SBAR Analysis of a Vietnam Veteran

¶ … individual health history and examination of a 61-year-old American male Vietnam veteran, "Mr. John Veteran" using the SBAR approach. Mr. Veteran is married, with two adult children and three grandsons, aged 4, 7 and 12 years by his older daughter who is a registered nurse in an intensive care unit; his younger daughter is a senior in college majoring in business administration (she received a full scholarship to a private college). Mr. Veteran earned his bachelor's degree in organizational leadership at a small midwestern university. Although Mr. Veteran continues to work full time as a paralegal, he advises that he intends to "semi-retire" when he turns 62 years next year and becomes eligible for Social Security payments. Mr. Veteran smokes two packs of cigarettes a day and drinks beer on occasion, but does not take drugs, even for severe pain, because he is worried about becoming addicted to them.

Although he served as a combat veteran in Vietnam, Mr. Veteran finished his tour of duty without incident. He was, however, wounded in 1976 while serving in Belgium at Supreme Headquarters Allied Powers Europe when his car struck a light stanchion on the autobahn, seriously injuring him with two broken ankles, severe traumatic brain injury, a broken right femur, a fractured pancreas and a broken mandible. Mr. Veteran has undergone 17 orthopedic surgeries over the years to repair these injuries, including a left femoral shortening by 1-1/2 inches to even his leg lengths to reduce the strain on his back which was causing him significant problems. Mr. Veteran had an artificial joint installed in his right ankle initially, but this failed after 2 years at which time his ankle was fused using a piece of bone harvested from his right iliac crest. Mr. Veteran is otherwise in good health.

Mr. Veteran is rated 90% disabled by the Department of Veterans Affairs but the veteran has been appealing this rating for several years in an attempt to secure a 100% total and permanent rating. Mr. Veteran concedes he may be suffering from posttraumatic stress disorder as well but has not sought service-connection for this condition because he is worried that the application process would exacerbate this condition further without helping his VA appeal. The veteran reports that the 100% disability rating pays nearly twice what his current rating provides, as well as healthcare insurance for his wife and younger daughter while she is attending college full time. In addition, if he can secure a 100 rating, he can use services on military bases such as commissaries and post/base exchanges.

SBAR Analysis

Situation:

Healthcare site: The healthcare site is the Department of Veterans Affairs Medical Center in Oklahoma City, Oklahoma which provides Mr. John Veteran's medical care.

Date: May 31, 2014

Problem/Issue: Mr. Veteran is a 90 disabled veteran with a number of residual orthopedic problems as well a potential psychological issue from posttraumatic stress disorder, problems which today are more than 36 years old.

Background

Mr. Veteran's healthcare problems began with an automobile wreck in Belgium in 1976 where he had been stationed for 3 years while he was serving as the personal secretary to General Alexander M. Haig, Jr., then Supreme Allied Commander of Europe. The automobile wreck resulted in a number of injuries to Mr. Veteran, including a broken mandible, severe traumatic brain injury (he was unconscious for 12 hours following the wreck), two broken ankles, a broken right femur and a fractured pancreas. Since that time, Mr. Veteran has undergone 17 orthopedic surgeries in an effort to repair the injuries and improve his physical condition. Mr. Veteran was the youngest recipient of an artificial joint but the device failed in 2 years and was replaced with an ankle fusion using a piece of his right iliac crest. Mr. Veteran has developed pancreatitis and complaints of shoulder and back pain, a continuously aching right ankle and diminished memory capacity (this has been confirmed by VA physicians). The most recent episode of pancreatitis in 2013 kept Mr. Veteran bed-bound for 2 weeks but he reports he believes this was due to the large amount of pumpkin seeds he ate during the days leading up to the episode which he has since found out can aggravate the pancreas. Mr. Veteran also suspects that he has posttraumatic stress disorder (PTSD) but has not applied for service connection for this condition but says he may if his latest appeal for an increase is denied again. Although Mr. Veteran smokes two packs of cigarettes a day and drinks beer occasionally, he reports not using drugs even for severe pain due to concerns about addition. The Department of Veterans Affairs is mandated to provide Mr. Veteran with healthcare and dental services because of his service-connected disabilities, as well as a compensation payment for his 90% disability rating.