheduled surgery to fit him with an artificial hip joint. He was released to his parents the following week to continue recuperating at home. He attends physiotherapy at the hospital on an out-patient basis three times a week for his leg-- his remaining injuries have since healed without further intervention. In addition he attends for mandatory psychiatric appointments on a weekly basis.
Prognosis: Aside from a minor limp, Kail has made a full physical recovery. Behaviourally he exhibits as a generally high-spirited, amiable individual, but has shown signs of a quick temper. Coupled with being highly energetic this can make him somewhat unpredictable. To the chagrin of the attending physician he apparently takes pleasure in pushing himself beyond the limits of his abilities, to the point of potentially hindering his recovery. The man is intelligent enough to realize the damage he is doing, but does it anyway. It is the opinion of this physician that he may be actively attempting to harm himself.
Quoting from the attending psychiatrist's report, "The patient has refused to date to discuss the emotional effects of the incident overseas. He freely admits that the three enlisted men under his command died, and that he knew each of them, but beyond that he consistently changes the topic. If asked he will talk at length about his family (his father was raised Roman Catholic and is a banker, his mother is Jewish and a real estate agent, and he was quite protective of his younger sisters while growing up), or religion (he is only nominally religious himself), or any of the other topics that a person is normally unwilling to discuss with a psychiatrist, but he will not discuss the one thing I am supposed to evaluate him on. Aside from this he has told me a great deal about himself. He enjoys the outdoors, physical activity, and tinkering with all things mechanical. In his own words he dislikes 'arrogant, lying, high-maintenance, desk jockey pricks' or most combinations therein. During one session he admitted to being afraid of becoming permanently disabled or losing someone important to him.
Given the degree of loyalty he displays to his friends and family I suspect he feels responsible for the deaths, despite all accounts clearly stating the event was an accident. Furthermore I suspect he is attempting to punish himself for it-- he says he fears disability, yet he keeps appearing to appointments with fresh minor injuries while still undergoing therapy for a potentially disabling injury. When asked about the injuries he happily tells an animated story about his own reckless behaviour. While I do not consider Kail a threat to his own life he is showing limited concern for his wellbeing."
Kail has recovered sufficiently to manage his daily life without assistance, but it is the recommendation of the attending physician at this time that he not be returned to active duty. Given the attending psychiatrist's opposition to assigning Kail to a desk it is a joint recommendation that he undergo a further four months of therapy, at which time if there is no improvement he be given an honourable discharge. Under no circumstances should he be placed in a high-risk environment without a further physical and mental evaluation.