The healthcare needs and challenges presented by the nation’s returning veterans are complex and critical.
That’s not news to all, yet not all clinicians realize how close and relevant the issues actually are. More than half of all returning veterans are treated outside of the military healthcare system and the VA, which means community-based clinicians are on the front lines of care delivery to veterans.
Very often, this also now means that veterans seek care on college campuses, which are seeing a huge surge in veteran enrollment. Some campuses have seen an increase of more than 50% in student-veterans as they take advantage of the Post 9/11 GI Bill after their service is complete.
The need for increased education on assessing and treating veterans in the campus environment became obvious during recent conversations with leaders of college-based healthcare and mental health services. Some weren’t aware of basic resources like the VA’s PTSD 101 online modules or the PTSD Check List – Military (PCL-M).
Some also were naïve as to why it was not safe to assume that everyone discharged from the military was properly screened for both PTSD and TBI.
And there’s good reason why you can’t assume that. Often, the Post-Deployment Health Reassessment Program (PDHRA) gets postponed (despite the best efforts of the Service branches) until a day before final discharge, and the “scuttlebutt” from veterans is that if you answer any of the screening questions affirmatively, you can be “held back” for a work-up (and possible Medical Board Evaluation) of any problems disclosed.
It’s therefore not a surprise that many symptoms go unreported at these exit evaluations.
As proof of this, consider the case of a Veteran whom I (Dr. Rosenman) saw at a community college where I did volunteer work. He was late thirties, 6′ 2″, close to 200 pounds with 1% body fat, blond hair, blue eyes, and a firm handshake. He could have stepped out of a recruiting poster.
He was registered as a student at the college and connected with the VA system so that his GI Bill educational benefits could start, but to the dismay of his case manager, he was unable to complete a class schedule, or to register for any classes. At that point, the student services personnel brought him over to chat with me.
I learned he had started and left the DOD at nearby military base, and was married and had 3 children.
My first question was whether or not he had been concussed in Iraq because of IEDs. His reply was: “Four times that I can remember.”
I quietly explained that sometimes these concussions cause damage to the brain that would not be apparent to him and, that with his permission, I was going to check for this, and he agreed – which, in essence, was a Mental Status Exam (MSE). He was oriented as to person, place and time.
However, he could remember none of the six items I asked him to remember, only got to 93 on Serial 7′s before he stopped and asked for a pen and paper, and remembered only one President.
Given his in-theater history, the reason why he was brought to my attention, and his clearly impaired MSE, I strongly suspected a TBI diagnosis.
I said to him, “Sir, I know that some people are so anxious to be discharged, that when they take the PDHRA, they report that they are totally symptom free. Was that the case for you?”
He paused, smiled sheepishly, and said, “Yes, Doc.”
At that point it was clear to me that he needed more thorough treatment. So I gently conveyed my thoughts to him and then called the local VA hospital, where a caseworker accompanied him and where later that day that based on further screening, an MRI, and their clinical evaluation the diagnosis was confirmed.
He was admitted for further care, and ultimately received a Medical Board 100% permanent Disability Rating secondary to his TBI.
That’s meaningful, because he got access to VA social workers to counsel his family on the diagnosis, a Palm Pilot to help with short-term memory, vocational training, and more significantly, a substantial disability payment – which means a much smaller financial impact on his family, and a decreased chance of divorce and/or homelessness.
Drawing on this example, we strongly encourage you to access the many resources that exist for community and college-based physicians, nurses, counselors and psychologists.
It’s imperative that on this very day you become more familiar with standard assessment tools for veterans, as well as next-step treatment-referral resources. There are plenty of educational resources on Medscape, a wealth of information from the VA’s National Center for PTSD, free online training from the Red Sox Foundation and Massachusetts General Hospital Home Base Program and the National Center for PTSD, and more.
It’s critical to identify individuals who need assistance, like the Veteran described in the example above. He may be sitting in front of you tomorrow, but may look more the part of scattered student than wounded Veteran. They served this country with courage and selflessness, and we have to show those same characteristics to raise our knowledge of the issues, screen effectively, and get them the best care possible.
David Rosenman is a psychiatrist and Emeritus Director, Student Health and Counseling Service, California State University-Fullerton. He has worked as a civilian psychiatrist at two Department of Defense hospitals with returning troops. Glenn L. Laudenslager IV is President of Charge Ahead Marketing and has worked on initiatives and education in veterans’ healthcare for several years.
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