Friday, March 02, 2007

Walter Reed -- The Ugly and the Bad

Just about everything to do with Walter Reed Army Medical Center (WRAMC) seems to be happening in twos these days.

But then, that was the way Walter Reed seemed to do things.

For example, at age 16, he entered the University of Virginia (UofV). To ease the strain on family finances, Reed persuaded a very dubious UofV medical department to award him an MD degree as soon as he had passed all required undergraduate and medical courses.

To the astonishment of University officials, Reed completed the entire curricula in two years. On July 1, 1869, at age 18, Walter Reed received his first medical degree. After spending the next year at New York City’s Bellevue Hospital Medical School, Reed – now age 19, completed the requirements for his second MD. For whatever reason, although earned, the second degree was not actually awarded until Reed was 21 – two years later.

I am quite familiar with WRAMC both from my years on active duty and now as a military retiree in the Washington, DC area. I use some of the medical clinics at WRAMC. The overwhelming majority of contacts I have with medical personnel are on an “out-patient” basis.

And here, I think, may be – if not the basic problem then a significant contributing element thereto – the root explanation of the differing levels of attention paid to the returned veterans. In sum, I suggest a complete absence of malice by anyone and everyone and a full measure of that never-ending danger: “Out of sight, out of mind.”

In re-reading the two-part (February 18 Washington Post and February 19) report about WRAMC’s handling (or mishandling) of wounded war veterans sent to the hospital, I think that the natural extension of the principle of “leaving no soldier, whether alive or dead, behind,” is not stressed enough. It is unconscionable for government to send soldiers to fight, die, and suffer life-changing wounds without assuring them and then fulfilling that assurance of first class care, rehabilitation, and providing the financial resources for a decent standard of living, consistent with the severity of wounds suffered.

A point might also be made that the description of the squalor in which some wounded veterans lived – notably in the now infamous Building 18 – was a surefire journalistic “hook” to draw the reader into the full story. This is not a criticism but an observation about the power of solid reporting of indisputable facts, reporting that in this case moved from the living conditions – easy to fix when the responsible authorities are put in train – to the more serious implications for the physical and mental recovery of those who become part of the WRAMC “family” upon arrival.

While the medical side of the care provided in the main hospital is not in question, other parts of the total “patient experience” are what failed. By this I mean the administrative, bureaucratic part of the reception, recording, rehabilitation, recuperative and re-assignment process that is suppose to be the enabler, the control center that ensures that patients actually are accounted for, that links them to appropriate clinics and doctors for treatment at the times prescribed, that periodically checks on patients’ well-being (physical, mental, emotional) at other-than-scheduled appointment times, tracks delivery of prescribed drugs, and intervenes, if necessary, when those being released from WRAMC encounter the always complex and sometimes absolutely incomprehensible “military way” of doing things.

When a soldier is in the multi-story main hospital building as a “real” in-patient, most of these medical and medical-support actions are either automatically done or readily accessible to patients. Doctor’s come onto wards; nursing staff is available and checking on patients around the clock; chaplains make daily rounds, a “mobile library” can be encountered in the hallways moving from room to room, and volunteers visit those unable to get out of bed. And then there are the dreaded physical therapy specialists that drive post-injury rehabilitation – and who, when nothing more can or need be done, invariably are deeply appreciated by their former charges for pushing rehabilitation.

What seems to have happened to those not in the main building is as understandable as it is inexcusable. This in-patient support structure – or at least some critical parts of it – didn’t exist or was wholly inadequate in providing services for those in the disconnected housing facilities on the WRAMC grounds or – as in the case of Building 18 – in the facilities outside the gates and across a multi-lane transportation artery into and out of downtown Washington.

Undoubtedly, as the number of casualties mounted – and they did much faster in these wars because improved medical procedures meant more troops survived their wounds – the medical support administrative staffs were too few in number to keep up. (Many positions, it turns out, were “privatized” in 2003 or 2004, reducing the number of federal employees from 600 to 60.) One can almost see the psychological “re-classification” by the contractors of the “out-rider veterans.” That is, only those patients in the main building are “in-patients”; everyone else, including those on and off WRAMC in different buildings and whose permanent homes are not in or near Washington, is an “out-patient.” And once soldiers are perceived to be in this latter population, they by definition do not need close monitoring because they are out-patients – again “by definition” able to navigate both physically and psychologically with little or no direction.

From this point on, it’s all down hill for the wounded troops. Down hill, that is, until the conditions are exposed to the public and the Congress. But then, inexplicably, the Army shoots itself in the foot. Commanders display what the public sees as inexcusable indifference or blame-shifting, troops are reportedly muzzled and threatened with reprisals. Then it becomes apparent that senior noncommissioned officers, officers, and even commanding generals had known of or had been told about the shortcomings in staffing, in the level of services provided to the “out-in-patients” assigned to their care, and in the conditions in which some of the wounded lived and functioned.

And when things reach this point – if not before – it’s time for heads to roll. To date, one Secretary of the Army is gone, 0ne general officer has been relieved, one company grade officer has also lost his position, a sergeant-major and a number of platoon sergeants have been “moved,” and a 120 person medical support unit has been assigned to Walter Reed to get the place straightened out. I am sure that at least one more general will be relived – giving us Walter Reed’s “two” once again.

Unfortunately, many returned wounded veterans are struggling with the same conditions in under-funded and under-staffed army and veterans’ hospitals across the country.

The point of it all? Not only is war in itself horrible, the aftermath of war has its own horrors, many of which last a lifetime.

(Just to add a bit more about Major Walter Reed,” he worked in New York City until joining the Army Medical Corps in 1875. After a not untypical career, he became in 1893 one of the original four professors at the new Army Medical School. Reed had two medical specialties – pathology and bacteriology, and since 1955, WRAMC has been the location of the Armed Forces Institute of Pathology. But Reed made his mark in an entirely different area: he headed an Army commission that definitively confirmed that the cause of yellow fever, which killed more U.S. soldiers in the Spanish-American War than died in combat, was the mosquito. Reed died in 1902, not knowing his discovery led to effective countermeasures for the laborers who, two years after Reed died, re-commenced construction of the Panama Canal.)

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