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Rehabilitation Colloquium Reflecting on the Past

Rehabilitation Colloquium Reflecting on the Past. 7 – 8 October 2008 Dr Graeme Killer AO Principal Medical Adviser Department of Veterans’ Affairs. AIM. My aim in this brief presentation is to revisit some of the health and rehabilitation challenges of World Wars 1 and 2 and Vietnam.

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Rehabilitation Colloquium Reflecting on the Past

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  1. Rehabilitation ColloquiumReflecting on the Past 7 – 8 October 2008 Dr Graeme Killer AO Principal Medical Adviser Department of Veterans’ Affairs

  2. AIM My aim in this brief presentation is to revisit some of the health and rehabilitation challenges of World Wars 1 and 2 and Vietnam

  3. I’ve come up with a definition which may not suit everyone but lets work through it. The word rehabilitation is derived from the medieval latin word rehabilitare, which means to restore. In the widest sense, the word rehabilitation, could be used in terms of restoration of confidence, self-esteem, reputation, physical, mental or social wellbeing, ability to work, or all these things. So it is important to understand the objectives of rehabilitation shouldn’t be thought of only in terms of returning to paid employment. To the individual and his or her family these other objectives are probably more important

  4. WORLD WAR 1

  5. With experience, doctors’ perspectives changed. They came to see that a man’s capacity to endure in war was determined by many things – heredity, upbringing, ‘character’, the society he came from, how he felt about the war, his relationship to his fellow soldiers, the length of time he had been fighting, whether his wife has been unfaithful – quite apart from the military circumstances in which he found himself. They realised, too, that in the military context collective factors often mattered more than individual ones such as morale and unit leadership.

  6. THE REPATRIATION COMMISSION MEETING THE REHABILITATION NEEDS The newly formed Repatriation Department put in place a package of rehabilitation that included medical treatment after discharge, provision of artificial limbs (for which the Repatriation Department developed special expertise), education fees, tools of trade, professional instruments, blocks of land and livestock.

  7. The key issues in rehabilitation from WW1 were: • The Government through the Repatriation Department provided wide ranging rehabilitation measures for returning WW1 veterans • There was strong community and political support for the veteran community • There was little understanding of the mental health issues of returning veterans and mental health services for veterans and the wider community were primitive and not conducive to rehabilitation • Some veterans with shell-shock self-managed their health problems through return to hard physical labour • There was an understanding that unit morale and leadership were important features in prevention of shell-shock in a post-war environment

  8. WORLD WAR 2 There are some comparative statistics between WW1 and WW2 that are important in understanding different challenges and rehabilitation between the two wars. While the numbers who served in WW2 were considerably greater than in WW1 both the numbers who died of wounds and total battle casualties deaths were far less. However, in WW2 we had in excess of 20,000 prisoners of war (POWs), many prisoners of the Japanese with high mortality rates from those working on the Thai-Burma railway.

  9. PRISONERS OF WAR (POWs)

  10. Dr Rowley Richards one of the 43 Australian doctors on the Thai-Burma Railway said the POWs responded well to rehabilitation on their return and this was because: • They were a survivor population • Mateship was paramount forged in hell and this continued after returning home • Strong family support • Many had been immunised for hard times because they came out of the depression • A positive mental attitude • Strong leadership in the camps

  11. VIETNAM

  12. On review there have probably been a number of initiatives that have contributed to the rehabilitation of Vietnam veterans and their families: • Vietnam Veterans’ Counselling Service (VVCS) – 1981 • Australian Centre for Posttraumatic Mental Health (ACPMH) – 1995 • The Heart Health Program – 1997 • Access to new pharmaceuticals • New education initiatives with the Australian General Practice Network (AGPN) (pathways to care study)

  13. VIETNAM VETERANS’ COUNSELLING SERVICE (VVCS) The VVCS was not based on the medical model and allowed veterans and later their families to seek counselling in relation to their mental health problems and it has pioneered health promotion programs particularly in relation to the use of alcohol but outcomes would be improved if stronger links were developed with general practitioners and divisions of general practice.

  14. AUSTRALIAN CENTRE FOR POSTTRAUMATIC MENTAL HEALTH (ACPMH) ACPMH has had a significant role nationally and internationally in policy direction by educating both providers and veterans alike in mental health Problems associated with military service. It has also had a pivotal role in accrediting in and outpatient PTSD rehabilitation programs.

  15. THE HEART HEALTH PROGRAM The Heart Health Program is about educating veterans in cardiovascular risk factors and encouraging lifestyle changes associated with regular exercise. It has been well accepted by the veteran community and many veterans have maintained ongoing participation after many years. The wife of a Vietnam veteran who had PTSD told me that her husband’s involvement in Heart Health was the best thing he had done in married life. The strengths of this program relate to the wellbeing that comes from physical fitness, mateship and the fact that it is a voluntary program.

  16. ACCESS TO NEW PHARMACEUTICALS New pharmaceuticals have indeed improved the management of some of the symptoms of PTSD, the SSRIs have reduced the hyperarousal symptoms and reduces irritability and anger and the atypical antipsychotics i.e. Olanzapine has improved the ability to sleep. The SSRIs have come into some criticism because of links to suicide in some individuals. The issue is primarily in this case about optimal patient management and careful monitoring of patients in the first two weeks of treatment because of the potential to develop agitated behaviour.

  17. SUMMARY • Keep rehabilitation program simple and don’t over medicalise i.e. Heart Health, “Men in Sheds” • Greater involvement of veterans in developing veteran self-help programs • Early intervention is the key and there should be properly structured case management approach • Rehabilitation programs need to be linked to preventive health programs and assessments particularly related to post discharge medical screening • Building on the current links in rehabilitation between Defence and DVA • Maximising rehabilitation outcomes within Defence • Transition programs for all those leaving the ADF • Inclusion of families in rehabilitation programs • Rehabilitation packages should include medical treatment, education and vocational arrangements • Improved education of health providers in terms of the impact of military service on health of serving members, veterans and their families • Greater promotion of self-care and health literacy programs

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