The Geography of Emergency Care: For rural veterans across Tennessee, Kentucky, and northern Georgia, the hardest part of getting care isn’t the diagnosis. It’s the drive
- Camille D. Ford | Founder & Editor-in-Chief
- May 1
- 7 min read
The call comes in from somewhere past the county line, from a veteran whose chest has been tight since morning. He doesn’t want to go to the hospital. He doesn’t have a car, the nearest emergency room is 40 minutes down a two-lane road, and the last time he made that drive, he sat in a waiting room that had never heard of him and was sent home with a note declaring him fine. So, he does what veterans in rural counties across the region have always done: he tells the nurse he’ll wait it out.
This is the moment Dr. Brett Cohen thinks about most. Not the dramatic presentations or the obvious emergencies, but the quiet decisions made in counties where the geography of care has already narrowed a veteran’s options to almost nothing. Cohen is a board-certified emergency medicine physician at VA Tennessee Valley Healthcare System, which serves 157,483 veterans across central Tennessee, southern Kentucky, and northern Georgia. He’s looked at what happens when distance and limited transportation meet a health care system built around the assumption that people can get to it.
“For our veterans, that can be very far in very rural areas,” he says. “Many times they don’t have access to vehicles or cars. That requires things like a 911 call.”
What that phrase contains, the idea that a veteran with chest pain in a rural county has no other option between ignoring it and calling an ambulance, is the problem Cohen has spent years trying to solve.
What the Triage Line Couldn’t Fix
For years, veterans in the TVHS service area who called the nurse triage line with urgent symptoms ran into the same wall. A registered nurse would work through her clinical protocol and arrive at the most defensible answer available: go to the emergency department. It was the right answer, most of the time. It just required a trip that wasn’t always possible. For a veteran near Nashville, that’s a manageable ask. For someone in a rural county an hour and a half from the nearest VA facility, with no car and no one to call, it was something closer to a closed door.
Cohen watched the mismatch accumulated. Some veterans made the drive, waited for hours, and were sent home. “The result, which may have been, you can go home, no emergencies were found, you have been over-triaged,” he says. Others never left the house. “There really weren’t any great mechanisms outside of the emergency room or finding the local urgent care they’ve got to go out and find on their own to get seen for these problems.”
The triage line was doing exactly what it was built to do. The problem was that it was built for a population with cars and proximity, and the population it was actually serving, in significant numbers, had neither.
What Service Leaves Behind
Cohen came to VA care without a military background, and he says the work changed his understanding of his patients in ways he hadn’t anticipated. What he noticed wasn’t in the intake forms. It was in the records, in the accumulation of diagnoses and service histories and specialist referrals that told the story of what service had cost people in their bodies, years after the fact.
“A lot of people my age that served when they were younger have the bodies of someone much older because whether it’s orthopedic injuries or some exposure they had while in service, there’s a lot of people that get sick after and need care,” Cohen says.
Most of it is invisible. There’s no outward marker that tells a triage nurse, or a community ER, that the man who looks healthy has been managing the delayed consequences of a deployment that ended fifteen years ago. The chart may tell you. The face won’t. “Most of it you can’t see,” Cohen says. “There are very visible injuries, but most of them are not like that.” He reads their records now the way you read a long story with a complicated middle, with attention to what accumulated and why.
It has reshaped what he thinks his job is actually for. “It motivates me to help connect the care however I can and give them what they need to live healthily after they’ve served.”
Five Minutes to a Doctor
In January 2025, TVHS launched Tele-Emergency Care. Cohen built the program’s application from scratch, working with VA’s local innovation team to design a system that routes a caller from the nurse triage line to a board-certified emergency physician on video, typically within five minutes of the initial call. From there, the physician can take a full history, order labs and imaging, send medications overnight, and in a genuine emergency, dispatch EMS directly to the veteran’s physical location. Since launch, 85% of veterans who use the program have been treated successfully at home, without a trip to the emergency department.
Dr. Andrew Neck, Section Chief of Emergency Medicine at TVHS, says the program was built around a deliberate clinical philosophy. Every physician in Tele-EC carries close to a decade of hands-on emergency medicine experience, and it is physician-only by design, not as a credential gesture, but because the particular instinct of experienced emergency medicine, the ability to read a patient across a screen and know who is actually sick, is what the program depends on. “We don’t really take care of veterans,” Neck says. “We actually work with veterans who take care of veterans.”
Cohen had worried that adding Tele-EC to the nurses’ workflow would feel like one more ask on an already packed shift. That’s not how it landed. “All of them speak to really being thankful for having us there,” Cohen says, especially for the veterans who refuse to go to the ER. “Being able to hand it off to a clinician who will then see the veteran gives them a sense of relief.” The nurses, it turned out, had been waiting years for somewhere to send the people who wouldn’t go.
When the Drive Is Across the Country
For some veterans, the distance problem isn’t measured in hours from home. Keith Cody, a Marine Corps veteran, was living in California when he was diagnosed with multiple myeloma. He went through chemotherapy, researched his options, and eventually found himself on the phone with a team at TVHS’s Nashville VA Medical Center campus discussing a procedure his home VA couldn’t perform: a bloodless autologous stem cell transplant. TVHS had recently launched the only comprehensive stem cell transplant program in the VA system, and was also the only VA facility in the country performing CAR T-cell therapy.
Cody made the decision to travel. “The level of confidence that they had in this procedure was kind of what made it a little easier for me to decide to make the journey and come here,” he said. In April 2025, he received the transplant. A month later, his oncologist confirmed complete remission. “The whole care team here,” Cody said afterward. “It’s actually sad to leave people behind that you really felt treated you like family.” He was talking about leaving a hospital. It sounded like leaving home.
The distance Cody traveled willingly, across a country, for a procedure that saved his life, is the same distance measured differently that a veteran in rural Tennessee can’t manage for a round of chemotherapy. It’s why the opening of a dedicated oncology clinic in Chattanooga in December 2025, the first site in a program called “Close To Me,” matters beyond the patients it immediately serves. Studies published through the National Library of Medicine suggest that veterans with consistent primary care access reduce their risk of cancer-related death by 21%. Proximity isn’t a convenience feature. It is, in the bluntest clinical terms, a survival variable.
A System Racing to Keep Up
The PACT Act, signed into law in 2022, expanded VA eligibility to millions of veterans exposed to burn pits and environmental hazards during their service, and the enrollment surge at TVHS has been significant. The system now serves 157,483 veterans across three states, with demand growing faster than the infrastructure built to absorb it. Former Executive Director Daniel L. Dücker has described veterans arriving at community outreach events in their sixties and seventies who had been eligible for decades and never known it. “Our care is excellent,” he said in a prior interview with Veteran Excellence. “The challenge is linking eligible individuals to appropriate care.”
Five facility expansions are underway, and new clinics are opening in Charlotte Avenue and Montgomery County in spring and summer 2026. The nursing retention rate at TVHS sits below 5 percent, well below the national VA average, a signal that the workforce is holding even as patient rolls grow. But buildings take time, and the veteran who called this morning with chest pain isn’t waiting for a ribbon cutting.
Cohen thinks about the ones who do. Who picked up the phone not knowing that five minutes later they’ll be talking to a doctor. Who’ve been carrying something quietly for longer than they let on. He reads their records and sees the whole story, and the question his program is built on isn’t really about technology, even though it depends on it. It’s about what it means to tell someone who sacrificed, often invisibly, for a country that mostly doesn’t know their name, that the care they were promised is actually there, and that the distance between them and it is finally, in some small but real measure, starting to close.
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