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Witness Testimony of Mr. Carl Blake, Paralyzed Veterans of America, National Legislative Director

Mr. Chairman and members of the Subcommittee, on behalf of Paralyzed Veterans of America (PVA), I would like to thank you for the opportunity to testify today on an issue that we consider the signature health crisis of the Global War on Terror.  Many Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans face difficult challenges ahead as they learn to deal with traumatic brain injuries that they have incurred during their combat service. 

The Independent Budget devotes significant attention to the issue of mental health care and specifically traumatic brain injury (TBI) in the FY 2008 edition.  In accordance with the policy information included in this year’s Independent Budget, most of my written statement will reflect those points.  However, I would like to focus on a few key issues that relate to care being provided to service members with traumatic brain injury at the Department of Veterans Affairs polytrauma centers.

Severe TBI results from blast injuries, particularly those caused by improvised explosive devices (IED), which severely shake or compress the brain within the skull.  This often leads to significant and sometimes permanent damage to the brain.  Many servicemen and women also experience traumatic brain injuries associated with a lack of oxygen to the brain as they are being treated for other serious injuries.  Likewise, service members who are in the vicinity of an IED blast or involved in a minor motor vehicle accident can suffer from a milder form of TBI that is not always immediately detected and can produce symptoms that mimic PTSD or other mental health disorders. 

Unofficial statistics also suggest that many OEF/OIF veterans have suffered mild brain injuries that have gone undiagnosed.  In many cases, symptoms have manifested themselves after the veterans have returned home.   The Department of Defense (DOD) admits that it lacks a system-wide approach for proper identification, management, and surveillance for individuals who sustain mild to moderate TBI.  It is essential that VA and DOD coordinate to better address mild TBI and develop a standardized follow-up protocol utilizing appropriate clinical assessment techniques to recognize neurological and behavioral consequences of TBI as recommended by the Armed Forces Epidemiological Board. 

PVA is particularly concerned about veterans who have experienced a TBI but whose symptoms have been masked by other conditions.  We have heard anecdotally that this is a particular problem for veterans who have incurred a spinal cord injury in the upper cervical spine.  Veterans who have incurred this level of injury as a result of a blast incident often have experienced a traumatic brain injury as well.  However, their symptoms may be diagnosed as the result of their significant impairment at the cervical spinal level.  Unfortunately, they may not get the critical treatment needed at the earliest stage to address the TBI.  We recognize that this is a difficult challenge facing physicians, nurses, and rehabilitation specialists as they must decide what condition must be treated first, even while not necessarily realizing that other conditions exist.  Furthermore, it is not uncommon for DOD health care facilities to miss these masked conditions as well because they do not have the specialized expertise to recognize multiple severe conditions.

PVA believes more research must be conducted to evaluate the symptoms and treatment methods of veterans who have experienced TBI.  This is essential to allow VA to deal with both the medical and mental health aspects of TBI, including research into the long term consequences of mild TBI in OEF/OIF veterans.  Furthermore, TBI symptoms and treatments can be better assessed for previous generations of veterans who have experienced similar injuries.

Ultimately, it is important to point out that the care being provided to those severely injured service men and women who have incurred a traumatic brain injury at the VA is nothing short of extraordinary.  As explained in the Administration’s budget submission for FY 2008, in 2006, VA’s Research and Development department established a Polytrauma and Blast-Related Injury Quality Enhancement Research Initiative (QUERI) that coordinates with the four polytrauma centers providing advanced medical care to veterans with complex disabilities, including traumatic brain injury.  The QUERI links VA researchers directly to the four centers located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA.  These centers are designated as level one trauma centers.  These lead centers provide a full spectrum of TBI care for patients suffering moderate to severe brain injuries. 

PVA is pleased that VA is also taking steps to establish level two polytrauma centers in each of its remaining Veterans Integrated Service Networks (VISNs) for follow-up care of polytrauma and TBI patients referred from the four lead centers or from military treatment facilities.  PVA believes that the hub-and-spoke model used in the VA’s spinal cord injury service serves as an excellent model for how this network of polytrauma centers can be used.  Second level treatment centers (spokes) refer spinal cord injured veterans directly to one of the 21 spinal cord injury centers (hubs) when a broader range of specialized care is needed.  These new level two centers will better assist VA to raise awareness of TBI issues.  These increased access points for TBI veterans will also allow VA to develop a system-wide screening tool for clinicians to use to assess TBI patients.      

To help facilitate access to these specialized services, VA assigns a case manager to each OEF/OIF veteran seeking treatment at one of its medical facilities.  The case manager is responsible for coordination of all VA services and benefits.  Additionally, VA has created liaison and social work positions at DOD facilities to assist injured service members.  However, these case managers continue to report problems related to transfer of medical records from referring military facilities; difficulty in securing long-term placements of TBI patients with extreme behavioral problems; difficulty in obtaining appropriate services for veterans living in geographically remote areas; limited ability to follow patients after discharge to remote areas; poor access to transportation and other resources; and inconsistency in long-term case management.  The Office of the Inspector General (OIG) stated in its July 2006 report Health Status of and Services for Operation Enduring Freedom/Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation that while many of the patients they assessed had achieved a substantial degree of recovery, “…approximately half remained considerably impaired.”   

Unfortunately, the ability of VA to provide this critical care has been called into question, particularly in recent weeks.  PVA recognizes that the VA’s ability to provide the highest quality TBI care is still in its development stages; however, it continues to meet these veterans’ needs while going through this process.  We believe many of the problems highlighted in recent newspaper articles regarding the TBI programs at the four polytrauma centers is a result of congressional inaction.  The VA is not being prepared for success by a Congress that is not fulfilling its responsibility to properly fund it in a timely manner.  The VA is learning to do more and more with less and less every year, and the TBI program is no exception. 

We are especially concerned about whether the VA has the capacity and the staff necessary to provide intensive rehabilitation services, treat the long term emotional and behavioral problems that are often associated with TBI, and to support families and caregivers of these seriously brain injured veterans.  As stated in the FY 2008 Independent Budget:

During a September 2006 House Veterans’ Affairs Subcommittee on Health hearing, a statement was provided for the record that indicated the 20-year health care costs for TBI could exceed $14 billion.  As noted in the OIG report, “these problems exact a huge toll on patients, family members, and health care providers.”  There are several challenges we face in ensuring these veterans and their families get the specialized care and support services they need.  Clinicians indicate that in the case of mild TBI, the [veteran’s] denial of problems that can accompany damage to certain areas of the brain often leads to difficulties receiving services.  Likewise, with more severe injuries, the extreme family burden can lead to family disintegration and loss of this major resource for patients.

To ensure a smoother transition for veterans with TBI and their caregivers, VA should evaluate ways to provide additional assistance to immediate family members of brain-injured veterans, including additional resources and improved case management, and continuous follow up.  The goal of achieving optimal function of each individual TBI patient requires improved coordination and inter-agency cooperation between DoD and VA.  Veterans should be afforded the best rehabilitation services available and the opportunity to achieve maximum functioning so they can re-enter society or, at minimum, achieve stability of function in an appropriate setting. 

Finally, the broader VA is unlike most, if not all, other health care systems in America.  While the quality of care may be outstanding during early stage treatment at some private facilities, those same facilities generally provide care in the short term.  On the other hand, the VA is the only real health care system in America capable of providing complex sustaining care over the life of the seriously disabled veteran.  Private treatment options often give no consideration whatsoever to the long-term care needs of the veteran.  Meanwhile, the VA has developed its long-term care program across the broad spectrum of services for many years. 

Mr. Chairman and members of the Subcommittee, the task of providing this critical care to this segment of the OEF/OIF veterans population is a daunting one.  Without coordinated efforts by DOD and VA and the backing of Congress through the appropriations process, the VA will struggle to adequately handle all of the expectations placed on it.  Veterans with TBI, as well as their families, should not have to worry about whether the care they need will be there when they need it. 

I would like to thank you for the opportunity to testify today.  I would be happy to answer any questions that you might have.