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Letter from the Publisher

TACTICAL MEDICINE 12

Revolutionary Joint Trauma System

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Two military docs review principles guiding Tactical Combat Casualty Care (TCCC)

Rehabilitating wounded warriors, step by step

By Drs. Frank K. Butler and Jeffrey A. Bailey

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Letter from Dr. Warner “Rocky� Farr

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Battlefield Medicine

Walter Reed National Military Medical Center By Sara Michael

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After 46 years in Special Forces medicine, Farr has a few things to say

San Antonio Military Medical Center The former Brooke Army Medical Center updates with the times By Nick Adde

Lessons learned from years of combat help medics save more lives By David Perera

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Landstuhl Regional Medical Center

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Regenerative Medicine Defense Department funds unique collaborative research to speed advances in next-generation medicine By Julie Bird

A look back at the hectic days treating combat casualties from Iraq and Afghanistan By David Perera

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TACTICAL MEDICINE 60

Traumatic Brain Injury A look at efforts to prevent TBI and to identify and treat victims more quickly

LOUDER THAN WORDS

By Sara Michael

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Electronic Medical Records Inside the push to digitize military medical records and make them easier to use

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Photo Gallery of Military Tactical Medicine

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Final Frame

By John L. Pulley

ON THE COVER Photo by Master Sgt. Jeremiah Erickson A pararescueman secures a “victim” to a stretcher while conducting a combat search and rescue extraction exercise at an “aircraft accident” outside Camp Lemonnier, Djibouti.

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he power of modern health care is amazing when you stop to think about everything medical professionals do to keep us healthy, and to fix us when we’re not. It enters the realm of astonishing when you step outside the controlled confines of a hospital or medical clinic and consider the challenges of tending to grievously wounded military members in a chaotic, dangerous and nonsterile combat environment. This issue is dedicated to the world of tactical medicine—those dedicated medical personnel who risk life and limb to save others. Fortunately, tools and technologies available to combat medics, field surgeons and the dedicated professionals throughout the military continuum of care have advanced by leaps and bounds since the first combat casualties of Afghanistan some 12 years ago. For this issue, two tactical medicine veterans— Drs. Frank K. Butler and Jeffrey A. Bailey—write about what they call a new era of combat casualty care, advancements since 2001 and guiding principles for the Joint Trauma System. They detail those advancements and why Tactical Combat Casualty Care guidelines work on today’s battlefield. We also hear from a 46-year veteran of Special Forces medicine, recently retired Col. (Dr.) Warren “Rocky” Farr. He doesn’t hold back in his letter, answering questions for the SOF medical community and offering advice about the way forward professionally. From there we look at advances in battlefield medicine, including some discussed by Butler and Bailey such as the reintroduction of tourniquets.

Other articles look at Landstuhl Regional Medical Center in Germany, which became the first stop for wounded warriors after they received initial treatment on the battlefield and field hospitals. For some, Walter Reed National Military Medical Center in Washington, D.C., became home away from home as they rehabilitated from devastating injuries. Sara Michael takes us inside the former Army hospital and introduces us to some of the dedicated staff. For others, the former Brooke Army Medical Center—now San Antonio Military Medical Center—is the place to rehabilitate. See how the medical center has evolved with the mission and the times. This issue also includes a look at a massive, Defense Department-funded research project into regenerative medicine; at efforts to better identify and treat traumatic brain injury, or TBI; and the massive migration of military medical records from paper to digital files. As always, thank you for your interest and your support.

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JOINT TRAUMA SYSTEM revolutionizes battlefield medicine

PHOTO: Adam Turner

By Frank K. Butler and Jeffrey A. Bailey

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PHOTO: Adam Turner

Sgt. Christopher Couchot secures his casualty to a litter for extraction during the 2011 Best Warrior competition at Fort Lee, Va.

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s the United States and its coalition partners approach the end of over 12 years of conflict in Afghanistan and Iraq, we should take time to reflect on the advances that have been made on behalf of our combat wounded during these years of war. The events of 9/11 shattered an interlude of peace and plunged the U.S. military into a war against an enemy that had no credible military, just a willingness to use the tactics of terror to achieve their political and religious objectives. As the war began, the U.S. military was in some respects not optimally prepared to care for those injured in the many battles to follow. Consider that in 2001: - Battlefield trauma care training in the U.S. military was based on courses that did not consider or accommodate for the austerity and lethality of the battlefield. - U.S. combatants did not routinely carry tourniquets and were trained to use tourniquets only a last resort to control life-threatening extremity bleeding. The reason for avoiding tourniquet use, unfounded in retrospect, was fear of causing ischemic damage to injured limbs. - U.S. combatants were not equipped with hemostatic agents. - Establishing a definitive airway for severely injured casualties focused primarily on endotracheal intubation,

a technique that has not been shown to improve survival in trauma patients in the prehospital setting, even when used by medical personnel who routinely intubate patients, which most U.S. medics do not. - There was no DoD trauma system to develop and update best-practice trauma care guidelines for our theater medical facilities. - There was no worldwide electronic patient care forum during which to review on a weekly basis the injuries sustained by our casualties, the care rendered, and the eventual outcomes. - There was no mechanism to systematically capture information related to casualty care in a registry format, so that it could be systematically analyzed and used to drive improvements in care. Now, 12 years later, all of the issues noted above have been addressed. The numerous advances in trauma care that have been implemented– along with the torso protection provided by modern body armor -- have resulted in the highest casualty survival rate in the history of modern warfare.

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rehospital trauma care in the military has undergone an unprecedented transformation. This is of paramount importance, because if you are a combatant wounded on the battlefield, the most critical

(Left) Sgt. James Byrnes, 615th Military Police Company, 18th Military Police Brigade, 21st Theater Sustainment Command, Grafenwoehr, Germany, arrives on the scene to find an injured soldier during the 2011 Best Warrior Competition at Fort Lee, Va.

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PHOTO: Master Sgt. Kevin J. Gruenwald

phase of your care is the period from the time of injury until the time that you arrive at the surgically capable medical treatment facility (MTF). Almost 90 percent of our service men and women who die from combat wounds do so before they arrive at an MTF. This highlights the importance of the battlefield trauma care that is provided by our combat medics, corpsmen, and PJs, as well as by the casualties themselves and their fellow combatants. Combat medical personnel in the U.S. military (and those of most of our coalition partners) are now trained to manage combat trauma on the battlefield using the Tactical Combat Casualty Care (TCCC) guidelines. TCCC started as a biomedical research project in the U.S. Special Operations Command (USSOCOM). The existing, largely tradition-based, trauma care practices in place in 1993 were systematically re-evaluated and there was found to be a need to reconsider these principles for use in combat. TCCC was introduced as a new framework on which to build trauma care guidelines customized for the battlefield. The original TCCC paper came out in Military Medicine in 1996 and provided a foundation, but TCCC has been in constant state of evolution during the last 12 years. These trauma care guidelines customized for battlefield use are now reviewed and updated by the Committee on TCCC (CoTCCC) on an ongoing basis. The CoTCCC is comprised

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of trauma surgeons, emergency medicine physicians, combatant unit physicians, and combat medics, corpsmen, and PJs. This group at present has representation from all of the U.S. armed services and has 100percent deployed experience. Although previously part of the Defense Health Board, the CoTCCC now functions as part of the Joint Trauma System. Changes in TCCC are based on direct input from combat medical personnel, an ongoing review of the published medical literature, new research coming from military medical research organizations, and lessons learned from both the U.S. and allied service medical departments. The CoTCCC publishes its recommendations both in the Journal of Special Operations Medicine and in the Prehospital Trauma Life Support Manual. The TCCC Guidelines are the only set of battlefield trauma care bestpractice guidelines to have received the triple endorsement of the American College of Surgeons Committee on Trauma, the National Associations of EMTs, and the DoD. As the CoTCCC has continued to work to improve battlefield trauma care, it has formed strategic partnerships with other organizations that also seek to improve prehospital trauma care. TCCC began its partnership with the Prehospital Trauma Life Support executive committee in 1998 and continues to work with this internationally recognized group of leaders in prehospital trauma care. PHTLS teaches their courses around the world and has recently established a program to provide TCCC training to law enforcement agencies and the militaries of allied countries when these groups request it. TCCC established a critical partnership with the U.S. Army Institute of Surgical Research (USAISR) in 2004. The USAISR undertook the first preventable death analysis on fatalities from Afghanistan and Iraq, which helped to highlight the critical need for all combatants to be trained in basic TCCC interventions. The USAISR subsequently developed a research effort with a strong focus on battlefield first responder care and published breakthrough reports on items such as tourniquets, hemostatic agents, junctional tourniquets, chest seals and prehospital fluid resuscitation. This ongoing work has since firmly established USAISR as the DoD leader in developing and evaluating battlefield trauma care technology and management strategies. The USAISR also led the very successful USSOCOM-sponsored TCCC Transition Initiative designed to ensure that deploying Special Operations units were equipped with the latest TCCC technologies and that feedback about both the training and the equipment was captured when the units returned from their combat deployment. It was the success of this project that provided the foundation for TCCC to eventually be adopted by conventional forces as well as Special Operations units. Pararescuemen provide medical care to a simulated downed pilot during a combat search and rescue integration exercise.


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ow has TCCC changed the face of combat medicine? One striking example is tourniquet use. Tourniquets -- which were in disfavor with the medical establishment at the start of the war – were strongly emphasized by TCCC and were re-introduced into use on the battlefield as a result of a strong combined effort of TCCC, USSOCOM, the USAISR and the U.S. Central Command. Tourniquets have been the signature success in prehospital trauma care in Afghanistan and Iraq. Prior to this re-introduction, military medics were taught that a tourniquet should be used only as a last resort for bleeding control in extremity hemorrhage. This approach resulted in a 7.4 percent rate of preventable death from extremity hemorrhage in 2600 combat fatalities from the Vietnam conflict. Since TCCC was used only by a select few units, mostly within the Special Operations community, in the early years of the wars in Afghanistan and Iraq, this high rate of potentially preventable deaths due to extremity hemorrhage continued at the start of those conflicts. A study of 982 combat fatalities from the early years of these wars found that 7.8 percent of our combat fatalities had bled to death from arm or leg wounds. Beginning in 2005, however, there was a DoD-wide implementation of the tourniquet recommendations from the TCCC

guidelines. A more recent comprehensive study of the 4596 U.S. combat fatalities from 2001 to 2011 found that only 2.6 percent of these fatalities resulted from extremity hemorrhage. This dramatic decrease in preventable death from extremity hemorrhage from 7.8 percent to 2.6 percent of combat fatalities was a direct result of the ubiquitous fielding of modern tourniquets and aggressive training of all potential first responders in the principles of tourniquet application. Tourniquets have been now been estimated by the Army to have saved as many as 2,000 American lives during these two wars.

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nother element critical to the success of TCCC has been the emphasis on integrating TCCC into good small-unit tactics. To that end, TCCC is divided into three phases of care to allow the care provided to be appropriate to the flow of actions that occur during a combat engagement. These phases are: Care Under Fire, Tactical Field Care, and Tactical Evacuation Care. Although there have been no studies that have evaluated the results of integrating best-practice tactical considerations with bestpractice medical strategies or of minimizing non-essential medical interventions on the battlefield, these two new aspects of battlefield trauma care have undoubtedly saved many lives and contributed to the successful execution of combat missions.

PHOTO: Senior Airman Christina D. Ponte

Other features of TCCC in 2013 include:

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- The use of Combat Gauze to control life-threatening hemorrhage from external bleeding at sites that are not amenable to tourniquet use. - The use of nasopharyngeal airways to protect the airway when there is no airway obstruction from direct maxillofacial or neck trauma. - Initial management of the airway in maxillofacial trauma that consists of having the casualty sit up and lean forward if possible, thus allowing blood to simply drain out of the mouth and thus clear the airway. - Surgical airways are emphasized for maxillofacial trauma when airway compromise is present and the sit-up-and lean-forward position is not feasible or not successful. - Aggressive needle thoracostomy is indicated for suspected tension pneumothorax and is done with 3.25-inch needles rather than the shorter 2-inch needles previously used by the military and still used in much of the civilian sector for this purpose. The McPherson paper from Vietnam noted a 2.9 percent incidence of potentially preventable deaths due to tension pneumothorax. In contrast, COL Brian Eastridge’s paper found that only 11 of 4,596 combat fatalities in Afghanistan and Iraq were due to tension pneumothorax -- a 0.2 percent incidence of preventable Senior Airman Dwight Funk carries a simulated survivor out of a house during a training scenario.


PHOTO: Adam Turner

deaths from this disorder. This is a reduction of deaths due to tension pneumothorax by over 90 percent. Some of that is certainly due to the body armor that now protects the chest area in our service members, but the longer needle and aggressive approach to NDC when indicated as recommended by TCCC are also factors in this dramatic success. - A different approach is now used to protect the spinal cord when neck or back injuries are present or suspected. Spinal immobilization is not emphasized for casualties with penetrating trauma only. Spinal immobilization is still recommended for use as tactically feasible when a blunt trauma mechanism of injury is present. - IV access is recommended only when it is required for medications or fluid resuscitation, thus saving time on the battlefield and allowing medics to focus on other aspects of care that are more likely to be lifesaving. - The use of intraosseous techniques when vascular access is needed, but difficult to obtain. - Hypotensive resuscitation with Hextend is performed for casualties in shock when no blood products are available, as outlined in the papers by Dr. John Holcomb and Dr. Howard Champion in 2003. - Faster and more effective battlefield analgesia – initially through the use of IV morphine, and now with Oral Transmucosal Fentanyl Citrate (OTFC) lozenges (as recommended by Army Cols. Russ Kotwal and Kevin O’Connor) and ketamine (as recommended by retired Air Force Lt. Col. John Gandy). The older analgesic standard of intramuscular morphine works more slowly and has been associated with overdose and cardiorespiratory depression. - Battlefield antibiotics to help reduce morbidity from combat wounds when evacuation is delayed, as is often the case early in conflicts before the tactical evacuation system is well-established. - Tactical scenario-based combat trauma training to emphasize that battlefield trauma care, as provided in a specific tactical situation, must often be tailored to the tactical circumstances of that situation. - The administration of tranexamic acid (TXA) to help prevent death from non-compressible hemorrhage. - Junctional tourniquets to help prevent death from hemorrhage in junctional areas, especially when dismounted IED casualties sustain very high bilateral lower extremity amputations. - A user-friendly TCCC casualty card that was designed by medics in the 75th Ranger Regiment and subsequently endorsed by the CoTCCC. This card helps to document care rendered at the point of injury and has been used very successfully by the Ranger Regiment. The TCCC Casualty Card was adopted by the Army several years ago, and an updated version has now been recommended to become a Department

Sgt. Christopher Couchot, assigned to the 98th Expeditionary Signal Battalion, United States Army Reserve, moves his littered casualty to the designated extraction point during the mass casualty trauma event at the 2011 Best Warrior contest.

of Defense form that would be used by all services to document point of injury care. The U.S. Central Command has directed the use of this card and a TCCC Medical After-Action Report for all casualties in the Afghanistan area of operations.

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CCC uses all of the techniques described above to maximize survival. As described in Col. Russ Kotwal’s paper “Eliminating Preventable Death on the Battlefield,” the 75th Ranger Regiment, which began training all of its unit members in TCCC prior to the onset of hostilities, has achieved an unprecedented low incidence of potentially preventable battlefield fatalities in Afghanistan and Iraq. The concept of training and equipping all combatants – not just combat medics – to perform the lifesaving interventions recommended by TCCC is a key facet of the Ranger Regiment’s success and was also used by the Navy SEALs, the Army Special Missions Unit, and selected other Army units throughout the entire duration of the wars in Afghanistan and Iraq with great success. To quote from Col. Brian Eastridge’s landmark study: “There has been a dramatic transition in the concepts and execution of battlefield trauma care during the last

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decade of war. … The value of TCCC implementation and use was highlighted in a recent study of preventable death on the battlefield in the 75th Ranger Regiment. Investigators demonstrated that the use of an aggressive command-directed casualty response system and TCCCbased Ranger First Responder program was able to reduce the incidence of preventable death to the unprecedented low level of 3 percent of their total fatalities.”

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he CoTCCC is now part of the DoD’s Joint Trauma System (JTS). The JTS was established in 2005 by the USAISR in collaboration with the U.S. Central Command, the service Surgeons General, and the Assistant Secretary of Defense for Health Affairs. The goal was to create a systems approach to improving trauma care for the coalition’s combat casualties. In 2013, at the direction of the acting undersecretary of defense for personnel and readiness, the CoTCCC was relocated to the JTS. On 19 June 2013, the JTS was designated to become a DoD Center of Excellence. In this capacity, the JTS will be the lead agency in the DoD for developing best-practice trauma care recommendations. This transformation is currently in progress. The Joint Trauma System encompasses all aspect of trauma care within the DoD. After point of injury care has been rendered, casualties are transported from the

point of injury to a Medical Treatment Facility (MTF). This phase of casualty care is designated as Tactical Evacuation (TACEVAC) Care and affords an opportunity to provide additional medical personnel and equipment to increase the level of care rendered. CASEVAC platforms are typically armed tactical assets that bear no Red Cross markings. These may be aircraft, vehicles or combatant craft of opportunity. During the drive on Baghdad in Operation Iraqi Freedom (OIF), some casualties were moved to the rear on tanks because evacuation by MEDEVAC aircraft and vehicles was not feasible given the tactical circumstances. Since casualty movement following Tactical Field Care may be accomplished by either CASEVAC or MEDEVAC, the third phase of care in TCCC is designated “Tactical Evacuation (TACEVAC) Care” to encompass both options. The wars in Afghanistan and Iraq have permanently changed the face of TACEVAC care. One landmark advance in TACEVAC Care during the last 12 years of conflict has been the realization that training the flight medics on evacuation platforms to the paramedic level instead of the older standard of EMT-Basic increases casualty survival. Another has been the use of advanced capability platforms such as the Medical Emergency Rescue Team (MERT) used by U.K. forces in Helmand in the latter half of the war in Afghanistan. Capabilities on the MERT include a larger aircraft, a larger, physician-led medical team, advanced airway capability, use of ketamine rather than opioids for analgesia, and aggressive use of prehospital plasma and Packed Red Blood Cells (PRBCs). The MERT has been shown in several studies to improve survival in the subset of casualties that has suffered severe, but not overwhelming, injuries. Casualty survival was also improved by the Secretary of Defense-directed onehour maximum evacuation time in the Afghanistan theater established by Secretary Robert Gates in 2009. Although the MERT is a MEDEVAC platform rather than a CASEVAC platform, several units that have primary combat missions, such as the 160th Special Operations Aviation Regiment (SOAR) and the Air Force Air Rescue units, also have highly developed medical capabilities on their aircraft, including paramedic-level flight medics and the ability to give blood products and TXA in the air.

PHOTO: Adam Turner

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he JTS, with the support of the CENTCOM Surgeon, uses various performance improvement initiatives to improve trauma care, including a weekly teleconference to review all severely injured combat casualties from the preceding week. The nature of the injuries sustained, the medical care rendered, the casualty’s present location, and his or her current condition are all discussed in a worldwide teleconference. Participants in this electronic forum include representatives from medical Cpl. Ryan Barger, of the 303rd Military Police Company, 384th Military Police Battalion, 300th Military Police Brigade, Jackson, Mich., provides aid to a simulated casualty during the 2011 Best Warrior Competition.


PHOTO: Staff Sgt. Ricky A. Bloom

Capt. Jessica Maverick, simulating a car crash victim, is carried on a stretcher by Air Force pararescuemen toward a Marine CH-53 Super Stallion helicopter during a search and rescue exercise.

treatments facilities in theater, in Landstuhl, and in the continental U.S. Also included are representatives from the wide array of military medical organizations that have a mission to assist in the care of wounded warriors. The JTS maintains a robust set of clinical practice guidelines to provide evidence-based recommendations for trauma care provided during enroute care and within theater medical treatment facilities. There are 39 of these CPGs at present. They have incorporated the use of the cutting-edge medical technology and treatment strategies that have been found to be successful during the recent conflicts. One example of an advance in trauma care contained in the JTS CPGs is hemostatic resuscitation (so called “Damage Control Resuscitation� or DCR) that calls for early plasma use in conjunction with PRBCs (and platelets when available), so that resuscitation for casualties in shock treats potentially evolving coagulopathy as it restores intravascular volume and oxygen-carrying capacity. Other advances include: - Accelerated evacuation back to Landstuhl Regional Medical Center and CONUS-based hospitals using evacuation aircraft with Air Force Critical Care Air Transport Teams on board to provide intensive care in the air. - Advanced rehabilitation techniques for neurological injuries and amputations.

- The use of tranexamic acid to help prevent death from hemorrhage; awareness and early treatment of hypothermia in combat casualties. - The aggressive use of fasciotomies in casualties at risk for development of compartment syndrome. - Negative-pressure wound therapy to promote better wound healing. - Better fluid resuscitation and burn flow sheets for burn patients. - The use of extracorporeal membrane oxygenation (ECMO) to increase survival in casualties with severely impaired pulmonary function.

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he JTS also maintains the DoD Trauma Registry (DoDTR) to facilitate improvements in trauma care and to guide future trauma-related research. This unique repository of trauma care information is the indispensable factor in enabling the JTS to understand and improve combat trauma care. It is at this point in time the largest combat trauma registry in history, containing trauma care information on 77,063 casualties as of August 2013. Two hundred and ninety-six research projects have been undertaken based on the trauma information contained in the DoDTR to date. This research has resulted in 80 scientific papers, 104 abstracts, 61 posters, and 47 presentations at medical conferences.

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The DoDTR has already enabled the trauma care research noted above and many more unpublished performance improvement initiatives and efforts. It has the potential to continue to make major contributions to trauma care in the military if: 1) military medical research funding is provided to allow DoD researchers to analyze the data contained in the DoDTR so that we can continue to learn as many lessons as possible from the recent wars during the peace interval; and 2) we can effect the culture change that is needed in combat units to achieve better documentation of point of injury care. The very large majority of our casualties have no documentation of care prior to TACEVAC. The JTS and USCENTCOM have addressed this deficiency by the recent direction that TCCC After Action Reports be submitted when casualties are sustained on combat missions (after the combat action has been concluded) to create a prehospital trauma registry that will document injuries sustained and what point of injury care was rendered. The JTS also works with the Armed Forces Medical Examiners System to review and discuss selected combat fatalities so that we can better understand the causes of death in our casualties and take the necessary actions to avoid future potentially preventable deaths. With trauma surgeons and pathologists working in concert, this process allows our fallen warriors to perform one last service to their country – to help prevent loss of life in future wars whenever possible. The JTS provides assistance and advice to the Command Surgeon for Combatant Commands engaged in conflicts. In the case of Afghanistan and Iraq, this has been the U.S.

Central Command, but similar working relationships with other Combatant Commands can be established should conflicts erupt in their geographic areas of responsibility. With the unprecedented casualty survival from the recent conflicts, the realignment of the CoTCCC as part of the JTS, and the designation of the JTS as a DoD Center of Excellence for Trauma, our military is clearly entering a new era during which further improvements in combat casualty care may be expected to continue to occur more quickly than ever before. Advances in trauma care require resources, experience, vision, focus, expert analysis, and the willingness to accept the appropriate degree of risk in implementing new advances. Despite the successes, the Joint Trauma System is a relatively new organization that must use the interval of peace that our nation will hopefully soon experience to make sure that the trauma care lessons of the past are not lost when our nation fights the wars of the future. New technology and new trauma care research findings will continue to present additional opportunities to improve the care of our nation’s combat wounded. The JTS, with the remarkable DoD-wide and international team that it has developed, will serve our armed forces well by helping to ensure that these new opportunities are quickly translated into lives saved. Butler, a retired Navy captain, and Bailey, an Air Force colonel, are both physicians. The opinions and assertions in the article are their private views and do not represent any military service or the Department of Defense.

PHOTO: Senior Airman Julianne Showalter

Staff Sgt. David Hernandez and Tech. Sgt. Joseph Vergona load an Iraqi trauma patient onto an Iraqi air force Huey II at Balad Air Base, Iraq.

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TECHNOLOGY BREAK THROUGHS IN THE FIGHT AGAINST BIOFILMS Bacterial infections in hospital environments are spread by two different ways: external contamination or in vivo contamination from implants. Patients can develop external infections through contact with surfaces such as door handles, pens, telephones, health care workers uniforms (“HCWU”), stethoscopes, or sterile packaging that have been colonized by microorganisms. Hospital-acquired infections (“HAI”) from contact with pathogenic microorganisms affect approximately 2 million people and result in more than 100,000 deaths in the U.S.A. each year. Such infections require 10-20 days of additional patient hospitalization, costing the already strained U.S. health-care systems approximately $25,000-30,000 per infection totaling billions of dollars per year. The second route for bacteria to infect patients is through hospital invasive support equipment such as intravascular lines and implanted medical devices such as artificial prosthetics, cardiovascular implants and urinary catheters. Implant associated infections (“IAI”) occur in more than one million patients and cost an estimated $3 billion in the U.S. per year. For example, approximately 10-50% of patients with implanted catheters run the risk of developing urinary tract infections (“UTI”) resulting in additional healthcare costs. The rise in the frequency and severity of HAI’s and IAI’s can be attributed to decreased antibiotic efficacy against drug resistant strains of pathogens found in surface biofilms. Biofilm formation involves three phases beginning with the initial reversible adhesion of bacteria on a surface through polysaccharides and adhesion proteins on the bacterial membrane (phase I). Under appropriate conditions, bacteria subsequently firmly attach to a surface (phase II), followed by the secretion of a protective polymeric matrix (biofilm, phase III) in which the bacteria typically show a marked increase in resistance to antibiotics, compared to none-adherent bacteria. As a result, once the infection occurs, it becomes difficult to treat. Thus, strategies that prevent bacterial contamination or destroy adsorbed microorganisms that lead to biofilm formation are actively sought. A newly patented, one of a kind, antimicrobial technology that will inhibit biofilm growth on both plastic and metal surfaces with a physical kill of bacteria versus a leaching or poisonous kill mechanism, virtually odorless and non-

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toxic will be available later this year. In a United States/ Canadian joint venture, University science officers have developed this innovative coating for both medical and non-medical devices. With over 5 years of research and development this new antimicrobial technology could revolutionize the approach to medical device related infections that exist today, as well as, application to equipment, textiles and coatings. The EPA has approved the first of the new technologies for application, which will be released by Priority Environmental Solutions, INC., home of the PRO1TEK® (PROTEK ONE) line of products. PRO1TEK® Biostatic Surface Protection comes in a RTU and concentrate formula, which is a non-toxic, non-leaching, and nonpoisonous surface protection for porous and non-porous surfaces. Biostatic Surface Protection effectiveness is it’s bound water technology, which means it is attached to the surface molecule as a substrate making it difficult or virtually impossible for the mutation of Superbug’s around the formulation. From textiles, transport, and hospitals to everyday high traffic touch points once applied it’s formulation makeup continuously fights the growth of microbes and cross contamination in areas that have high levels of risk for infection and contaminates. Because of PRO1TEK®’s Biostatic Surface Protection ability to bond to a surface the application of the product uses are virtually limitless. Additionally, the applications in larger areas that previously may have been cost prohibitive with their large-scale operations are now affordable with the application of the product.

How Does It Work? PRO1TEK® Biostatic Surface Protection forms a bond with the surface substrate and a ‘wheat field’ of tiny spike like carbon shafts is produced to protect the surface from microbes. Microbes are drawn to the ‘wheat field’ of shafts by the positively charged nitrogen atom and while the microbe tries to attach to the surface, the spike like carbon shafts then ruptures the microbe’s cell wall. A positive charge from the nitrogen atom then delivers a fatal electrical charge to the cell wall of the microbe. PRO1TEK® is the only antimicrobial technology that performs without diffusion or leaching off the substrate and whose product’s efficacy in this form remains for a long period of time working in-between cleanings to protect the surface from cross contamination.


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Catheters: http://www.healthytransit.com/challenge/ health-safety.html HAI Info: Klevens, R.M. Edwards, J.R.. Richards, C.L., Horan, T.C., Gaynes, R.P., Pollack, D.A., Cardo, D.M., 2002. Public Health Rep. 122, 160 (2007)

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PHOTO: Staff Sgt. Ricky A. Bloom

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A Letter from Rocky Farr, M.D. F or those who did not read the Spring 2013 issue of the Journal of Special Operations Medicine (JSOM) from cover to cover (I was on page v), I retired as of 1 May 2013 with a mere 46 years and a week in Special Forces. My exalted retired graybeard status permits me to ramble on as I please and jump from subject to subject at will. All that follows will show those traits:

1. Special Operations Medical Association (SOMA): SOMA is extremely important and it has come a long way from when Steve Yevich and Bob Clayton held it under the shade trees at the John F. Kennedy Special Warfare Center and School at Fort Bragg, N.C. It is even more important to support SOMA fully with the recent Department of Defense attack on going to meetings. SOMA is the ONLY Special Operations medical meeting and we need it more than ever with the coming hard times in the military. SOMA and the USSOCOM Surgeon’s Office have both worked hard to get this meeting “legitimized” for your commands to be able to support attendance. Go home and sing its praises, and go find Bob Mabry and volunteer to help SOMA continue to grow and morph into what we need it to be. We all need SOMA and we all need a bigger, better, more robust, expanded SOMA. Also, go see the vendors. It is not just to see the new toys and to get free handouts. It is to meet the people. Our vendors have always been like family and they have stuck with SOMA through the bad times and good. 2. Journal of Special Operations Medicine (JSOM): The JSOM is also very important and it has come a long way from when it started in the USSOCOM Surgeon’s Office more than a decade ago. The editor, Lt. Col. (Ret.) Duguay-Landers, USAF, has poured her heart and soul into it as it transitioned to an independent publication and now is finally back to being SOMA’s official journal. It is even more important to support the JSOM with the recent Department of Defense attack on going to meetings. Distance learning and journals to read may be the ONLY Special Operations medical meetings that we might get in the future, if times get hard, so we need the JSOM more than ever with the coming economic hard times in the military. 3. Certifications, CME, licenses: As the conventional military transitions back to a peacetime footing, all of these -- certifications, continuing medical education, licenses, red tape in general, will become more important to them. We (SOF) may not be at peace but the big, conventional services will revert to those markers of pseudo-success. During the war, “we are too busy” worked with them;

that will stop. You just must play that game. Do not let them lapse. P.S., SOMA can help.

4. Special Operations Medicine history: Special Operations Medicine history is always important but I think it is even more important now. We have a decade of wartime history to be explored and we need to refresh the long history of unconventional/guerrilla warfare and return to our roots. Some of the lessons learned from the war (the “Golden Hour” comes to mind) are just plain wrong and we need to learn that history to then UN-learn it. Feeling very strongly about history is what encourages me to write a book review each and every JSOM issue. I could use the help! 5. Is SOF better off? It depends. Yes, we have an experienced, combat-proven force with a record of accomplishment of success. We are better equipped and trained in some areas than before the war. We got direct action down. We know what we have been doing for over a decade, but what about all the missions we claim to have and have not performed lately? 6. Is SOF worse off? It depends. We have lost some of our regional focus and expertise. Regional language skills and local contacts with our counterparts are in the dumper. Some can no longer, or never could, spell UW/ GW (that’s “unconventional warfare/guerrilla warfare” for those out there who did not know, and you know who you are). It is time to return to our roots and relearn the core competencies that brought us to where we are today. 7. The Regiment: I can only speak about my regiment, the 1st Special Forces Regiment. De Oppresso Liber. Support your regiment. Connection to the regiment is all-important. It is the continuity of service, the band of brothers, and the thread that connects all. You will leave the service but you will never leave the regiment. 8. Our allies: Look around you at SOMA and you will see many different uniforms and languages. We will fight, we will live, and we will die with our allies. Get to know them (and their quirks; they are busy studying yours) and let them know you. All war is joint and combined and has been for some time. SOMA is a great place to make such contacts.

In summary, SOF is the place to be. SOMA is the place to be. It is up to you to make the most of it. If you can find me under my beard at the next meeting, come say hello.

U.S. Army Col. Warner Farr, Command Surgeon, U.S. Special Operations Command, speaks during Col. Charles “Dahl” Farr’s room dedication ceremony, at Hurlburt Field, Fla.

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The importance of controlling hemorrhage as quickly as possible is one of the most important concepts in care of the injured patient, and a range of therapeutic options have been developed to control the spectrum of bleeding from compressible regions. Tourniquets and junctional devices are useful in only specific areas and hemostatic agents require several minutes of direct manual compression to be effective. A need exists for a tool that can be used across all compressible areas (scalp, junctional areas, extremities) and applied in a few seconds, particularly in the care under fire scenario. The FDA has recently cleared a new device, the iTClamp™50, that was developed by a military trauma surgeon specifically to address rapid hemorrhage in the field and ED. The device controls bleeding by closing the wound edges forming a fluid tight seal, which traps the blood inside the wound pocket to create a hematoma under pressure. As soon as this pressure equalizes with the bleeding source, arterial or venous, flow into the wound stops and a stable clot eventually forms. The device is only applied superficially at the skin and works to control deep arterial bleeding without damaging the wound edges. Wound edges have been excised after 6 hours and there are no microscopic changes to the tissues detectable by a pathologist. The features that make the iTClamp a unique solution in tactical situations are: 1. Applied in a few seconds. 2. Effective in all compressible areas (scalp, junctional areas, extremities). 3. Light (weighs 1 oz), small volume (state size here easy to carry), and rugged packaging. 4. Minimal pain (brief needle poke and then no pain). 5. Does not damage tissues. 6. Intuitive (minimal training). 7. Multiple devices must be used to close larger wounds and it can be used in combination with all other hemostatic devices, depending on the situation and the wound.

How this new device fits into hemorrhage management can be illustrated by a recent case of its use in the emergency department: A 36-year-old male transported to the hospital by air with a crushed right leg from an industrial accident. The air service had infused two units of pRBCs during transport and applied two tourniquets to his thigh to control massive hemorrhage on scene. During examination two open wounds were found. The first was a large medial wound over an open tibia fracture. The second was a small 3 cm wound lateral to the knee joint with an open fibular head fracture and a large degloving injury. When the tourniquets were removed bleeding recurred through the smaller wound. Rather than reapply the tourniquets the degloved space was packed with hemostatic gauze and the iTClamp was applied to seal the wound shut. The hemorrhage was rapidly controlled allowing the team to focus on preparing the patient for surgical repair of the crushed extremity, which occurred nine hours later. The iTClamp is an useful new addition to the hemorrhage control toolkit and provides a rapid method to control bleeding from compressible regions without the need for prolonged direct manual compression. By John B. Holcomb, MD, FACS

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BATTLEFIELD MEDICINE

By David Perera

PHOTO: Staff Sgt. Alfred Johnson

Lessons learned during years of combat lead to life-saving technological advances

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PHOTO: Christopher V. Willis

Capts. Mario Ramirez and Suzanne Morris confirm a patient’s identity and prepare to administer a blood transfusion during a flight out of Bagram Airfield, Afghanistan.

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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 field, and they will bleed to death before they get to us,” said Air Force Maj. Gary Vercruysse, a theater hospital trauma surgeon who had been 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 coldresistant 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,” said Col. Dallas Hack, director of the Army Medical Research and Materiel Command’s combat casualty care research program.

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edics and battlefield doctors have a slew of technologies improving the odds of survival. Forward surgical teams have laptop-sized digital imaging systems. Rugged anesthesia machines much smaller than hospital versions put soldiers under for surgery. Wounds vacuum-sealed rather than sewn shut let surgeons

(Left) A soldier from 1st Battalion, 64th Armor Regiment, 2nd Brigade Combat Team, 3rd Infantry Division applies a tourniquet to a mock wounded soldier who fell victim to a simulated roadside bomb during training at Fort Stewart, Ga. Winter 2013 DEFENSE STANDARD 31


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 soldiers’ treatment from the front line to Landstuhl Regional Medical Center in Germany and the hospitals in the United States, giving each physician fingertip access to their patients’ record of treatment. But the major cause of preventable death remains blood loss. Finding ways to stop the bleeding in the battlefield is 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 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 recalled. 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 – and 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 next generation keeps blood fresh up to 93 hours in extreme cold and 82 hours in extreme heat. “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 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.”

PHOTO: Lance Cpl. Brandi M. Carter

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similar story of collaboration underpins a second-generation blood-clotting bandage called Combat Gauze, manufactured by Wallingford, Conn.-based Z-Medica. 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.

A Marine medic simulates applying a tourniquet during training for a squad competition.


PHOTO: Staff Sgt. Jamal D. Sutter

Staff Sgts. Eric Braddock, left, and Ryan Onely prepare Capt. Nicholas Morgans for a medical evacuation during a training mission at Avon Park Air Force Range, Fla.

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 governmentfunded 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 out to be a common clay mineral called kaolin. Coming up with a solution wasn’t just a matter of laboratory experimentation. Promising products found by Stucky’s team were sent to the Naval Medical Research Center for animal testing. “The in vivo tests are very expensive and they’re timeconsuming. Consequently, we had to be careful that we gave them good suggestions,” he says. Meanwhile, Z-Medica was working on the problem as well. “It was 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. And, he adds, 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. 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 manufacturing,” he said.

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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 in the 1800s but eventually falling out of favor. But 7 percent to 10 percent of battlefield deaths in Vietnam and Somalia were caused by profusely bleeding arm or leg wounds and could likely have been averted by use of a tourniquet, according to the Defense Department. “They had a Army tourniquet from World War II, used it for 50 years, and the reports from World

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PHOTO: Staff Sgt. Dennis J. Henry Jr

War II said they didn’t work so well,” says Col. John Kragh, an Army Medical Corps orthopedic surgeon and proponent of the devices. Mounting groundswell support for tourniquets, intensified by soldiers’ tendency to buy them through the Internet because the military’s basic training strap-and-buckle unit clearly fell short, led to a re-evaluation. In 2004, the Army Institute of Surgical Research decided to test commercially available products. It recommended acquiring the Combat Application Tourniquet, distributed by Greer, S.C.-based North American Rescue Products AT. The CAT, invented by former serviceman Mark Esposito of Golden, Colo., is designed for single-handed application so a soldier can put it on himself. The Army surgeon general facilitated widespread re-introduction in 2005. Now, the CAT is part of every soldier’s standard field issue. The device consists of an inner and outer band: The outer band wraps the tourniquet around the wounded limb while a rod tightens the inner band to cut off circulation. “The bad devices aren’t commonly used any more, and the effective ones are issued,” Kragh says. The Combat Application Tourniquet won an Army Greatest Invention of 2005 award.

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When Kragh was deployed to Bagdad’s Ibn Sina Hospital in 2006, he used a reusable, pneumatic tourniquet made by Vancouver, British Columbiabased Delfi Medical Innovations during surgery. He communicated often with Delfi about ways the company could improve the product – small changes, he says, that nonetheless made a big difference. For one thing, a cap on the pneumatic bladder fell off easily. “It being the same color as the floor, you couldn’t see it,” he says, and the surgical team wasted time scrambling for it on the floor when a patient was bleeding to death. Kragh recommended that the cap be attached with a leash. He also wanted the tourniquet to open with less force. “They changed the [clamp] arc to be gentler, so there’s less force, more roll, to open up 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.

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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 signed a contract with Siemens Healthcare to develop a portable device that would staunch deep limb wound bleeding using ultrasound waves – a kind of high-tech tourniquet. A cuff-like device would first search for bleeding and then send a concentrated dose of high-intensity ultrasound waves prompting quick coagulation. Focused ultrasound has already proven effective during animal tests. The directed energy raises tissue temperature, causing it to shrink and small blood vessels to collapse. Tests show tissue can be safely heated to between 158 and 194 degrees Fahrenheit within 30 seconds. The device’s acoustic properties also appear to push blood away from the injured area. DARPA has already developed automated bleed detection algorithms. Meanwhile, SRI International of Menlo Park, Calif., wanted more DARPA funding to move forward with what could be the most futuristic medical addition to the battlefield: a robot doctor. “Ideally the system would be completely automatic, autonomous, making its own therapeutic decisions,” says Thomas Low, SRI director of medical devices and robotics. With $12 million in DARPA funding, SRI conducted a two-year research and development project ending in March 2007 before lobbying for “substantially more” funds, Low adds. 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 U.S. Army Spcs. Lisa Dueker (left) and Cecilia Morales provide medical aid to an Iraqi soldier wounded by gunshot in Mahmudiyah, Iraq


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 conditions, Low says. He cites a cricothyrotomy as an example; it involves puncturing a large-bore hollow needle into a patient’s neck when the airway is obstructed. Frontline medics are somewhat reluctant to perform a cricothyrotomy “and don’t do particularly well under fire,” he says. But a robot given an image of the airway can do so easily. “It’s putting a needle to a target, based on imagery.” The first two years of the project were just the first phase of a research and development effort that could last up to a decade, Low says. The Trauma Pod team successfully demonstrated a surgical procedure being controlled remotely by humans. Robots already exist in the surgery theater, Low notes. And, he says, automated external defibrillator devices in public places let laymen treat heart attacks with electric shocks by monitoring a victim’s heart rhythm and firing at the right moment. “Certainly it’s better than the alternative of dying,” he said.

ODDS OF SURVIVAL

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n 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 England Journal of Medicine article. Col. Mark Mavity, commander of the Balad Air Force Theater Hospital, said the in-theater rate survival rate in Iraq was nearly 98 percent by the late 2000s.

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LANDSTUHL

REGIONAL MEDICAL CENTER By David Perera

PHOTO: Courtesy U.S. Army

A LOOK BACK AT THE FIRST MAJOR TREATMENT STOP FOR TROOPS WOUNDED IN IRAQ AND AFGHANISTAN

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PHOTO: Courtesy U.S. Army

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

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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. Two years later, with the day’s planes yet to touch down, triage nurse Navy Cmdr. Richard Gallaway estimated 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. By that point, thankfully, outpatient cases outnumbered inpatient admissions. “That’s what we want,” he says. “The less numbers we see, the better things are going downrange.” The largest military medical facility outside of the United States, Landstuhl is just six hours air time north

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of Iraq. Wounded warriors were 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. 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 in 2009, Landstuhl is also the eye of a storm.

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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 onto a gurney by rubber-gloved medics congregated at the hospital’s emergency entrance. Recuperating from surgery in a second-floor 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, his eyebrows partially singed off. The explosion threw him to the ground after a blinding burst. Everything turned white, Darnell remembers. “I took a couple of seconds to regain my breath, started


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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 now he’s recovering from an operation. 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.

PHOTO: Courtesy U.S. Army

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efore combat operations ramped up in earnest in the early 2000s, 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 at the time of the Deployed Warrior Medical Management Center, the hospital unit created in January 2004. Unit members now access electronic records of each incoming patient, informing doctors of what’s coming long before the A military member is awarded a Purple Heart at Landstuhl.


PHOTO: Courtesy U.S. Army

Landstuhl Regional Medical Center

airplane’s wheels are down. It prevents patients from slipping 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 and makes it more routine, “which is very important when you’re receiving 40 people a day,” Lindsay says, talking quickly with the air of a very busy person. He’s dressed in green operating room scrubs (he’s also an ear, nose and throat surgeon) 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 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.

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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 II trauma center. Level I is the highest 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

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Army Col. James Griffith, the chief Army chaplain and a Presbyterian minister. Chaplains meet every new inpatient as they’re unloaded from the ambulance, reassuring each one that they’re safe now. 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. 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 met them previously 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. Eighteen months later he returned 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.

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

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

PHOTO: Staff Sgt. D. Myles Cullen

• Number of inpatient, non-ICU beds: 64, with a reserve capacity of 34 more

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• In one typical day in 2009, 19 new patients were admitted, 14 patients underwent surgery, 6.2 patients were in the intensive care unit and 1,226 meals were served • About 18 percent of patients return straight to duty Source: Landstuhl Regional Medical Center


Walter Reed

National Military Medical Center WHERE WOUNDED WARRIORS FIGHT THE WAR TO RECOVERY

PHOTO: Jay Westcott

By Sara Michael

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rmy Master Sgt. John Souza talks tough, with a hint of a Boston accent and a wit that comes across as sarcastic, yet laid-back. 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., in 2008, Souza showed off how he can slowly lift his leg – including the spatial fixator correcting his broken bones – a few inches without the help of a nylon blue handle. Just a week earlier, 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 staff at Walter Reed, now known as Walter Reed National Military Medical Center. The staff 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. Each day, therapists, physicians and support staff at Walter Reed cared for hundreds of troops wounded in the 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. Yet they maintain a dedication and focus matched only by the soldiers on the battlefield. Hundreds of amputees from the wars in Afghanistan and Iraq have been treated at military medical facilities, including Walter Reed; Brooke Army Medical Center in San Antonio (now the San Antonio Military Medical Center); 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 Military Advanced Training Center teem with patients working to rebuild their strength and mobility, with the staff visibly by their sides.

PHOTO: Jay Westcott

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omero’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 had 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 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 Army Master Sgt. John P. Souza had to learn how to navigate a simulated home in a wheelchair while recovering from injuries sustained in Iraq at Walter Reed Army Medical Hospital – now National Military Medical Center -- in Washington.


PHOTO: Jay Westcott

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Army Cpl. Christopher Levi, a double amputee, works with Physical Therapist Technician Army Staff Sgt. Sara Sutton.

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, he says. “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 said 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 last to accommodate the growing number of active-duty service members who lost limbs in Iraq or Afghanistan.

he at-times miraculous turnarounds the soldiers make motivate 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 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 pointed to the flexibility they are given 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

Winter 2013 DEFENSE STANDARD 45


PHOTO: Jay Westcott

Levi makes progress in his rehabilitation with Sutton’s help.

them to offer the most state-of-the-art treatments, staff members said. Amputees were getting the latest version of the C-Leg – a high-tech computerized artificial leg created by Otto Bock – the same day it went on the market, Janze said. “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,” she says. 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 said, allowing them to overcome the speech and memory barriers to complete a task. “It’s the ‘ah-hah’ moment,” she said, sitting in the small living room. “It’s rewarding when it happens.”

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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-

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ending stream of patients, she says. 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 are hard days,” she says. That’s when Quilty steps 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,” said Quilty, who also noted 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.”


PHOTO: Jay Westcott

Levi works to get steadier on his two prosthetic legs. Winter 2013 DEFENSE STANDARD 47


PHOTO: D. Myles Cullen

A nurse’s scrubs stand out in a row of camouflage pants and tan combat boots during an address from the Army chief of staff to the staff at San Antonio Military Medical Center.

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SAN ANTONIO By Nick Adde

MILITARY MEDICAL CENTER THE FORMER BROOKE ARMY HOSPITAL UPDATES FACILITY – AND TREATMENT – WITH THE TIMES

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hen Dr. James K. Gilman served there back in the 1970s, Brooke Army Medical Center in San Antonio consisted only of three major buildings – a main hospital that dated to the 1930s, a cavalry barracks that had been converted to hospital use during World War II, and a psychiatric facility. To say the least, times – and Brooke – have changed. The old buildings, with their open-bay wards and outdated facilities, are long gone. And in 2009, Dr. Gilman, by then a brigadier general, was commander of the facility where all three of his daughters were born. “There’s nothing we do facility-wise that’s what it was when I first got here 31 years ago,” Gilman, a cardiologist and internist, said at the time. Patients, staff and visitors will now find Brooke a state-of-the-art facility that is still expanding. Most of the services that had been provided in the three old buildings – including all inpatient treatment and most clinical care – were consolidated in 1996 under one roof, when the new hospital opened. In an arrangement that began in the mid-1990s, Brooke and Lackland Air Force Base’s Wilford Hall Medical Center combined in 2005 and were renamed collectively as the San Antonio Military Medical Center. Brooke became SAMMC North; Wilford Hall, SAAMC South. Services were divided between the two facilities.

PHOTO: Linda Hosek

Brooke kept gynecological surgery, women’s health services, rheumatology, and infectious diseases, for example. And it remains the only burn-treatment center in the Defense Department’s health-care system, treating members from all five armed forces. Wilford Hall took inpatient pediatrics, newborn and intensive care nurseries, labor and delivery, and endocrinology. Both facilities covered vascular and neurosurgery, and trauma treatment as well. Psychiatric care moved to Lackland too. The consolidation that began a decade ago as an effort to operate more efficiently will continue as Brooke and Wilford Hall implement changes set forth under the 2005 Base Realignment and Closure Commission (BRAC), Gilman says. In September 2011, all inpatient care moved to Brooke as that facility became known as the San Antonio Military Medical Center. Wilford Hall was redesignated Wilford Hall Ambulatory Surgical Center. At the same time the San Antonio Military Health System began operations, overseeing both facilities with rotating Air Force and Army general officers as director and deputy director. “The president and members of Congress don’t come in here. We’re not in the mainstream news as often as [they are] in the national capital region,” Gilman says, referring to Walter Reed Army Medical Center in Washington, D.C., and the National Naval Medical Center in Bethesda, Md. As a result, Gilman says, “Our focus has always been on taking care of everybody who came in here in a fairly egalitarian environment. The idea is if you treat everybody well, everybody’s happy.” The 760,000-square-foot consolidated tower has 425 beds, more than doubling capacity. Renovations also included a 1.8 million-square-foot parking garage, a central energy plant and renovations to another 288,000 square feet of the existing hospital. “We’ll run out of parking spaces before bed spaces, but that’s kind of the way it works out,” Gilman says, without exaggeration.

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hange does not occur within a vacuum, and with U.S. troops engaged in combat operations in two foreign countries for years, that certainly was the case at Brooke. The burn center had to be expanded to handle all of the burn casualties from Operations Enduring Freedom and Iraqi Freedom come to Brooke. Serious cases still arrive from Landstuhl Regional Medical Center, Germany, accompanied by a Brooke burn augmentation team consisting of a respiratory therapist, burn doctor or burn nurse. The burn center’s mission has become even broader than the past concepts of inpatient and outpatient treatment. “[It] relates to having a significant number A mosaic of a Purple Heart medal in an outdoor patio acknowledges those who have received the honor at the Warrior and Family Support Center in San Antonio.

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PHOTO: Linda Hosek

Army Cpl. Ian Stauffer, who is recovering from injuries he suffered in Afghanistan, frequently lingers in a landscaped area with a waterfall and vegetation at the Warrior and Family Support Center in San Antonio.

of outpatients here who need not only ongoing care, but also a wider range of comprehensive rehabilitative capability than we’ve provided in the past,” Gilman says. The Brooke burn center and the facility at the University of California Los Angeles have a partnership, under which UCLA will perform reconstructive surgery on patients with severe facial burns, he says. Traditionally, Brooke and other military facilities treated wounded service members and either returned them to duty or discharged them. If they suffered long-term or permanent maladies relating to their service, the Department of Veterans Affairs’ Veterans Health Administration assumed responsibility for their treatment. Even though the treatment for burns has not changed dramatically over the years, the focus on their rehabilitation is different, Gilman says. Before hostilities started, service members who suffered head or spinal cord injuries were sent to the VA and typically never heard from again by anyone in military medicine. That line is no longer so distinct, Gilman says. Increasingly, military treatment facilities throughout

the Defense Department – not just at Brooke – have been taking a more active role in making those who are hurt in the line of duty whole again. It is now commonplace to treat someone with a recent head injury or traumatic brain injury to the point where the patient is stable, send the patient to one of the VA’s polytrauma facilities -- in Palo Alto, Calif.; Minneapolis; Tampa, Fla.; or Richmond, Va. -- for inpatient treatment, remain in contact with the patient, and take the patient back once he or she finishes the VA’s treatment protocol, Gilman says. The staff at Brooke will then assume the responsibility for rehabilitation, with the intent of returning the injured member to active service. Brooke also is home to the Center for the Intrepid, the Defense Department’s first building solely dedicated to rehabilitative medicine. Built with $600,000 in private donations through the New York-based Intrepid Fallen Heroes Fund, the center opened in 2007 as what Gilman calls “a brick-and-mortar-and-glass example of our commitment to rehabilitation.” Inside, patients and visitors see a place that is a far cry from typical rehab wards and physical therapy clinics, and more akin to a high-tech gymnasium. The pool, for

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PHOTO: Robert T. Shields

Army Sgt. Christopher Haley works out at the Center for the Intrepid, the medical center’s rehabilitation facility. Haley lost his left leg and his right leg was injured when a roadside bomb exploded in Afghanistan in September 2011.

example, offers users the chance to learn kayaking and surfing, as well as swimming. Sports areas are designed to allow injured service members to compete against one another, as well as against able-bodied persons. In seated volleyball games, for instance, ambulatory players forego the use of their legs and compete against those who cannot walk. The center’s crown jewel is the Computer Assisted Rehabilitation Environments (CAREN) system, used for orthopedic and neurological movement therapy. Built by an Amsterdam-based company called MOTEK Medical, the CAREN debuted with the center’s opening. “It’s designed for ‘tactical athletes,’ ” Gilman says, using the term he prefers to describe his patient populace. “It leverages technology and our current younger generation’s fascination with extreme sports, to motivate and rehabilitate more rapidly.” The CAREN provides patients and rehabilitation therapists with a virtual-reality environment, complete

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with interfaces that essentially turn the arduous process of making damaged or prosthetic limbs, or shattered neurological systems, functional again into a fancy, super-charged video game. “We’re trying to coin the term ‘integrated reality,’ mixing elements of both visual/auditory and physical feedback,” says Oshri Even-Zohar, MOTEK Medical’s chief technology officer. Even-Zohar developed the CAREN units in 2000, based on an idea to incorporate motion-capture systems used by the gaming industry in the 1990s. “Imagine Wii Fit, in a 300-degree dome. That’s how real the virtual reality is,” says Gilman. “We can suspend patients by harness, make sure they never fall down and hurt themselves, and never lose confidence or their cool when trying this thing.” While other CAREN systems are in use around the world, Brooke’s was for a time the only one with the 300-degree dome. The others were 180 degrees.


Therapists and researchers, in turn, can monitor patients’ progress and determine how recovery protocols should be tweaked to become more effective. Patients, too, can compare their performance with that of earlier sessions, and get a clear idea of how they are progressing on the road to recovery. “We use it primarily to normalize gait in our amputee population,” says Lt. Col. Rachel Evans, the center’s research director, a trained physical therapist who holds a doctorate in exercise science. Very often, Evans says, prosthetic patients still have slight limps even after completing traditional physical therapy regimens. In time, if not corrected, the irregular gaits can cause lower-back pain and other problems. Using CAREN, patients can walk a treadmill in a virtual-reality environment of, say, a path through the woods – complete with the sound of chirping crickets and birds, and the sight of insects flying by. “If they are limping, they can see an image of themselves and self-correct,” Evans says. Patients tell her they notice the improvement in their gaits within a few sessions, she says. “To be quite honest, patients really enjoy it,” Evans says.

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Army Sgt. John Tomsich and his wife, Catrina, leave with their son, Brayden, after visiting the Warrior and Family Support Center in San Antonio.

PHOTO: Linda Hosek

ut while CAREN is intended to be fun for patients, the staff takes it very seriously. “It is incumbent upon us to assure that we do the proper evidence-based research to support the efficacy of using rehabilitation within this dome system, in order to improve patients’ functional outcome,” Evans says. Still, the biggest reward is “seeing the smiles on the faces of guys losing both legs and walking after being in these environments,” Evans says. “It’s very humbling.” Ultimately, CAREN could serve as a rehabilitation tool for post-traumatic stress eisorder (PTSD) patients, says Even-Zohar. “It is a tool for exposure therapy that is very efficient,” Even-Zohar says. “If you want to simulate an explosion 50 yards away, you will feel the explosion by the shaking of the ground – not only the essence [of the blast], but it also will be correctly localized. If it happens in front of you, you will feel it coming from the front, not randomly.” The Center for the Intrepid also has nine permanent employees of the VA’s health and benefits administrations, working alongside DoD counterparts to ensure that the transition from service member to veteran is a smooth one. The VA staffers tell patients what they can expect when they seek treatment at a VA facility near their hometown. “They can reassure you they know all about you, and are ready to take care of you,” Gilman says. It is not, he adds, “your grandfather’s VA.” The decision to build the Center for the Intrepid

that way was no accident, and it was not done merely to create a trendy-looking building full of whistles and bells. “We needed to get into rehabilitation medicine in a major way,” Gilman says. “In a protracted conflict with an all-volunteer force, rehabilitation turns out to be a very important, high-profile issue.” Because of advancements in prosthetics and rehabilitative medicine, roughly 20 percent of all amputees are returning to duty. Gilman says those who volunteer to serve their country appreciate reciprocity for their sacrifice: They want to know they will be welcomed back to duty if they can and want to return. “People who don’t want to be anything else but a soldier or Marine have a chance to do that,” Gilman says. “It’s a very powerful message for the young people we’re trying to recruit, and for their families. It’s not an automatic that if you are broken in service to your country, your future will be out of uniform. We’ll do what we can to enable you to serve.”

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Body,

Heal Thyself MASSIVE PENTAGON PROGRAM TEAMS WITH ACADEMIC RESEARCHERS TO SPEED ADVANCES IN REGENERATIVE MEDICINE

By Julie Bird

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PHOTO: Courtesy Wake Forest University

In a modified version of ink jet printing, each cell type is placed in a vial, rather than in cartridges, and are then “printed� through an ink jet printer head.

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“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. University researchers are studying using polymerbased 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. PHOTO: Courtesy Wake Forest University

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 private-industry researchers in the field, Bonsale says, including nine of the top 10 regenerative medicine research universities and eight of the 10 most-published scientists. 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.” The 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, in which 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 had three active clinical trials and four in the works.

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ollaboration 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 RutgersCleveland Clinic consortium. By quickly dropping dead-end 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 ReCell technology, an alternative to traditional grafting, allows skin cells harvested in the operating room to be sprayed onto a burn -- able to cover an area 80 times the size of the biopsy.

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PHOTO: Courtesy Cleveland Clinic

The Cleveland Clinic’s Dr. Maria Siemionow is working on ways to reduce the risk of the body rejecting transplanted or regenerated tissues.

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-square-centimeter skin graft can be easily processed outside of a lab in less than a half-hour, and 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 early 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.” 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, but we also want to return soldiers to full function in work and life,” he says.

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r. Maria Siemionow of the Cleveland Clinic was 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 or lymphoma, Siemionow says. One clinical trial examined 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 could be in for decades of anti-rejection drugs. Her second project fused transplant donor and recipient cells extracted from bone marrow, then replicated them in the patient’s body. Because the fused cells are partly the

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PHOTO: U.S. Army Institute of Surgical Research

Because the stakes are so high for wounded warriors, Defense Department-funded research is proceeding at a more rapid pace than research funded by the National Institutes of Health or the Department of Veterans Affairs.

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 highrisk 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 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 transplantations are not technically regenerative medicine, the science of improving the

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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 a 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 a success. AFIRM’s Bonsale says some of the compartment syndrome projects, in particular, were abandoned after disappointing early


PHOTO: U.S. Army Institute of Surgical Research

The five-year AFIRM project promotes collaboration among academic researchers who normally would be scientific competitors.

James H. Holmes IV, M.D., director of the Burn Center at Wake Forest University Baptist Medical Center, directs a clinical trial of ReCell, a new treatment for burns.

PHOTO: Courtesy Wake Forest University

results. But the overall progress is staggering, she and the researchers said two years into the program. 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 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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PHOTO: Cpl. Brian Reimers

Pfc. Fred M. Linck, infantryman, C Company, 1st Battalion, 25th Marine Regiment, Regimental Combat Team 5, 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.

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By Sara Michael

TRAUMATIC BRAIN INJURY RESEARCH FOCUSES ON PREVENTION AND ON RECOGNIZING SIGNS OF TBI IN THE FIELD

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ith every roadside bomb and enemy fire, vehicle crash and speeding shrapnel, troops in combat 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 the soldier. 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,” says 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 were a

leading 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.

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ven relatively mild head impacts, while not life-threatening, can cause short-term impairment from dizziness, headaches, memory loss, lack of ability to concentrate, and irritation,” Dr. John Crowley, science program director for the U.S. Army Aeromedical Research Laboratory at Fort Rucker, Ala., says in an e-mail. “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.”

PHOTO: Mass Communication Specialist 2nd Class Jonathan Chandler

A composite photo illustration to promote awareness of traumatic brain injury. The artist, assigned to Combat Camera Pacific Reserve, suffered a traumatic brain injury in Afghanistan. He combined an image of himself with a magnetic resonance imaging scan to create the photo illustration.

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PHOTO: Spc. Kissta Feldner

U.S. Army Spc. Christian Leonbache screens Spc. Thomas Hinkle, a simulated casualty, for a traumatic brain injury during a mass casualty exercise at Camp Ramadi, Iraq.

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The laboratory has a 40-year history of research into the performance of helmets for helicopter crews. In the late 1990s it turned its attention to ground troops, Crowley says. Most 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 soldier’s 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, Frund says. 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 have 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.”

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arine 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, 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. The command 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

PHOTO: Seaman Alexandra Snow

Dr. David Williamson, medical director for the Inpatient Psychological Heath and Traumatic Brain Injury program at the National Naval Medical Center in Bethesda, Md., and his staff are breaking new ground in identifying and treating traumatic brain injuries and mental-health issues.

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PHOTO: Spc. Kissta Feldner

U.S. Army Spc. Christian Leonbacher, a medic with Charlie Company, 407th Brigade Support Battalion, 2nd Advise and Assist Brigade, 82nd Airborne Division, screens Spc. Thomas Hinkle, assigned to Headquarters and Headquarters Company, 2nd Advise and Assist Brigade, for a simulated traumatic brain injury during a mass casualty training exercise on Camp Ramadi, Iraq.

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. The hope was to provide them to troops by the end of 2010, speeding development by focusing on developing the shell and using existing suspension and retention systems. 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. Team Wendy pads became the only suspension

system authorized for use inside Army and Marine Corps helmets. “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. 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

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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.”

T

PHOTO: Courtesy U.S. Army

he proliferation of improvised explosive devices has challenged engineers to understand what is happening to the 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. Military 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 has 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

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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. “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,” Coltman says in an e-mail. About 7,000 HEADS packages were being used by Army and Marine Corps personnel, he says, giving warfighters some piece of mind that an injury can be more accurately diagnosed. The system “has proven that it is a valuable tool in the identification of head injuries in general,” he says, “and specifically, in the prevention of permanent damage associated with an untreated traumatic brain injury.” Meanwhile, in 2005 officials at the Defense and Veteran’s Brain Injury Center, a component of the Defense Centers of Excellence 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 firstresponder 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 says. “For the more severe injuries,” he says, “the initial response has a direct effect on the outcome.”

(Left) Army Spc. Kevin Wear talks on the radio while deployed in Afghanistan. Wear suffered a brain injury when the armored vehicle he was riding in hit a roadside bomb. (Right) Army Cpl. Shane Parsons, a 4th Infantry Division soldier who lost both legs and suffered a traumatic brain injury in Ramadi, Iraq, shimmies up the rockclimbing wall at the National Disabled Veterans Winter Sports Clinic in Snowmass Village, Colo.


PHOTO: John Buehler

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PHOTO: MSgt Val Gempis

Senior Airman Shavonda Tariuwa, a diagnostic imaging technician from the 374th Medical Group, Yokota Air Base, Japan, uses a computer to reconstruct 3D images of a “patient� during CT scanner training. Military imaging records are stored and accessed digitally.

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ELECTRONIC MEDICAL RECORDS DOD WAS AN EARLY ADOPTER OF DIGITAL HEALTH RECORDS, BUT IMPLEMENTATION HASN’T BEEN EASY By John L. Pulley

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PHOTO: Senior Airman Julianne Showalter

n 2009, the Defense Department’s initiative to create a global system of comprehensive electronic medical records was at a crossroads. Ten years and an estimated $4 billion to $5 billion into the initiative, the vaunted Armed Forces Health Longitudinal Technology Application (now known simply by its former acronym, AHLTA) was beloved in some quarters, beleaguered in others. Amid a turbulent backdrop -- congressional inquiries, allegations of contracting irregularities, technological barriers and breakthroughs, and an unshakable conviction among many that the system saves lives -- the success or failure of AHLTA hung in the balance. Army Staff Sgt. Matthew Sims became a true believer. In March 2005, Sims was on a joint patrol convoy with the Iraqi army when he witnessed, at close range, the carnage wrought by an improvised explosive device. Fifteen Iraqi soldiers riding in a lightly armored truck suffered “amputated legs and arms, blown up faces and severe burns,” says Sims, who at the time was a medic with the 1st Armored Division’s Company B, 270th Armor Battalion. Moving among the wounded, Sims assessed and treated their injuries. With the aid of an Iraqi interpreter and a newly acquired handheld electronic device, he catalogued

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the men’s wounds and the aid each received, including tourniquets to staunch bleeding and morphine to dull pain. Evacuation teams used the information logged by Sims to route casualties to appropriate treatment facilities, where medical caregivers used his wirelessly transmitted notes to prepare for the wounded to arrive. Before his unit received AHLTA mobile handheld devices, Sims would have documented mass casualties on field medical cards that attached to soldiers’ uniforms. “You’d have to stop and write it out. You’re getting shot at, sweating, the paper gets thin,” Sims says. “By the time they get [to a military hospital], they’re bleeding, hurt, their uniform is ripped off. If the paper is lost, the doctor doesn’t know what’s been done to them.” In a medical crisis, imperfect information leads to bad outcomes. Tourniquets left on for too long can result in loss of limbs. Giving too much morphine to a head-trauma patient can be fatal. “We had no loss of life in that incident,” Sims says. “I’m very impressed with AHLTA.”

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n another battlefield, however, AHLTA looked less impressive. At a congressional subcommittee hearing on Capitol Hill in spring 2009, detractors labeled the military’s electronic medical record an abject failure. Panelists testified that the system, despite its benefits, is frequently slow and inefficient. The name of the hearing said it all: DoD’s Health Information Technology: AHLTA is “Intolerable,” Where Do We Go From Here? In June of that year, Sen. Judd Gregg, R, N.H., asked the Government Accountability Office to investigate the AHLTA program, including the program’s costs and the issuance of non-competitive, sole-source contracts. A month later, Nextgov.com reported allegations by the chief of product development for the Defense Health Information Management System (DHIMS) that DoD’s Military Health System provided an unethical advantage to Adara Networks. Adara’s routers, which would “sit at the heart of the new Military Health System electronic record architecture,” would serve as a bridge between AHLTA and the VA’s electronic health record system, reported Nextgov.com. The lack of interoperability between those systems has vexed DoD and VA health-care providers. AHLTA’s harshest critics advocate killing the program and starting over. The Pentagon, however, doesn’t appear inclined to surrender. Before his retirement in April 2009, S. Ward Casscells III, the assistant secretary of defense for health affairs, unveiled (Left) Maj. (Dr.) Michael Charlton and Capt. Michael Raethka check a rod against the leg of a patient prior to boring out the center to make a canal for the permanent rod at Joint Base Balad, Iraq. Electronic records from field hospitals provide a full picture of initial treatment for medical providers down the road. (Right) U.S. Air Force Master Sgt. Kevin Preston, an Aeromedical Evacuation Technician with the 651st Expeditionary Aeromedical Evacuation Squadron, cares for an Afghan local national in critical but stable condition for transport to a larger medical facility at Forward Operating Base Tarin Kowt, Afghanistan.


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PHOTO: Staff Sgt. Greg C. Biondo


a “long-term plan to switch from AHLTA’s client-server architecture with a centralized database to a Web-based, service-oriented architecture and a network of distributed databases,” reported Modern Healthcare. Moreover, the military’s medical leaders were assembling a “Red Team” of IT sector heavyweights -among them Intel, Microsoft Corp. and GE Medical – to help with the transition, Casscells said.

I

PHOTO: Tech. Sgt. Thomas Coney

n scope and ambition, AHLTA is unprecedented. The goal is to create a comprehensive paperless medical record for every soldier, dependent and retiree that can be readily accessed by civilian and military health-care professionals -- anytime and anywhere. The objective is to create an interoperable, deployable, user-friendly, secure system that works for Special Forces in the mountains of Afghanistan and for sailors at sea, for in-patient and out-patient treatment, for routine physicals and major surgeries, for dental and mental health, for active-duty care providers and VA doctors. More than 77,000 health-care providers routinely use AHLTA at 889 fixed military medical and dental facilities, on board ships and at deployed medical facilities. The system, which holds clinical records for more than 9.4

million beneficiaries, has processed and stored data for more than 116 million outpatient encounters, including more than 2 million in Afghanistan, Iraq and Kuwait. AHLTA was developed in the aftermath of the first Gulf War. The absence of records documenting the health and treatment of deployed troops hampered the military’s understanding of what came to be known as Gulf War Syndrome. Congress responded by mandating the creation of a system for electronically documenting medical care of soldiers outside the United States during all kinds of operations. Development of AHLTA, originally known as Composite Health Care System II, began in 1999, with Integic serving as the primary contractor. (Northrop Grumman acquired Integic in 2005.) Its precursor, Composite Health Care System I, was developed by Science Applications International Corporation (SAIC), which won the $1 billion contract in 1988. Largely an administrative system, CHCSI is still in use today. Some critics contend the Defense Department erred in creating an electronic medical record from scratch, that it should have adopted and customized the celebrated VistA system developed by the VA. (VistA served as the basis for CHCSI.) But Army Col. Claude Hines, program manager of the Defense Health Information Management System (DHIMS) and overseer of its $350 million annual budget, says unique requirements of active-duty medical care necessitated creation of a new system. “Our environment is so complicated, there’s not a product on the market that has all the electronic health record pieces that we need,” says Hines. “It has to be available 24/7 and work across every time zone, on ships and in austere environments. What we do is so unique. We had to develop our own.”

I

T vendors and contractors have propelled AHLTA’s development and deployment, which uses off-the-shelf hardware and some standard applications in addition to proprietary technology. In March 2009, DHIMS awarded a $31.1 million contract (with a potential value of $56 million) to CliniComp to deploy Essentris, an interim inpatient solution, to 28 military treatment facilities. It also awarded a contract to SAIC for maintenance and support of AHLTA, a total value of more than $158 million “if all options are exercised,” reported SAIC. Accelera Solutions worked to correct performance problems that vexed many users, particularly those who run AHLTA on computers with inadequate resources. The result is often sluggishness, crashes and required upgrades to computer memory and processing speed. (Left) A 59th Medical Wing Trauma Team performs emergency resuscitation procedures during a mock exercise. (Right) Medical technicians assigned to an all Air Force Forward Surgical Team on Forward Operating Base Ghazni, Afghanistan, practice lifting a simulated patient in and out of a Mine-Resistant Ambush Protected (MRAP) vehicle that replaced two ambulances more vulnerable to enemy blasts.

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PHOTO: Staff Sgt. Greg C. Biondo


Portsmouth Naval Hospital, a test site for AHLTA, was grappling with these issues in 2004. The code-intensive “heaviness” of AHLTA precluded the hospital’s IT staff from making system upgrades over the hospitals’ widearea network. Upgrading the system required manually loading new software on each user’s machine. Accelera Solutions proposed a remedy using Citrix application virtualization technology. Rather than running AHLTA on each user’s computer, Accelera implemented a pilot program that relied on a centralized computing model. Users would interact with the application by way of a virtual interface, freeing their computers from the burden of running the application, which resided in a data center. In terms of user friendliness, it’s the difference between renting movies in variable formats (Beta, VHS, DVD, Blue Ray) from a bricks-and-mortar store and ordering a streaming on-demand video from your couch. Impressed, Pacific Air Forces deployed Accelera’s solution at its nine hospitals.Eager to improve AHLTA, the command went outside the regular procurement process dictated by the Tri-Service Infrastructure Management Program Office (TIMPO), which delivers and manages the communications and computing infrastructure throughout the Military Health System (MHS).

THEY FOUND THE FUNDS AND DID IT. THAT WAS THE BEGINNING OF WHAT IS AN ENTERPRISEWIDE REMOTEACCESS SOLUTION FOR AHLTA.

PHOTO: Tech. Sgt. Cecilio Ricardo Jr.

From left, Airmen 1st Class Mark Finney, Art Boyd and Josh Frost carry Airman 1st Class Matthew Macella during a mass casualty incident exercise at Kirtland Air Force Base, N.M.

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PHOTO: Senior Airman Grovert Fuentes-Contreras

U.S. Air Force Senior Airman David Cummings, medic attached to Provincial Reconstruction Team Zabul, wraps a village elder’s injured foot during a visit to his village in Mizan, Afghanistan.

“They found the funds and did it,” says Joe Brown, Accelera’s president. “That was the beginning of what is an enterprise-wide remote-access solution for AHLTA. We have been engaged to roll out servers in strategically located hospitals across the globe.”

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ven as the Military Health System worked to debug AHLTA and undergird it with a more modern IT architecture (the Unified Strategy Regional Distribution Approach), it continued to deploy new functionality. Version 3.3 of AHLTA was released in 2008, but not without incident. According to an industry insider, deployment of AHLTA 3.3 “brought Portsmouth’s entire system down,” requiring a switch back to an older version of AHLTA. Efforts wee under way to incorporate the dental component of the electronic record into the version of the application used in Iraq and Afghanistan. And at a time when the mental health of service members is getting renewed attention, AHLTA added a behavioral health module that sought to overcome the stigma that impedes soldiers from seeking help. The application walls off mental health notes in the electronic record so

only behavioral-health providers can see them. Military leaders hope the extra layer of privacy will make it easier for troops to seek out appropriate care. Next, HLTA users gained access to a global data base of all medical images, such as X-rays and MRI scans. The Healthcare Artifact and Image Management Solution (HAIMS) allowed a doctor in Kansas, for example, to see a medical image taken in Germany. Another new tool documented mild traumatic brain injuries also known as concussions. A series of such injuries, whether sustained in an IED blast or from an elbow during a pickup basketball game, can result in serious neurological deficiencies. Additional functionality was to allow medics to assess the condition of service members in blast areas and log the data in their electronic medical records. “Later, if they experience problems,” says Hines, “we can go back and see the occasions that caused mild trauma to the head.”

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Spc. Jonathan Melendez-Santiago from the U.S. Army Garrison’s Provost Marshal Office in Schinnen, the Netherlands, tends to a casualty in the Army’s Best Warrior competition.

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PHOTO: Adam Turner

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Staff Sgt. BIll Cenna, 212th Rescue Squadron pararescueman, prepares to move a patient on a litter while the HH-60G Pavehawk helicopter lands during training at Joint Base Elmendorf-Richardson, Alaska.

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PHOTO: Staff Sgt. Zachary Wolf

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A pararescuemen and “victim” celebrate after successfully rappelling down a rock climbing wall during Rescue Fest.

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PHOTO: Staff Sgt. Jason Lake

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Marines carry a casualty into an MV-22 Osprey aircraft during a mass casualty evacuation exercise on Marine Corps Base Camp Lejeune, N.C.

PHOTO:  Sgt. Austin Hazard

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