The Fog of War
VA rehabilitation nurses help war veterans with traumatic brain injuries reclaim their prewar lives — and peace of mind
By Heather World
November 15, 2004
The patients of Stephanie Alvarez, CRRN, remind her of her two toddlers: Some need prompting to brush their teeth or use the bathroom; some can follow only simple instructions or answer questions indirectly through long narratives.
But these patients are not children. They are soldiers who once executed complex tactical maneuvers and handled dangerous weapons in Iraq and Afghanistan. All suffered some kind of brain injury and are being treated at the traumatic brain injury unit at the Veterans Affairs Palo Alto (Calif.) Health Care System, where Alvarez is a nurse manager.
More than 1,100 soldiers have been killed in Iraq, but nearly four times as many have been wounded in action and not returned to duty, according to the Department of Defense. Many of those coming home are treated by nurses at military and VA hospitals across the country.
Soldiers who once would have died now survive, thanks to better body armor and improved field medicine. Nonetheless, they are left with devastating wounds — spinal cord injuries, brain trauma, amputations, post-traumatic stress disorder. Their initial rehabilitation experience will affect them emotionally and functionally for the rest of their lives, says Barbara Conroy, CRRN, BSN, a case manager for the wounded veterans who pass through the Denver VA in Colorado.
“Rehab nurses are a special breed,” she says. “We can make sure they have positive outcomes.”
Rehabilitation nurses in various specialties work in interdisciplinary teams that include occupational, physical, and recreation therapists, as well as physicians and psychologists.
The coordination of the teams combined with the generous outpatient services — soldiers receive a full range of equipment as well as home modifications to help them cope — make the VA a particularly effective partner in rehabilitation, nurses say.
Wounded soldiers often pass through military hospital hubs like Walter Reed Army Medical Center in Washington, D.C., before being moved closer to home. Some are sent on for further treatment at specialty centers like the traumatic brain injury unit at the VA Palo Alto Health Care System’s Palo Alto Division.
So far, Alvarez’s unit has treated 24 soldiers since the conflicts began in 2001, she says. The symptoms of traumatic brain injury are not well-known, and Alvarez has spent hours at health fairs telling veterans and their families that while the injury may not have a physical face, its imprint is deep.
Initially, patients do not recognize that anything is wrong, and even to family members they might seem normal at first glance, Alvarez says. But after a few weeks, the signs become apparent. These soldiers start to show an inability to find words or perform routine household chores, a tendency to fill in gaps in conversation with unrelated information, or agitation and impatience.
Families are often at a loss as to why their loved ones cannot seem to manage even simple tasks like dental hygiene, and nurses educate the caregivers as well as the patients about how to help those with brain injuries, Alvarez says.
Recovery depends on how long a patient was unconscious following the trauma, but few patients will be as independent as they were before the injury, she says.
Palo Alto VA Assistant Nurse Manager Tanya Araneta, RN, goes back to basics with her patients, helping them establish a daily routine — brushing their teeth, combing their hair — that is written down and checked off a grease board above the bathroom mirror. A “memory book” organizer is used not only to write down memories, but also to orient patients to the day, the time, even the president of the United States, she says.
Life adjustment
Elaine Detwiler, RN, CRRN, BSN, a nurse manager at the VA Puget Sound Health Care System in Washington, says part of the nurse’s job is teaching patients how to learn to live again.
“It’s not just getting up and brushing your teeth every day,” she says. Detwiler has worked for 14 years in the spinal cord injury unit.
“They need to look at what they can do, not what they can’t do,” she says. “Life is not over, just changed remarkably.”
Medicine has no real cure for spinal cord injuries, Detwiler says, so rehabilitation for patients is more a matter of readjustment.
She pushes her patients back into the same activities that thrilled them before they were injured: they go kayaking, bowling, and to baseball games. Swimming is a popular sport with her clients because buoyancy from the water allows them to “walk” again.
The VA is a good place for rehabilitation, nurses agree, because it provides sophisticated equipment needed for modified activity — everything from bars for mobility in the bathroom to wheelchairs to communication augmentation devices. For example, Alvarez is able to equip her patients with a keyboard for typing messages and controlling elements of the environment, like light switches or the television.
Furthermore, the VA cosponsors a summer wheelchair games and a winter sports clinic, which have proved popular with clients from the spinal cord injury unit as well as others such as amputees.
Seeing patients snowboarding or skiing is amazing for the nurses who treated them, said Barb Conroy, CRRN, BSN, a rehabilitation nurse case manager who has worked at the Denver VA for 18 years.
“It’s a testimony to their will to get on with their lives,” she says.
Conroy says that will to get on with life is bolstered by efforts of the interdisciplinary team of rehabilitation specialists.
Margaret Kent, BPT, works with Conroy as a physical therapist for amputees who pass through the Denver VA.
“You figure out a way to adjust the amputation so the person can snowboard,” she says. Less glamorous but no less important, she works with amputees who need to practice the tasks relevant to their daily lives.
Many of the soldiers have new families and new babies, she says. A group of therapists practices age-specific rehabilitations. They steer the young veterans away from wheelchairs and, instead, teach them how to get around on an artificial leg while carrying a 3-month-old baby, for example. They practice by balancing inanimate objects in their arms or by carrying groceries, and the use of wheelchairs is actually discouraged.
Kent and Conroy say they sometimes have to resort to tough words to get patients up and practicing another day.
Conroy knows that the soldiers’ injuries extend beyond the physical.
‘I’m not crazy’
“Not only are they coping with the loss of limbs but also with the effects of being in a war zone and how that’s played on their minds,” she says.
Some suffer from post-traumatic stress disorder, but don’t want to admit it for fear of being stigmatized, she said.
Although some of the stigma has lessened since Vietnam War veterans made the disorder more well-known, many still do not seek treatment for fear of hurting their career, says Paula Rose, RN-C, a mental health nurse.
Still, she has seen the newest veterans much sooner than veterans from past conflicts, and that has made a difference in rehabilitation. The disorder is better known and soldiers, their families, and the military more quickly recognize when a patient needs help. Soldiers from Iraq have not yet had time to develop the destructive adaptive behaviors to deal with the disorder that Vietnam veterans have, she says.
Rose also works within an interdisciplinary team at the San Diego Vet Center, one of 206 centers that treat veterans suffering sexual trauma or post-traumatic stress disorder referred through the VA in outpatient settings, like a strip mall storefront rather than a hospital. Originally a grassroots peer support movement started by Vietnam veterans, the centers became authorized and professionally staffed in the 1980s, Rose says.
The psychologists, nurses, and therapists treat clients from a range of ethnic and economic backgrounds, but they all exhibit the same symptoms: irritability, rage, hyper-startle reactions, a numbing of emotions, and a physical flashback to the original trauma. Many isolate themselves, feeling more comfortable at home. Some isolate themselves emotionally because they are so fearful of losing people they love.
“I call it a symphony with variations on the theme,” she says. “You always know what the melody is, even if it’s played by different instruments or at a different tempo.”
Because the conflict in Iraq is ongoing and has prominence in the news, in political debates, and in conversation, veterans of the war can experience stressful associations, Rose says.
Rose starts by securing a patient’s trust, then moves on to the education portion of her job: demonstrating through literature and studies that the reactions these veterans are having are the textbook reactions of people suffering from PTSD, she says.
“There’s a sense of relief, of ‘I’m not crazy,’” she says.
Breaking through to patients to provide that sense of relief is the challenge faced by nurses and others in the field of rehabilitation. Finding out exactly what each patient wants and needs can be tough because soldiers are trained to set their feelings aside to do the job they’ve set out to do, Kent says.
“Sometimes it’s hard to get out of that he-man mode and say, ‘I have a problem,’” she says. “You have to have a rapport with them that allows them to talk to you and express their needs.”
The sooner a nurse can break through the shell, the sooner rehabilitation begins, and all nurses agree that time is an important factor in a patient’s success.
Traumatic brain injury symptoms
- Inability to find words
- Inability to perform tasks
- Confabulating (putting unrelated bits of conversation into conversation gaps)
- Impulsivity
- Agitation
- Poor judgment and poor insight
- Sexual inappropriateness, including a lack of sexual inhibitions
For more information, call (800) 877-VETS, or visit www.va.gov.