Living in a pandemic doesn’t have many plus sides to it. But there is one bright side for rural America. Telehealth is finally getting to flex its muscles. But adjusting to technology isn’t easy for older patients, and that’s one thing small towns have lots of: senior citizens. So, we take a trip to Sheridan, Wyoming to see how well telehealth is working for veteran Ron Loporto.
[ ↓ Transcript ↓ ]
Last time on the Modern West, we learned the story of Vietnam Vet Gabby Hayes and his breakdown. Gabby ended up breaking out the windows of a bunch of businesses on Main Street with the butt of a rifle. He was sent to a psych ward at a VA hospital 360 miles away in Sheridan, Wyoming.
It makes you wonder what might have happened if the hospital had been closer to Walden, Colorado, where he lived, so Gabby could have had the regular ongoing access to that kind of care before a breakdown. What if Gabby could have been seeing the VA therapists all along? Could it maybe even have prevented the incident from happening in the first place?
Living in a pandemic month after month doesn’t have very many plus sides to it, let’s face the facts. But there is one bright side for rural America. Telehealth is finally getting to flex its muscles.
For years, there was all this lip service about how someday telehealth would bring healthcare into people’s homes…someday. But now that everyone needs that kind of care, including urban families, the road blocks have started to come tumbling down. Even at the VA hospital in Sheridan, Wyoming where Gabby went. But adjusting to technology isn’t easy for older patients like him. And that’s one thing small towns have lots of: senior citizens. So I took a trip to Sheridan to see how well telehealth is working for another veteran, Ron Loporto.
The first time Ron realized he may need some help was when he went to the kennel to drop off his dog before a trip overseas.
“I had my back against the wall, but the door was here. And another customer came and his dog ran in to meet the other dogs and brush my leg, which startled me,” Ron recalled. “And then the man came in. And he was really, really big. I mean, he about filled up that door. So I got startled by the dog. And then a shadow came. And I didn’t realize that I was having an episode. I had my hands over my ears and I was screaming and I just wanted to get out of there. It was a pure flight. And I didn’t know I was doing it. It was like an out of body experience. I wanted to physically get away and stop the sound. So when we came home my wife said, ‘What is going on with you? You do this all the time.’ In essence I do. And that’s when I knew it was pretty serious,” Ron said.
Ron started looking back and realized his wife was right.
“I was jumping and covering my ears, subconsciously. And the fight there. There have been times where the trigger was so deep. It brought up a combination of traumas. And I was ready. I was ready to fight in public places,” said Ron.
Ron had just recently moved from Cheyenne to Sheridan, a town of around 17,000 people. He had tried to join volunteer groups but couldn’t handle that they were not organized like the military. So he was doing nothing and anxiety and depression started. Plus, he kept on reacting badly to situations and it wasn’t helping his marriage.
“I wasn’t happy with myself. I really wasn’t,” Ron told me. “And I was scared because I didn’t know what I was doing. And I was taking it out on my wife and then she was having a hard time understanding because this is all invisible. My alternative was to lose my wife.”
So Ron started seeking help. He saw his primary physician who gave him some meds but he didn’t want to do it alone.
“I’m not going to just take drugs without help. So he recommended a counselor. So I went to a counselor here in church for two years. And we made a lot of progress up until the point where she said, ‘You have Post Traumatic Stress Disorder’.”
New York Beginnings
A few months before, I went in search of someone to talk to for this story. I was hoping for someone who lived in a rural place and has to drive hours to get the mental health care they need. Kinda like Gabby who had to drive five hours up to Sheridan to get to the VA.
But mental health unfortunately is still a taboo subject to talk about so many people just don’t feel comfortable coming out with their story. But Ron was willing. And although he doesn’t live far away from a mental health facility, his story with telehealth still portrays why it’s so important, and the challenges for older clients in using the technology.
The first communication I had with Ron was about our connection to New York. He wrote me an email saying, “I’m anxious to know if we have any common interests as I spent 30 years living in the Hudson Valley with my wife prior to moving to Cheyenne in 2000. We are both New York natives and apparently still have an East Coast accent so I tell folks I now live in Wyoming, but am from New York”
It’s up for debate whether either of us still have an accent, but I totally get what he means. Raised in New York, you are always a New Yorker at heart.
But Ron had a little different childhood than I did. He grew up on the south shore of Long Island.
“So you can go to one of the state beaches and have plenty of room for a beach towel and a blanket and an umbrella,” Ron said. “And we used to listen to AM radio on a transistor and there was a guy named Brucey and about every 20 minutes he’d just say, ‘Roll over,’ because he knew we were all at the beach.”
When college rolled around, Ron went to a two-year college and then enrolled in New Paltz further upstate. He met his soon-to-be wife during this time.
“Well, I didn’t know that colleges at that time in 1970-71 would notify the Selective Service because I was on a college drafter,” Ron said. “So I was in love with my girlfriend, and just kind of hanging out with old friends and didn’t realize I became part of the draft pool. So, then came a little notice in the mail. I had a very low number and the way it worked is low numbers go first.”
“Do you remember what number?” I asked Ron.
“It was like four,” he said with a laugh. “So I had to make a decision, you know, what was I gonna do?”
Ron was studying conservation with his eyes set on becoming like Jacque Cousteau, a marine biologist studying the area around the Caribbean.
“I knew I had an obligation and I was fine with having an obligation. I just wasn’t mentally prepared to go to Vietnam because I had been living with Vietnam since ‘64 over the news and it wasn’t something I wanted to do with my life,” Ron said. “So, I heard about the National Guard where you work for the governor and you stay in your state.”
He figured I’ll stay close to the girl I’m in love with, serve six years and get out, obligation fulfilled. But it didn’t work out that way. He ended up enjoying his time at the National Guard so much he re-enlisted.
In his 13th year, he became an officer, which committed him to be a guardsman until 1996. He then went on active duty for the guard and eventually became a full-time federal employee, retiring in 2010.
“I know the oath by heart and nowhere in that oath does it say I’ll willingly subject myself to trauma for the rest of my life,” Ron said. “[It says] support and defend the Constitution of the United States of America against all enemies foreign and domestic.” He recited this by memory. “That’s what it says, part of it. Nowhere does it say I subject myself to a mental illness for the rest of my life, which could lead to divorce, alcoholism, drug overdoses, and homelessness. So I think that should be part of the story too. Joining the military as a lot more than then leaving your home to go to a foreign land.”
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An Air Force Mortuary Officer
On a sunny July day, I threw my black duffel bag into my car and got ready to head out.
I was just leaving my house in Red Lodge, Montana, heading to Sheridan, Wyoming and it was going to be about a three-hour drive, which is actually weirdly normal for this job. Traveling around Wyoming takes a lot of time to drive. And the weird thing about Sheridan is, the fastest way is to go up and around the Big Horn mountains, so I stayed in Montana for most of the trip.
Since it’s the summer, the roads are clear and easy but as many Mountain West residents know, when the snow starts hitting the pavement a three-hour drive can become a four or five-hour drive or one that isn’t even passable. This really increases my anxiety in the winter. I’m always debating whether the drive is worth it because, to be honest, the roads become pretty scary. And as a New Yorker, I’ve only just learned how to drive in that type of weather.
As I drive along, I think of veterans who live in small towns as far away from the VA as I do and whether they’d take the risk to see their mental health provider or just skip the appointment. Is it really worth risking your life or even just worsening your anxiety to go to the doctor?
But it’s a nice July day which means I didn’t have as much to worry about.
After an easy three-hour drive, I arrived in downtown Sheridan. I parked outside of the WYO Theatre where I scheduled to meet Ron. I saw Ron right away, leaning back against the wall of the theatre.
I waved at Ron and he waved back. The first question he asked, “How do you feel with COVID?”
We discussed that we felt comfortable not wearing masks outside but when we are inside I’ll be wearing a mask the entire time. Ron said he was good with that.
We walked towards his house where he lives with his wife. When we got to his house, we took our shoes off and his golden retriever Murphy greeted us happily. Ron gave me a quick tour of the house. His wife comes out to say hi for a moment but doesn’t want to be taped.
“So this is my little room. The nice thing about a three-bedroom house never having children is we each have our own space.”
Ron’s own space was a small room, a twin bed in one corner, and shelves full of pictures of horses, books, and folders. A guitar hung on the wall. Ron took a seat down on a grey exercise ball in front of a side table with his computer on it.
Ron didn’t skip a beat and dove into his career in the National Guard, skimming over all the different positions he had until he got to 1984 when he became a mortuary officer in the Air Force.
“An Air Force mortuary officer is the person responsible for two things really: meeting with the next of kin, to find out their wishes for what the deceased will have,” Ron said as he bounced slightly on his exercise ball.
“So, that’s one piece. But the other piece, the real trauma piece, is when you go to mortuary officer’s school. In the Air Force, they basically talk about aircraft crashes.” He talked slowly, as if letting the memories come back in a controlled way. “So, you go through training about seeing aircraft on the ground and it’s usually burned people. So you have to train for this and it’s called search and recovery, not search and rescue.”
“I had taken our team for active duty training at Dover Air Force Base, Delaware. So, I volunteered to work in the mortuary and on March 13th, 1991…” He looked back at a calendar on the wall as he tried to calculate when an event exactly took place…”a second lieutenant–may be your age, maybe even a little younger, I don’t know–she was in an Iraqi helicopter with a group of other four people, some high VIP people, and then some coalition people. Well…”
He paused for a long moment as he rubbed his hands together in a fist.
“We had known that helicopters in a sandy desert do not do well. They ingest the dust and they crash. Well, there were two [helicopters]. There was the one she was in and another one. I still don’t know why they took off because they knew dust storms were a pretty sure bet you weren’t going to go very far. And they crashed.”
His hands kept rubbing together and began to tremble.
“The lieutenant arrived in what’s called a shipping container; it’s basically an aluminum casket, if you will.”
He paused, closed his eyes, and opened them. His hands continue to shake.
“And she was wrapped in an OD green blanket as you’re supposed to. And her remains were about maybe two-foot-by-18 inches. So I knew what I had to do. You take the remains out of the shipping container and you place them in a casket, her in a casket, and you get a brand new uniform with all her medals and badges and ranks and you place it over the blanket.”
He paused, letting the moment pass. “That was pretty tough and I used to know her name and I still can recall a picture I saw of her.”
But, all of a sudden, Ron quickly checked his watch and realized it’s time for his telehealth session. As he turned around on his ball and opened his laptop, I was still semi-shocked at how open he had been with me in just the last half hour.
And how he is able to handle his trauma.
Ron had been seeing a specialist for his PTSD for a while. It helped him handle his triggers like the one he just had. So when COVID-19 hit and the Sheridan VA closed, he knew he needed to continue his sessions but he was hesitant about using telehealth.
“But my psychologist, she called me and she said, ‘You can’t come to the office. We’d like you to try this VVC VA Video Connect.’ And again, I said, ‘I don’t know anything about it. I really don’t want to sit in front of the computer for an hour. It’s just not my thing’.”
He realized it probably would be better to still have some kind of sessions with his psychologist versus the possibility of the episodes coming back. Ron had been using telehealth for his sessions since March when the Sheridan VA announced it was closing its doors to the public due to COVID-19.
He opened his laptop and pulled up the VVC VA Video Connect, a special software the VA uses for all it’s telehealth appointments. As he began to type out specific information, he said, “My hands are shaking, I can’t type.” But he continued to slowly type out using his index finger and hit connect.
A garbled sound came out of the laptop.
“That was a little gobbled up, it just says, waiting for the host,” Ron told me.
As we continued to wait, Ron told me he had to put down the information like where he physically is and contact information because if he does have an episode and needs help his psychiatrist immediately knows where to send help.
And then a woman popped up on his screen.
“Good morning,” Ron said. He waited a moment and a garbled voice came out again. “I’m having trouble hearing you right now. Can you hear me?” He turned to me and said, “For some reason, this is the first time I’ve ever had static.”
On his screen, the psychologist mouthed something. Ron followed her lips carefully, “She said she’s gonna log in again, is what she said.”
After a couple more moments of trying to figure out what’s wrong, they decided to use the phone to hear each other but stay on video so that they can still see each other.
“Sure, sure, I can see you and I can hear you fine over the phone,” said Ron to his psychologist. “And I’m also going to turn off my computer speaker. Okay, so, if you’ll just hold on for a second, I’ll escort our guest out.”
Ron walked me out and we decided to meet at the house again in an hour when he’ll be done with his session.
The Barriers of Telehealth
This is the first time Ron had encountered such a problem and later Ron emailed me and told me it was caused by a Spectrum-Charter application and that a technician fixed the problem.
Technical glitches and just not being able to get the same results were some of the things Ron was originally worried about when he couldn’t go into the office for his appointments.
It turned out Ron’s psychologist, Robin Lipke, was herself a reluctant telehealth convert.
“I would identify myself as a reluctant convert to VVC,” she told me.
Dr. Lipke has done telehealth in the past but it was always done with an intermediary. This means an individual arrived at a clinic somewhere in Wyoming, was checked in by a nurse and then would enter a room where there was a screen that Dr. Lipke would appear on.
“There was always a second set of eyes on the veteran and how they were doing so, if you know if something in session happened, there was somebody right there,” Dr. Lipke said. “With VVC into the home that layer is gone. And I think, as a provider, that leap to working with people and doing some of the very difficult work of therapy when they’re in their home there was some hesitation.”
But she said COVID-19 really made her realize telehealth was the best alternative, even to face-to-face with a mask on.
“So, much of what we do has to do with how people are expressing their emotions or not. And so when my option was to not see them face-to-face or talk to them on the phone, or talk to them via VVC, I gotta tell you, I was really thrilled to be able to see them again,” she said.
Dr. Lipke said there are positives and negatives but she definitely has found little gems that she didn’t expect.
“For a veteran coming in, they’re coming into my space. They know where they sit. There’s a great deal that is mine or the institutions. When I go into their home, they’re in their home. They are comfortable there,” she said.
“I’ve had people [who] have said or indicated in some way, demonstrated that being in their own home, they feel more comfortable about talking about certain things. Because if, for example, there’s something that is stressful to them, maybe their pet is right there with them, maybe there’s something else that is comforting, or, again with trauma-informed work, one of the biggest pieces is safety and trust. And so there’s something different about being in one’s home,” Lipke said. “People would show me things or do things that I never would see if I just saw them in my office. Like, let me show you, ‘Oh, here’s something that I’ve spoken about.’ Where they might not bring a photograph of their, let’s say somebody had passed away, they might not bring that to session unless I asked. But as we were talking, they might say, ‘Oh, you see this photograph back here?’ And might start talking about something that I might not have gotten if we were only in the office.”
And this is something Ron mentioned. At home, he can pet his dog Murphy or listen to soothing music to help him calm down.
For many people, telehealth seems impersonal but there are actually many benefits to it that have been highlighted during the pandemic. Living in Wyoming, Ron was lucky when he needed the special help the VA could provide he was in the same city. For others traveling from small towns to reach a specialized healthcare provider or even to their general doctor can be an hour or longer like the three-hour drive I had to take to see Ron.
“You can’t talk rural health care without talking about transportation,” said Alan Morgan, the CEO of the nonprofit National Rural Health Association. “It’s a huge issue. The farmer or rancher who is remote and can’t get in, and that may just be because of the weather or it may be because of multiple factors.”
Morgan said transportation issues all come from one main issue: access to healthcare in rural places.
“Rural populations have tremendous health disparities and those health disparities can largely be traced to the fact that there’s a lack of access to care,” said Morgan.
One of the main reasons is recruiting and keeping healthcare providers in these regions. “The real concern is you just can’t get specialty care to live and work in a rural community,” Morgan told me. “And telehealth has the potential to bridge this. Most of us think of telehealth like the Jetsons, where you’ve got your primary care physician beaming into your room. [But] we need to start realizing that you’ve got telebehavioral health, you got telepharmacy, you got teleradiology, telecardiology. All these have different roles and different applications and they really need to be thought of separately. Telehealth is a tool and that’s the best way to look at it. It’s a tool for expanding access to care.”
But this tool received lots of pushback for many reasons. First, many insurances don’t cover telehealth so it can cost more money, facilities that use it need to invest in technologies, and many regulations didn’t make it easy like not being able to use Facetime or Skype but a specific video program. But when COVID-19 hit, everything opened up. As healthcare facilities and hospitals had to close their doors for non-essential services, people in charge realized telehealth may be their only option to continue taking care of people like Ron who can’t have a gap in their care.
“You cannot overstate the dramatic impact that COVID has had on access to care in relation to telehealth,” Morgan said. “Once federal and state officials removed many of the regulatory barriers prohibiting that and provided funding for Medicare and Medicaid for these telehealth services. It really opened the opportunity to enhance healthcare in a rural setting. And the benefit to the patient has been dramatic. Number one, primary care, allowing physicians and rural health clinics to actually see their patients remotely. And then number two, telebehavioral health. And you’ve heard from policymakers both on Capitol Hill and the White House, and also at the state level, indicating that they have no intention of going back to the way that we were before. I think that we are now locked into a new paradigm of how we deliver healthcare in a rural setting.”
During the pandemic, the Sheridan VA, where Ron gets his sessions, telehealth appointments, including mental health and primary care, increased by 1,116%. And the VA as well as other healthcare institutions don’t want to stop this momentum since they believe utilizing telehealth in the future will help them provide better care for their patients in rural places.
When I came back to Ron’s house after his session, Ron led me back to his room where I took a seat on a small white straw chair and he sat back down on his exercise ball. He didn’t want to talk about the young lieutenant anymore but rather wants to tell me how his therapy has helped manage his episodes.
He scooched himself forward on his exercise ball to a wooden bookshelf and pulled out a white binder and started flipping through.
“Everything [my psychologist] sent me going back, actually all the way back to my time with the private counselor, all different things, handouts about depression, trauma and memories, New Year’s resolutions, which are really tough. I don’t mean just keeping them, they might be unrealistic like I’m gonna stop having PTSD. Well, that’s not gonna happen. Taking power naps, which I like to do,” he said with a chuckle. “But this was all with my neuro-linguistic counselor. So she works on words, how words affect your mind, which is also a trigger. Words trigger phrases. So that’s how we kind of got into it. She says your triggers are from PTSD. So it’s an analysis of how I process the event and we just started there because she didn’t really know what my particular trauma was, so we had to break it down.”
As he continued to go to his sessions, Ron slowly realized different triggers like fear.
“The fear is a result of military training because I was a leader and I was in charge. So it was a threat assessment. So we may say fear, but it’s a threat assessment. ‘What’s happening? How does it affect me? The people I’m with the mission, right?’” Ron said he’s always doing threat analysis or situational awareness even in civilian life.
And he became aware of certain events in his life that were triggers. But by becoming aware of these trigger points and going through therapy, he realized there’s a way to manage the potential episodes.
“If somebody dropped something behind me, I would jump. I would put my hands over my ears. And I quickly assess, ‘Am I in danger? Do I need to fight, flight, freeze, or fake dead? And now I can do that analysis pretty quickly. I used to get stuck. I used to freeze.”
Those four F’s are important to his ability to not get stuck in his reaction. Fight, flight, freeze or fake dead: four different ways a person can react to a trigger badly. One trigger for him is 9/11. He was in Nova Scotia one time on a tour with his wife.
“[The tour guide] says, ‘Well, I want to share an interesting fact with you. She said when 9/11 was happening, many commercial airline flights were diverted to this airport.’”
Ron asked to see her privately afterward.
“I said ‘You probably don’t realize this. But when you talked about aircraft being diverted here for 9/11, I was having a panic attack and I had a real hard time controlling myself. All I could think about was people jumping out of buildings.’”
As a New Yorker, that hit me. I knew kids whose parents did just that.
When I told Ron this, he said, “This is a whole lot more than I think we’ve wanted to get into but.”
I interrupted him. “Just for 9/11, I was there. I was in the city. It’s probably a traumatic event for me and I don’t even know.”
“You may have PTSD,” Ron said to me. “Now you’re still actively engaged in your profession. You’re still learning. You’re still doing. I looked at your bio, so I know you’ve traveled around different countries, different parts of the U.S. So you’re still learning. But there will be a time when you’re alone on a beach or on a mountain type or hiking and you hear something and it just comes back.”
It made sense to me. When I think about 9/11 nowadays it’s usually a quick thought or somebody realizes, ‘Oh, you grew up in New York, where were you on 9/11?’ And I go into what seems a little like a rehearsed story of how I was in a classroom with my teacher waiting for my parents to pick me up. Every other kid was picked up in the morning but my mom arrived promptly at three o’clock and how I could sense something horrible had happened but I had no idea what. It turned out they were searching for a family friend who worked right next to the Twin Towers.
I never really lag on it. But Ron said ever since he’s retired just the mention of 9/11 and it brings him back.
“I was a communications officer in charge of the classified and unclassified networks. So unclassified is your typical Microsoft browsers and internet. And classified is everything from top-secret all the way down,” Then Ron told me what he did during 9/11. “Yeah, so I was responsible for both those platforms for 33 straight days. Finally, I hit the wall and recovered for a little bit, then went right back to it and in my mind never left it really.”
When 9/11 comes up, he realizes it’s just a memory. And he’s able to control himself, not let the trigger take him to one of his bad reactions.
“So, now I don’t get stuck quite as bad. I do a quick analysis, assess the threat. It’s what I’ve been trained to do. Am I in danger or people I’m responsible for in danger? Is there no danger? Am I imagining this? What is going on? So you have to take in your environment, you’re in a very safe environment.”
His weekly therapy sessions are vital for him to figure these triggers out and learn how to properly react to them. He mentioned that in the morning when he started shaking while talking to me about the young lieutenant, he was able to realize that it was a memory.
“She’s not here. She’s not there. Although you look very much like her,” Ron told me. “I only saw a picture of her. The only thing I saw of her was a blanket. So I’m able to appreciate her sacrifice and what I did, and an honorable manner, but it’s a memory.”
At the moment when he said this I kind of just nodded and let him speak. But when I looked back, I felt horrible that I caused a bad moment for him. But for Ron, it’s a success story of his therapy. Where he has gotten from when something like this could really throw him off to him realizing it’s just a memory.
But his therapy sessions still ground him and help him discover new triggers. So if he didn’t have telehealth as an option he’s worried that he would lose progress in his recovery. And unfortunately, many people in rural health don’t have telehealth as an option, like he does. The current momentum will hopefully change that.
Mental healthcare saved Ron’s marriage and really his life. He believes he would’ve fallen into some other kind of trap if he didn’t seek out help.
“I’m really happy where I am now with my medication and my providers both at the VA and civilian. I couldn’t be doing today involved in five organizations volunteering, getting up at five every morning. I couldn’t be doing it four years ago,” Ron told me.
Ghost Town(ing) episode art by John McNamis
Blue Dot Sessions