Behind the wall of silence
On Jan. 2, my wife called me from her office with tragic news. The husband of a coworker had committed suicide at Tripler Army Medical Center. He was a retired Air Force master sergeant with a history of clinical depression. His name was Robert Roth -- "Bert" to his family and friends.
My immediate reaction wasn't surprise. It was anger. I was angry because his death could have been prevented. His wife, Satsuki, had told us that Bert twice had sought help at Tripler, where he worked as a clerk, but each time they refused to admit him for treatment.
The story wasn't made public until Aug. 2, after her attorney, Rick Fried, released the Army's internal investigative report to me and two other reporters.
(Disclosure: My wife, Isabel, contacted Fried's law firm on Satsuki's behalf, because English isn't Satsuki's first language. We had urged her to consider filing a lawsuit to make sure this type of thing didn't happen to anyone else at Tripler. I also shared information with Fried about Bert's background, which Isabel and I had learned from Satsuki.)
In May, Fried filed an administrative "Claim for Damage," which stated her case for medical negligence based upon evidence his law firm had compiled. If the claim isn't settled by the end of November, she can then file a malpractice lawsuit against Tripler.
Fried asked me not to write about the case until the Army's own investigation had been completed. That 87-page report confirmed virtually everything Satsuki had told me. It also revealed many other details.
Tripler's medical records show that twice in December, Bert Roth went to the emergency room because he was having suicidal thoughts. Both times he had to wait for hours before anyone would see him. For reasons that have yet to be explained, the ER staff did not admit him to the psychiatric ward, as he had requested. The report also indicates the ER staff did not inform his psychiatrist that he had threatened to kill himself on those two occasions.
From the beginning, I wondered if the delays in Bert's getting help were related to staff shortages because of the war in Iraq. I had read about other military suicides on the mainland after vets were put on waiting lists for psychiatric care. Then the Walter Reed Army Medical Center scandal broke in March, and it became painfully clear that the U.S. government wasn't doing enough to provide adequate health care for veterans.
Military spouses and medical professionals who have worked in the military health care system say there is already a staff shortage at Tripler and not enough hospital beds. If that's true, what will happen when thousands of soldiers and Marines begin to return from tours of duty in Iraq and Afghanistan?
A former nurse at the Spark M. Matsunaga VA Medical Center in Moanalua said doctors and staff there are "overwhelmed" as it is, and have been talking about this potential crisis for some time.
"They know it's coming. But they're afraid to speak out about their concerns," she said.
The VA center has only about 60 beds, and refers veterans to nearby Tripler for hospital procedures. The U.S. Department of Veterans Affairs Web site says the VA also provides 20 psychiatric care beds at Tripler, which serves active duty military and their families. As near as I can determine from various sources, between the two, there are approximately 300 hospital beds available.
According to the nurse, who requested anonymity, the VA center's primary function is dispensing prescriptions to patients with mental problems. Her fear is they aren't getting enough one-on-one counseling due to a lack of doctors and funding.
Officials at Tripler denied a request for an interview and would not answer any questions related to Bert's death or the projected impact of the Iraq war on caseloads.
The truth is, we don't know if Tripler has taken any steps to ensure that severely depressed vets or returning troops are getting immediate help. They aren't talking. And active duty military cannot file medical malpractice claims against military hospitals. For all intents and purposes, Tripler has put up a wall of silence.
Collateral damage from war can take many forms, including post-traumatic stress disorder. PTSD often leads to substance abuse and domestic abuse. Untreated, it can cause good people to harm themselves or others.
Bert didn't have PTSD, but he understood mental illness. He had a degree in psychology. His job at Tripler involved working with patients' records and keeping track of medical supplies. He was certified as an ambulance driver and emergency medical technician. Satsuki said he had twice had been hospitalized for severe depression years earlier, and he recovered each time once the suicidal feelings had passed. This was a guy who knew something about his mental condition. Yet it seems no one at Tripler was listening when he told them he wanted to check himself in.
Depression is widely believed to be linked to genetics and faulty brain chemistry. A combination of counseling and antidepressant medication can help. However, doctors know that each person reacts differently to these drugs -- which is another thing that makes Bert's death so troubling. In a one-month period, Tripler's records show he was prescribed four different antidepressants.
When I asked Satsuki how Bert felt about the care he was receiving, she slowly shook her head. In halting English, she said, "He didn't think the psychiatrist understood him. He kept telling her the medication wasn't working, but she told him that it worked for everyone else."
The Dec. 16 ER report notes that Bert couldn't "remember dosage" of the meds he was taking: Lithium, Effexor, Trazodone and Seroquel.
Job stress and the high cost of living in Hawaii also might have been factors contributing to Bert's depression. The owner of the house he and Satsuki had been renting decided to sell it. Born and raised in Japan, Satsuki recently became a U.S. citizen and planned to put down roots in Hawaii. She wanted to buy a house, but they couldn't afford it in today's sky-high real estate market. Finding a new place to rent was difficult and created a strain on their marriage.
Bert was frustrated at work, too. He told Satsuki the Army's system of record-keeping for patients was "horrible," and he complained that the medical supply room was disorganized. The Army's report on his death indicates he was having trouble doing his job, which could have been a result of his depression or of being on medication.
However, it's possible his complaints were valid. A 1999 study cited record-keeping problems at Tripler related to a "cluster" of seven suicides (see sidebar).
In the weeks before he died, Satsuki said there were days Bert couldn't get out of bed. He cried a lot. Tripler's records confirm he saw a psychiatrist on Dec. 4, Dec. 8 and Dec. 13. Notes by staff members quote him as saying the meds weren't working and his depression was worsening.
Bert waited with his wife in the Tripler ER on Dec. 16 for five and a half hours before anyone saw him. He was told there were people with more serious illnesses ahead of him -- even though the ER form has handwritten notes on it saying he had plans "to jump off Makapuu." Although he finally did see a physician, Fried says no one from the ER ever told Bert's psychiatrist of his suicide threat. The psychiatrist "adjusted" Bert's medications when she saw him on Dec. 18 and noted in her files that he didn't seem suicidal.
On Dec. 26, Bert returned to the ER with his overnight bag. There was only one doctor on duty because it was the day after Christmas. This time he waited alone for three hours, according to the Army's report, before he got angry and left. He told them he was going to jump off a building. They asked him to sign an agreement that he wouldn't commit suicide, but he refused. The report says Tripler staff members were unable to stop Bert from driving away. No one from Tripler followed up or contacted his wife to tell her of Bert's suicide threat, says Fried. On Dec. 27, Bert met with his psychiatrist again. The Army's report says there was no mention in the psychiatrist's notes of the ER visit the day before. It is not known why the psychiatrist was not aware of Bert's ER visits on Dec. 16 and Dec. 26.
Satsuki said he seemed a little better after the New Year's weekend. He assured her that he was OK, so she went to the office. Bert packed his overnight bag again and drove to work. According to the Army's report, he told a coworker that he had an appointment with his psychiatrist. But Bert's appointment actually was scheduled for the following day. It was a tragic mistake.
The psychiatrist's office was closed Jan. 2 because President Bush had declared it a federal holiday in honor of President Ford's death. The psychiatric ward also was closed. Satsuki says he probably didn't go back to the ER because "he had lost hope" after waiting for hours the last two times he went there.
Instead, Bert went up to the 10th floor. An emergency exit door was open. The Army's report says the alarm had been turned off for maintenance work. No one noticed him go out to the balcony. No one saw him jump.
In the months following his death, Satsuki has struggled with sorrow and grief. She says she feels lonely without Bert. She has lost weight off her thin frame. She had been to a psychiatrist, but after Bert's problems with the meds he was prescribed, she said she didn't want to take the Prozac her doctor had given her. She says she no longer trusts doctors or the drugs they use to treat depression.
After the Army's report on his suicide was made public, Satsuki and I talked on the phone. She asked: "I just want to know ... what has Tripler done to keep this from happening to someone else?" I haven't been able to give her any answers.
Rich Figel is a screenwriter who lives in Kailua. His column appears periodically in the Insight section. E-mail firstname.lastname@example.org
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A ‘cluster’ of suicides indicates previous problems at Tripler
Tripler Army Medical Center initiated a study intended to improve the identification and treatment of mental patients after the suicides of several patients in the mid-'90s.
Seven suicides occurred during a 15-month period from 1996 through 1997, according to the 1999 study. All were patients who had received treatment at Tripler.
The Suicide Prevention Advisory Group was formed by the Tripler psychiatry department to look for possible patterns and make specific recommendations, according to David Hough, the author of a paper on the study.
Most of the patients were suffering from depression or a personal loss, Hough wrote. As with Robert Roth, peers and staff were aware of their "suicidal state of mind," but action came too late.
The advisory group made 11 recommendations to Tripler. Two areas specifically addressed were "poor communication between the staff" and problems with "documentation" of patients who expressed suicidal feelings -- the same things that show up in the Army's investigative report about Roth's suicide on Jan. 2.
Hough also wrote in 1999 that Tripler was installing an "electronic record-keeping system that will allow mental health providers at any point in the system continuous access to patient records." If that system was implemented, why didn't Roth's psychiatrist know he had told the emergency room staff he was thinking of killing himself?
The Tripler advisory group's other recommendations stressed the importance of ongoing education for mental health care providers, redefining admission criteria for suicidal patients and educating the community about suicide prevention. It also noted that many ER patients are evaluated by second-year residents, who have had "minimal adult psychiatry experience" and should be given special classes on assessing suicidal patients.
The 1999 paper by Hough cited progress, noting there had been no suicides in the 22 months following the last of the cluster of deaths in 1997. Ironically, Roth might have benefited from that study because the last time he sought to be admitted for depression was in 1999. He went to the Tripler ER and was admitted right away.
It's also possible that he got quicker treatment at that time because he was still on active duty. According to a career Army wife, who requested anonymity, vets get "treated like third-class citizens" by the military. She said active duty personnel and their families get priority, followed by reserves, then vets and, last, the veterans' family members.
"The main goal is to keep those that are of service to the military in working order, and keep their families happy and healthy," the Army wife wrote in an e-mail. "As far as the vets are concerned, they've already been put out to pasture in a way."
Tripler officials declined to answer questions about the hospital's priority system and the 1996-1997 suicide cluster.