Feature Story
In a World of Medical Miracles, VA Hospitals Rise to the Challenge
By Doug Childers

In one area, though, the two wars are strikingly different.  While more than 58,000 American soldiers died in the decade-long conflict in Vietnam, 3,735 American soldiers have died in four years of fighting in Iraq, with an additional 27,662 wounded.  (Iraq casualty figures are current as of August 31, 2007.)

US Marines of the 1st Division pass by a wall painting of an Iraqi Army soldier during training in a former Iraqi army barrack outside Fallujah, Iraq.

The reasons for the lower number of U.S. military deaths in Iraq are multiple.  Improved medical care in the field helps reduce combat deaths today, for example.  Some wounds that might have proved mortal 35 years ago are now survivable because of the prompt care provided by sophisticated medical field hospitals, along with rapid transport to more advanced care at Landstuhl Regional Medical Center, an American military hospital in Germany.

“There have been soldiers with penetrating brain injuries who have survived because they can get medical treatment almost immediately,” said Linda Riffel, RN, associate chief of nursing for mental health at VA Medical Center Salem.  “In Vietnam, they wouldn’t have made it back to a medical treatment facility in Germany.”  Riffel said this is true of amputations as well:  “Twenty years ago, they would have bled to death.”  Now, soldiers go from “sophisticated treatment in the field to a sophisticated hospital in a matter of hours.”

The protective gear worn by American soldiers today offers better protection as well, although it doesn’t shield them completely from some of the Iraq war’s most traumatic injuries.  Riffel said the widespread use of improvised explosive devices in Iraq has led to more traumatized brain injuries than U.S. soldiers received in Vietnam, for example. “We’re seeing a lot of traumatic brain injuries from those blasts.”

In fact, brain injuries combined with life-threatening injuries are one of the unique signatures of the Iraq war, according to William Gregg, nurse manager for Hunter Holmes McGuire VA Medical Center in Richmond.

“We’re now finding that if you’ve been in the neighborhood of a blast, you may have a minor or moderate injury to your brain” that initially goes undiagnosed, Riffel said.  The injured soldiers “come into mental healthcare and talk about anger, memory loss and personality changes.  Road rage can be the result of a brain injury.  They didn’t even realize they’d been injured.”

The combat death rates for U.S. soldiers have dropped steadily in American wars.  In an article published in the Dec. 9, 2004 issue of the New England Journal of Medicine, Atul Gawande noted that while 30 percent of U.S. soldiers wounded in the Second World War died from their injuries, 24 percent of soldiers wounded in the Vietnam War died from their injuries.  From 2001 to 2004  (the scope of Gawande’s article), the mortality rate for wounded U.S. soldiers in Iraq and Afghanistan was about 10 percent.

Gregg said today’s higher survival rates make the rehabilitative work done at VA hospitals more challenging.  “But it’s more rewarding because we’re seeing them go home.  You have to think outside the box when working with these patients – like teaching wound care to someone who is blind, for example.  We have to have more patience and try different things.”

Soldiers whose wounds are serious enough to require extended treatment are transferred from Landstuhl Regional Medical Center to one of three medical facilities in the U.S.: Walter Reed Army Medical Center in Washington, D.C., Brooke Army Medical Center in Fort Sam Houston, Tex., or Bethesda National Naval Medical Center in Bethesda, Md.

“Then they are assessed and treated, this may be surgery or initial stages of rehabilitation,” Gregg said.  “Then they can go back or go to a polytrauma center if they need more rehabilitation.”

The 20-bed polytrauma center at McGuire VA Medical Center is one of four such centers in the U.S.  The others are in Tampa, FL, Palo Alto, CA, and Minneapolis, MN.  All four inpatient centers have had acute rehabilitation programs for several years.  McGuire’s polytrauma center has 17 registered nurses, 10 licensed practical nurses, three nurse assistants, a medical director and residents from Virginia Commonwealth University’s School of Medicine. 

The patients the center treats have one life-sustaining injury and at least one other injury – like a brain injury and an amputation, for instance.  But the range of injuries is broad.

“On one end, we see mild brain injuries – severe headaches, confusion, poor memory; they don’t look injured, but they can’t function,” Gregg said.  “On the other end, we see penetrating brain injuries.  They sometimes come here in comas.  We also see a lot of amputations and multi-limb injuries, spinal cord injuries and post-traumatic stress disorder (PTSD).  We don’t see a lot of substance abuse or depression initially.  We see it later on in our outpatients.  It’s a way of coping.”

Among the services offered in the polytrauma center are occupational therapy, physical therapy, speech therapy and psychological treatment.  Gregg said that treating Vietnam veterans for PTSD in the past has improved the care offered to today’s war-wounded.  He also pointed out that the Veterans Administration does not limit capacity at the polytrauma center because “it feels it has an obligation to help with these patients.  We’ll go above and beyond to make sure these patients’ needs are met.” 

To date, the center has treated 250 soldiers wounded in Iraq.  They may stay as little as two weeks, although some have stayed as long as 10 months.

“We transition them once they’re medically stable, and we transfer them to other VA hospitals,” Gregg said.  “Those are level-two sites – they offer outpatient rehabilitation.”

In addition to McGuire VA Medical Center, which offers outpatient services, Virginia’s two other VA hospitals offer outpatient rehabilitative services:  VA Medical Center Salem and VA Medical Center Hampton.  Most of their patients are veterans, but some are still active-duty soldiers.

Riffel said the Salem medical center has not been overwhelmed by the number of wounded soldiers they’re treating.  “No matter what, if they come here to us, we bend over backwards to make sure they get the care they want and need.  They will be seen in a 30-day time frame.  If an Iraq veteran wants to see us today, I can make that happen.”

The Salem facility, which has about 80 doctors and 525 nursing staff, has 1,400 Iraq war veterans registered for care, but that doesn’t represent the number of veterans receiving care there.

“These guys are often reservists or National Guard, so they have medical services in the community” through their employer’s medical plan, Riffel said.  “They register here in case they need to use us down the road.  Iraq veterans get two years of free service.”

While Riffel said the Salem facility offers most medical procedures (except for neurosurgery and more complex cardiac surgery), she pointed out that most patients are stabilized by the time they reach Salem.

“We rarely have any hospitalized here,” she said.  “If so, it’s a recurrence or exacerbation of their injury.  It’s mostly outpatient services for Iraq veterans.  The Army won’t discharge them until they’re healed – then we take over when they’re veterans.  We only have one Iraq veteran in-house” (right now).

The injuries that the Salem facility is treating in Iraq veterans range from traumatic amputations and traumatic brain injuries to PTSD, depression and substance abuse.

Sometimes, the facility’s assistance can be fairly simple.  Riffel recalled one active-duty soldier who visited the Salem medical center on convalescent leave.  He had received treatment for an amputated foot at Walter Reed, which had given him a customized wheelchair.

“He even picked the color – metallic red,” Riffel said.  “It almost looked like a motorcycle.”

Soon, she received a phone call:  the soldier couldn’t maneuver the wheelchair through his house. 

“It was a beautiful wheelchair, but it wasn’t useful to him,” Riffel said.  “It could go through doors because it was collapsible, but once he opened it, he couldn’t navigate his home.  We got him a new wheelchair that was almost as nice.”

Since receiving care at the Salem medical center, the man has transitioned out of the military.  He is married and lives in Northern Virginia.

“He has gotten a job and transitioned into the community nicely,” Riffel said.  “He continues to check in with us on different things.  He wants to help other veterans like him.”

Seeing lives put back together is one of the joys of offering rehabilitative services to wounded soldiers and veterans.

“We have a dedicated nursing staff here,” Gregg said.  “They go above and beyond on a daily basis.  There’s an emotional component to this treatment.  They take care of their patients’ families as well.”  A lot of the patients are young fathers and husbands, and the nurses work closely with them and their families, he pointed out.  “It’s nice to see the men with their families, who will continue to assist them in their transition home.”