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Iraq Vets Falling Through Health-Care Cracks

Despite lifesaving care, many with severe head injuries not getting follow-up they need, report suggests

WEDNESDAY, Dec. 20, 2006 (HealthDay News) -- Sergeant Jason Pepper returned from the conflict in Iraq with a traumatic brain injury, symptoms of post-traumatic stress disorder, and a desperate need for help in navigating the U.S. health-care system.

But, like many of his peers, Pepper, who was also blinded in a blast from an improvised explosive device, is now largely invisible in a system ill-equipped to deal with the type and magnitude of injuries showing up in veterans returning from Iraq, according to a report published in the Dec. 21 issue of New England Journal of Medicine.

"He has sort of fallen through the cracks as far as medical care goes," said Dr. Susan Okie, contributing editor of the New England Journal of Medicine. "He has made, physically, a fairly remarkable recovery considering how badly he was wounded, but he has significant residual medical problems and symptoms."

Pepper, along with Sergeant David Emme, were first profiled in the pages of the journal last year while undergoing treatment and rehabilitation at Walter Reed Army Medical Center, in Washington, D.C.

Emme also has a traumatic brain injury (TBI) and symptoms of post-traumatic stress disorder (PTSD) as a result of his service in Iraq.

Okie revisited the two men, this time in their homes -- Pepper, an hour outside Nashville, Tenn., and Emme, north of Allentown, Pa.

Pepper and Emme are among some 22,600 U.S. soldiers who have been wounded in the conflicts in Iraq, Afghanistan and other locations, most commonly by blasts. Fifty-nine percent of those injured by blasts have been found to have a TBI, which has been called the signature wound of this war. This and other features of the conflicts may be overwhelming the veterans' health-care system.

"There are probably more people like these two guys who have a combination of PTSD and TBI, and that's probably something the VA has not seen in such numbers before," Okie said. "Because of the body armor, there is a higher survivor rate of those with multiple wounds, so a bigger influx of those with severe injuries and maybe head injury as well as amputations or wounds to the limbs. The VA's obviously got a big burden of people recovering from severe injuries, more than in previous conflicts."

"The nature of the wounds is completely different because of the improvised explosive devices," added Phil Kraft, program director for the National Veterans Services Fund, in Darien, Conn. "The guys who were injured to this extent in Vietnam are dead. These guys are being saved when, ordinarily, they wouldn't have made it. The VA system is designed for soldiers who took a bullet, stuff like that. These aren't your traditional wounds."

The VA's plans for a "seamless transition" from military to civilian health care are largely unrealized. About 80 percent of soldiers recently discharged after serving in Iraq have not even enrolled as patients in the VA system.

Pepper, a former Army combat engineer, hasn't seen a doctor since he left Walter Reed in September 2005. He did enroll with Tricare, an agency that administers a national health-care plan for military personnel, veterans and their families, but said he was unable to contact the civilian primary-care physician that Tricare referred him to.

Pepper takes escalating doses of a barbiturate-containing pain medication left over from Walter Reed, along with medications to reduce his anxiety and help him sleep. At the same time, he has cut his daily antidepressant dose in half and has gained 50 or so pounds since his discharge from Walter Reed. He feels he can't exercise safely because he can't see.

Emme also has not seen a doctor since his discharge. His headaches have largely disappeared since his skull was reconstructed, but he still has muscle twitching (a result of his brain injury), sleep apnea and anxiety, which may be a symptom of PTSD. Emme also enrolled in Tricare but has yet to follow up with a civilian neurologist.

Neither Pepper nor Emme has a case manager to ensure continuity of care.

"Everybody has tried to come up with a system that involves case managers to try to help them stay on top, but they're not using them," Okie said. "Theoretically, they could both get them simply by arranging it."

And it's hard to say precisely where or how people are slipping through the cracks.

"Just the sheer size of the caseload is unbearable for any health-care organization," Kraft said. "I couldn't with any conscience point my finger at the VA, and say they're doing this on purpose. They're trying. They really are, but they're not being given any money. How the hell are you going to take care of these people if there's no money to do it? They're always willing to send young men and women over there, it's just they don't think it all the way through."

More information

For more on issues facing returning veterans, visit the National Veterans Services Fund Inc..

SOURCES: Susan Okie, M.D., contributing editor, New England Journal of Medicine, Washington, D.C.; Phil Kraft, program director, National Veterans Services Fund, Darien, Conn.; Dec. 21, 2006, New England Journal of Medicine
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