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Contents 12

30

18

11

44

Letter from the Publisher

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Military hospital in Germany is the first stop for wounded warriors headed home.

2012 Medical Book

By David Perera

38 12

Landstuhl Medical Center

Intense Therapy

Taking the Plunge

Rehabilitation specialists help wounded warriors rebuild their lives.

Navy-sponsored medical research tries to minimize the dangers of the deep.

By Sara Michael

By Dave Smalley

44 18

Step By Step Prosthetic technology advances by leaps and bounds as wartime amputee ranks swell.

Battlefield Medicine A decade of war brings game-changing advances in reducing blood loss.

By Sara Michael

By David Perera

24

54 Medicine at 35,000 Feet Air Force aeromedical evacuation mission evolves along with the modern battlefield.

Healing Trauma Growing understanding of modern warfare drives better treatment of PTSD. By Sara Michael

By James Kitfield

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Contents 56

73

62

80

‘13 Procurement preview 2012 Medical Book

69

Air Force: Space Fence By Rich Tuttle

56

Traumatic Brain Injury

71

By Sara Michael

62

73

Marine Corps: M777A2 By Matthew Cox

Body, Heal Thyself Pentagon invests big to harness the healing power of regenerative medicine.

Army: CERV By Matthew Cox

The Pentagon and industry join forces to build a helmet to prevent TBI.

75

Navy: DDG-51 By John T. Bennett

By Julie Bird

Louder than Words on t he cov er

80

Snapshots from Afghanistan Design by Samantha Gibbons

Dan O’Shea, a lieutenant commander in the Naval Reserve, is loaded down with gear in Afghanistan.

82

Final Frame

S u m m e r 2 0 1 2 D E F E N S E S TA N D A R D

7


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www.defensestandard.com 2012 SUMMER EDITION

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CREATIVE DIRECTOR PRODUCTION ASSISTANT VICE PRESIDENT OF MILITARY & GOVERNMENT RELATIONS SENIOR ADVISER MILITARY ADVISER Special Operations Adviser LEAD RESEARCHER OPERATION IRAQI FREEDOM ANALYST Field Operations

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Copyright 2011-2012. All rights reserved. Reproduction in whole or in part is prohibited. The opinions expressed within this publication do not necessarily represent the views of the publisher. Defense Standard LLC assumes no responsibilites for the advertisements or any representations made in this publication. Defense Standard LLC in unable to accept, or hereby expressly disclaims, any liability for the consequences of inaccuracies or omissions of such information occurring during the publishing of such information for publication. Disclaimer: Neither the Department of Defense nor any other United States Government agency has approved, endorsed or authorized this publication in any form. No such inference is suggested, promoted or communicated in any manner.


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Publisher’s Note

S

ince its beginning nearly five years ago, DEFENSE STANDARD has remained committed to covering the medical issues that most impact our warfighters. Military medicine is never more important than when our troops are engaged in combat, nor is the motivation to drive innovation in partnership with industry ever stronger. As we looked back at our coverage, we thought it was time to revisit some of those stories. They represent a retrospective, if you will, of some key advances in military medicine, as well as a tribute to the people that make it happen. It’s been an inspiring journey, to say the least. We start with the Office of Naval Research’s ground-breaking research into two debilitating conditions affecting combat divers – decompression sickness and oxygen toxicity. Scientists at ONR labs and affiliated private and academic research centers are confident their work will have applications far beyond the combat diving arena. University research also is playing a major role in the Defense Department’s foray into regenerative medicine. The Pentagon ponied up $120 million over five years to kick-start eye-popping research into technologies that promote better healing of skin, muscle and cartilage – and eventually, maybe even organs and appendages. We also look at advances in battlefield medicine, with much of the military and industry research centering on reducing blood loss in the field. As the head of the Army combat casualty care research center says, “The simplest of devices sometimes makes the greatest difference.” Then we take a ride on an Air Force aeromedical evacuation flight from Afghanistan to Germany,

learning along the way how the mission has changed to reflect changes in the modern battlefield. In Germany, we report from Landstuhl Regional Medical Center, where all serious casualties from Afghanistan are treated before heading stateside for longer-term care. We continue our tour in the rehabilitation wings of Walter Reed Army Medical Center, where doctors and therapists helped wounded warriors transition back to normal life following devastating injuries. The century-old hospital closed almost a year ago, but the mission continues at Fort Belvoir, Va., and the National Naval Medical Center in Bethesda, Md. The continuum of care continues with the Department of Veterans Affairs. We look at VA-funded research into the advanced prosthetics technology revolutionizing the lives of amputees, and at VA efforts to better treat post-traumatic stress disorder. Finally, we come full circle with a selection of photos from Afghanistan provided to DEFENSE STANDARD by Dan O’Shea, a Navy Reservist currently deployed there. (That’s O’Shea on our cover.) As we see these images of our troops, still in harm’s way even when things appear calm, it’s a vivid reminder of why military medicine is so important. We want each and every one of them to come home – safe, sound and whole.

David Peabody PUBLISHER

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PHOTO: Mass Comm. Spc. 1st Class Jayme Pastoric

Combat Camera divers like Mass Communications Specialist 3rd Class Scott Raegen aren’t immune from the possible ill effects of deep-water dives.


Navy-sponsored medical research tries to minimize the dangers of the deep

TAKING THE

S

By Dave Smalley omewhere, in dark waters far below the ocean’s surface, a Navy diver cannot see his hand in front of his face. But that can’t stop him from performing his mission, whether it’s a covert operation or explosive ordnance disposal, deep-sea salvage or maintaining the hull of a ship. Amid the crushing depths and utter blackness of the deep, even basic work for a skilled diver can result in decompression sickness, oxygen toxicity and other potentially debilitating, even fatal, afflictions.

“There’s no such thing as a pure, 100-percent-safe dive,” says Cmdr. Matthew Swiergosz, a program manager with the Office of Naval Research (ONR) in Arlington, Va. “The things they do are extraordinarily dangerous, and they do them with a poise and professionalism that would inspire every American who could see it. The same can be said for our submarine force.” A day at the office is anything but routine, but scientists supported by ONR are working to keep divers safe in their duties. Undersea Medicine is an official National Naval Responsibility— meaning the Department of the Navy has deemed it critically important to maintaining naval superiority. “The Navy,” notes Adm. Jonathan Greenert, chief of naval op-

erations, must “continue to dominate the undersea domain.” And undersea medicine, experts agree, is a key to dominance. Chief Warrant Officer 3 and Navy diver John Theriot pulls no punches on how important the field is. “Without undersea medicine,” he says, “we would still be in the stone age when it comes to underwater operations.”

“T

he ocean is still unexplored and full of danger and mystery,” says Master Chief Michael Herbert, an explosive ordnance disposal technician and Navy diver for more than 20 years. “Our divers face a multitude of dangers on each mission that they run.” S u m m e r 2 0 1 2 D E F E N S E S TA N D A R D

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PHOTO: MC1 Jayme Pastoric

Divers searching for underwater mines are at risk for getting the bends or oxygen toxicity, both serious and potentially fatal conditions.

The technologies emerging in this field could have revolutionary implications for not only the Navy and Marine Corps, but the world at large. “Undersea medicine isn’t just about undersea,” says Michael Qin, principal investigator at the Naval Submarine Medical Research Lab in Groton, Conn. “It has huge implications to medicine across the board.” Swiergosz agrees. A number of illnesses, not only diving afflictions, are caused by gasses in the body—a topic front and center for ONR researchers. “If we can discover and understand all of the means by which gasses travel within the body, and how it affects our health and performance, then I think that there would be a complete paradigm shift in the way we think about developing pharmaceuticals,” he says. “It could affect multiple fields of study.” Learning about ONR-supported undersea medical research is like taking a crash course in science, verging on science fiction. Scientists are fighting the two most stubborn foes: decompression sickness, aka the bends, a malady that hits divers as they ascend to the surface; and hyperbaric oxygen toxicity, a perilous byproduct of breathing oxygen in the deep. In the face of these and other challenges, ONR’s work must be cutting-edge. “ONR has sponsored many individuals who have been later recognized as Nobel laureates,” says Swiergosz, “and I think it’s because we often seek out the avant-garde scientist—the one who can really push us into the new frontier.” 14

D E F E N S E S TA N D A R D S u m m e r 2 0 1 2

O

ne of the main missions for undersea medicine is to prevent problems associated with decompression as divers surface from the deep, where bubbles can form in the body. “If they are breathing air, they’re going to dissolve a lot of nitrogen in their bodies when they’re at depth,” or deep under water, says Dr. Jay Buckey, an ONR-supported researcher at Dartmouth-Hitchcock Medical Center in New Hampshire. “So when they come back up, they’re at risk for having these bubbles.” When that occurs, it can lead to everything from skin rashes and joint pain, if a bubble forms in a joint, to catastrophic paralysis or death. Buckey’s work includes studying the formation of bubbles, hoping to find a way to stave off the significant afflictions associated with returning from the ocean’s depths. The current treatment for decompression sickness is to place the diver in what’s called a hyperbaric chamber. These machines, which resemble an MRI tube, artificially reproduce conditions under the sea, slowly bringing the diver back to the normal pressures found at the surface. But hyperbaric chambers are large, bulky and not easily transported aboard ships. Nor can most of them be used on multiple divers simultaneously.


“It’s hard to get treatment chambers in remote areas,” Swiergosz notes. “The issue is to try to develop medical technologies that can augment or replace hyperbaric oxygen chambers. I’m not saying we’re throwing away the chambers, but that should be our goal for the future: to replace something that’s such a logistical burden.” The what-if scenarios are sobering. If a submarine were disabled, with rescued submariners numbering in the dozens or even hundreds, a lone hyperbaric chamber on a rescue vessel would be dramatically insufficient. One promising development is being studied at the Naval Medical Research Center in Silver Spring, Md. It involves accelerating the healing process for decompression using perfluorocarbons, which carry more carbon dioxide and oxygen than blood alone. “When a submariner would come up to the surface from being trapped in a disabled submarine,” says Capt. Richard Mahon, “we could actually treat decompression sickness without needing all the machinery,” using per fluorocarbon injections.

W

hile scientists do pioneering work studying the most minute parts of cell membranes—looking at how gas molecules move through gas channels in the blood—researchers are also taking a broader biomedical approach, looking at immune system reactions and genetic responses. Navy diver Theriot welcomes the efforts. “Undersea medicine is an important function in every aspect of the business, from submarine operations to open water air diving,” he says. As if the perils of decompression sickness weren’t enough for divers to worry about, oxygen toxicity is another unwelcome, but constant, concern. While oxygen is necessary for survival, in one of life’s ironies, too much of it can kill. “It’s a very complex thing,” says Swiergosz. “In a way, our entire physiology is built on thresholds. You could say that about anything—oxygen, medications, what you eat, anything. Yes, fruit is good for you. But if you keep eating too much of it, it can become toxic. There’s a balance.” Divers face the same issue with oxygen. While it’s necessary to breathe oxygen to sustain life underwater, the ratio increases to hazardous levels as divers go deeper. In other words: The deeper the dive, the greater the danger. “When you dive, your blood and tissues can become saturated with gasses that you’re breathing, based on ambient pressure,” Swiergosz explains. “So the deeper you dive, unless you’re adjusting your oxygen mixture, you’re getting more oxygen because of the partial pressure. It’s physics.” While mechanical devices can adjust the oxygen in a diver’s breathing gasses to some degree, it’s not the best so-

PHOTO: Senior Chief Mass Comm. Spc. Andrew McKaskle

Navy divers and special operators from SEAL Delivery Vehicle Team 2 and Naval Special Warfare Logistics Support conduct Lock Out Training with the nuclearpowered fast-attack submarine USS Hawaii for material certification.

S u m m e r 2 0 1 2 D E F E N S E S TA N D A R D

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rs ve di as

D E F E N S E S TA N D A R D S u m m e r 2 0 1 2

o st ou er ng da as st ju

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re sa ve di e ag s. lv on sa ssi d mi an at ng mb di el co W AL SE

PHOTO: MC2 Jimmie Crockett

PHOTO: Mass Comm. Spc 2nd Class Kori Melvin

PHOTO: John F. Williams

g in iv by D d l ta ge , in n en ima ing ca d p s im er be am tist rize p l n u Ex to h c cie ss y er re s av old atc at a p N h h p t in e th in a lled so ity ith e ca ne tiv c a w d b tro que br l a a m o lec hni em tric l e c lm c o l C g is din a te ce ele n e or g a ll’s D t. rec urin d to ce L l d e he or el h at e-c ope ac rd t g l i t c att co o s s re ve wh cro re l in s a mi s a nd a p ce ric de e a ci t in pla rba ctro ula r P it e le m n p i U hy h e , st nt. e a hic itor w on onm r i m v en


PHOTO: Mass Comm. Spc. 2nd Class Kathleen Gorby

Mass Communication Specialist 1st Class Shane Tuck trains Mass Communication Specialist 3rd Class Scott Raegen in underwater videography off the coast of Guantanamo Bay, Cuba.

lution. Stealth capabilities vital for Special Forces divers, for instance, are jeopardized by the use of such devices. But without them, divers face grim risks. Oxygen toxicity takes two forms: central nervous system, or CNS, toxicity, and pulmonary. CNS toxicity symptoms include visual disturbance, ringing in the ears, nausea, muscular twitching, irritability, dizziness, convulsions, seizures, unconsciousness or coma. It can strike without warning—and because the symptoms don’t happen in any particular order, divers could simply, suddenly, black out, lose a respirator and drown, without ever having known they were in danger. Pulmonary oxygen toxicity, considered less dangerous, is nonetheless serious. Chest pain and general lung dysfunction, coughing, increased blood flow to the nasal passages and even ocular damage are among the potential worries facing divers as they perform their missions. “The goal for [every diver] is to go deeper, longer and do it safely,” says Lt. Levi Kitchen of the Navy Experimental Diving Unit (NEDU) in Panama City, Fla. But oxygen toxicity remains one of the major obstacles to achieving that goal. So researchers at NEDU are studying, among other things, how cells behave in deep water, to learn how to one day treat or even prevent the symptoms.

O

NR-sponsored research at the University of South Florida in Tampa is breaking new ground studying brain-cell response to elevated oxygen levels. Earlier detection of changes in breathing, blood pressure or heart rate could help predict when oxygen toxicity or seizures might occur. “The data showed that

the cells that are important in the control of your breathing, as well as your cardiovascular system in the brain stem, are very sensitive to oxygen,” says the university’s Jay Dean. Based on that, Dean and fellow researcher Dominic D’Agostino are developing keytone esters—caloric substances that act essentially as a super fuel for the brain—to help the metabolism fight off the dangers of hyperbaric oxygen toxicity. “We have found two particular keytone esters that have a very strong neuro-protective and anti-convulsant properties,” says D’Agostino. “And we think that these keytone esters, in addition to preventing CNS oxygen toxicity, have application for not only ONR projects, but other neurodegenerative diseases.” At ONR headquarters in Virginia, Swiergosz knows that much work remains. “We do have some interesting advances” in the fight against oxygen toxicity, he says, “but there’s still a long way to go.” While the perils remain for divers, the progress is real for undersea medicine. The fight continues, in labs at Case Western University in Cleveland, where scientists are analyzing gas channels in the body; in Philadelphia, where University of Pennsylvania scientists have discovered elevated quantities of “micro-particles” in the blood after decompression; and in Durham, N.C., where researchers at Duke University are studying genetic responses during dives – all under the auspices of the Office of Naval Research. J --Dave Smalley reports for the Office of Naval Research. S u m m e r 2 0 1 2 D E F E N S E S TA N D A R D

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BattlefieldMedicine Army Staff Sgt. Mark Ramsey, right, looks on as a soldier applies a tourniquet to a mock wounded soldier who fell victim to a simulated roadside bomb during training.

Life-saving technology advances minimizE blood loss in the field Originally published in the Fall 2008 issue.

A

ir Force pararescueman Jason Cunningham saved at least 10 lives on an Afghan mountaintop in 2002 after their MH-47 Chinook crash-landed under heavy fire while on an ill-fated rescue mission during Operation Anaconda. He continued treating the wounded even after being shot through the lower back by a bullet that would drain the life out of him before a medevac helicopter could get to the chaotic scene. Senior Airman Cunningham posthumously was awarded the Air Force’s highest honor, the Air Force Cross, in recognition of his bravery and sacrifice. But Cunningham’s death also stands as a reminder that blood loss continues to kill soldiers, sailors, airmen and Marines who could have survived if the bleeding had been stopped on the battlefield. Similar scenes played out in the streets of Mogadishu in 1993 when soldiers were pinned down by Somali gunfighters, in Vietnam before the choppers could land, in wars stretching back millennia. One problem was medics couldn’t carry sufficient amounts of blood for frontline care because blood spoils quickly when unprotected. They could stuff gauze bandages into wounds and apply pressure, but in many cases they could only watch someone with curable wounds die. Better body armor helps, of course, but it also has concentrated devastating wounds to the arms and legs. “When somebody gets blown up, they can have sometimes two, three, maybe all four extremities terribly injured or amputated in the 18

D E F E N S E S TA N D A R D S u m m e r 2 0 1 2

field, and they will bleed to death before they get to us,” says Air Force Maj. Gary Vercruysse, a theater hospital trauma surgeon deployed in Balad, Iraq. But new options now available to battlefield medics are beginning to change that.

A

second-generation blood-clotting bandage coated with coagulant material can stop the bleeding. Medics can now carry blood in heat- and cold-resistant boxes that allow them to give transfusions on the battlefield. And a new generation of redesigned tourniquets is saving limbs -- and lives. “The simplest of devices sometimes makes the greatest difference,” says Col. Dallas Hack, director of the Army Medical Research and Materiel Command’s combat casualty care research program. Medics and battlefield doctors have a slew of technologies ​ improving the odds of survival. Forward-based surgical teams have laptop-sized digital imaging systems. Rugged anesthesia machines much smaller than hospital versions are used to put soldiers under for surgery. Wounds vacuum-sealed rather than sewn shut let surgeons treat battle casualties with a series of operations instead of a single, stamina-testing marathon surgery. New pain-blockers relieve suffering without risk of addiction. Databases track casualties’ treatment from the front line to Landstuhl Regional Medical Center in Germany to hospitals in the United States, giving each physician fingertip a​ ccess ​to their patients’ record of treatment. ​But the major cause of preventable death remains blood loss. With

PHOTO: Staff Sgt. Alfred Johnson

By David Perera


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greatest inventions. Throughout the process, the company worked closely with the Walter Reed Institute, Flora says. They did whatever they could to assist, “so that we were informed and that we weren’t just being shoved on some back shelf.” similar story of collaboration underpins a secondgeneration blood-clotting bandage called Combat Gauze, manufactured by Wallingford, Conn.-based Z-Medica, which the Army subsequently purchased for use in the field. The story begins with Z-Medica’s first product aimed at staunching blood loss, granules of a volcanic mineral applied directly into wounds. Revolutionary when introduced to the battlefield in 2002, Z-Medica’s product was 100 percent effective at stopping hemorrhage. But it had nasty side effects, including second-degree burns caused by the physical reaction between the mineral and water molecules. Then, in 2003, University of California-Santa Barbara scientist Galen Stucky got a call from the Office of Naval Research. A chemist dedicated to studying interactions between inorganic molecules and organic matter, Stucky had research experience with the Z-Medica mineral. Navy researchers wanted to know if he could do something about the heat reaction, ideally within six months. Stucky went to work and came up with a solution relatively quickly. “But we paid a price for ​​that,” he says. The new product was only 80 percent to 90 percent effective, a large enough margin​ of fallibility to send Stucky on a new round of government-funded research. To come up with a better solution, he would have to understand exactly how to best trigger the cascading effect of blood clotting. Stucky wasn’t the only researcher examining how to induce clotting, but other efforts focused on blood proteins, a more expensive route. Stucky and his team of researchers zeroed in on investigating the properties of metal oxides. “Once we understood what were the key parameters, then we were able to say, ‘OK, I know what kind of material we need.’ ” That turned

​A

PHOTO: Sgt. Timothy Stephens

casualties continuing to pile up in two ongoing wars, finding ways to stop the bleeding in the battlefield has become a top priority of military medicine and private industry partners. After the casualties of Operation Anaconda, the Army was newly determined to solve the problem of blood transportation. Walter Reed Army Institute of Research officials tasked industry with finding a way to transport blood under extreme temperatures and keep it fresh for 24 hours. The transport mechanism had to maintain an internal temperature between 33 degrees and 50 degrees Fahrenheit while the ambient temperature cooled to minus 4 degrees or heated up to 104 degrees. It also had to weigh no more than 6 pounds and contain no active machinery. “They showed us pictures of these soldiers – it’s like they’re carrying a house. Every ounce counts,” says George Flora, co-founder of Minnesota Thermal Science, a startup company formed specifically to develop a blood-transportation solution. The small company decided at first to concentrate on designing a temperature-resistant box. It didn’t quite work, in part because the prototype used water as a cooling agent. “They came back and told us we were half a [Celsius] degree too cold,” Flora recalls. The company went to work on a new solution, this time developing a proprietary fluid that would keep the internal box temperature stable. The key was to find a fluid resistant to temperature change – it takes 136 units of heat measured in British Thermal Units to convert liquid water to steam – that would freeze at a precise temperature. Following months of experimentation, the company sent the institute a new prototype. It worked. “Then they said, ‘George, can you make it last 48 hours?’ ” Flora says. Later, they asked for a 72-hour model. The final product can keep blood fresh up to 93 hours in extreme cold and 82 hours in extreme heat, he adds. “We gave them as much as we could get in a 6-pound box,” Flora says. In 2003, Army Special Forces officially adopted the company’s box for blood transportation. In 2004, the Army named the company’s work one of the preceding year’s 10

If battlefield medics get the tools they need to quickly stop blood loss, field surgeons will have better opportunities to save life and limb.

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PHOTO: Courtesy of CMSGT Don Sutherland

out to be a common clay mineral called kaolin. serviceman Mark Esposito of Golden, Colo., is designed Coming up with a solution wasn’t just a matter of laboratory for single-handed application so a soldier can put it on experimentation. Promising products found by Stucky’s team were sent himself. The Army surgeon general facilitated widespread reto the Naval Medical Research Center for animal testing. “The in vivo introduction in 2005. Now, the CAT is part of every soldier’s tests are very expensive and they’re time-consuming. Consequently, standard field issue. we had to be careful that we gave them good suggestions,” he says. The device consists of an inner and outer band: The outer Meanwhile, Z-Medica was working on the problem as well. “It was band wraps the tourniquet around the wounded limb while also an issue that we were asking caregivers to pour granules into a wound, which was never done,” says Bart Gullong, chairman of the Z-Medica board. The presence of granules in the body made wound healing awkward and there was the danger of pouring in too much, causing severe burns. The company responded by packaging granules into a “tea bag,” then into a sponge. After Stucky hit on kaolin, however, Z-Medica managed to impregnate the clotting agent directly into gauze. “The gauze was a brilliant way to go,” Stucky says, adding there’s no way he could have devised it himself. “I can come up with something on the bench stoop, but that isn’t going to do the soldier any good on the field,” he says, referring to a laboratory test environment. “It’s got to get to him, somehow, in a useful form. I’m not set up here to do packaging, do marketing or do Medical personnel carry an “injured” airman on a litter during an exercise to manufacturing.”  prepare field medics for treating patients on the battlefield. ​​  sk military doctors for an important battlefield medicine innovation and one of the first things they’ll mention is the tourniquet, first used in battle a rod tightens the inner band to cut off circulation. “The bad in the 1800s but eventually falling out of favor. But 7 percent to 10 devices aren’t commonly used any more, and the effective percent of battlefield deaths in Vietnam and Somalia were caused by ones are issued,” Kragh says. The Combat Application profusely bleeding arm or leg wounds that likely could have been Tourniquet won an Army Greatest Invention of 2005 award. averted by use of a tourniquet, according to the Defense Department. ​​When Kragh was deployed to Bagdad’s Ibn Sina Hospital “They had a Army tourniquet from World War II, used it for 50 in 2006, he used a reusable, ​pneumatic tourniquet made by years, and the reports from World War II said they didn’t work so Vancouver, Canada-based Delfi Medical Innovations during well,” says  Col. John Kragh, an Army Medical Corps orthopedic surgery. He communicated often with Delfi about ways the surgeon and proponent of the devices. Mounting groundswell support company could improve the product – small changes, he says, for tourniquets, intensified by soldiers’ tendency to buy them through that nonetheless made a big difference.  the Internet because the military’s basic training strap-and-buckle unit For one thing, a cap on the pneumatic bladder fell off easily. “It clearly fell short, led to a re-evaluation. being the same color as the floor, you couldn’t see it,” he says, and In 2004, the Army Institute of Surgical Research decided to test the surgical team wasted time scrambling for it on the floor as patients commercially available products. It recommended acquiring the bled. Kragh recommended that the cap be attached with a leash. He Combat Application Tourniquet, distributed by Greer, S.C.-based also wanted the tourniquet to open with less force. “They changed the North American Rescue Products AT. The CAT, invented by former [clamp] arc to be gentler, so there’s less force, more roll, to open up

A

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the tourniquet,” he says. “They were fairly minor things, so we were able to get them out within a few months,” says Delfi President Mike Jameson. f many of today’s advances sound prosaic – even though they’re anything but – potential advances sound like the stuff of science fiction. The Defense Advanced Research Projects Agency contracted with Siemens Healthcare in 2008 to develop a portable device that would

​I

Odds of SURVIVAL

DARPA funding, SRI conducted a two-year research and development project ending in March 2007. The idea of a robot medic – which SRI and DARPA call a “Trauma Pod” – becomes a lot more believable when it’s described as a machine that recognizes patterns and does something simple as a result, such as putting a needle to a target. “This is not blue sky,” Low says. “We can address a number of serious battlefield injuries, temporarily. We’re not trying to do definitive surgery. We’re not trying to install on a machine the intelligence of a surgeon.” Still, a robot could probably do better with some frontline procedures than a soldier operating under high-stress

In World War II, 30 percent of the Americans injured in combat died,

according to Defense Department figures. In Vietnam, the proportion dropped to 24 percent. During the early years of Iraq and Afghanistan, about 10 percent the injured died, according to a December 2004 New

staunch deep limb wound England Journal of Medicine article. Col. Mark Mavity, commander of bleeding using ultrasound the Balad Air Force Theater, said the in-theater rate survival rate in Iraq waves – a kind of highhad always been at least 95 percent and edged close to 98 percent by tech tourniquet. A cufflate 2008. like device would first search for bleeding and then send a concentrated dose of high-intensity ultrasound waves prompting quick conditions, Low says. He cites a cricothyrotomy as an example: puncturing a patient’s neck with a large-bore coagulation. Focused ultrasound has already proven effective during hollow needle when the airway is obstructed. Frontline animal tests. The directed energy raises tissue temperature, medics are somewhat reluctant to perform a cricothyrotomy causing it to shrink and small blood vessels to collapse. “and don’t do particularly well under fire,” he says. But a Tests show tissue can be safely heated to between 158 and robot given an image of the airway can do so easily. “It’s 194 degrees Fahrenheit within 30 seconds. The device’s putting a needle to a target, based on imagery,” he says. The first two years of the project were just the first acoustic properties also appear to push blood away from phase of a research and development effort that could the injured area.  ​Meanwhile, SRI International of Menlo Park, Calif., last up to a decade, Low says, noting robots already exist requested more DARPA funding to move forward with in the surgery theater. And, he says, automated external what could be the most futuristic medical addition to defibrillator devices in public places let laymen treat heart the battlefield: a robot doctor. “Ideally the system would attacks with electric shocks by monitoring a victim’s heart be completely automatic, autonomous, making its own rhythm and firing at the right moment. “Certainly it’s better than the alternative of dying,” therapeutic decisions,” says Thomas Low, SRI director of medical devices and robotics. With $12 million in he says. J

SRI International tested a robotic battlefield doctor with DARPA funding.

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Originally published in the Winter 2011 issue.

B

AGRAM AIR BASE, Afghanistan -- The wounded return home from war much the way they left, largely invisible to a distracted nation. In this instance the long journey begins on a darkened, wind-swept flightline at Bagram Air Base, a sprawling airfield that sits in a wide valley surrounded by mountains. An old flight control tower dates back to the Soviet occupation of this Afghan air base in the 1980s. Another aeromedical evacuation flight is collecting the wounded from America’s longest war. In a familiar choreography rendered silent by the constant backwash of jet engines, a bus bearing a red cross parks next to the open rear door of a C-17 Globemaster III. Those who can walk shuffle their way up the ramp to webbed seats lining the aircraft’s cavernous hold, followed by stretchers carrying the more seriously wounded and ill, which are lashed bunk-bed style to metal stanchions running down the center of the plane’s cargo bay.  Finally, two critically wounded troopers tethered to gurneys and nearly invisible beneath an emergency room’s worth of medical equipment are hoisted into the back of the aircraft. Though they operate out of sight on restricted military air bases, aeromedical evacuation flights are helping to revolutionize combat medical care. Since Sept. 11, 2001, the Air Force’s Air Mobility Com-

mand has flown more than 35,600 medical evacuation sorties, transporting more than 177,000 wounded or ill service members. A U.S. trooper wounded in Operation Enduring Freedom in Afghanistan tomorrow likely will reach Landstuhl Regional Medical Center in Germany in about 30 hours, and arrive at a U.S. medical facility in an average of three days. In 1991, troops wounded in Operation Desert Storm reached home in about 10 days. During Vietnam the whole journey took on average of 45 days. Combined with advances in combat medicine and body armor, the rapid air evacuation system has resulted in a historically low lethality rate compared with other U.S. wars. Service members wounded on a battlefield today have a remarkable 98 percent chance of survival. As a recent trip aboard one such flight underscores, however, behind every fatality lies a long roll call of the wounded and maimed. ​The air and medical crews on this 10th Expeditionary Air Force Evacuation Flight were cobbled together from various active-duty, Air Guard and Air Force Reserve units, which is typical. Though they represent the ultimate “pick-up team,” the crews mesh easily after years of conducting this type of mission. “We blend active-duty and reserve pretty

MEDICINE

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By James Kitfield

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PHOTO: Master Sgt. Adrian Cadiz

Warfare has changed, and so has the way the military evacuates its wounded


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seamlessly on these missions, because all of us are trained to the same standards and procedures, and like me most of the team have been doing this quite a while,” says Tech Sgt. Mike Malone, a reservist with the 360th Aeromedical Evacuation Squadron out of Pope Air Force Base, N.C. A former Marine, Malone is an emergency medical technician in his civilian life. “This mission is different from my work as an EMT, which usually involves moving one or two injured patients a short distance. Here we pick up a whole planeful of injured, and move them halfway around the world. I also like that we are the ones who get to bring these wounded troops home.” That is an oft-repeated sentiment for aeromedical evacuation team members. “This is an e​ specially challenging mission, but we all do it for those guys in the stretchers,” says Capt. Chris Lane, a National Guardsman and flight nurse who runs an emergency room in Fort Worth, Texas, in his civilian life. “It’s important that those soldiers and Marines understand that if they get injured, they’ll get outstanding care from the time they are hurt until we can get them home, whether it’s on (ABOVE): Capt. Reggie Brown (left) teaches his Iraqi counterparts how to secure the ground or at 30,000 feet. We owe it to them.” a litter to the floor of a C-130 Hercules. Six Iraqi medics learned the basics of   aeromedical evacuation over two days with Air Force and Army advisers. he rapid air evacuation of wounded troops and the new (BELOW): Crew members from the 10th Expeditionary Air Force Evacuation Flight model in combat medical care was largely dictated by take servicemembers wounded in Afghanistan off a C-17 at Ramstein Air Base, the nature of the counter-insurgency conflicts in Afghanistan Germany, for transport to nearby Landstuhl Regional Medical Center. and Iraq over the past decade. Fighting multiple wars with very dispersed and fluid front lines and no safe rear areas, the U.S. military did not have the luxury of having huge field hospitals near the fighting. That forced the Pentagon to embrace an entirely new approach to combat medical care that emphasized quickly stabilizing wounded warriors on the ground and then flying them back to the United States for definitive care as rapidly as possible. It also reunites wounded soldiers with their loved ones more quickly. Rapid aeromedical evacuation that transports the wounded to definitive care within a “golden” 72-hour window, coupled with advances in combat medical care and body armor, dramatically diminished the lethality of the conflicts in Iraq and Afghanistan. According to Dr. Ronald Glasser, a Vietnam-era Army surgeon and author of the recent book, Broken Bodies, Shattered Minds: A Medical Odyssey from Vietnam to Afghanistan, for every battlefield death in the past decade, 16 U.S. service members have survived their wounds. The ratio in Vietnam, he said, was 2.4 wounded for every death. In the Civil War, the ratio was less than 1-to-1, with few soldiers surviving battlefield wounds. least 60 percent disabled. Department of Veterans Affairs hospitals and The result of that revolution in combat medicine, however, has been medical centers have already treated 508,000 veterans of today’s wars. that the past decade of war has produced a surfeit of service members With tactics and geography shifting over the past decade, those with serious,and even catastrophic wounds. According to the Penta- transporting and treating the injured noticed that the pathology of the gon, 168,000 service members wounded or injured in these wars are at wounds also mutated over time. Early on in Afghanistan, for instance,

PHOTO: Tech. Sgt. Jason Lake

MEDICINE

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small arms caused many injuries. A few years into the fighting – as insurgent bombs got bigger and the armor on U.S. military vehicles got thicker – troops increasingly absorbed blast waves through their seats, causing a spike in spinal cord injuries, concussions and brain trauma. Over the last 18 months in Afghanistan, the profile of wounds changed again. “As Afghanistan has turned primarily into a war of dismounted infantry, our polytrauma wards have seen a huge influx of troops with really massive injuries from absorbing blasts while on foot patrol, including multiple amputations, really severe brain injury, and the emotional wounds that go with all of that,” says Dr. Shane McNamee, the chief of physical medicine and rehabilitation at the VA’s Polytrauma Rehabilitation Center in Richmond, Va. “In the past five years, I can’t tell you how many times we have re-geared to tailor our care delivery to subsequent waves of service members with different kinds of wounds.”   uring the flight from Afghanistan to Ger- An Air Force aeromedical evacuation team secures wounded Marines, their gear many one of the two critically wounded sol- and medical equipment onto a C-130 Hercules at Camp Bastion, Afghanistan. diers nearly flat-lines, and the onboard Critical Care Transport Team consisting of a doctor, a critical-care sive device (IED), and their signature wounds account for the more nurse and a technician works frantically to save him. Eventually, the than 1,300 amputees among U.S. service members, numerous burn emergency medical physician, Lt. Col. George Dockendorf, is able to victims and unknown numbers of troopers suffering from traumatic stabilize the patient.  The soldier on the gurney next to him has lost both brain injury. According to the advocacy group Veterans for Common legs, and never moves throughout the emergency. Sense, more than 190,000 troops have suffered a concussion or brain “Being at this altitude affects everything, because you can’t hear injury from operations in Iraq and Afghanistan. There is also growing alarms from the equipment, reactions to medicine are different, and evidence of links between traumatic brain injury (TBI) and post-traueven the flow of vital fluids through tubing is impacted,” says  Maj. matic stress disorder, or PTSD. Kathy Miller, a critical-care flight nurse and Reservist out of Luke Air ​In the back of the C-17, Sgt. Edward Pheifer speaks directly to the Force Base, Ariz. The austerity of the operating environment also puts gray area of war and its toxic impact. A military dog handler who typia premium on careful preparation, she says, because there is no running cally spends his days searching for IEDs and mines, Pheifer is flying down the hall to the supply room for additional equipment or medicine his German shepherd, Alf, to the Daniel E. Holland Military Workto handle unexpected emergencies. Despite those challenges, however, ing Dog Hospital at Lackland Air Force Base, Texas. He strongly susMiller prefers aeromedical ​evacuation missions to her civilian work in pects that Alf is part of the roughly 5 percent of military dogs deployed a hospital emergency room. with U.S. combat forces that have developed canine PTSD. Making “I’d much rather be taking care of these soldiers,” Miller says. Alf more proof, if anyone needed it, that war is hazardous to all living “Honestly, this is the most rewarding job I’ve ever had. I would do it things. full time if I could.” “I think Alf does have PTSD, because he just doesn’t want to The severity of the wounds to the two critically injured troops un- work any more,” says Pheifer. When asked if Alf’s work in Afghanderscores another toxic byproduct of these wars. The enemy’s weapon istan had been that stressful, Pheifer doesn’t hesitate. “It’s stressful of choice in both Afghanistan and Iraq has been the improvised explo- on everybody.” J

D

PHOTO: Master Sgt. Adrian Cadiz

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LANDSTUHL

REGIONAL MEDICAL CENTER By David Perera

PHOTO: Courtesy U.S. Army

U.S. military hospital in Germany is the first stop for wounded warriors heading home

Originally published in the Spring 2009 issue.

L

ANDSTUHL REGIONAL MEDICAL CENTER, Germany – Two waves of the wounded and sick from Afghanistan and Iraq will be delivered today through the front gate of this U.S. Army-run hospital in western Germany. Two sets of blue school-bus-sized ambulances will carry stretcher-bound troops and contractors fresh from the airstrip of nearby Ramstein Air Base and deliver them into the hands of a multiservice and civilian assemblage of orderlies, doctors and nurses. The number of new patients is nowhere near what it once was; the stream of men with their arms or legs blown off, their internal organs punctured, their brains turned to pulp by bomb blasts is thankfully a comparative trickle. During the worst weeks of the troop surge in Iraq in mid-2007, about 1,200 new cases were admitted per month. Now, in the spring of 2009, triage nurse Navy Cmdr. Richard Gallaway estimates that about 600 new patients come here monthly. Well awake despite having started his shift at 4 a.m., Gallaway pores over paperwork describing incoming patients’ symptoms, mapping out where in the medical center to send them. These days, thankfully, outpatient cases also outnumber inpatient admissions by more than ever. “That’s what we want,” he says. “The less numbers we see, the 30

D E F E N S E S TA N D A R D S u m m e r 2 0 1 2

better things are going downrange.” The largest military medical facility outside of the United States, Landstuhl is just six hours air time north of Iraq. Wounded warriors are sent here after being patched up at field hospitals. It’s a hub, a place to clean out wounds, check for traumatic brain injury, administer physical therapy and most often send patients onward for long-term care in the United States. Inpatients usually stay here just two to four days before they are U.S.-bound. Overall hospital admissions are at their lowest level since January 2004, but medical personnel warn that the numbers almost certainly will climb again should troop numbers expand in Afghanistan. “When the war kicks up, we’re of course going to get a lot more,” Gallaway says. Caregivers describe Landstuhl as the middle point of an hourglass funnel. Patients come in from everywhere and they’re sent back out to everywhere, too. During this period of relative calm, Landstuhl is also the eye of a storm.​ allaway says he remembers only a single day in his two years of duty at Landstuhl when an ambulance didn’t disgorge new patients. Just a few days earlier, Army 1st Lt. Joshua Darnell was on one of those buses, his stretcher handed down from the ambulance

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PHOTO:Staff Sgt. D. Myles Cullen

onto a gurney by rubber-gloved medics congregated at the hospital’s emergency entrance. Recuperating today from surgery in a secondfloor ward, Darnell wonders whether he will lose his lower right arm. “I’m getting pretty good doing things with my left hand,” he says, his face strawberry-red from the flash of a suicide-bomber explosion five days earlier in Hutal, Afghanistan (just northwest of Kandahar), his eyebrows partially singed off. The explosion threw him to the ground after a blinding burst. Everything turned white, Darnell r​emembers. “I took a couple of seconds to regain my breath, started trying to push myself up and noticed that my right arm was just dangling in the mud – a complete open fracture on the arm, it was just barely hanging,” he recollects in a quiet tone. Darnell’s right arm is shattered, held together with a metal device that’s all rods and bolts connecting remaining healthy sections of bone. This is Darnell’s third day here; by the next night, he’ll be in a military hospital in Georgia, near his wife and parents. There, surgeons will decide whether they can put in an artificial joint, fuse the existing bone, “or whatever,” Darnell adds without emotion after a miniscule pause. This is the third year Army 1st Lt. Andrea Ruff has spent as a ward nurse. When she first arrived at the hospital, “We were totally full,” she says. “You worked all the days you were scheduled to work and got called in to work the day you weren’t.” Ruff asked to be posted to Germany. “I figured what better place to take care of soldiers, just one spot removed from where it happens,” she says. It was a request prompted by her younger brother joining the Army and being tagged to go into combat. “It could be him in a second in one of these beds,” she says, then exhales deeply. “And here I am.” Army Sgt. James Bryant still suffers from a wound received in the bad old days of fighting in Ramadi, Iraq, during 2006. A sniper’s bullet hit him and he fled by swimming in a canal with 80 pounds of field gear still on his back, herniating three discs. He had hoped to avoid surgery but that wasn’t to be; he’s in recovery now. Navy Lt. Cdr. Mitchel Ideve wants him to walk as far down the hallway as he can. Ideve is a physical therapist with a realistic assessment of his job. “The things we do cause pain. It can’t be helped. But we like to come back and tell patients that PT [physical therapy] means ‘pretty terrific,’ ” he says. Ideve gets Bryant a walker and Bryant swings himself slowly out of bed. Ideve straps an orange belt around Bryant’s abdomen, grabbing the belt firmly in back. Together the two edge out of the room into the hall. Don’t grab tightly onto the walker, Ideve advises, just push it along. They get about 10 yards down the hall and turn around. “This may be a Percocet moment,” grunts Bryant.​   efore combat operations ramped up in earnest, Landstuhl was basically a quiet community hospital focused on outpatient care, say people who recall life before war here. Even after casualties from Iraq and Afghanistan began appearing in earnest, at first each busload of patients was a mystery until the doors were thrown open. A patient’s medical record from downrange might not have been any more detailed than a list of symptoms written with a Sharpie pen on a patient’s leg. “Maybe they’d have a piece of paper with them, if they were lucky,” says Navy Cmdr. Dr. Fred Lindsay, head of the Deployed Warrior Medical Management Center, the hospital unit created in January 2004

Army Spc. Cocin Laird Pearcy, who is about to be awarded the Purple Heart, recuperates from his wounds at Landstuhl.

to rectify that situation. Unit members now access electronic records of each incoming patient, informing doctors of what’s coming long before the airplane’s wheels are down. It makes it harder for a patient to slip through the cracks. Military physicians call it a “continuum of care,” a steady line of documented medical attention ensuring the next stage can immediately build on predecessors’ work. It’s one reason the odds of surviving a battle injury are better than ever before -- as high as 98 percent, according to some military physicians. DWMMC removes the elements of spontaneity from patient receiving


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SOLUTIONS FOR THE U.S. MILITARY


PHOTO: Cherie A. Thurlby

Then-Defense Secretary Robert M. Gates presented the Purple Heart to Army Staff Sgt. Brent A. Homan at Landstuhl Regional Medical Center. Homas was wounded in action in Balad, Iraq, in June 2007.

and makes it more routine, “which is very important when you’re receiving 40 people a day,” Lindsay says, talking q​ uickly with the air of a very busy person. The ear, nose and throat surgeon is dressed in green operating-room scrubs and he wolfs down two Burger King fish filet sandwiches as he speaks, eyes darting back and forth. On his desk is a bowl full of candy and a half-empty bottle of aspirin. The system isn’t perfect, Lindsay allows – there are in fact a couple different medical databases DWMMC staff might need to access to gain the most comprehensive medical picture of an incoming patient. It would be nice if the applications could talk to one another, but at this point they can’t. And, ideally, inputting new information could be done by barcodes or scanning rather than manual data entry. Anything can be made better – but even as it is, DWMMC underpins “the best medevac system in the world, in the history of time,” Lindsay says matter-of-factly. ​   ospital operations themselves have undergone significant change during wartime. “We have a lot more advanced equipment and clinical skills that are available here, as well as manpower,” says Army Lt. Col. Dawn Garcia, head nurse in the intensive care unit. Patients show up with more critical injuries than in the past, she notes. In mid-2007, the hospital for the first time gained American College of Surgeons certification as a Level

H

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II trauma center, second only to Level I designation. Garcia says the hospital staff has racked up lessons learned. Nurses are particularly careful to monitor for hospital-acquired pneumonia, particularly with ventilator patients whose lungs are especially vulnerable. Prevention is as simple as propping up a patient’s head and brushing teeth, but skipping those everyday tasks could be a deadly oversight. Caregivers also screen each patient for signs of traumatic brain injury. Better body armor means many once-fatal bomb blasts are survivable, but the shock waves they send to the brain can have cumulatively bad effects. Landstuhl was among the first medical facilities to recognize TBI. They’re also careful to note symptoms of combat stress. “Nobody comes back untouched from a war,” says Army Col. James Griffith, the chief Army chaplain and a Presbyterian minister. Chaplains meet every new inpatient as they’re unloaded from the ambulance. More likely than not, warfighters will have trouble sleeping, Griffith says. They’ll be prone to recurrent, intrusive thoughts and nightmares. “It’s common for people to have night sweats for awhile,” he adds. Griffith tells his chaplains they should encourage warfighters to speak about their time downrange; turning experience into stories normalizes what happened. It helps the patients start to feel like themselves again.


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Landstuhl by the numbers As of early 2009: • Total personnel: 2,837 • Number of intensive care unit beds: 18, with a reserve capacity of 10 more • Number of inpatient, non-ICU beds: 64, with a reserve capacity of 34 more • Number of treated battle injury patients since operations Enduring Freedom and Iraqi Freedom began: 10,616; 9,434 from OIF and 1,182 from OEF • Total number of patients treated

Griffith, Garcia and others say they’re also careful to monitor their own staff for signs of burnout. Ruff said after her first year here she found herself coming down with a case of secondary trauma stress disorder, or as most people call it, “compassion fatigue.” “You hear so much,” she says. Ruff said she didn’t want to turn to her family – they couldn’t understand anyway and she didn’t want to explain in any detail the suffering she saw while her brother was deployed. In the end she turned to coworkers for support. Seared into her memory is the case of two ambushed soldiers. She had previously met them during a training exercise in which they played war casualties, only this time it wasn’t fake. One soldier had shrapnel wounds down the side of his head and the other lost a leg. “They’re all important patients, but it just made it extremely real. … It’s real anyway, but I knew these people,” Ruff says. Griffith, the chaplain, says he goes through similar experiences. As the father of a 22-year-old, it’s hard not to identify with many of the young men admitted to the hospital, he says. A rare chance to see someone broken made whole again can make his day. ​He recalls a badly disfigured soldier with his jaw blown off who 18 months later came back as a normal-looking military aide. That was a good day, he says. But not the best. The best days, he says, are when no new patients show up at all. J

since the start of OEF and OIF, including outpatients: 52,367 • In a recent typical day, 19 new patients are admitted, 14 patients are operated on, 6.2 patients are in the intensive care unit and 1,226 meals are served • About 18 percent of patients return straight to duty.

PHOTO: Courtesy U.S. Army

Source: Landstuhl Regional Medical Center

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Army Secretary Pete Geren visits wounded soldiers at Landstuhl in western Germany in September 2008.


Walter Reed

armymedical CENTER Army Master Sgt. John P. Souza has to learn how to navigate a simulated home in a wheelchair while he recovers from injuries sustained in Iraq at Walter Reed Army Medical Hospital in Washington.

By Sara Michael Photos by Jay Westcott

With intense rehabilitation and support, amputees learn their lives are still full of possibilities Originally published in the Summer 2008 issue.

W

ASHINGTON, D.C. -- Army Master Sgt. John Souza talks tough, with a hint of a Boston accent and a wit that comes across as laidback sarcasm. Sitting in a wheelchair with his left leg extended in front of him, surrounded by what looks like a medieval torture device, Souza, 52, pauses to swig from a bottle of red PowerAde. He tells the horror story of how a 3-pound mine laden with ball bearings the size of his pinky tip ripped through the wall of a local council building in Sadr City, Iraq. “I could feel below the knee just flop,” he says with ease, as if the explosion hadn’t happened just three weeks earlier. At Walter Reed Army Medical Center in Washington, D.C., Souza shows off how he can slowly lift his leg – including the spatial fixator correcting his broken bones – a few inches without 38

D E F E N S E S TA N D A R D S u m m e r 2 0 1 2

the help of a nylon blue handle. Just a week ago, Souza relied on a nurse to clean him, leaving this 30-year Army mechanic intensely frustrated. Souza says he wouldn’t have come this far without the support of the Walter Reed staff: their professionalism, respect, personal touch – and perhaps their ability to take a joke. The staff have helped speed his recovery and buoyed him to keep up the witty banter despite intense pain and frustration.  “I’m not just a number,” he says, his eyes filling with tears as he looks away and takes a breath. “These guys here – I love them. I can joke with them. I haven’t ticked anybody off,” he says with a grin, looking at Hector Romero, the occupational therapist sitting next to him. ​ ach day, therapists, physicians and support staff at Walter Reed care for hundreds of troops wounded in the

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PHOTO: Jay Westcott

Staff Sgt. Sara Sutton, a physical therapist technician, works with Army Cpl. Christopher Levi as he relearns how to walk.

wars in Iraq and Afghanistan. Some are service members themselves, others are civilians. But all chose to care for the country’s military members, becoming a vital part of their rehabilitation and support. These doctors and therapists see an endless stream of critically ill patients, a constant onslaught of what are often the most horrendous and complex injuries. More than 800 amputees from the wars in Afghanistan and Iraq have OCCUPATIONAL THERAPIST HECTOR ROMERO been treated at military medical facilities as of mid-2008, including Walter Reed; Brooke Army Medical Center in San Antonio; the National Naval Medical Center in Bethesda, Md., and the Naval Medical Center in San Diego, according to Walter Reed officials. ​At Walter Reed, the orthopedics ward and the new Military Advanced Training Center teem with patients working to rebuild their strength and mobility.  ​Romero’s friends think his job as an occupational therapist at Walter Reed must be depressing because he sees military members at their lowest point, physically and mentally. But for Romero, 28, the opportunity to see them rise from that low is unparalleled. And they do rise. One of his patients who came to him missing part of his leg now wants to kayak, said Romero, who has worked at Walter Reed for about two years. “We watch them fly,” he says. The quick progress the staff see in the patients is unique to 40

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the population, said Col. Jeff Gambel, medical director of the amputee care program. About 1.7 million Americans have ​lost a limb, according to the Amputee Coalition of America. Most civilian amputees are older and lost a limb because of poor circulation caused by arterial diseases or diabetes; diabetics account for more than half of all amputees. At Walter Reed, the patients are strikingly different from the image of a typical amputee, Gambel says. These soldiers were tactical athletes, in peak shape, with all the dreams and plans of any 25-year-old. The expectations of a young, wounded soldier are very different from a civilian amputee, he says. They want to return to the level of functioning they had before they lost a limb in battle. “One of the early decisions was to co-locate injured service members here together,” he says. “At a local hospital, they would be among people who are older and have lower expectations.”The soldiers feed off each others’ high expectations – and the signature military can-do attitude. “And that pumps up the staff.” Cpl. Chris Levi, a youthful-looking 25-year-old Long Island native, explains how the military attitude translates from Army training to rehabilitation.“Just because we got blown up doesn’t mean our standards drop,” says Levi, who lost both his legs and the back of his hand in Baghdad from an “EFP,” an explosively formed projectile, that he says could “rip through armor like a hot knife through warm butter.” “It’s the same mentality we had in the Army. You may not have the proper equipment, but you can do better,” he says, peddling on a stationary bike in the spacious workout room in the Military Advanced Training Center, an outpatient facility opened in September 2007 to accommodate the growing number of activeduty service members who lost limbs in Iraq or Afghanistan.   he at-times miraculous turnarounds the soldiers make motivates Capt. Aeneas Janze, a resident in physical medicine and rehabilitation in his final year of training. He described his time at Walter Reed as a blessing. A soldier may be

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PHOTO: Jay Westcott

After his leg was shattered by a mine in Iraq, Souza has to learn how to navigate common, daily chores like getting in and out of the bathtub.

in intensive care one month and then an outpatient three months later, walking with a prosthetic limb, says Janze. “To have this patient population that does get better is rewarding.” Working at Walter Reed also gives Janze unparalleled training. He’s in the “eye of the storm,” he says, treating patients with complex and often multiple injuries he wouldn’t see at a local hospital. “The exposure is really startling.” Other therapists and physicians point to the flexibility they have to treat a spectrum of ailments. The military provides staff with the training and certification to do several tasks. So rather than just being able to order an X-ray, for example, a therapist could order it, read it and send the patient to orthopedics, says Capt. Dora Quilty, an occupational therapist. The barrier of health insurance known to plague civilian doctors is absent in the military setting. That frees up military doctors and paves the way for them to offer the most state-of-theart treatments, staff members say. Amputees were getting the latest version of the C-Leg – a hightech computerized artificial leg created by Otto Bock – the same day it went on the market, Janze says. “The military takes care of its people.” For Quilty, the motivation to come to work each day is intensely personal. Her husband, Capt. Scott Quilty, lost an arm and a leg and spent two years at Walter Reed recovering. She wants the patients she sees to live the life her husband now enjoys. “Everyone deserves a chance for the way they want to live. If we come in here and do our jobs, we are giving them all the tools they need to get where they want to be.” Dora Quilty works with patients at Fort Independence, a miniature apartment set up in the occupational therapy wing. A complete kitchen and a living room with a couch, chairs and table provide the setting for recovering soldiers to relearn skills needed for daily living. Working in a familiar setting also can help soldiers suffering from Post Traumatic Stress Disorder to focus, Quilty says, allowing them to overcome the speech and memory barriers ​to complete a task. “It’s the ‘ah-hah’ moment,” she says, sitting in the small living room. “It’s rewarding when it happens.” 42

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ut those breakthroughs don’t happen every day, and working in the mental health field can be particularly draining, Quilty says. It can often seem like a never-ending stream of patients. One is discharged and a new patient arrives, perhaps only able to move his thumbs and blink his eyes. Then there are days when a soldier she has been working with for two months who was showing progress doesn’t show up for his appointment because he’s back in the lockdown unit where he can’t hurt himself. “Those,” she says, “are hard days.” OCCUPATIONAL THERAPIST ​That’s when Quilty steps CAPT. DORA QUILTY away from the mental health part of her job and works with a patient undergoing physical therapy, shifting her efforts to someone else in need. “When you get discouraged you change your focus on something else,” says Quilty, who also notes she and her husband take frequent weekend trips to ease the stress. Romero does the same. When he gets particularly frustrated with a patient, he’ll visit one who has made significant strides. He tells himself, “This guy got through it. He’ll get through it too.” But staff members say none of the stress and struggle of working with severely injured service members compares to the challenges the soldiers endure. “We are pretty honored to be able to do what we can to help,” says Lt. Col. Paul Pasquina, chief of the integrated department of orthopedics and rehabilitation at Walter Reed and Bethesda. “We all feel a sense of importance in what we do, as we certainly don’t want to let people down in an organization where you have pride.” J


Originally published in the Summer 2010 issue.

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he lightweight materials and high-tech software of today’s prosthetics are a far cry from the woodcrafted limbs used for decades. The technology continues to advance, with prosthetics becoming more comfortable and their use more intuitive. Clinicians and researchers at the Department of Veterans Affairs are developing and testing some of the newest prosthetic technologies, such as bionic limbs and powered joints, as well as devices such as GPS systems and reading machines to assist veterans who sustained other injuries. Advanced technology is also commercially available in VA medical centers across the country, where some 40,000 amputee veterans receive care.​ “It’s very different today,” says Terry Kalter, chief of the prosthetic labs for Veterans Integrated Service Network 3 at New York Harbor Healthcare System, one of 21 health-care networks within the Department of Veterans Affairs. Kalter has watched the industry evolve dramatically over the last 30 years. “Now you are more of a clinician” than a craftsman.   fter a warfighter is discharged from a military hospital, his or her care falls to the VA. The VA is in a

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unique position to provide just about any health-care solution in the marketplace, regardless of cost and availability, says Frederick Downs, chief of prosthetics and clinical logistics at the VA’s Veterans Health Administration. “We do not limit stuff,” he says. “You name it, we provide it.” In fact, the VA has historically been a leader in prosthetics, says Dr. Joel Kupersmith, chief research and development officer for the VHA. More than 20 years ago, for example, the VA developed the Seattle Foot, which included a spring that revolutionized lower-limb motion. Today, that tradition continues as the VA collaborates with industry to develop and test more cutting-edge prosthetic technology.  Take the advanced prosthetic arm being developed by DEKA Integrated Solutions with funding from the Defense Advanced Research Projects Agency, or DARPA. In 2009 the VA launched a three-year optimization study which clinical researchers tested the DEKA arms on veterans. The DEKA arm provides increased functionality, allowing users who have lost an arm up their shoulder joint to pick up small objects. The arm can be raised, twisted and bent. Controlled by foot movements transmitted through sensors in the shoe, the arm can eventually also be adapted to work with other control systems, such as switches wired to muscles and nerves in the upper body and to impulses from the brain, ac-

STEP BY STEP: By Sara Michael

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cording to the VA. “We now think the arm provided by Mt. Sterling, Ohio-based Ohio is a great leap forward in arm prosthetic Willow Wood. Using the company’s Ometechnology,” says Kupersmith. ga Tracer, clinicians at each of the hospitals Downs, who lost his arm in Vietnam can scan a patient’s residual limb, make in 1968 and has worn a mechanical arm adjustments on the computer, and elecfor 40 years, was among those who gave tronically send the file to Kalter’s team. the arm a test run. “It was extraordinary The alternative is having a prosthetist take the amount of control I had on that,” says and fill a liquid plaster cast, which is then Downs, who confessed to initial skeptimodified and fit. “It’s time-saving,” Kalter cism. He was fitted with a shoulder socksays. “It expedites the delivery of the proset, and pads were placed in his cowboy thesis to the veteran.” boots. “You can teach an old dog new In the last four years, the CAD system tricks,” he says. The prosthetic “felt like has advanced to using a laser-based scana part of me. ... This arm is going to come ner providing more precise measurements closest to being like their regular arm; it’s eons above the and shape, says Steve Byers, new product development ofbody-part arm.” ficer for Ohio Willow Wood. Byers notes that a majority of ​ prosthetists are still doing plaster casting, with many feelome of the technology currently available to VA med- ing that’s the only way to attain proper compression. Howical centers already markedly increases comfort and functionality. Kalter’s facility in New York fabricates prosthetCpl. Garrett Jones, injured in Iraq in 2007 by an insurgent’s ics for all six labs in his network using a ​computerbomb, is the first Marine with an above-the-knee amputation aided design and manufacturing (CAD/CAM) system to deploy to Afghanistan.

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PHOTOS: Sgt. Ray Lewis

Propelled by the growing ranks of military amputees, prosthetic technology advances by leaps and bounds  


manager of Ossur Academy, the comever, he says, “We believe as people pany’s education arm. get more and more used to the comOssur has also developed the newerputers, [the CAD system] will be technology Power Knee, with the VA common practice.” and the Defense Department among    the largest customers of the first-geneveral years ago, a new techeration Power Knee. The knee uses nology emerged as an altersensors and motors to provide positive native to mechanically controlled power to generate lift for the user. The prosthetics: microprocessor-conknee helps the amputee by propelling trolled lower-limb prostheses. These him forward and actively lifting for insensor-equipped knees promised to clines and stairs. It replaces muscle acimprove a person’s gait, provide tivity to bend and straighten the knee. more natural movement and help This solution is ideal for those prevent falls. About 10 years ago, whose mobility is restricted or who the VA evaluated the technology. struggle with movements such as Today many veterans are using the climbing stairs or getting out of a chair, prostheses. Fothergill says. “They don’t have the “Now evidence shows it does power. They don’t have the balance, benefit patients at multiple activity or some of the necessary parts to get levels, whether they are just walkout of the chair to get walking. We are ing around their house or they are looking at power in the prosthetic deout in the community,” says Kristen vice to help with mobility.” Knox, senior marketing manager As the power sources have gotfor Otto Bock, a German company ten smaller, the powered knee bewith North American headquarters comes smaller, Fothergill says. Just in Minneapolis. Otto Bock produces a few years ago, the motors were too the C-Leg, which is powered by senbig to fit in a knee joint. Now, Ossur sors in the knee and ankle that detect is working on a second generation the weight being displaced. Inside that’s smaller, fits average-sized users the knee joint is a tiny microprocesbetter and has significantly longer batsor that takes readings at 50 times tery life. per second, making adjustments to Fothergill notes that much of Osstability and stance of the knee and TOP: The Department of Veterans Affairs’ sur’s focus in research and develophelping prevent falls, Knox says. Frederick Downs demonstrates the DEKA arm, ment is on wearability, with the aim C-Leg users also have more con- which is controlled by foot movements transthat prosthetics should be delivered to fidence in their walk and tend to mitted through sensors in the shoe. the market quickly. watch the ground less, a habit many Indeed, the major challenges to amputees picked up to avoid trip- BOTTOM: Army veteran Henry Diaz walks down stairs on the microprocessor-controlled Rheo prosthetic progress, particularly for ping while wearing less ergonomic Knee. The knee, developed by Ossur, helps artificial limbs, are making sure the prostheses, she says.  prevent buckling and falls. device is comfortable, which means When the C-Leg first hit the marcomposite materials and mechanics ket, officials were skeptical, and a must be lightweight enough for ease mechanical knee was still the first of control. More power and functionchoice. However, prosthetists increasingly are fitting users with the C-Leg first, Knox says, ality can often mean more weight. The prosthesis also must particularly Iraq and Afghanistan vets receiving care at Wal- be comfortable on the skin and fit well with the socket in a​ load-bearing body part. ter Reed Army Medical Center. As research drives the field of prosthetics to integrate Other companies are providing similar devices, including Foothill Ranch, Calif.-based Ossur. The company developed more with the user’s nervous system, more advanced systems the Rheo Knee, which uses bionic technology to adapts to a will continue to emerge, providing even more mobility and person’s working style. The knee, intended for people with dexterity. Still, size and comfort remain critical. “It’s the little things like that,” Downs said, “that are so good control over their residual limb, includes a mechanism that limits falls by preventing buckling, says Ian Fothergill, important.” J PHOTO: Courtesy of Department of Veterans Affairs

PHOTO: Courtesy of VA

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Originally published in the Fall 2010 issue.

s the notion of a front line of combat has changed, so too has the understanding of how battle affects service members. Troops engaged in direct firefight aren’t the only ones who may experience trauma, and a single event isn’t the only culprit. Similarly, the understanding of post-traumatic stress disorder (PTSD) has evolved, prompting the Department of Veterans Affairs to make regulatory changes to ease the burden of proof for receiving covered mental health treatment. “Over time, we have come to realize that PTSD can be triggered by other kinds of stressful life experiences that can’t be boiled down to a single incident,” says Dr. Antonette Zeiss, the VA’s deputy chief for mental health services. She calls the VA’s rule change regarding the claims process for PTSD treatment coverage “a response to a growing understanding of warfare, and a growing understanding of PTSD.” The VA’s extensive nationwide network of medical centers provides PTSD treatment for the nation’s veterans through personalized, evidence-based programs. Through early intervention efforts, the VA has sought to connect veterans with effective programs and ensure they receive the proper treatment.

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A veteran seeking PTSD treatment from the VA submits a claim seeking an evaluation, which is conducted by a VA clinician who collects information about the event that could have resulted in PTSD. Before the rule change, the VA tried to substantiate the experience and confirm that it occurred when the veteran was in the military. Health administrators then determined whether the patient suffered a service-connected trauma. “This is about that step -- looking at the evidence that an event actually occurred while the person was in the military,” Zeiss says. “Previously if someone was claiming a combat-related PTSD, they had to produce very rigorous evidence,” such as an after-action report, a medal or a description of the event. Not only is that information extremely difficult to produce, but the combat experience is not that cut and dried. And soldiers not engaged in active battle may still experience stress. ​Some veterans who weren’t eligible for benefits may now be eligible, and those who hesitated to submit claims may decide to do so, Zeiss says. Tom Tarantino, an Iraq veteran and legislative associate for the nonprofit Iraq and Afghanistan Veterans of America, calls the change “monumental,” reflecting a recognition of how wars are


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PHOTO: Senior Airman Renae Kleckner

Senior Airman Joseph Vargas uses the Virtual Iraq program at Malcolm Grow Medical Center’s Virtually Better training site at Andrews Air Force Base, Md. The program uses prolonged exposure therapy, one of the two evidence-based PTSD treatments used by the Department of Veterans Affairs, to help patients confront and overcome the incidents that scarred them.

rs e b m u n by the f those, 19 percent O f were veterans o the wars in Iraq . and Afghanistan

65,836 In fiscal 2009, 3 eated veterans were tr for PTSD. fought and who may experience stress or trauma. People like medics, truck drivers and other support members often have a hard time proving specific traumatic incidents occurred, Tarantino says. “More people are going to have access to more care and benefit from this change.”   lthough the change opens the doors for more veterans to receive PTSD treatment through the VA system, it doesn’t impact the treatment programs themselves, officials say. Each veteran entering the VA system is screened for mentalhealth conditions, including PTSD. The screenings can lead to further evaluations. For the first five years after separation, a veteran is screened annually, says Stacey Pollack, director of the trauma service program at the VA Medical Center in Washington, D.C. “We all know there is a huge stigma for people coming forth, so by making screening a part of our standard practice, we are able to get people into treatment and find o​ ut who needs to be referred,” Pollack says. PTSD is caused by exposure to a direct or indirect threat of death or serious injury. Symptoms can include recurring thoughts of the traumatic event, or stressor, reduced involvement in work or outside interests, emotional numbness, anxiety

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2-2009, From fiscal 200 Iraq and nearly 130,000 rans Afghanistan vete nal isio received a prov SD in VA diagnosis of PT . medical centers

0 VA mental More than 3,70 nals have health professio longed Pro been trained in itive ogn Exposure and C rapy Processing The treatments. Source: VA

and irritability. According to the VA, the disorder can be more severe and last longer when the stress is a human-initiated action, such as war. The VA relies on two evidence-based treatment methods for PTSD: Cognitive Processing Therapy and Prolonged Exposure. Both focus on the trauma, Pollack says, with the veteran talking or writing about his or her traumatic experience in a structured environment. These two treatment options were determined as the most effective based on an extensive Institute of Medicine (IOM) study commissioned by the VA, says Thomas Berger, senior policy analyst for veterans’ benefits and mental health issues at the Vietnam Veterans of America. The institute reviewed more than 2,700 programs, many of which lacked scientific evidence or a connection to veterans. “Those are the two treatment programs that pass with flying colors by the IOM,” says Berger. “Clearly, unless the evidence is there based on the IOM report, then we don’t know if the other stuff is good or not.” Although the VA is always considering innovations in PTSD treatment, officials want to make sure the programs are being researched, and are based on strong evidence, Pollack notes. “PTSD is treated much better today than, say 25 years ago,” she says.


PHOTO: Lance Cheung

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Cognitive Processing Therapy involves learning about the symptoms and becoming aware of thoughts and feelings. The goal is to look closely at how the trauma is affecting the veteran, and then help him or her look at it differently. The patient learns the skills to question or challenge the thoughts. Prolonged Exposure treatment, on the other hand, centers on the exposure to the thoughts and feelings that cause the distress, and practicing in real-world situations the patient may have avoided, such as driving after a roadside bomb experience. The patient also talks extensively with a therapist about the trauma memory. The duration of the treatment depends on the veteran, and whether he or she is suffering from a recent stressor or one that has gone untreated for 40 years, Pollack says. Some veterans fare better than others. The stigma about receiving mental health services may surface in the beginning, she says, but often a vet will quickly start to see a difference. “They can see week to week how their symptoms are going down and they are feeling somewhat better,” she says. The decision on which course of treatment is most appropriate is based on clinician judgment and patient preference. However, the VA is researching whether one is a better fit for certain patients, Pollack says. “It would be great if we had research out there to let us guide particular patients toward particular treatments and know a better algorithm to see what works for who.”   oving forward, one challenge for the VA is to ensure that clinicians, both within the system and in the private sector, are well-trained on the treatment programs, Pollack says. More than 3,700 VA mental health professionals are trained to provide the two therapies, according to the VA. The administration also has a mentoring program that works with personnel at treatment sites to improve care. The mentors make

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sure the clinicians are up on the latest research and best practices. Similarly, many veterans seek treatment outside of the VA system, Pollack notes, and it’s important that non-VA programs and clinicians also are current on treatment and research. Indeed, the treatment network for veterans extends far beyond the VA. Dozens of community-based organizations are providing so-called “wrap-around” care for veterans who need additional support, either as VA contractors or as independent groups. “The VA is more of a medical model, [which] relies on organizations to provide benefits advocacy, housing [assistance], employment and training -- all that wrap-around care they simply can’t handle,” explains Colleen Corliss, communications manager at Swords to Plowshares, which provides transitional housing and other services to veterans in the San Francisco area. The n​ onprofit is one of about 50 groups that make up the Coalition for Iraq and Afghanistan Veterans, a partnership of organizations that offer care and support. Veterans will still go to the VA center to access mentalhealth treatment, and more intensive medical care, Corliss explains, but community groups can fill in some gaps. Ensuring a veteran seeks treatment at all can be a struggle, officials say. The stigma around mental illness among the military is still strong.  Thomas Hall, a Vietnam veteran and national PTSD/Substance Abuse Committee chair at Vietnam Veterans of America, says his organization and others are working to shift the notion of what is considered a strong service member. Someone who is truly mission-ready takes care of every weapon and equipment he will need in battle, Hall says, including his mind. “It seems incongruous that someone would be punished or ridiculed for pulling maintenance on that equipment,” he says. “You’d do the same with other weapons. Clear head, and clear mind, and be ready.” J


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military and industry join forces to build a better helmet By Sara Michael

Originally published in the Winter 2009 issue.

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ith every explosion from a roadside bomb or blast of enemy fire, vehicle crash or flying piece of shrapnel, troops serving in Iraq and Afghanistan face the threat of a debilitating head injury. As traumatic brain injuries become increasingly more common, military and industry officials have worked to understand what happens to the brain – and what kind of equipment will best protect warfighters. Head gear has evolved dramatically since the days when a leather strap suspended the stiff metal helmet away from the soldier’s head. Today, high-tech, energy-absorbent materials mitigate the impacts and withstand multiple beatings. Military medical leaders also have changed how medics respond to and treat battlefield casualties, with an eye toward better identifying head injuries and preventing further trauma. “It’s a marriage of physiology and physics and material science,” said Zane Frund, manager of material science and chemical research for Mine Safety Appliances Co., or MSA, describing the complexity of developing combat equipment minimizing the risk of brain injury. Blasts from improvised explosive devices are a leading

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cause of injury – particularly traumatic brain injuries – in the Iraq and Afghanistan wars, according to a Government Accountability Office report on traumatic brain injury screening. About 30 percent of troops evacuated to Walter Reed Army Medical Center between January 2003 and June 2007 sustained some form of traumatic brain injury, according to the report. The equipment industry has been feverishly developing and meticulously testing new materials to reduce the number of brain injuries. “Even relatively mild head impacts, while not lifethreatening, can cause short-term impairment from dizziness, headaches, memory loss, lack of ability to concentrate and irritation,” says Dr. John Crowley, science program director for the U.S. Army Aeromedical Research Laboratory at Fort Rucker, Ala. “Given the necessity for speed and aggressiveness in combat, these symptoms become militarily significant, no matter how temporary, by seriously jeopardizing soldier survivability and the success of the unit’s mission.” The laboratory has researched helmet performance for helicopter crews for 40 years. Ten years ago it turned its attention to ground troops, Crowley says.


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Pfc. Fred M. Linck was shot in the head and walked away from the incident. The enemy round struck his Kevlar helmet, which saved his life by stopping the bullet from penetrating his head. A piece of fragmentation caused a small laceration to the Marine’s forehead too small even for stitches.

PHOTO: Cpl Brian Reimers

says Lt. Col. A.J. Pasagian, program manager for infantry combat equipment at the Quantico, Va.-based command. There’s an urgent need for a new helmet shell, he says, prompting the command to put out a request for information for new helmet designs with improved blast, ballistic and blunt-impact protection. The next-generation helmet, called the Enhanced Combat Helmet, will likely use a light-weight polyethylene material providing more protection than traditional Kevlar fibers. “We have come up against some promising technology in the area of the base material that is used to make the helmet,” Pasagian says, referring to the polyethylene material. “Polyethylene gives protection on the ballistic and nonballistic side with the same weight. That’s extraordinary.” Marine Corps Systems Command awarded contracts to four vendors – MSA, Gentex Corp., Ceradyne Inc., and BAE Systems Aerospace and Defense Group Inc. – to test designs for the Enhanced Combat Helmet, focusing primarily on shell development. ​The suspension system – the pads lining the shell – is a major component in protecting against closed head injuries associated with concussions and mild traumatic brain injury. After a series of analyses a few years ago, the military selected pads developed by Team Wendy, a company based in Cleveland, Ohio. “Consistently our foam provides better management of these blunt impacts than anything out there,” says Ron Szalkowski, a senior product development engineer at Team Wendy. Team Wendy’s pads, made from trademarked Zorbium foam, were originally developed for ski helmets. The company expanded into the military market about five years ago. “The pads absorb the impact energy so your head doesn’t have to,” Szalkowski says.

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ost of today’s ground troops don the Advanced Combat Helmet or the Lightweight Helmet, which consist of a base shell, a suspension system (the pads between the shell and the head) and a retention system (the strap). The federal government mandates a range of requirements based on projectile weight and speed that dictate the strength of the outside shell. “It’s the objective of that shell to defeat the projectile, to stop it,” says Frund, whose company, Pittsburgh, Pa.-based MSA, manufactures combat helmet shells. But, Frund adds, that means stopping the projectile from penetrating or even deforming the shell. The shell must have an elastic response to absorb the energy of the projectile. Roughly 85 percent to 90 percent of the shell is made up of a Kevlar-like fabric, known as a paraaramid, which is woven and coated in a resin material. The fabric has some flexibility and absorbs energy, and the resin material becomes solid under heat and pressure. The exact number of layers of the woven fabric and amount of resin to optimize the helmet’s effectiveness is what Frund called the “sweet spot.” There must be enough, but not too much. Engineers can manipulate the materials to find that ideal combination. “Subtleties of material can h​ ave a great impact on the performance,” he says. “At the end of the day, you want to stop the projectiles and absorb the energy so that we don’t get traumatic brain injuries.” Marine Corps Systems Command, which serves as the life cycle manager for infantry combat equipment, has been working to improve helmets, monitoring damaged equipment for clues,

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The pads are designed to limit the speed at which the head stops moving after an impact. Slowing it down too quickly can mean the brain keeps moving inside the skull, thus damaging the brain. The pads aim to spread out the impact over 10 or 20 milliseconds, he says. Impacts that would otherwise have been severe or fatal are less so with the pads, as the foam absorbs the energy. And unlike the foam lining bike helmets, the Zorbium foam is designed to handle multiple impacts. But the company continues researching ways to improve the material, including the development of a new foam pad system that would have adjustable soft comfort pads in addition to the impact-foam liner piece. “We are constantly tweaking it and trying to make it better,” Szalkowski says. “We are looking at trying to improve protection and comfort.”  ​ The proliferation of improvised explosive devices has challenged engineers to understand what is happening to the

“Within minutes, medical professionals have the critical data they need to ascertain the extent of a​ head injury, identify treatment options and determine whether the exposure, if left untreated, could potentially result in a traumatic brain injury,” he says. With 7,000 HEADS packages used by Army and Marine Corps personnel, warfighters have some piece of mind that an injury can be more accurately diagnosed, Coltman says. The system “has proven that it is a valuable tool in the identification of head injuries in general, and specifically, in the prevention of permanent damage associated with an untreated traumatic brain injury.”    Meanwhile, military officials changed the protocols for responding to potential brain injuries on the battlefield. In 2005, officials at the Defense and Veteran’s Brain Injury Center, a component of the Defense Centers of Excellence

"Within minutes, medical professionals have the critical data they need to ascertain the extent of a head injury, identify treatment options and determine whether the exposure, if left untreated, could potentially result in a traumatic brain injury”" Joe Coltman Vice President of Personnel Protection Systems, BAE Systems soldier’s brain, which is more vexing than the impact on the body, and adapt the systems to provide better protection. “If there is something we can adjust in the pad system, change the design with the pads to mitigate that pressure getting into the head, that’s something we want to do,” Szalkowski says. In the next couple of years, Pasagian says, military officials need “to do a full and competitive all-things-under-the-sun comprehensive analysis.” ​ ilitary and industry officials are also turning their attention to the response on the battlefield in an effort to better identify and immediately treat a potential brain injury. For example, BAE Systems developed a small sensor that secures inside the helmet to record impact data. The Headborne Energy Analysis and Diagnostic System (HEADS) is equipped with a series of accelerometers and pressure sensors and activates upon impact, recording the data associated with an explosion. The information can be quickly downloaded using a USB connection, says Joe Coltman, vice president of Personnel Protection Systems in BAE Systems’ security and survivability business.

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for Psychological Health Traumatic Brain Injury, revised the response protocols. They also changed the guidelines for screening for mild traumatic brain injury and incorporated them into first-responder medic training. “That has really significantly helped to standardize the approach and care and screening for mild TBI in the deployed setting,” says Col. Michael Jaffee, director of the center. The guidelines were based on those used by emergency medical technicians in a civilian setting, but were adapted to battlefield conditions, says Kathy Helmick, director of TBI clinical standards of care. For example, she says, instead of using the traditional mannitol medication for brain swelling, responders use a hypertonic saline solution that is easier to carry. Overall, the idea is to ensure adequate oxygenation of the blood and blood pressure, to prevent secondary injury after the initial brain injury, Helmick says. Military officials are also shifting away from a self-report process to a system where every soldier is screened and evaluated if he or she has been at high risk for a concussion, Jaffee said.“For the more severe injuries,” he says, “the initial response has a direct effect on the outcome.” J


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BODY,heal thyself

Regenerative medicine holds promise for healing burns, shattered bones and more By Julie Bird

Originally published in the Fall 2010 edition.

“P

ixie dust” isn’t the kind of term you’d expect to be tossed around among the green-suited medical minds at the U.S. Army Institute of Surgical Research. The power of the white, powdery substance to help grow muscle, tissue, cartilage and even body parts has captured the imagination of military medical researchers, who long have sought better ways to repair devastating combat injuries. But the pixie dust nickname for the substance officially known as extra-cellular matrix drives Smita Bonsale a little crazy. “Pixie dust is magic, and this is science,” says Bonsale, who manages a $120 million, five-year Defense Department project to jump-start major advances in the relatively new field of regenerative medicine. Science or magic, what they’re doing is pretty amazing. 62

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University researchers are studying using polymer-based materials to rebuild damaged bones in their original shape, and extra-cellular matrix to regenerate chunks of missing muscle. They’re examining how to marry a transplant patient’s cells with donor cells, tricking the body into thinking it’s receiving its own tissue. They’re developing a device like a dot-matrix printer to spray varying thicknesses of treated skin cells onto unevenly burned tissue, prompting rapid skin regeneration with little scarring. Ultimately, they hope to find ways to regenerate not just muscle, skin, bone and nerves, but limbs and appendages. The Armed Forces Institute for Regenerative Medicine (AFIRM) at Fort Detrick, Md., rounded up the top academic and privateindustry researchers in the field, Bonsale says, including nine of the top 10 regenerative medicine research universities and eight of the 10 most-published scientists.


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Hundreds of university and private-industry researchers are working on 240 projects under two major research consortia. One is led by North Carolina’s Wake Forest University and the University of Pittsburgh in Pennsylvania. The other is led by Rutgers University in New Jersey and Ohio’s Cleveland Clinic. The U.S. Army Institute of Surgical Research, or USAISR, at Brooke Army Medical Center in San Antonio is the third research partner, providing overall guidance and participating in clinical trials. The last scientific collaboration on that kind of scale was the Manhattan Project, says Army Col. Robert G. Hale, USAISR’s representative to AFIRM. “This isn’t a bomb, it’s healing. And that’s fantastic.”

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he project is indeed “a very, very large enterprise,” says Dr. Rocky Tuan, director of the Center for Cellular and Molecular Engineering at the University of Pittsburgh. “Somebody said, ‘How is that possible that all of these Type-A people that compete with each other are supposed to work together?’ But it is possible to get the top researchers in the regenerative field to work together toward the common goal of regenerative therapies for the wounded warrior.” The five targeted research areas are limb repair, craniofacial repair, burn repair, scarless wound repair and compartment syndrome repair, compartment syndrome being when an injured limb swells so severely that muscle dies. “We aren’t asking for the moon,” Hale says. “We are asking for improvement. And that’s inspiring researchers.” It seems to be working. AFIRM’s original goal was to have one active clinical trial treating patients in five years, says Wake Forest’s Dr. Anthony Atala, co-chair of the Wake Forest- Pittsburgh consortium. Just two years in, though, his consortium alone already has three active clinical trials and four in the works. 64

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PHOTO: Courtesy Wake Forest University

Engineered tissues and organs are often built using threedimensional, porous molds or scaffolds that support cells as they develop. This ear scaffold is being coated with cartilage cells.

Collaboration accelerates technological advances by enabling researchers to quickly share both their discoveries and their failures, says the Cleveland Clinic’s Dr. George Muschler, co-director of the Rutgers-Cleveland Clinic consortium. By quickly dropping deadend research and concentrating on successes, he says, 20 years of advancements could be squeezed into two to four years. Some of the most promising research has been in the high-priority area of burn treatment. “It sucks to go to the operating room and do a big burn case and it may be no different from what was done in 1980, or 1996,” says Dr. James H. Holmes IV, director of the Wake Forest Baptist Burn Center and head of AFIRM’s burn project. “We can do better. We have our chance here.” He is especially optimistic about a commercial product called ReCell already in use in other countries. Cells from a thin, 4-squarecentimeter skin graft can be easily processed outside of a lab in less than a half-hour, then sprayed onto the patient’s wound to create more than 320 square meters of skin – an 80-to-1 expansion rate. The Australian manufacturer, Avita Medical, says the new skin heals more quickly than traditional grafts, with significantly less scarring. AFIRM funded a clinical trial to gain FDA approval of ReCell. If the technology is widely adopted in the U.S., it will be the first major advancement for treatment of major burns since the mid-1970s, Holmes says. It is one of several research projects addressing one of the biggest challenges in military burn treatment: finding enough healthy skin for grafts on a severely burned patient. “We are very aggressively trying to answer the charge given us … to provide treatment for wounded servicemembers as rapidly as possible,” Holmes says. “I really, truly believe we are going to make advances that will make an absolute difference.”


PHOTO: Courtesy Wake Forest University

The goal behind this computercontrolled system to grow human skin the lab is to create large amounts of skin for reconstruction.

Other researchers are developing an engineered skin that can be used to temporarily cover burns as a first stage of treatment, according to the Army’s Hale, director of cranio-maxillofacial research at USAISR. “Our primary goal is to save lives and close wounds,” he says, “but we also want to return soldiers to full function in work and life.”

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r. Maria Siemionow of the Cleveland Clinic is working on three major projects to reduce the risk of rejection in face and hand transplants. As director of plastic surgery research and head of microsurgery training, Siemionow was part of the team performing the first U.S. face transplant in December 2008. Immuno-suppression drugs that transplant patients must take for the rest of their lives have serious potential side effects, including tumors and lymphoma, Siemionow says. One clinical trial examines how a protein antibody can selectively block certain receptors, minimizing the need for lifelong anti-rejection treatment. The therapy is important for all transplant patients, she says, but is especially applicable to young military members who otherwise could have to take anti-rejection drugs for decades. Her second project fuses transplant donor and recipient cells extracted from bone marrow, then replicates them in the patient’s body. Because the fused cells are partly the patient’s, the theory is that minimal immuno-suppression treatment would be required. The third project represents a new generation of cell therapeutics, she says. Siemionow says AFIRM funding is critical to the research. The National Institutes of Health, another major governmental provider of regenerative medicine research grants, won’t generally fund what it considers high-risk procedures. AFIRM, she says, considers the risk in relation to the potential for innovation. Tuan, who co-chairs the Wake Forest-University of Pittsburgh consortium, expands on that idea. “In treating civilian injuries we often are conservative in what we do. As a result, development happens very sequentially,” he says. “Injuries from war-related trauma are usually very extensive. It’s an upside-down pyramid – the most severe injuries are the most frequent. The approach therefore is totally different from that of projects funded by NIH and even by the VA. We have taken very drastic and sometimes even somewhat risky approaches.” Hand transplants are an example, Tuan says. A soldier who loses a hand can live a productive life with a prosthetic. “But this is exactly 66

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what you want to do – use this opportunity to really push the envelope. We are committed to going for broke and trying out these crazy ideas. I think by doing this we will break new ground.” Although transplants are not technically regenerative medicine, the science of improving the interface between graft and host tissue is, Tuan says. “We very constantly keep track in the consortium of the status of so-called enabling technologies,” he adds. Enabling technologies include scaffolds that serve as fundamental building blocks for generating bone, tissue or nerves. Extra-cellular matrix is one such scaffold. So are adult stem cells and cells extracted from fat, or adipose tissue. “So the people who do cells need to be in touch with the people who use cells. The probability of being able to take advantage of any development is greatly enhanced.”

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he Cleveland Clinic’s Muschler, vice chair of the Institute for Orthopedics and Rheumatology, says that optimizing the environment for bone, muscle and nerve regeneration also can lead to fewer amputations. Rocket-propelled grenades and other explosives can easily blow a gap in bone or muscle that “without very, very aggressive treatment doesn’t heal with very good reliability,” he says. Muschler says researchers are working on processes to use polymer scaffolds to prepare stem cells harvested from the patient and use them to regrow missing chunks of bone. Related research is looking at ways to better prepare the damaged site to accept the stem-cell therapy. Not every project has been successful. AFIRM’s Bonsale says some of the compartment syndrome projects, in particular, were abandoned after disappointing early results. But the overall progress is staggering, she says, adding, “We might have to reassess our fiveyear goals.” Regenerative medicine is a new field for the Department of Defense, Bonsale adds. “We’ve made a tremendous amount of progress, and I wanted to be part of it. Not a single day do I regret it.” She knows the research will one day help people like retired Master Sgt. Todd Nelson, who sustained extensive burns and other debilitating injuries in a 2007 suicide bomber attack in Kabul, Afghanistan. Nelson serves on a regenerative medicine advisory committee in San Antonio, where he still undergoes treatment. “If they can start doing some of the things they’re talking about, it will just be heaven-sent to the folks that have this happen in the future,” says Nelson, who was a senior maintenance supervisor in the Army. “Being in their shoes, I can see it will mean the world to them. We should do this.”✪


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’13 AIR FORCE Preview

Space Fence New radar to see 5 times more orbiting objects

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By Rich Tuttle

PHOTO: Courtesy Lockheed Martin

But that doesn’t mean Space Fence he job of keeping track of as far away as 3,000 kilometers, well thousands of objects in Earth over the 22,000 objects being tracked isn’t being scrutinized on Capitol Hill. The House Appropriations Committee’s orbit falls to the Air Force’s today. It won’t be perfect. There may be defense subcommittee has targeted the Space Surveillance System, a network of six radar antennas stretching from millions of pieces in low to medium program for budget cuts, which Haines Georgia to California that has been in Earth orbit. Still, networked with other calls “very, very frustrating.” She says her response is to “increase systems, Space Fence is expected to operation since 1961. The system works, but it sometimes revolutionize the art of space situational the confidence” of Air Force, Pentagon shows its age. For instance, it signaled awareness – knowing what is where in and congressional leaders “that you have a good plan and you’re executing last summer that a piece of space junk Earth orbit. to that plan and you’re keeping your Haines declined to address whether was approaching the International Space Station. But the warning came too late the trackable objects include stealthy promises.” Congress’s Government Accountability for the station to take evasive maneuvers. satellites. Office, meanwhile, The six astronauts has been worried had to climb aboard that Space Fence two Russian Soyuz technologies are capsules docked to immature. But Haines the station, ready to says the GAO used return to Earth if the old data. “Basically station was struck. the technologies The debris for this program whizzed by only are mature,” or will 820 feet away be by the time the -- reportedly the preliminary design closest any space review is conducted junk has ever come next February. to the space station. John Morse, A new ground Lockheed Martin’s radar system, slated This still photo from a Lockheed Martin film dramatizes the collision of two satellites Space Fence to begin operation and indicates how debris can be added to Earth orbit. Space Fence operators would have earlier warning of potential collisions. program manager, in 2015, would says technology and have given an Lockheed Martin Corp. and Raytheon manufacturing risks will be reduced earlier warning, says Linda Haines, program manager of the new system. Co. are competing for Space Fence, “to almost nothing” as the preliminary It’s called Space Fence because, like its which is expected to have a lifetime cost design phase ends this summer. One of the technologies is digital predecessor, its radar beams will shoot of $4 billion to $5 billion. Each got $107 beam forming, according to Doug straight up like a fence to detect objects million in 2011 for preliminary design. The companies have extensive Burgess, senior Space Fence program passing through. But with S-band radar instead of the experience with big, ground-based manager at Raytheon. He describes old VHF radar, Space Fence will see radars. The Air Force’s Electronic it as the ability to simultaneously put smaller objects – important, because Systems Center at Hanscom Air Force multiple beams of radar into a large even a centimeter-sized object traveling Base, Mass., which is handling the volume of space. To help reduce risk, both companies at 20,000 mph could destroy a satellite. program, is the service’s center of are building prototypes. J It will track more than 100,000 objects excellence for ground-based radar.

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’13 ARMY Preview

hybrid tactics

Diesel-electric vehicle adds stealth to range

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By Matthew Cox

PHOTO: Courtesy of TARDEC

he Army is working on a hy- miles of “stealth range.” “You can’t cause deployed cost of fuel is really brid electric vehicle for its hear any noise,” Truong says. “As soon damn high.” Quantum Technologies began workspecial operators, but this as they get to a certain range from the objective, they can switch to the stealth ing with TARDEC on the CERV probattle wagon is no Toyota Prius. gram in 2008 to build a lightweight The Clandestine Extended Range mode.” Program officials would not com- hybrid vehicle for Special Operations Vehicle (CERV), made by Quantum Technologies Inc., is designed to be a ment on how much money has been Command that’s compact enough to be carried aboard the highly deployable V-22 Osprey aircraft, vehicle capable of Mazaika says. That sneaking up on the meant it could be no enemy. “The vebigger than 60 inches hicle could roll up wide and 60 inches next to you and tall, making for a veyou wouldn’t even hicle that is slightly hear it,” says Dave longer and lower to Mazaika, chief opthe ground than a erating officer for standard Jeep. Quantum TechnoloIt also had to be gies. able to perform in Quantum built rough terrain. “This six test prototypes thing can jump off for the Army’s sand dunes, and Tank Automotive climb 40 percent Research, Develgrades,” Mazaika opment and Ensays. gineering Center The CERV has (TARDEC). The The Army’s Clandestine Extended Range Vehicle, made by Quantum Technologies Inc., has a 300-mile range with the diesel engine keeping the batteries charged, and about to weigh less than future of the CERV eight miles of “stealth” range running just on electricity. 5,200 pounds, so is uncertain, but there is no exterior Quantum officials maintain that the excitement generated spent on the CERV and remain tight- armor, doors or windows. “It’s a different mission,” Mazaika by this new vehicle will be hard to ig- lipped about its future. Hybrid electric vehicles, however, are nothing new. says. “It wasn’t intended to be a Joint nore. ​The CERV runs on a 100-kilowatt Toyota has sold more than 2 million of Light Tactical Vehicle.” The vehicle is capable of speeds up to 85 miles motor and a 7-kilowatt lithium-ion its popular Prius model. The CERV program demonstrates per hour, but it would have to creep battery pack. The vehicle has a 1.4-liter diesel engine, but it’s there only to how the concept continues to hold val- along when operating in stealth mode, keep the batteries charged, says Phat ue in the face of high fuel costs, says Mazaika says. “Obviously the faster Truong, electrical engineer and CERV Bill Van Amburg, senior vice president you go and the higher power you use, for CALSTART Inc., which develops it’s going to shorten your range.” program manager for TARDEC. It can travel silently for about eight With all components running, the advanced transportation technologies vehicle has a range of about 300 miles such as hybrid-electric vehicles. “The miles over rough terrain, he says, but over rough terrain. But when the diesel hybrid truck world is starting to take “if you are just cruising around on asengine is turned off, it has up to eight off,” he says. “The Army gets it be- phalt roads, it would be a lot more.” J

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’13 MARINE CORPS Preview

M777A2

IMPROVEMENTS TO HOWITZER CONTINUE

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By Matthew Cox

PHOTO: Spc. Michael Blalack

he U.S. military’s new, light- weight should mean that Marine and as the new MV-22 Osprey tilt-rotor airweight 155mm howitzer may Army combat units can put the M777A2 craft, Branham says. When the program began in the midone day be able to tell gun anywhere they want on the battlefield. “It’s uniquely suited for Afghani- 1990s, BAE’s gun soon became known crews if it has been fired too long withstan, where it’s been light enough to be for its durability. Marines in particular out a break. were impressed that Officials at BAE they couldn’t break Systems, the maker it during testing, of the M777A2, say BAE officials mainthey are working tain. The Marines on improvements had a requirement that could equip the for 511 M777A2s, gun system with an Gonzalez says; electronic thermal the Army planned to warning system. “It buy 418. tells them the gun BAE officials, is getting too hot,” who planned to prosays Geoff Gonzaduce the M777A2 lez, M777 integrated for both services project team leader into 2013, say the at Global Combat program has gone Systems and Weap“fantastically well.” ons at BAE Systems. “It is one of the The Marine few programs I have Corps, like the Army, An artillery round exits the barrel of an M777A2 155mm Howitzer during a live fire been involved with has been replacing its exercise. where we have never heavy M198 155mm missed a delivery,” towed howitzer with the M777A2 for about 16 years. The lifted into high-altitude forward operat- Gonzalez says. “The feedback I have Corps budgeted $21.6 million for fiscal ing base locations,” says Christopher received is it is extremely reliable, ex2012 and planned to complete fielding Hatch, deputy program manager for the tremely maintainable and extremely acArmy and Marine Corps Lightweight curate.” the lightweight gun in 2013. The M777A2 is the latest version of But the work at BAE is nowhere near 155mm Joint Program Office at Picatindone. In addition to the electronic ther- ny Arsenal, N.J. “We can’t lift an M198 the system. Produced in 2009, it features a digital fire-control system that mal warning system, Gonzalez’s crew into those places.” Because of its lower weight, two helps crews calculate wind speed, mecontinues to work on improvements to the M777 series such a hydraulic power M777s can fit into a C-130 Hercules teorological conditions and even the pack that would help raise and lower the tactical airlift aircraft, versus only one Earth’s rotation for delivering accurate M198, says David Branham, who man- fire.It can fire the precision-guided Exgun, a job now done by hand. The M777A2 weighs 9,700 pounds, ages congressional and public affairs calibur munition up to 24 miles with far significantly less than the 16,000-pound for the Marine Corps Program Execu- better accuracy than traditional artillery weight of the M198. The weight savings tive Office Land Systems. Unlike the shells. That makes the gun safer to use comes from using titanium and alumi- M198, the M777 also can be airlifted in populated areas, Branham says. Canada and Australia also purnum alloys in all of the major structures by helicopters such as the Marine Corps except the steel gun tube. The lighter CH-53E, CH- 46E and CH-53Ds as well chased the M777A2. J

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’13 NAVY Preview

DDG-51

FULL STEAM AHEAD FOR DESTROYER

T

By John T. Bennett

PHOTO: Courtesy Huntington Ingalls Industries

hese have been an eventful incremental approach of developing in Mississippi. Bath is working on the final pair of few years for the DDG-51 new technologies,” Navy acquisition destroyer program. But it executive Sean Stackley and other 51s awarded under previous contracts appears all is well with the program service officials said in a 2011 joint (DDG-111, the USS Spruance, and that at one time was slated to stop statement for the House Armed DDG-112, the USS Michael Murphy). Services seapower and projection Picking up work started under the churning out ships. Northrop banner, The Navy decided ​ Huntington-Ingalls to build only a few Industries is under models of an entire contract to build new class of ships DDG-113. -dubbed DDGThe Navy also has 1000 -- and restarted awarded Huntingtonproduction of the Ingalls a contract to Arleigh Burke-class build DDG-114. Bath war ship. The Obama is building DDG-115 administration made and Arleigh Burke the Aegis Weapon 116, which will System-equipped be named the USS ships a central part Thomas Hudner. of its missile defense Despite breaking plan. And one of the off from Northrop, two manufacturers of Brenton said the ships, Northrop Huntington-Ingalls Grumman Corp., spun The Aegis guided missile destroyer USS Gravely (DDG 107), built by Huntington is focused on off its shipbuilding Ingalls Industries, plows through the Gulf of Mexico. becoming the Navy’s business. “shipbuilder of choice in the design and But with the smoke clearing from forces subcommittee. The restart plan also “strengthens build of future Aegis destroyers.” But those moves, Navy and industry officials say the DDG-51 program is and stabilizes the industrial base to its top shipbuilding rival reports it has more efficiently and cost-effectively made big strides in ship design tactics. progressing on schedule. The sea service made the call to produce ships to meet our national And that could give it an edge when pursuing DDG contracts. revive Arleigh Burke production in needs,” they told the panel. Jim DeMartini, a General Dynamics Each new ship will cost 2008, and talked of building eight new ships. But now, “the Navy’s plan around $3.5 billion, according to spokesman, said the shipyard’s work Research Service on the first vessel in the DDG-1000 includes at least 10 continuation DDG- Congressional 51-class ships, and the number of analyst Ron O’Rourke. That means class “is coming along better than any platforms could ... increase,” says Beci both Huntington-Ingalls and General lead ship has before.” DeMartini credited threeBrenton, a spokeswoman for Northrop Dynamics stand to benefit from the dimensional computer-aided design, spin-off Huntington-Ingalls Industries. revived production. The Navy several years ago had a technology he calls a “game“The approach for the [DDG-51] restart leverages the cost savings every intention of ceasing production changer” in improving the company’s process. General of existing production lines, [and] of the ships at General Dynamics Bath shipbuilding reduces the potential for cost Iron Works shipyard in Maine and Dynamics is slated to build three overruns and delays through the Northrop Grumman’s Ingalls Shipyard DDG-1000s. J

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SNAPSHOTS from

AFGHAN


D

DEFENSE STANDARD presents this diverse look at operations in Afghanistan thanks to Lt. Cmdr. Daniel O’Shea, a qualified Navy SEAL, Navy Reservist and recipient of the Meritorious Citation from the Navy League of the United States. These photos were taken by O’Shea and his colleagues during their current deployment. At far left, a scene from Bazar-e-Sharif, capital of Balkh

Province. Clockwise from top left, a dog named Sgt. Panzer and his U.S. Army dog handler in Faryab Province keep watch; a Security Forces Assistance Team is on combat patrol on Afghanistan’s Highway 1; members of a Security Forces Assistance Team and Afghan army soldiers break bread with village elders in Ghormach, Faryab Province.

NISTAN


Better medical technology dramatically improves a wounded warrior’s chances of survival, but this photo taken during the Battle of Normandy is a reminder that at its heart, battlefield medicine is still about dedicated medics risking their lives to save the fallen.

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FINAL FRAME


2012 Summer Edition  

Focused on the warfighter