NO MORE BS: Bureaucratic Fiat, a Veteran Suicide – Scrutinizing the Government

ApathyThe Department of Veterans Affairs (VA) is in trouble due primarily to the employees’ lack of written directions, procedures, and processes to complete work.  Of the poor Veterans Health Administration (VHA), there is none worse than the Carl T. Hayden VA Hospital system in Phoenix, AZ.  I support this conclusion with both personal observations and through comparative analysis.  Much research has gone into this conclusion, and while there are other VHA’s that compete for the bottom, the clear winner remains the Phoenix VA Medical Center (VAMC).

What is bureaucratic fiat?

Bureaucratic fiat is government employees who make decisions in their positions who rigidly adhere to any rule not to perform their job, inconvenience the customer, or thwart responsibility, accountability, and maintain their positions.  Bureaucratic fiat survives sections from the Office of Inspector General (VA-OIG) through designed incompetence, lack of training, confusing processes, unwritten rules and guidelines, and simple negligence.

LinkedIn VA ImageVeteran Suicide!

Outside of first responders and active military, the suicide rates of veterans are too high and rising.  The suicide rate is disgusting to behold and tragic beyond words.  Of all the topics I discuss, veteran suicide remains my pet topic.  When veterans or military members (Reserve, National Guard, or Active) commit suicide, this rips a hole in communities, families, and the guilt the family and friends carry is so intense, they struggle not to commit suicide themselves.

Scrutinizing the Government!

DetectiveThe VA-OIG reported on a veteran who committed suicide, with ties to the Carl T. Hayden VA Medical Center in Phoenix.  The veteran reported to the hospital, asking for help.  The VA-OIG found that processes were intentionally not followed.  Help was not forthcoming, and the veteran committed suicide before the VA got their thumbs out and offered this veteran help.  The VA-OIG found the following:

      • “While the patient awaited the testing, facility staff failed to offer mental health treatment.
      • The social worker did not complete a suicide risk assessment and relied on another social worker’s suicide risk assessment completed eight months prior.
      • A family member called and left a voicemail message for the social worker. However, the social worker’s documentation did not include essential information, specifically that the patient died by suicide.
      • Upon learning of the patient’s death by suicide, a Suicide Prevention Coordinator failed to complete timely documentation of outreach to the patient’s family… the mental health delegate did not approve the community care psychology consult within three business days, as required by VHA.
      • The third-party administrator scheduled the patient for therapy rather than psychodiagnostics testing.
      • The facility scheduling staff did not complete required outreach efforts when the patient missed a primary care appointment one day before the patient’s death by suicide.
      • The Suicide Prevention Coordinator did not complete the patient’s behavioral health autopsy within 30 days, as required.”

One incident, one VAMC, one veteran, and nothing from the VA will protect veterans and improve the adherence to the policies and procedures moving forward; why even investigate by the VA-OIG?.  I weep with this family who lost their loved one to suicide.  I scream in frustration that the VA can continue to kill veterans struggling with suicide with impunity.

Detective 3Do not be deceived; this is not the only incident in Phoenix or all of the VA Healthcare System.  A veteran reaches out for help with suicide ideation, receives bureaucratic nonsense instead of support, and is treated to the red tape that becomes the noose in the suicide of that veteran.  One event a year is a tragedy of epic proportions.  The list never seems to end, nor do the bureaucrats ever get held accountable for their inactivity, contributing to veteran suicide.

12 November 2020, The Military Times reported that from 22005 through 2018, veterans committing suicide had risen dramatically, to a high in 2014 of 6,587.  Is the epicness of this tragedy more apparent?  Presuming that each of these veterans had two parents who came together and invested time to create the child that became the veteran,  13,174 parents now weep to lose their son or daughter who committed suicide.  According to the US Census, families in America had 1.9 children per couple (2014), rounding up to 26,348 is the potential parents and grandparents affected by suicide, and 52,696 is the pool when siblings are added.  If each of these suicides had a significant other, with two parents and two siblings, the potential affected by suicide is now approximately 105,392.  Add employers, friends from employment, communities, and educational or academic acquaintances, and the number of people affected by suicide can quickly reach a million people.  I used 2014 as the year to base the numbers upon as this was the highest number currently available, but 2020 saw a dramatic increase in suicide among all age groups and those with the Census delays; I doubt America will learn the full impact from COVID government madness any time soon.

LookNow, consider the following, each of those veterans who committed suicide in 2014 (6,587) had a suicide prevention team in place at the VA who failed to act.  6,587 people who deserved better treatment at the hands of the government employees, who have pledged to fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.  Failed the veteran and played a role in the suicide of the veteran.  Rarely do the veterans who commit suicide, in VA parking spots, on Federal property receive the attention they deserve.  I am intimately aware of one such issue with the VA Medical Center in Albuquerque.  The veteran could not get help, became frustrated, walked to his car, and killed himself.

2019, The Washington Times, who proudly continues to declare that “Democracy Dies in Darkness,” ran a story about veterans who take their lives on VA Campuses, is a “form of protest” against the VA Healthcare system.  No, this is not generally the case; the veteran is not protesting; they are fed up with the fight to be respected, noticed, and receive assistance from people who have pledged to fulfill the Department of Veterans Affairs Mission Statement.  To fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.”

DutyI demand to know where are the legislative branches of government in scrutinizing the operations at the VA?  Why are suicide rates allowed to climb without significant input from the legislative branch?  Why are veterans, directly after an encounter with the VA bureaucracy, committing suicide without in-depth investigations where heads roll for failing to perform the most basic customer service in fulfilling the VA’s Mission Statement?

While an employee of the VA, to get to the directors of the hospital’s offices, I had to walk past this mission statement that hung on brass letters, and all my attempts to aid in change fell on brass ears and plastic lips!  Every time the VA-OIG reports another death by suicide, death by negligence, with ties directly to VA employees not performing their jobs, I want to scream in frustration!  Veteran suicide rates are egregiously high, and for veterans to commit suicide within 96 hours of a visit to the VA is 100% unacceptable!  Why 96 hours; because to date, this is the longest time between actions by the VAMC and the death by suicide the VA-OIG has reported where VA employees should have been held accountable for their refusals to act in a manner to prevent a veteran from committing suicide.

Millstone of Designed IncompetenceAfter over a decade of reading and reporting VA-OIG reports and investigations, the deaths by suicide and negligence are the ones that raise my ire the most!  I would see the VA improve, but until the VA admits, or is forced by elected representatives to admit, they have a problem, nothing will change.  But the horror in that sentence is that veterans will continue to commit suicide and die through VA Employee negligence, and their deaths are as unremarked as if these heroes were common criminals who died in a prison brawl.  This remains an abysmal testimony to the incompetence and uncaring bureaucrat found in the VA’s vaunted halls!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

NO MORE BS: Suicide

LookAmerica lost a soldier last week.  For the second time in my sister’s life, suicide has deeply affected her.  Maybe this article is being written for me; perhaps, this article might help someone struggling, I do not know.  I know that suicide deeply affects everyone involved, some carry guilt over another person’s suicide to the grave, and others will always feel sad and empty.  Suicide hurts!

When I served Active-Duty US Army, I was a Chaplain’s Assistant.  My duties were mostly clerical in nature, but I supported every soldier’s beliefs, regardless of their religious belief or flavor.  I loved that job; I sat on the front lines between religion and personal faith, and often my duties were most impactful as I held the hands of grieving people.  I held up the weak knees, lifted hands that hung down, and tried to help people.  I was not perfect then, I am not perfect now, but I can say I did the job.  Like all of life, there is a cost to be paid, and many times that cost is very high!

As a Chaplain’s Assistant, my education included psychology, trauma, hidden wounds, and spotting and helping people seek professional help.  I was often a resource to community support, options, and many times just a listening ear.  Frequently, my day began after I closed the chapel and went downrange, off base, and walked among my fellow soldiers in various bars throughout Dongducheon, S. Korea.  Where I heard about love life’s, extra-marital affairs, affairs gone sour, divorces, pay problems, and every stress known to deployed soldiers.

ToolsBecause I was frequently downrange, I heard about unit problems, offered suggestions, and tried to help the people that make up an Army.  I was handling a situation in my own unit the night a soldier drank himself into alcohol poisoning and died; only later was it discovered the soldier wanted to commit suicide and did not know how except through drinking.  I was not downrange the night a young soldier walked in front of a very large truck; he survived his suicide attempt and received the help he needed.  I hope he is better!

I was supposed to be getting a vehicle ready to take the chaplain to see a training exercise.  Instead, I was in a Quonset Hut, sitting beside some medics who were trying to help their buddy not step in front of a tank.  They found his note, found me, grabbed hold of that soldier, and saved a life.  I was proud to take the Article 15 UCMJ action my chaplain ordered, my friend the medic got the help he needed from a friendlier chaplain and our Battalion Commander.  I am not bragging in relating these episodes, and I do not have aspirations of grandeur that I could have helped.  I describe them because problems with suicide lurk just beneath the calm waters that surround each of us.

I was not in the country of S. Korea when my mechanic friend accidentally hit a little girl who darted out into traffic, and my friend could not stop the truck he was driving in convoy in time.  Unfortunately, I lost track of my friend, but I grieve with him over this event in his life.  The calm waters always hide problems, rocky shoals, traumatic events, and much more.  This brings up the first and most principal point; suicide has long been portrayed poorly by media, Hollywood, and popular culture.

Thin Blue LineUnfortunately, the media, Hollywood, and popular culture get paid to get suicide wrong, and will not change.  As a kid, I was expected to be like John Wayne, Clint Eastwood, and Marlon Brando.  Strong, tough, unyielding, and capable!  Then, Hollywood and the media said this was too stressful, labeled masculinity as toxic, and all men were suddenly supposed to be some mix of Pee-Wee Herman, Rudolph Valentino, and Rock Hudson.  Now, men are appendages, sex toys for women, or other men, and absolutely spineless.  How does this apply to suicide?  Where are the examples, the role models, and those people a person can look up to and see good or emulate?

When I was in Junior High School, I planned to kill myself and make it look like an accident.  I knew where, I knew how, I was not going to leave a note, and on the day of the planned event, a friend saw me walking home from school and offered me a ride.  We talked, not about anything important, but by the time we reached my house, I knew I could not commit suicide to escape my home life.  I looked for role models of who I wanted to be, there were plenty to choose from, and I slowly took the best of each of them and created a life.  I was exceedingly blessed to have such an amazing friend!  Long have I tried to be the same for others.

When counseling those who had tried or were considering suicide, one of the questions I was commonly asked usually was framed like, “Who do I look up to?”  Too often followed by a story of a broken home, abuse, failures at sports, pressures to perform, the list is endless.  Role models are essential, role models are needed, but do you steer a child to model the president, a governor, an athlete, etc.; not bloody likely!  Hence one of the foundational problems in our society is a dearth of role models.  People committed to living honorably where the media talk about them, instead of the latest athlete bashing his girlfriend’s face in an elevator.

Friends QuoteOne of the best pilots recently died.  His story was pointed out to me, his exploits became legend, and his skills were the stuff of dreams and fanciful imaginations.  Chuck Yeager could and did do things to an airplane that caught and held my imagination.  The world lost a great and talented man, I lost a person I would love to call a friend, and we never met!

Hollywood and the Media keep getting the story wrong on suicide because of the toxic culture they have invented to punish good, demean the strong, handicap the great, and dumb down the wise.  We see the results daily.  Sports figures beating up their domestic partners, drugging, or merely acting like a spoiled brat.  From politicians that cannot respect each other or their constituents, Hollywood types acting like puerile rubes off camera.  Magazines are selling sex like a new toy to America’s continuing issues with drugs (legal and illegal), cigarettes, and alcohol.  Every waking moment is filled with toxicity, acting like acid on the mind, detracting from the good, and creating unequal comparisons through social media that can never be matched.

CourageI talked to a depressed person, a guy who got so lost in comparing his life to his friends’ lives on Instagram and Facebook, he was contemplating suicide.  He said it started when he was 11 or 12, first with girls, then the size of his manhood, his inability to be good at sports, his mid-level grades, and the pressures just kept building.  This same person was a Force Recon Marine, had battle badges, and an amazing service record.  Because he could not raise his personal value to meet social media demands, he considered himself a failure.  I sincerely hope he is doing better now.

A friend of mine in the U.S. Navy got caught in the same comparison problem, devised a method to get more money through housing allowances, and got caught.  He is in Leavenworth now, I lost track of his wife and kids, and my friend got lost.  He should be getting out of Fort Leavenworth later this year.  I wish him the best of luck!  Between toxic culture and a lack of role models, Hollywood, and the media, including social media, have a stranglehold on people, and suicides keep increasing!

Another factor in suicide rates is the increasing lack of a nuclear family.  Not to say that a nuclear family is all roses and lollipops, but every democratic society worldwide is suffering from a staggering increase in broken homes through murder/suicide, divorce, hookup culture, and friends with benefits lifestyles, add in homosexuality and gender fluidity.  It is no wonder people are confused, and single parenthood and suicide continue to climb.  When religious decline due to media attacks on religious thought and standards are added to the equation, it is not a wonder that more people are contemplating and committing suicide.  There is no wonder why depression and anxiety are rising steadily as mental diseases.

Duty 3I will offer some ideas for consideration, both to aid in reducing suicide and to aid in helping those struggling.  Of a truth for certain, I contemplated suicide in late December 2020, and had it not been for mental mechanisms installed through learning; I would not be here typing this article.  These ideas for consideration are things I daily apply to help me.  Hence, when I ask you to consider these ideas, I am in the same trenches, doing the same things, and working right alongside you.

    1. Most importantly, find a religion you can live.  There are hundreds of flavors of religious belief systems.  Experiment until you find one that works for you. Faith helps by placing a buffer between how you think and how you act while supplying a why as a motivating force towards action.  Believe it or not, even atheism is a religion; it’s just really hard to live.
    2. Unplug the TV, disconnect from social media, and spend at least one day a week technology-free. Your mind needs to rest from all the inputs of modern living.  Choose a day, any day that works for you is perfect, and put down the cellphone, walk away from the computer, turn off the TV, and plug into mental relaxation.  Make cookies; I used to pound bread dough, do something where your activity levels are up, your mind is down, and you are not plugged in.
    3. Reduce your social media commitments. Twitter, Instagram, Facebook, LinkedIn, etc., are time sponges where you will spend a ton of time trying to compare, keep up, stay afloat, and you never will succeed!  It is okay to end social media commitments!  It is perfectly normal to have a life not posted every 20-seconds to Instagram or another social media platform.
    4. Reach out to people, real people. Use letters, emails, phone calls, or walk down the street and talk with a complete stranger.  I find that when I am reaching out, I am not as self-conscious and not as depressed.  One of my favorite activities is to go to a long-term care facility and ask people about their lives.  I have met incredible people; I have learned, laughed, cried, and celebrated lives that have reached their pinnacle.
    5. Mental toxicity feeds upon what comes into our bodies through the senses and social environments. Change music genres.  Change the authors you read.  Change the magazines to which you subscribe.  Change social settings.  If you are struggling with mental toxicity, change something small and watch how impactful that small item becomes.  A friend of mine is oft to quote, “It’s a matter of a few degrees;” there is a cool story on the internet that accompanies this quote.

Regardless, please talk to someone if you are hurting and thinking about suicide.  Please listen to your friends and close associates.  Do not be scared to ask, bluntly, baldly, openly, “Are you considering something?”  An acquaintance related to me a story where a friend saw something, asked bluntly and saved a life.  On the phone one night, I talked to a friend; he mentioned he was considering swallowing his shotgun and hung up.  I called 911 and asked for a health and welfare check, stated what I heard, and waited anxiously for the authorities to call me back.  Eventually, they did; they helped my friend.  I am exceedingly grateful for the first responders who too often are the front line when suicide happens.

Detective 4I am going to offer one other idea for consideration.  Every time you hear a siren or see flashing lights offer a prayer for the first responders and those involved.  The prayer does not have to be grand and eloquent; your religious flavor does not matter; we are all connected, and those responding can sure use the help.  When you see a medic/EMT/Paramedic, Firefighter, Police officer/Sheriff, please thank them.  The suicide rates among first responders are incredibly high and always tragic.  Nothing grand or embarrassing, just a simple word of kindness will help the first responders in your area.  Until injuries took me, I used to be a first responder as well.

Thank you for taking the time to read this post!  May God bless and keep you!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

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.