MARADMIN 245/11 - Purple Heart Medal - Revised Criteria for Mild Traumatic Brain Injury and Updated Coordinating Instructions

Scope

MARADMIN 245/11 announces a revision to the Purple Heart (PH) criteria for Mild Traumatic Brain Injuries (MTBI). The MARADMIN clarifies PH eligibility requirements for every type of wound or injury and publishes updated coordinating instructions for awarding the PH. Guidance covers Marines and Sailors assigned to Marine commands. PH eligibility criteria date to Executive Order in 1942. Revisions to the MTBI criteria are retroactive to 2001-09-11. Applicability is the Total Force.

Audience

• PH approval authorities (COMUSMARCENT, COMMARFORSOC). Apply the revised criteria. Coordinate medical determinations.
• Commanding officers. Ensure PCRs contain sufficient information for the PH approval authority to determine eligibility. Include the command recommendation in the Remarks section.
• Medical officers. Provide verification of treatment required for the wound or injury. Document MTBI dispositions.
• Casualty Assistance Calls Officers (CACOs). Present approved PH certificates and medals to families.
• Wounded Warrior Regiment and Battalions, Marine Liaison detachments at medical treatment facilities. Inform Marines of PH decisions following evacuation.
• HQMC MMMA. Adjudicates reclamas based on the revised MTBI criteria.
• Active duty, reserve, and veteran Marines. Submit reclamas under the revised criteria.

Two key PH eligibility requirements

Under SECNAVINST 1650.1H Article 230.9, the wound or injury must be the direct or indirect result of enemy action, and must have required treatment by a medical officer at the time of the injury.

Direct or indirect enemy action

• Direct. Physical effects of an enemy weapon are the immediate cause. Projectiles, fragmentation, or blast from an enemy weapon or IED.
• Indirect. A subsequent action solely resulting from enemy weapon effects. Enemy automatic weapons fire blows out vehicle tires causing an overturn. A Marine is blown off a roof by a near miss RPG.
• Excluded. Battlefield accidents not caused directly or indirectly by enemy weapon effects. A vehicle overturning in a ditch while moving to a new firing position. A Marine falling while running for cover.
• Friendly fire. PH only when actively engaging the enemy at the time of injury.
• Outside the combat theater. Wounds caused by criminals or civilians not determined to be terrorists do not qualify.

Treatment by a medical officer

• A medical officer is a physician with officer rank.
• The requirement establishes a severity threshold. The PH is not awarded for minor wounds requiring only minimal treatment from a corpsman or fellow Marine.
• Physician extenders. Physician Assistants (PA), Nurse Practitioners (NP), Independent Duty Corpsmen (IDC), Special Amphibious Reconnaissance Corpsmen (SARC). PH approved when the PH approval authority determines the wound would normally have required medical officer treatment if available.
• Evaluation only. A medical officer reviewing X-rays and returning the Marine to duty does not establish a medical officer treatment requirement.

Wounds and injuries warranting the PH

Provided paragraphs 2A and 2B requirements are met.

• Fragmentation wounds.
• Lacerations.
• Fractures.
• Gunshot wounds.
• Perforated eardrum.
• MTBI or concussions severe enough to cause either loss of consciousness (LOC) or medical officer disposition of "not fit for full duty" due to persistent signs, symptoms, or findings of functional impairment for over 48 hours from the concussive incident. Revision retroactive to 2001-09-11. The 48-hour period excludes administrative light duty solely for a mandatory observation or screening period.
• Moderate or severe penetrating TBI.
• Smoke inhalation severe enough to cause 1st to 3rd degree burns to the respiratory tract.
• Corneal abrasions.
• Effects of chemical, biological, or nuclear weapons, including chlorine gas used by the enemy with an IED.
• 2nd and 3rd degree burns.

Only one PH is authorized for multiple qualifying wounds from the same instant, missile, force, explosion, or agent.

Wounds and injuries not warranting the PH

• Cold and heat injuries (frostbite, heatstroke).
• Hearing loss and tinnitus.
• MTBI or concussions without LOC and without a greater-than-48-hour medical officer disposition of not fit for full duty.
• Post-traumatic stress disorder (PTSD) or combat stress injuries.
• Disease (unless caused by enemy biological agents).
• Abrasions (unless of a severity to be incapacitating).
• Bruises (unless caused by direct impact of enemy weapon and severity requires medical officer treatment).
• First degree burns.
• Soft tissue injuries (ligament, tendon, muscle strains or sprains).
• Friendly fire wounds when the Marine was not engaging the enemy.

TBI classification

Three severity categories in decreasing order. Severe or penetrating TBI. Moderate TBI. MTBI.

MTBI is the physical injury to the brain from a blow or blast (inflammation of brain tissue). A concussion is the brain function impairment resulting from the inflammation injury. Severe and moderate TBI require treatment by a medical officer and qualify for the PH when paragraph 2A requirements are met.

MTBI revised criteria

Award of the PH for MTBI or concussions caused by enemy action on or after 2001-09-11 requires one of the following.

1. LOC of any duration as a result of a diagnosed MTBI or concussion.
2. Persistent signs, symptoms, or findings of functional impairment from a diagnosed MTBI or concussion resulting in a medical officer disposition of "not fit for full duty" for a period greater than 48 hours.

The medical officer disposition must be made within 7 days of the concussive event. A diagnosis weeks or months after the event citing additional or more severe symptoms does not warrant the PH. This restriction prevents the PH from issuing for PTSD-like symptoms or a subsequent concussive injury unrelated to enemy action.

PCR requirements

The Personnel Casualty Report (PCR) Remarks section.

• Command recommendation on whether the wound or injury meets the direct or indirect enemy action criteria.
• Medical officer verification of treatment required. A detailed wound description and treatment summary. Phrases such as "treated by competent medical authority" do not suffice.
• Medical officer confirmation when a physician extender provided treatment normally requiring medical officer treatment.
• Initial PCR for MTBI without LOC. Indicate "Marine suffered an MTBI/concussion. Additional information on PH eligibility to be provided after initial period of observation by medical staff." Supplemental or final PCR provides the disposition outcome.

Reclama submissions

Active duty, reserve, and veteran Marines submit a request for reconsideration with new and relevant information.

• Reclamas for non-MTBI wounds. Letter to the appropriate PH approval authority via the original operational chain of command at the time of injury. Include PCR, certified true copies of medical record pages, and any new and relevant information. Two notarized eyewitness statements when no new medical documentation exists.
• Reclamas based on revised MTBI criteria. Send to CMC (MMMA) for adjudication. Email HQMC.MANPOWER.PH MTBI RECLAMA@usmc.mil with subject line "RECLAMA BASED ON REVISED PURPLE HEART CRITERIA FOR MTBI/CONCUSSION." Mail to Commandant of the Marine Corps (MMMA), 3280 Russell Road, Quantico, VA 22134-5103.
• Veteran Marines obtain medical records from Department of Veteran Affairs, Records Management Center, P.O. Box 5020, St. Louis, MO 63115-8950.

Connection to higher policy

• SECNAVINST 1650.1H. Navy and Marine Corps Awards Manual. PH eligibility criteria.
• Executive Order authorizing the Purple Heart, 1942.
• Secretary of Defense 2008-11. Reaffirmation. PTSD is not PH-eligible.
• CENTCOM FRAGO 09-1656 dated 2010-07-13. Required observation periods for concussive events.
• COMUSMARCENT MOD 1 to FRAGO 28 to OPORD 08-001 dated 2010-10-27. Required actions for concussive events.

Connection to Marine Corps doctrine

• MCO 3040.4. Marine Corps Casualty Assistance Program. PCR framework.
• CMC MSG 161556Z SEP 09. PH approval authority delegation to COMUSMARCENT.
• CMC MSG 191538Z APR 07. Wartime awarding authority delegation to COMMARFORSOC.
• MARADMIN 074/21. Updated CMC delegation of awarding authority. Successor delegation guidance.
• MARADMIN 398/10. Awards Update. Background on HSM and JMUA processing.

Status

Released 2011-04-15, DTG R 151135Z APR 11. Originator CMC Washington DC MRA MM. Release authorized by Major General A. Salinas, Director, Manpower Management Division. Applicability is the Total Force Marine Corps. POC LtCol E. Himler at HQMC MMMA, 703-784-9206. The MTBI criteria are retroactive to 2001-09-11. Reclamas under the revised MTBI criteria continue to process through CMC MMMA.