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Beyond The Battlefield: Lack Of Long-Term Care Can Lead To Tragic Ends For Wounded Veterans

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KARIE FUGETT PHOTO
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"Beyond the Battlefield" is a 10-part series exploring the challenges that severely wounded veterans of Iraq and Afghanistan face after they return home, as well as what those struggles mean for those close to them. Other stories in the series can be found here.

Jimmy Cleveland Kinsey II was a good Marine who got blown up in Iraq and struggled for years with his wounds and with the demons that came with them. Eventually he lost, dying sick and alone, facedown on the floor of a Houston hotel room. He was 25 years old.

His young wife, Karie, had stayed with him in the years leading up to his death, in countless hospital wards and hotel rooms, changing his dressings, soothing his pain, managing his medicines, absorbing his moods, struggling to keep his well-being ahead of her own.

The wounded warriors visible to most Americans are the survivors, those who overcome debilitating injuries through their own perseverance and the hard work of military medical teams, friends and family.

There are those who rise even further above adversity, competing in the Paralympics, giving motivational speeches, enjoying standing ovations and special guest appearances at ballgames and State of the Union addresses.

Others come home wounded, and don't make it much further. For them, the quality and type of medical care they require simply isn’t available on a long-term basis, and that’s a problem the military and the Veterans Administration have yet to fully wrestle to the ground.

Kinsey was among those who are burdened with chronic pain and depression, with drug addiction, with the anguish of losing buddies in battle. Along with their physical injuries, they seem wounded with the shock and loss of finding themselves flung abruptly from the high-adrenaline camaraderie of battle into a harsh, solitary world of hospitals and rehab -- disoriented in a civilian world where nobody understands war or is paying much attention, and where they struggle to come to terms with their future as young, disabled Americans.

Jimmy Cleveland Kinsey II -- "Cleve,'' to tell him apart from his dad -- was a south Alabama boy, six feet and three inches of energy and mirth, with a weakness for radio-controlled model planes and, later, a 1988 Mustang Saleen. He also had an eye for a pretty local girl named Karie Fugett, whom he met in the eighth grade and, years later, met again when he was a Marine riding US Airways into Jacksonville, N.C., on his way to Camp Lejeune, and she was a flight attendant.

Jimmy and Karie became inseparable, joking and laughing and partying, and it wasn't long before they eloped. Ninety-nine days later, Jimmy, deployed on his second combat tour in Iraq, drove over a land mine in Ramadi, Iraq. He was trapped in the overturned burning vehicle; the blast left him with shrapnel wounds, burns, a mangled leg, post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI).

That was in April 2006. He was 21 years old. Karie, who rushed to his side at Bethesda Naval Hospital, was 20.

"The next four years were spent in hospitals and hotel rooms,'' Karie wrote in her blog. "I was scared, I was exhausted, and I felt very alone.

"We were fighting to get his life back, and fighting to make a marriage work through pill addiction, overdose, miscarriage, family feuds, infections, amputation, PTSD and TBI.

"There were amazing times that made everything worth it, and there were times I truly felt like I was in hell.''

'THE GOOFIEST AND FUNNIEST PERSON EVER'

Jimmy had been bedridden for three months after he was blown up, and then was able to hobble around on crutches. Surgeons were trying to save his leg, which the blast had shattered. Most of his calf muscle was gone and doctors were trying to replace it with muscle transplants from his back.

He was also going to an outpatient clinic to deal with the brain injury he had suffered in the blast. He hurt all over. He had nightmares and anxiety attacks. He was on methadone and Percocet, a narcotic pain reliever, and over the months was taking morphine and Dilaudid, addictive pain relievers. Occasionally, according to Karie, he was prescribed Seroquel and Klonopin for anxiety and panic disorders.

The pills helped. More pills helped even more.

"He used the pills to escape,'' Karie recalled. "The thing is, he took more than he was supposed to … and that, mixed with his brain injury, was scary,'' fueling fits of anger and violence. "I felt he was abusing his pills and I didn't want that.''

She begged doctors to find alternative treatments but she said she was told the pills were necessary. She was at her wits' end.

"The thing that got me was the amount of times I told the military to please, please help me come up with a way to help him with his addiction and wean him off of the pills. I thought he needed inpatient drug addiction therapy. He needed help and I didn't feel like anyone would listen to me.''

So she flushed the pills down the toilet.

She and Jimmy got into an argument over the pills and he flew into a rage. Karie stood her ground. He headbutted her and tried to choke her.

"I knew he had his anger problems just like I did,'' said Justine Brown, one of Jimmy's closest Marine buddies, who also had been wounded. "They tend to throw you on a lot of medications, and you know you need to get off them but you just can't. It makes you sad and angry.''

For his part, Jimmy told Karie the pills made him crazy, that he "didn't feel right,'' but couldn't stop.

"He was the goofiest and funniest person ever,'' Karie told me. "Those are the times you live for, and they love you so much, and then he'd hit me and go into a rage and then when he realized what he did he'd fall to the floor and bawl. You'd just want to hold him.''

For years, Karie stuck with it. "I convinced myself that I was okay with him hurting me. As long as at the end of the day I know I was there for him, I didn't even care if I died.''

Eventually, the bone in Jimmy's left leg became infected, and doctors at Bethesda concluded they couldn't save it. He called Karie, who was at work in North Carolina, and said they were going to take it off. She drove all night and got there in the morning to find him with a bandaged stump. It seemed to throw them both deeper into depression.

"He fought so hard to keep that leg,'' Jimmy's mother, Penny, recalled, through tears. "It was a year and a half of surgeries, antibiotics … I was devastated.''

A RESPITE

For a brief time, things got better. Doctors moved Jimmy from Bethesda to the former Walter Reed Army hospital several miles away for a prosthetic leg and physical therapy. He began to walk haltingly, and joined outings and trips for the wounded and their families; he and Karie went to New York City and stayed at a hotel in Times Square, watching the celebrations on Election Night 2008.

Karie discovered a group of other despairing spouses of wounded soldiers and Marines and found support in online chat rooms. She got away with them once for a gala weekend in Las Vegas organized by a nonprofit, Wounded Warrior Wives.

But the loss of Jimmy's leg, and the ravages of his brain injury and post-traumatic stress disorder, were weighing them both down. Eventually, Jimmy's pain and depression brought deepening addiction.

One night in late 2008, Karie awoke with a start to find Jimmy bucking and grunting in bed, purple-faced and covered with vomit. He was overdosing. She heaved him off onto the floor, called 911, cleared his mouth and throat and gave him CPR. When the EMTs arrived, they found Jimmy almost dead and shot him with adrenalin before taking him to the hospital.

Karie stayed with him there the rest of the night.

When Jimmy awoke in the morning he was furious at her for calling 911, and yelled at her to get out. She left, found a corner where she could be alone, and sobbed with exhaustion and anger and frustration and loss. Days later he apologized; he hadn't understood that she had saved his life.

A week after the overdose, Karie found out she was five weeks pregnant. She was overjoyed. A few days later, she miscarried.

"At this point, I'm afraid to even talk to God,'' she wrote in her blog. "Maybe He's mad at me. Maybe I've asked for too many favors and He's tapped out.''

Jimmy was granted medical retirement from the Marine Corps. He received a 90 percent disability rating, which meant $1,100 a month less than they were expecting. And there was a months-long gap between the end of his military pay and the start of his veteran's disability payments.

Karie got a job as an online matchmaker, earning $10 an hour. The police arrested Jimmy one night for unpaid parking tickets and nobody could afford his bail. He would disappear for days at a time, then return and threaten Karie at gunpoint.

"Basically I was scared for my life,'' Karie recalled. She was having her own breakdown: nightmares, fits of anger, panic attacks so bad she'd rip off her shirt so she could breathe. For her own sanity, she began to see her girlfriends from high school.

Jimmy was furious when he’d come home and find her gone. One night he threw her clothes out into the yard and smashed beer bottles on top of them, and yelled at her that he'd kill her if she ever came back. She fled.

Karie said she finally realized that Jimmy was going to have to climb up out of his addiction and depression by himself. She sent him a list of things he'd have to do to win her back.

That seemed to work. He enrolled in PTSD therapy. He began to pay his own bills.

"He was making changes,'' she said. "They were slow, but I could see it happening. For the first time he was doing things on his own because he finally wanted to.'' But it was hard, she said, bearing "the pain of leaving the person I cared about more than anything in the world.''

A few months later, while Jimmy was a patient at Project Victory, a private, nonprofit facility for veterans in Houston, the bottom fell out.

NEUROSPSYCHIATRIC CASUALTIES

No one seems to know how many people there are like Jimmy and Karie, whose young lives and dreams are abruptly shattered by a random explosion, and whose trajectories seem to spiral down through layers of misery and depression and disintegration.

But there are enough of them to have prompted growing concern among some senior officials in the Defense Department and the VA that caring for the physical, visible wounds of the combat-injured is not enough.

"If you have a severe injury, you can get to a high level [of activity] with intensive care, but it's really hard to keep doing that,'' said Dr. Shane Mcnamee, chief of physical medicine and rehabilitation at the Veterans Administration Polytrauma Hospital in Richmond, Va.

"It's hard every day to struggle with the pain and stress, the forgetfulness. If we're not there to support them, they will get worse,'' he said. "You need strong, loving, caring advocates who can care for these individuals and continue to push them, and a health care team that can be responsive not just to the day-to-day pieces, but can pick their head up above the horizon and set goals that are significant and reachable.''

That theme -- that the military and veterans health care systems fail to provide "strong, loving, caring'' support -- was hammered home in a hearing this summer of the Senate Veterans Affairs Committee, whose chair, Patty Murray (D-Wash.), noted the awful toll of veterans who slip through the cracks.

Suicide is only one indication of their despair, but it's a powerful one. Among the troops who have returned from war with severe mental health issues, including those from the Vietnam era, "an average of 18 veterans kill themselves every day,'' Murray noted.

A senior Veterans Affairs official acknowledged poor coordination among various bureaucracies of the VA and other federal and private agencies.

"For those veterans with a complex interplay of mental health, medical and psychosocial issues, VHA [Veterans Health Administration] needs to better coordinate care internally among providers and clinics, between VBA [Veterans Benefits Administration] and VHA and when possible between private sector health care providers, families and VA,'' Dr. John D. Daigh, of the Veterans Affairs Inspector General's Office, told the Senate hearing on July 14.

"The military is faced with a problem: we have salvaged people, we can give them the physical tools back, and they begin to fall into another category of injury, the neuropsychiatric casualty,'' said Dr. Dale Smith, a medical historian at the Uniformed Services University of the Health Sciences in Bethesda, Md. "Some of it is the stigma of a prosthesis. The other piece is a psychological component of having been wounded, having had their bell rung. They aren't as quick to jump back to the fight -- the resilience is just not there."

"We have to get a better handle on understanding this problem,''' he added.

Military medical authorities have been aware of the links between PTSD, narcotics, risk-taking behavior and suicide for years. A U.S. Army study on pain management, chartered in August 2009, said the Army is "deeply concerned'' about drug addiction and suicide. But it faulted military medicine for failing to have any "routine or standardized screening for those at risk.'' Nor, it added, "is there a system to share'' information on what medications the combat injured are being given and how that might affect their treatment.

Seeming to describe the peril into which Jimmy Kinsey had fallen, the Army's Task Force on Pain Management reported that the "highest risk patients for unsafe behaviors have a 'trio diagnosis' of psychiatric disease, substance abuse, and pain."

"These patients are complex and need multidisciplinary evaluations … patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients,'' the report warned. "Often patients, especially with a history of impulsivity or medication misuse, will choose to use lethal medication as a means of suicide.''

That clarion call, for close professional supervision of these "complex'' patients who are at an increased risk of overdose, appears to have gone unheeded during Jimmy’s struggle. Once during that hard period, Karie wrote in her blog:

"Cleve has been taking the morphine the VA gave … I've been holding onto it and giving it to him when it's due. It still pisses me off so bad that I am being put in this position. It is bull-youknowwhat. Luckily, so far, it hasn't been so bad other than the lack of sleep from waking up and checking his pulse sporadically. I can feel the "I NEED MORE BECAUSE I'M STILL IN PAIN" argument lurking, though. He mentioned it yesterday, but I don't care. I'm giving him what is on the bottle. If it doesn't work, he needs to take it up with his doctor. I just hope I get more sleep. I had a nightmare last night, too, that was pretty gnarly ... When I woke up from it Cleve wasn't snoring. I put my hand on his chest to.... well... make sure he was still alive. He was actually awake. I told him I had a nightmare. He turned my way and put his arm around me, then everything was OK.

"If the VA doesn't solve this pill issue I'm ready to raise hell. Pills are not OK for this family! End of story. Find something else!''

A few days later: "VA appointment today. I hope we get his meds fixed and maybe his other injury [prescriptions] filled, or started at least.''

The next day: "The VA appointment was crap. All they did was give him more morphine. Ugh. I guess this is a battle I'm going to lose. They set up an appointment with the actual pain management clinic. Today was just some random doctor. I really don't think they can do anything. Such crap. I just felt defeated. Couldn't even fight her on it. The doctors hands are tied anyway.''

By the fall of 2009, the Kinsey’s marriage had reached a tipping point. Karie had come to the painful decision that Jimmy would have to take charge of his life himself; she'd done all she could. She had moved out and was struggling to make ends meet.

She was on the phone with Jimmy almost once a day, and things were up and down. She was hounded by doubts about what she was doing, trying to force him to take control of his own life.

"I failed to make this work. I can honestly say I have never tried so hard at something in my life. I wish this wasn't happening,'' she wrote.

"I'm terrified. I'm depending on others. I hate this. I wonder how many other caregivers end up on the street because they are scared of their husband or have been kicked out. I feel really alone. My mind is not working correctly right now. I feel destructive. I'm embarrassed … I've been a wife and caregiver for so long, I don't know where else I fit. Who am I? What do I do?''

PROJECT VICTORY

Continuing to seek help, Jimmy enrolled in a private PTSD clinic in Houston called Project Victory, where treatment for traumatic brain injury was offered free to veterans of Iraq and Afghanistan. Project Victory is funded with grants and donations through the TIRR Foundation, a Houston nonprofit that, according to its website, serves patients with central nervous system damage. The TIRR Foundation set up Project Victory in 2007, according to its website.

Jimmy was still on pain meds, with a Medtronic Restore Ultra neurostimulator implanted near his spinal cord, prescribed for chronic pain, and Fentanyl, a powerful painkiller, normally given to patients with severe pain. He received the drug through a skin patch, which was well known to be a risk to patients with a history of drug abuse and addiction. On the street, the word was that drying the Fentanyl contained in the patch and smoking it would give you a powerful high. In Florida alone, 115 people had died in overdoses of Fentanyl in 2003 and 2004.

Despite their separation, Karie drove Jimmy to the airport for the short flight to Houston. "If I knew he would die I would have hugged him longer,'' she wrote later. "I would have … well, caged him up and not let him out of my sight. Told him I loved him one more time. Touched him one more time.''

At Project Victory, patients were housed in a Marriott Residence Inn adjacent to the Project Victory facility. Patients typically stayed eight to 10 weeks. Jimmy and other patients lived at the Marriott, and during the day, walked the short distance to Project Victory's therapy sessions. Late afternoons and evenings, they were on their own, according to Jimmy's family.

Karie and Jimmy talked by phone around 4:30 p.m. on Monday, April 19, 2010, and it was a good conversation. "For the first time, he had a plan,'' Karie wrote. "He had hope. He wanted to change. He wanted to really work on fixing us.

"I remember getting off the phone and thinking, I really really hope I'm not disappointed again.''

Jimmy said he would call back later that night after he ran some errands. He didn't call. Karie sent him a text message.

No response.

Late afternoon the next day, Karie was at work when her friend Robin called. Jimmy was dead, she said. His mom had put the news on Facebook.

Houston police had received a call at 11:40 that morning. Report of a male deceased, “natural DOA” -- meaning no sign of trauma. Police found him facedown in the hotel room's kitchenette, lying next to a plastic bag containing a black tar-like substance and a piece of metal cut from a soda can with a black tarry residue on it. A pipe lay nearby.

The Harris County assistant medical examiner, Marissa L. Feeney, examined Jimmy's body. She found and removed the Medtronic neurostimulator and an empty Greenfield filter, used to prevent pulmonary embolism, in his abdominal cavity. She also found his breathing passages, the trachea and bronchi, clogged with foam.

Her diagnosis: Jimmy Kinsey died from acute fentanyl toxicity.

"He died from an accidental overdose,'' Jimmy's mother, Penny, told me from the family home, at the end of a small dirt road in Foley, Ala. "He was dependent on his drugs, that had a lot to do with it.'' I asked her gently if she felt it really was accidental. After a long pause, she said, "I honest-to-God don't know. He was going through so much at the time. He always swore to me he would never do that. I don't know if it was intentional or …

"I do feel,'' she said, "like he was forgotten.''

The last days of Jimmy Kinsey's life are shrouded in mystery, owing in part to restrictions on the release of private medical records. Jimmy's widow and family were devastated by his death and exhausted by the long struggle. They have not demanded to know the details of his final hours.

In a telephone interview last spring, I talked with Shawn Brossert, the program coordinator of Project Victory, without mentioning the case of Jimmy Kinsey. Brossert told me she had moved the clinic to a new facility in Galveston, Texas.

"We found we wanted a more restrictive environment'' for the patients, she said. "Some [patients] needed more oversight than we could provide'' as an outpatient clinic at the facility in Houston. The move to better facilities with more supervision came just months after Jimmy's death.

I called her again in August and said I had questions about the death of Jimmy Kinsey. She declined to talk other than to say someone "more responsible'' would have to answer, and hung up. She didn’t respond to further phone calls and emails.

I sent a detailed email to Cynthia Adkins, executive director of the TIRR Foundation, which founded, funds and solicits donations for Project Victory. Its website asks for checks "payable to: TIRR Foundation, Project Victory.'' I asked if she could shed any light on Jimmy Kinsey's death, and, in particular, whether it was the VA, a caregiver, or some other third party that was in charge of his care.

Adkins didn’t respond to these questions via email, and when I got her on the telephone she dismissed any inquiries about Jimmy’s death. "We have nothing to do with this,'' she said. I asked who was responsible for Project Victory. "I have no idea,'' she responded. "I cannot visit with you about this.'' Then she hung up.

I sent two subsequent emails to her with the detailed questions, but never received a response.

It was Jimmy himself, of course, who was most directly responsible for his own death. But where was the help and support he needed?

Technically, like all veterans, Jimmy was under the care of the Veterans Administration and it was under the agency’s auspices that he received his pain medication. But he was under no obligation to turn to the VA for help with his addiction.

"Veterans do have a choice about where they receive their care,'' said Antonette Zeiss, a senior VA official in Washington responsible for all VA mental health programs, including substance abuse. She said the VA has an extensive and vigorous outreach effort to contact veterans and advise them of the program available to them. "But these are American citizens with full rights and they can make choices,'' she said.

"We are not in the business of tracking down and forcing anyone to come in for care.''

Drug addiction due to chronic pain is difficult to treat, but the VA has a wide range of programs designed to help veterans like Jimmy Kinsey. Although she could not discuss individual cases, she said that for veterans "who need more complex, intensive care we have residential rehabilitation programs'' for pain management, substance abuse disorder and other health problems.

The problem with relying on the drug-abusing veteran to seek VA treatment, she acknowledged, is that some part of that veteran, some part of the time, simply doesn't want to be treated. "That ambivalence is very much a part of substance use disorder,'' Zeiss said, "and we have a full continuum of care for that.''

Zeiss, a psychologist, seemed to understand and empathize with veterans like Jimmy Kinsey, and clearly she knows how to help them. Tragically, she and Jimmy never met. The VA doctors and pharmacologists and therapists who saw Jimmy did not get him into the VA programs that might have saved him. Instead, he spiraled on down to his death.

Karie acknowledged that the initial care provided by the military and the VA is superb.

But the follow-up? Not so good, she told me. "Can they reconstruct a leg? Hell yeah, they can. It's what happens after the surgeries that they don't have a good grip on.''

Karie is the first to admit that Jimmy was hardly an ideal patient -- that his irresponsible behavior made things worse. But she also feels let down by the country that he volunteered to serve in combat.

"I felt the military would not listen to us,'' she wrote to me in a long, anguished email. "But all of his actions, I believe, were a result of the injuries he received at war. And now, I'm hearing more and more of accidental overdoses, suicides, homicides … what is wrong with this picture?

"For a while I thought it was only us. I thought there was something wrong with us. The reality, I'm finding, is that we were the norm. I'm afraid that the way the military and the VA handle these men and women is going to result in many more deaths similar to my husband's.

"Why were these fragile people not looked after more carefully?''

If Jimmy had been killed outright in that IED blast in Ramadi, he would have been flown home in a flag-draped casket with a white-gloved honor guard and buried with full military honors. The wounded are not returned home with such honors. Nor is recognition given to the severely wounded who struggle with and finally succumb to pain, addiction and despair.

In Jimmy's case, the family was left to battle with the VA to get them to pay for a graveyard headstone.

"I truly feel like I lost my husband to this war,'' Karie wrote late one night. "He would not have died at the age of 25 if he had not gone to Ramadi, Iraq, and been hit by an IED. If he hadn't lost his leg, he would never have had to take those strong pain medications. He never would have had PTSD and TBI. He wouldn't have been left alone in a PTSD therapy facility to die.

"I hate this stupid war,'' she wrote. "Everyone we knew from the military has been negatively affected by it.

"SO sick of hearing about all the tragedy. SO sick of it.''

Jimmy Kinsey didn't get the long-term care he needed, but some of the severely wounded have been more fortunate. NEXT: Meet an Army sergeant who reports benefiting tremendously from therapy built around "the permanent caregiver" -- his family.

Huffington Post Impact has compiled a list of organizations that seek to help veterans like the ones featured in "Beyond The Battlefield." You can read more about those groups, and ways you can help, here. Other stories in this series can be found here.

Clarification: An earlier version of this article could have been understood to suggest that wounded veterans are not given full military honors at their funerals. This is not the case. It has been changed to make clear that wounded soldiers do not receive the same attention or tribute that their fallen comrades do upon their return to the U.S.

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