The Weight of War

Mark Kosobucki

After the blasts and the blood and the smoke and the screams and the sorrow, they return.

America's fighting men and women return from the grave traumas of combat to their family, to their friends, to their community, and to their country – that same sacred soil from whence they went to war.

Sometimes they return, zippered inside thick black bags, after making a sacrifice most profound on behalf of their family, their friends, their community, and their country. Sometimes they return, disabled physically, yet deeply grateful to be alive after some onerous tragedy. Sometimes they return whole, substantially wounded neither in body nor mind. But sometimes they return, wounded not on the outside, yet deeply burdened with oppressive psychological trauma not visible to most.

Sometimes they return wounded in ways unseen, laboring desperately, arduously, and intensely beneath the weight of war.

Like Phillip Azevedo did.

Venus Azevedo-Koenig speaks – and cries – freely. She says a lot of things twice, for emphasis. She has an air of agitation about her as she chugs coffee and smokes her long, thin Newport cigarettes, one after another. A dark-skinned, middle-aged Mexican-American woman, her big, brown eyes appear younger than their years; her short, sassy hair falls across the left side of her face and plays near the sparkling bedazzlement on the left shoulder of her shirt, all serving as external manifestations of her short, sassy, sparkling personality.

With her is Christina Kwitowski, lifelong friend of Phillip and Venus. Taller, paler, younger, more reserved, and more reflective than Venus, Christina seems like more of a sister to Phillip and Venus than a neighbor. With her light-colored hair neatly pulled back under a cap, she and Venus settled in to a quiet booth in a nondescript restaurant and began to talk about Phillip.

"I hated him when I first met him," Christina said, knowing deep down inside that she really didn't. "He made me cry."

Venus strenuously yet lightheartedly objected. "Yeah, but you were a little girl!" They both laughed.

"I don't like that boy that's moving in next door!" Christina squealed, channeling that little girl.

Venus said that Christina's family and her own family were one. Born on June 6, 1983, into a broken home that Venus described as "rough," Phillip received good grades and stayed out of trouble in school. But just as Christina was more of a sister than a neighbor to Phillip, Venus was more of a mother than a sister to Phillip – 10 years her junior. "I always had him; all through his life, he was with me," she said. "Christmas, Christmas Eve, everything. He was attached to my hip. Always."

After graduating from Cathedral Preparatory School in 2002, Phillip became a criminal justice major at St. Mary's University in San Antonio, Texas, with plans of entering law enforcement, until a chance encounter with an old friend altered his plans.

"I was on vacation in San Diego and ran into a friend of mine who was a first class [petty officer]," Phillip told Mass Communication Specialist 2nd Class Alexander K. Ameen of the Naval Medical Center San Diego Public Affairs department in October 2009. "I started talking to him about joining and getting that extra bullet on my resume, because nowadays that college degree just isn't enough. I decided I wanted the whole Navy experience."

Phillip enlisted in the United States Navy in 2005, and deployed to Afghanistan in 2008 as a Hospital Corpsman. United States Navy Hospital Corpsmen are enlisted medics; they work at sea and on land not only to treat and prevent disease, but also to administer emergency procedures in combat situations. Phillip loved being a corpsman, but Venus made it clear that Phillip's primary tool was a rifle, not a scalpel.

"He was on the front lines. On the front lines," she declared. "He was attached to the Army, because they needed someone who had a lot of skill. And he had a lot of skill."

By all accounts, Phillip was an outstanding corpsman; he took the heavy responsibilities of his job seriously, and consistently received dazzling performance reviews from his superiors in the Navy. In an interviewer's appraisal sheet from his application to the Medical Enlisted Commissioning Program dated July 20, 2010, Commander Veronica Armstrong of the United States Navy's Nursing Corps described him as impressive, articulate, mature, sincere, compassionate, and professional. "He is my CANDIDATE OF CHOICE and a MUST select for the MECP," she wrote. In six different categories on the application – from appearance to communication to leadership to desirability to motivation to potential – Phillip received no rating less than "outstanding," the highest rating possible.

"Because of everything he could do, they didn't want him on a boat," Venus said, proudly. "He would never be at sea. He was boots on ground. He was boots on ground, which meant he would never be out on a boat."

Phillip's role – fighting first, healing as needed – placed him right up front in the increasingly savage war in Afghanistan. Nevertheless, Phillip repeatedly acted with fearlessness and heroism.

"He was with 11 guys; two were Afghanis," Venus said. Members of the Afghan National Army were leading a vehicle convoy, with Phillip and his commanding officer riding in another vehicle behind them. The Afghanis in the lead vehicle triggered an improvised explosive device (IED); their vehicle on fire, Phillip could hear their screams.

His first instinct was to rush out and help the men – a selfless, sincere, and dangerous desire; sometimes, IEDs are akin to a bird dog, flushing out a brace of quail ripe for harvesting by sitting snipers.

"Phillip's boss is saying, 'You can't get out.' He disobeyed the order, and he ran out there, and pulled them out and saved their lives," Venus continued. For this and other heroic actions on his 12-month deployment to Afghanistan in 2008, Hospital Corpsman 2nd Class Phillip Azevedo received a Bronze Star. But as both a warfighter and a healer, Phillip experienced profoundly traumatic events – events no person should ever have to experience. Nonetheless, Phillip repeatedly acted with valor and bravery, including saving the life of his lieutenant, with whom he had a close relationship.

"They had to go in this house, looking for whoever they were looking for," Venus said. Phillip went one way, and his lieutenant went another, with catastrophic results; Phillip's lieutenant found himself staring down angry Afghani arms, his death imminent. "Phillip heard it, so he came the other way and killed them all. Killed them all. One of them was a dad, with a kid standing right there…that haunted him."

Despite the horrific nature of Phillip's day-to-day activities in Afghanistan, his distinguished service had an upside; after receiving state-of-the-art medical training from the Navy and returning to San Diego a decorated veteran, Phillip then returned to his family, his friends and his community, well on his way to acquiring his own small piece of the American Dream. He enrolled in the nursing program at Gannon University in 2010. His tuition paid by the Navy, Phillip's only job was to go to school; by all accounts, Phillip was as good a student as he was a corpsman – that is, an outstanding one.

"He was an amazing nurse," said Alison Stacy, a nursing student at Gannon and classmate of Phillip's.

Alison said that Phillip generously shared his knowledge with the other students in class; having already received extensive medical training in the military, he was the smartest student in class. "He would go out of his way to teach people, which I thought was really nice," she said. "We met for open lab one time. I was practicing injections and he was very helpful because he had obviously done stuff like that before."

In sharing his impressive real-world experience, Phillip was as humble as he was helpful. "When we were learning catheters, he would bring up, like 'I've done this before, so far, and this was how we did this,' but he never really bragged about how he knew everything already."

At that time, what Alison and her classmates in Gannon's nursing program saw was a happy, healthy, intelligent, experienced young man who had the whole world ahead of him. What Alison and her classmates could not see was that Phillip – beneath his smooth, solid surface – was still shouldering a grave psychological burden.

As winter turned to spring, Phillip grew darker and more distant. "He slowly started cutting people off," Christina said. One person he couldn't cut off was his sister – when Phillip confided in anyone, it was Venus.

"Venus, I can't stop drinking," he once told her; Phillip's self-medicating with alcohol had begun post-deployment in San Diego, but had grown worse after his return to Erie. Venus cited the death of their cousin, a Marine named Mark David Juarez, on January 9, 2010, as another substantial weight added to Phillip's already-heavy load. "That was a huge trigger, and he started to go downhill."

Then, on Saturday, March 17, 2012 – St. Patrick's Day – Venus detected something different beneath Phillip's usually smooth and solid surface. Something concealed. Something dangerous.

That day, at least to Venus, it was becoming exceptionally clear that something was amiss; part of Phillip had not returned from Afghanistan, and as his days turned into nights, ominous signs threatened with obvious imminence.

"At night, everything would change," Venus said. "At night is when everything would surface… His PTSD was bad.

According to the U.S. National Library of Medicine, PTSD is an anxiety disorder that can arise after a person experiences a traumatic event that involves the "threat of injury or death." Common causes include assault, domestic violence, incarceration, rape, and war, but can also include natural disasters or accidents. PTSD affects people of all ages, genders, and races, and can occur years or even decades after the incident that may have inspired it. Scientists now know that there is both a genetic and environmental component to PTSD, and that minorities appear to suffer from it at a far greater rate than whites do. A recent study by the U.S. Department of Veterans Affairs concluded that Vietnam veterans who are African-American are stricken with PTSD nearly 50 percent more often than whites; Hispanics, like Phillip Azevedo, 100 percent more often. But regardless of the type of incident that inspired it, and regardless of the race, gender, or age of the afflicted, PTSD produces symptoms in three main categories – re-experiencing, avoidance, and arousal.

Re-experiencing, for those facing PTSD, means that traumatic memories can haunt their days as well as their nights, in the form of both flashbacks and nightmares. These traumatic experiences, like an IED dangerously concealed beneath a smooth and solid surface, often lie in wait until the unwitting trip the trigger, unleashing unusually destructive, traumatic memories.

"They're different from normal memories in that if you think of a normal memory as a movie, like you can push the 'play' button and watch a memory, traumatic memories are more like virtual reality," explained Dr. Jennifer Pasternack, in a voice as calm, soft, and comforting as her tiny office, tucked away down a neutral-toned hallway in an unassuming building perched on Eighth Street and Pittsburgh Avenue. A general psychiatrist with a special interest in trauma, Pasternack works for the Stairways Behavioral Health System in Erie and has a small private practice on the side. "They tend to give you an experience as if you're re-living the memory. And in particular, a traumatic memory comes with full emotional content, so a traumatic memory is something you can't think about without re-experiencing all the feelings that came with it the first time it happened."

Avoidance, another symptom of PTSD, refers to the tendency of those tormented by PTSD to attempt to avoid triggering that unusually destructive, traumatic memory in the first place. "That re-experiencing is a horrible experience, like a panic attack," she said. "People want to avoid that, so they try to avoid things that will trigger that memory. For example, someone who was involved in a terrible car accident and develops PTSD as a result might avoid driving in cars, or driving in cars when it's snowy, or driving over bridges. People tend to avoid specific things that remind them of the trauma."

Another common yet dangerous method of avoiding those traumatic memories is engaging in the use of drugs or alcohol to numb the pain and temporarily relieve the burden of conscious thought; however, as anyone who's ever tried to "drown their sorrows" knows, alcohol mars logic, exaggerates emotion, and exacerbates circumstances. But more generally, avoidance also refers to the tendency of some people pained by PTSD to become darker and more withdrawn.

"We talk about feeling distant from other people, and something called a sense of a foreshortened future," said Pasternack. "What that means is, someone with PTSD may very well feel like nothing good's ever going to happen or that they have no future. They can't really imagine the future."

Arousal – or rather, over-arousal – produces an almost-manic hypervigilance that leads to angry outbursts, difficulty sleeping, and being easily startled. "Arousal refers to the fact that someone with PTSD is often going to be triggered," Pasternack said. "People with PTSD tend to have really bad temper problems related to what they've gone through. They tend to have an exaggerated startle response. They're on edge all the time."

As long as man has dared raise his hand in anger against his fellow man, the scourge of the survivor has manifested itself as the weight of war.

Thousands of years ago, accounts of PTSD permeated the literature of the Egyptians, Greeks, and Romans. The Greek historian Herodotus related an account of a man who went "blind" upon witnessing the death of a soldier near him, even though the blinded soldier "was wounded in no part of his body." In more recent times, English author Samuel Pepys described his own PTSD-like symptoms following the great Fire of London in 1666, writing, "Both sleeping and waking…such fear of fire in my heart, that I took little rest."

Not long after that, Swiss and German physicians began to identify and label this disorder – the Swiss called it "nostalgia," the Germans, "homesickness." Unfortunately, this newfound definition for PTSD – that of mental weakness – soon evolved into a far more sinister conclusion that persisted well into this century; in fact, it wasn't that long ago that the symptoms of PTSD were still looked upon outright as indicators of cowardice.

In August of 1943, as Allied armed forces probed the soft underbelly of Europe, one of America's most revered military men encountered a soldier clearly suffering from the effects of PTSD – at that time, called "shell shock" – during a tour of a medical facility. When four-star General George S. Patton asked Private Charles Kuhl what injury warranted his stay in that Sicilian hospital, Kuhl stated, "I guess I can't take it," citing "nervousness."

Patton slapped him full in the face with his gloves.

Not content to merely humiliate and assault one of his own soldiers, Patton then grabbed Kuhl, dragged him to the tent's entrance, and kicked him square in the ass, demanding Kuhl's removal from the medical facility.

"You hear me, you gutless bastard?" Patton bellowed. "You're going back to the front."

In other words, Patton saw no problem putting a weapon in the hands of a man clearly incapable of safely using it.

Any soldier or sailor in today's military guilty of such unbecoming and misguided conduct would probably be run out of the service in an instant, but, reflective of the attitudes toward PTSD at the time – and the status of the offender – Patton was most certainly not run out of the service. In fact, he did it again – just one week later, assaulting Private Paul G. Bennett both verbally and physically.

In Patton's defense – if such behavior can ever be defended – General Clarence Huebner, commander of the 1st Infantry Division in which both Kuhl and Bennett served, told Patton before these incidents occurred that there were a number of "malingerers at the hospitals, feigning illness in order to avoid combat duty," which was, again, reflective of the prevailing attitudes of the time. And although Patton did eventually apologize, calls for his firing fell upon Supreme Allied Commander – later president – General Dwight D. Eisenhower's deaf ears, proving that the prevailing attitudes regarding PTSD ran all the way to the top of the chain of command as late as the 1940s, if not later.

Today, largely as the result of advances in neuroscience and America's experience in two extended wars over the past decade, as well as scores of Vietnam veterans entering their contemplative retirement years, attitudes within the U.S. government appear to be evolving. In a letter published in the San Antonio Express-News on June 26, 2012 – National PTSD Awareness Day – U.S. Defense Secretary Leon Panetta opined that "…the unseen wounds of war are every bit as pressing – and every bit as treatable – as the visible wounds that have left a permanent physical mark on thousands of our heroes."

Tragically, many of those unseen wounds still go untreated, often with catastrophic consequences. Former Chairman of the Joint Chiefs of Staff Michael Mullen recently claimed that 18 veterans kill themselves each day in the United States, and in April, New York Times Op-Ed Columnist Nicholas D. Kristof wrote that for every American soldier who dies in combat this year, 25 veterans will die by their own hand – the ultimate act of avoidance.

While veterans who have retired from the military still face the social aspects of the stigma, current members of the military face the professional aspects of that stigma; many believe it will hurt their prospects for advancement within the military, and therefore shun treatment.

Dr. Anthony Mancini is a Clinical Psychologist for the U.S. Department of Veterans Affairs who treats veterans – and some reservists – for PTSD at the Erie Veterans Affairs Medical Center. Sitting in a small yet comfortable outbuilding on the campus of the Erie VAMC off Old French Road, Mancini's been practicing for almost 20 years, and says, in a tranquil, reassuring manner, that the stigma – at least among current members of the armed forces – still exists. "I think everyone knows there's a sort of stigma," he said. "From what I hear from the guys, it's somewhat magnified when you're in the service, although they really are trying to get away from that."

Mancini was, however, optimistic about the Department of Defense and the VA's progress in dispelling this stigma. "They're really working hard on saying, 'It's okay to seek treatment,'" he said. "But then I think sometimes when you're all comrades, you're supposed to be tough guys, and it's hard to admit that you're having trouble with something. I do think they're doing a much better job; we can see that firsthand. I think they have a ways to go but they're moving in the right direction."

 "We have to work really hard on saying, 'It's okay, just tell me what's going on, and nobody's going to ridicule you here, or bust you down, or keep you from getting that promotion,'" he said.

The real tragedy of the situation is that the prognosis for those who do avail themselves of treatment for PTSD has never been better, according to Mancini. "We promote evidence-based psychotherapies, which are therapies that have been shown in the research to actually work."

Over the past few years, the therapies for the unseen wounds of war have received the same level of scrutiny as therapies for physical conditions like high cholesterol or heart disease; psychotherapies that have consistently demonstrated their efficacy in treating previously untreatable mental health conditions like PTSD during scientifically controlled research studies are called "evidence-based" psychotherapies.

One of these evidence-based psychotherapies is Cognitive Processing Therapy, or CPT. CPT centers on the connection between thoughts and feelings that often obstruct recovery from PTSD – specifically, the way that traumatic experiences alter one's thoughts, which then manipulate behavior. A pamphlet from the U.S. Department of Veterans Affairs explains that CPT can be administered to patients over "approximately 12 weekly therapy sessions in either an individual (50 minutes) or group (typically 90 minute) setting." The pamphlet goes on to state that many veterans "have had a significant reduction in PTSD symptoms" and that in other cases, "after competing CPT, some veterans no longer met criteria for a diagnosis of PTSD."

Another evidence-based psychotherapy is called Prolonged Exposure Therapy, or PE. PE seeks to address the symptoms of PTSD – especially avoidance – through education, breathing exercises, imaginary exposure (working through traumatic memories with a therapist) and in vivo exposure (identifying situations that trigger the patient's avoidance methods). Another pamphlet from the U.S. Department of Veterans Affairs asserts that after nine to 12 90-minute sessions of PE, "80 percent of clients experience significant gains."

"The VA has spent a lot of money, a lot of money and time and energy into training," Mancini said. "We have some great programs here, we really do."

Dr. Pasternack concurred with Dr. Mancini's assessment of a favorable prognosis for those who receive treatment. "It is possible to recover 100 percent from PTSD," she said. "But not common. It's more common for things to improve to the point that they can resume a good life. People with PTSD often say to me, 'I just want my old life back.'"

"I ask them to wish for something else."

That St. Patrick's Day was warm in Erie, topping 80 degrees. The city's annual festivities were in full swing, as a loud crowd of mostly-green revelers roamed State Street. Beneath a cloudless blue sky, an undulating mass of merrymakers pulsed and vibrated and surged in and out of Perry Square as the Sun, that same bright Sun that warmed those beer-soaked roisterers, also shone on Phillip Azevedo, who was searching desperately for any remnant of his old life – his life before PTSD.

"On St. Patrick's Day, I remember looking at him from a distance, and I saw black in his eyes," Venus recalled. "I saw black. And it was as if nobody was moving around me. And I knew. I knew it was bad."

Phillip was caught in the throes of something he neither asked for, nor could control. In spite of the festal, jovial nature of the day, Phillip must have both gazed upon and walked past thousands of people who would never suspect that he was laden with substantial mental baggage. Days later, on Thursday, March 22, he began to buckle under the arduous stress.

"He thought that his fiancée [Lieutenant Junior Grade Tara Desjardins, a Navy nurse who was prohibited from commenting on this story by her commanding officer] was cheating on him," Venus said. "You know when you hang up the phone, you think you hang up the phone but you don't? So there was restless things going on, and he swore he could hear her having sex with another guy." Venus listened to the inadvertent voicemail and didn't think Phillip was justified in his suspicions. She continued.

"The thing is though, that was his PTSD. He was starting to hear things." Tara would give him a timeline outlining her busy schedule to allay his fears, insisting she didn't have time to cheat on him, even if she had wanted to cheat on him. "He was hearing things in that voicemail. I've never seen my brother like that."

"I knew that it was going to be a long day," Venus said, her voice breaking slightly and the first glossy signs of sadness appearing in her big, brown eyes. "That whole day, that Thursday, was not him," Venus professed, as she lit another long, thin cigarette.

That Thursday, feeling the immensity of it all – those things he saw on the other side of the world, and those things he heard on the other side of the country – Phillip, his classes at Gannon finished for the day, sent an alarming text message to classmate Alison Stacy as he was leaving campus.

"I have things to take care of," he told her. "Take care of yourself."

Phillip lumbered off campus and onto Erie's streets, hoping to avoid arousing a re-experience.

"Thursday night he got really, really wasted," Christina said.

Venus interrupted. "Waaaaaaaa-sted."

Christina continued. "We couldn't find him. Venus called me, and I went with her, and we ended up finding him at the bar that he was always at." Phillip had shown up to a local bar, the One Way Inn, early Thursday afternoon.

Venus interrupted. "They were calling me too… they said, 'Phillip is not acting like Phillip, and he's saying he might have a gun in his car.'"

Christina continued, as the pace of the conversation began to take on the tone of 10 people trying to walk through an open door at the same time. "So, we were able to get his keys from him. That way he wouldn't drive home.

Venus interrupted. "He was enraged. He got mad at me because I brought Christina, I called my mom, I called everybody."

Christina continued. "He was getting more and more agitated the more people that showed up."

Sensing Phillip's agitation, the small crowd of friends and extended family who showed up left him alone with Venus, in that darkened bar. As Venus recalled, Phillip was fuming.

"Oh, you trying to do an intervention?" he screamed at Venus.

"I'm trying to save your life!" She screamed right back at him.

"You don't understand!'" he barked, revealing to Venus that he often re-experienced oppressive traumatic memories. "You don't understand! I hear the clicking of my gun. I hear the screams!"

Phillip then told Venus another story about his lieutenant, the man whose life he'd saved earlier.

During a firefight, concern arose when Phillip's lieutenant somehow became separated from his squad, which does happen from time to time. Upon contacting the missing lieutenant and notifying him of coordinates for rendezvous, apprehension turned to relief when he was sighted on foot, returning to his squad.

Just yards away from Phillip – and relative safety – he stepped on an IED, dying almost instantly.

Phillip told Venus that there was little left of this man for him to recover. "There was nothing…he only had…what was left of him, was his torso," she said. "And he brought it out, put it on his back. He grabbed it and brought him out."

"And then I had to put him in a black fucking bag!" Phillip shouted at his sister, in the cold and dim glow of that empty barroom. "And that's what I had to send to his family!"

Phillip's volatile fury was no longer concealed beneath his smooth and solid surface.

"I could take you right now. Snap your neck," Phillip whispered into Venus' ear. "I could take you out here, by your neck."

"Do it," Venus said, defiantly.

Venus persevered, prodding and pacifying Phillip; the situation at the bar eventually wound down, and Venus walked Phillip outside to her car. "I took him home; I just thought he was going to pass out," she said, hopeful that a long day of drinking that had ended around 11:30 p.m. would help Phillip find solace in slumber. But no sooner than Venus dropped him off and returned to her home, just a few minutes away, she received a disturbing text message.

It was a picture of Phillip with a gun in his mouth.

"His fiancé sent it to me," Venus said, as she sobbed. Venus hastily returned to Phillip's apartment. She let herself in with her key.

"Nate, what are you doing?" Phillip yelled from the basement, assuming his step-brother/roommate had unexpectedly returned.

"No. It's your sister," Venus said.

"How the fuck did you get in here?" Phillip growled angrily, not realizing Venus had that key.

Venus desperately made her way to the basement, only to find Phillip seated in a chair. "He had a beer right next to him, cans of beer, had the phone on speaker on his lap, and had the loaded gun. And I started freaking out."

"You better call 911 Venus, because I'm not coming out," Phillip said.

All of a sudden, Phillip cocked the gun and put it in his mouth.

"I just screamed."

"When I screamed, it startled him, and he took it out," Venus said. Frantically, she dialed 911. Just then, impaired and encumbered, Phillip turned the gun on Venus. "I knew he wouldn't hurt me. He wanted me to go. He didn't want me to see it."

But Venus stood still, staring back at him.

"I'm not going anywhere," she asserted.

A SWAT team from the Millcreek Township Police Department cleared the neighborhood and established communication with Phillip, who refused their requests for him to leave his apartment.

"I'm going to lose my job! I'm in the Navy officer program! You cannot get into trouble because you'll get kicked out," Phillip told them. His self-perceived foreshortened future looked bleak, as that small piece of the American Dream he had fought so hard for seemed to be slipping away.

After 5 1/2 hours of stalemate, tensions had risen to their breaking point. Venus recalled the negotiator, in what was possibly a last-ditch effort, telling Phillip, "I will not call the Navy. I will not – if you come out peacefully – I'm not going to call them."

"PTSD is not something that's going to hurt someone's career," said Commander Jason Anders, Commanding Officer of Naval Operations Support Center – or NOSC – in Erie. NOSC Erie's job is to manage all of the operational and administrative support for U.S. Navy reservists in the area, including Phillip Azevedo.

Originally from Florida, Anders took over at NOSC Erie in November 2011; he's young-ish, fit, polished, and professional, from his short black hair to his immaculately pressed uniform to his orderly office to the pair of antique Navy cutlasses hanging on his office wall. In addition to serving in the Navy for 18 years, Anders grew up as the grandson of a Navy sub chaser in WWII and the son of an Army intelligence officer, so the military isn't like a family to him – it is a family to him. While prohibited from speaking directly about Phillip, Anders sat upright and rigid at his big brown desk and talked about the stigma of PTSD, both within the Navy and the civilian community.

Anders was vehement in his assertion that a medical diagnosis would end up only on the patient's medical record, which is privy solely to the patient, the Navy's medical department, and the patient's commanding officer, whether for wounds seen or unseen. Injury, he said, is not a disciplinary issue.

"If you get a clue about somebody, you should never consider the impact that saying something might have on their career," he affirmed. "You should always consider the person first. Whether or not it does have an impact on their career, that should not be a consideration. When you're looking to help somebody or simply to ask them to get help, what should not come across anyone's mind is, 'Yeah, but if they get help, it'll hurt their career.' That should never come across."

Anders seemed deeply disturbed about the toll PTSD continues to take on his "family" – meaning veterans like Phillip Azevedo. The toll PTSD takes on returning veterans has not spared Western Pennsylvania; indeed, a rash of recent suicides has rocked communities from Erie to Pittsburgh and beyond. "To my knowledge, there was one suicide attempt [locally] and one successful suicide [in Pittsburgh]," Anders said. Watching his sailors come home, physically unscathed by the enemy yet dying by their own hand clearly frustrates and angers Anders, yet he is realistic about what, exactly, the Navy can do about PTSD.

Several evaluations screen returning sailors for PTSD, he said. One occurs immediately upon demobilization, then another one 90 days later, and then again yet another one 180 days later. Help is always available from the Navy for those who want it, but these evaluations are all self-assessments, and it becomes extremely difficult to detect a problem and provide treatment when they deny that they have one during an evaluation.

"Recognizing the warning flags of PTSD is not something that can just be done by the chain of command," Anders said. "There's three sides to this triangle: there's the service member themselves, there's the community, which includes family and friends – for that matter it includes police and hospital – and then there's the chain of command. And that's us, the chain of command. Any one of those three sides of that triangle can raise the flag, and we need to educate all three."

Anders repeatedly cited the role of the community in assisting those affected by PTSD. "I believe the community, when they see a behavior that may be indicative of a problem, [they have to] make it their business."

"Making it their business" can be difficult, however, because the events that produce PTSD often transpire in situations that are uncomfortable ask about, and, when it comes down to it, most people don't truly care and wouldn't feel comfortable telling others in the community about someone's PTSD. However, the Navy has a mantra Anders hopes the community will follow: ask, care, treat.

"Ask. And don't just take a simple yes or no. Ask them, 'Is everything all right? Because, quite frankly, I see you out drinking every night. I see you with a different girl or a different guy every night. Or, I see you neglecting your family.'

"Care. You have to care – you have to care about what they tell you. If they tell you, 'Well, I'm really not doing so well,' don't just say, 'Well, things will get better' because they're not basing that on any scientific evidence that things are going to get better at all.

"Treat. You have to tell someone – someone that is in the position to get them the treatment they need. You could tell the service member, 'Listen, I think you need to talk to a professional about this. I think you need to talk to your chain of command. I think you need to talk to somebody that you feel confident in talking to.'

"So you have to ask, you have to care, and you have to treat," Anders said. "I didn't just make that up. It's called ACT, and it's one of the Navy maxims. Ask, care, treat. If you see something that you consider risky behavior, and you feel like a hypocrite because sometimes you engage in that risky behavior... I tell my guys, you feel like a hypocrite? Get over it. You're part of their chain of command. I tell their family and friends – if you see that and you don't feel right about approaching them about it, get over it. It's everyone's responsibility. This can't just fall on the chain of command. It can't just fall on the service member. We need the community involvement also."

After almost six hours, Phillip Azevedo ended his standoff by surrendering peacefully to the police who patrolled the community where he was born and raised.

"In the end, it was good," Venus said. "Millcreek Police, SWAT, the negotiator, they were amazing. They were so respectful to my brother… some of them were in the military, and they understood. And when he came out, they didn't like, jump on him or anything, they just calmly…" She smiled sweetly, her big, brown eyes shining as the sun does after storm clouds pass. "I just grabbed him and he looked like he was disoriented." Venus's volume hushed to a whisper. "It was like it wasn't him."

Phillip went immediately by ambulance to Millcreek Community Hospital on Peach Street for a mental health evaluation.

"Why am I here? How did I get here? How did this happen?" he said to Venus. Shrouded in blankets and lying in a hospital bed, he was calm and compliant but terrified to learn what had transpired.

"He didn't want the Navy to find out," Christina supposed. "He thought that if he was involuntarily admitted, they would find out and his command would be called and it would look bad."

Venus spoke with someone at the hospital – she doesn't remember who – and expressed the same concern as Phillip. "How can we do this without it being on his record?" she asked. "And because he became a voluntary [admission], it was no longer in their hands."

The stigma that had heretofore prevented Phillip from receiving prior treatment for the hefty yoke he constantly bore had put him at risk of losing his life, yet he still attempted to avoid involuntarily admission, which might have finally resulted in him receiving the help he so urgently needed. "He was saying all the right things to be voluntarily admitted," Christina said. "When you are voluntarily admitted, you are able to voluntarily sign yourself out. It's called AMA."

"I knew," Venus said. "I knew he was going to leave the hospital."

Phillip's visit lasted about 16 hours, until he freely walked out of Millcreek Community Hospital, of his own accord, AMA – against medical advice.

"He had to stay with me, and he knew that," said Venus. Those first glossy signs of sadness appearing earlier in her big, brown eyes had become tender, mournful tears, flowing down her cheeks, into her short, sassy hair, on to the sparkling bedazzlement on the left shoulder of her shirt. "So he came in Friday night. He came to my house."

Thanks to the stress of the previous days, the unseen wounds Phillip was still nursing, and the alcohol withdrawal symptoms he was already experiencing, Phillip would have a fitful night of sleep that Friday, albeit under Venus' watchful eye. "When he would start shaking, like, getting cold, my fiancé would have a big comforter in the dryer, getting it hot," she said. "I'd run upstairs and put it around him. Meanwhile, he's putting in another big blanket and getting it hot and getting it ready. And then, when he would get sweaty, we'd open the door up, and I'd take all the blankets off and throw on a light sheet, to make him feel cool."

"He wouldn't sleep the whole time. I watched him. I didn't even sit; I stood up and was watching him the whole night, watching every move, and he kept on getting up, like reaching for a gun. You could tell. I mean, he's lying, you would see him like…when he was lying, he would like come up, looking for his gun. He was having those nightmares, and physically, he was trying to get his gun."

After that restless night of "sleep" on March 23, a now-sober and contemplative Phillip awoke the morning of Saturday, March 24, worried about the onerous consequences of the previous night.

"Oh my God, they're going to evict me, I just know it, I'm going to lose the apartment," he told Venus.

"He felt like he was going to lose everything," she said.

Phillip remained with Jeff as Venus unwillingly trudged off to her job at the mall. "He's going to have to get his laptop, some clothes, and whatnot," she told Jeff, on her way out. "You guys go and do that."

Somehow, Phillip found the keys to his apartment that Venus had previously hidden.

According to Venus, Phillip assured Jeff he was fine as he left Venus' house, alone. "I'm fine, I'm fine,"  Philip said. "I know I fucked up, I'm trying to fix it now. I've got to get some stuff together. I'm gonna grab my laundry and stuff and I'll be right over."

But at work, Venus sensed that things weren't fine. "I got this bad feeling," Venus said, eerily foreshadowing a message that she would receive moments later.
"I got a text from his fiancée that he was going to hang himself."

For the second time in less than 36 hours, Venus rushed over to her brother's house, hoping to save his life.

"I was at the door. I couldn't get in. And I'm texting him, and texting him," Venus said, looking 1,000 yards into the distance at nothing in particular.

Meanwhile, Christina received an unexpected phone call from a co-worker who lived next to Phillip. "What's going on over at your brother's?" the caller asked her.

"What do you mean?" Christina queried in return.

"There's a bunch of cops and ambulances and they're taking somebody out of there and there's a girl outside screaming, 'Phillip! Phillip!'" the caller answered.

"He's supposed to be at Venus' house – what is he doing at his place?" Christina asked rhetorically.

Venus and Christina paused for what seemed like an eternity until, finally, Venus carried on. "The cops came, and they looked around and noticed it was barricaded, so they went in through the back. And I heard them yelling, 'Phillip! Phillip!'" she said, fighting through tears. "Then I didn't hear anybody yelling anymore."

Christina called Phillip's fiancée, Tara, the Navy nurse in San Diego who sent Venus the text message at work. According to Christina, Tara screamed into the phone.

"Phillip's dead! He hung himself!"

Venus – unleashing a torrent of tears from those big, brown eyes, her cheeks awash, her short, sassy hair as soaked as the sparkling bedazzlement on the left shoulder of her shirt – took a sip of coffee, lit another cigarette and wept. Freely.

"To me he was like my child; he was my brother; he was my first."

Finally relieved of the weight of war, United States Navy Petty Officer 2nd Class Phillip Azevedo forever rests peacefully in the sacred soil of Fort Sam Houston National Cemetery in San Antonio, right next to his cousin, United States Marine Corporal Mark David Juarez. Left behind to mourn him are his loving family and his adoring friends and his appreciative community and his deeply-indebted country. Also left behind are his fiancé – Lieutenant Junior Grade Tara Desjardins, the Navy nurse – and, from his previous marriage, a 5-year-old son.

One day, probably soon, Phillip's young son will begin to wonder, Who was my father? What kind of man was he?

As Phillip's young son becomes a young man, he will then wonder, In what manner did my father live? In what manner did my father die?

When Phillip's young son becomes an old man, he will finally wonder, For what reason did my father live? For what reason did my father die?

That young boy, Petty Officer 2nd Class Phillip Azevedo's only son, will quickly learn that his father was a hero. He will learn that his father was a good and decent kind of man, a lover of family who adored his friends, appreciated his community, and gave everything his country asked of him. Freely.

That young man, Phillip Azevedo's only son, will quickly learn that his father lived in the manner of one who exists only to help others. He will learn that his father died in the very same manner he lived; his heart helped return a vital, vigorous pulse to a 58-year-old male; his lungs helped return robust respiration to a 48-year-old female; his kidneys helped two teenagers; his liver helped an infant; and his eyes – his big, brown eyes – helped give sight to two people, for the very first time, on the very same day, including the first adult-to-child transplant ever performed.

That old man, Phillip's great-grandchildren's grandfather, will finally learn that the reason his father lived was for his only son, in hopes of handing down a part of that American Dream he'd acquired through intensive study, hard work, and brave service to his fellow man. He will learn that the reason his father died was because he couldn't get the help he needed despite returning from the grave traumas of combat neither zippered inside a thick black bag after making a sacrifice most profound, nor wounded on the outside; he will learn that his father was wounded in ways unseen, and his father labored desperately, arduously, and intensely, in spite of the red flags and the missed opportunities, beneath the weight of war – not PTSD itself, but the stigma that still surrounds those who seek treatment for PTSD.

This story would not have been possible without significant contributions from Erie Reader Managing Editor Ben Speggen; others from the Erie Reader who were generous with their time and their talent include Editors-in-Chief Brian Graham and Adam Welsh, Copy Editors Alex Bieler and Julia Nene, writers Jay Stevens and Rebecca Styn, photographer Joe Cottrell, and designer Mark Kosobucki.

Contact Cory Vaillancourt at cVaillancourt@ErieReader.com or on Twitter @VLNCRT.

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