Hidden Battles on Unseen Fronts

by Patricia Driscoll

  Two weeks later, on July 28th, another crisis occurred when Jose developed an infection around the shunt in the back of his head. Doctors removed the shunt and put in an outside drain, twice. In the process, an intravenous line became infected, and that infection spread throughout his body. Nellie found herself back in the ICU with her son on three antibiotics tending to his 102-degree temperature and praying. “During that time Jose was fighting harder to stay alive in the ICU than he ever did in Iraq,” she remembers. On August 12, 2008, Jose was operated on again to remove a newly discovered piece of shrapnel from his brain, possibly the reason his body rejected the first two cranioplasties.

  Nellie admits that as a caregiver, she too probably suffers from a secondary form of PTSD. “The big things I can handle great. It’s the little things that hit me. I don’t have the patience to deal with the details. I get frustrated by all the paperwork, and how nobody will give me a direct answer about my son.” In Nellie’s opinion, Jose’s doctors are vague about how much more he will improve once his skull is rebuilt, assuming a third cranioplasty takes place and isn’t rejected. However, Jose’s doctors may be clearer than she is willing to admit that his quality of life will never be anything near what he experienced before he was injured. Yet Nellie is determined that her son will eventually leave the hospital for good.

  “No matter what the doctors say, I know he knows what is going on,” Nellie says. “He and I will get through this together, no matter how long it takes.” Elizabeth and Nellie are looking for a house in Tampa near the hospital where they can live with Jose and care for him. In the past two years the Armed Forces Foundation has given several thousand dollars to support Nellie’s housing needs, as well as several hundred dollars to Jose’s wife Kelly. Jose and Nellie were also honored at the Armed Forces Foundation’s 2008 Gala.

  MEDALS

  Army Service Ribbon, 2 Purple Hearts, 3 National Defense Service Medals, Army Achievement Medal, Army Commendation Medal, Army Good Conduct Medal, Army reserve Component Achievement Medal, Global War on Terrorism Service Medal, Armed Force Reserve Medal with M Device, Non Commissioned Officer Professional Development Ribbon, 3 New Hampshire National Guard Service Bars, Iraqi Campaign Medal, Combat Action Badge.

  26

  THE FACES BEHIND THE FILES

  VA’s Polytrauma System of Care

  By Barbara Sigford, MD, PhD

  Glen Vanitallie’s life hung in the balance after an improvised explosive device (IED) struck his Humvee in Baghdad. Now, five years after his injuries, he is back in his community, going to school, studying photography and snowboarding.

  Caroline Carter, a single mother, saw the Army as an opportunity, a fresh start. However, her future changed when she was exposed to multiple IEDs in Iraq. Now, she suffers from a severe Traumatic Brain Injury (TBI) and has lost sight in one eye. She is working hard to rehabilitate her body and mind and to reconnect with her son.

  Sean Bianca turned 19 years old in basic training, 20 in Iraq, and 21 at the Minneapolis Veterans Affairs (VA) Medical Center. He was hit by an IED. Some thought he would not live, much less be able to sit on top of a horse. Through aggressive rehabilitation, Sean is learning to do the basic tasks while living at home with his family in a handicapped accessible house.

  These three are among the hundreds of veterans and members of the Armed Services faced with life-altering challenges who have received care for severe TBI or polytrauma in the Department of Veterans Affairs’ Polytrauma System of Care.

  Glen, Caroline and Sean are in different stages of recovery after undergoing polytrauma/TBI rehabilitation tailored to their specific goals. Their determination and desire to recover from their wounds provides inspiration to us all.

  The clinicians, therapists, counselors and staff who work with these patients are committed to providing these brave and inspiring people with “the best care anywhere.” At the VA, the clinicians, therapists and professional staff who work with these patients do so because “we really want to do this challenging work. It’s not just a job for us. We are truly committed to helping. We want to make a difference.”

  Active duty service members and veterans such as Glen, Caroline and Sean may enter the Polytrauma System of Care at any of the more than 100 polytrauma care centers, depending on the extent of their injuries and the treatment and care that is needed. Those with the most severe injures will be referred from a Military Treatment Facility (MTF) run by the Department of Defense (DoD) to one of four VA Polytrauma Rehabilitation Centers. Those with less severe injuries may be referred from the military treatment facilities, or other DoD or community providers, and obtain care and treatment at any medical facility in VA’s Polytrauma System of Care.

  VA’s Polytrauma System of Care is a tiered system comprised of four components: Polytrauma Rehabilitation Centers (PRCs); Polytrauama Network Sites (PNS); Polytrauma Suppport Clinic Teams (PSCT); and Polytrauma Points of Contact (PPOC). This system balances access and expertise.

  Four regional rehabilitation centers (PRCs), provide care for those with the most intense needs and severe injuries. The 21 network sites provide care for individuals who are medically stable but still require the support of a full rehabilitation team of services at a complex medical center.

  The support clinic teams are typically at smaller VA facilities. Each has a full dedicated rehabilitation team, but may not have all medical and surgical support services. The points of contact are sites with a dedicated care manager who is able to connect the veteran with the required level of care.

  To support rehabilitation efforts across the entire system, VA developed the Polytrauma Telehealth Network, which allows remote clinical and educational activities by way of state-of-the-art multipoint videoconferencing. This ensures that polytrauma and TBI expertise are available throughout the system and that care is provided at a location and time that is most accessible to the patient.

  Coordination of care for veterans and troops with polytrauma and TBI is ensured through a network of social work and nurse case managers. Every patient seen at one of the polytrauma programs is assigned a case manager who coordinates care, identifies resources for emerging medical, psychosocial, or rehabilitation problems, and provides psychosocial support and education.

  From the experience of the Polytrauma Rehabilitation Centers, VA has learned that inpatient rehabilitation is only the beginning of a long road toward recovery for many polytrauma patients. An extensive continuum of care is vital to enabling patients to achieve the highest level of function possible.

  The cornerstones of VA’s Polytrauma System of Care are the interdisciplinary teams that work together in the assessment, planning and implementation of a patient’s care. Each VA rehabilitation professional has specific skills and knowledge, gained through firsthand experience, education and clinical training. These professionals are licensed and certified with respect to their discipline requirements and receive additional training in specific treatment areas for TBI and polytrauma.

  These areas include visual rehabilitation, cognitive rehabilitation and neurorehabilitation, as well as the latest and best in medication and equipment. New therapists receive mentoring from experienced therapists, and they attend training conferences sponsored by VA, the Department of Defense, and the private sector on state-of-the art techniques and treatments.

  Members of the interdisciplinary team include, but are not limited to, a physician specializing in physical medicine and rehabilitation (physiatrist), a rehabilitation nurse, neuropsychologist, rehabilitation psychologist, physical therapist, kinesiotherapist, occupational therapist, speech language pathologist, social worker, recreational therapist and a military liaison.

  The patients that we treat and care for are either veterans or service members who are still on active duty. These patients were highly trained people, in the best shape of their lives, who led very active lives before they were injured. The primary goal for rehabilitation is to return to a full, active, independent life. In addi
tion to returning to work and school, they want to play basketball, ride bikes, go hiking, swimming and increase their endurance and build their muscles.

  While they cannot do many of these activities the way they used to, rehabilitation therapy programs can provide ways for them to take part in and perform active tasks while also serving to help them regain their basic motor skills, cognitive skills and self-care skills while adjusting to their limitations. Success for individuals such as Glen, Caroline and Sean often comes literally in very small steps. Through the combined application of different therapies, however, small steps can lead to big changes.

  For example, Glen Vanitallie had multiple injuries, including severe brain injury, a shattered femur and severe soft tissue damage. He went through physical therapy and learned to walk again. Occupational therapy helped him learn to manage his day. Speech therapy helped him use his mind.

  Glen now leads an active life. He lives at home. He just finished his first year of college, and he has a girlfriend. He goes skiing and snowboarding and took part in the recent National Veterans Winter Sports Clinic. VA considers him a model for disabled sports.

  As a result of his determination, he exceeded all expectations; however, he still faces challenges every day. Glen has memory problems and does not manage his own finances. He still receives therapy to help with interpersonal skills, such as interacting with others. Glen benefited from the interdisciplinary approach, applying a variety of TBI recovery programs, as has Caroline Carter.

  After being exposed to seven IED blasts while serving in Iraq, Caroline thought she had a minor concussion. Then came severe headaches. When she arrived at the VA in Palo Alto, California, she was stumbling and falling. She could not complete a sentence. It took her as long as 20-minutes to answer a question.

  Caroline Carter went to aggressive therapy five days a week. She benefited from therapies such as occupational therapy, recreational therapy, visual therapy and cognitive therapy, which range from performing simple tasks such as putting away dishes, to playing basketball to painting by numbers.

  After working hard and undergoing a full course of rehabilitation, she returned home to Kentucky. She now is able to play with her child and can conduct a conversation the way she used to before being wounded. She still goes to the hospital for physical therapy. Upon seeing her with a patch over one eye, her young son wanted to know if she was a pirate. “Yeah,” she said, “I am a pirate.”

  Sean Bianca was semi-comatose when he came to the VA for care. His face was broken. The only thing completely intact was his lower jaw. In fact, the medic on the scene where the IED had exploded did a great job of keeping Sean alive. He was sent to Bethesda Naval Medical Center. His parents and brother were told he might not survive. He had to be fed through a tube. He went into ICU. They wanted to send him to sub-acute care. Observers said his head was as big as a basketball. His parents were only able to recognize him by his freckles and by his feet.

  When he arrived at the Minneapolis VA Medical Center, he was confined to bed. He received the full complement of rehabilitation therapies, and doctors noticed he had incredible resilience and a drive to succeed. Those with severe TBI often have trouble doing simple tasks such as feeding themselves. But he pushed on, and went to physical therapy. When he started he could not sit up straight in a wheelchair. Now, he is able to sit on top of a horse.

  The official term for it is hippotherapy. Eleven months and 11 days after he was wounded, Sean left the VA hospital, sitting straight up in his wheelchair. He hopes to be able to walk on his own some day. He also went to speech therapy. There was not a dry eye in the hospital when he was able to repeat what the nurses taught him to say: “I love you, Mom.”

  Sean went home to Eau Claire, Wisconsin, where they gave him a welcome home parade. Motorcycles and convoys drove past, and people lined up along the roads. A group on the bridge held up a sign, “WELCOME HOME, THANK YOU FOR YOUR SERVICE.”

  The VA provides a continuum of rehabilitation services. The facilities in the Polytrauma System of Care have a shared system of managing medical information, and an integrated system of care management, including access to several Transition Patient Advocates who can travel with veterans to their points of care as needed. Extensive support to families is also available, and the environment of care is modified to meet the needs of young patients and their families. Combined with the special programs, the rehabilitation services provided are unique to the VA.

  The therapies and treatments available through VA’s Polytrauma System of Care reflect those services utilized by Glen Vanitallie, Caroline Carter and Sean Bianca. The three are featured in a recently released DVD produced by VA called “The Face Behind the File: The Long Road Back.”

  27

  PORTRAIT OF RESILIENCE

  The Story of Army Sergeant Brent Bretz

  “The Landstuhl surgery was a low point for me because Brent had lost so much blood, and the medical staff wouldn’t guarantee anything. I was afraid we would lose him.”

  So far, 26-year-old Brent Bretz has had sixty surgeries, more minor procedures than he can count, and several close calls with death. Yet his journey to recovery is headed in the right direction, as Kathy Pearce, his mother who has been with him every step of the way, points out again and again.

  “The reason I tell and retell the story of my son is in the hopes it will help other families that are going through the same thing. To let them know it takes prayer, faith, hope and courage to get through every day. Everything we experience in life changes who we are; it is up to us to see the silver lining of each experience. The silver lining in this story is that my son is alive and he is rebuilding his life.”

  Brent was a sniper and team leader in a platoon attached to Charlie Company, 1st Batallion, 5th Regiment out of Fort Lewis. They deployed to Iraq in the fall of 2004. An extrovert who missed his huge Ford F-150 truck and 4-year-old daughter Celeste back home in Mesa, Arizona, Brent was popular and respected by his teammates. He was the kind of soldier who covered watch patrol shifts for his buddies and took on the tough assignments. The excitement of participating in an operation and coordinating sneak attacks on the enemy that required him to slip in, shoot, and then slip out appealed to him.

  “Brent is the youngest of five children, with three older sisters and one brother, and he was the mischievous one, a handful. Although I knew that Brent and his unit were doing what is right and what Americans have stood for from the beginning of this great country, it was hard to send him off to war.” A devout Mormon and single mother (Kathy and Brent’s father were divorced when Brent was very young) it was Kathy who he called once he was in Iraq. For the first three months that fall of 2004 she hung on each phone call, e-mail or instant message for proof that her youngest was “safe for another day.”

  On December 19, 2004, Brent was patrolling the desert outside of Mosul. He’d just been certified to drive a massive five-ton supply truck called an FMTD and he was behind the wheel with his platoon sergeant when the truck hit an IED. He remembers nothing about the day, the truck or the explosion. The blast severed both his legs, ruptured his spleen and broke his left elbow. He suffered severe head trauma, fractured facial bones, nerve damage and hearing loss in his left ear, second degree burns over half his body and collapsed lungs. At each of the various stops at military emergency units, along what has become a tragically familiar route to stateside medical care at Bethesda Navy Medical or Walter Reed Medical Center, the doctors did not think he would live.

  “On Saturday night, Dec 18, 2004, Brent e-mailed me so I knew he was okay, but the next morning I received a phone call from the Department of Defense saying that he’d been very seriously injured.” Brent was taken to the makeshift hospital in Mosul where the first surgeries took place to stabilize him. “With every phone call and each passing day the only good news was that he was still alive. I wanted nothing more than to be with my son and touch him and let him know that I was there and loved him and would stay by his
side, but it wasn’t possible.”

  While in Balad, Iraq, Brent’s lungs filled with fluid, his blood failed to clot and he had bleeding and swelling of the brain. It would be 48 hours before he could be put on a flight to Landstuhl Medical Center. “I received a phone call saying we had been cleared to go to Germany and be with Brent. I left Arizona with his brother and two sisters, and my other daughter left from Utah and we met up in DC so the kids could get their passports. I was beside myself and it truly was only my faith that kept us going. The whole family was determined to be strong for Brent. “

  They arrived in Germany on Dec 23rd, but by the time they arrived Brent had been taken to Koblenz two hours away. When they finally got to see him the next day he appeared to be in a coma. “We entered the room two at a time, and I know he heard our voices. His sister Shilo was in the room with me, and the doctors were concerned he might not keep his left arm, so Shilo was massaging his hand and forearm to help with the circulation. Shilo asked Brent if he could squeeze her hand and he did, but to make sure it was not just reflexes she asked him again and he responded again.” Progress.

  “We spent the next three days traveling to Koblenz to be with Brent before he was transported back to Landstuhl. They had tried the day before to move him back to Landstuhl, but bad weather made it impossible. On the day they transported Brent, we were torn as to whether to travel to Koblenz or stay at Landstuhl. The skies were gray and looked like snow. If this happened he would not be transported, but if we drove to Koblenz we might miss him. After many prayers, the skies open up and it was a sunny day with blue skies. Soon after the helicopter landed at Landstuhl the skies turned gray again and it snowed the rest of the day.”