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New Navy Purple Heart Standards
RTTUZYUW RUEWMCS0000 3432016-UUUU--RUCRNAV.
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R 092016Z DEC 11
FM SECNAV WASHINGTON DC
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INFO SECNAV WASHINGTON DC
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ALNAV 079/11
MSGID/GENADMIN/SECNAV WASHINGTON DC/-/DEC//
SUBJ/DEPARTMENT OF THE NAVY STANDARDS FOR AWARD OF THE PURPLE HEART (PH)//
REF/A/DOC/POTUS/25APR1962//
REF/B/DOC/DOD/23NOV2010//
REF/C/DOC/SECNAV/22AUG2006//
REF/D/LTR/USDPR/25APR2011//
REF/E/LTR/DEPSECDEF/21JUN2010//
REF/F/GENADMIN/CMC/151135ZAPR11//
REF/G/DOC/CMC/01MAR2011//
REF/H/DOC/CNP/22AUG2002//
NARR/REFERENCE A IS EXECUTIVE ORDER 11016 AUTHORIZING THE PH. REFERENCE B IS
DEPARTMENT OF DEFENSE MANUAL (DODM) 1348.33 VOLUME 3, MILITARY DECORATIONS AND
AWARDS. REFERENCE C IS SECNAVINST 1650.1H NAVY AND MARINE CORPS AWARDS MANUAL.
REFERENCE D IS THE MEMORANDUM FROM UNDER SECRETARY OF DEFENSE PERSONNEL AND
READINESS TO MILITARY DEPARTMENT SECRETARIES REGARDING PH FOR MILD TRAUMATIC
BRAIN INJURY (MTBI). REFERENCE E IS DIRECTIVE-TYPE MEMORANDUM 09-033, POLICY
GUIDANCE FOR MANAGEMENT OF CONCUSSION/MILD TRAUMATIC BRAIN INJURY IN THE
DEPLOYED SETTING UPDATED W CH2 ON 22 FEB 2011. REFERENCE F IS MARADMIN 245-
11. REFERENCE G IS MCO 3040.4 MARINE CORPS CASUALTY ASSISTANCE PROGRAM. REFERENCE
H IS MILPERSMAN 1770 CASUALTIES AND SURVIVOR BENEFITS.//
POC/J. NIERLE/CIV/NDBDM/TEL: 202-685-6397/-//
RMKS/
1. THIS ALL NAVY (ALNAV) MESSAGE CLARIFIES AND UPDATES THE DEPARTMENT OF THE NAVY (DON) POLICY FOR AWARD OF THE PH. The purpose of this ALNAV is to enhance consistency across the DON by providing amplifying guidance to assist PH awarding authorities in applying the PH criteria to individual cases. Detailed guidance is included concerning award of the PH for MTBI. The basic eligibility and criteria contained in references a through c remain unchanged, and this Message does not cancel previous guidance published within DON concerning award of the PH for wounds other than MTBI. The standards set forth in this ALNAV are effective immediately and may be retroactively applied for certain instances of MTBI suffered on or after September 11, 2001. Retroactive awards are addressed further in paragraph 11 of this ALNAV.
2. PER REFERENCE C, THE PH MAY ONLY BE AWARDED WITHIN THE DON IF BOTH OF THE FOLLOWING CRITERIA ARE MET:
a. The wound was the direct or indirect result of enemy action, and
b. The wound required treatment by a medical officer at the time of injury.
3. CLARIFICATION OF CRITERION 2A: Wound was the direct or indirect result of enemy Action.
a. Wound is defined by reference B as an injury to any part of the body from an outside force or agent.
b. Wounds/injuries are the direct result of enemy action when the physical effects of an enemy weapon on the service member are the immediate cause of the wound/injury (e.g., being struck by projectiles, fragmentation, or blast from an enemy weapon or improvised explosive device).
c. Wounds/injuries are the indirect result of enemy action when the service member is injured by a subsequent action that is solely the result of the effects of the enemy weapon (e.g., aircraft is damaged by enemy missile, forcing the crew to eject and they sustain injuries as a result of the ejection).
d. Accidental injuries. Injuries suffered due to an accident that is neither directly nor indirectly caused by the effects of enemy weapons do not meet the eligibility requirements for the PH, even if the accident occurs in a combat zone or during an engagement with the enemy. Examples of such accidental wounds/injuries that would not qualify for the PH are:
(1) Injuries suffered due to a motor vehicle mishap that is not caused by impact of an enemy weapon to the vehicle or driver, even if the mishap is due to evasive maneuvers.
(2) Injuries sustained while seeking shelter, escaping, or evading.
e. Wounds caused by unknown/unidentified individuals. Within a combat zone, the wounded service member's Commanding Officer shall make the determination as to whether weapons fired by unknown individuals were likely fired by enemy combatants. If so, wounds received from those weapons may qualify for the PH. Outside of a combat zone, wounds/injuries caused by the actions of unknown individuals, or as a result of criminal actions, shall not be assumed to be caused by enemy action, and shall not qualify for award of the ph unless the wound is determined to be the result of an international terrorist attack.
4. CLARIFICATION OF CRITERION 2B: Wound required treatment by a medical officer at
The time of injury.
a. Per reference B a medical officer is a physician with officer rank.
b. Medical officers are distinct from civilian physicians and physician extenders, a term that applies to other personnel who may be involved in the treatment of wounds, such as Physicians Assistants (PA), Nurse Practitioners (NP), Independent Duty Corpsmen (IDC), special forces medics, and Special Amphibious Reconnaissance Corpsmen (SARC). Basic corpsmen and basic medics are not classified as physician extenders.
c. Sometimes a wound that would normally require treatment by a medical officer must be treated by a physician extender or corpsmen/medic at a forward deployed location because evacuation to a facility with a medical officer is not tactically feasible. in such situations, a PH may be approved if the commander with PH approval authority determines that the wound/injury would have normally required treatment by a medical officer had one been available. This determination can be made based upon either the information provided in personnel casualty reports or review of the wounded service member's medical record by the supervising medical officer, or the advice of the commander's staff surgeon after review of the medical documentation available. In any case, per reference B there must be a written statement from a medical officer substantiating the determination.
d. Evaluation by a medical officer solely to determine the extent of an injury does not meet the ph threshold of requiring treatment by a medical officer if the injury is determined to be at a level that could have been adequately treated by a physician extender or a corpsman/medic. Likewise, a decision by a medical officer to treat a minor wound that a corpsman could have adequately treated does not mean the wound required treatment by a medical officer. Award of the PH would not be authorized in either of these two example situations.
5. EXAMPLES OF WOUNDS THAT NORMALLY QUALIFY FOR AWARD OF THE PH. In cases in which the requirements in paragraphs 2a and 2b have been met, the following types of wounds/injuries are consistent with department of the navy standards for award of the PH:
a. Fragmentation Wounds.
b. Lacerations.
c. Fractures.
d. Gunshot Wounds.
e. Perforated Eardrum.
f. Moderate or severe/penetrating traumatic brain injuries (TBI) (see additional information in paragraph 9 below).
g. MTBI/Concussions severe enough to cause either loss of consciousness (LOC) or restriction from full duty due to persistent signs, symptoms, or clinical findings of impaired brain function for a period greater than 48 hours from the time of the concussive incident.
(1) The 48 hour period does not include assignment to administrative light duty solely for a mandatory period of observation/screening as required by medical protocols (such as reference E) for evaluation of individuals who may have had some blast exposure, regardless of the presence of any signs, symptoms, and findings of impaired brain function.
(2) The medical officer disposition of MTBI/Concussion with either LOC or more than 48 hour restriction from return to full duty must be made within seven (7) days of the concussive event.
(3) See additional information on TBI in paragraph 9 below.
h. Smoke inhalation severe enough to cause 1st to 3rd degree burns to the respiratory tract.
i. Corneal abrasions.
j. Effects of chemical, biological, or nuclear weapons (to include chlorine gas used by the enemy in conjunction with an IED).
k. 2nd and 3rd degree burns.
6. FRIENDLY FIRE INCIDENTS. Navy and Marine Corps personnel receiving the above wounds/injuries as a result of friendly fire are only eligible for the PH If they were actively engaging the enemy at the time of the injury.
7. MULTIPLE WOUNDS. If multiple wounds are received at the same instant or from the same missile, force, explosion, or agent, only one award of the PH will be made.
8. NON-QUALIFYING WOUNDS. The following are examples of wounds/injuries that are not consistent with department of the navy standards for award of the PH:
a. Cold and heat related injuries (e.g., frostbite and heatstroke).
b. Hearing loss and Tinnitus (i.e., ringing in the ears).
c. MTBI/Concussions that do not either result in LOC or restriction from full duty for a period greater than 48 hours due to persistent signs, symptoms, or clinical findings of impaired brain function.
d. Post Traumatic Stress Disorder (PTSD) or combat stress injuries.
e. Disease (unless the result of an enemy or terrorist nuclear, biological, or Chemical attack).
f. Abrasions (unless of a severity to be incapacitating).
g. Bruises (unless caused by direct impact of enemy weapon and severe enough to require treatment by a medical officer).
h. First degree burns.
i. Soft tissue injuries (e.g., ligament/tendon/muscle strains or sprains).
j. Any wounds/injuries received as a result of friendly fire when the individual was not engaging the enemy at the time of the injury.
9. AWARD OF THE PH FOR TBI.
a. TBI are classified into three categories based on severity of the injury. in decreasing levels of severity, these categories are: severe/penetrating TBI; moderate TBI; and MTBI.
b. MTBI and concussion are frequently used interchangeably. MTBI is a medical term defining the physical injury to the brain from a blow or blast. concussion is the layman term describing impairment to brain function (e.g., alteration of consciousness, loss of consciousness (LOC), or post-traumatic amnesia) resulting from the injury.
c. Diagnosis of either a severe/penetrating TBI or a moderate TBI necessarily requires treatment by a medical officer and, therefore, will qualify for the PH if the wound was the direct or indirect result of enemy action.
d. However, there are varying severity levels of MTBI/Concussions which can produce signs, symptoms, and clinical findings of impaired brain function, ranging from "Seeing Stars" and disorientation to post-concussive amnesia and LOC. Only the more severe instances of MTBI/Concussion will require treatment by a medical officer, and therefore qualify for award of the PH. Even though a medical officer may be required to evaluate the sailor/marine based on displayed signs, symptoms, or findings of impaired brain function, such evaluation does not in itself mean the wound required treatment by a medical officer.
E. Recent research into MTBI effects and treatment has led to a clearer understanding of the relationship between the severity of an MTBI and the time required for brain tissue to recover and return to its normal state. Although there is currently no method to directly measure the actual severity of a mild traumatic brain injury, the duration of the signs, symptoms, or clinical
findings of impaired brain function serve as a proxy for estimating MTBI severity, and thus whether the MTBI meets the PH threshold of necessitating treatment by a medical officer. The most mild forms of MTBI may result in less severe cognitive impairment lasting only minutes or hours, with no lasting damage to brain tissue or impaired brain function. In the more severe cases of MTBI, the level of injury may result in irreversible damage to brain tissue with long term impairments of brain function. Research also indicates that many service members suffering MTBI/Concussions without any LOC can have signs, symptoms, or clinical findings
of impaired brain function that last significantly longer than those resulting from an MTBI/Concussion with LOC. For these reasons, military neurologists now consider the duration of brain function impairment to be a more accurate measurement of the degree of brain injury than whether or not a LOC occurred.
f. For the reasons cited in the preceding paragraphs, Dept of the Navy has updated and revised its standards for awarding the PH for MTBI. Specifically, an MTBI/Concussion will be considered severe enough to have required treatment by a medical officer, and therefore may qualify for the ph:
(1) When the service member suffers a LOC of any duration as a result of a diagnosed MTBI/Concussion, or
(2) When the persistent signs, symptoms, or findings of functional impairment from a diagnosed MTBI/Concussion result in a medical officer disposition of "not fit for full duty" for a period greater than 48 hours. This 48 hour restriction from return to full duty does not include assignment to administrative light duty by a medical provider or medical officer in the absence of persistent symptoms of impairment for the sole reason of compliance with administrative screening protocols for concussive events.
g. Signs, symptoms, or findings of brain function impairment manifest within the first few days after suffering an MTBI/Concussion. Therefore, a medical officer or civilian physician diagnosis weeks or months after a concussive incident, citing additional or more severe symptoms of brain impairment than were diagnosed during the initial seven (7) day period following the concussive event, will not warrant award of the PH. This restriction is necessary to ensure the PH is not awarded for symptoms of Post Traumatic Stress Disorder (PTSD) that are similar to those of MTBI/Concussion, or for a subsequent concussive injury that was not the result of enemy action.
10. PERSONNEL CASUALTY REPORT (PCR).
a. Commanders at all levels shall ensure that PCRs are submitted IAW reference F and G (Marine Corps) and reference H (Navy), and contain sufficient information for the PH approving authority to determine if the wound/injury met the requirements for the PH contained in paragraph 2 above.
b. The Commanding Officer of the wounded/injured service member must ensure the PCR contains verification from a medical officer that the wound/injury for which the member was treated required treatment by a medical officer, or would have required treatment by a medical officer if one had been available per paragraph 4 of this ALNAV. A sufficiently detailed
description of the wound/injury and treatment required must be provided to support the opinion of the medical officer. Phrases such as "treated by competent medical authority" do not provide sufficient information to make a determination as to whether the wound/injury was of a level of severity to require treatment by a medical officer, regardless of whether a medical officer was available to provide the treatment.
11. RETROACTIVE AWARDS OF THE PH. The updated standards for award of the PH for MTBI listed in paragraphs 4.g and 9.g of this ALNAV are retroactive to September 11, 2001. Personnel who suffered a diagnosed MTBI on or after September 11, 2001 that was the direct or indirect result of enemy action, but who were not awarded the PH for that MTBI (or other wound suffered during the same action), may request reconsideration. Reference F contains detailed reconsideration procedures for Marines, and for Navy personnel who were serving in Marine Corps UNITs at the time of the wound/injury. All other Navy Personnel may request reconsideration by contacting the Office of the Chief of Naval Operations (Code DNS-35), 2000 Navy Pentagon, Washington, DC 20350-2000.
12. THIS ALNAV IS APPLICABLE TO THE TOTAL FORCE NAVY AND MARINE CORPS.
13. RELEASED BY RAY MABUS, SECRETARY OF THE NAVY.//
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Secretary Of The Navy Outlines New Standards For The Purple Heart Medal 22DEC11
Recently, due to advances in the diagnosis and treatment of mild traumatic brain injuries (MTBI), the Secretary of the Navy (SECNAV) updated the standards and procedures for the awarding of the Purple Heart Medal.  Sailors and Marines may be awarded the Purple Heart for certain mild traumatic brain injuries that were caused by direct or indirect enemy actions with intent to kill or maim.  Those who suffered a loss of consciousness or were ‘'not fit for full duty' by a medical officer for more than 48 hours after a concussive event may qualify for the Purple Heart Medal. 
The SECNAV stated that Purple Heart Medals awarded for MTBI will continue to meet the historical standards of severity applied to all types of wounds, ensuring the prestige and integrity of one of the U.S. military’s most recognized wards is maintained.  To learn more about these recent changes to the standards and procedures for award of the Purple Heart Medal you can go here.  

Purple Heart Eligibility Revised 20May11

Both the Army and the Marine Corps will allow more battlefield concussions to be eligible for the Purple Heart.  The decision to expand the definition for concussions means thousands of Purple Heart medals could be going to soldiers and Marines who may have been denied in the past.  The new eligibility still requires all injuries to be the result of direct or indirect enemy action.  The change is retroactive to Sept. 11, 2001. 
*   Soldiers should reapply through their chain of command; Army veterans can call 888-276-9472 or send an e-mail to hrc.tagd.awards@conus.army.mil.  Read more at https://www.hrc.army.mil/site/index.asp.
*        Marines should consult the Commandant's coordinating instructions at http://www.marines.mil/news/messages/Pages/MARADMIN245-11.aspx/.  Read more at http://www.marines.mil/unit/hqmc/Pages/Marineswithconcussion,mildbraininjuryqualifyforPurpleHeart.aspx.
*     The Departments of the Air Force and Navy are still considering regulation changes. 

Army Clarifies Purple Heart Rules For Soldiers
T. Christian Miller and Daniel Zwerdling

March 17, 2011

Purple Hearts were initially awarded to recognized meritorious service, but during World War II, the medal was changed into a recognition of combat injuries and deaths.
In addition, the Army is planning to prioritize appeals from brain-injured soldiers who feel they should not have been turned down for the medal, a hallowed military honor that recognizes those injured in combat.

Gen. Peter Chiarelli, the Army's second in command, said he reviewed the Army's policies on the Purple Heart and called for the new guidelines as a result of an investigation by NPR and ProPublica. In a report published last September, we found that Army commanders denied Purple Hearts to some soldiers who sustained concussions, despite regulations that make those who suffer such wounds eligible for the medal.

"What was clear to us is that there's confusion about concussion and the Purple Heart," Chiarelli said. "There's confusion on the part of commanders, and there's confusion even on the part of doctors."

Though the new guidelines do not change the rules concerning eligibility for the Purple Heart, a modern version of an award originally created by George Washington, they add a clarity that should make it easier for soldiers to prove they deserve recognition.

To receive the Purple Heart, the Army's current regulations require that a soldier be injured by enemy action and receive documented treatment from a medical officer. The Army's official list of wounds that "clearly justify" the award includes, "Concussion injuries caused as a result of enemy generated explosions."

The NPR and ProPublica report, however, found that some senior officers and medical officials did not consider concussions serious enough to merit the award. Concussions, also called mild traumatic brain injuries, typically do not leave visible damage. While most people recover from them within days or weeks, civilian studies suggest that about 5 percent to 15 percent of victims may suffer lingering cognitive problems.

More From This Investigation
 
Purple Hearts Elusive For Traumatic Brain Injuries
The Army routinely denies Purple Hearts to soldiers who sustain mild traumatic brain injuries.
A History Of The Purple Heart
 
 Brain Wars Coverage From ProPublica
 The report showed that a senior medical officer in Iraq, Brig. Gen. Joseph Caravalho, issued a 2008 memo that discouraged awarding the Purple Heart in cases in which soldiers required only "minimum medical intervention." Other senior medical officials had turned down soldiers for the medal out of concerns that giving it for concussions lessened its value when compared to soldiers who had suffered other types of injuries.

The new guidelines, which will be distributed throughout the Army, provide a checklist that makes clear that concussions requiring any sort of treatment by a medical professional—including bed rest or over-the-counter headache medication—is sufficient to meet award criteria.

The guidelines also clarify that soldiers diagnosed and treated by any medical professional, including nurses and physician's assistants, are eligible, as long as their standards of care match those a military doctor would apply.

Chiarelli said the checklist was part of an ongoing effort to ensure that soldiers, commanders and medical officers take so-called "invisible wounds" seriously. Recognizing soldiers who have suffered concussions drives home the Army's commitment to improving care and treatment, he said.

"It is very important if we're going to get at this stigma issue," Chiarelli said. The Purple Heart "shows to everyone that these hidden injuries are truly injuries that affect folks."

After the ProPublica and NPR reports, Chiarelli ordered officials at the Army's Human Resources Command to review whether Purple Hearts had been erroneously denied.

Col. Tom Quinn, the Army's director of soldier programs and services, initially reviewed nine applications from soldiers that had suffered a mild traumatic brain injury. Three soldiers had received the award. Six others had been denied or were still awaiting an answer because commanders disagreed on their cases. Four of the six clearly merited Purple Hearts, the review determined.

What was clear to us is that there's confusion about concussion and the Purple Heart. There's confusion on the part of commanders, and there's confusion even on the part of doctors

- Gen. Peter Chiarelli
The results prompted Chiarelli to order a more-in-depth review this fall, a task made more difficult because the Army does not centralize the award of Purple Hearts, which are often handed out in the field.

Reviewers looked over more than 6,000 paper records, including applications for awards other than Purple Hearts. They found about 100 applications for Purple Heart concerning soldiers with concussion injuries. Some appeared to have been wrongly denied, Quinn said, but he did not have statistics.

"We determined that the guidance is not very clear out in the field and it's not being uniformly applied across the force," Quinn said. "We think some deserving soldiers may not have been appropriately recognized."

Army officials decided the most equitable way to rectify erroneous denials was to ask all soldiers who applied for Purple Hearts for concussions to re-apply.

Quinn promised the Army would move "aggressively and impartially" to resolve the requests as quickly as possible. "We don't want to miss anybody. We want to give everybody the same opportunity." Quinn said.

The new guidelines will apply only to the Army. Other military branches are reviewing their criteria, however, according to the Military Times. Currently, the Marine Corps recognizes soldiers with the medal only if they were knocked unconscious, even though the medical definition of concussion encompasses blows that leave patients dazed or confused, but conscious.

Rep. Bill Pascrell (D-N.J.), has asked the military to apply a uniform standard for awarding the Purple Heart.

Soldiers and their advocates welcomed the Army's new guidelines. The Purple Heart brings few medical or financial benefits, but is a tangible symbol of having fought and suffered for one's country. It is also the only military award that is considered an entitlement—an honor earned through individual sacrifice, rather than awarded by a superior officer.

NPR/Frontline Sgt. Nathan Scheller was twice denied for a Purple Heart, though roadside bomb explosions left him with lasting cognitive damage. Above, Scheller walks with his wife, Miriam, and his family.
"It's encouraging that soldiers will finally get the awards they deserve and that their injuries will be acknowledged," said Jayna Moceri Brooks, an Army wife and nurse who helped found Recognize the Sacrifice, an organization which helps soldiers with concussions apply for Purple Hearts. "It's very encouraging."

Nathan Scheller, a retired sergeant, has battled for years to receive a Purple Heart for concussions that he received in Iraq. He expressed cautious optimism that the new guidelines would help.

"It's about time," he said. "If they keep track of the system and they keep track of what's going on, I believe it will get better."