caring for our nation`s veterans

Report
CARING FOR OUR NATION’S VETERANS
Valerie J. Cook, RN, MSN
Ellen M. Piskac, RN, EdD, CNE
April 22, 2013
Conference Objectives
• Describe the “Joining Forces” program.
• Compare and contrast the Veterans from Operation Iraqi Freedom
(Iraq) (OIF) and Operation Enduring Freedom (Afghanistan) (OEF)
with Veterans from Vietnam, Korea and World War II.
• Describe issues affecting female Veterans.
• Discuss physical issues affecting OIF and OEF Veterans
• Discuss the mental health issues affecting OIF and OEF Veterans
• Discuss the importance of educating future nurses about the unique
clinical challenges and best practices associated with caring for
military service members, Veterans, and their families.
• Access the most up-to-date information as it relates to traumatic
brain injury (TBI) and psychological health conditions, such as posttraumatic stress disorder (PTSD).
VETERANS HEALTH ADMINISTRATION
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Operation New Dawn
(OND)
• September 1, 2010 marked the official end to Operation Iraqi
Freedom and combat operations by United States forces in
Iraq.
• During Operation New Dawn, the remaining 50,000 US service
members serving in Iraq will conduct stability operations,
focusing on advising, assisting and training Iraqi Security
Forces.
• Operation New Dawn also represents a shift from a
predominantly military US presence to one that is
predominantly civilian.
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Joining Forces Program
http://www.whitehouse.gov/joiningforces
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Joining Forces Program Objectives
• Educating America’s future nurses
• Enriching nursing education
• Disseminating the most up-to-date
information
• Growing the body of knowledge
• Leading and advancing the supportive
community of nurses, institutions, and health
care providers
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Joining Forces Program Facts
• Since September 11, 2001, more than
2 million US troops have been
deployed to Iraq and Afghanistan.
About 40% of current military service
members have been deployed more
than once.
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Joining Forces Program Facts
1.4 million active duty service members
14% of whom are women
1.1 million Guard and Reserve members
2.0 million spouses and children/
dependents of active duty service
members
44% of active duty service members have
children
76% of these children are age 11 and
younger
37% of families live on military installations,
the remaining 63% live in over 4,000
communities nationwide
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Joining Forces Program Facts
•
There are an estimated 22.2
million Veterans in the U.S.—
8% of whom are women.
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Joining Forces Program Facts
In the current conflicts, the military has experienced
• multiple redeployments
• short dwell time between deployments
• greater dependence on the National Guard and
reserve components
• deployment of high numbers of women and parents
of young children
• higher number of service members who survive
serious injuries that in previous wars would have
been fatal
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Joining Forces Program Facts
• The majority of returning service
members and their families are
resilient to the stresses of war and
successfully readjust to life after
deployment.
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Joining Forces Program Facts
•
About one in four U.S. service members
returning from Iraq or Afghanistan
experiences signs of combat stress,
depression, post traumatic stress disorder
(PTSD) or symptoms of a traumatic brain
injury (TBI).
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Joining Forces Program Facts
• Only 53% of returning troops
who screened positive for
PTSD or major depression
sought help from a provider
for these conditions in the
preceding year. Of those who
had PTSD or depression and
sought treatment only slightly
over half received adequate
treatment.
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Joining Forces Program Facts
• Only 57% of those
with a probable TBI
had been evaluated
by a physician for a
brain injury in the
preceding year.
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Joining Forces Program Facts
• Although 53% of recent Iraq and Afghanistan Veterans
receive their health care through the VA, many
Veterans and their families will seek care in
community settings from primary care and
community mental health clinicians.
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Joining Forces Program Facts
• Of recent Operation Enduring Freedom/Operation
Iraqi Freedom (OEF/OIF) Veterans who used VA care,
48% were diagnosed with a mental health problem
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Joining Forces Program Facts
• In the 5 years from 2005 to 2010, on average, one
service member committed suicide every 36 hours.
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Joining Forces Program Facts
• U.S. Army suicides reached an all-time high in July
2011 with the deaths of 33 active and reserve
component service members.
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Joining Forces Program Facts
• Mental and substance use disorders caused more
hospitalizations among U.S. troops in 2009 than any
other cause.
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Joining Forces Program Facts
• Children of deployed military personnel
have more school, family,
and peer-related emotional difficulties,
compared with national samples.
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Women Veterans
Not Your Traditional Veteran
The number of women Veterans is
growing rapidly, with increasing
demands for healthcare as well as
an influx of younger Veterans.
Since 2000, the number of female Veterans using the
VA health system has more than doubled, from nearly 160,000
(FY00) to more than 337,000 (FY11). This growth has outpaced
that of the male Veteran population.
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Women Veterans
Statistics
Today, women comprise approximately:
• 14% of all active duty military
• 18% of all National Guard and
Reserves
• 6% of VA health care users
55.5% of female OEF/OIF/OND Veterans
have received VA health care. Of this
group, 89.2% have used VA health care
services more than once.
VETERANS HEALTH ADMINISTRATION
Among women Veterans returning
from the current conflicts,
Operation Enduring Freedom,
Operation Iraqi Freedom, and
Operation New Dawn
• 79.6% are age 40 or below
• 51.5% are 30 or younger
Average age of VA users 2009
• Female Veteran=48
• Male Veteran=63
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Women Veterans
With the recent decision to allow
women in all areas of combat, the
numbers of women seeking
treatment will continue to rise.
Frequent Conditions Affecting Female
Veterans:
• Musculoskeletal conditions such as back
and joint pain
• Mental Health Conditions (including PTSD,
anxiety, depression)
• Military Sexual Trauma (1 in 5 female
Veterans responded yes when asked if
they experienced MST)
• Hypertension, diabetes, high cholesterol
TOP THREE MEDICAL CONDITIONS 2009/2010:
• PTSD
• Hypertension
• MST
VETERANS HEALTH ADMINISTRATION
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Military Health History
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General Questions
Are you a Veteran?
Tell me about your military service?
When and where do you/did you serve?
How has military service affected you?
If “YES” to the following, explore further
Did you see combat, enemy fire,
casualties?
Were you or a buddy wounded or injured?
Did you ever become ill while in the
service?
Were you a prisoner of war?
VETERANS HEALTH ADMINISTRATION
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Sexual Harassment, Assault and Trauma
Have you ever experienced physical,
emotional, or sexual harassment or
trauma?
Is this experience causing you problems
now?
Do you want a referral?
Hepatitis C Virus (HCV) Infection
Have you ever had a blood transfusion?
Have you ever injected drugs such as
heroin or cocaine?
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Military Health History
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Exposure Concerns
Were you exposed to chemical (pollution,
solvents, agent orange, toxic smoke),
biological (infectious disease), or physical
hazards (radiation, heat, vibration, noise)
What precautions did you take?
(avoidance, PPE, treatment)
How long was the exposure?
When and where were you exposed?
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Living Situation
Where do you live?
Is your housing safe?
Are you in danger of losing your housing?
Do you need help caring for dependents?
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Stress Reactions
Have you experienced anything so
horrible, frightening or upsetting that in
the past month you…….
Had nightmares or thought about it when
you did not want to?
Tried hard not to think about it or went
out of your way to avoid situations that
reminded you of it?
Were constantly on guard, watchful, or
easily startled?
Felt numb or detached from others,
activities, or your surroundings?
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Women Veterans Resources
http://www.va.gov/womenvet/
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General Military Issues
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Participant in experimental projects
Exposure to unusual or toxic substances
Blood transfusion prior to 1992
IV drug use (heroin or cocaine)
Homelessness
Sexual harassment, assault and/or trauma
Post Traumatic Stress Disorder
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World War II
• Veterans are dying at the rate of approximately 1500
per day
• Surviving Veterans have chronic diseases, similar to
those of the general population
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World War II Exposures
(September 1, 1939-September 2, 1945)
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Noise
Cold Injuries
Ionizing Radiation (“Atomic Veterans”)
Mustard Gas
Occupational Hazards—chemicals, paints and
machinery
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Korean War Exposures
(June 25, 1950-July 27, 1953)
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Cold Injury/Frostbite
Noise
Occupational Hazards
Asbestos
Industrial Solvents
Lead
Radiation
Fuels
PCBs
Vibration
CARC Paint
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Vietnam War Exposures
(November 1, 1965-April 30, 1975)
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Agent Orange or other Herbicides
Hepatitis C
Noise
Occupational Hazards
Asbestos
Industrial Solvents
Lead
Radiation
Fuels
PCBs
Vibration
CARC Paint
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Gulf War Veterans’
Medically Unexplained Illnesses
• Gulf War Veterans are plagued by unexplained illnesses
which are a cluster of medically unexplained chronic
symptoms that can include fatigue, headaches, joint pain,
indigestion, insomnia, dizziness, respiratory disorders and
memory problems.
• These clusters of vague symptoms are referred to as
“chronic multisymptom illness” and “undiagnosed
illnesses”.
• These symptoms have existed for 6 months or more and
appeared during active duty in the Southeast Asia theater
of military operations or by December 31, 2016.
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Gulf War I Exposures
(August 2, 1990-March 3, 1991)
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Vaccinations
Pyridostigmine Bromide (PB)
Oil Well Fires, Smoke and Petroleum
Pesticides
Chemical & Biological Weapons
Sand, Dust and Particulates
Depleted Uranium
Toxic Embedded Fragments
Noise
Infectious Disease
CARC Paint
Heat Injuries
Occupational Hazards
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Iraq War Exposures – Operation Iraqi Freedom
and Operation New Dawn
(March 19, 2003-December 15 2011)
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Sand, Dust and Particulates
Burn Pits
Infectious Diseases
Depleted Uranium
Toxic Embedded Fragments
Noise
Traumatic Brain Injury
Rabies
Mefloquine - Lariam®
Heat Injuries
Sulfur Fire
Chromium (Qarmat Ali)
Occupational Hazards
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Operation Enduring Freedom Exposures
(Afghanistan)
Operation Enduring Freedom (October 7, 2001-present)
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Sand, Dust and Particulates
Burn Pits
Infectious Diseases
Depleted Uranium
Toxic Embedded Fragments
Noise
Traumatic Brain Injury
Rabies
Mefloquine - Lariam®
Heat Injuries
Cold Injuries
Occupational Hazards
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Mental Health Issues affecting
Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF)
Posttraumatic Stress Disorder (PTSD)
• Previously known as “Soldier’s Heart,” “Shell Shock,” “Combat Fatigue”
• Symptoms
• Re-experiencing—feeling the same fear and horror previously
experienced during a traumatic event; sometimes triggered by a sound,
site or smell
• Avoidance and numbing—trying hard to avoid things that might remind
a person of the traumatic event endured, such as crowded places,
places where there are too many choices (shopping malls), certain types
of terrain (hot, dry places); acting numb to effects of the distress
• Hypervigilance or Increased Arousal—operating on continuous high
alert, having a “short fuse,” startling easily, having sleep problems,
anger and difficulty concentrating
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Mental Health Issues affecting
Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF)
Posttraumatic Stress Disorder (PTSD)
• Factors contributing to PTSD—what makes the person
more likely to get PTSD?
• Severity of the trauma
• Injury sustained
• Intensity of reaction to the trauma
• Death or injury of someone close to the veteran
• Threat to life
• Lack of control
• Help and support following the event
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Mental Health Issues affecting
Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF)
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Depression
Suicidal Thoughts and Suicide
Violence and Abuse
Substance Abuse
Concussions or Mild Traumatic Brain Injury (mTBI)—
several symptoms parallel those of PTSD
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Chronic Pain as a Continuing Problem
for the Veteran
• Study of 340 OEF and OIF Veterans showed 81.5% experienced
chronic pain
• Over 48,000 deployed service members have been wounded in
action while serving in OEF and OIF
• Blast related injuries account for 65% of combat injuries
• 50% to 79% of combat injuries are traumatic extremity
injuries—amputations, mangled leg or arm injuries
• Among OIF and OEF Veterans sustaining traumatic limb loss,
62.5% have residual limb pain and 76% have phantom limb
pain
• Nearly 90% of OEF and OIF service members survive their
injuries, compared with 76% survival rate in Vietnam
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Chronic Pain as a Continuing Problem
for the Veteran
• Polytrauma patients experience the “3Ps”—chronic pain, PTSD and
persistent postconcussive symptoms
• Postdeployment multisymptom disorder has been identified to address pain
clustered with PTSD, mild TBI, PTSD with mild TBI, or substance abuse in
patients with polytrauma
• Multimodal treatments for optimal pain management can include:
• Pharmacologic treatments
• Psychological treatments
• Physical and occupational therapies
• Procedural treatments
• Use of complimentary and alternative medicine (CAM) practices are also
being seen more frequently in the management of pain
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Nursing School Commitment
• Over 500 nursing schools in all 50 states, DC, and
Puerto Rico have committed by 2014 to:
• Educating America’s future nurses to care for our
nation's Veterans, service members, and their
families facing post-traumatic stress disorder,
traumatic brain injury, depression, and other
clinical issues;
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Nursing School Commitment
• Over 500 nursing schools in all 50 states, DC, and
Puerto Rico have committed by 2014 to:
• Enriching nursing education to ensure that current
and future nurses are trained in the unique clinical
challenges and best practices associated with
caring for military service members, Veterans, and
their families;
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Nursing School Commitment
• Over 500 nursing schools in all 50 states, DC, and
Puerto Rico have committed by 2014 to:
• Integrating content that addresses the unique
health and wellness challenges of our nation’s
service members, Veterans, and their families into
nursing curricula;
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Nursing School Commitment
• Over 500 nursing schools in all 50 states, DC, and
Puerto Rico have committed by 2014 to:
• Sharing teaching resources and applying best
practices in the care of service members, Veterans,
and their families;
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Nursing School Commitment
• Over 500 nursing schools in all 50 states, DC, and
Puerto Rico have committed by 2014 to:
• Joining with others to further strengthen the
supportive community of nurses, institutions, and
healthcare providers dedicated to improving the
health of service members, Veterans, and their
families.
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Veteran Eligibility
• Eligibility is based on a number of factors:
– Years of service
– Combat service
– Service connected disability
– Exposure (agent orange, radiation,……..)
– Income
– Service in recent conflicts
• www.va.gov/healthBenefits/resources/eligibility_check.asp
• 1-877-222-VETS(8387)
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OEF/OIF/OND
Combat Veterans who were discharged or released from
active service on or after January 28, 2003, are eligible
to enroll in the VA health care system for 5 years from
the date of discharge or release.
Veterans, including activated Reservists and members of
the National Guard, are eligible if they served on
active duty in a theater of combat operation after
November 11, 1998.
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OEF/OIF/OND
Benefits:
Medical care and medications provided for conditions potentially
related to combat service
Full access to VA’s Medical Benefits Package
Limited Dental Care
Benefits are based on a priority rating, groups 1-8.
Certain Veterans may be eligible for more than one Enrollment
Priority Group. The Veteran will always be placed in the
highest Priority Group for which he/she is eligible.
Under the VA Health Benefits Package, the same services are
generally available to all enrolled Veterans.
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References
American Nurse Today: special report war on pain. September 2011
Defense Manpower Data Center Data, Analysis and Programs National Center
for Veterans Analysis and Statistics, Veteran Population Projection Model
(VetPop) 2012
Returning Home from Iraq and Afghanistan: preliminary assessment of
readjustment needs of veterans, service members and their families. 2010.
Institute of Medicine
National Center for PTSD. Mental health effects of serving in Afghanistan and
Iraq. http://www.ptsd.va.gov/public/pages/overview-mental-healtheffects.asp
Losing the Battle: the challenge of military suicide. Center for a New American
Security. October 2011
Chandra, A., Lara-Cinisomo, S., Jaycox, L. H., et al. (2010). Children on the
homefront: The experience of children from military families. Pediatrics,
125, 16–25.
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References
Center for Women Veterans www.va.gov/womenvet
Special Environmental Health Registry Evaluation Programs for Veterans.
www.publichealth.va.gov/exposures
Public Health World War II Exposures.
www.publichealth.va.gov/exposures/wars-operations/ww2.asp
Public Health Korean War Exposures.
www.publichealth.va.gov/exposures/wars-operations/korean-war.asp
Public Health Vietnam War Exposures.
www.publichealth.va.gov/exposures/vietnam-war.asp
Public Health Operation Enduring Freedom Exposures.
www.publichealth.va.gov/exposures/wars-operations/oef.asp
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References
Public Health Iraq War Exposures. www.publichealth.va.gov/exposures/warsoperations/iraq-war.asp
Seahorn, J. J.,Seahorn, E. A. (2010). Tears of a warrior: A family’s story of
combat and living with PTSD, 2nd ed. Fort Collins, CO: Team Pursuits
Slone, L. B., Friedman, M. J. (2008). After the war zone: A practical guide for
returning troops and their families. Philadelphia, PA: Da Capo Press
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