Treat Them, Move Them Out, Forget About Them

Last week, on a dazzling fall afternoon at West Point, a beribboned Marine gunnery sergeant held a roomful of military medical officers captive. They didn't object; they were locked in on the story he had to tell. I was there, too, invited to give a talk about our hospital rankings and medical quality and safety that evening for military physicians and nurses and civilian consultants at a conference with the theme "Taking Care of Our Warriors." Ken Barnes's message was disturbing, a tale of marines wounded in Iraq or Afghanistan, treated at stateside military hospitals, and cast adrift to fend for themselves. After I'd chewed over his account and talked with him, I found myself thinking: How different, really, is civilian care? Roll your eyes—I understand—but stay with me.

Barnes—"Gunny," as gunnery sergeants are called—was wounded in Iraq late in 2004 by an improvised explosive device. His left arm was shredded. He had multiple surgeries at Bethesda Naval and then was sent back to his base, Camp Lejeune in North Carolina, with "the Claw," his children's bleak term for his ruined hand. Join back up with your unit, he was told. But they were in Iraq—and he was too disabled for combat.

With no duties assigned to him, in pain, depressed, haunted by dreams filled with excruciating combat experiences like the day he was pulling a wounded buddy across a road to safety and the soldier was shot three times as he was being dragged, Barnes slid into a despairing cycle of painkillers and alcohol. He gave up his golf clubs, his motorcycle, his rifles—all needed two arms, and he would never regain use of his left arm and hand. He slowly emerged from his funk after many months, sought out and began intensive physical therapy, and began to wonder how many others like him there were at the base, wounded and ignored. No one he asked had any idea.

Barnes resolved to seek them out, talk with them marine to marine about the events that had put them in the hospital, perhaps give them something to do so they'd have a purpose beyond self-medicating with drugs and booze. In a little over two years, working with a colonel who suffered grievous brain injuries in Iraq, Barnes has created a program, now expanding beyond Lejeune, that tracks wounded Marines starting when they leave the combat zone and ending...never. Even after leaving Lejeune to return home, each marine gets a call once a month to stay in touch and check up. At Lejeune, they are identified, rounded up, placed into squads with squad leaders, given duties, and encouraged to talk. The "Wounded Warriors" program has been a life preserver for countless young combatants.

"How does this happen?" I asked Barnes during the social hour before dinner that night. "What possible excuse is there?" Barnes shrugged philosophically. "Of course there's no excuse," he said. "But it's a big system. It's easy to get lost. That's just the way it's been."

That's when it came to me. Think about elderly patients sent home from civilian hospitals with a few sheets of discharge instructions, their ability to understand and absorb them unknown. Beyond a follow-up appointment with the surgeon and a call or two from a nurse after the first month, they're on their own. Is it any wonder that many don't take their medications as directed? What about "cardiac cripples"—the estimated quarter, perhaps a third, of those who have coronary bypass surgery and sink into depression, never returning to work even if physically capable, because they look in the mirror and see damaged goods? Diabetics who lose toes and limbs that could be saved if they got periodic calls to remind them to check their feet carefully for cuts that could become infected?

It's a human tendency to want to fix a problem and then move on. But our entire health system, military and civilian, defines people as patients, and patients as problems. No more problem, no more patient. Next! Wouldn't it be smarter, kinder, and less expensive to spend a few pennies of every health dollar on follow-up—good follow-up? Why should it take a career marine infantryman to point this out?