At the VA, preparing brain-injured veterans for the real world

Dr. Joel Scholten

WASHINGTON — I recently met my friend Don at Independence Way, the model community rehab unit at the Washington DC Veterans Affairs Medical Center, the first of its kind at a VA hospital. Don was injured while serving in the Marine Corps in Afghanistan in 2003. Since then, he has largely conquered a brain injury so severe that he wasn’t expected to ever be able to function on his own. But from what I can tell, he is functioning better than some non-injured people I know. And during his ongoing therapy at the VA here, he discovered the hospital’s new rehabilitation area and encouraged me to check it out.

Independence Way is an environment that simulates real life, so veterans who suffer from traumatic brain injuries (TBI), other neurological conditions or physical injuries can train for community re-entry within the safe setting of a medical center.

Designed by Patricia Moore of Moore Design Associates in Phoenix, Independence Way is similar to other simulation environments Moore has developed at more than 300 health care facilities around the world. She said the projects range from $250,000 to $1 million. At this hospital, the TBI case load is about 200 patients, and some of them work with therapists as many as five days a week.

Independence Way opened in October, so Don–whose brain injury left him unable to do things like lift a fork or read a clock– didn’t have the benefit of this tool when he began his rehabilitation. But as we walked through the simulated community with Dr. Joel Scholten, the hospital’s Associate Chief of Staff for Rehab Services, it was clear that the setting would have been invaluable in his healing.

One area of the community features an ATM, a Metro turnstile` and a small convenience store—complete with dry goods, plastic fruit, refrigerated items and a cash register. Typically, a patient would sit with his or her therapist, come up with a shopping list and a budget, then walk to the ATM, withdraw fake money and shop at the store.

“This was designed to provide an unlimited combination of therapeutic options for training, so you can make real world progress in a semi-controlled manner,” Scholten said. “Our goal with rehabilitation is to maximize independence in the community.”

Scholten said Independence Way makes the rehab job easier—for both the therapists and the patients. In Don’s case, he would talk about these tasks—hypothetically– with his therapist and then practice the skills on “field trips” outside the hospital–where it was inherently more stressful. You never know when, for example, there will be a line behind you at the ATM, an ambulance wailing , a dog barking, a baby crying, gum popping or simply two people conversing. Any one of these things could be paralyzing for someone  with a brain injury or post-traumatic stress disorder (PTSD), who is trying to operate an ATM.

In fact, therapists will increase the difficulty at the simulated ATM by adding distractions once the patient is comfortable withdrawing money. They might position other patients in line, turn on a radio or ask people to talk in the background. They can also make things more complicated at the store. If a patient masters his or her shopping list and budget, the therapist may alter the milk’s expiration date or change the French’s mustard price to $15—details that most of us notice out of habit.

Scholten told me that rarely does a patient just have a brain injury. “It can also be PTSD, balance issues, anxiety, pain, depression. Then there’s the memory issue—say you go into the store for three times and only remember two,” he said, noting that for the balance-challenged, even walking through a store with a shopping basket, while adding items, can be tricky. “So you want to set them up for success in therapy, which is a lot easier to do here. If they fail here, it’s not a big deal. In the real world, it can be traumatic.

Don said he was impressed by Independence Way’s level of detail. “I can see a dozen things here that would have posed a challenge for me,” he said. “If you have tea on your list, and you go into grocery store and there are two kinds of tea, I wouldn’t know what to do. This happened to me, and I was paralyzed.” He said the first time he went to Best Buy during his recovery, he got stuck in what he called “decision lock.” “I found myself trying to make a decision for about three hours, and it was pretty traumatic.” He said some of his trips to the grocery store had to be aborted, because there were too many distractions.

We walked to another area of the simulated world, which included a curb, a yard gate with a combination lock, and some turf and cobblestones leading up to a front door. Don explained that the uneven turf and transitioning to the cobblestone could be problematic for anyone with balance or vision issues, including patients who have prosthetic legs. Tasks as seemingly uncomplicated as balancing while unlocking a front door; or opening a screen door, using a door knock and then stepping back away from the door, could take patients weeks to master.

There are three different types of mailboxes by the front door, and I wondered about the lessons taught here. Don explained one of the challenges: When a patient sees mail in his mailbox, he has to figure out, “Is it mail I put there to go out, or mail that’s been left there for me?”

There is also a full kitchen and laundry area, complete with a coffee maker, three different microwaves (with different knobs and buttons to learn), and a stove. Patients might bring their groceries here and practice preparing a meal—following a recipe, measuring ingredients and remembering to turn off the oven.

Finally, we walked over to the sink area, where the faucet dripped. My first instinct was to tinker with the handle and try stop the drip. Don glanced at the sink and smiled. “Nothing is by chance,” he said, “which leads me to believe this [drip] is on purpose. It’s a pretty powerful distraction for me.”

We decided to have lunch, so I used the sink to wash my hands. By this point, even I had become distracted by the dripping. Plus, I wanted to test Don’s theory that it was a set-up. I pushed down the handle, fiddled with it for a moment, and waited. The dripping resumed.

Read more on healing brain-injured veterans: New facility will address TBI, PTSD in returning soldiers