Chicago Sun-Times....

Long-term care a challenge for soldiers

December 5, 2004

BY LORI RACKL HEALTH REPORTER





In World War II, for every soldier killed in combat, there were three wounded on the battlefield, according to historians with the U.S. Army Medical Command. In Korea, the ratio of killed-to-wounded was one to four. The ratio was the same for Vietnam. In Iraq, the ratio is one to 12.

"If they're alive when medical care gets to them, 98 percent are surviving," said Dr. Michael Kilpatrick, one of the top medical officers for the assistant secretary of defense for health affairs.

Those combat survivors -- along with thousands more service members in Iraq and Afghanistan who are injured or who fall ill off the battlefield -- will add to the growing demand for services from an already struggling federal Veterans Affairs Department. The Sun-Times reported Friday that the VA's regional office in Chicago is among the stingiest in the nation when it comes to deciding how much to pay disabled Illinois vets.


ABOUT THE SERIES
Wounded warriors
The Chicago office of the federal Veterans Affairs agency consistently awards less disability pay to disabled vets than do VA offices elsewhere. With more wounded soldiers surviving today, the problem is likely to get worse as more return from Iraq, reporters Cheryl L. Reed and Lori Rackl found.
PHOTO GALLERY
• Gabe Garriga, burned in Iraq
CHARTS
Illinois vets each receive thousands of dollars a year less in disabilty pay, on average, than vets from other states and U.S. territories.
• Veteran Affairs average annual amount per veteran for disability
• How Illinois compares to other states

As the growing ranks of the wounded from Iraq and Afghanistan leave the military, they will be ready to apply for health care and disability benefits from the VA. The question is: Will the VA be ready for them?

Not likely, said Rep. Lane Evans (D-Ill.), the ranking Democrat on the House Committee on Veterans Affairs.

"We'd better be prepared for the people coming back home, and I don't think we are," Evans said. "The resources are simply inadequate."

Last year, the VA temporarily stopped certain veterans from enrolling for health care because demand was too high. Claims for disability benefits also are on the rise in Illinois, while the staff to process those claims has shrunk.

"The VA would have a problem keeping up even if the war weren't going on," said Joe Violante of the Disabled American Veterans in Washington, D.C.

Body armor saves lives
Shortly before Garriga's life would change forever on July 14, 2003, the Illinois National Guardsman was manning the machine gun in his Humvee. A suspected suicide bomber had just driven past a checkpoint. When Garriga's vehicle tried to block the car, it rear-ended another Humvee with fuel cans tethered to the back. The crash sparked an explosion. Garriga landed right in the middle of it.

Burns scorched the soldier's arms and legs but largely spared his torso -- a familiar pattern among the wounded in Iraq. Experts credit the military's new body armor, which shields the torso's vital organs. Made of Kevlar and ceramic plates, the Interceptor body armor can stop a high-velocity round from an AK-47 that would've torn through vests worn by troops in Vietnam.

"There have always been flak jackets," Kilpatrick said. "But we're having people survive being hit with rocket-propelled grenades or improvised explosive devices because the body armor has protected the torso. In the past, these individuals would have died."

Soon-to-be-published trauma data suggest the extent to which the $1,585 body armor is making a difference. Of 598 soldiers treated at the 31st Combat Support Hospital in Baghdad, 14 percent suffered injuries to the torso. Among Iraqi prisoner patients, the rate was nearly twice that, at 27 percent.

"The body armor has probably had a very real effect, cutting in half the number of chest and abdomen injuries," said Col. John B. Holcomb, commander of the U.S. Army Institute of Surgical Research at Fort Sam Houston, Texas.

The war on terror has seen the debut of several tools aimed at the same goal: stopping the bleeding -- the leading cause of preventable death on the battlefield. Holcomb saw firsthand the need for better hemorrhage control during his stint in Somalia, where several Army Rangers and Special Operations soldiers bled to death on the streets of Mogadishu in 1993.

"We came back and started working on better ways to stop bleeding," said Holcomb, whose surgical research center is the starting point for many of the medical advances that make their way to war zones. "We've now fielded five or six new products since that time."

Some injured troops are being treated with Quick Clot, a powder sprinkled on wounds to staunch bleeding. Other wounds are dressed with pricey new bandages that greatly speed up clotting. This also marks the first war in which soldiers carry tourniquets that can be applied with one hand.

Race against the clock

All doctors who deal with trauma -- whether they're based on a battlefield in Iraq or an E.R. in Chicago -- know the importance of treating victims within that "golden hour" after injury.

This was no easy feat in past wars, when wounded troops had to travel lengthy distances from the front line to a field hospital or mobile army surgical hospital, or MASH. Now the military is dispatching smaller, highly mobile surgical teams much closer to the action.

"We're there to do damage-control surgery -- fix gunshot holes and bleeding arteries -- and then send them off as soon as we can to a combat support hospital," said Dr. Scott Gering, part of a "forward surgical team" in Kuwait and Iraq. "We can stop and set up an O.R. in 25 minutes. Having a bunch of surgeons that far forward definitely saves lives."

The percentage of those wounded in action who die after being seen by a physician -- a good barometer of how well military medicine is working -- has never been lower.

During the Iraq war, only 1.8 percent of soldiers hurt on the battlefield have died despite doctors' efforts. In World War I, before antibiotics were added to the medical arsenal, the "died of wounds" rate was 8.1 percent. It hovered just over 14 percent in the Civil War, "when there was no such thing as sterile surgery, and they had no idea what germs were or how infections were spread," said John Greenwood, the Army's chief medical historian.

Gravely injured soldiers, such as Garriga, need to be evacuated to sophisticated medical care quickly. Helicopters proved invaluable in Vietnam. Today's choppers are faster, and some military planes have been transformed into airborne intensive care units.

"The evacuation is stunning," Holcomb said. "They can get to Germany [Landstuhl Regional Medical Center] in 24 hours and get [to Texas] not long after that. That's unheard of in military medicine."

Strain on the VA

For every injured soldier military medicine keeps alive, that's one more who might need years of care and disability benefits from the VA, which historically has struggled to keep up with demand.

Some worry that things will get worse with this new influx of enrollees, many of whom are members of the National Guard and Reserves, who typically wouldn't have qualified for VA benefits in the past had they not gone to war.

"Look at Gabe Garriga," said Eric Schuller, senior policy adviser to Illinois Lt. Gov. Patrick Quinn, an outspoken advocate for service members and their families. "If he hadn't been activated, he wouldn't have been injured. Now, he's a permanent part of the VA system -- a system that's already strained.

"Since 9/11, there have been over 11,000 National Guard and Reservists called up in Illinois. Most of them wouldn't have been eligible for the VA in the past. Now, they will be. That will be a problem down the line."

VA Secretary Anthony Principi said his department was overburdened when he took over in 2001.

"You had 300,000 veterans who were promised health care enrollment and were told they had to wait six months to a year for their first appointment," Principi said, adding that the number has since fallen to about 5,000. "We've made tremendous progress."

Principi wants to cut the time it takes to process veterans' disability benefits claims from 160 days to an average of 100 days. In Illinois, the number of claims is up since last year, although the staff of "raters" who process those applications is down, according to officials at the Chicago VA regional office.

"We don't have enough people processing claims," said Rep. Evans, "and we need about $1.6 billion just to catch up with the current level of health care services."

VA officials say they have enough money to do their job -- and do it well.

"Everybody in government and the private sector can use more," Principi said. "But I've been the beneficiary of some extraordinary budgetary increases. This is not my dad's VA. This is a wonderful VA."

Uncertain future

Principi insists the VA is capable of absorbing the newest crop of veterans.

"Those numbers are still small relative to the entire veteran population, and they're certainly small relative to Vietnam, where you had millions in the conflict," he said. "Today, we have a few hundred thousand. But it's going to create demand, no question about it."

It already has. Among the 168,528 Iraq war vets no longer on active duty, 16 percent have sought VA health care, according to a Veterans Health Administration report.

"Status quo right now, the VA is struggling," said Geoffrey Collver, spokesman for the Democratic office of the House's Committee on Veterans' Affairs. "Add 15 to 20 percent of the new veterans, and that's a lot of people."

As more troops return from a hostile war zone, one of the biggest demands for VA services could stem from post-traumatic stress disorder. A study in the New England Journal of Medicine estimated that at least 15 percent of service members in Iraq and Afghanistan will develop the disorder.

Can the VA handle that volume of patients? No one knows -- not even the VA, according to a report in September from the Government Accountability Office, the investigative arm of Congress. Its investigators found that the VA doesn't know how many vets are being treated for post-traumatic stress disorder at its facilities and "lacks the information it needs to determine whether it can meet an increase in demand."

That kind of uncertainty troubles wounded soldiers such as Spc. Aaron Wernz. The Illinois National Guardsman from Downstate Marshall nearly died in September when a mortar strike on his compound sent shrapnel into his heart, lungs, kidney, colon and face. Wernz isn't sure if his injuries will let him go back to his job as a farmer. And he isn't sure whether he wants to rely on the VA for his future health care.

"I'm only 26," Wernz said. "Who knows how well they'll fund the VA 20 or 30 years from now?"

Garriga also worries about the future, and whether the country he fought for will return the favor when it comes to disability payments and health care.

But most of his worries are more immediate, like whether the 8-inch incision in his stomach will leak again, or if nerve damage in his leg will be permanent.

"I'm never going to be the same," Garriga said, "but at least I'm alive. I guess that's all that really matters."