Thursday, June 24, 2010







Today Megan McCloskey (Stars and Stripes) reported that the National Intrepid Center of Excellence opened today at Bethesda. The military and assorted generals are attempting to claim credit for it but McCloskey points out, "The $65 million to build the center came from 125,000 Americans, including donations as small as $10. The project broke ground in December 2008. When the Intrepid fund was in danger of missing its fundraising mark this spring, Bob Barker of The Price is Right fame stepped in and donated $3 million." So the government didn't shoulder the cost, no military weapons went unpurchased in order to put the wounded first. And that's not the only problem with the center. TBI and PTSD were discussed on the first hour of The Diane Rehm Show today and we'll note this on the new center.
Daniel Zwerdling: The troubling questions I have about this center include these, there are -- my investigations at NPR and with T. Christian Miller of ProPublica showed that there are tens of thousands of troops who have -- perhaps more -- who have had Traumatic Brain Injuries who have not been diagnosed, many of them have not had proper treatment so when you talk about sending only 500 a year to this center, that's only a drop in the bucket. Second of all, this new center is not going to treat these folks. It's going to evaluate them over two weeks and then it's going to send them back to the military bases from which they came. And one thing we found in our investigation which is quite troubling is that many of these bases do not have adequate staff to treat Traumatic Brain Injury, they don't have staff occupation therapists or doctors who have really been trained to treat Traumatic Brain Injury so, the center is going to send troops back to the bases where they've been having problems. So, yes, it's a great step but a lot of questions still.
With T. Christian Miller, Zwerdling is the author of the joint-investigative reporting by NPR and ProPublica. Click here for one audio report at NPR and, on that page, there are links for other reports in the series. You can click here for ProPublica's folder for the (text) reports from the investigation. Since generals are not doctors and since they couldn't stop spinning and lying to the Senate Armed Services Committee this week (See Tuesday's snapshot and Wednesday's snapshot), let's note this section where Diane's speaking to Dr. Gergory O'Shanick, Zwerdling and Dr. S. Ward Casscells.
Diane Rehm: Dr. O'Shanick, let me ask you brain injuries and how they actually occur.
Dr. Gregory O'Shanick: Diane, good to be back with you.
Diane Rehm: Thank you.
Dr. Gregory O'Shanick: And I appreciate the comments of Mr. Zwerdling and Dr. Casscells'. Brain injuries occur whenever there is a force imparted to the head or body that results in either a direct blow to the head or what we call an acceleration-deceleration injury to the brain -- that is, if you think about the brain being about the consistency of Jello, if you shake a bowl of Jello, you'll see the motion bounce -- the force wave bounce across the bowl. That process involves straining the appendages if you will, the arms of the brain cells called axons and can cause a tearing of those in terms of the function or, in the case of mild Traumatic Brain Injury, causes a series of changes in terms of how the brain cell handles sugar and oxygen -- the two things that it uses -- which then results in a disolving -- fairly similar to what happens to a tadpole's tail. A disolving of that appendage over time. These two processes then result in what is called Diffuse Accidental Injury which is really the hallmark of Traumatic Brain Injuries -- mild, moderate or severe. .
Diane Rehm: And --
Dr. Gregory O'Shanick: In addition --
Diane Rehm: I'm sorry, go right ahead.
Dr. Gregory O'Shanick: Yeah, in addition, you can have focal contusions or bruises to the brain from the brain bouncing inside. We also know the pressure wave associated with blast inury creates a change in terms of whenever there's different densities -- whether it's liver, whether it's lung, even within the brain, we'll see a change in terms of the tissue in those areas as well.
Diane Rehm: And I gather, Dr. Oshanick and Daniel Zwerdling, that many of these brain injuries are caused by the explosion of IEDs.
Daniel Zwerdling: Well the extraordinary thing is, I never knew before I undertook this investigation, is that a blast wave -- First of all, you can see it. Troops have told me they saw the wave coming almost like something in a horror film. These ripples coming through the air and through the soil. And those blast waves go through metal, they go through your helmets, they go through skulls, they go through the brain. And here's what this means for the soldiers who come home based on the soldiers we've met around the country and at Fort Bliss where we talked with more than a dozen soldiers: A soldier named Victor Medina comes home. This is a guy who was in a blast a year ago. He, uh, speech is slurred. He stutters terribly which is not a terribly common side effect but is a side effect of Traumatic Brain Injury. He goes to the supermarket with his wife. He suddenly disappears. She goes looking all over the supermarket for him and when she finds him, he says, "Hey, when did you get here?" He has totally forgotten that they came together. He used to devour novels, now he reads a page -- struggles to read a page -- and then forgets what he said. Or Brandon Sanford who was in two blasts in Iraq. He had a dog that sniffed out bombs. He used to help his little boy with his homework. Now his son is ten, he cannot comprehend his son's homework. Or William Frost who got a Bronze Star With Valor, who helped save a bunch of Iraqi troops and his major. He now -- He was driving one day and realized, "Oh my God, I can't drive anymore." He just couldn't put it together. He couldn't wrap his brain around what it means to drive so he gave his keys to his wife. So these -- Even when you call these injuries mild Traumatic Brain Injuries, you know, you can't see blood, there's no broken bones, this can cause a huge problem for years or for the rest of the person's life.
Diane and her panel spoke of how the thrust of care is forced off onto the service member or veteran and/or his/her family. That's The Wounded Veterans and Service Members Story This Decade, isn't? Attend any Congressional hearing where veteran and service member advocates testify, speak to any number of veterans and you find that receiving care is a full time job and that hasn't changed, the system hasn't streamlined. You can throw as many generals before the public as you want -- with so many bars and stripes they look like human Christmas trees -- and they can spin like crazy but they cannot change reality. For the second half of the first hour, Diane opened up the phone lines to her listeners. We'll note Marlene from Ohio.

Marlene: My son was in Iraq for 15 months and directly effected by two IED explosions -- with shrapnel to his head. He continues -- my son continues to say everything is fine. But two weeks ago, the bank repossed his car. He had been faithfully paying on this car prior to his diagnosis of PTSD. Now, as the Mom and the next of kin, I was not able to assist in any way. The bank would not work with my son other than to demand the total payment of the balance. There was no bailout for this soldier. Now I as the Mom had no right to advocate on his behalf. I called my Congressman, the military and who ever else I thought could help. My question is: Who does advocate for these soldiers?
"Of the nearly eight million veterans who are enrolled in the VA health care system, about three million are from rural areas," declared US House Rep Michael Michaud as he brought the House Veterans Affairs Subcommittee on Health's hearing to order this morning. "This means that rural veterans make up about 40% of all enrolled veterans. For the 3 million veterans living in rural areas, access to health care remains a key barrier, as they simply live too far away from the nearest VA medical center."
Chair Michaud and the Subcommittee were exploring the barriers to providing health care to rural veterans. There were four panels. The first panel was composed of West Wireless Health Institute's Dr. Joseph Smith, the Brookings Institution's Darrell West and The Healthy Applachia Institute's David Cattell-Gordon. AirStrip Technologies' Dr. Wililam Cameron Powell, Continua Health Alliance's Rick Cnossen, MedApps, Inc's Kent Dicks, Cogon Systems Inc's Dr. Huy Nguyen, Three Wire System's Dan Frank and LifeWatch Service's John Mize composed the second panel. The third panel was FCC's Kerry McDermott, DoD's Col Ronald Poropatich, VA's Gail Graham. Lincoln Smith, of the Altarum Institute, was the fourth panel.
The rural health care, it is argued, will be improved through telecommunication systems via computers and telephones and various monitors attached to the body. We'll note this exchange from the first panel.
Chair Michael Michaud: I have a quick question, actually, for all three. I assume that all three of you, from your testimony, believe that there is a great opportunity for the VA to move forward in this wireless health solution. So my question is, is what steps should the VA, FCC and FDA take to clear the way for this new type of technology? We'll start with Dr. Smith -- keeping in mind that some states like Maine and other states are very rural and we might not have the broadband that we need for this type of technology. So start with Dr. Smith.
Dr. Joseph Smith: So I think it starts with assuring the wireless infrastructure is present. I think that to the extent that we can avoid the health care delivery system being centered in hospitals and clinics and move it to being centered in patient's homes where they can be appropriately monitored with- with relatively low sophistication devices and that information be liberated from their homes and their bedsides to caregivers independent of their location, I think that's critical. I think for the -- To achieve the great value, that you speak of and the opportunity that's in front of us, we have to make sure that the regulatory and the reimbursment path for the innovators who are on the front door making these things is quite clear to them. And, at the moment, it is clearly not clear. At the moment, there is great concern that aspects of the system including the handsets, you know, the wireless handsets or, in fact, the telecommunications companies can be part of an FDA regulated concept of a medical device or that they can be the target for the plantiff's bar in the event of some untoward event. And that those concerns are chilling the engine of innovation that could deliver the techonologies that matter so much. And then I think lastly, we need to incentivize the appropriate use of this technology once it's available and that's not so simple as to say, "They are available." It is to provide the appropriate incentives for appropriate use. Because I think, as the VA program has demonstrated, there's dramatic cost savings in quality improvement and satisfaction of the patients' waiting -- and they are waiting. And what we need to do is make sure that we incentivize the use. You know, the Institute of Medicine has told us it can take 16 years from the time novel technology has proven to be useful to the time it's fully adopted and patients are waiting.
Darrell West: Mr. Chairman, I'd like to address the Food and Drug Administration part of your question because I think, in general, the VA has made tremendous progress on encorporating new technology. There's still work to be done, but they are ahead of many of their parts of society but the FDA, I think, has a problem in the sense that the policy and regulatory regime is way behind the technology. The FDA plays a role in certifying new devices that come on the market and I think, especially, the pace of technology and innovation has been very intense and very rapid in recent years -- the remote monitoring devices that I've been talking about, some of the new apps that have been developed for smart phones. The FDA needs to revamp it's regulatory review process to speed up the approval of these new innovations because there are tremendous new devices that are coming on to market but it's been a slow process to get approval of many of those things so if there is one specific thing that I would recommend, it would be taking a close look at the FDA and encouraging it do all that it can to speed up its certification and review process.
David Cattell-Gordon: I would very much agree with the points my colleagues have made concerning this and further say that the VA is the leader. You guys wear that mantle of leadership in the nation and you need now, because now is the time, I think for us to continue to debate this subject as to whether or not this is an effective capability, we're way beyond that. The data is overwhelming whether you look at what we do with Traumatic Brian Injury and reminders for appointments, whether we look at how we monitor a veteran with diabetes to lower that A1C and prevent blindness and follow their care or whether it's a weight loss program, the evidence is overwhelming. So we know that that's true. So now it is about adoption and we have to push that across the government at a lot of levels -- whether it's the defintions of rurality, whether it's encouraging and incentivizing investments by health systems to use this, rural veterans use a variety of health systems so we have to integrate that, we have to intergrate their VA records into health care. There are a lot of things we need to do and I would just encourage that the most important thing we can do is act now.
Let's take a breath.
Woman beaters
and Huck Finn shucksters
hopping parking meters
I never loved a man
I trusted
as far as I could pitch my shoe
-- "Lucky Girl," written by Joni Mitchell, first appears on her Dog Eat Dog album
Huck Finn shucksters. That's what the panel had. With the Gulf Disaster continuing, who the hell really wants to advocate for loosening regulations? And to do it on something as important as health care?
We're told by the panel that diabetes can be monitored via these 'new' devices. Uh, it is already. Anyone who knows a diabetic knows all about the test strips and checking blood sugar. What are a few body monitors going to do? And weight loss? Are we confusing Jenny Craig with actual health care?
'Things must move and must move quickly!!!!' That was the message. Did you notice that -- doctor or not -- everyone testifying (plus VA stooges) was testifying on behalf of . . . their own financial interests. There were no doctors present testifying on the value of this or the ethical issues that might arise. It was just a bunch of Huck Finn shucksters who want to make a buck and they're offended that the FDA makes them do this and that and -- Well everything the FDA has always made people do to get approval.
There was nothing listed in the hearing that was, for example, a cure for cancer. Meaning, nothing was earth shattering. There was nothing that couldn't go through a traditional FDA process. The FDA exists, at least allegedly, to ensure the public good. Things need to be checked out by the FDA. Again, no one's promising a cure for cancer. Just a few mobile devices that they hope to market. Basically, they've got this decades beepers and they want to bypass the normal process because they're hungry to make a fast buck.
This hearing pointed out a very real flaw in Congress' hearings. They need to bring in people, doctors, on health issues to be witnesses. Not doctors who have a company on the side that wants to sell this or that. An objective doctor who can say, "Wait, why are we whining about the FDA? Of course we want to prove that these devices are safe and that they actually do what they're portrayed as doing." Hucksters. They may honestly believe in their product -- I have no reason to doubt that they do -- but what does it do? What does it actually do? How does this improve anything for veterans health care?
US House Rep Tom Perriello raised the issue of suicides and drug addiction concerns -- "to what extent does the telemedicine and some of the techonology run the risk that we're not seeing some of the signs or screenings from people being physically present or is this an opportunity because we're going to be able to monitor -- what kind of a dynamic do you see between the technology and that particular problem?"
That's a fairly straightforward question. Let's make it real simple: Will telemedicine cut out the face-to-face factor that would normally allow a greater chance of telling if a veteran needed help with a drug problem or with suicidal thoughts/actions?
Try to find the answer in the pitch that's delivered -- and I'm including every word that was supposedly a reply to a direct question -- and Perriello asked this question directly to -- and only of -- Cattell-Gordon.
David Cattell-Gordon: I'm very proud of the fact that we have psychologists at U VA, Dr. Larry Merkle who has done extensive review of rural issues and suicide. The numbers are overwhelming. You look at the Virginia Dept of Health, you look at rural areas -- in particular, you look at the coal fields of Virginia, the suicide rate is twice that of what it is of the state as a whole. And then you look at issues like fatal, unintentional overdoses from addiction to pain medications the mortality rate in the coal fields of Virginia is 40 deaths per 100,000 adjusted as opposed to 8.3 deaths for the rest of the state. These are huge problems. The level of disability. The lack of access to care. Uhm, the isolation that people experience in rural areas create a perfect storm of problems for mental health issues. Then you add to that the absence of practitioners, there are just way too few practitioners and they are going to be even greater shortages in primary care and mental health care folk for this region and for our vets and everyone else. So telehealth and the use of wireless capabilities become a key tool to reduce isolation to send reminders -- Just the appointment reminders alone -- and this has been a VA study -- to look at folks with Traumatic Brain Injury and reminders over the cell phone for their appointments and daily contacts has dramatically changed the number of people who show for their appointments. Those small things will add up to the large indicators about how we can address mental health issues in rural areas.
That doesn't address the question. And why he's bringing in non-military rural populations? Because he doesn't know the answer. So he's at length and never answers the damn question. Never. Wow. An alarm clock will help many wake up in the morning. And apps on a cell phone can be used as reminders for appointments. What does this have to do with health care? Gizmos aren't health care.
And Dr. Merkel? I don't know him. I asked around to find out about his expertise on veterans issues and was told repeatedly -- by medical doctors who study and treat veterans -- that he has none. He's apparently very big on adolescent health (an important issue) but he's not an expert on veterans issues. Why is he being name checked? Oh, that's right, it's a sales pitch. It's not about veterans issues, it's about making a sales pitch. Got it.
Senator Kent Conrad has issued a statement (which Senator Daniel Akaka's office kindly passed along):

Washington -- In an effort to bring greater attention to Post Traumatic Stress Disorder (PTSD), the United States Senate last night passed a resolution authored by Senator Kent Conrad designating June 27 as National PTSD Awareness Day.

"The stress of war can take a toll on one's heart, mind and soul. While these wounds may be less visible than others, they are no less real," Senator Conrad said. "All too many of our service men and women are returning from battle with PTSD symptoms like anxiety, anger, and depression. More must be done to educate our troops, veterans, families and communities about this illness and the resources and treatments available to them."

The Senator developed the idea for a National PTSD Awareness Day after learning of the efforts of North Dakota National Guardsmen to draw attention to PTSD and pay tribute to Staff Sgt. Joe Biel, a friend and member of the 164th Engineer Combat Battalion. Biel suffered from PTSD and took his life in April 2007 after returning to North Dakota following his second tour in Iraq.

Earlier this month, Senator Conrad visited the Fargo VA Medical Center and met with physicians and social workers to discuss their capabilities for helping those suffering from PTSD. He also met with friends of Sgt. Biel and presented them a copy of the resolution designating June 27 -- Biel's birthday -- as National PTSD Awareness Day.

According to the National Institute for Mental Health, PTSD is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, accidents, and military combat. From 2000 to 2009, approximately 76,000 Department of Defense patients were diagnosed with PTSD.

"This effort is about awareness, assuring our troops -- past and present -- that it's okay to come forward and say they need help. We want to erase any stigma associated with PTSD. Our troops need to know it's a sign of strength, not weakness, to seek assistance," Senator Conrad said.

To learn more about PTSD and locate facilities offering assistance, visit the U.S. Department of Veterans Affairs' National Center for PTSD at

Veterans in need of immediate assistance can call the VHA Suicide Hotline at 1-800-273-8255 and press 1.

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