1. CARING FOR OUR NATION’S VETERANS Valerie J. Cook, RN, MSN Ellen M. Piskac, RN, EdD, CNE April 22, 2013

2. VETERANS HEALTH ADMINISTRATION 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 post- traumatic stress disorder (PTSD). 1

3. VETERANS HEALTH ADMINISTRATION 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. 2

4. VETERANS HEALTH ADMINISTRATION Joining Forces Program http://www.whitehouse.gov/joiningforces 3

5. VETERANS HEALTH ADMINISTRATION 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 4

6. VETERANS HEALTH ADMINISTRATION 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. 5

7. VETERANS HEALTH ADMINISTRATION 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 6

8. VETERANS HEALTH ADMINISTRATION Joining Forces Program Facts There are an estimated 22.2 million Veterans in the U.S.— 8% of whom are women. 7

9. VETERANS HEALTH ADMINISTRATION 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 8

10. VETERANS HEALTH ADMINISTRATION 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. 9

11. VETERANS HEALTH ADMINISTRATION 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). 10

12. VETERANS HEALTH ADMINISTRATION 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. 11

13. VETERANS HEALTH ADMINISTRATION 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. 12

14. VETERANS HEALTH ADMINISTRATION 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. 13

15. VETERANS HEALTH ADMINISTRATION 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 14

16. VETERANS HEALTH ADMINISTRATION Joining Forces Program Facts In the 5 years from 2005 to 2010, on average, one service member committed suicide every 36 hours. 15

17. VETERANS HEALTH ADMINISTRATION 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. 16

18. VETERANS HEALTH ADMINISTRATION Joining Forces Program Facts Mental and substance use disorders caused more hospitalizations among U.S. troops in 2009 than any other cause. 17

19. VETERANS HEALTH ADMINISTRATION Joining Forces Program Facts 18 Children of deployed military personnel have more school, family, and peer-related emotional difficulties, compared with national samples.

20. VETERANS HEALTH ADMINISTRATION Women Veterans Not Your Traditional Veteran 19 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.

21. VETERANS HEALTH ADMINISTRATION 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. 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 20

22. VETERANS HEALTH ADMINISTRATION 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 21

23. VETERANS HEALTH ADMINISTRATION Military Health History 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? 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? 22

24. VETERANS HEALTH ADMINISTRATION Military Health History 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? 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? 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? 23

25. VETERANS HEALTH ADMINISTRATION Women Veterans Resources http://www.va.gov/womenvet/ 24

26. VETERANS HEALTH ADMINISTRATION General Military Issues 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 25

27. VETERANS HEALTH ADMINISTRATION 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 26

28. VETERANS HEALTH ADMINISTRATION World War II Exposures (September 1, 1939-September 2, 1945) Noise Cold Injuries Ionizing Radiation (“Atomic Veterans”) Mustard Gas Occupational Hazards—chemicals, paints and machinery 27

29. VETERANS HEALTH ADMINISTRATION Korean War Exposures (June 25, 1950-July 27, 1953) Cold Injury/Frostbite Noise Occupational Hazards Asbestos Industrial Solvents Lead Radiation Fuels PCBs Vibration CARC Paint 28

30. VETERANS HEALTH ADMINISTRATION Vietnam War Exposures (November 1, 1965-April 30, 1975) Agent Orange or other Herbicides Hepatitis C Noise Occupational Hazards Asbestos Industrial Solvents Lead Radiation Fuels PCBs Vibration CARC Paint 29

31. VETERANS HEALTH ADMINISTRATION 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. 30

32. VETERANS HEALTH ADMINISTRATION Gulf War I Exposures (August 2, 1990-March 3, 1991) 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 31

33. VETERANS HEALTH ADMINISTRATION Iraq War Exposures – Operation Iraqi Freedom and Operation New Dawn (March 19, 2003-December 15 2011) 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 32

34. VETERANS HEALTH ADMINISTRATION Operation Enduring Freedom Exposures (Afghanistan) Operation Enduring Freedom (October 7, 2001-present) 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 33

35. VETERANS HEALTH ADMINISTRATION 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 34

36. VETERANS HEALTH ADMINISTRATION 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 35

37. VETERANS HEALTH ADMINISTRATION Mental Health Issues affecting Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Depression Suicidal Thoughts and Suicide Violence and Abuse Substance Abuse Concussions or Mild Traumatic Brain Injury (mTBI)— several symptoms parallel those of PTSD 36

38. VETERANS HEALTH ADMINISTRATION 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 37

39. VETERANS HEALTH ADMINISTRATION 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 38

40. VETERANS HEALTH ADMINISTRATION 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; 39

41. VETERANS HEALTH ADMINISTRATION 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; 40

42. VETERANS HEALTH ADMINISTRATION 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; 41

43. VETERANS HEALTH ADMINISTRATION 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; 42

44. VETERANS HEALTH ADMINISTRATION 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. 43

45. VETERANS HEALTH ADMINISTRATION 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) 44

46. VETERANS HEALTH ADMINISTRATION 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. 45

47. VETERANS HEALTH ADMINISTRATION 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. 46

48. VETERANS HEALTH ADMINISTRATION 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-health- effects.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. 47

49. VETERANS HEALTH ADMINISTRATION References Center for Women Veterans www.va.gov/womenvetwww.va.gov/womenvet Special Environmental Health Registry Evaluation Programs for Veterans. www.publichealth.va.gov/exposures www.publichealth.va.gov/exposures Public Health World War II Exposures. www.publichealth.va.gov/exposures/wars-operations/ww2.asp www.publichealth.va.gov/exposures/wars-operations/ww2.asp Public Health Korean War Exposures. www.publichealth.va.gov/exposures/wars-operations/korean-war.asp www.publichealth.va.gov/exposures/wars-operations/korean-war.asp Public Health Vietnam War Exposures. www.publichealth.va.gov/exposures/vietnam-war.asp www.publichealth.va.gov/exposures/vietnam-war.asp Public Health Operation Enduring Freedom Exposures. www.publichealth.va.gov/exposures/wars-operations/oef.asp www.publichealth.va.gov/exposures/wars-operations/oef.asp 48

50. VETERANS HEALTH ADMINISTRATION References Public Health Iraq War Exposures. www.publichealth.va.gov/exposures/wars- operations/iraq-war.aspwww.publichealth.va.gov/exposures/wars- operations/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 49