Monday, December 22, 2014

Wounded veterans return to unprepared medical system

By Andy Marso
KHI News Service

TOPEKA — A sniper’s bullet tore through U.S. Army Sgt. Jamie Jarboe’s neck while he was on patrol during a tour of duty in Afghanistan in April 2011. The bullet shattered three vertebrae, severed Jarboe’s spinal cord and caused severe bleeding. It was the kind of wound that almost certainly would have been fatal in previous conflicts.

But an Army medic was at Jarboe’s side almost immediately to keep him from bleeding out, and within 17 minutes of the shooting a helicopter lifted Jarboe out of the danger zone. In less than an hour, he arrived at a state-of-the-art field hospital in Kandahar, where a medical team was waiting to stabilize him enough so that he could be evacuated from the country.

Jarboe arrived back on American soil paralyzed but alive and was able to get the best care the military had to offer at Walter Reed Army Medical Center in Washington, D.C.

But less than a year later he was dead from complications of surgery, one of several medical errors that his wife, Melissa Jarboe, documented in a self-published memoir about her husband’s last months.

“It wasn’t the sniper that shot him that killed him,” Melissa Jarboe, of Topeka, said in a recent interview.

Rather, it was a mistake made during a surgery that took place in May 2011 that eventually killed Jamie Jarboe. A surgeon in training nicked Jarboe’s esophagus. Dozens of attempts were made over the next nine months to repair the damage. But none of them worked. Jarboe died in March 2012.

Jamie Jarboe’s story illustrates a military medical system that is better than ever at saving lives on the battlefield but has not kept pace when it comes to ensuring quality of life for the severely wounded once they come home.

Growing VA problems

An estimated 2.6 million American men and women served in Iraq and Afghanistan, and more than half now receive government medical care through military facilities, the U.S. Department of Veterans Affairs or TRICARE, which provides coverage for private-sector care to military members and their families.

In the last year media and congressional investigations have documented widespread problems in the VA medical system. Stories about veterans being forced to wait months for treatment and accounts of wounded veterans receiving inadequate care forced U.S. Army Gen. Eric Shinseki to resign as secretary of the department in May.

But Melissa Jarboe said overhauling the VA leadership is not enough to provide veterans the long-term support they need. Jarboe, who started a foundation called the Military Veteran Project in honor of her husband, said investments are needed in veteran-supported nonprofits and the VA health system.

Linda Bilmes, a lecturer at Harvard University’s John F. Kennedy School of Government who has studied the costs of the Iraq and Afghanistan wars, said in a phone interview that VA backlogs that led to Shinseki’s departure were the short-term consequence of failing to anticipate the influx of new patients into the veterans medical system and build the VA capabilities accordingly.

Larger consequences are on the horizon, she said, if Congress doesn’t start preparing now for the long-term medical needs of Iraq and Afghanistan veterans — whose care she estimates is likely to cost at least $1 trillion.

“The longer-term problem is we now have a large liability sitting on the books and nobody has made any provision to pay for it,” Bilmes said. “Actually, I should correct myself. The liability exists, but it’s actually not sitting on the books. It’s not accounted for, but it’s there. There is no strategy for how we’re going to pay these obligations.”

Overburdened system

Melissa Jarboe tried several times to have her husband transferred from a VA hospital in Richmond, Va., before she was finally successful.

By then she had become well-versed in medical procedures and drugs for those with spinal injuries and wary of some of what she saw of her husband’s care.

“I started seeing inconsistencies in the medical procedures,” Jarboe said. “I started seeing the staff being short-staffed. Medical equipment was not functioning properly. Individuals without proper experience were doing new-wave surgeries without consent or communication to us as a family on what they were going to do.”

Jarboe started sleeping at her husband’s bedside after she arrived early one morning to find he had been taken to surgery without anyone notifying her.

Despite the issues, Jarboe did not blame the medical staff so much as their working conditions.

“The doctors are so short-staffed because of the wages they get, and then the nurses, they’re overworked and understaffed as well,” Jarboe said. “So they compromise the level of training and education needed to get in because it’s like, ‘We need you now.’”

Within the past year, emergency services at Topeka’s Colmery-O’Neil VA Medical Center had to be cut back due to doctor shortages. Earlier this month, U.S. Sen. Jerry Moran, a Republican from Kansas, introduced a bill in Congress to allow qualified physicians from outside the VA system to volunteer their services at VA facilities in an attempt to quell shortages nationwide.

The VA’s annual budget rose from $61.4 billion in 2001 to $140.3 billion in 2013. In large part, the increase is due to the rising cost of health care and the burgeoning number of new VA patients returning from Iraq and Afghanistan.

Bilmes’ research found that as of 2013, 56 percent of the veterans of those conflicts were receiving government medical care, a higher percentage than after past conflicts.

Bilmes said that prior to 2001 there were about 26 million U.S. veterans and 4 million using the VA. Now there are about 21 million veterans and 6.5 million using the VA. The deaths of World War II veterans have reduced the overall numbers, but the influx of Iraq and Afghanistan veterans, and aging Vietnam veterans, has increased the number of them needing medical care.

The new VA patients have increasingly complex cases. More than a third of new returning veterans have been diagnosed with a mental illness such as depression, anxiety or post-traumatic stress disorder, contributing to a doubling in the Army suicide rate.

Armored vehicles helped more soldiers survive the improvised explosive device blasts that were the weapon of choice for insurgents in Iraq and Afghanistan. But the blasts contributed to traumatic brain injuries suffered by more than 200,000 veterans. They also caused widespread tinnitus, a persistent ringing in the ears that can be debilitating.

Bilmes said other health problems stem from conditions on the ground during those wars, including carting heavy packs long distances and living in the extreme heat and desert sand.

Multiple deployments in those conditions contributed to large numbers of veterans coming home with musculoskeletal pain, rashes and eye problems, often in addition to mental illness.

“The average claim of a veteran coming back from Iraq and Afghanistan has 10 disabling conditions on it,” Bilmes said.

About 50,000 veterans of Iraq and Afghanistan are considered “polytrauma” patients, meaning they’ve suffered multiple traumatic injuries. That includes more than 1,600 with significant brain injuries, 1,400 amputees and nearly 1,000 with severe burns.

Bilmes found that the facility now known as Walter Reed National Military Medical Center in Maryland treated more than 100 returning amputees each year from 2010 to 2012, during the Afghanistan “surge.”

Many of them later turned to VA hospitals for expensive prosthetic care, an ongoing medical cost.

According to data released by spokesman Jim Gleisberg, the VA Eastern Kansas Health Care System, which includes hospitals in Topeka and Leavenworth, has treated between 18 and 23 cases of burns and/or amputations each year since 2011, at a cost of about $300,000 in the most recent fiscal year.

Those wounds are expensive, but Bilmes said the number of veterans returning with horrific injuries is a “tiny, tiny fraction” of those with some sort of service-related condition that qualifies them for benefits. That number is likely to grow, she said, because service-connected conditions tend to crop up as veterans get older and their bodies break down.

She said the government has spent about $2 trillion on the recent wars and can expect to spend another $1 trillion to $1.5 trillion going forward to treat those who served in them. That doesn’t include social and economic costs, and Bilmes said she’s likely underestimating the final tab.

“I’ve tried to be pretty conservative in my assumptions, and every year the numbers are coming out higher than what I’ve predicted,” Bilmes said.

Debt-financed wars

During World War I and World War II, the U.S. sold bonds and asked citizens at home to sacrifice by eating from “victory gardens” and submitting to rationing.

However, the most recent wars were financed largely through debt. Bilmes said she was disturbed to see that method used again in August to provide $15 billion in emergency aid to the VA.

“Not only have the rest of us not fought in the war, we haven’t actually paid for it either,” Bilmes said. “We just put it on the national credit card. But the funding of current veterans benefits by putting that on the card is sort of a new and disturbing financial approach.”

The emergency bill allowed $10 billion for veterans who live more than 40 miles from a VA medical facility to get services at private hospitals and another $5 billion to help VA facilities hire more staff.

She said the ad hoc spending method leaves veterans in danger of having their benefits reduced or eliminated in the future.

“We’re in the middle of a national mood that is favorable to veterans,” Bilmes said. “Congress could (someday) just decide there isn’t enough money, and they could cut these benefits. It’s unlikely, but they could.”

Her research found that as of last year the United States had spent about $260 billion in interest on the $2 trillion in debt it incurred fighting the wars, which accounted for 20 percent of the total debt accumulated by the country during the war years.

Bilmes said she has long supported the establishment of a war tax or bond sales to support a national veterans trust fund. She testified for the fund before the U.S. House of Representatives Veterans Affairs Committee in September 2013.

But Jarboe said she’s wary of the idea of a trust fund, a large pot of money she fears could be misappropriated.

“Who’s going to manage the trust fund?” Jarboe asked. “That’s scary to me.”

However, she does want to see more resources put into support for veterans, through both the VA and organizations like the Military Veteran Project. She’s learned that the needs are too big for anything less than a national commitment.

“I thought when I started a small little nonprofit in Topeka, Kansas, I would basically advocate and empower and honor veterans,” Jarboe said. “That was my goal. But when I started digging into some of the cases, people would contact us from all around the world, all across the nation, at all hours of the day, and some of the cases were just inconceivable.”

Jarboe said voters should hold elected officials accountable for their rhetoric about supporting veterans. She says she prefers to stay out of politics and is wary of politicians who frequently reach out to her foundation. The one exception is former U.S. Sen. Bob Dole, himself a wounded World War II veteran and Kansan, who wrote the foreword to Jarboe’s memoir.

“He’s never once asked me for a photo (with him),” she said. “I like him.”

More accountability

Jarboe watched her husband endure more than 100 surgeries in the final year of his life. She believes some of the procedures were unnecessary and certainly outside the experience of the doctors who performed them. Walter Reed Army Medical Center closed a few months after he was treated there.

Jarboe has learned that the “Feres doctrine” complicates, and in some cases prevents, suing the federal government for medical malpractice in military or veterans hospitals. She’s also learned that military and VA doctors are not regulated by the medical boards in the states where they practice. While she wants more accountability for military and VA medical personnel, Jarboe said she’s not necessarily interested in suing anyone for what happened to her husband.

She wants to work within the system to make it better for other military families.

“Even through everything my husband endured and everything we’ve seen, we’re still very pro-government, pro-military, pro-VA,” Jarboe said. “Because there’s no way I can go up against and fight with them. Why not work with them and help them change things with the power of numbers?”

“There’s no sense in pushing more negativity out,” she added. “I’ve already had enough negativity in my life to last a lifetime. I’m good. Plus, my husband told me not to.”