There are approximately 21 million living U.S. military veterans, and the Veterans Health Administration (VHA) is the largest healthcare system in the country. Despite its size, the VHA is overwhelmed by the need to provide healthcare to the huge number of eligible veterans. As a consequence of this high demand for care, Congress enacted the Veterans Access, Choice, and Accountability Act of 2014, which allows veterans to seek government-funded care in the private sector under certain circumstances. This act may cause an influx of veterans into private physician practices.
The provision of healthcare for veterans, particularly those who have been deployed in a theater of war, can be challenging, and the presentation of symptoms may not always be what it appears. It is important that practitioners inquire about military service and deployment overseas during a patient evaluation.
Why military service needs to be part of the medical history
The AMA recommends that physicians and other healthcare providers ask about military service and deployment as part of a patient’s social and medical history. Mental health issues, traumatic brain injury, infectious diseases, and residual effects of chemical exposure are some of the conditions that may be inaccurately ascribed to other causes if the veteran’s service history is not considered. Key points regarding these conditions are highlighted below.
Although one normally thinks of post-traumatic stress disorder (PTSD) as the primary ailment afflicting veterans, they may face a myriad of health issues. There are, however, certain conditions that are commonly encountered in caring for veterans. These may include:
- Musculoskeletal injuries and chronic pain
- Mental health issues (PTSD, alcohol and substance abuse, depression, suicidality, etc.)
- Chemical exposure (sarin gas, Agent Orange, smoke from oil well fires, etc.)
- Infectious diseases (brucellosis, Campylobacter jejuni, Coxiella burnetii (Q fever), malaria, TB, nontyphoid salmonella, shigella, leishmaniasis, and West Nile virus)
- Noise and vibration exposure
- Traumatic brain injury (TBI)
- Urologic injuries (traumatic injuries that may not be addressed until after the life-threatening injuries have been resolved)
PTSD key points
- PTSD may occur after a severe traumatic and terrifying event such as serious injury or watching other people die, although not everyone who experiences such an event will develop PTSD.
- PTSD may manifest itself immediately after the event or years after the event.
- Diagnostic criteria for PTSD include re-experiencing symptoms, hyperarousal symptoms, and avoidance symptoms.
- Diagnosis is confirmed (according to NIMH) if the patient experiences one re-experiencing symptom, two hyperarousal symptoms, and three avoidance symptoms in the past month.
- The condition qualifies as PTSD if symptoms persist for more than 1 month.
- The primary mode of treatment is medication and psychotherapy, including cognitive behavioral therapy and antidepressant medication.
Suicidality key points
- The risk of suicide among recently discharged veterans may be higher than the rate in the general population.
- An assessment of the risk of suicide needs to be multi-factorial and involve the exploration of a number of issues.
- If the patient is felt to be at risk of suicide, appropriate interventions need to be taken.
Traumatic brain injury (TBI) key points
- TBI is often seen in veterans of the wars in Iraq and Afghanistan.
- TBI can be mild, moderate, or severe.
- The severity of the injury can be estimated by the length of the loss of consciousness, length of memory loss or disorientation, and how responsive the individual was after the injury.
- TBI may arise after severe injury, while chronic traumatic encephalopathy (CTE) may be caused by multiple, relatively minor head injuries.
- The primary treatment strategy can be mitigation of symptoms through the use of medication as well as physical, occupational, and speech therapies.
Infectious disease key points
- Leishmaniasis is caused by a parasite; it can be either cutaneous or visceral.
- Its vector is the sand fly that is found largely in tropical regions in both the old and new worlds.
- Veterans with visceral leishmaniasis are eligible for VA benefits for treatment of it; patients with cutaneous leishmaniasis are not.
- Symptoms of clinically manifest visceral infection include fever, cachexia, hepatosplenomegaly, pancytopenia, and a high total protein level and a low albumin level with hypergammaglobulinemia.
- Q fever is caused by infection with Coxiella burnetii.
- Human infection is generally through inhalation of dust contaminated with particles of dried placentas, urine, and feces from infected cattle, sheep, and goats.
- Doxycycline is the first line of treatment against Q fever.
- Brucellosis, Campylobacter jejuni, malaria, TB, nontyphoid salmonella, shigella, and West Nile virus may also be encountered in veterans, but these conditions are more likely to have immediate onset of symptoms and be detected by VA/DoD practitioners.
Chemical exposure key points
- Agent Orange was a commonly used herbicide during the Vietnam War and on the Demilitarized Zone between the Koreas.
- It is presumed that any service member serving in these locations during the periods when Agent Orange was used was potentially exposed to this agent.
- There are certain diseases and conditions that are presumed to have been caused by exposure to Agent Orange.
- Service members who served in Kuwait during the Gulf War may have been exposed to smoke from oil well fires that contained particulate matter and volatile organic chemicals known to cause cancer.
- Veterans who served in Kuwait during the Gulf War may have asthma as a result of their service.
- Gulf War syndrome presents with a constellation of non-specific symptoms; the cause is currently unknown.