Saturday, July 24, 2010

Stop talking about them!











Yesterday the US House Veterans Affairs Subcommittee on Health held a hearing on physical war wounds. Chair Michael Michaud explained in his opening statement, "The purpose of today's hearing is to explore how we can best serve our veterans who have sustained severe physical wounds from wars in Iraq and Afghanistan. Today, we will closely examine VA's specialized services for the severely injured, which include blind rehabilitation, spinal cord injury centers, polytrauma centers and prosthetics and sensory aids services. With advances in protective body armor and combat medicine, our service members are surving war wounds which
otherwise would have resulted in casualties."
The first panel was made of veterans advocates: Blinded Veterans Association's Thomas Zampieri, Paralyzed Veterans of America's Carl Blake, Disabled American Veterans' Joy J. Illem, Iraq and Afghanistan Veterans of America's Tom Tarantino and the American Legion's Denise Williams.
Thomas Zampieri: The VA, I want to start off on some good news, the blind rehab services have expanded services throughout the system. Ironically, back in 2004, they developed the plans for a continum of care based on the idea that the aging population of veterans would need a lot of low vision and blind rehabilitative services. Little, I think, did they realize back then that the plans that they were making to expand services would suddenly be immediately useful for the returning service members with eye trauma and Traumatic Brain Injuries with vision impairments associated with the TBIs. And so what we have is now the VA has expanded. They've had ten in-patient blind centers which offer comprehensive, rehabilitative services for those with blindness but they also have all the specialized staff in those centers such as consultants with orthapedics, general surgeons, neuroligists, psychologists, pharmacologists, occupational therapists, physical therapists, speech pathologists, the list goes on and on. So those individuals refered to the ten blind centers get, I think, excellent care. But the VA has also expanded and they now have 55 sites where they have either low-vision specialists or advanced blind rehabiltative centers. And those centers have specialized staff -- they've actually hired about 250 staff including about 60 low-vision optometrists and they're screening these patients with visual problems and visual impairments. And so that's the good news.
In addition, Zampieri noted problems such as the fact that BROS (Blind Rehabilitative Outpatient Specialists) can visit the VA and do various things but they can't do what they're trained to and so he asks that the VA grant BROS the same Medical Treatment Factilities (MTF) clinical privileges as VA clinical staff. We're going to stay with opening statements and, please note, this is what was stated. It may or may not track with the prepared written opening statement which are submitted ahead of time and submitted for the record. So here's a sampling of the first panel, via their opening statements. And these are excerpts, not their entire opening statements.
Carl Blake: It is important to emphasize that specialized services are part of the core mission and responsibility of the VA. For a long time, this has included spinal cord injury care, blind rehabilitation, treatment for mental health conditions -- including Post-Traumatic Stress Disorder -- and similiar conditions. Today, Traumatic Brain Injury and polytrauma injuries are new areas that the VA has had to focus its attention on as part of their specialized care programs. The VA's specialized services are incomparable resources that often cannot be duplicated in the private sector. For PVA, there is an ongoing issue that has not received a great deal of focus: Some active duty soldiers with a new spinal cord injury or dysfunction are being transferred directly to civilian hospitals in the community and bypassing the VA health care system. This is particularly true of newly injured service members who incur their spinal cord injuries in places other than the combat theaters of Iraq and Afghanistan. This violates a memorandum of agreement between VA and DoD that was effective January 1, 2007, requiring that "care management services will be provided by the military medical support office, the appropriate military treatment facility and the admitting VA center as a joint-collaboration" and that "whenever possible the VA health care center closest to the active duty member's home of record should be contacted first." In addition, it requires that to ensure optimal care, active duty patients are to go directly to a VA medical facility without passing through a transit military hospital -- clearly indicating the critical nature of rapidly integrating these veterans into an SCI health care system. This is not happening. For example, service members who have experienced a spinal cord injury while serving in Afghanistan and Iraq are being transferred to Sheppard Spinal Center, a private facility, in Atlanta when VA facilities are available in Augusta. When we raised our concerns with the VA regarding Augusta in a site visit report, the VA responded by conducting an information meeting at Sheppard to present information and increase referrals. However, reactionary measures such as this should not be the standard for addressing these types of concerns. Of additional concern to PVA, it was repoted that some of these newly injured soldiers receiving treatment in private facilities are being discharged to community nursing homes after a period of time in these private rehabilitation facilities. In fact, some of these men and women have received sub-optimal rehabilitation and some are being discharged without proper equipment. PVA is greatly concerned with this type of process and treatment.
Joy Ilem: Today's injured military service members are experiencing higher survival rates than in previous wars, with the overall survival rate among wounded troops being about 90 percent. This increase is attributed to the widespread use of body armor, improved battlefield triage procedures and expedited medical evacuation. For a majority of our wounded service members, the first level of complex intervention on their journey to a VA PRC nomrally occurs at the Landstuhl Regional Medical Center in Germany, operated by the US Army. Up until 2009, VA received little or no information about wounded service member transport, the full extent of the acute care process that service members had undergone or the stress that these patients had experienced before arriving at a VA PRC. However, in October of 2009, a team of two VA physicians and two nurses from VA's Polytrauma System of Care spent four days at Landstuhl to gather information and put a system in place to establish a regular exchange of information between medical teams in the military and VA's PRCs. The PRCs are now able to track patients from the beginning of their jouneys and can identify medical complications much earlier. This system of coordination has established a continuum of care that is not proprietary to the DoD or VA and has aieded them to develop one system that benefits our wounded personnel and veterans.
Tom Tarantino: We asked our members what they though of the treatement they were receiving at the VA and we've received a wide range of opinion, both complementary and critical. However, several-several common themes appeared: Long waits for appointments, frequent interaction with rude administrative staff, a growing distrust of VA health care and long drives to VA facilities. Fortunately, we received very few complaints about the actual quality of care at VA medical centers. But in addition to the concerns listed above, our members have expressed concern with how the VA deals with Traumatic Brain Injury. To properly treat returning combat veterans with mild to severe TBI the VA must completely rethink and adapt their medical rehabilitation practices. IAVA is concerned that the VA has limited or denied access to some veterans seeking recovery services for TBI because current statute requires that the VA provides services to restore functions to wounded veterans and while full recovery should always be the desired outcome for rehabilitation, sustaining current function or just preventing future harm should also warrant access to VA services.
Denise Williams: In response to the large number of veterans with prosthetics and rehabilitative needs, VA established Polytrauma Rehabilitation Centers (PRC). The VA Polytrauma Rehabilitation Centers provide treatment through multi-disciplinary medical teams including cardiologists, internal medicine, physical therapist, social work and transition patient case managers and much more specialty medical service areas, to help treat the multiple injuries. Currently, VA maintains four VA Polytrauma Rehabilitation Centers in Richmond, VA; Minneapolis, MN; Palo Alto, CA and Tampa, FL. However, the American Legion is concerned about VA's ability to meet the long term needs of these young veterans. As stated by the Military Medicine Journal, rehabilitation is a crucial step in optimizing long-term function and quality of life after amputation. Although returning veterans with combat-related amputations may be getting the best in rehabilitative care and technology available, their expected long term health outcomes are considerably less clear. It is imperative that both DoD and VA clinicians seriously consider the issues associated with combat-related amputees and try to alleviate any forseeable problems that these OIF-OEF amputees may face in the future.
We'll note this exchange.
Chair Michael Michaud: This question is actually for all the panelists. I've heard some anecdotes from veterans who applaud prosthetic services that they receive at the Dept of Defense but are very leery of the care that they might receive through the VA system. Do you believe that DoD provides better overall prosthetic services compared to the VA? Or do you believe that these anecdotes that I'm hearing are just a few isolated cases? And I don't know who wants to address that.
Joy Ilem: I'll go ahead and take a stab at that. I think early on, you know, we heard reports -- I mean, I remember from hearings even with [Iraq War veteran] Tammy Duckworth [now the Assistant Secretary for Public and Intergovernmental Affairs at the VA], one of the situations that's very unqiue is DoD and Walter Reed obviously have had -- you know, the focus has been on them for really doing much of the prosthetics and rehab there on site. I know that VA, from attending their prosthetics meeting, have integrated their people to go out and see, you know, what's going on as these people start to transfer back to the VA. But the complaints were that when they returned to the VA to have either their item serviced or to continue their rehabiliation they ran into sort of a disconnect from anyone at the facility they had been working with. The prosthetician had very much attention to and all the access to the newest items and options at the DoD site -- it seemed very different within the VA. I think that, you know, VA's prosthetic services tried to really improve that and make good strides in trying to make sure that they are ready to accept these veterans as they transition back into VA to repair their equipment , to have -- I know that they have access to all of the vendors that are working out there and they have done this liason work. I'm hoping that -- that percetion, as Tom has mentioned, you know, it lingers when you hear so much about DoD and then people want to return there because it's a very sensitive issue in terms of the people that they're working with and the items that they're working with and then to have to go to a new system where people that haven't seen the high tech equipment, you know, you don't have a lot of confidence, I'm sure. They're saying, 'That's the first time I've seen that' but the truth is they're getting access to some of the most high quality equipment that nobody has seen, so I'm hoping it's changing but it still may be the case in some situations.
Carl Blake: Mr. Chairman, I just want to sort of piggy-back a little on what Joy had to say and also make another comment first. Representing a membership that is probably one of the highest in the users of prosthetic devices and equipment from the VA, I would say that our members generally never -- I won't say "never" -- generally do not have problems getting the most state of the art wheel chairs and other types of equipment that they need. In the occasion where maybe there's some difficulty getting some prosthetic equipment or whatever it may be, it's usually just a matter of working with the prosthetic department through our service officers or what have you to make sure that the right steps are taken. But-but our members are not experiencing a lot of problems getting what they need and, believe me, when it comes to state of the art wheel chairs, you'd be surprised at what's out there. I want to sort of tag along on what Joy had to say, I think you would find that DoD is not unlike VA in sort of the prosthetic structure and some of VA's prosthetic services is not unlike the rest of its health care, it has to become adaptable to the changing needs of this generation. Prosthetics is no exception. I think a lot of focus is put on the high tech -- we talk about these advanced prosthestics the service members are getting from DoD but it really boils down to them getting through Walter Reed, Bethesda, Brooke or some of the major military checkpoints. But if they went back to a lot of home stations, I think you'd find that a lot of these military treatment facilities, they don't exactly have the capacity to meet their needs when it comes to prosthetics or the maintenance required for that equipment either. So DoD is not unlike the VA in that respect and I think that VA is probably trying to address it more than DoD would in that respect and we've heard time and again from Mr. [Fred] Downes who overseas the VA's prosthetics that -- I think he recognizes the need for them to become more adapatable and get it to the field so that, as these men and women are ultimately going to come to their local facilities, the VA can meet their needs particularly on the maintance of this high-end equipment. I mean, they are intimately involved in what's going on out at Walter Reed in particular because that's sort of where everything begins when it comes to these advanced prosthetics. So I -- You can beat up on the VA for it but in fairness to the VA, they're seeing demands on their system that they never could have imagined before now also.
Chair Michael Michaud: Thank you very much. My next, my last question for all the panelists actually is: When you look at speciality care within the VA system, do you believe that speciality care is provided equally among all of VA facilities talking to your membership?
Carl Blake: I'll speak to the SCI [spinal cord injury] side of it. I think because of the model that's been established, we feel pretty confident that it's sort of a uniform policy in the way that all SCI care is provided across the system. That again is a function of how the entire SCI service has been set up through the hub-and-spoke model. We're encouraged to see that the VA is sort of moving that way in the polytrauma aspect. And yet there are a lot of challenges as it relates to TBI that Joy raised and going forward that the VA is going to have to figure out how to deal with along the way. But I feel pretty confident that they do the right thing across the board when it comes to SCI service in particular.
Joy Ilem: I would add on to that, some of the complaints that we've heard from veterans contacting us about mild to moderate TBI is that their family sort of recognized that they had an issue, they had been using the VA system for other things, they went to the VA, weren't satisifed in certain areas of the country -- I mean, I'd received calls from sort of different locations saying, you know, 'I ended up in the private sector with VA fee-basing me into an out-patient program that really offered a range of things that I've learned so much in the last six months in terms of mild TBI, how to deal with it for my family centered care, addressing a range of issues and opportunities for them to have this wide range of out-patient care.' And in those cases, you know, I've contacted the VA directly and tried to find out is it just this location that they're having this problem or is it a systemic problem. It's hard to say unless, you know -- someone like PVA really has people on the ground that are doing site visits and the Legion. But in that specific area, that's a concern of ours. We're hoping that in certain areas, we're hoping that they've got the interdisciplinary teams that are needed to provide that care and that they've developed a wide range of services and a good type of program for that but I'm not convinced of that, that it's everywhere yet. I think it's in certain locations -- obviously with the major polytrauma centers -- but as you go further out, and then obviously in the rural areas where those services are-are not available and they have to connect them with the nearest prviate sector facilities. You know, we'd like to see some continuity of care and make sure that care is available everywhere.
Denise Williams: I'd like to add that during our site visit that was a main issue: staffing shortages. As Joy just mentioned, in the areas where they have the polytrauma centers, you'll see where they have a lot of speciality care available but as you go out to the other facilities there is definitely a shortage for speciality care. And we hear that from the veterans and we also hear that from VA staff themselves at the facilities, that there's a shortage.
Thomas Zampieri: Same thing. The major centers, both the military polytrauma centers, Walter Reed, Bethesda, Brooke Army Medical Center, Balboa out in San Diego, or you go to any of the four VA polytrauma centers, it's amazing. I think everybody gets seen by everybody. I mean it's not unusual to have a team of thirty different specialists seeing a patient and the hand off has improved dramatically since 2005 when I was sitting in this room, I think, with a couple of things. One is that we're always concerned with everybody focuses on -- the famous beat-up in this town is Walter Reed. You know, when something goes wrong and the universe focuses there. But the patients who are evacuated back through Landstuhl come back into the United States, I think there's a misperception that everybody goes through Bethesda or Walter Reed and actuality, some people will admit that about thirty percent of all the wounded and walking wounded actually go back to the original home platform base of deployment. So if you go to Fort Drum or Fort Carson, Coloardo or Fort Gordon, Georgia or -- just name a base. Fort Hood, Texas. You'll find individuals who are evacced back through the system that didn't get seen in one of these highly specialized centers. And some of those are the ones that we find that have a vision problem -- you know, they didn't have a lot of other severe injuries so they were evacced back and then they sort of get lost. Somebody on one side doesn't notify the VA Blind Rehab Services or the local VIST coordinator that they have somebody that's experiencing vision problems and that there's treatment available, that there's specialized devices from prosthetics that are available to help them in their recovery and treatment. And so that's why the visions centers of excellence is important -- because it isn't just the major trauma severe cases that need to be tracked, it's all of the types of injuries -- mild, moderate, severe -- as far as vision goes -- that need to be carefully tracked and followed and the providers need to be able to exchange the information between them -- between the VA providers, the opthamologists and the military, their colleagues, and the military treatment facilities. Because, again, a person at Fort Drum, New York may suddently have somebody come in that was evacced back from Landstuhl with injuries and that's where one of the problems is. Thank you.
Turning to peace news, Mick Kelly (Fight Back!) reports that Minneapolis groups are gearing up to protest at the 2012 DNC convention. Meredith Aby is quoted stating, "We are prepared to organize a significant protest of thousands of people to demand an end to the wars and occupations of Afghanistan and Iraq. For the 2008 RNC we organized an impressive coalition of anti-war, economic rights, student, immigrant rights and labor groups to protest the war on Iraq and these forces are ready to come together again to give a loud and clear message of opposition to the Democrats' support for the war in Afghanistan." Let's take the pulse of the political parties.
CNN reports, "The Senate passed an emergency supplemental spending bill to fund the wars in Afghanistan and Iraq, setting aside a House package that includes additional social spending." So the Democratically-controlled Senate is sending the war supplemental -- which Barack swore would take place once and only once in 2009 and never again under his watch -- back to the Democratically House and welcome to Bizarro World. Michael Steele, chair of the GOP, calls the Afghanistan War Barack's war and he's only 'wrong' in that he forgot the Iraq War. They're both Barack's wars. And welcome to Bizarro World. Governors do photo ops in Iraq and praise the conditions there -- and they're Democrats -- like Governor Tim Pawlenty. And Governor Jim Douglas. And welcome to Bizarro World. Michael Bell (Globe and Mail) writes a strong column which opens with, "The American-led interventions in Afghanistan and Iraq are failing." A UN report this week, [PDF format warning] "Regional Response Plan for Iraqi Refugees," explains that Iraq continues to be unstable, that "human rights violations continue, including illegal detention, targeted killing, kidnapping and discrimination. The formation of a new Government following the Parliamentary elections in March continues to be delayed and the political vacuum may continue until August or September 2010." And, for those wondering, the Green Party continues to refuse to mount a left critique of Barack yet again signaling that they are content to forever be the kid sister of the Democratic Party.
Still on peace news, Peace Mom Cindy Sheehan notes in "Myth America II: FREE PDF FILE" (Cindy Sheehan's Soapbox), "Last year in January, I found myself in an awkward place--being pro-peace in a nation that had seemed to have turned itself upside down either in questionable euphoria or abject fear because a new member of the elite class had been installed as president of the United States." Cindy's offering Myth America as a PDF for free or for a donation to Cindy Sheehan's Soapbox.

RECOMMENDED: "Iraq snapshot"
"Come Undone"
"Veterans issues"
"No recipe in the Kitchen"
"Science Friday"
"My BFF Kevin Zeese"
"From books to movies"
"I feel something in the air"
"Student loans"
"It's time to work on the list"

1 comment:

MediTouch said...

Tele-rehabilitation using readily available web tools needs to be an essential part of the VA offering to ensure that the patient remains motivated and encouraged to continue intensive active exercises.
Quality of life is dependent on healthy hand function. Numerous orthopedic and neurological disease and injuries lead to hand impairments that affect hand function and decrease quality of life.
The objective of Physical rehabilitation is to return the patients performance of everyday functional and vocational tasks to their pre injury level and the main element of Physical rehabilitation is intensive active exercise practice.
The HandTutor is a glove and dedicated rehabilitation software that uses biofeedback to improve hand function. The HandTutor encourages patients to perform exercises customized to their finger and wrist movement impairment. Doing customized exercises in a motivating environment ensures that the patient is encouraged and motivated to continue intensive exercise practice. The HandTutor is used in hospitals and community clinics and through tele-rehabilitation. Indications also Orthopedic hand/ arm surgery.