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  • BIOETHICS FORUM ESSAY

For Brain-Injured Soldiers and Their Families, the Battle Never Ends

Every war creates military and civilian casualties — not just those who die but also those who survive with the wounds typical of that conflict. Every war also creates new approaches to military medicine, many of which have been translated into better civilian care. Surgical techniques, rapid evacuation to trauma centers, antibiotic use, infection control — all have antecedents in wartime medicine. The specialty of plastic surgery developed as a result of the huge numbers of facial wounds suffered by World War I soldiers who fought in trenches, where their lower bodies were protected. The Korean War is the origin of M.A.S.H. (mobile army surgical hospital) units. The Vietnam conflict pioneered helicopter evacuation and created heightened awareness of post-traumatic stress disorder.

What will be the medical legacy of the Iraq and Afghanistan wars?  This is the war of “polytrauma,” a combination of multiple injuries, including traumatic brain injury (TBI), sustained from explosive devices, landmines, and shell fragments. Sophisticated military facilities are located close to combat sites; specially trained staff are able to save lives and stabilize patients who can then be transported to military hospitals in Germany and the U.S. From there patients with severe injuries may be sent to newly created “polytrauma centers” set up in Palo Alto, Ca.; Richmond, Va.; Tampa, Fl.; and Minneapolis, Minn. These centers offer comprehensive rehabilitation for patients with TBI alone or in combination with amputation, blindness, complex orthopedic injuries, auditory disorders, and mental health concerns.

And then what? Aye, there’s the rub. Even with its much admired integrated health care system, the Veterans Administration (VA) has not been able to establish a comprehensive care management system for TBI patients after they leave rehab. Nor has it been able to provide the needed counseling and support for these patients’ families. Long-term care at the community level, like its counterpart in the civilian world, tends to fall apart.

This was the conclusion of an investigation by the VA’s Office of Inspector General, released July 12, 2006. The report found difficulties in the transition from Department of Defense (DOD) care to the VA health care system. Some patients were confused about whether they were still on active duty or had been discharged. Delays in obtaining recommended treatment resulted from lack of coordination. (To anyone who has had to deal with a “COB” or Coordination of Benefits problem within private insurance, this sounds depressingly familiar.) Patients reported problems in obtaining appropriate therapy, a lack of money, and transportation difficulties, as well as uncertainties about quality of care, getting prescriptions refilled, and making follow-up appointments.

The report stressed the importance of family support in patient recovery and ability to live at home. A wife reported that her husband is often up all night, punching the wall and pacing the floor but the next day remembers nothing about his behavior. Their children are isolating themselves from him. A mother feared that she might lose her job because she was frequently required to leave work to care for her son and had to make telephone calls during business hours to arrange his care. One wife did lose her job and had to send a ten-year-old son to live in another state with grandparents.

Although families wanted (and some occasionally received) counseling and support, many reported that their calls were unanswered. Some resorted to media pleas or contacted their Congressional representatives. In his response to the report, Jonathan Perlin, Undersecretary for Health Affairs, explained that the VA, unlike the DOD, is not “authorized, except in very limited situations, to use its medical appropriations to provide services to families.”

Sen. Daniel K. Akaka (D-Hawaii), a member of the Senate Veterans’ Affairs Committee, said that “The [Inspector General] found that VA does an excellent job of caring for service members at its specialty hospitals but fell short when the patient moves home. These men and women are quite young and are living with brain injuries for the rest of their lives. VA must do more than simply send them back to their communities.”

Nothing can completely restore the lives of these veterans and their families. But a lasting, positive legacy of this war would be a coordinated system of community care that served them well and could be a model for the civilian sector.

Published on: August 3, 2006
Published in: Health and Health Care

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