Wounds of War

Shortages, turnover afflict military health care
by Laura Unger

Injured in a roadside blast in Iraq, Sgt. Gerald Cassidy was assigned to a new medical unit at Fort Knox devoted to healing the wounds of war.

But instead of getting better, the brain-injured soldier from Westfield, Ind., was found dead in his barracks Sept. 21. Preliminary reports show he may have been unconscious for days and dead for hours before someone checked on him.

U.S. Sen. Evan Bayh, an Indiana Democrat, linked his death in part to inadequate staffing at the unit. Only about half of the positions there were filled at the time. The Army is still investigating the death and its cause, and three people in Cassidy’s chain of command have lost their jobs.

"By all indications, the enemy could not kill him, but our own government did," Bayh told the Senate Armed Services Committee last month. "Not intentionally, to be sure, but the end result apparently was the same."

As more wounded soldiers return home from war, critics say staff shortages and turnover have affected the quality of health care at Army posts across the nation…

Overall, the Army’s Medical Corps has downsized significantly since Desert Storm, dropping from 5,400 to 4,300 physicians and from 4,600 to 3,400 nurses. According to the U.S. Department of Defense, more than 29,000 service members have been wounded in action in Iraq or Afghanistan over the past six years, compared with fewer than 500 in Operation Desert Storm.

Warrior Transition Units, created after The Washington Post revealed substandard outpatient care at Walter Reed Army Medical Center, have struggled to find enough doctors, nurses and squad leaders to serve a growing number of patients. The Defense Department allocated about $1.4 billion in operations, maintenance and construction funds for unit facilities and projects.

Military doctors and nurses at Fort Knox move every three to five years, and some are deployed overseas. For patients, that turnover often results in them being treated by doctors and nurses unfamiliar with their cases.

Earlier this month, Congress passed legislation pushed by Bayh requiring the Defense Department and Veterans Affairs to develop a policy on improving care for the wounded. And Army officials say they are already doing better, noting that Warrior Transition Units are approaching or meeting staffing goals across the nation.

"We’ve progressed quite well" on those units, said Brig. Gen. Michael S. Tucker, assistant surgeon general for Warrior Care and Transition. "We’ve done it while we’re at war and really strapped."

But some positions have been filled with workers temporarily borrowed from other areas of the military, and critics say that as the number of returning soldiers grows, the need for more doctors and nurses will grow, too.

Meanwhile, officials said, Army hospitals need more staff now. Fort Knox’s Ireland Army Medical Center is struggling to fill more than 100 vacancies. It also lacks certain specialists, including neurologists who treat traumatic brain injury, considered the signature injury of the Iraq War.

"It would be very generous to say we’re at the proper staff," said Constance Shaffery, public affairs officer at Fort Knox. "We are not at the staffing levels we want."

Positions unfilled

Cassidy, 32, came to Fort Knox in April, and was eventually assigned to the Warrior Transition Unit, which opened in June to handle outpatients who need at least six months of care.

The injured or ill soldiers live in barracks one or two to a room, have medical appointments in a special clinic at the hospital, and are supposed to get three visits a day from squad leaders, Army personnel usually at the rank of staff sergeant. They are told, in posters and by staff, that their mission is to heal.

In Cassidy’s case, something went awry.

Bayh said the soldier tried unsuccessfully for five months to get transferred to a specialized private facility in Indianapolis "after receiving substandard care at Fort Knox."

Bayh pointed to a September report from the Government Accountability Office showing that more than half of the Warrior Transition Units nationwide, including those at Fort Knox and Fort Campbell, had shortages in key positions at the time. Of 2,410 positions, 1,127 — or 47 percent — had not been filled.

Jonathan Swain, Bayh’s press secretary, said Cassidy’s family is not talking to the press as the military continues to investigate his death. Calls to his wife and mother were not returned.

In response to a reporter’s questions about the case, Shaffery said: "There’s been nothing to indicate staffing had anything to do with it."

But Bayh disagreed, and Swain said the senator wants to know if problems because of low staffing are occurring in units elsewhere.

At the Senate committee hearing where the case was discussed, Army Secretary Pete Geren pledged that officials would "rectify the situation." Other high-ranking Army officials say they have been filling vacancies among physicians, nurse case managers and squad leaders.

Nationally, Tucker said, the 35 transition units have reached 80 percent to 85 percent staffing and are on target to reach at least 90 percent by Jan. 1.

Lt. Col. Chip Pierce, deputy director of the Warrior Transition Office, said all key positions at the Fort Knox Warrior Transition Unit had been filled as of mid-December and Fort Campbell has met its goals for doctors and squad leaders but still lacks two of 11 nurse managers.

Although the numbers are encouraging, officials acknowledge that needs are always changing. For instance, Fort Campbell’s staffing goals were developed based on an estimate of 403 patients, and there are 459. Nationwide, 8,700 soldiers are assigned to the units.

Sgt. Dwight Blackman, a 38-year-old Iraq veteran who suffered a heart attack, is one of 277 in the Fort Knox unit. In the past few months, he said, staffing "has improved a lot" and he has no problem getting the care he needs.

"We’ve still got a little ways to go," said Unit Commander Lt. Col. Lanier Ward. "It’s a work in progress."

Residents asked to apply

Staff shortages at Army hospitals have existed for years.

Nationally, the number of doctors has remained the same since 1999, Army officials said, while the number of nurses has fluctuated from a high of 4,615 in 1992 to a low of 3,381 in 2000.

Some patients at Ireland Medical Center say staff shortages have led to long waits, overworked doctors and visits to private physicians.

Army Staff Sgt. Linda Brashears, who suffered a brain injury in Iraq, sees a private practice neurologist off post, paid for by the military health system, and said that until a couple of months ago she faced three-hour waits as a walk-in patient at Ireland.

Although a new appointment policy has meant shorter waits, "We still need more people," she said. "…There’s more patients."

Overall, about 210,000 people are eligible for care at Ireland, officials said, and total hospital staff stands at about 1,100.

Lt. Col. Dawn Erckenbrack, hospital administrator, appealed to Louisville-area residents to apply for their vacancies for doctors, nurses, social workers and others. She said Kentucky’s doctor shortage and competition from the civilian world make these vacancies especially difficult to fill.

Despite shortages, Erckenbrack and Col. Rhonda Earls, the hospital commander, said they do all they can to ensure patients see doctors in a timely fashion — using contracted physicians and referring patients to private-sector providers.

Pvt. Ike Staple, a 39-year-old with high blood pressure assigned to the Warrior Transition Unit, said he goes off the post for procedures such as EKGs.

Keeping records

Army officials said they also must compensate for the higher-than-usual level of turnover that has resulted from deployments.

Jessica Torres, who just moved from Louisville to Colorado and whose husband serves in Iraq, said turnover affects the care she and her two children have gotten at military hospitals because new doctors aren’t as familiar with their medical histories.

Ireland officials — who wouldn’t say how many staff members have been deployed, citing security concerns — acknowledged that turnover can hurt patient care. But they said they try to minimize problems with detailed electronic records, good communication between incoming and outgoing doctors and the use of civilian workers.

"We have a core group of civilian physicians who never deploy. Some have been here for 20 years," said Lt. Col. Carolyn Tiffany, deputy commander for clinical services at Fort Knox. "They keep our clinics and services running the same way, providing the continuity of care that our patients deserve and expect."

Still, officials said they’d like to have a more ideal staffing level in line with the demand for care.

"It’s sort of like winning the lottery," Shaffery said. "It’s something we dream about."

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