Emergency physicians, perhaps more than any other health care provider, can make a difference in the lives of recent war veterans, many of whom will end up in EDs with minor complaints masking more serious problems. While getting to the root of a vet's problems in a crowded ED may seem daunting, patients allowed to talk without interruption usually reveal important information in just about a minute, studies show. “No doctor that I have seen over the years, in so far as I can remember, has ever asked me anything about Vietnam or about my war experience,” said Lawrence Winters, a licensed mental health counselor associated with Four Winds Hospital in Katonah, NY, and the author of The Making and Un-Making of a Marine: One Man's Struggle for Forgiveness. “This question of whether a person has seen combat needs to be more common in several medical contexts.”
Although recent combat veterans who have left the military are eligible for two years of free health care from the U.S. Department of Veterans Affairs, just one-third of them take advantage of that, according to VA statistics, said Stephen Hunt, MD, MPH, the director of the Deployment Health Clinic at VA Puget Sound.
“If ever there was a time when it was important for there to be a good collaborative effort between the VA and private providers, this is the time,” said Dr. Hunt. “We at the VA depend upon a strong collaborative relationship with all the medical systems involved. And more importantly, the veterans depend on that.”
Americans who have been to Iraq and Afghanistan since 2001 are at elevated risk in a number of areas, explained Mack Lipkin, MD, the founding president of the American Academy on Communication in Health (formerly the American Academy on Physician and Patient) and a professor of medicine at the New York University School of Medicine. Dr. Lipkin said patients allowed to talk will bring up information clinicians would never think to ask about. “What I would ask is, ‘Tell me about your time in Iraq,’” said Dr. Lipkin. “Then the patient will take you where you need to go. By and large, if you let the patient talk, he will tell you what is relevant.”
This strategy is efficient, and supported by clinical studies, Dr. Lipkin said. It is the physician's job to reassure veterans that “having and discussing symptoms is a sign of realism and strength rather than indicating weakness,” he added.
While emergency physicians may cringe at the idea of a long conversation in the ED, Dr. Lipkin said studies of physician-patient interviews in which the patient was allowed to talk without interruption have shown that patients do not talk about a single subject for very long. “Typically they talk about a minute to 90 seconds, at most,” he said. “You are not usually in danger of being overwhelmed. If you happen to have a rambler or someone who cannot punctuate himself, you can interrupt.” The physician also must communicate the risks of wartime service, alert the patient about which symptoms to watch for, and explain “that having difficulties after going through war is very common,” Dr. Hunt said.
Common Health Problems
Combat veterans have had the same five common health problems since World War II, Dr. Hunt said, and veterans returning from Iraq and Afghanistan are no exception. Topping the list are musculoskeletal injuries followed by hearing disabilities from exposure to high-intensity noise. Dental problems are the third most common because many veterans have spent extended periods in inadequate living conditions.
Those are followed by mental health complaints, often conditions and symptoms that do not meet the standard criteria for a formal diagnosis. “Depression is even more common in the group I see than PTSD,” Dr. Hunt noted. Many vets experience more subtle mental health problems that do not meet standard criteria for a formal diagnosis, including nightmares, recurrent troubling thoughts, mild depression, and difficulties in social interactions. These symptoms “may be bothering these veterans enough that they should at least be monitored and talked about,” he said.
The fifth most common health problem affecting these patients is what might be considered medically unexplained symptoms with no clear underlying diagnosis. “These sorts of symptoms were very common among veterans in the first Gulf War,” Dr. Hunt pointed out. “We want to know about psychological trauma and about the sort of combat experiences they had. Were they exposed to direct fire or indirect fire? Were they exposed to blast waves, which may be associated with mild brain injuries?
“Did they see people injured? Did they take care of people who were injured? Did they handle bodies or body parts? Find out if they were treated for any problems when they were in Iraq or Afghanistan.”
Dr. Hunt advised emergency physicians to ask about alcohol, smoking, and other substance abuse and about exposure to chemicals, diesel fumes, kerosene fumes from tent heaters, and other exposures related to air quality. There also may have been exposure to depleted uranium, something for which the VA has a well established program. Physicians also should be mindful of the potential for parasitic and other diseases a patient might have contracted in Iraq and Afghanistan.
Screening for PTSD
Physicians also should be attuned to military sexual trauma, said E. Jackson Allison Jr., MD, a professor of emergency medicine at Western Carolina University in Cullowhee, NC. Gently ask questions such as, “Were you the victim of sexual trauma while you were in the military?” Many patients have a minor complaint just to get in the door of the emergency department because they are embarrassed or reluctant to reveal what happened to them. Although a patient may be on psychotropic medication, he still should be thoroughly evaluated for organic disease.
For emergency physicians whose time is severely limited, Dr. Lipkin said they should ask each returning veteran whether he was hurt or if he suffered trauma of any kind. And, “regardless of the answer to that question, for all people returning from Iraq who were in combat or exposed to combat, everybody should be screened for PTSD using the SNAP screening tool and for depression using the PHQ-2.”
SNAP reminds physicians to look for startle, numbness (emotional), arousal (autonomic), and persistence (of nightmares, intrusive thoughts, or flashbacks). “The screen itself is quick; it takes about a minute. And if it is positive, you need to make a prompt referral. The time to prevent chronic PTSD is a matter of weeks to months,” said Dr. Lipkin, who is currently focused on teaching physicians about diagnosing and managing psychosocial aspects of terrorism and disasters. (See http://chip.med.nyu.edu.)
The PHQ-2 asks: During the past month, have you often been bothered by feeling down, depressed, or hopeless? During the past month, have you often been bothered by little interest or pleasure in doing things? If the PHQ-2 is positive, do the full PHQ-9 or refer promptly to psychiatry, Dr. Lipkin advised.
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