On any given day, the hallways at the Veterans Affairs (VA) Connecticut Health System in West Haven are bustling with doctors, staff, and patients of various ages, including veterans who served in Europe, Vietnam, Korea, Iraq, Afghanistan, and other places. Many seem to know each other, and often a passerby will stop them in the hall or on the elevator, shake their hand, and say, “Thank you for your service.”
The VA’s mission fulfills a promise made by President Abraham Lincoln to care for those “who shall have borne battle.” This means that veterans who served in the active military, naval, or air service, and who received an honorable or general discharge, qualify for free or low-cost health care at VA hospitals and facilities.
This has brought military veterans to the VA hospital in West Haven not only from Connecticut, but also from other New England states. Some come for routine checkups; others are seeking treatment for complex issues ranging from post-traumatic stress disorder (PTSD) to prostate cancer. The Yale School of Medicine has a deep and multifaceted relationship with the West Haven VA that goes back 60 years. Veterans, including many who have multiple issues, sometimes compounded by mental health problems, have access to highly specialized Yale Medicine doctors who provide care approaches and treatments that are difficult to find elsewhere.
This story covers three of those approaches and treatments.
A new option for sleep apnea
During his 30-year military career, Edgar Martinez was a naval lieutenant commander based, at different times, in England, Scotland, and Italy. At some bases, he oversaw a few hundred people. But there was a problem: Sometimes in the afternoons, he would be hit by a wave of fatigue. It could get so bad he’d stop to take a nap. And, at home, his wife was complaining about his loud snoring.
“At that time, nobody ever talked about sleep apnea,” Martinez says. “You just assumed the snoring and tiredness were normal.” What he did know was that sleep problems were even more difficult with a military schedule, where routines in general could be crucial, and you couldn't nod off on an assignment like a night watch.
Eventually, Martinez was diagnosed with a severe case of obstructive sleep apnea (OSA), a type of sleep apnea in which the muscles that support the soft tissues in your throat relax during sleep, which can cause them to collapse and block the airway. Martinez learned that the condition caused intermittent pauses in his breathing while he slept, as well as daytime drowsiness (that made him want to nap) and headaches, and that it might even lead to heart disease. The first treatment he tried was a continuous positive airway pressure (CPAP) ventilator, a machine that helps regulate breathing during sleep and involves wearing a mask to bed. “But I couldn’t tolerate the mask. In the middle of the night, I would take it off without realizing it,” he says. So, like many patients, he stopped using the device, and Brian Koo, MD, a Yale Medicine sleep specialist who directs the Sleep Medicine Program at the VA hospital, referred him to Mark Bianchi, MD, a Yale Medicine otolaryngologist.
This year, Martinez, who is now the director of safety at Naval Submarine Base New London in Groton, Connecticut, became the first patient at the VA Connecticut Health System in West Haven to try a new FDA-approved sleep apnea treatment. Not yet widely available, its name, “hypoglossal nerve stimulator,” sounds like it was taken out of a science fiction story. The pacemaker-like device monitors breathing and is activated during sleep to stimulate the hypoglossal nerve, which controls upper airway muscles.
“It's remarkably successful at treating certain people with sleep apnea,” says Dr. Bianchi, who hopes the device will help other veterans who have difficulty using a CPAP, including those who have OSA related to neurological or physical damage suffered during service. Treating sleep apnea for these patients can improve co-existing conditions, such as diabetes and high blood pressure, in addition to making it easier to sleep. “Patients should have fewer symptoms of sleep deprivation—their cognitive function should get better, and they should do better at work,” Dr. Bianchi says. “Treating a sleep problem also has the emotional effect of making people less depressed, and happier and more hopeful about things.”
This past April, Martinez went to the West Haven VA hospital for the three-hour procedure to implant the device in his chest. He uses a remote device to turn it on every night before he goes to sleep.
The hypoglossal nerve stimulator doesn’t work immediately, and it can take months to adjust to the strength of the stimulation for each patient, Dr. Bianchi says. But in October, Martinez said this adjustment was about 80 percent complete, and he was confident he would get to 100 percent. “I’m snoring less, I’m not taking afternoon naps anymore, and I feel more energized. I can see that it’s going to get better,” he says.
Telehealth is helping with the mental health side of trauma
Veterans with PTSD can feel like they are in a strange, unfriendly world, even once they are back home with their families. PTSD is a psychiatric disorder that can develop in people who have experienced a dangerous event. Veterans who have been in active duty may have had their lives threatened in combat or seen friends killed. They may continue to struggle with the effects many years later, even in normal, safe situations. Their PTSD symptoms vary, but they are almost always distressing. Noises are rattling. Crowds, even in the grocery store, cause anxiety. They have flashbacks and nightmares.
These veterans may also struggle with chronic pain, other mental health conditions, and/or addiction to alcohol or opioid pain medications. Adding further to their challenges, many live in rural communities, far from academic medical centers, such as the West Haven VA, that offer the specialized care they need. Because of this limited access to much-needed services, rural veterans have historically had decreased life expectancies, and increased risks for suicide and overdose.
To tackle these problems and bring first-line treatments to these veterans, the VA Connecticut Health System in West Haven launched a telehealth program specifically for those with PTSD and other mental health challenges. The program serves veterans who live in rural, often underserved areas in New England, providing the care they need, right in their homes. “These veterans, often with severe PTSD, might live several hours away from a VA medical center, and they can’t travel because driving may be a trigger. So, there is an enormous need,” says David Moore, MD, an assistant professor of psychiatry at Yale School of Medicine.
Also the director of VA New England Telemental Health Hub at the West Haven VA hospital, Dr. Moore uses specialized computer equipment to deliver sensitive care in an efficient manner. “On a typical day, I sit down at my computer, which is a dedicated terminal,” says Dr. Moore. “The connection is not unlike FaceTime or Skype, but it’s a big screen, and I can see and hear the patient clearly. In one morning, I can shift from a patient in northern Maine, on the Canadian border, to another in eastern New Hampshire, and then down to northwestern Connecticut.”
One of a dozen such hubs bringing much needed mental health services to isolated areas ranging from Guam to Maine, the West Haven VA launched its telehealth program in 2017. It now serves 11 rural clinics in New England. Based at the Yale West Campus, the hub’s Yale-affiliated psychiatrists and psychologists (and administrative staff) have already provided mental health care for hundreds of veterans, including those who have served in Vietnam, Korea, Afghanistan, Iraq, and even World War II.
For veterans with PTSD, a major focus of treatment is their feelings of numbness and disconnection, “problems that don’t get enough attention,” Dr. Moore says. “Part of PTSD therapy is to help veterans access emotions that they’ve learned not to feel.” For those just returning from service, providers offer help with the transition back to civilian life, which can be especially stressful for those with families.
Dr. Moore and his colleagues also focus on reducing veteran suicide risk and treating opioid addiction, two problems that are intertwined with PTSD.
For instance, one of Dr. Moore’s patients was a veteran in a remote town who attempted suicide after years of chronic pain that had left him with an opioid addiction and worsening depression. Through telehealth, Dr. Moore and his colleagues were able to work with him and provide effective treatment for his depression and addiction issues. They used a combination of talk therapy, antidepressants (carefully selected to reduce the intensity of his pain), and buprenorphine, the first-line treatment for opioid addiction.
“He told me that for years he woke up every morning wondering how he would be able to get heroin that day,” Dr. Moore says. Now in recovery, that patient is taking up hobbies that he lost during his dark days and reconnecting with his family.
Without telehealth, this positive outcome would have been unlikely. The integrated mental health and addiction program that he so desperately needed was brought right into his home from hundreds of miles away, Dr. Moore adds. In fact, Dr. Moore is now collaborating with Marc Rosen, MD, a Yale psychiatry professor and addiction specialist, to develop a toolkit that might allow other telehealth providers to offer buprenorphine-based treatments for opioid addiction. It’s part of the West Haven hub’s plan to not only connect to individual veterans, but to help other VA sites throughout the United States improve how they provide high-quality care.
A comprehensive approach to prostate cancer
One in nine men are diagnosed with prostate cancer in their lifetimes, and that includes many aging military veterans. Those who served in Vietnam and were exposed to Agent Orange, a chemical defoliant that was sprayed by the United States during the Vietnam War to kill plants and clear land, are at higher risk for this, among other serious conditions.
Men with prostate cancer may face difficult choices. Options may include undergoing prostate surgery, which can result in sexual and urinary side effects, or “watchful waiting,” which means consulting the doctor if and when symptoms develop. There is also “active surveillance” for men with low-risk prostate cancer. This has traditionally meant combining a prostate specific antigen (PSA) blood test every six months with an annual biopsy.
But in 2015, the VA Connecticut Healthcare System in West Haven joined leaders in the field of prostate cancer care by offering another, more precise Active Surveillance Program. This program at the VA adds to active surveillance the use of magnetic resonance imaging (MRI), which is more likely to identify cancer and more accurate in grading (or determining the aggressiveness of) prostate cancer. “This definitely has changed the way we approach prostate cancer patients,” says Preston Sprenkle, MD, a Yale Medicine urologist and division chief for urology at the West Haven VA hospital. “In many cases, we have found prostate cancer earlier than we would have otherwise.”
Technology made it possible. “The prostate is one of the only solid organs where we had been performing a random biopsy sampling because we couldn't see inside of it,” Dr. Sprenkle says. The Active Surveillance Program now screens patients using a special prostate MRI. It takes multiple pictures of the prostate, providing images that are so clear doctors can pinpoint the exact location of an aggressive cancer that may have been missed in a single random biopsy—or that may have taken multiple biopsies to find.
The approach is revolutionary for men with low-grade prostate cancer. This type of prostate cancer grows and spreads slowly, and hasn’t yet spread to the lymph nodes, which can carry the disease to other parts of the body. “When the results of the MRI are negative, we feel more comfortable avoiding treatment,” says Dr. Sprenkle. If the patient is found to have a localized cancer, the doctor can treat that small area, instead of treating the whole prostate with radiation, or removing it altogether, he adds.
The Active Surveillance Program in West Haven has treated veterans from as far as New York, New Jersey, Massachusetts, and Maine. For some, these visits have been lifesaving, and Dr. Sprenkle says there are other benefits as well. “Each visit is another checkpoint where a doctor can take time to talk to the veteran,” he says. He notes that he is especially aware of the special needs of veterans who have PTSD, and personalizes their care as much as possible. “We want to give all of our patients concrete information, let them know what the risks are, what is hopeful about their situation, and what we can treat.”
In the end, every visit offers a chance for veterans to connect and know that they are part of a community. Sometimes when they come into the hospital someone is playing a piano in the lobby, and there are warm hellos and pats on the back among veterans, doctors, and staff passing by.
As for Martinez, he feels fortunate to have received a cutting-edge sleep apnea treatment that would have been more difficult to get otherwise. He would have had to pay out-of-pocket for the surgery, which would have been very expensive, he says. "I have had nothing but excellent service from our VA system. I greatly appreciate Dr. Bianchi. Taking care of the veteran is apparent in all he does, and I credit him for contributing to my quality of life for many years," he says.