Michael Terry, Professor, USD Hahn School of Nursing and Health Science
Related Story: USD Training Nurses To Assist Veterans
ALISON ST JOHN: You are listening to Midday Edition. I'm Alison St. John inform Maureen Cavanaugh. It's estimated that 400,000 service members have returned from recent military complex and are living with the invisible wounds of war. Including combat stress, depression and post-traumatic stress disorder. That doesn't even include the number who may have suffered a traumatic brain injury while deployed. That is nationwide, but San Diego is home to the largest number of veterans from the resource of any county in the country. And so it is good news at the University of San Diego is launching a key initiative to serve veterans and specifically those suffering from these invisible wounds. Our guest is Prof. Michael Terry who is clinical associate professor at the Hahn school of nursing and health sciences at USD. Dr. Terry, thanks so much for joining us.
MICHAEL TERRY: Good afternoon.
ALISON ST JOHN: So what is the need that's prompting you to change the way you are training nurses at UCSD.
MICHAEL TERRY: There a couple of things Allison the first thing is that the program, hospital nursing has been affiliated with the military for a number of years and a number of our students seeking Dr. degrees or Masters degrees as our military active duty or retired, and about five years ago the leadership at Balboa Naval medical Center came to us and said we really need nurse practitioners and one of the persons that contention and came to us was John DiNardo, who is actually one of the first Naval nurse practitioners. And he saw the need being a nurse practitioner himself and and the rear admiral and other folks had come to you USD and talk to Dean Sally Hartman said we need a program like this. We are really short on resources and we see this as being a critical problem in the future.
ALISON ST JOHN: Why nurses as opposed to any other doctors for example, why nurses are so critical?
MICHAEL TERRY: Good point, nursing has had a unique relationship with patients or clients from the very beginning because of the type of model the biopsychosocial and communication model that kind of embodies the spirit of nursing, where nursing has been around caring and an unnecessarily caring. So nurses are often the first people that a patient arrest someone seeking help talks to when they call in. They often man the communication lines or the hotlines. There are more nurses than any other health professional in the country. And the psychiatric nurse practitioner has been a more recent add-on to that and brings and a unique set of skills that are different than a psychologist or psychiatrist for example.
ALISON ST JOHN: I think that is one of the big problems is connecting to servicesThat are growing increasingly out there with the people in need them, right? Are you looking at where these nurses would be place so they could actually reach the people who need what they have to offer?
MICHAEL TERRY: Yes that is part of it. You know that I think that one of the things that has been in cringing and at the same time dismaying of the last several years is we've seen a huge development about services for returning service members who have been recently deployed right at the post deployment stages, and now who have left the service and become veterans and yet the services are, I mean they are huge, they are all over the place and you could pick up any journal or go to any website for the military in you could see all the services that are offered, but not at one place.
ALISON ST JOHN: And yet there are 20% of people homeless on the streets in San Diego of the veterans are suffering from PTSD and never access the services. Do you think that the stigma is making it more difficult for these professionals to actually reach the people that need the help?
MICHAEL TERRY: That is actually one of the key things that we can't actually treat someone until they come in the door and increasingly there are technologies such as on-site web-based services that are being made available so that service members can contact essentially a program online that they can download services or links or actually participated some screenings and even have a chat with someone who they remain anonymous with so they can avoid this kind of stigma. Because the stigma that is presenting a lot of services. The services, they are fragmented and everyone is starting up a banner and literally seeing and when they get Amanda qualify because they are limited in terms of the scope they can do, or that location so there's a huge problem with the integration when you actually get it, but getting it is a huge part of the problem and it is because of what Paul Chappelle was talking about in terms of the warrior mentality. It is the warrior mentality and stuff that leads to its own built-in stigma that's really the hardest thing to overcome because the very thing that makes you a key kind of factor in part of the team in the team mentality is that you can depend on the person next to you. You risk your life for the person and the person is always there for you and the bond is insoluble. To think that the person could be a weak link because our country stigmatize mental illness and to think that the person might have an emotional breakdown and not be there for you when you really are depending on your life or that create such a statement that weekend, people cannot come in and say I might have a problem and they go through a huge amount of suffering and stress before they ever get help just out of this absolute denial. It can't be happening to me. And also our whole society and tequila the warrior mentality, the warrior ethic and courage is, you don't deal with it because you cannot deal with that when you are in a combat zone. You can't afford to let it John you just put it aside the problem is reported the site but we don't come back and pick it up again.
ALISON ST JOHN: Is there something in the training of the nurses that you are doing that addresses the issue?
There isn't a lot of it has to do with the type of sensitivity of the way you do an assessment, the way US questions, the ways you pose a problem. This is not a job for a census taker which much of medicine ends up being in terms of just asking a yes or no question. You ask them do you feel like hurting yourself, you know, there's hardly any service member present or past was going to say right away that that is the first thing on their mind is hurting himself that is the last thing you want to do but they feel like they just like to get out of the pain and suffering, whatever it takes.
ALISON ST JOHN: Our training vendors this question. Getting help from the military health establishment?
MICHAEL TERRY: Yes we are the placement sites as you mentioned on your piece and I know we've talked about this before we have two trucks right now the program is very small so we filled the graduated one class of only four people so far. One was a civilian nurse practitioner who was working at Balboa Naval who is now a psychiatric NP, and the other two are, one is retired and what is currently Lieut. Navy commander and once an Air Force major who are working with the military but because of this connection of our history and safety ago and because of the school of nursing's connections we've been able to work through placements so we have placements out the different VA sites in San Diego area, and also with the veteran center and with Kim Pendleton and Balboa Naval.
ALISON ST JOHN: So there won't be any problem with the students getting a job after they finish training?
MICHAEL TERRY: No, in fact Balboa Naval at one time one psychiatric nurse practitioner and now there are seven.
ALISON ST JOHN: That's right so what kind of students are applying are these people who have been in the military themselves or civilians, were the nurses?
MICHAEL TERRY: They are both. For example in our current class we have a retired Army nurse who really feels like she wants to go back and, her heart is there with the servicemembers and she wants to work in the VA having received services herself. And then we have another nurse who is current active-duty military naval, and she's working doing her rotations at Camp Pendleton at the VA. And she intends to continue in her current job as a psychiatric NP. Well she is employed and while she is still in service.
ALISON ST JOHN: I was interested to hear that also you're going to be doing some research, is that right?As part of the initiative into dramatic brain injury and PTSD?
MICHAEL TERRY: We are looking, part of the issue is training people to recognize that this triad exists between TBI, PTSD and chronic pain for example. Because to pick up on what you really have to be looking for the other two, because together they are synergistic in terms of the level of symptomatology that they present with. And because each individual one of those don't present typically with what you would think of when you typically go to a primary care center, civilian center in particular where people are not trained to begin to recognize how these show up
ALISON ST JOHN: Can you give an example of some of the symptoms that might be telltale signs but you might not recognize?
MICHAEL TERRY: For example, someone walks into remember 50% of service members whether veteran or currently in the service end up in civilian primary care sites, often because of the stigma. When they actually do stakeout help, when the present, they will present with trouble sleeping, they will prevent nightmares agitation, frustration, the fact they do not feel like themselves, they feel like the world does not feel like normal anymore to them and literally their brains have changed from this path of cortisol for the stress of being deployed from these periods of time the more you are deployed the more cortisol you bring and the more likely it is to change it. That does not mean that they will develop PTSD but it means that the brain can changed and if there are underlying factors that can, including childhood neglect and abuse, those kinds of things can actually can actually create a susceptibility to this showing up later on. We don't have any good ways of screening for that now but the way the symptoms present is that someone comes in and the same agitated I'm frustrated I'm angry I find myself yelling for no reason. I don't feel like people understand me. The only people I can talk to are my buds, but they are not around. They're all over the country and I feel like I've been dropped off and dumped off and I don't know what to do
ALISON ST JOHN: Then the question arises what (inadible) split the client into a whole series of things that are healing, what kind of treatments are you offering is a drug-based or talk-based?
MICHAEL TERRY: Both there are a number of evidence-based treatments that have been promoted for this. One, there are some that are related directly to treating PTSD. The first thing you have to do is great for them the military is doing a better job screening for this weekend gone to any kind of check about the VA or insulation without asking about suicide these days matter where you are coming in for you will definitely be asked about that and you are doing a good job at right at post employment first when you get back several months later in six months later about screening for PTSD. But not everybody shows up. And it's not always picked up and the screening tools are somewhat superficial. So that screening, if you get a hit on it you get it more of a diagnostic assessment. So first you've got to be picked up on event you've got to agree to come back. You've got if you like the person you talk to or the area where you are getting services going to actually be receptive to you, where they are not going to turn you away and say this is normal, in some cases it is operation or combat stress not helping PTSD yet, everyone's having symptoms for the cortisol in their brain but they are not at full PTSD, and so helping people to access services that they can normalize some of the stress that are there. Some hyper alert, hyper focused always looking for the sniper around the corner, hearing sounds that set off reexperiencing and traumatic flashbacks that might not be fully PTSD but might be on the border of a.
ALISON ST JOHN: So Dr. Terry the nurses are obviously being trained to release but the symptoms, but then are they qualified and authorized Just prescribed drugs.
MICHAEL TERRY: They are. Nurse practitioners prescribed drugs in all 50 states in the district of Columbia psychiatric Nurse practitioners are licensed to do therapy as well as prescribed we do PTSD, progressive exposure therapy we do personal integration therapy and cognitive and behavioral therapy. Those are non-, drugs, but we use them with medication if necessary.
ALISON ST JOHN: Got it ingested the minute we have left there's a lot we don't know about genetic brain injury. Are you also participating in research into what are the best ways of helping people who have symptoms of TBI
MICHAEL TERRY: We are consumers of the research now that's being developed we have a focus called evidence-based practice we take things further developed and proven to be efficacious and we look for ways to best apply it in the current situation and the research that we are looking at doing here in the hospital of nursing is based on the center that we are just getting funding for right now and we are halfway there to developing Institute of nursing research and I expect to have it up and running within the next five years and in that site we are going to be developing more research particularly around these areas and we do have PhD students right now conducting research individually around us but we hope to have a laboratory set up to focus more on this in the future.
ALISON ST JOHN: Do you have a sense of the numbers of people in the San Diego community looking for these kinds of services?
MICHAEL TERRY: I have no idea. I just know that it's huge.
ALISON ST JOHN: That's good thank you so much for sharing. Yet one more resource that people who are coming back from the war zones can turn to. That is on school of nursing and health sciences is treating psychiatric nurse practitioners and Prof. Michael Terry, thank you so much for joining us.
MICHAEL TERRY: Thank you