The ways in which VA health care, and the research efforts that support it, are administered and delivered acknowledge that military deployments may have involved experiences or exposures that many Americans – and often many veterans – have not encountered. VA’s health care system has been shaped over the past decade by the distinguishing characteristics of post-9/11 warfare.
The conflict that began in 2001 as Operation Enduring Freedom (OEF), and which has involved Operations Iraqi Freedom (OIF) and New Dawn (OND), has been America’s longest war, with many service members deploying multiple times to Southwest Asia over a span of more than 13 years. The most common cause of combat injury among veterans of these operations is blast injury, which can be inflicted from sources including artillery, rocket and mortar shells, mines, aerial bombs, and rocket-propelled grenades, but has been most commonly caused by improvised explosive devices (IEDs).

Because of improvements in body armor and in-theater trauma care, a growing number of service members have survived polytrauma they would not have survived in previous conflicts. These service members return to civilian life with complex injuries that can include TBI; limb loss; burns; mental health issues; nerve damage; wounds; and loss of vision, hearing, or balance.

Battle in Afghanistan and Iraq has taken a considerable toll on service members returning to civilian life. According to a report issued by the Congressional Research Service (CRS) in February of 2014, casualty statistics among these service members include, as of Dec. 31, 2013:

• 118,829 diagnosed cases of post-traumatic stress disorder (PTSD);
• 287,911 diagnosed cases of traumatic brain injury (TBI), 7,224 of which are classified as “severe or penetrating;” and
• 1,558 major limb amputations (Last year’s CRS report, which included “minor limb” amputations, such as fingers or partial foot amputations, listed 1,715 total amputations among service members as of Dec. 3, 2012).

Blast injuries often involve polytrauma, meaning they affect multiple body systems or organs. Because of improvements in body armor and in-theater trauma care, a growing number of service members have survived polytrauma they would not have survived in previous conflicts. These service members return to civilian life with complex injuries that can include TBI; limb loss; burns; mental health issues; nerve damage; wounds; and loss of vision, hearing, or balance.

The VA and Department of Defense (DOD) have both stepped up research efforts with initiatives designed to help service members and veterans recover from the “signature wounds” of Iraq and Afghanistan, including limb loss. For the past four years, VA researchers, in partnership with investigators from Brown University, have been evaluating a sophisticated robotic arm developed by DEKA Research and Development Corporation under the Defense Advanced Research Projects Agency’s (DARPA’s) Revolutionizing Prosthetics program. A motorized mechanical arm equipped with finely calibrated sensors that allows users to unlock doors with keys or use power tools, the DEKA arm is the most advanced upper-limb prosthetic ever tested by the VA.
Following on the VA’s rigorous evaluations, the DEKA arm was approved for the commercial market by the U.S. Food and Drug Administration (FDA) on May 9, 2014. The approval paves the way for the arm to be manufactured and made available for purchase by the VA health system – a landmark development in upper-limb prosthetics for veterans, according to the VA’s Director of Deployment Health Research Dr. Robert Jaeger.
“The last outstanding issue,” he said, “is who is going to manufacture this arm and make it commercially available. We’ve collected data, both in the VA medical centers and currently in a take-home study in which veterans are taking the arm home and using it unsupervised every day. We don’t have any results to report from that study yet, but our initial impression is that the arm is working for people. So the FDA approval, coupled with the preliminary results from the take-home study – I hope those two things are going to lead to a manufacturer saying: ‘Hey, I think this is something we can manufacture and make available to our veterans and service members.”’

The unprecedented number of polytrauma survivors has presented a unique challenge to VA’s health care providers and researchers, who continue to work together to address the multiple issues – the comorbidities – resulting from post-9/11 combat.

To help veterans with polytraumatic combat injuries recover and rehabilitate, the VA developed the Polytrauma System of Care, a hub-and-spoke system organized around five polytrauma rehabilitation centers (PRCs), which provide acute inpatient rehabilitation; 23 polytrauma network sites providing TBI-related care, referrals, and education services; and polytrauma support clinic teams, which evaluate, monitor, and support veterans with positive TBI screens.
The unprecedented number of polytrauma survivors has presented a unique challenge to VA’s health care providers and researchers, who continue to work together to address the multiple issues – the comorbidities – resulting from post-9/11 combat.
To better understand the health care needs of the combat-injured – and to promote their successful rehabilitation, psychological adjustment, and reintegration into the community – the VA has established, as part of its Quality Enhancement Research Initiative (QUERI), the Polytrauma and Blast-Related Injuries (PT/BRI) QUERI, aimed at improving and refining the overall Polytrauma System of Care and improving veterans’ ability to manage persistent symptoms and functional impairments related to polytrauma and TBI. According to Jaeger, evaluating outcomes in a nationwide system of polytrauma care is a new frontier in health services research.
“We see polytrauma in civilian society, of course,” he said, “but we don’t see it on the scale we see among the casualties coming back from combat. I think ultimately the Polytrauma Centers are going to tell us a lot, build our knowledge about medicine in this area. But I think we’re still very much in the data collection and research phase.”

Building Resiliency: New Insights

The broad scope of the PT/BRI QUERI’s research is an indication of just how complicated it can be for OEF/OIF/OND veterans – many of whom have worked in a state of constant alertness to danger, and perhaps witnessed disturbing events – to heal, rejoin their families and friends, and enjoy civilian life.
More than a million mental health conditions have been diagnosed among active-duty service members since 9/11. A 2011 VA study of OEF/OIF veterans using VA health care reported that more than 11 percent had been diagnosed with a substance use disorder; VA data shows that percentage jumps to 22 percent among veterans with PTSD. Over the past several years, suicide rates among OEF/OIF/OND veterans have spiked – particularly among younger veterans and females – and the DOD and VA have stepped up their prevention efforts. A study of OIF veterans has reported a link between combative behaviors – angry verbal outbursts, threats, and property destruction, for example – and violent combat exposure; other studies have shown that OEF and OIF veterans also experience high levels of conflict in family and social relationships.