COUNTERING MILITARY RECRUITMENT
Articles: Military Service: Casualties
THE WOUNDED: Taking On the System; For War's Gravely Injured, A Challenge to Find Care
DEBORAH SONTAG AND LIZETTE ALVAREZ, New York Times
March 12, 2007
When
Staff Sgt. Jarod Behee was asked to select a paint color for the
customized wheelchair that was going to be his future, his young wife
seethed. The government, Marissa Behee believed, was giving up on her
husband just five months after he took a sniper's bullet to the head
during his second tour of duty in Iraq.
Ms. Behee, a sunny Californian who was just completing a degree in
interior design, possessed a keen faith in her husband's potential to
be rehabilitated from a severe brain injury. She refused to accept what
she perceived to be the more limited expectations of the Veterans
Affairs hospital in Palo Alto, Calif.
''The hospital continually told me that Jarod was not making adequate
progress and that the next step was a nursing home,'' Ms. Behee said.
''I just felt that it was unfair for them to throw in the towel on him.
I said, 'We're out of here.' ''
Because Ms. Behee had successfully resisted the Army's efforts to
retire her husband into the V.A. health care system, his military
insurance policy, it turned out, covered private care. So she moved him
to a community rehabilitation center, Casa Colina, near her parents'
home in Southern California in late 2005.
Three months later, Sergeant Behee was walking unassisted and abandoned
his government-provided wheelchair. Now 28, he works as a volunteer in
the center's outpatient gym, wiping down equipment and handing out
towels. It is not the police job that he aspired to; his cognitive
impairments are serious. But it is not a nursing home, either.
Like the spouses of many other soldiers with severe brain injury, Ms.
Behee, also 28, transformed herself into a kind of warrior wife to get
her husband the care she thought he deserved. By now, there is a
veritable battery of brain-injured-soldiers' relatives who have quit
their jobs and, for some extended time, moved away from their homes to
advocate for and care for these very wounded soldiers during long
hospitalizations.
In the eyes of five such relatives interviewed, the military health
care system, which is so advanced in its treatment of lost limbs, has
been scrambling to deal with an unanticipated volume of traumatic
brain-injury cases that it was ill equipped to handle. Largely because
of the improvised explosive devices used by insurgents in Iraq,
traumatic brain injury has become a signature wound of this war, with
1,882 cases treated to date, according to the Defense and Veterans
Brain Injury Center.
In general, these caregivers said that their grievously wounded
soldiers had either been written off prematurely or not given
aggressive rehabilitation or options for care. From the beginning, they
said, the government should have joined forces with civilian
rehabilitation centers instead of trying to ramp up its limited
brain-injury treatment program alone during a time of war. That way,
soldiers would have had access to top-quality care at civilian
institutions that were already operating at full throttle and might be
closer to home.
In fact, many soldiers do have that access. But unlike Ms. Behee, many
caregivers only belatedly come to understand how to negotiate the
daunting military health care system.
Generally, after severely brain-injured soldiers are medically
evacuated to the United States, they are treated first at Walter Reed
Army Hospital or Bethesda Naval Hospital. Relatively quickly, the
military, depending on the branch, initiates a medical retirement
process that turns the soldiers' health care over to the V.A. If
soldiers succeed in deferring retirement, they remain covered by a
military insurance policy that, if pressed, pays for private care.
Still, the military hospitals tend to discharge seriously brain-injured
soldiers to V.A. hospitals, regardless of their active or retired
status. It is how the system works, and challenging it requires
constant haggling, which often leaves the families of the severely
wounded soldiers feeling abused, resentful and anxious for those
soldiers without an advocate.
''We have been let down by a system that is so bungling and
bureaucratic that it doesn't know what it can and cannot do and just
says 'No' as a matter of course,'' said Debra Schulz of Friendswood,
Tex., whose son, Lance Cpl. Steven Schulz of the Marines, 22, suffered
a severe brain injury during his second tour in Iraq.
Offers of Help
Early on, at least two top-ranked nonprofit civilian centers, the
Rehabilitation Institute of Chicago and the Kessler Institute for
Rehabilitation in New Jersey, made overtures to the government. Since
the Vietnam War, their leaders said, while the V.A. has focused
primarily on the chronic care of aging veterans, the civilian acute
rehabilitation system has been dealing daily with brain-injured
patients, fine-tuning their care.
Dr. Bruce M. Gans, chief medical officer of the Kessler Institute,
contacted senior military and V.A. physicians. ''I said, 'Please let us
help. Please let us be used as a resource,' '' Dr. Gans said.
''Especially in the early days, they had no capacity to take care of
these kids. There was either no response or a negative response. We
just didn't understand.''
Last week, Dr. Joanne C. Smith, chief executive officer of the
Rehabilitation Institute of Chicago, met in Washington with senior
Pentagon officials and found far keener receptivity to the idea of
extending civilian sector treatment to more soldiers, she said. After
revelations by The Washington Post of problems with outpatient care at
Walter Reed and Bob Woodruff's reporting on ABC about traumatic brain
injury, the tenor of the conversations was ''action-oriented,'' Dr.
Smith said.
''There was a high degree of acceptance that there is a gap in the
military system's current ability to take care of particularly the
profoundly injured,'' she said.
V.A. officials, however, do not believe there is a problem or any need for rescue by the private sector.
The V.A. has centralized the care for severe traumatic brain injury at
four hospitals that specialized in brain injury before the war. Those
four, converted into ''polytrauma centers'' by Congress in 2005, have
been gradually beefed up and the level of care has improved since
Sergeant Behee arrived at Palo Alto in the summer of 2005, advocates
for veterans say. But they still have a total of only 48 beds.
Some 425 soldiers have been treated for moderate and severe traumatic
brain injury at the polytrauma centers in the past four years,
according to the Defense and Veterans Brain Injury Center.
''At the moment we are handling the numbers,'' said Dr. Barbara
Sigford, the V.A.'s national director for physical medicine and
rehabilitation. ''The trauma centers are running close to capacity, but
there are always beds available.''
Harriet Zeiner, the lead clinical neuropsychologist at the V.A.'s
polytrauma center in Palo Alto, said care at the polytrauma centers was
''tremendous.'' She and Dr. Sigford said the great majority of soldiers
and their families had been satisfied. A few disgruntled families, they
said, grew frustrated with the slow recovery process and directed their
anger at the V.A.; many went ''through the system early on while we
were still building the blocks,'' Dr. Sigford said.
Susan H. Connors, president of the Brain Injury Association of America,
said she was more concerned about follow-up care once soldiers returned
to their communities, a concern of all advocates for these soldiers.
The polytrauma centers, Ms. Connors said, are ''pretty good.''
Dr. Sigford of the V.A. said, ''We really are able to take care of a high-acuity group.''
But Dr. Smith of the Rehabilitation Institute of Chicago disagreed in the strongest terms.
''The V.A. has not been doing this for the last 35 years, and there is
no way, with the complexity of this injury, that the V.A. system is
prepared to get to parity with the civilian acute rehabilitation system
overnight,'' she said. ''They're dabbling in brain injury, and you
can't dabble in brain injury.''
A Growing Group
The severely brain-injured are among the most catastrophically wounded
soldiers, and recovery can be painfully slow or, in some cases,
entirely elusive. ''There is no prosthetic for the brain,'' said Jeremy
Chwat, vice president for program services at the Wounded Warrior
Project, an advocacy organization.
The Wounded Warrior Project organized a meeting on traumatic brain
injury in Washington attended by about three dozen caregivers last
fall. One raised ''a huge, sad ethical question,'' Mr. Chwat said,
related to the advances in military trauma care that have saved so many
lives: ''Are we doing these young men and women a service by bringing
them home alive?''
Mr. Chwat said the severely brain-injured soldiers were a relatively
small, but growing, subset of the wounded whose needs were particularly
acute. ''Their families need to know that they have options,'' he said.
''Our message to the V.A. is that the V.A. is still providing them care
if they're paying for a private facility. But that's a cultural shift
for the V.A., and, while their ears are now open, bureaucracies don't
change on a dime.''
That is a lesson Edgar Edmundson, 52, of New Bern, N. C., has been
learning and relearning since his son, Sgt. Eric Edmundson, sustained
serious blast injuries in northern Iraq in the fall of 2005.
Mr. Edmundson was aggressive, abandoning his job and home to care for
his son, calling on his representatives in Washington for help,
''saying no a lot.'' But even he did not come to understand his son's
health care options quickly enough to ensure that his son was not
''shortchanged'' in the critical first year after his injury.
Two days before Sergeant Edmundson was wounded near the Syrian border,
he visited with his father on the telephone. Mr. Edmundson urged his
son, then 25 with a young wife and a baby daughter, to ''stay safe.''
In an interview last week, Mr. Edmundson's voice cracked as he recalled
his son's response: ''He said, 'Don't worry, because if anything
happens, the Army will take care of me.' ''
While awaiting transport to Germany after initial surgery, Sergeant
Edmundson suffered a heart attack. As doctors worked to revive him, he
lost oxygen to his brain for half an hour, with devastating
consequences.
A couple of weeks later, at Walter Reed in Washington, on the very day
that Sergeant Edmundson was stabilized medically and transferred into
the brain injury unit, military officials initiated the process of
retiring him.
''That threw up the red flag for me,'' Mr. Edmundson said. ''If the
Army was supposed to take care of him, why were they trying to
discharge him from service the minute he gets out of intensive care?''
Mr. Edmundson fought the retirement on principle, winning a temporary
reprieve. Still, he did not understand that his son's military
insurance policy covered private care. When Walter Reed transferred
Sergeant Edmundson to the polytrauma center in Richmond, Mr. Edmundson
believed that he was, more or less, following orders.
Mr. Edmundson was disappointed by what he considered an unfocused,
inconsistent rehabilitation regimen at what he saw as an understaffed,
overburdened V.A. hospital filled with geriatric patients. His son's
morale plummeted and he refused to participate in therapy. ''Eric gave
up his will,'' he said. In March 2006, the V.A. hospital sought to
transfer Sergeant Edmundson to a nursing home.
Mr. Edmundson chose instead to care for his son himself, quitting his
job at a ConAgra plant. For almost eight months, Sergeant Edmundson,
who was awake but unable to walk, talk or control his body, received
nothing but a few hours of maintenance therapy weekly at a local
hospital.
One day, by chance, Mr. Edmundson encountered a military case manager
who asked him why his son was not at a civilian rehabilitation
hospital. That is when Mr. Edmundson learned that his son had options.
He did some research and set his sights on the Rehabilitation Institute
of Chicago.
Sergeant Edmundson is now the only Iraq combat veteran being treated there.
The first step in his treatment in Chicago, Dr. Smith said, was to use
drugs, technology and devices ''to reverse the ill effects of not
getting adequate care earlier, somewhere between Walter Reed and here.''
For example, she said, Sergeant Edmundson's hips, knees and ankles are
frozen ''in the position of someone sitting in a hallway in a chair.''
They are working to straighten out his joints so that he can eventually
stand, she said. They have taught him to express his basic needs using
a communication board, and they hope to loosen his vocal cords so he
can start speaking. He is also learning to chew and swallow.
''He has a profound cognitive disability,'' Dr. Smith said. ''But he
can communicate, albeit not verbally, and can express emotions,
including humor and even sarcasm.''
A couple of weeks ago, she said, when his family came to visit him, Dr.
Smith asked Sergeant Edmundson if he was happy to see his daughter. He
used his board to say yes. She asked him the same about his mother. He
said yes. And then she asked him about his older sister, Anna Frese. He
said no. She repeated the question twice more, wondering if he was
pushing the wrong button, until, Dr. Smith said, ''he looked up at me
with a huge, wicked smile.''
Searching for Options
In early 2006, Denise Mettie of Selah, Wash., signed away her son
Evan's health care options without realizing it. She agreed to a
medical retirement for her 23-year-old son only weeks after he was
initially declared ''killed in action'' only to be saved. That left him
dependent on the veterans' health care system, where, after a
tumultuous journey through several hospitals, he now faces transfer
from the ''coma stimulation'' program at Palo Alto to a nursing home.
''At the very beginning, there was a V.A. doctor who said, 'You know,
he's not going to come any further, let's put him in a nursing facility
and let you get on with life,' '' Ms. Mettie said. ''I was not ready to
give up on him then and I'm not now. If there is a private rehab that
will take him, I'm going to get him there and finagle the finances by
hook or by crook.''
Mr. Chwat of the Wounded Warrior Project said severely brain-injured
soldiers should be offered a one-year moratorium on medical retirement
so they can remain on active duty status with the insurance-covered
privileges to seek private care if they want it. Dr. Smith and other
civilian rehabilitation doctors suggest that the V.A., too, give the
option of private care to soldiers who have been discharged or retired.
On the other hand, Dr. Alan H. Weintraub, medical director of the brain
injury program at the private Craig Hospital in Denver, said wounded
soldiers were probably better off in the military health care system,
which he said offered open-ended care tailored to combat soldiers. Dr.
Weintraub, a retired major in the Army Medical Corps, said private
acute care was too expensive for the ''funding stream'' to cover.
Dr. Smith disagreed: ''Are we accepting that these people are not going
to amount to something anyway, so they're not entitled to the best
acute care that the United States has to give -- at the front end of
their potential life?''
Looking Ahead
''Jarod Behee was headed for a nursing home,'' said Felice L. Loverso, the chief executive of Casa Colina in Pomona, Calif.
When Sergeant Behee arrived from the V.A. in Palo Alto, he was in
severe condition, essentially nonresponsive, said Dr. Loverso, a speech
pathologist. Casa Colina, which now has two other soldier patients and
also provides their families housing, first worked to ''wake him up,''
weaning him from medications he no longer needed. He quickly started
getting therapy bedside, making relatively steady progress and then
quite rapid progress after a cranioplasty that repaired his skull.
''Potentially the same good things could have happened to Jarod at the
Palo Alto V.A.,'' said Dr. Loverso, a former V.A. employee himself. ''I
like to think it was due to our aggressive therapy.''
Because of his impairment, Ms. Behee said, her husband, who still has
his old Superman tattoo on his calf, does not agonize over his
situation. ''He wakes up every morning with a smile on his face,'' she
said.
Lance Cpl. Steven Schulz, on the other hand, is just cognitively
rehabilitated enough to experience anguish, his mother, Debra Schulz,
said. Occasionally, Lance Corporal Schulz gets angry at his situation
or feels guilty toward his mother, who describes herself as an ''Old
South yellow dog Democrat'' who was not pleased when her son enlisted.
''He has told me that he needed to apologize to me for ever joining the
Marines,'' Ms. Schulz said. ''I say, 'Son, we can't look back.' ''
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