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How The VA Can Help Our Female Veterans

Women are the fastest growing segment in the US military, already accounting for approximately 14 percent of deployed forces. According to statistics from the Department of Veterans Affairs (VA), 20 percent of new recruits and 17 percent of Reserve and National Guard Forces are women. As the number of women continues to grow in the military, so does the need for health care specifically targeted to their unique concerns.

Historically, lower rates of female veterans have used the VA system. “Research has shown that women didn’t define themselves as veterans in the past, and this is changing,” said Antonette Zeiss, PhD, a clinical psychologist and Acting Chief for Mental Health Services at the VA Central Office in Washington, DC.

Now, “Women are among the fastest growing segments of new VA users with as many as 44 percent of women returning from Iraq and Afghanistan electing to use the VA compared to 11 percent in prior eras,” said Sally Haskell, MD, Acting Director of Comprehensive Women’s Health, at the VA Central Office.

This change is due in large part to the wars in Iraq and Afghanistan, and the different military service opportunities available to women there. Although women are technically prohibited from participating in front-line combat, they have served in counterinsurgency operations in large numbers. Women are also often in convoys, which may be attacked, leading to serious injuries resembling those of their male counterparts.

“We found in the cohort of veterans of Iraq and Afghanistan using VA care in their first year after deployment that the most common conditions in female veterans were back problems, joint disorders, post traumatic stress disorder (PTSD), mild depression, musculoskeletal disorders, adjustment disorders, skin disorders, major depression, ear and sense organ disorders and reproductive health disorders,” said Haskell.

In addition, female veterans are more likely than their male counterparts to be confronted with childcare issues. “Women veterans may also need to reestablish childcare when they return home,” said Zeiss. “The VA is increasing family-oriented services and offering options to include the family in healthcare, if the veteran wants.”

According to a recent study in the journal Women’s Health Issues, female veterans had similar rates of physical conditions in the first year after combat, but higher rates of certain mental disorders, including depression and adjustment disorders. Men had slightly higher rates of PTSD.

According to the National Institute of Mental Health, PTSD is a condition that develops after a distressing ordeal that involved physical harm or the threat of physical harm. PTSD can cause a multitude of symptoms including: flashbacks, bad dreams, frightening thoughts, avoidance, difficulty remembering things, stress, anxiety, anger, being easily startled, and sleep and eating disturbances. Among military personnel serving in Operation Iraqi Freedom and Operation Enduring Freedom, more than 17 percent of service members screened positive for PTSD.

There are some notable gender differences when it comes to PTSD. According to survey results from PTSD in Women Returning From Combat – a report by the Society for Women’s Health Research, clinicians treating female patients reported more depressive symptoms in women, while men exhibited more irritability and anger, nightmares and flashbacks.

The report also revealed that female patients were more receptive to psychotherapy, while male patients expressed a stronger preference for medication. One key sex difference that almost 65 percent of doctors noted was that sexual trauma (previous or otherwise) was an issue in the treatment of their female patients but not at all for male patients.

Military Sexual Trauma (MST), a term coined by the VA, is the experience of sexual assault, or severe, repeated sexual harassment experienced during military service. MST can be experienced by both women and men and many VA facilities have designated a Military Sexual Trauma Coordinator to oversee the screening and treatment referral process.

When it comes to MST, “many women would like to have women providers,” said Zeiss. “Every facility needs to find out what gender providers are available, especially with sensitive topics. In my experience, men who experience sexual trauma also request women providers.”

Growing numbers of women in the military have posed challenges and sparked changes in VA services. “We are changing the treatment environment so women feel safe, supported and get the care they need,” said Zeiss.

Sources:

Meehan S. Improving Health Care for Women Veterans Health Services Research and Development Service, Office of Research & Development, Department of Veterans Affairs, Washington, DC, USA.

Fihn S. Washington DC: Women’s Health Conference; Women’s Health: A Research Priority in VA. November 8–9, 2004.

Haskell S, et al. The Burden of Illness in the First Year Home: Do Male and Female VA Users Differ in Health Conditions and Healthcare Utilization, Women’s Health Issues 21-1 (2011) 92–97.

*This blog post was originally published at Society for Women's Health Research (SWHR)*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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