Welcome to unit six, Service Transformed, Lessons in Veteran Centered Care. Where do soldiers really come from? We're gonna also focus on combat related illnesses, as they relate to veterans. We hope in this unit that we'll focus on issues related to triage and assessment of PTSD and TPI. We'll first focus on combat related illnesses. So, if you look at this study by Spellman from 2012, and they looked at VA healthcare records, this is an administrative database. And they said, what are the most common diagnosis for recently returning veterans utilizing VA healthcare?. Lo and behold, though we might think that mental health disorders is top on the list, and it does represent over 52% of all diagnoses. And remember, a patient can have more than one diagnosis at that time of a visit. Musculoskeletal issues really are upfront, and number one in terms of complaints, recent diagnoses, etc. And if you think about it, I'm a civilian, I've actually never participated in military exercises. But you can imagine wearing Kevlar, carrying backpacks, jumping out of planes, or participating in combat-related effort. Or even state-side, doing the every day things that we expect our military folks to do. They will have an impact on the musculoskeletal system. And so you will see things like early-onset arthritis, joint pain, and other musculoskeletal injuries. That come, just from often overuse, and increased use syndromes. The other organ systems are also affected. And so again, we wanna make sure we do a thorough assessment. When you see a veteran coming to your healthcare environment. And again, this is a study from the VA healthcare system. But these are questions that you wanna ask within the civilian healthcare system as well. Especially if you're encountering a veteran. You want to ask about digestive systems. And then you actually wanna do a little bit of a hunt around infectious disease issues. Especially around where the person might be deployed, and other issues. So here's a list of the most common ones. So, if you recall from the prior list, 52% of veterans, recently returning veterans, who are seeking care at the VA hospital. Have a diagnosis of a mental health issue. Here is what some of those common diagnoses are. Depression; post- traumatic stress syndrome. There is TBI, which both has a psychological component as well as a physical component. As well as other mental health issues, such as substance abuse, anger issues, anxiety, etc. So, there are common issues in this new type of warfare. So we have seen an increase in traumatic brain injury. And that's really because of the way that warfare is being conducted in terms of blast injuries. And also the fact that we actually have good safety mechanisms, be it Kevlar, be it reinforced tanks, etc. That actually are saving veterans' lives. However, we also need to continue the work that needs to be done in terms of protecting the brain. And TBI symptoms and other injuries vary from person to person. So there's no common one-size-fits-all way to think about TBI. The prevalence is that it's estimated that over 200,000 veterans from all eras. Are currently experiencing some sort of manifestation from traumatic brain injury. It's unfortunately the "signature wound" of Operation Enduring Freedom and Operation Iraqi Freedom. Again, for the reasons I talked about. About the fact that warfare has changed. And this idea about roadside bombs becoming more common. And affecting more service members, really does have an impact on this type of injury. There is a specific definition of how the Department of Defense and the VA define traumatic brain injury. And it really talks about any traumatically induced structural injury or disruption. Psychological or structural, to brain function, as a result of an external force. Or we think about the symptoms, they can be multifaceted. Can start at pretty severe when you wanna think about concussion, headache, confusion. But also have persistent impacts such as changes on mood, changes in sleep. And persistent significant changes in sorta every day mental functions. For instance, things like persistent attention and concentration issues. When you think about, or you encounter a patient with mild traumatic brain injury. And you will do that if you work at the Veterans Healthcare Administration. We hear a lot about this on the news as well, as we think about people who have injuries from many of the sports. And really having the patient, along with their family, really engaged around what those issues are. And how you can help minimize some of the impact of the injury is important. So we talk about patient education. Being sure to write things down, finding verbal and visual review and clues in terms of notes, Post its, etc. Have the person really understand that the symptoms are not special to them. That really these are the things that happen for most folks who suffer from traumatic brain injury. And so, really issues around concentration and normalizing those symptoms for that group is important. You wanna provide reassurance. There is expected positive recovery. It's just that we, as healthcare providers don't actually, and can't predict, how fast or how slowly that will happen. But we do know that most of these cases do get better. And then you really wanna help with stress management techniques, such as sleep, relaxation and minimizing substances. The interesting thing about these stress management techniques, it's actually something we all should be focused on. And as healthcare providers, I think for all of our patients that we encounter, whether they have traumatic brain injury or not. Having a cadre of understanding of how to educate patients around these issues of stress management. And dealing with everyday stresses, actually pretty important to our repertoire as providers. Again, to review, there are other common mental health illnesses, PTSD, depression and substance abuse. When we think about PTSD, we talked a little bit about military sexual trauma, or sexual trauma, as being one experience that can lead to PTSD. But there multiple experiences that can lead to PTSD. Combat exposure would be the one that we think about right off the top of our head, as we think about returning veterans. However, there's a whole host of other things. There could be a terrorist attack. So, on soft targets where unexpected trauma really does have an impact on the brain. And the mental structure to really think about the impact of PTSD. We talked about sexual assault, other accidents. And natural disasters also are all things that could potentially contribute to the likelihood of having PTSD. When you look at a symptom profile for those who have PTSD. Again, asking about flashback, nightmares, small reaction to reminiscent events, smells, words, etc. Or the complete opposite of feeling emotionally numb, detached or hopeless. Those are all things you wanna inquire about, as well as irritability and sleep issues. When we think about PTSD in veterans. We think, looking at population-based studies. That PTSD is gonna affect 11 to 20% of all veterans returning from the wars in Afghanistan and Iraq. We know that those who were exposed to combat in the Gulf War, that about 10% of those veterans have symptoms of PTSD. And if we think about the largest bullet list of patients that we're seeing right now within the VA healthcare system. Which is our Vietnam era, war veterans. 30% of those veterans can experience, and have manifestations of PTSD. There's a lovely website that the VA provides about understanding the symptoms. And veterans can use this, as well as healthcare providers, as a resource. Again, if we wanna review screening questions. Similar to military sexual trauma or sexual trauma. There are some key screening questions that you wanna think about, as they relate to PTSD. And those are, have you had any nightmares about, or thoughts about experiences that were horrible or frightening that you didn't wanna think about? Have you tried hard not to think about those experiences, or find ways to avoid situations? Are you constantly on guard? And again, this question about feeling numb and detached. We wanna always remember that last question, cuz often we think about PTSD as a hypersensitivity. But it also can manifest itself as being numb and detached. We will see the overlap of PTSD and traumatic brain injury. You can think about, if you were exposed to a blast injury, it could cause issues with your brain. But it also can result in post-traumatic stress syndrome. So, this slide gives you a nice overview of how those symptoms might overlap, making it somewhat difficult to really tease out. But you really want to understand if a veteran has both, one, or the other, and where those symptoms might be shared. There's lots of attention given to PTSD, traumatic brain injury. But we also don't wanna forget the most common, one of the most common diagnoses that show up to all offices in healthcare. Be it patient is a veteran or not, is depression. And we know from recent population trials. That 13% of those veterans who participated in Operation Iraqi Freedom will have a prevalence of depression. And about 17% of all veterans seeking healthcare at the VA. Military retirees, so if you wanna think about them as a group in general. Have the same prevalence of depression as the general population. So again, we talked about some of the social determinants and remember, only 30% of veterans seek care at the VA. There is something different about that population that is coming to the VA. Or, they know that the VA has the support systems that they need in order to seek, in particular, mental health care. There's a new phenomenon that is troublesome to most of us who take care of veterans. And it's really this combination of not only depression, but also the risk of suicide. And understanding those veterans who participated in Operation Enduring Freedom, or Iraqi Freedom. That there is an increased risk and an increased incidence of suicide deaths. Of 43 per 100,000 veterans, versus 12 per 100,000 veterans in the general population. It is really key that we try to get as many contacts and help for veterans out there. This is an example of the National Vietnam Suicide Hotline. And there's multiple other hotlines out there that you can direct friends and family to. In order to get them help if you are worried about suicide. Screening questions that are key is, are you feeling hopeless about the present or the future? And then if yes, have you had thoughts about taking your life? It's really important, and I have to say as a physician and a provider, that we ask, has anyone had thoughts about taking their lives? I think we tend to ask the first question in healthcare. It's the second question about, do you have a plan, have you thought about taking your life, that we tend to shy away from. But actually asking the question, getting an answer and acting on that can actually really save lives. So, it's important to ask about suicidality. And the same risk is, the same issues with homicidality as well. Have you thought about taking anyone else's life? As it relates to how you're feeling. The other issue that we often see, concomitant with some of the other mental health issues that we've just talked about. But it also can be manifested on it's own, is issues related to substance abuse. 80% of patients will try to self-medicate many times or have a concomitant substance usage disorder with PTSD. And you can see substance abuse in about 10% of all recent returning veterans, as well as those from Vietnam. And there are some clear risk factors for substance abuse. Being a male, being younger, not having close relationships in terms of a significant other, combat exposure, etc. Give you a high risk for substance abuse. And it is really interesting as we think about the new DSM-5 criteria, that about 25% of all veterans have some alcohol misuse. So this might not be an issue, but you always wanna ask every one about how they use alcohol. And screen for alcohol and give suggestions about abstinence, moderation, etc., as appropriate for your patient. In reaction to a lot of these mental health issues that not only manifest themselves as we might see them, as those who take care of veterans. But also as they might manifest themselves for active duty service personnel. Is that the Navy and the U.S. Marine Corps actually developed this kind of stress model that I think is actually easy to intuit. The colors actually give a nice way to think about what the continuum of stress is, and when one might wanna intervene. And how well one is managing stress in their everyday. We can think about that in terms of training healthcare professional trainees. These are things that you wanna think about. So this is the nice gradation. So, if you look at the red, this is where we have serious mental health issues, and we wanna actually refer and get help. Versus the green, where people have issues, but they have found ways to cope. They're using good stress mitigation techniques to address these issues. So, this is a nice tool that you might wanna think about asking patients to sort of self-identify where they are on this continuum. Again, this just gives you an idea about how to define the difference between green, yellow, orange and red. And again, the red is really the serious issue, where you wanna seek additional help from a medical or mental health provider. This just shows this again in a more simple format that we can all understand. As we focused on physical illness, and we looked at that list that we showed. We also don't want to forget the physical impacts of combat or military service. And so we do wanna be sure that you do an adequate physical exam. And you wanna look at things like musculoskeletal complaints, gastrointestinal illnesses. Infectious disease exposures concerns, as well as those from the environment. Those are all things that should be part of your physical exam, as well as your history, and your review of systems. In terms of trying to understand what the risk profile is of a veteran, or anyone who might come to your office
