Tragedies, Travesties, and Uncomfortable Truths – Shifting the Paradigm at the Department of Veterans Affairs

For the uninitiated, the Department of Veterans Affairs (VA) has three chief administrations the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemetery (NC).  The majority of the problems a veteran is going to experience originates in decisions from the VBA, which then influence care with the VHA.

I believe in giving credit where, and when credit is due; thus, please join me in congratulating the VBA for meeting a significant milestone.  From the VBA press release we find the following:

“On August 11th, VA updated portions of the rating schedule that evaluate infectious diseases, immune disorders and nutritional deficiencies. By updating the rating schedule, Veterans now receive decisions based on the most current medical knowledge of their condition.”

The reason this is good news stems from so many veterans leaving the military with problems caused in the service where the VBA has dictated there is no injury due to the rating scales, forcing the VHA into a treatment problem where the patient is concerned.  More on the rating scales issue momentarily.

I-CarePlease join me in mourning another death at the hands of the VHA, which is labeled by the Department of Veterans Affairs Office of Inspector General (VA-OIG) as “largely preventable.”  A patient in the West Palm Beach VA Medical Center was in a mental health unit and committed suicide.  Largely preventable is a vast understatement when hospital leaders only begin caring about the veteran committing suicide after the suicide, where training and policy adherence was not mandated prior to the suicide, and the lack of cameras and staff monitoring allowed for a patient, already having trouble and this trouble is known to the hospital providing treatment, to take their own life.  No staff monitoring every 15-minutes was occurring; why?  Why were the cameras non-functioning?  How long had these problems been known and nothing was being done to correct these discrepancies.

Let me emphasize a truth about suicide.  A person expressing desire to suicide is not weak or lazy, and they will not “find a way.”  Having had depression sufficient to consider suicide in the past, I can tell you from personal experience that friends help, talking openly and honestly helps, and the emotional burdens placed upon a family when a suicide is successful are tremendous, as well as the guilt the surviving family must overcome.  This veteran did not have to die, their death was “largely preventable,” and for their death to occur on VA property, in a mental health ward, remains a tragedy.  That the VHA dropped the ball and allowed, through leadership failures, non-working technical means, and training deficiencies, this veteran to die is disgraceful!

The VBA is committing travesties of justice every day.  Consider the following, in the past 15+ years since I left the US Navy, I have had discussions with veteran service officers (VSO’s) across the continental United States on my own claim, and while supporting other veterans with their claims.  A recent example serves to illustrate the problem.  A Spine Anatomyveteran has bulging disks in the cervical spine.  The MRI shows disk degeneration, stenosis, and other problems in the cervical spine.  The veteran has an “S-Curve” in the thoracic spine caused by carrying bottled gas containers from the pier into the ship.  There is stenosis and disk degeneration in the thoracic spine.  The lumbar spine has bulging disks, degeneration, and stenosis.  Three separate areas of the spine, three distinct injured areas, yet, the VBA calls the spine issues, “Lumbar strain.”

Any person who has taken human biology in K-12 education can tell that spine issues in cervical and thoracic are not “lumbar strain” and would not need “new and material evidence” to understand that the first decision was flawed.  Yet, for the veteran to obtain a rating for their spinal issues, they must find an orthopedic spinal specialist, not affiliated with the VHA, and get a letter of diagnosis detailing why these separate areas of the spine are not “lumbar strain.”  The current corporate medicine world, finding an orthopedic specialist will require a non-VHA doctor as a primary care provider (PCP) to refer the veteran to a specialist.  Without a significant cash investment, time investment, and replication of VHA completed tests, x-rays, and MRI’s, the veteran will not be able to obtain a letter detailing the issues sufficient to sway the VBA in correcting their initial judgment.

The veteran will be stuck between three bureaucracies, the VBA who is denying the claim for spinal injury, the VHA who cannot diagnose and document a problem sufficient to meet the VBA standards, and the corporate medicine outside the VHA.  Yet, anyone with a passing understanding of human anatomy and biology can logically make the leap that the spinal issues cannot all be lumped under “lumbar strain.”

I continue to ask, “What is a veteran to do?”  Many times, the veterans in this position are either unemployed or employed below their skill level because they are in pain, they have medical issues requiring treatment, and they cannot obtain the treatment needed because the VBA has not allowed a military service claim to be placed upon the medical records for the VHA to treat.  To chain medical professionals to a rigid and dead bureaucracy, by refusing their ability to diagnose a problem for another VA administration is, without a doubt, a terrible decision, and dangerous practice.  To refuse to investigate a medical problem, restricted breathing with chest pain because the pain is not related to heart and lungs remains a travesty and an abuse of the patient.

To the elected Federal officials, why are you not demanding improvement to the VHA and the VBA?  Why do veterans have to die in the care of the VHA before any improvement is made to the bureaucracy you created?  Where does a veteran go to obtain relief from the bureaucratic nightmare where the VBA and the VHA are refusing to help the veteran?  The tragedy in this entire article is that the VA cannot enforce policy adherence, controlling the risks to avoid incidents like those detailed, and demand better performance from the people and the systems that are supposed to help the veterans.  The travesty in this article is the policymakers between Secretary Wilkie and the front-line employees; who is helping the veteran navigate these rocky shoals and dangerous waters of government policy?

I have met some great VSO’s, employees of the VBA and VHA, and interviewed with phenomenal people working in the National Cemetery; yet, they all have the same problem, the millstone around their necks is the regulations, policies, procedures, and red-tape of the VA that has been designed to refuse help as the first response to every question posed.  Thus, as I have asked Senator Udall (D-NM) and Representative Haaland (D-NM), as well as countless other Federally elected officials between 1997 and the present, what is a veteran to do to obtain the help they need from the VA?  Who would the veterans approach for guidance and support?  When the VBA is demanding “new and material evidence” before acting to support a veteran, how does a veteran obtain this evidence?

I know of hundreds of veterans who were affected by an independent duty corpsman in the US Navy who threw records over the side of the ship to avoid being held accountable for bad decisions and patient abuse.  Because these records are not in the medical files, injuries sustained in the service are not documented, and the VBA will use this as an excuse to deny claims.  What is a veteran to do?  Where does the veteran go?  How does a veteran correct something that occurred beyond their control to obtain treatment for decades-old injuries?  You the elected officials allowed the bureaucracy to be built, you are responsible for correcting these issues experienced, what are you doing to affect change and support Secretary Wilkie in fixing the VA, and by extension the VBA, the VHA, and the NC?

The American people are watching how you treat veterans, and we are not pleased!

 

© 2019 M. Dave Salisbury

All Rights Reserved

The images used herein were obtained in the public domain; this author holds no copyright to the photos displayed.

 

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msalis1

Dual service military veteran. Possess an MBA in Global Management and a Masters degree in Adult Education and Training. Pursuing a PhD in Industrial and Organizational Psychology. Business professional with depth of experience in logistics, supply chain management, and call centers.

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