Lessons Learned While Caring for Dying Veterans

Originally published in the July 22, 2022 issue of the Transformational Times (Focus: Geriatric and Palliative Medicine)

Lessons Learned While Caring for Dying Veterans 

Adrienne Klement, MD

Dr. Klement, who completed a fellowship in Hospice and Palliative Medicine, cares for Veterans at the Zablocki VAMC in Milwaukee. As we approach Veteran's Day, she shares two stories from the COVID-19 pandemic that show some of the lessons she has learned caring for her patients…

“These doctors have the hardest job in the world.” It was a cold January evening during the pandemic, and the Milwaukee VA ICU was buzzing with a symphony of ventilator alarms, bedside monitor alerts, the closing and opening of isolation carts, and staff conversing about patient care needs. 

Visitor restrictions were in full force. Despite the noise, the unit felt empty and stark with closed doors and without families at bedside, except for one room. I gowned up and greeted our dying patient, Mr. D, and his family. 

There were several grandchildren joining on Facetime. We (they) had twenty minutes. We all had to speak loudly through our N95s to be heard over the Vapotherm. Mr. D acknowledged he was very sick. We talked about his hopes and wishes, and he gave his loving family all the appreciation he could muster. He just wanted to hug his grandchildren. At the end of the conversation, his son hovered in close to him and said, “Dad, these doctors have the hardest job in the world—they have done everything they can to help you. You are going to die soon, we are here now, and we love you.”

Lesson number one: Sometimes, the best way to reach a patient is through a trusted and familiar face.

I could tell Mr. D was holding back tears throughout our conversation. I wondered if this suppression of emotion was something he had learned in the military, and what trauma he had been through in the past. Was it a sign of weakness to admit feelings of fear or sadness? Was he trying to stay strong in front of his family as a way to bear their grief? I noticed a few quiet tears of my own while in the room, and I couldn’t help but wonder if my reaction was acceptable, or if it was detrimental to my roles as comforter and healer. 

When I got home later that evening, I started to unpack my (unexpected) reaction further, realizing that my tears were complex. They were a reflection of empathy, as I recalled holding my mother’s hand as a teenager when she took her last breath. They embodied frustration with the end-of-life isolation protocols. And they were tears of immense gratitude for the life of service Mr. D gave to our country, and for the care given by his Oncology and ICU teams.

Lesson number two: Showing emotion in front of patients, colleagues, or families is part of healing, for all of us.

The appreciation given to us by our Veterans and their families is transformative. Medical training is a long road that comes with many sacrifices, but also deep bonds and human connection. 

I had the privilege of helping to take care of Mr. R, who had end-stage leukemia, in both a consultative role, and also as his primary Medicine attending. It was so special to me as a teacher, to witness my resident-in-training also provide exceptional care and supportive listening. Mr. R and his wife expressed their deep appreciation for the unique care that he gave, and all that our VA providers gave through to his dying day. 

As an educator, I felt fulfilled in witnessing our team experience the most rewarding aspect of practicing medicine, relationships with patients. Mr. R’s military and life stories were therapeutic for all of us, and he reminded us daily that we are caring for some of the most selfless and resilient servants in the world.

Lesson number three: Reflecting on our Veterans’ acts of service and life experiences through attentive listening and presence cultivates gratitude for our work.

I am grateful every day for the meaning that my work brings me. I am most thankful for our Veterans who have served our country, and from whom we have much more to learn.

Adrienne Klement, MD, is an Assistant Professor in the Department of Medicine, and is a faculty member in the Division of Geriatric and Palliative Medicine at MCW. She attends on the inpatient Internal Medicine and Palliative Care consult services at the Zablocki VAMC, where she was recognized in 2022 as "Employee of the Year."

Reflecting on My Journey to Women’s Health Care a Year After Dobbs

From the July 14, 2023 issue of the Transformational Times - One Year post Dobbs

Reflecting on My Journey to Women’s Health Care a Year After Dobbs

Amy H Farkas, MD, MS

Dr. Farkas shares her longtime passion and perspective on the advances and freedoms in women’s health care, both locally and globally, as the nation marks one year since the Supreme Court ruling on Dobbs v. Jackson Women’s Health Organization ended the constitutional right to abortion...

My path to women’s health care began in 9th grade world geography class. Mr. Nickels required us to report on a current world event each week, which meant I often found myself reading the world news section of the Kansas City Star. One day, as I read a story about the treatment of women by the Taliban in Afghanistan, I found myself wishing I could do more to help women around the world. Recognizing that I would not be traveling to Kabul any time soon, I decided to call my local Planned Parenthood to volunteer. I honestly can’t remember if I even knew what Planned Parenthood did, other than I had a vague understanding they were active in women’s health care and were a lot closer than Afghanistan.

My first job as a volunteer was to learn about local anti-abortion groups, specifically the Army of God, an organization known for acts of violence against abortion facilities and clinicians. I was shown pictures of known members in hopes that I could pick them out from the mostly peaceful protestors. Within a few weeks, I was the Saturday morning clinic escort. My main job was to stand opposite the protesters who showed up each Saturday and be a friendly face to women who were coming for care. Most Saturdays it was just me and the security guard standing across from five to fifteen protestors who were yelling and holding signs.

My time as a clinic escort was mostly uneventful. The police would frequently drive by and sometimes park across the street until everyone had gone home. But there were incidents of violence, real and threatened. One day, the clinic had to close when all its windows were shot out. Another day, it closed when someone committed suicide in the parking lot in protest. My fellow escort had a rock thrown at her head. Most staff at the facility had their pictures published on the internet by anti-abortion groups, and my picture might have been out there, too.

I remained a volunteer for Planned Parenthood throughout high school. In college, I founded a chapter of Planned Parenthood’s student advocacy organization. While I entered college as an international studies major, my time with the student advocacy organization grew my passion for women’s health care and specifically, reproductive care. It inspired me to pursue medicine.

I was fortunate in medical school to meet another educator, Dr. Melissa McNeil, a general internist, and leader in women’s health, who became my mentor. Throughout medical school, residency, and fellowship, she helped foster my knowledge and skills in clinical women’s health and the practice of academic medicine. She also connected me to the VA.

Since I began working at the VA in 2018, I have become convinced there is no other healthcare organization in the US more committed to serving women’s health care needs. You may find this surprising, given the military and VA's reputation for being male dominated.

Yet, women Veterans represent the fasting growing demographic group within VA, and the VA invests in their care across all its missions. It supports women’s health fellowships for physicians, researchers, psychologists, and nurses. This, in turn, helps grow the next generation leaders in academic medicine and women’s health. It funds research in contraception, maternal mortality, intimate partner violence, and breast cancer. It offers targeted educational programs for primary care teams, including physicians, APPs, and nurses to ensure they have the skills necessary to provide comprehensive, gender-specific care.

And in the post-Roe v. Wade world, the VA committed to ensuring women Veterans have access to the full range of reproductive health, including access to abortion care to “promote,preserve, or restore the health” of Veterans.

To achieve this goal, educators will be key to success. Educators will be the ones who translate government policy into clinical practice. They will teach clinicians who likely have never engaged in pregnancy options counseling and certainly not abortion care to provide compassionate and comprehensive reproductive health care. This change at VA will take time, and there are many pieces left to be figured out. But the VA's commitment to women’s health gives me hope that in the post-Roe world, medicine will not allow six justices to define health care.

The VA’s commitment to all aspects of women’s health care takes me back to my early passion to serve women’s health, both locally and globally. Thankfully, American women have far more options than were allowed to their counterparts living under the Taliban, both then and now. I am reminded that the advances and freedoms in women’s health remain only when we fight for them.

As a physician and educator, I can do my part in my clinic with my patients and in the classroom with students by helping to ensure the next generation of physicians have the necessary skills to provide comprehensive care to women. I’m grateful to have the VA as an ally in my own work to ensure health freedom for women.

Amy H Farkas, MD, MS, is an associate professor of Medicine at the Medical College of Wisconsin and works clinically as a women’s health primary care physician at the Milwaukee VA Medical Center. She also serves as faculty at the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, where she is Director of the KICS program and part of the GME Pillar.

A Psychiatrist Veteran Reflects on the Real Meaning of Memorial Day

From the May 26, 2023 issue of the Transformational Times - Memorial Day

A Psychiatrist Veteran Reflects on the Real Meaning of Memorial Day 

 

 

 Michael McBride, MD, MS, CDR U.S. Navy Reserves, LTC U.S. Army Reserves  

 

 

Dr. McBride cared for Soldiers during two military deployments in Iraq, one in Afghanistan, and two in Germany. He shares thoughts about Memorial Day and remembers the toll that military service took on his father and his father’s friends during the War in Vietnam. He remembers a devastating loss with which his unit grappled and passes along important lessons every medical student should understand as they care for Veterans ...  

 

 

Memorial Day is upon us and, for most of our community, it represents the start of summer with parades, ball games, picnics, family gatherings, and celebrations to mark the holiday. It was only when I joined the Army that I learned the real meaning of the day. And my work as a psychiatrist at the Milwaukee Veterans Affairs Medical Center has driven this awareness to a deeper level. 

 

In the Veteran community, Memorial Day is the saddest day of the year -- an anniversary to remember those service members who have died, especially those who died while still wearing the uniform. I no longer say, “Happy Memorial Day” to a Veteran, as this would be equivalent to telling someone to “…have a happy funeral.”  

 

 

Vietnam War hit home, despite my father’s military service stateside  

 

My father, Fuller McBride, MD, graduated from the Medical College of Wisconsin (formerly the Marquette Medical School) in 1961, the year I was born. After completing his OB/GYN residency at St. Mary’s Hospital in Milwaukee, he started a private practice in Fond du Lac. Within a year, he was drafted into the U.S. Navy. Most of his classmates also were drafted, and if you had surgical training, you could be sent to MASH units in Vietnam. 

 

He was lucky he was assigned to the Lemoore Naval Air Station in California, where he delivered babies for families of Navy pilots. We all lived on a dusty, sunbaked military base in the middle of the San Joaquin Valley. My siblings and I built tumbleweed forts and ducked every time a jet broke the sound barrier, causing a sonic boom. I remember the fear and anxiety of my young friends whose fathers were flying missions over Vietnam. 

 

Then my mother and father’s best friend crashed his plane in the jungles of Vietnam and there was a massive search to rescue him. My mother had all her children praying, “Help Uncle Art come home safely.” Months later, they found his remains and my parents were devastated. I asked my father about this memory a few years ago. It’s one of the only times I ever saw him cry.  

 

My father was reluctant to identify himself as a Veteran. He felt guilty about not serving in Vietnam like his good friend Mike Kubly (MCW-MUMS ’63), an orthopaedic surgeon whose Milwaukee residency in orthopaedics was interrupted by his service in the Army. The Kublys and McBrides were close, and each had seven kids. My mother was able to bring her brood to the Naval base for the two years of active duty. The Kublys had to uproot and live with relatives in Monroe while Mike was stationed in Qui Nhon for a year, though they were reunited for his second year of service at Fort Gordon.  

 

When Mike Kubly returned, my father noticed he had changed, and attributed this to the trauma of caring for severely injured troops in Vietnam. I don’t know if they ever talked about it. Vietnam Veterans returned to a country that had been severely polarized by the war. I recently asked my oldest brother if he remembered any “welcome home” events after we returned from service. (I use the word we, as any time a family member joins the military, the whole family joins.) “Nobody talked about it,” my brother recalled. There were no parties or parades, or “thank you for your service.” 

 

Last December, my father made the announcement he was stopping his medical treatment and going into hospice. For selfish reasons, my siblings and I tried to talk him out of it, but he had made up his mind and his medical team agreed with the plan. 

 

For the next week, he was able to visit with family and friends. He died in peace. It was as if he scripted this as a gift for all of us on how to embrace death with integrity. He maintained a sense of humor and mindfulness that left us in awe. 

 

 

Enlisting after 9/11 

 

I lost my hearing in childhood, due to the mumps (paramyxo virus), so there were no options for me to serve in the military until 9/11, when I called an Army recruiter and told him I am a psychiatrist. The recruiter found a way to commission me as an officer in the Army Reserves Medical Corps. I volunteered for deployments to Landstuhl Army Hospital in Germany in 2003 and 2006.  

 

At that point, I left my private practice and joined the VA in 2007, as I was scheduled to deploy in 2008 to Iraq, where I served in the Combat Stress Clinic in Camp Victory Baghdad. 

 

I returned to Iraq for a second deployment in 2010 and served at the Combat Stress Clinic in Camp Liberty Baghdad.  Captain Russell Seager, a nurse practitioner at the Milwaukee VA, was part of the unit that I joined there. Russ and twelve other Soldiers were killed at Fort Hood in 2009, as they were preparing for the deployment.  Russ was a friend of mine and joined the Army at age 47, after losing over 100 pounds to qualify. He was the first Soldier shot, and his comrades took cover behind his body. There is a memorial plaque in his honor outside the Red Clinic at the Milwaukee VA. 

 

I left the Army after that tour, believing I was done serving. Then my Marine Veterans at the VA said, “Doc, you can’t be a Marine, but you could help Marines by serving in the Navy.”  So, I called the Navy recruiter and took a commission as Commander in the Navy Reserves Medical Corps. I was 50.  

 

Soon after, I volunteered for a deployment to the Combat Trauma Hospital in Kandahar, Afghanistan. 

 

Six years ago, I transferred back to the Army Reserves, hoping I could deploy again. But the Army was no longer sending psychiatrists overseas. 

 

 

Helping Veterans in Milwaukee  

 

I joined the Milwaukee VA in 2007 to help the team with the new generation of young Veterans who served in Iraq and Afghanistan. I am the Local Recovery Coordinator and a staff psychiatrist at the VA. Trained as a child psychologist, I also offer family counseling as well as parenting groups. 

 

As a volunteer instructor with the MCW Department of Psychiatry, I run experiential groups for senior psychiatry residents and the child and adolescent psychiatry fellows.  I offer an elective to clerkship students through which they can explore any area of psychiatry that interests them. 

 

 

Since the pandemic, I have collaborated with medical students and Veterans in the development of a clinic focused on teaching clerkship students about military culture and empathy. We presented at the Psychiatry Grand Rounds on May 17, 2023.   

 

Medical students who may be reading this: 

• I ask you to remember to include in your H&P the question, “Have you served in the military?”  This is better than asking, “Are you a Veteran?” 
• Keep in mind nearly 20% of the military are women. Woman Veterans often feel invisible. 
• Assume every Veteran has been exposed to trauma. Ask any Marine about their first hour in boot camp and you will understand why. 
• If your Veteran suffers from GERD, sexual dysfunction, HTN, IBS, or chronic pain, consider all of these as a direct result of living with Post Traumatic Stress Disorder. If we can help our Veterans engage in trauma treatment, we can improve all these conditions. 
• It is okay to say, “Thank you for your service.”  But follow it with, “Tell me about your service.” And since Memorial Day is upon us, ask your Veteran whom they will remember. 

 

If you would like to honor the true spirit of Memorial Day, consider attending the Memorial Day service at Wood National Cemetery on the VA grounds, beginning around 9:30 AM on Memorial Day. 

 

 

 

Michael McBride, MD, MS, served in both the U.S. Army and Navy Reserves. He has been affiliated with the Department of Psychiatry and Behavioral Medicine at MCW in various roles since 1988, and currently practices at the Clement J. Zablocki Veteran Affairs Medical Center.