Healing the Heroes

Texas Group Seeks Better Care for Military Veterans

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Cover Story – March 2012

Tex Med. 2012;108(3):20-25.

By Ken Ortolon
Senior Editor   

Former Army medic Timothy Stroud faced serious difficulties transitioning to civilian life after returning from combat in Operation Iraqi Freedom in 2003. 

"Since I was a combat medic, I saw a lot of things over there from both sides," Mr. Stroud said. "Some of the images that will stay with you forever aren't some of the most benevolent things that our culture has done."  

He internalized his feelings and hesitated to seek help because in the military culture it is taboo to talk "outside the circle." Thus, he says, seeking help from the U.S. Department of Veterans Affairs (VA) "was a tough step for me." Despite the VA's help, his problems cost him his marriage. 

"My wife and I quit communicating," he said, "because she simply did not understand and didn't want to go to therapy sessions. She thought it was just that I quit trying. She didn't understand what I went through and why I was closed off." 

Mr. Stroud, who lives in Hutto near Austin and who is involved in veteran support activities as military affairs director for ArmedZilla, an online social networking community for veterans, service members, and their families, is one of thousands of veterans returning home from the wars in Afghanistan and Iraq who are dealing with physical and mental health issues. And while numerous government agencies and private groups help returning veterans, some experts call for greater community awareness of the issues facing our former fighting men and women, and how physicians, educators, employers, and others in the community can help them. 

Now, a national organization based in Austin addresses that very issue. I SUPPORT VETS (ISV), a veterans' advocacy group founded in January 2011, plans to unveil this month a series of online and onsite training courses designed to help physicians, nurses, first responders, educators, corporate managers, and others understand the unique needs of veterans. 

Stephanie Moles, ISV founder and executive director, says the goal is to help communities care for veterans and their families. 

"Based on the recent findings of the Pew Research Center, nearly three quarters of our population does not have an understanding of today's veterans." And with the end of the Iraq war, some 40,000 men and women are "returning to their communities from combat earlier than expected, and it is necessary that we – the public – educate ourselves to ease their reentry." 

Austin oncologist John Costanzi, MD, a retired Air Force Reserve flight surgeon, says preparing primary care and emergency physicians in the community to care for veterans could be critical because the VA system is stretched thin. 

"When you look at the statistics, the VA hospital system is doing a good job for our troops, but they're limited," said Dr. Costanzi. "They're running at full capacity, and they can't take care of everybody. What this group [ISV] wants to do is develop some training programs to make the medical community aware of this problem and to guide them in taking care of these people away from the VA hospital system." 

A New Veteran

According to ISV, nearly 23 million veterans and service members, plus their family members, live and work in communities across America, including 1.7 million in Texas alone. Federal statistics show that 5.5 million of those veterans are disabled, 1.8 million are women, and 4 million served after 9/11. 

An additional 220,000 veterans leave the military each year, the group says. 

Pew Research data also shows that 48 percent of post-9/11 veterans say they have felt strains in family relations as a result of their military services, and more than 40 percent report difficulty readjusting to civilian life. 

The VA estimates that 107,000 veterans are homeless on any given night, while Pew says the veteran unemployment rate tops 11.5 percent. 

Matthew Evenhouse, MD, a Cleveland, Ohio, emergency physician and SWAT medic, says part of the problem is that America hasn't seen veterans like those returning from Afghanistan and Iraq. Many survived wounds that in earlier wars would have killed them. And many have lost one or more limbs or suffered traumatic head injuries. 

"A lot of doctors are trained in VAs, but they're used to the Vietnam-era guys. They're used to seeing guys with COPD [chronic obstructive pulmonary disease], some PTSD [post-traumatic stress disorder], and maybe an amputation here and there," said Dr. Evenhouse, co-owner of Medical Security International (MSI), a training and consulting company that describes itself as integrating tactics and medicine learned on the battlefront to improve survival rates. Dr. Evenhouse says MSI employs veterans and has earned its knowledge about the medical needs of vets through supporting its own people. 

"The new veterans are coming out of two wars over the last 10 to 11 years with very different wounding profiles, very different injuries, particularly related to traumatic brain injury and post-traumatic stress disorder," said Dr. Evenhouse, who helps design the training modules for ISV. 

According to July 2011 data from the VA, the most frequent diagnoses in post-9/11 veterans include musculoskeletal system issues, mental disorders, nervous system diseases, digestive system diseases, and ill-defined symptoms and signs. The most frequent mental disorders reported since 2002 include PTSD, depressive disorders, neurotic disorders, affective psychoses, and specific nonpsychotic mental disorders due to organic brain damage. 

Stephen Holliday, PhD, chief mental health officer for the VA's Veterans Integrated Service Network (VISN) 17 based in San Antonio, says it is important for physicians and other health professionals to be alert for emerging mental health issues, particularly PTSD, depression, and substance abuse. They need to be ready to help veterans with those issues and to refer them to VA mental health services, if necessary. 

Ms. Moles says community physicians must be aware of veterans' needs because relatively few get most of their health care from a VA clinic or hospital. Fewer than half of them access services through the VA, and only 8 percent of Afghanistan and Iraq veterans seek their primary care at VA facilities. 

She also sees the training and community education as prevention: prevention of impaired health, unemployment, and suicide. "The medical community has a significant opportunity to improve care and improve lives," Ms. Moles said.

According to the National Coalition for the Homeless, about 5 percent of homeless veterans live in rural areas where access to a VA clinic or hospital might be limited. Studies show that rural veterans have greater health care needs than their urban counterparts. Specifically, they have lower health-related quality-of-life scores and a higher prevalence of physical illness compared with urban veterans.

"Accessing care for rural veterans is a challenge for both the private sector and the VA," Dr. Holliday said. "We've moved in the last 10 years in the VA from being mainly a hospital-based organization, where everything has to come to us, to moving out and creating smaller community clinics in a lot of areas. We also have a mobile van that delivers medical and mental health care as it drives a route through the rural areas." 

In January, VISN 17 started contracting with some local mental health and mental retardation centers in rural counties to provide additional points of care, Dr. Holliday says. 

Still, many rural veterans will end up seeking care in primary care physicians' offices or local emergency rooms, he says. 

And some may not be able to access VA services because of less than honorable discharges, Ms. Moles says. 

"Over four or five years, shamefully, kids were getting discharged for a personality disorder – which is less than honorable – and come to find out, it's PTSD," she said. 

Because of that less than honorable discharge, they must seek medical or mental health care in the private sector, she says. "So they are in our emergency rooms, they are in our urgent care clinics, and they are in our primary care offices." 

Asking the Right Question

ISV is developing three separate training courses, each targeting health care professionals, educators, and students, and corporate management and employers. A fourth course is a 30-minute military cultures module designed specifically to educate the public. ISV is working with a group of military veterans and clinical experts, including a Navy SEAL commando, U.S. Air Force flight medics, Navy psychiatrists, trauma experts, and primary care physicians. 

Ms. Moles says they focus on these areas because they are the primary issues affecting every returning veteran: health care, higher education, and jobs. Some 40 percent of returning veterans go back to school; most of those who don't, enter the workforce. 

The clinical training program, called the Veteran Emergency Treatment Screening Tool Training, is aimed at physicians, first responders, emergency care personnel, nurses, and other community health care professionals. The course addresses the medical needs of military veterans and their families, military culture, veteran services and the challenges of veteran reintegration in civilian life, and crisis intervention. 

The course also provides an in-depth discussion of mild traumatic brain injury among returning veterans and how it affects their medical needs. It also explores myths surrounding PTSD. 

Dr. Evenhouse says the course will train physicians, particularly emergency physicians, to ask the right questions. 

"If you don't understand whom you're dealing with, if you don't know what the reasonable questions to ask are, you just miss out on what could be critical information," he said. "So the whole tool is designed around asking that first question: Have you served or are you serving in the U.S. military? If they say yes, then the training program that I SUPPORT VETS puts on will take you through a series of screening questions that you can ask, and the training program teaches you about what the answers mean and the next steps." 

Dr. Evenhouse says asking that first question will create a better experience for the patient in the emergency room after a car wreck, for example, because the physician will build a positive rapport with the patient and "can figure out which injuries are from the car wreck and which ones are from the IED [improvised explosive device] he was exposed to." 

According to ISV course materials, the training will enable physicians, nurses, and other health care professionals to:   

  • Quickly identify and connect with patients who are veterans and their families, and with those currently serving in the military; 
  • Gain awareness of both the visible and invisible wounds some veterans bear; 
  • Thoroughly understand the impact of mild traumatic brain injury on the returning veterans; 
  • Understand the resources they can use to care for veterans and their families; and 
  • Assist veterans and their families by connecting them to veteran-specific resources in the community, region, state, or VA system.   

Dr. Evenhouse says identifying a patient as a veteran allows physicians and other health professionals to tap into resources not available to other patients. "That designation as a veteran unlocks enormous potential for their care and for resources – federal, state, and local," he said. "If you're not asking that question, you're missing out on solutions for patients." 

Saving Lives

Dr. Costanzi sees great potential in this type of training for physicians and other health professionals.  

"If you take a community and really give it a thorough going over, you're going to find a lot of veterans who are down by the wayside, who do not have health care, and who don't know where to turn," he said. "The VA can only do so much. If community physicians could band together and be aware of the problems the veterans are coming back with, they could help a lot by taking the load off the federal agencies." 

 Mr. Stroud knows "100 percent" that if physicians and other community members got involved, "it would make the transition a whole lot better for our military and their families. 

 The Army Times reported in April 2010 that VA statistics show there are 950 suicide attempts by veterans monthly and some 18 suicides a day.  

"If the community understands what these veterans are dealing with, maybe we could reduce that number, maybe even to zero," Mr. Stroud said.       

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Texas Medical Schools Join Effort to Stress Veterans' Health Needs

 Several Texas medical schools are among some 130 U.S. colleges of medicine pledging to include courses on post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) in their curricula. 

In January, First Lady Michelle Obama announced a collaboration with the Association of American Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine to put more emphasis on the conditions that affect many veterans returning from the wars in Iraq and Afghanistan. 

In 2012, medical schools participating in the Joining Forces initiative have committed to:   

  • Enrich medical education to ensure that physicians are trained in the unique clinical challenges and best practices associated with caring for military service members, veterans, and their families;
  • Disseminate the most up-to-date diagnostic and therapeutic information on TBI and psychological health conditions, such as PTSD;
  • Grow the body of knowledge leading to improvements in health care and wellness for our military service members, veterans, and their families; and
  • Join with others to strengthen the community of physicians, institutions, and health care professionals dedicated to improving the health of military service members, veterans, and their families.   

Texas medical schools in the project are Baylor College of Medicine, the Texas A&M University Health Science Center College of Medicine, Texas Tech University Health Sciences Center School of Medicine, Texas Tech's Paul L. Foster School of Medicine, The University of Texas Medical School at Houston, and the UT School of Medicine at San Antonio.

In all, 105 allopathic and 25 osteopathic colleges said they will include the two conditions as part of their curriculum, says Brad Cooper, director of the White House's Joining Forces initiative.

"Our nation's health care providers, wherever they are, need to have some fundamental understanding of PTSD and TBI in order to best recognize and most positively impact the health care outcomes of our veterans," Mr. Cooper said.


Online Services for Veteran

Most veterans know they can access medical, mental health, and other support services through the U.S. Department of Veterans Affairs (VA). But they may not be aware of a whole network of state and local veteran support organizations that may be available in their communities. 

Stephen Holliday, PhD, chief mental health officer for the VA's Veterans Integrated Service Network 17 in San Antonio, says an organization called TexVet: Partners Across Texas maintains a searchable database of public and private sector organizations that provide services for veterans.  

TexVet's database includes state and local organizations that can help veterans with health and wellness issues, as well as education, employment opportunities, and crisis hotline numbers. The database also includes information on peer-to-peer support, readjustment help, post-traumatic stress disorder, and more. 

Dr. Holliday says information on veteran support services is available via telephone from 211 Texas, a program operated by the Texas Health and Human Services Commission. Information on how to access 211 Texas is available online.  

Additional information about support services for veterans is available on an online social networking site. The site includes information on groups such as the Wounded Warrior Project, I SUPPORT VETS, and more. 

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