It was a near-freezing morning, made even colder by the surrounding desert-like isolation of Khost, a base camp in a mountainous region of Afghanistan near the Pakistan border. Lilliman, a sergeant in the U.S. Army, decided to leave her warm room to go outside.
She was smoking a cigarette and drinking coffee when she felt the ground shake.
Lilliman wasn't alarmed. She had been in the camp for 11 months, and the Taliban frequently attacked it with rocket fire. She didn't hear the whistle of an incoming rocket, leaving her with a false sense of security that the base was firing on outside targets. Seconds later, she looked up just in time to see a rocket coming right toward her.
The blast slammed Lilliman into a wall.
'It was like somebody hit "Pause'," Lilliman recalls. "Everything stopped. Everything was humming. I kept trying to lift my head up and I couldn't. The sergeant ran over, picked me up and brought me in the bunker, and I still didn't have any control. I didn't feel pain or anything. I was just numb. Then it was like somebody hit "Fast-forward' and everything just hurt and I was bleeding."
In the bunker, Lilliman's staff sergeant held her, and she could see the veins in his neck sticking out. He was yelling at her, but Lilliman could no longer hear. For the next hour until the attack ended, she sat with her sergeant in the bunker, bleeding from her ears, mouth and hands in her new silent world.
Now, back home in Marrero, honorably discharged from the Army and with a chest full of medals for her bravery, Lilliman still lives in a mostly silent world and she continues to fight. But this time, she is fighting government bureaucracy and the battle is over health care.
For injured and disabled veterans returning to the New Orleans area, getting adequate health care is a challenge. There is no central hospital for inpatient treatment, there are far fewer doctors than before the storm, specialty services are scattered and sometimes unavailable in the region, and many veterans travel outside the state for care. Disabled veterans don't have private health insurance, but are part of the Veterans Administration (VA) system, so they have few choices. Without insurance, they can't switch hospitals, and, if they're unhappy with a doctor, they often have a hard time finding another. Local hospitals treat these veterans, but it is with the understanding that the VA is slow to pay the bills and won't pay for inpatient care.
With more and more disabled veterans returning to New Orleans and no end in sight to the Iraq War, is this the best we can do for all of these people who put their lives on the line in defense of our country?
Lilliman, a petite 34-year-old with short ash-blond hair and a sun-kissed face, looks like the girl next door, someone's younger sister or someone's daughter. She is all of those things, but she also is a soldier. Her shy smile and healthy appearance belie the physical and mental injuries she will carry with her the rest of her life.
Due to her extensive injuries, she was honorably discharged from the Army and is now living on disability checks she receives from the VA. After four surgeries on her ears, she is 90 percent deaf. She's undergone four additional surgeries on her right leg, which was fractured and torn at the hip from the rocket blast. Despite all of this, Lilliman struggled just to get into the VA system.
When she left the Army in December 2006, Lilliman already had undergone three surgeries on her ears, so the Army was aware of her hearing loss (somehow, the medical staff had missed the fractures in her right leg and her torn hip). Prior to her discharge, she went before an Army medical board that decided the Marrero sergeant was only 10 percent disabled and ineligible for benefits. Lilliman returned home thinking she would only receive a standard six months of full medical coverage for returning veterans.
After the 10 percent disability determination from the Army, Lilliman didn't think she would receive much better from the VA. The Army told her not to approach the VA for assistance until she had finished the remaining six months of her Army insurance.
Neither turned out to be true.
Through the military insurance, Transitional Assistance Management Program (TAMP), which the Army provides for six months after a soldier is discharged, she received another round of surgery for her right ear at West Jefferson Medical Center. A month later an orthopedic surgeon repaired her right hip, leaving her unable to walk for six months. The ear surgery wasn't successful and left her "completely deaf" for four months. When TAMP refused to pay for post-operative physical therapy for her leg, Lilliman had had enough.
'So I was deaf and I couldn't walk," Lilliman recalls.
She went to a VA benefits office in June 2007 and found out she'd been given the wrong information: she had been eligible for VA assistance since her discharge. It was incumbent upon Lilliman to know how the system worked. A VA nurse took charge of Lilliman's care, and she began seeing a neurologist; a physical therapist; an ear, nose and throat doctor; a brain-injury specialist and a counselor.
'Finally, I had this big weight lifted off my shoulders," Lilliman says. "Because I didn't know what the hell I was doing."
Doctors at the VA clinic soon realized that her wounds from the attack were much more severe than the medical board had surmised. They diagnosed her with Post Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI), which helped explain Lilliman's ongoing insomnia, severe migraines and vertigo.
She now spends many of her days receiving care at the downtown VA outpatient clinic in what remains of the pre-Katrina VA hospital facility. If the clinic can't offer her the services needed, she is sent elsewhere.
Lilliman isn't alone. Last year, the Southeast Louisiana Veterans Health Care System (SLVHSC), which covers 23 parishes, provided services for more than 33,000 veterans. Like Lilliman, the system suffered a catastrophic attack in 2005 Hurricane Katrina and it is far from recovered.
Before the storm, the VA hospital in New Orleans housed 206 beds including 20 psychiatric beds. A staff of 1,720 doctors, nurses and support personnel worked for the hospital and the three outpatient clinics in New Orleans, Baton Rouge and Houma. In fiscal year 2005, the hospital treated 4,135 inpatients with a total of 40,212 veterans receiving services. That all changed when the levees broke, flooding the hospital and leaving SLVHSC with no hospital to provide inpatient care for the estimated 170,000 veterans living in the 23-parish system.
The system was decimated. The central hub of activities was lost, and like many other local facilities, VA services were set up in parking lots or housed in VFW posts. By December 2005, SLVHSC managed to open an outpatient clinic on the hospital's campus located on the ninth and tenth floors of the former VA nursing home. Since then, SLVHSC has opened another three outpatient clinics Hammond, St. John and Slidell doubling the number of outpatient clinics the system had pre-Katrina.
That's the irony of the SLVHSC: in some ways, it's better than it was prior to the federal flood. Dr. Richard Wallace, chief of ambulatory and primary care for SLVHSC, says that finding enough space for health care operations in the area and restoring full services likely won't take place until a new central hospital is open, but there have been improvements.
'The tragedy of the storm allowed us to create a system that now provides more access points for veterans remote from New Orleans than they ever had before," Wallace says.
The six outpatient clinics mean that 80 percent of all veterans in the system are within 30 minutes travel time of a clinic, with virtually all veterans receiving an appointment within 30 days of their request, Wallace says. He adds that SLVHSC still offers many specialty services like chemotherapy, cardiology, neurology and others. If it can't provide a service at its clinics, or is unable to do it within 30 days, SLVHSC contracts with local specialists and other facilities. For disabled veterans, this can translate into bouncing from one clinic to another.
Jay Walsh, a deputy service officer for the American Legion, reports the regular travel plight of one of the veterans he assists. "Instead of being in one building, you're going all over the place," Walsh says. "One vet I know goes to the New Orleans clinic for one thing (due to confidentiality, Walsh can't reveal which services), to the clinic in Reserve, La., for another and to Baton Rouge for another."
Veteran Archie Boyette isn't a fan of the current system of outpatient clinics. Boyette, commander of the American Legion Department of Louisiana, considers the clinics to be "like a production line: get them in and get them out." He advocates for in-house care like that of a large hospital. That way, Boyette says, if a veteran requires a specialist, he or she can be referred to a specialist in the same facility, which means better continuity of care.
Lilliman says that even though much of her care now takes place under one roof, her doctors change frequently. She hardly ever sees her neurologist; instead she is seen by a slew of neurology residents. That can be problematic when it comes to the prescription medications that Lilliman relies on for her migraines and vertigo.
'Every time I'd go in, I'd see a different resident and they would give me a different medication," Lilliman explains. "This went on for about six months."
Currently, SLVHSC cares for 80 percent of the total number of veterans it served before Hurricane Katrina, but it is doing so with only 1,000 employees, or only 58 percent of the pre-Katrina staff. (Gambit Weekly made repeated requests to SLVHSC for a breakdown of the number of doctors it currently employs, their specialties and the number of doctors employed before the storm, but SLVHSC did not provide the information.) Still, Lilliman, Walsh and most of the veteran advocates contacted for this story, believe the local VA is doing the best it can for local veterans; it's just doing it with less. The real problems occur when the veteran is forced to go outside of the system without private health insurance.
As Rhonda George, a public affairs specialist for the Veterans Benefits Administration New Orleans Regional Offices, puts it, "VA doesn't offer insurance to veterans because we have a hospital."
So what happens when there is no hospital?
In medical emergencies, a veteran can go directly to any local hospital for care, and the VA is expected to pay for those services. But as Bruce Naremore, chief financial officer at East Jefferson General Hospital, explains, there's a difference between how the system should work and reality.
'Any veteran who shows up at the ER (emergency room), we should get paid for Naremore says. "But it is difficult and the VA is a huge governmental bureaucracy. So it's hit or miss for us being reimbursed."
In 2007, New Orleans hospitals posted a combined operating loss of $135 million.
After a veteran is treated for an emergency and is stabilized, Naremore says that it's unlikely the veteran will be admitted to EJGH. Instead, he or she will be transferred to a VA hospital. The closest VA hospitals for veterans under SLVHSC's care are located in Jackson, Miss., Alexandria and Shreveport, La., and Houston. Naremore adds that immediately following the storm, the VA did pre-authorize care so that veterans could stay at local hospitals, but in general that no longer happens. When contacted, Touro Infirmary confirmed Naremore's assessment: slow and confusing reimbursement with stabilized veterans sent to VA hospitals outside of the region.
SLVHSC disputes this claim. Stephanie Repasky, an assistant to SLVHSC director Julie Cavalier, says it's "not completely" true that once a veteran is stabilized, he or she is sent outside the SLVHSC service area.
'There's legal guidelines that dictate and part of that is dependent upon service connection disabilities (disabilities or injuries incurred while the veteran was in active duty)," Repasky says. "If their care is pre-authorized for example if we're aware they are there then we follow and monitor the care. So we know that they're there, so we work with the community facility to coordinate the discharge and transfer of services back to the VA."
Sometimes the VA isn't aware that one of its veterans is in a local hospital's emergency room. Bill Detweiler, former national commander for the American Legion, says that's because the VA's reputation for paying hospital bills slowly precedes them.
'Even when it's pre-authorized, a hospital is going to grab Medicare or private insurance," says Detweiler.
It's likely because the hospitals have learned the hard way, just as Jim Stokes, a 100 percent disabled Vietnam veteran, discovered. In late 2005, Stokes began experiencing chest pains. He had suffered a previous heart attack, so he was driven by ambulance from his Bogalusa home to a local hospital. Assured he wasn't having another cardiac episode, Stokes was given medication and sent home. Later that night, the chest pains returned and this time Stokes' wife Liz drove him to another facility, where they discovered Stokes had been administered the wrong medication. Doctors there were able to stabilize Stokes and he again returned home.
More than two years later, the VA hasn't paid any of the bills connected with these two episodes even though Stokes is entitled to 100 percent coverage. Collection agencies call their house daily, says Liz Stokes.
They aren't the only bill collectors calling. While driving his motorcycle in 2006, Stokes was hit by a car and thrown 30 feet in the air. He landed on his head, breaking his neck in seven places and severely damaging his back. Stokes was rushed to a nearby hospital, but doctors there said that his case was beyond their capabilities and he was transferred to Lakeview Regional Medical Center.
Once there, an ER doctor wanted to admit Stokes into inpatient care, but he couldn't until a neurosurgeon evaluated the patient. Hours later, the neurosurgeon still hadn't visited Stokes. Furious, Liz Stokes complained to a nurse about the doctor's reliability.
'He's been told your husband is a vet and that's how his bills would be paid," a nurse confided to Liz.
When the neurosurgeon finally did arrive, he wasn't aware that Liz was in the room and he instructed the nurse to load Stokes into an ambulance and have him taken to the VA hospital in Jackson. Knowing the drive to Jackson could possibly kill her husband, Liz managed to find another neurosurgeon at Lakeview to care for him.
The Stokes' ordeal was far from over. Jim would spend another five weeks shuttled from one hospital to another. Eventually, Liz drove Jim in their pickup truck to the VA hospital in Houston, where he underwent 10 hours of surgery. After he was discharged, Stokes has had to travel to Houston monthly for follow-up care. For these trips, the Stokes are reimbursed $70, which is supposed to cover their gas, two nights' stay in a hotel and meals. Liz feels the trips to Houston aren't about continuity of care Stokes rarely sees the same doctor and the surgeon who performed the surgery is no longer with the VA but has more to do with the VA's bureaucratic lethargy regarding outside care.
'If a private doctor would see him with the VA card, it would make it much easier on him," Liz Stokes says.
Since his chest pain ordeal and the motorcycle accident, the Stokes have amassed more than $5,000 in outstanding medical bills. Most of the bills from Lakeview Regional Medical Center have been paid, but that money came from Medicare. Medicare and private insurance require that cardholders pay a deductible, so the Stokes have been saddled with that. Technically, the VA is responsible for the remaining portion, but more than two years later, the bills continue to pile up and the bill collectors keep calling.
Because of his heart condition and the severity of his spinal injuries, Jim Stokes can't talk about his ongoing problem with medical bills. Liz simply says, "It upsets my husband." After his latest examination at the Houston VA, doctors told the couple that Jim has a blood clot on his spinal column and it is inoperable. At any time, the clot can break free, travel to his heart or brain and kill him.
'He is just waiting for the Lord to take him home," Liz says.
Liz is adamant that her husband will receive a full military funeral when the time comes. She is bitter about the treatment Jim has received in the past three years since the local VA hospital was destroyed. With this experience, she says she empathizes with those "kids" who are returning to the states after serving overseas.
'I see who is coming back," Liz says. "I see what's going on, and I know what's going to happen to these new Iraq and Afghanistan veterans."
The Southeast Louisiana Veterans Healthcare System is participating in a managed-care pilot program. It is administered by a subsidiary of Humana, the health insurance corporation, and sets up a network of healthcare providers, allowing veterans to get authorized (paid) care outside of the VA system. Although Humana Veterans Healthcare Services couldn't provide the total number of SLVHSC veterans who were taking part in the program, it reports that it has scheduled more than 3,500 medical appointments since its inception in October 2007.
The program is titled "Project Hero."
Tiffany Lilliman is not one of the program's participants, but she is a hero.
Within a few hours of the rocket attack, Lilliman was evacuated by helicopter to the main U.S. Army base in Bagram. Her ears popped and drained and she could hear noises. She stayed in the base hospital for two weeks and another two weeks on the base recuperating. Despite being unable to walk or discern voices, Lilliman begged her chain of command to let her return to Khost.
Doctors at the Bagram hospital couldn't determine the extent of her injuries and debated sending her to a hospital in Germany for further testing. Lilliman fought against this idea. Few in her company had her training she had worked in the Khost camp battle room, controlling video feed from an unmanned surveillance plane that provided essential reconnaissance for the camp. She worried about her fellow soldiers. If they sent her to Germany, then the Taliban won.
Somehow, Lilliman convinced her commanders to let her return to Khost. With little hearing and on crutches, she was back in the battle room within a month of her injury.
'I didn't want to be sent back. I wanted to fulfill my duty," Lilliman says.
Sgt. Lilliman has fulfilled her duty, and it is now up to the federal government to keep its end of the bargain.