On the Other Side of the Rails

EXPLORING THE HEART OF NURSING


Veterans in Your Emergency Department: Serving a Hidden Population

Veterans

One in 14 American adults is a veteran*, but for various reasons, most veterans seek medical care outside of Veterans Affairs (VA) hospitals and clinics.1 Add in the fact that most cities don’t have VA emergency departments, and you may be caring for veterans more often than you realize. I’d like to offer a veteran’s perspective on why it’s important for all caregivers to know if a patient has served, and I’ll suggest some steps that can help you provide even better care to the veterans that enter your emergency department.

The Importance of Identifying Veterans

As service members, we encounter different scenarios in our jobs than civilians do, and these scenarios can cause injuries seldom suffered by American civilians. As a result, veterans often present with unique medical needs.

Due to the impactful experiences of war, combat veterans suffer from post-traumatic stress and traumatic brain injury at disproportionate rates compared to our civilian counterparts. Veterans also suffer a higher rate of mental health issues,2 with veterans accounting for 1 in 7 American suicides.3

Veterans also experience a higher rate of substance use disorders than civilians.2 Homeless veterans in particular tend to visit the emergency department for alcohol-related disorders, substance use, suicidal behaviors, and mental health issues.4,5

But also bear in mind that not all veteran-specific health concerns are combat related. To train the greatest forces in the world, the service branches regularly push the physical limits of their members. As a result, chronic pain is a common complaint among the veteran population.

Barriers to Identifying Veterans’ Needs

Identifying those who have served and acknowledging their unique medical needs is important, but there are several barriers to accomplishing this:

  • Often, veterans don’t associate their medical problems with events that occurred when they served, potentially making it difficult for their nurses and physicians to connect the dots.
  • Military culture can ingrain a “just suck-it-up” attitude and a feeling that discussing mental health shows weakness. On top of that, veterans can feel misunderstood by non-veterans (both within and outside of health care settings). As a result, they may not seek the care they need, and when they do, they may not be the most open communicators.
  • Many of the wounds associated with military service are invisible, so identifying them as a root cause can take some investigation.
  • We all suffer from bias, and caregivers are no exception. Keep in mind that today’s veterans are more diverse than ever, so there’s no such thing as a “typical veteran.


What Can I Do for Patients Who Are Veterans?

Screen for Past or Present Military Service. At some point during your nursing career, you may have inferred a military connection when you saw a “Korean War Veteran” baseball cap or a Navy tattoo, but the best way to determine if your patients are veterans is to ask directly if they have ever served. If they have, follow up by asking about any service-related or combat-related injuries or illnesses. If possible, incorporate the information you gather into their patient history and pass along knowledge of veteran status to case workers--future caregivers may find this information helpful, and they may have more time to ask follow-up questions and screen for certain conditions.

If asking every patient if they have served is just not feasible, consider doing one of the following:

  • Post a sign in the waiting room to let patients know that their veteran status is an important aspect of their medical care.
  • Add veteran status as a follow-up question to aid in identifying pertinent resources for the most vulnerable populations. For example, homeless veterans represent 11% of the adult homeless population, so if you encounter someone with nowhere to turn, consider that they could be a veteran.
  • Keep this blog article in the back of your mind. While a veteran’s broken ankle may have no connection to their 2008 deployment to Afghanistan, determining veteran status may be useful if diagnosis is difficult or if underlying causes need to be investigated.


Share Resources.
As an emergency nurse, you often have the opportunity to guide veterans to better resources, but you have to balance that opportunity with the 1 million other things on your plate. If possible, try 1 of the following in your emergency department:

  • Remember (or keep handy, perhaps electronically) 1 or 2 critical veterans resources (such as va.gov or the Veterans Crisis Line) that you can suggest to those who need it most.
  • Have available a flyer with local and national veterans resources and hand it out as necessary, or keep some available in the waiting room. You can copy-and-paste the resource list below and edit it to reflect local contact info.
  • Refer veterans to the closest VA when appropriate. For prior service members, the VA is often the best source for veteran-specific care. However, many veterans choose to avoid VA facilities, and others don’t even know they are eligible for VA benefits for various reasons:
    • VA eligibility is not black and white. Even if a veteran is not eligible for full VA health care benefits, they may still be able to receive care for certain conditions such as post-traumatic stress disorder (PTSD), depression, and substance abuse.
    • VA eligibility rules change. Even if a veteran was denied VA benefits in the past, they may be eligible today, so encourage them to apply.
    • The Mission Act of 2018 expanded community care options for VA-eligible veterans, opening up a large network of civilian primary care and urgent care providers. This is especially helpful to those who live a significant distance from a VA medical facility.


Educate Yourself and Your Team.
Expanding your knowledge about veterans not only increases awareness and empathy but may also make you more confident about speaking with those who have served.

  • Nursing program coordinators, consider incorporating veteran awareness into your program. Example curriculums and simulations are posted by the American Association of Colleges of Nursing (AACN).

  • Managers and nurse educators, consider integrating veteran-centric training, and encourage nurses to inquire about previous service and ask pertinent follow-up questions. AACN posts PowerPoints and other educational resources.

  • Individual nurses, consider dedicating at least one continuing education credit per year to a veteran-centric topic such as military culture, veterans’ health care needs, PTSD, or advocacy for veterans. Several organizations, such as Center for Deployment Psychology, AACN, and Medscape, as well as many CE websites, offer veteran-related content for credit.

Want to Learn More?
Some links to additional resources that may help you better understand and serve the veteran population:

Selleck CS, Teena M, McGuinness TM, McGuinness JP, Stanley GJ, Miltner RS. Identifying Veterans in Your Practice: What Clinicians Need to Know. J Nurs. Pract. 2021;17(5)574-578. https://doi.org/10.1016/j.nurpra.2020.10.011

US Department of Veterans Affairs. National Center for PTSD. https://www.ptsd.va.gov/

Hanrahan NP, Judge K, Olamijulo G, et al. The PTSD Toolkit for Nurses: Assessment, Intervention, and Referral of Veterans.  Published ahead of print. The Nurse Practitioner. https://www.nursingworld.org/~48e191/globalassets/foundation/the_ptsd_toolkit_for_nurses__assessment.99783.pdf

Disabled American Veterans. Women Veterans: The Journey Ahead. https://www.dav.org/wp-content/uploads/2018_Women-Veterans-Report-Sequel.pdf
 
US Department of Veterans Affairs. Eligibility for VA Health Care. https://www.va.gov/health-care/eligibility/

* “Veterans” are those who served honorably on active duty in one of the federal uniformed services, the Reserves, or the National Guard.

[Just a Handful of] Veterans Resources


Veterans Affairs Resources:

The Veterans Crisis Line connects veterans in crisis and their loved ones with VA responders 24/7 through confidential help in 3 ways:

 - Toll-free hotline: 1-800-273-8255 (TALK), Press 1
 - Online chat: https://www.veteranscrisisline.net/get-help/chat
 - Text: 838-255

1-877-4-AID-VET (1-877-424-3838) – VA’s 24/7 service for homeless and at-risk veterans

VA Health Benefits Hotline: 800-827-1000

Find the nearest VA health center: https://www.va.gov/find-locations

Vet Centers – Community-based centers that provide readjustment counseling to help veterans resolve war-related psychological traumas
Find the nearest Vet Center: https://www.va.gov/find-locations/?facilityType=vet_center

1-877-WAR-VETS – 24/7 confidential call center where combat veterans and their families can call to talk about their military experience or issues they are facing in their readjustment to civilian life.

Volunteer/Nonprofit Groups:

Volunteers of America (VOA) – Assist vulnerable groups (including veterans) with housing, mental health care, and more:
Phone: (703) 341-5000
Website: https://www.voa.org/find-an-office

Iraq and Afghanistan Veterans of America (IAVA) – IAVA’s Quick Reaction Force offers 24/7 free and confidential assistance (peer support and resource connections) to U.S. veterans of any era, location, or discharge status
Phone: 855-91RAPID
Website: https://iava.org/quick-reaction-force/

Disabled American Veterans (DAV) – Assist with VA claims, transportation to VA medical facilities, and more
Find nearest DAV office: https://www.dav.org/veterans/find-your-local-office/
Find a ride to a VA medical facility: https://www.dav.org/wp-content/uploads/HSCDirectory.pdf

American Legion – Assist with linking veterans to their benefits and more
Find the nearest Service Officer: https://mylegion.org/PersonifyEbusiness/Find-a-Service-Officer

Veterans of Foreign Wars (VFW) – Assist with VA claims, offer grants, and more
Find the nearest VFW Post: https://www.vfw.org/find-a-post


References


1. U.S. Department of Veterans Affairs. Department of Veterans Affairs statistics at a glance. National Center for Veteran Analysis and Statistics. Updated December 31, 2019. Accessed September 13, 2021. https://www.va.gov/vetdata/docs/Quickfacts/Stats_at_a_glance_4_6_20.pdf

2. Selleck CS, McGuinness TM, McGuinness JP, Stanley GJ, Miltner RS. Identifying veterans in your practice: what clinicians need to know. J Nurse Pract. 2021;17(5):574-8. doi:10.1016/j.nurpra.2020.10.011

3. U.S. Department of Veterans Affairs. National veteran suicide prevention annual report 2020. Office of Mental Health and Suicide Prevention. Accessed September 13, 2021. https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf

4. Tsai J, Szymkowiak D, Kertesz SG. Top 10 presenting diagnoses of homeless veterans seeking care at emergency departments. Am J Emerg Med. 2021;45:17-22. doi:10.1016/j.ajem.2021.02.038

5. Gundlapalli AV, Jones AL, Andrew RE, Ying SU, Pettey WB, Mohanty A, Brignone E, Gawron L, Vanneman M, Samore MH, Jamison D. Characteristics of the highest users of emergency services in veterans affairs hospitals: homeless and non-homeless. Stud Health Technol Inform. 2017;238:24. doi:10.3233/978-1-61499-781-8-24

Whitney Hawknuff is immediate family to a section editor of the journal, who had no role in the publication decision of this blog.

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Guest Contributor

Whitney Hawknuff, MPH, MLS(ASCP)

Whitney Hawknuff, MPH, MLS(ASCP), is a retired Army Chief Warrant Officer 3 who completed 4 overseas tours during her military service. Whitney has experience as a medical laboratory scientist, and she currently works as a freelance editor and writer. Whitney is pursuing a master of science in strategic brand communication with a goal of helping start-ups and veteran-owned businesses find success.

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We encourage submissions from any reader who has been touched by the healthcare system. Some contributors may be involved directly in patient care and might want to share the impact a patient, family, or colleague had on them. Others may want to write about life “on the other side of the rails” …those moments when the caregiver becomes the patient…or maybe sees healthcare from the vantage point of a family member. Inquiries can be sent to [email protected]

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