Veterans Affairs and Military Medicine Outlook Fall 2018

Respiratory Health Combat Casualty Care Orthopedics

INTERVIEWS U.S. Rep. Gus M. Bilirakis, R-Fla.

Vice Chairman of the Veterans’ Affairs Committee and Co-chairman of the Military Veterans Caucus

Lt. Gen. Nadja Y. West

Surgeon General of the U.S. Army and Commanding General, U.S. Army Medical Command

HELP SHATTER HCV

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A PROMPT, QUALITY REFERRAL IS VITAL TO GIVE YOUR PATIENTS THE BEST CHANCE OF BEING CURED.1 Your role in HCV makes an impact on patients’ lives.

HCV = hepatitis C virus Cure, or sustained virologic response (SVR12), is defined as undetectable levels of HCV in the blood at 12 weeks after completion of therapy.1,2 References: 1. AASLD, IDSA, IAS-USA. http://www.hcvguidelines.org. Accessed September 21, 2017. 2. HHS/FDA/CDER. Guidance for Industry. Chronic Hepatitis C Virus Infection: Developing Direct-Acting Antiviral Drugs for Treatment. November 2017. 3. Holmberg SD et al. N Engl J Med. 2013;368(20):1859-1861.

4. McGowan CE et al. Liver Int. 2012;32(suppl 1):151-156.

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AS MANY AS 1/3 OF THOSE WHO TESTED HCV POSITIVE DID NOT RECEIVE FOLLOW-UP CARE3

TREATMENT DELAYS CAN INCREASE THE MORBIDITY AND MORTALITY RISKS OF HCV1

TAKE ACTION: LINK ALL OF YOUR DIAGNOSED HEPATITIS C PATIENTS TO CARE Inform and educate your patients that HCV often can progress without symptoms and that the earlier treatment is initiated, the more likely they can achieve cure1

Find and schedule the appointment with a provider who treats HCV and is conveniently located for your patients

Follow up to ensure the patient saw a treatment provider because 25% to 50% of HCV patients miss their first appointment4

Consider treating HCV in your practice to help mitigate drop-off in follow-up care

Find information, tools, and educational resources on screening, diagnosing, and referral at HCVcanbecured.com/J13 or download the RETHINK HCV app from the App Store or Google Play.

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2018 FALL EDITION

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CONTENTS INTERVIEWS

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10 U.S. REP. GUS M. BILIRAKIS, R-FLA.

LT. GEN. NADJA Y. WEST

By Rhonda Carpenter

By Rhonda Carpenter

Vice Chairman of the Veterans’ Affairs Committee and Co-chairman of the Military Veterans Caucus

Surgeon General of the U.S. Army and Commanding General, U.S. Army Medical Command

RESEARCH

16

DRUG-RESISTANT INFECTIOUS DISEASES

24

RESPIRATORY HEALTH

By Craig Collins

By Craig Collins

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CONTENTS 28

EDUCATION AND ADVANCEMENT THE VHA WAY Programs support current and future VHA medical professionals.

By J.R. Wilson

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WEARABLE TECHNOLOGY

On the threshold of clinical care

By Craig Collins

46

ORTHOPEDICS

52

STAFF SHORTAGES

By J.R. Wilson

VHA faces a unique set of recruitment and retention challenges.

By J.R. Wilson

58

A PATH TO INDEPENDENCE

The U.S. Army Wounded Warrior Program

By Eric Tegler

64

COMBAT CASUALTY CARE

Advances and lessons for the next war

By Craig Collins

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Published by Faircount Media Group 4915 West Cypress Street Tampa, FL 33607 Tel: 813.639.1900 www.defensemedianetwork.com www.faircount.com EDITORIAL Editor in Chief: Chuck Oldham Managing Editor: Ana E. Lopez Senior Editor: Rhonda Carpenter Contributing Writers: Rhonda Carpenter, Craig Collins, Eric Tegler, J.R. Wilson DESIGN AND PRODUCTION Art Director: Robin K. McDowall Designer: Rebecca Laborde ADVERTISING Advertising Sales Manager: S​ teve Chidel Advertising Team Lead: Beth Hamm Representative: ​Art Dubuc OPERATIONS AND ADMINISTRATION Chief Operating Officer: Lawrence Roberts VP, Business Development: Robin Jobson Business Development: Damion Harte Business Analytics Manager: Colin Davidson Accounting Manager: Joe Gonzalez Marketing Interns: Patrick Freer, Ryan Hansen FAIRCOUNT MEDIA GROUP Publisher: Ross Jobson

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INTERVIEW

U.S. REP. GUS M. BILIRAKIS, R-FLA. Vice Chairman of the Veterans’ Affairs Committee and Co-chairman of the Military Veterans Caucus

By Rhonda Carpenter

n CONGRESSMAN GUS M. BILIRAKIS represents Florida’s 12th Congressional District. He is currently serving his sixth term in the U.S. House of Representatives.

Bilirakis serves on the Energy and Commerce Committee and is vice chairman of the Veterans’ Affairs Committee.

He is co-chairman of the Military Veterans Caucus and a member of the Congressional Veterans Jobs Caucus.

He requested a seat on the House Committee on Veterans’ Affairs, because of his commitment to advocate on behalf of veterans and their families in the U.S. Congress. In his role as vice chairman of the Veterans’ Affairs Committee and member of the Health Subcommittee, Bilirakis continues to ensure the nation’s heroes remain a top priority.

Prior to being elected to Congress, Bilirakis served four terms in the Florida House of Representatives (1998-2006), where he chaired several panels, including Crime Prevention, Public Safety Appropriations, and the Economic Development, Trade, and Banking Committee.

Bilirakis earned a Bachelor of Arts degree from the University of Florida in 1986 and a J.D. from Stetson University in 1989.

He interned for President Ronald Reagan and the National Republican Congressional Committee, and worked for former U.S. Rep. Don Sundquist, R-Tenn. He also currently teaches government classes at St. Petersburg College.

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■■ Rep. Gus Bilirakis, R-Fla., is the vice chairman of the Veterans’

Affairs Committee and co-chairman of the Military Veterans Caucus.

and guardsmen, dependents, surviving spouses, and surviving dependents; provides full eligibility to Post-9/11 Purple Heart recipients; restores eligibility for service members whose school closes in the middle of a semester; and creates a pilot program to use the GI Bill for certain high-technology courses. Additionally, the bill contained a provision I

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VIA THE WEBSITE OF WWW.SPEAKER.GOV

Veterans Affairs & Military Medicine Outlook: Could you briefly explain what the “Forever GI Bill” is? Also, could you highlight one or two of its most popular provisions that help veterans utilize their educational benefits?

U.S. Rep. Gus M. Bilirakis: This important new law will improve and extend GI Bill benefits while maximizing flexibility for the veteran and their family. Most importantly, the bill removes the expiration date by which a veteran previously had to use his or her GI Bill benefits. Future recipients will be able to use their GI Bill benefits their entire lives. The Forever GI Bill also increases GI Bill funding for reservists

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

sponsored that will modernize the VA’s [Department of Veterans Affairs] information technology systems. We recently obtained an update from the VA regarding the law’s implementation. Based upon that report, I believe we are making progress in assisting veterans, but there is still more work to be done.

Are there educational institutions that prey upon veterans, knowing they can reap profit from their GI Bill benefits?

I believe the vast majority of educational institutions have our veterans’ best interests at heart and provide incredible opportunities to student veterans looking to learn and invest in their future through education. However, I have heard from stakeholders that there are bad actors in the industry who shamefully take advantage of veterans for their own benefit. One example of this is the implementation of the 90-10 rule, which states that for-profit institutions can receive a maximum of 90 percent of their revenue from federal financial aid sources. Unfortunately, GI Bill benefits are exempted from this rule, leading [to] the potential for bad actors to target veterans for their own purposes rather than for the educational benefit of the student veteran. I support closing this loophole and ensuring that VA benefits are treated on an equal playing field as other federal financial aid sources.

You co-sponsored the SIT-REP Act – the Servicemembers Improved Transition through Reforms for Ensuring Progress Act – that would protect veterans from educational institutions charging penalties due to potential delays in the processing of their tuition payments. How common had the practice of billing punitive fees become? In order to correct the erroneous fees, is the burden to report inappropriate charges on the institution or the veteran?

My legislation, the SIT-REP Act, was formed as a result of an implementation hearing held by my colleagues and I on the House Veterans’ Affairs Committee. At the hearing, stakeholders highlighted that because of delays in the processing of GI Bill benefits, some schools had imposed these burdensome penalties on student veterans. Again, while the majority of educational institutions are doing the right thing and ensuring veterans are not unfairly penalized for bureaucratic delays, there are still bad actors that have restricted access to education. In our legislative hearing on the bill, we heard of at least 15 cases where this practice occurs, and many believe the practice to be more widespread than advertised. I believe it is important to stop this practice across the board. To accomplish

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this, prior to and in order to receive GI Bill benefits approval, the burden falls on the schools to specifically adopt a new policy disallowing them from imposing a fee or denying access to education for student veterans.

■■ “Too often we see bureaucracy get in the way of doing the right thing for our heroes.”

The newly formed Subcommittee on Technology Modernization will oversee the VA’s transition from VistA, short for the Veterans Health Information Systems and Technology Architecture, to the Cerner Millennium Electronic Health Record (EHR) System, among other projects. Committee Chairman Rep. Phil Roe, M.D., R-Tenn., stated in remarks on June 26 that “… we are at the beginning of the beginning.”

What did the chairman mean by that?

This massive project undertaken by the VA and DOD [Department of Defense] has been a long time coming.

While then-Secretary [David] Shulkin announced his decision in the summer of last year, the goal of achieving continuous interoperability between the two agencies is well overdue. I believe the chairman is saying that despite the progress that we have made, we still have a long way to go to achieve this goal. We must ensure that the planning activities and critical workflows are standardized across the board before beginning with implementation in any initial sites. I am confident the VA committee, under the leadership of Chairman Roe, as well as the new Subcommittee on Technology Modernization, will work to ensure proper oversight of this critical mission.

Has the Cerner EHR System been deployed to the three initial sites as planned? If so, what is your impression of the success of the system? What progress has been made in implementing it?

My understanding is the new system has been deployed in their initial sites in the Pacific Northwest, but that there is still a significant amount of work to be done in ensuring better workflows, training, and full functionality. As a result of poor initial implementation and dissatisfaction amongst its users, the Defense Health Agency has been strategically evaluating its next steps by collecting feedback and addressing areas that need improvement. This is a significant change of 11

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

■■ U.S. Rep. Gus Bilirakis (third from right) presents an official signed copy of the Jason Simcakoski PROMISE Act to the Simcakoski family,

system across the board. I look forward to hearing more about the progress of these improvements in committee hearings in the coming months.

As of today, more than 150,000 service members and veterans have registered with the VA’s Airborne Hazards and Open Burn Pit Registry. Are committee and caucus members able to access and use the data available in the registry?

I have not been able to access or use the specific data that has been submitted into the VA’s Burn Pit Registry.

Furthermore, the VA’s registry plan does little to help veterans who are suffering now, which is unacceptable.

Recently, the VA committee held a hearing assessing the health effects of burn pit exposure. We had an opportunity to question the VA on the shortcomings of the registry and its lack of implementation. I believe the VA should be doing more to prioritize toxic exposure and involve other federal scientific and medical research agencies, such as NIH [National Institutes of Health], CDC [Centers for Disease Control and Prevention], and EPA [Environmental Protection Agency].

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It is a widely known fact that veterans serving in Operation Enduring Freedom and Operation Iraqi Freedom were exposed to toxic chemicals in burn pits during their deployments. Many of these veterans are now battling a wide range of diseases, some of which have proven fatal. I partnered with Rep. Raul Ruiz [D-Calif.], a physician and public health expert by trade, to craft legislation to address this issue. My bill, the Protection for Veterans’ Burn Pit Exposure Act, seeks to remedy an injustice that is preventing veterans from being able to access the medical care and disability compensation benefits to which they should be entitled. Specifically, this critical legislation will provide a presumption of service connection for exposure to toxic burn pits, which will enable the veterans battling illness to immediately access VA medical care and disability benefits. To accomplish this, my bill establishes an Open Burn Pit Advisory Commission, an independent body that would be tasked with gathering the medical and scientific data necessary to make recommendations on the association of diseases connected to toxic burn pit exposure. The commission, comprised of 15 members with distinguished backgrounds in medical, scientific, and

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U.S. REP. GUS BILIRAKIS WEBSITE

joined by Sens. Tammy Baldwin, D-Wis. (left), and Shelley Moore Capito, R-W.Va. (right), in December 2016.

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

epidemiological research, as well as expertise in military and veteran health care, would be able to access data from all federal agencies and award grants for original research for the purposes of determining this scientific connection. We can’t change the fact that they were exposed and are sick, but we have the power to get them the help they need. I will not stop fighting on their behalf until they get the benefits and medical treatment they deserve.

You co-authored, with Rep. Peter Welch, D-Vt., as part of the final DOD spending bill, a measure to include $1 million to improve interagency coordination between the DOD and the VA to study the effects of toxic exposure to burn pits. Could you talk about this briefly?

The final Defense Appropriations bill contained language I co-sponsored with Rep. Welch to allocate $1 million to improve interagency coordination between the DOD and the VA as both agencies study the effects of toxic exposure to burn pits. We must expedite the process of ensuring that our men and women who are experiencing hardship due to exposure to these toxins during their service get the medical treatment and benefits they need. Coordination between these two agencies is necessary and these funds are key to making that happen. Too often we see bureaucracy get in the way of doing the right thing for our heroes. I’ve met with many of these veterans. They are suffering and their stories are heartbreaking. They don’t have time to wait any longer. As I stated [earlier], I will not stop fighting for them.

Additionally, what is being done by Congress to reduce the danger of burn pit exposure to those who are currently serving in uniform?

While the practice of utilizing burn pits has largely been discontinued, hearing reports that some burn pits are still in use in Iraq and Afghanistan is certainly troubling. The VA committee has conducted their hearing on this issue, and I support the movement of legislation to continue to bring burn pit exposure to national attention. My bill, the Protection for Veterans’ Burn Pit Exposure Act, focuses on the VA’s role in addressing benefits and health care for those who have returned home. However, I am hopeful the House and Senate Armed Services committees can address this by calling DOD in to testify on their practices and on these reports.

Funding for veterans wishing to see a private health care provider has moved from mandatory to discretionary spending. What are your thoughts on this?

One of the many reforms of the recently enacted VA MISSION [Maintaining Systems and Strengthening

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Integrated Outside Networks] Act was to gradually move the VA’s community care programs from mandatory to discretionary spending. I believe this is a fiscally responsible effort to return budgetary authority back to congressional appropriators. Congress has always and consistently spent the money needed to fund our nation’s military and provide for our nation’s veterans. The VA has seen consistent budget increases over the past decade, and I am confident the Budget and Appropriations committees will continue to provide the funding needed for our nation’s heroes under regular order, much like we do on an annual basis with the NDAA [National Defense Authorization Act] and defense appropriations processes.

■■ “Specifically, this critical legislation will provide a presumption of service connection for exposure to toxic burn pits, which will enable the veterans battling illness to immediately access VA medical care and disability benefits.”

Last fall, you and many of your colleagues sent a letter to then-VA Secretary David Shulkin to request coverage for health conditions related to Agent Orange exposure for “Blue Water” Navy Vietnam veterans. Could you explain the request and what it could mean for these veterans? What is the status of your request?

The VA has not complied with our request to grant presumptive status. I am personally offended by the commentary offered by a high-ranking VA official in a recent Senate hearing. Not only did his comments show a complete lack of understanding for the plight of those who were exposed to burn pit toxins, but also for the injustice that has been perpetuated against Blue Water Navy veterans. Our focus should be on the cost that has been incurred by these veterans, who are sick and, in some cases, dying, as well as the financial and emotional hardship that their families have endured – not the cost to the system. Congress has given the VA record increases in funding in recent years. These dollars are to be used to help our veterans. The brave men and women who have been exposed to these toxins risked their lives to defend our nation. Now it 13

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is our job to defend them against this bureaucratic way of thinking, to remove the red tape, and to ensure we honor our commitment to them by providing the medical care and benefits they have earned through their sacrifice and service. Therefore, the House passed the Blue Water Navy Vietnam Veterans Act of 2018, which extends the presumption of exposure to [that] group of veterans. The bill passed the House by a 382-0 vote. We are working with our Senate colleagues to get this bill to the president for enactment as soon as possible.

best practices for prescribing opioids. It also required the VA to increase information-sharing with state licensing boards. This legislation ensures that the same safeguards are in place at the VA as exist in private settings. Both the PROMISE and COVER acts have provided for more personalized and individualized care options and alternatives to opioids.

What do you consider the biggest challenges facing the VA today?

There is no doubt the VA has experienced an incredible amount of change and reform over the past few years, and implementing these reforms is no easy task. Nevertheless, the VA has the critical mission of providing care and benefits to our nation’s heroes, who have sacrificed so much. Beyond many changes in leadership, I believe one of the biggest challenges the VA faces is the morale and retention of its employees. We want to be able to attract the best and the brightest in to the Veterans Health Administration, for example, but the VA often has trouble recruiting and incentivizing these individuals to work and stay in the agency.

Additionally, while progress has been made, the VA still faces challenges in improving its efficiency and transparency. I am confident the reforms we are making in Congress are helping and not hindering this process, but the VA needs strong leadership to be able to see this through. I am hopeful the new secretary will be able to establish stability and vision as it moves forward under continual scrutiny.

■■ “There is no doubt the VA has experienced an incredible amount of change and reform over the past few years, and implementing these reforms is no easy task.”

What legislative accomplishments regarding veterans do you feel most proud of?

In 2016, I passed two critical pieces of legislation dealing with mental health and substance abuse as part of the Comprehensive Addiction and Recovery Act. The first was the Creating Options for Veterans’ Expedited Recovery [COVER] Act, which established a commission to examine VA’s current therapy model and the potential benefits in incorporating complementary, alternative therapies. The COVER Commission is currently undergoing its public meetings to study and make recommendations for integrative and alternative treatments at the VA, and I look forward to seeing these new therapies implemented into traditional care models.

The second is the Promoting Responsible Opioid Management and Incorporating Scientific Expertise [PROMISE] Act, which increased patient safety by ensuring that VA physicians are trained in and utilize

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Is there anything you’d like to add?

One additional measure that is very near and dear to my heart is the Transition Improvement Act, which passed the House [at] the end of July [2018]. We spend a minimum of six months preparing service personnel for their military assignments and a maximum of one week preparing them for successful reintegration into civilian society. We owe these brave [people] more than that, and local veterans in my community who were able to provide direct input into this bill tell me that this is one of the most serious challenges currently facing the men and women who are exiting the military. I am hopeful that the Senate will take action on this important issue.

Another priority of mine is expanding veterans’ access to dental care. Oral health is an important part of overall wellness and studies show that preventative dental treatment of patients with certain chronic illnesses provides long-term savings in health care costs for treating the medical illness. I filed the VET CARE bill to expand veterans’ access to dental care while saving the VA money. Many people do not realize that very few veterans receiving health care through the VA qualify for dental care. I hope to demonstrate those potential savings in a pilot project authorized by my legislation, which can be replicated for all veterans in the years to come.

Additionally, I also filed the VA Community Care Enhancement Act, a bipartisan bill that provides a pilot program to test integrative centers between the VA and community health centers. I believe we can improve veterans’ access to care by having local VA medical centers work together with community health centers to get veterans the care they deserve.

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

VA RESEARCH:

DRUG-RESISTANT INFECTIOUS DISEASES

n THE DEPARTMENT OF VETERANS AFFAIRS’ (VA) infectious disease research program is all encompassing, involving fundamental investigations of what makes a bacterium, virus, fungus, or parasite into a disease-causing pathogen; of how infectious diseases are passed from person to person; and of the effectiveness of preventive strategies, vaccines, and drugs.

In recent years, the infectious disease research community has turned much of its attention to multidrug-resistant organisms (MDROs), a group of pathogens that has led to an increase in microbial infections over the last few decades.

For a number of reasons, our arsenal of antimicrobial drugs, so effective for decades in treating infectious microorganisms, has not evolved – but in the meantime, the organisms they were designed to kill have adapted. The U.S. Centers 16

for Disease Control and Prevention (CDC) estimates that at least 2 million people are infected by MDROs annually, and that at least 23,000 die each year as a result of these infections. An additional 15,000 die every year from Clostridium difficile (C. diff), a pathogen associated with long-term antibiotic use in health care settings.

MDROs are a significant concern for the VA medical community, whose patient population is statistically older and more vulnerable to infection than other Americans due to battle injuries, comorbid diseases, and other factors. Many MDROs are implicated in health care-acquired infections (HAIs), which occur when pathogens colonize and linger in health care settings. One of the most virulent MDROs, methicillin-resistant Staphylococcus aureus, or MRSA, can

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NIH PHOTO BY RHODA BAER

By Craig Collins

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

survive for more than nine months on inadequately disinfected surfaces. About three-fourths of all HAIs are from organisms that resist first-line antibiotics. A 2012 study conducted by the Alliance for Aging Research found that 99,000 Americans died of HAIs annually, and that MRSA infections killed more than emphysema, HIV/AIDS, Parkinson’s disease, and homicide combined.

The VA’s attack on MDROs is two pronged. Its MDRO Prevention Initiative, a collection of procedural guidance for professionals throughout the Veterans Health Administration (VHA), has greatly reduced infection rates for organisms such as MRSA and C. diff throughout its health care facilities. Updates and improvements to the program continue, along with a robust research program into effective infection control techniques and protocols.

In the absence of effective antimicrobial treatments, VA investigators are also probing the weaknesses of these MDROs in basic research that may lead to effective vaccines or drug treatments. Researchers are focusing particular attention on a group of organisms known as the ESKAPE pathogens, highly resistant pathogens responsible for the majority of HAIs: • Enterococcus faecium (E. faecium) • Staphylococcus aureus (S. aureus) These two organisms are unusual for Gram-positive bacteria, which respond to Gram staining due to their lack of a rugged outer cell membrane. Gram-positive bacteria have historically been vulnerable to penicillin-derived antibiotics such as methicillin, but E. faecium and S. aureus have evolved a resistance to these and other drugs.

• Klebsiella pneumoniae • Acinetobacter baumannii • Pseudomonas aeruginosa • Enterobacter species These four Gram-negative bacteria have a built-in defense against many classes of antibiotics. Broad-spectrum “lastline” antibiotics, such as carbapenems or cephalosporins, that used to be effective against these organisms are losing their edge, and in many cases, are contributing to their evolution into “superbugs.”

VA researchers, however, are discovering new vulnerabilities and possible modes of attack against these organisms, often at the molecular level.

CDC IMAGE

TAKING CUES FROM CANCER RESEARCH

The increasing resistance of infectious organisms to known antibiotics has led investigators to explore other ways of penetrating and killing pathogens. In some cases, promising treatments have been suggested by findings in cancer research.

“One of the biggest areas of research over the last 10 years that has transformed cancer treatment, to some degree,” said Robert Striker, M.D., Ph.D., associate professor at the University of Wisconsin School of Medicine and a researcher

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■■ OPPOSITE: Multidrug-resistant organisms are linked in health

care-acquired infections, because these pathogens can colonize and linger in places like hospital rooms.

■■ ABOVE: A medical illustration of methicillin resistant

Staphylococcus aureus, one of the most virulent multidrug-resistant organisms.

with the William S. Middleton Memorial Veterans Hospital, “has been a class of drugs called kinase inhibitors.” Kinase, an enzyme, works as a kind of switch to turn certain cell functions, such as protein formation, on or off. In cancer cells, kinases have become “dysregulated,” leading to unchecked cell growth. Kinase inhibitors target this dysregulation, essentially turning the switch to the “off” position.

According to Striker, there are more than 500 kinases at work in human cells, and cancer researchers have so far formulated about 25 FDA-approved kinase inhibitors that will target specific switches on cancer cells, slowing or stopping tumor growth while leaving the rest of the body’s cells alone.

In his laboratory, Striker’s team has discovered that some of these drugs can hit a kinase switch on the MRSA organism and re-sensitize it to methicillin, which kills S. aureus by preventing it from building a cell wall.

Methicillin is one of a family of antibiotics known as the beta-lactams, commonly denoted as β-lactams, which also include penicillins, cephalosporins, carbapenems, and monobactams. One of the oldest and most successful classes of antibiotics, the β-lactams have also contributed significantly to the evolution of drug resistance among pathogenic organisms. Striker and his team have used kinase inhibitors to re-sensitize other organisms, such as Streptococcus pneumoniae and Listeria monocytogenes, to β-lactams.

The switch targeted by Striker is known as the PASTA kinase: “A penicillin-associated serine/threonine kinase,” 17

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said Striker. “The acronym doesn’t quite work.” It’s unique to Gram-positive organisms, including some, such as tuberculosis, that haven’t been treated with β-lactam antibiotics in the past – but which can be made sensitive to them now, Striker said, with the use of kinase inhibitors. “We’re not just creating new antibiotics,” he said, “but we’re creating antibiotics that will rescue some of the old antibiotics and make them more active against bacteria that contain these PASTA kinases.”

In her work as chief of the Division of Infectious Disease at the Stony Brook University School of Medicine and as a researcher with the Northport VA Medical Center, Bettina Fries, M.D., has studied the effectiveness of fighting Klebsiella pneumoniae, the most common drug-resistant Gram-negative bacterium, with a cancer treatment pioneered by Nobel laureates in the 1970s: hybridoma technology, which boosts the immune system’s ability to attack and kill invasive cells.

When an animal is injected with a substance that provokes an immune response, specialized white bloods cells known as B cells produce antibodies that bind to the injected antigen, and then antibody-producing B cells are then harvested from the spleen of the animal – typically, a mouse.

These B cells are then fused with mutated B cells known as myelomas, producing a cell line called a hybridoma, which both produces antibodies and reproduces like a cancer cell.

These hybridomas, also known as monoclonal antibodies, are chemically identical and built to target specific cells.

Klebsiella is an organism that’s often harmless, commonly found on the skin or in the mouth or gut, but can turn virulent and, when found in the lungs, is a major cause of HAIs. It has developed a resistance to broad-spectrum

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■■ A 3-D computer-generated image of a group of multidrug-resistant

Acinetobacter bacteria.

carbapenems, one of the last lines of defense in treating MDROs in hospital patients, and is associated with high mortality rates.

Fries and her colleagues are studying ways to get around this drug resistance by boosting the body’s own immune response, creating monoclonal antibodies that target the polysaccharide capsule of Klebsiella, part of the bacterium’s outer envelope. “When the antibody binds to the bacteria, then the bacteria are taken up by inflammatory cells in the patient and killed,” said Fries.

People make antibodies on their own all the time, when they’re vaccinated or infected, but in many Klebsiella infections, Fries said, the antibodies come too late. “If you can make the antibodies in the laboratory and give them to the patient early in the infection, when they haven’t made their own yet, you can help them fight the infection.” So far, her team has produced monoclonal Klebsiella antibodies in mice, and are now investigating ways of “humanizing” the antibody, or changing its protein structure to make it match the structure of a human B cell. “Once you humanize the antibodies,” she said, “then you have a product you can get FDA approved for use in human patients.”

ACINETOBACTER BAUMANNII: AN IMMUNOLOGIST’S NIGHTMARE

An ESKAPE pathogen of particular concern to VA researchers is Acinetobacter baumannii, a Gram-negative 19

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bacterium that can form biofilms and adhere to surfaces for extended periods of time, or become airborne in water vapor. A. baumannii’s natural habitat is still unknown, as it’s rarely found outside hospital environments. Last year, the World Health Organization named multidrug-resistant A. baumannii as one of its three most critical priorities.

In health care settings, the organism is notoriously difficult to eradicate, and has evolved a vigorous resistance to antibiotics, including carbapenems.

In the mid-2000s, A. baumannii was the cause of an outbreak among wounded service members returning from the Middle East, particularly from Iraq, earning it the nickname “Iraqibacter.” As patients moved from one level of care to another – from forward facilities to Landstuhl Regional Medical Center in Germany to stateside hospitals such as Walter Reed Army Medical Center and Brooke Army Medical Center – many became infected and brought the organism with them, where it infected others.

A. baumannii’s strong antibiotic resistance has turned an organism with a relatively low level of virulence into a killer, said Philip Rather, Ph.D., professor of microbiology at Emory University School of Medicine and a research career scientist at the Atlanta VA Medical Center. Estimates of the mortality rates of A. baumannii-infected patients vary widely; Rather puts it at between 25 and 60 percent, depending on the patient population. Most who are infected with A. baumannii are already sick or wounded, “so, they’re already weakened to begin with,” Rather said. “And some of these strains now are just very difficult to treat with antibiotics. And in fact, some strains are completely resistant to every available antibiotic.”

As Rather and his investigative team have discovered, one of the features that makes A. baumannii so dangerous is its ability to switch back and forth from an avirulent form – one that does not cause disease – to a virulent pathogen. Either form will be attacked by the body’s immune system, he said, but the virulent form typically survives by throwing

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■■ An illustration of Clostridium difficile, or C. diff. The bacteria is often spread in health care facilities, like hospitals or nursing homes.

up defenses. At lower temperatures in the surrounding environment, Rather’s team believes, the avirulent form has a survival advantage, lying low until it’s taken up by a host.

In spring 2018, Rather and his team at Emory’s Antibiotic Resistance Center, which includes another VA investigator, David Weiss, Ph.D., reported not only that they’d discovered how A. baumannii performs this switch – with a regulatory gene, ABUW_1645 – but also that they’d figured out how to manipulate that switch, turning the virulent form back into an avirulent one. “We’ve now been able to show that when you lock cells into that avirulent form,” Rather said, “they act as an incredibly effective vaccine, at least in animal models.”

After Rather’s team has demonstrated the vaccine’s effectiveness and ability to keep the avirulent cells “locked” in animal models, it hopes to move on to clinical trials. The ability to flip A. baumannii’s virulence switch may also enable treatments for already infected patients. “We could identify

chemicals we could treat humans with,” he said, “and if the chemical causes all the virulent cells to switch to avirulent, our immune system would clear them almost immediately, and it could be a next generation of therapies for this bacterium.”

Among the first VA researchers to study A. baumannii isolates from U.S. military hospitals was Robert A. Bonomo, M.D., professor at Case Western Reserve University (CWRU) School of Medicine and chief of medical service at the Louis Stokes Cleveland VA Medical Center. By mapping the genes of these organisms, Bonomo and Dr. Mark Adams, also of CWRU, found that not only were A. baumannii strains evolving to become more resistant, but that several strains had multiple genes conferring resistance to multiple antibiotics. “There were some isolates that had never seen certain antibiotics before,” he said, “that were already resistant to them, even before those antibiotics were used to treat them.”

Bonomo and Adams mapped out the entire genome of one of these early 21

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multidrug-resistant organisms from the outbreak at Walter Reed Army Medical Center, and have now published about 70 papers on A. baumannii, attempting to understand its resistance genes and looking at novel combinations to treat multidrug-resistant strains. Two years ago, they were part of a U.S.-Argentinian study that discovered how an A. baumannii bacillus and other MDROs could make themselves immune to antibiotics they had never seen before: They had devised several ways of sharing genes with other bacteria, one of which was a new wrinkle in bacterial genetic exchanges. The team, led by Dr. Alejandro Vila, observed MDROs sloughing off little bits of their protective outer membranes and sharing them with other bacteria: “… kind of like little blebs of lipids, with enzymes or genes in them,” said Bonomo, “that go off the surface of MDROs onto the surface of another cell and fuse with the surface of that cell, and directly transfer the gene, as well as the protein, over to the other recipient.”

Understanding this particular defense mechanism may aid researchers in designing an attack, and Bonomo, Vila, and colleagues have since widened their focus. “We’ve also, with the support of the VA, tried to understand how other carbapenem-resistant bacteria, or bacteria that are resistant to our last-resort antibiotics, evolved.” They’ve studied carbapenem-resistant K. pneumoniae and P. aeruginosa, and recently began working with Brad Spellberg, M.D., an

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■■ Airmen from the 179th Airlift Wing, Mansfield, Ohio, assist in

outbound patient movement from Landstuhl Regional Medical Center, Germany, to their awaiting C-17 Globemaster III at Ramstein Air Base, Germany, June 21, 2018. In the mid-2000s, A. baumannii was the cause of an outbreak among wounded military members returning from the Middle East.

immunologist at the University of Southern California, to generate a monoclonal antibody that might be used as a vaccine against A. baumannii. In collaboration with Rather at Emory, Bonomo also studies the impact of new drugs on bacteria with altered transport systems.

Bonomo is a standout among VA researchers: In 2017, he received the William S. Middleton Award, the highest honor awarded annually by the department’s Biomedical Laboratory R&D Service to senior research scientists for their outstanding contributions in areas of prime importance to the VA research mission. But like many VA investigators, Bonomo is also a clinician, and he and his colleagues never lose sight of what this micro-level research is all about: “The people who do research in the VA are very dedicated to the welfare of their patients, and are hopeful of eventual cures.

Our lab is driven not just by science, but by a desire to bring good therapies to patients, to prolong life, and mitigate suffering,” he said. “We’re privileged to take care of veterans.”

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

VA RESEARCH:

RESPIRATORY HEALTH

PHOTO BY JAMES HEILMAN, M.D., VIA WIKIMEDIA COMMONS

By Craig Collins

24

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CDC IMAGE

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n BECAUSE A VARIETY OF FACTORS – including infectious diseases, cancer, genetics, and environmental hazards – can cause or contribute to respiratory illness, the Department of Veterans Affairs’ (VA) respiratory and pulmonary research portfolio is broadly focused, including studies of the basic science of respiratory illnesses and how they might be prevented or treated.

One of the challenges of studying respiratory diseases or disorders is the number of ways they restrict breathing not only by themselves, but also as comorbidities associated with other conditions. Respiratory problems are the leading cause of death among those who have spinal cord injury (SCI), for example, and investigators at the VA’s Center of Excellence on the Medical Consequences of Spinal Cord Injury, in the Bronx, New York, are studying ways to prevent and treat these and other complications among veterans with SCI. Among the most serious respiratory illnesses is chronic obstructive pulmonary disease (COPD), a broad term used to describe airflow restriction, usually progressive, that can be due to emphysema (damaged and enlarged air sacs in the lungs) or chronic bronchitis (excessive mucus in and inflammation of the bronchi or air passages within the lungs) – or a combination of both of these conditions. COPD is associated with an inflammatory response of lung tissue to harmful gases or particles, such as cigarette smoke. Tissue damage associated with COPD is irreversible, and treatments are minimally effective. A 2011 VA study, published in Military Medicine, suggested that COPD is more prevalent among veterans than among other Americans. One of a few likely reasons for this may be that compared to other Americans, higher percentages of active-duty military personnel and veterans smoke cigarettes.

COPD is a complex and multi-faceted disorder; while not an infectious disease, it nevertheless is often characterized by acute exacerbations, about half of which are caused by bacteria. The most common pathogen involved in COPD exacerbations, nontypeable Haemophilus influenzae (NTHi), causes much of the discomfort and distress associated with COPD, because it is capable of rapid mutation, adapting to individual hosts. NTHi is often directly linked to patients’ clinical outcomes.

A recently completed 15-year study, a joint effort involving researchers at the University of Buffalo in collaboration with the VA Western New York Healthcare System, provided some insight into how NTHi lives and adapts to its host in real time over a period of months or years. Investigators collected samples among 192 COPD patients for a period of 15 years, yielding 269 different strains of NTHi. By sequencing the genome of the pathogen and tracking its changes over time, the team was able to see when, and in what ways, the NTHi organism was switching particular genes on and off – for example, in the nutrient-poor environment of the lower respiratory tract, the pathogen activates mechanisms that allow it to scavenge iron. Now that the team has revealed the

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■■ OPPOSITE: A chest X-ray demonstrating severe chronic obstructive

pulmonary disease, or COPD. Note the small size of the heart in comparison to the lungs.

■■ ABOVE: Photo of Haemophilus influenzae (NTHi) using direct

immunofluorescence. NTHi is often directly linked to patients’ clinical outcomes.

organism’s mechanisms for survival, the team hopes further research will suggest targeted attacks for particular mechanisms, enabling eradication of NTHi in the airways.

Environmental hazards such as cigarette smoke, allergens, and viruses, activate immune receptors in cell membranes that sustain the airway inflammatory response in chronic disorders of the airways – and one of these receptors has become the focus of recent investigations. The lungs of COPD patients contain higher levels of toxins associated with cigarette smoke, known as advanced glycation end products (AGEs). Investigators have revealed that these toxins interact with a receptor for advanced glycation end products (RAGE) that may promote inflammation, though the role of RAGE in emphysema is still unknown.

Thanks to a research team led by John Hoidal, M.D., associate chief of staff for research with the VA Salt Lake City Health Care System, it is known that mice treated with a RAGE inhibitor are protected from emphysema in response to prolonged cigarette smoke exposure. Having established the importance of RAGE in the development of emphysema, the team now are engaged in further study of the receptor, aimed at discovering more specific information about the RAGE-induced response and how it propagates inflammation, oxidation, and cell death (apoptosis). More detailed knowledge of the pathways for developing emphysema may 25

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

■■ A 2011 VA study suggested that COPD is more common among veterans than among other Americans. This may be because compared to

one day lead to treatments that reverse the inflammatory response and protect the lungs from COPD-related damage.

DEPLOYMENT-RELATED RESPIRATORY HAZARDS

Another important contributor to higher veteran rates of COPD may be the service-related exposures of military personnel to infectious agents or environmental hazards. The dioxin herbicide known as Agent Orange, for example, has created numerous health problems for veterans of the Korean and Vietnam wars. Establishing a link between Agent Orange exposure and disease has been notoriously difficult, as there is no way to quantify past herbicide exposure. COPD, typically a midlife-onset disease, has not been classified as one of the “presumptive diseases” the VA recognizes as being associated with exposure to Agent Orange or other herbicides during military service, and research on COPD and herbicide exposure among Vietnam veterans is limited.

Several years ago the VA launched a study of Army Chemical Corps (ACC) soldiers who handled Agent Orange 26

and other herbicides to explore relationships between their herbicide exposure and health conditions, such as high blood pressure and chronic respiratory diseases. The team examining COPD among ACC members, from the VA’s Post Deployment Health Epidemiology Program, have discovered a seeming contradiction, reported in summer 2018: Surveys of ACC personnel show a significant correlation between herbicide exposure and self-reported physician diagnoses of COPD – but no correlation between herbicide exposure and airflow obstruction as objectively measured through spirometry, a common diagnostic tool for diseases that affect breathing. The result suggests more research needs to be done to understand both the relationships between COPD and herbicide exposure, and how COPD is diagnosed among veterans.

Over the last decade, the respiratory health of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans has become an issue of increasing concern, as a number of returning veterans have reported respiratory illnesses. Studies, both within and outside the VA research

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PHOTO BY STAFF SGT. JASON EPPERSON

other Americans, higher percentages of active-duty service members and veterans smoke cigarettes.

IMAGE BY LADYOFHATS VIA WIKIMEDIA COMMONS

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

system, have shown that the air in Iraq and Afghanistan – both the ambient air and the smoke from the hundreds of open-air burn pits used to dispose of waste at forward facilities – contained toxic contaminants that presented health hazards to service members.

VA-commissioned studies have established that exposure to burn pit smoke may cause short-term reductions in lung function, but the research community hasn’t gathered enough data to make conclusions about their long-term consequences to veterans’ respiratory health.

Several efforts at examining the link between deployment-related airborne contaminants and the long-term respiratory health of veterans are underway. Researchers from VA’s Airborne Hazards Center of Excellence at the New Jersey War Related Illness and Injury Study Center (WRIISC), for example, examine lung function among active-duty service members deployed to Iraq and Afghanistan, as well as among veteran volunteers, to better understand the effects of airborne hazards and compile data about the long-term effects of exposure.

The VA’s large-scale studies of respiratory illness among Iraq and Afghanistan have yielded data suggesting these military deployments may be associated with higher rates of respiratory illness: The first wave of the National Health Study for a New Generation of U.S. Veterans, also known as the NewGen study, which examined the medical histories and survey data from more than 20,000 veterans, revealed some correlations between respiratory disease and multiple respiratory exposures among OEF/OIF veterans, including petrochemical fumes, emissions from local industry or burn pits, dust storms, and particulate matter. The NewGen research team concluded that respiratory exposures “should be considered a hazard of military service in general, not solely deployment.”

“Correlation,” the study’s authors cautioned, is not a word that describes a causal effect. A greater accumulation of correlational data, acquired through epidemiological studies linking risk factors to respiratory illness, will be necessary. “Future research on this topic is needed,” wrote the NewGen team, “to determine if a causal relationship exists between these exposures and diseases, ideally including biological indicators, such as premilitary and pre-deployment lung capacity measurements.”

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■■ The respiratory system consists of the airways, the lungs, and the respiratory

muscles that mediate the movement of air into and out of the body.

As the nation’s largest integrated health care system, the VA is in a unique position to coordinate such research. Its Cooperative Studies Program plans and conducts large multicenter clinical trials and epidemiological studies throughout VA facilities and those of federal, international, university, and private-industry partners. VA researchers are now recruiting for such a study – the Service and Health Among Deployed Veterans (SHADE) study – to be conducted at six VA sites, which are currently recruiting participants.

Led by Dr. Eric Garshick, an epidemiologist and pulmonologist with the VA Boston Healthcare System and an associate professor of medicine at the Brigham and Women’s Hospital, the SHADE study aims to characterize the relationship between post-9/11 deployment-related exposures and current respiratory health, using standardized physiologic and epidemiologic measures. Among a cohort of 6,200 veterans who were deployed to Central Asia, Southwest Asia, or Africa, investigators will test hypotheses by combining data, primarily detailing cumulative exposures to fine particulate matter, with current measures of pulmonary function and medical record data.

In meticulously documenting and measuring the respiratory health of service members before, during, and after exposure to specific environmental hazards during post-9/11 deployments, the SHADE study, along with the work of other VA researchers, may begin to form definitive links between these exposures and long-term respiratory illnesses – and, ultimately, to produce treatments and bring relief to a new generation of service members with deployment-related respiratory illness.

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

EDUCATION AND ADVANCEMENT THE VHA WAY Programs support current and future VHA medical professionals.

By J.R. Wilson n THE VETERANS HEALTH ADMINISTRATION (VHA) has created a number of programs to assist its employees with further education and future advancement. The programs fall into two broad categories: educational programs most closely tied to employee professional development and highly relevant educational topics enabled by work on face-to-face conferences. In FY 2018, more than 95,848 people took one or more of the programs offered by the Department of Veterans Affairs (VA) Employee Education System (EES).

EES is dedicated to providing VA health professionals with new learning opportunities through the VA’s nationwide Employee Education Resource Centers (EERCs). These centers provide VA professionals with the most up-todate resources, a collaborative environment, and necessary training.

“VA health care professionals are constantly learning, from diagnostic methodology to advanced treatments and the latest in experimental technologies,” according to EES, “and we’re continually improving our ability to provide top-notch care for America’s veterans. Continuous learning is essential to the work we do. That’s why we also encourage VA employees to pursue higher education by offering one of the most comprehensive education support programs in the nation.

“One excellent support tool is the Education Debt Reduction Program [EDRP], which authorizes VA to provide student loan reimbursement to employees with qualifying loans who are in difficult-to-recruit positions in direct patient care. Participants may receive up to $120,000 toward a qualified loan over a fiveyear period, covering tuition and other reasonable educational and living expenses, including fees, books, supplies, equipment/materials, and laboratory costs.”

While EDRP addresses debt from existing degrees, the Employee Incentive Scholarship Program (EISP) authorizes the VA to award scholarships to permanent full- and part-time 28

VHA employees still pursuing degrees or training in health care disciplines for which recruitment and retention of qualified personnel is difficult. EISP led to a second program – the VA National Education for Employees Program (VANEEP) – which also provides scholarships to employees pursuing degrees or training in health care disciplines for which recruitment and retention of qualified personnel is difficult.

VANEEP provides scholarship and replacement-salary funding to VA facilities to allow certain scholarship participants who are enrolled full time in an approved education program to accelerate their degree completion by attending school full time. VANEEP participants agree to work at their VA facility during academic breaks and, in return, receive full salary and payment for education costs, including tuition, books, and certain fees.

Another program stemming from the legislative authority of EISP is the National Nursing Education Initiative (NNEI), a scholarship awarded to permanent full- and part-time VA registered nurses seeking baccalaureate and advanced nursing degrees from an authorized, accredited education program.

This helps nurses meet the VA requirement to have a bachelor’s in nursing (BSN) degree to advance beyond the Nurse Level 1 position. However, NNEI scholarships also may be used to pursue other advanced degrees in related fields.

According to Dr. Elizabeth James, EES acting chief learning officer, one of the VA’s professional development programs provides educational project managers and technicians with training for master instructional designer certification.

“This training provides VHA clinicians, as well as veterans, the skills expected of world-class trainers, enhances their job performance, and enhances their opportunities for advancement within the organization,” she said. “Twelve Events employees earned this certification over the last two

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■■ Labor and delivery nurses from the Samaritan Medical Center in Watertown, New York, observe as Army and civilian health care

PHOTO BY WARREN WRIGHT, FORT DRUM MEDDAC PUBLIC AFFAIRS

professionals train to stop life-threatening complications of a simulated mother who just gave birth during a training simulation at the Samaritan Medical Center. Obstetrics and gynecology health care professionals from Fort Drum, New York, work side by side with their civilian counterparts at Samaritan to provide pregnancy and labor and delivery care to Fort Drum service members and their families.

years [and VHA has gained] confident employees with critical job skills and the potential for advancement.

“The program has been well received by employees, creating a continuous demand for provision of this training. EES will continue to offer this training to all employees desiring to take it.”

The second category of programs includes what EES calls Process Improvement Training (Yellow/Green/Black belts).

“Change from the top can be ponderous, at best, but employee understanding of process fundamentals creates an environment of change at the lowest levels, quick wins gained through continuous small changes enabled by employee knowledge and understanding. Thirty-five Events employees earned this certification in the last two years,” James continued.

“Events has provided opportunities for this training for at least five years, seeking to provide employees the basic tools

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to recognize process flaws, recommend solutions, and execute approved solutions. As a result, we have gained employees capable of influencing positive and rapid change in VA from the lowest levels.”

VHA-level training in the prevention and management of disruptive behavior (PMDB) has continually evolved and improved since the late 1970s.

“Health care employees are at risk from potentially harmful disruptive behaviors. Widespread availability of training focused on handling disruptive encounters, provides VA health care providers an increased level of situational awareness, proven techniques to manage encounters, and a greater level of confidence in their ability to enhance workplace safety,” she explained.

“Staff are trained to identify disruptive situations, recognize the signs that a disruptive situation could escalate to 29

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violence, and master their own personal responses, empowering them to intervene appropriately to reduce risk of injuries to self and others.”

The PMDB curriculum will be updated in FY 20 to be better aligned with the needs of clinical participants and veterans, she added.

EES also works with program offices throughout VHA to provide focused, relevant training to take care of specific needs of veterans through a mix of peer-to-peer and guided discussion forums.

Educational incentive programs the VA has offered its employees and trainees during the past five years include: • Women’s Health – provides care specific to the needs of female veterans • W hole Health 101 – provides training to veterans to directly counsel each other on mental health care and suicide prevention options • VA Voices – provides training and information for veterans transitioning to civilian life • Warrior to Soul Mate – training to repair spousal relationships after deployment

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• Stepped care for opioid use disorder train-the-trainer conference – improves access to substance use disorder (SUD) specialty care • Improve access to SUD specialty care by increasing knowledge of medication-assisted treatment for opioid use disorder – saves lives by reducing the risk of overdose, suicide, and all-cause mortality • National Veterans Wheelchair Games educational sessions and National Blind Services Conference – serve veterans with spinal cord injury, multiple sclerosis, amputations, and other central neurological impairments, with the goal to increase their independence, healthy activity, and quality of life through wheelchair sports and recreation • Clinical Team Training (CTT) Champions Course – participatory leadership, followership, and assertive communication, situational awareness, team decision-making, and just culture; content is delivered via simulation and use of adult learning principles • VA/Department of Defense (DOD) Suicide Prevention Conference – a forum for sharing state-of-the-art 31

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INTERVIEWS U.S. Rep. Gus M. Bilirakis, R-Fla.

Vice Chairman of the Veterans’ Affairs Committee and Co-chairman of the Military Veterans Caucus

Lt. Gen. Nadja Y. West

Surgeon General of the U.S. Army and Commanding General, U.S. Army Medical Command

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■■ The VA offers incentives, scholarships, and career development support to nurses and nursing students.

practices and state-of-the-science findings related to suicide prevention efforts among service members and veterans • Peer Support Specialist Blended Learning Certification Training – transforming VHA’s mental health programs to the recovery model “About 1,200 people participate in these programs each year and we’ve had requests for more offerings,” James said.

“These programs – and emerging programs based on identified needs – will continue to be developed and executed as required.”

The VA also has scholarship programs that could be compared to DOD’s ROTC programs, awarding competitive scholarships to students receiving education or training in a direct or indirect health care services discipline in exchange for a commitment to work in a VA health care facility.

While NNEI scholarships are designed for nurses already employed at the VA, the VA Nursing Academic Program (VANAP) reaches out to those still in nursing school. VANAP scholarships are intended to expand the VA’s future cadre of BSN-prepared nurses to provide quality veteran-centric care

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designed to improve patient outcomes and reduce the overall cost of care.

A sister nursing program scholarship is offered to those pursuing bachelor’s, master’s, or doctoral degrees in nursing and requires a two-year minimum post-graduate commitment to the VA as a full-time clinical employee.

The Physical Therapy Program awards scholarships to students working on doctor of physical therapy degrees. The scholarship requires a minimum two-year commitment to full-time clinical employment with the VA as a physical therapist.

The Physician Assistant Program awards scholarships to students working toward a Master of Science in physician assistant studies. As with other VA scholarships for nonemployees, it requires a post-graduate commitment of at least two years as a full-time clinical VA employee.

“The VA’s goal in offering these incentives is to increase opportunities for care for the whole veteran to maintain positive and productive quality of life,” James said. “Through them, the VA has gained a cadre with enhanced skills to better understand the patient population of veterans and facilitate development of complete, effective care regimens.”

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INTERVIEW

LT. GEN. NADJA Y. WEST Surgeon General of the U.S. Army and Commanding General, U.S. Army Medical Command

By Rhonda Carpenter

n LT. GEN. NADJA Y. WEST is the 44th surgeon general of the U.S. Army and commanding general, U.S. Army Medical Command, and is a graduate of the U.S. Military Academy with a Bachelor of Science in engineering. She attended the George Washington University School of Medicine in Washington, D.C., where she earned a Doctor of Medicine.

She completed her internship and residency in family medicine at Martin Army Hospital, Fort Benning, Georgia.

During this assignment, she deployed with the 197th Infantry Brigade, 24th Infantry Division, during Operation Desert Shield and was attached to the 2/69th Armor Battalion during Operation Desert Storm. She then served at Blanchfield Army Hospital, Fort Campbell, Kentucky, as a staff family physician and then the officer in charge of the Aviation Medicine Clinic. While there she also participated in a medical mission with the 5th Special Forces Group (Airborne).

West completed a second residency in dermatology at Fitzsimons Army Medical Center and the University of Colorado Medical Center in Denver, and afterward was assigned as the chief, Dermatology Service at Heidelberg Army Hospital in Germany. In her following assignment, she served as the division surgeon of the 1st Armored Division, Bad Kreuznach, Germany, deploying to the former Yugoslav Republic of Macedonia and Kosovo as the deputy task force surgeon.

She was then assigned as chief, Department of Medicine and the Dermatology Service at 121st General Hospital in Seoul, Republic of Korea. West then commanded McDonald Army Community Hospital, Fort Eustis, Virginia, and served as the deputy commander for integration at the National Naval Medical Center (NNMC), Bethesda, Maryland, where she became the first Army officer to join the leadership team at NNMC. She then served as the director of operations for Joint Task Force National Capital Region Medical. Following this assignment, West commanded Womack Army Medical Center, Fort Bragg, North Carolina, and went on to serve as the commanding general, Europe Regional Medical Command.

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Following her command in Europe, she served as deputy chief of staff, Office of the Surgeon General. She then moved into her most recent assignment as the Joint Chiefs of Staff surgeon at the Pentagon. As the Joint Chiefs’ surgeon, she served as the chief medical adviser to the chairman of the Joint Chiefs of Staff and coordinated on all issues related to health services, including operational medicine, force health protection, and readiness within the U.S. military.

West completed the Army Medical Department Basic Officer and advanced courses and graduated from the Army Command and General Staff College. She is also a graduate of the National War College, earning a Master of Science in national security strategy.

Her awards and decorations include the Distinguished Service Medal, the Legion of Merit with three Oak Leaf Clusters, the Defense Meritorious Service Medal, the Army Meritorious Service Medal with two Oak Leaf Clusters, the Army Commendation Medal, the Army Achievement Medal with two Oak Leaf Clusters, the NATO Medal, various campaign medals, the Combat Medical Badge, the Flight Surgeon Badge, the Army Parachutist Badge, the Army Air Assault Badge, and the German Armed Forces Proficiency Badge in Gold.

Veterans Affairs & Military Medicine Outlook: You have 11 siblings. What life lessons did you learn from growing up in a large family?

Lt. Gen. Nadja Y. West: Growing up in a large family, I learned a lot about sharing, teamwork, patience, and compromise. However, being the youngest and the favorite, I also learned what it meant to be protected and taken care of, but also the importance of speaking up and being heard.

Why did you enlist, and why did you join the Army?

I joined the Army because I had such a great experience being the daughter of a career Army officer and because of

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the example my father set for my brothers and sisters and I on the importance of service to country. Nine of my brothers and sisters went on to serve in the military, most in the Army, but one sister joined the Air Force and another sister joined the Navy. Again, being the youngest, I saw the pride and dedication as each one of them followed my father’s footsteps, and I could not wait for my turn to serve as well.

You are the highest-ranking female graduate of the U.S. Military Academy at West Point. You now command the U.S. Army Medical Command, and you are the Army’s surgeon general. To what do you attribute your successes?

There are so many factors that have contributed to my success that it would be difficult to describe them all, but a major factor is the phenomenal foundation established by my parents. Both were very hard-working people of tremendous faith who demonstrated selflessness and taught us kids the importance of being girls and boys of character and the importance of ensuring all of our actions were in keeping with the values we were taught and observed. Interestingly, they are almost the same ones that we identify as our Army values. To build upon that base, there have been many people along the way who have provided additional examples, mentored me, provided opportunities for me to excel, and encouraged me along the way. Most importantly, the teams of wonderful people I have had the privilege to work with and lead deserve maximum credit for any success that I may have enjoyed during my 35-plus-year career as a soldier.

U.S. ARMY OFFICIAL PHOTO

You’ve been in your post for almost three years. What has been the biggest challenge for you as commander of U.S. Army Medical Command?

The greatest challenge is ensuring that my vision and intent is disseminated through every level of the organization given the scope, scale, geographic dispersion, and variety of the subordinate units that make up the 130,000-member Army Medical Department. Ensuring that each member of the team – comprised of soldiers, civilians, contractors, and volunteers; medics, doctors, nurses, dentists, veterinarians, dieticians, researchers, administrators, educators, and pilots, to name only a few, in over 120 medical occupational specialties – understands how he or she contributes to the overall mission of conserving the fighting force in an ever-changing environment is the greatest challenge.

What advice would you give to a newly enlisted soldier?

And what advice would you offer to a newly commissioned physician?

The advice I would give to a new member of the Army team, both enlisted and officer, is to learn early not only what you do in your specific area of expertise, but what you are for in the big picture to support our Army. She or he must be proficient in their chosen profession, be it a radiology technician or an optometrist. They must also understand how practicing

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■■ Surgeon General of the U.S. Army and Commanding General of U.S.

Army Medical Command Lt. Gen. Nadja Y. West.

those specific specialties contributes to our Army’s No. 1 priority of readiness. I would tell him or her to never stop learning, to never forget to live by the Army values that must serve as the undercurrent for all you do, and to never take for granted that you have the privilege of serving in the finest organization on the planet: America’s Army.

What is MEDCOM’s role in Total Force health readiness?

Army Medicine enables the medical readiness of the Total Army. Soldiers come from cultures, communities, and environments that produce a variety of health and fitness outcomes. Unit commanders are responsible for soldier readiness, but rely on Army Medicine’s technical expertise and capabilities to prevent, identify, and treat health problems while optimizing the performance of healthy soldiers.

Army Medicine enables medical readiness by: 1) developing Army policies and standards for expeditionary medical readiness; 2) advising commanders on the health readiness of their soldiers; 3) assisting commanders to identify and reduce environmental health threats; 4) developing knowledge and tools to positively modify physical performance and behavior; and 5) identifying and, when necessary, providing support to responsibly transition soldiers who are 35

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

■■ Lt. Gen. Nadja West, U.S. Army surgeon general and commanding general of U.S. Army Medical Command, speaks at a town hall hosted by

Regional Health Command Europe in Sembach Kaserne, Germany, on June 22, 2016.

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Through the directed efforts of access, quality, and command emphasis, Army Medicine continuously focuses on the health readiness of the Total Army.

The fiscal year 2017 National Defense Authorization Act calls for transferring the administration and management of military MTFs to the Defense Health Agency (DHA).

What are the advantages and disadvantages of migrating MTFs to DHA? There are several advantages of migrating the responsibility for the administration of all military MTFs to the DHA. First and foremost is the opportunity for the Army Medical Department to transform to better focus on its Title 10 functions to recruit, organize, train, and equip Army medical personnel in order to fully support the Army’s operational readiness requirements. Another advantage is the DHA will become the single point of accountability for the administration of all MTFs, which creates an opportunity for the Department of Defense [DOD] to standardize health care delivery and reduce variance among the service MTFs.

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U.S. ARMY PHOTO BY CAPT. JEKU ARCE, 30TH MEDICAL BRIGADE PUBLIC AFFAIRS

medically unqualified for continued military service. The medical readiness of the Total Army ensures that our nation can rapidly and reliably project ground combat power that will physically dominate in missions across the range of military operations.

For each soldier or other service member who receives care, we view each one of these encounters as an opportunity to improve that individual’s health and improve their readiness or ability to do their military specialty.

In a typical day, through its 32 military [medical] treatment facilities [MTFs], Army Medicine performs more than 50,000 outpatient clinic exams and more than 28,000 dental procedures, fills nearly 50,000 outpatient prescriptions, and performs more than 10,000 radiology procedures. We perform these services not only on Army soldiers, but also for sister service members in the Air Force, Navy, Marine Corps, and Coast Guard who receive health care at an Army MTF. Within the last two years, our medical readiness transformation [MRT] efforts have resulted in a dramatic increase in the total number of soldiers who are deployable and not limited by a medical condition.

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I do not look at this transformation in terms of disadvantages, only new approaches on how to continue to improve and optimize the integration of DOD readiness functions with the health care delivery functions within the military MTFs to support the warfighter’s readiness. Army Medicine is working closely with the DHA, the Army, and the other services to help lead and to shape the way forward for the entire Joint Health Service Enterprise.

You have talked about the success of Army Medicine’s approach to help reduce a soldier’s addiction to opioids or other pain medications. What are some of the pain management methods that are working in treating substanceuse disorders?

It is important to note that the incidence of opioid use disorder is considerably lower in the active-duty Army at 0.15 percent [fiscal year 2016 data], compared to 0.9 percent of the overall United States adult population. Additionally, opioid use peaked in the Army in 2012. Over the next four years, there was a reduction of more than 19 percent in the number of soldiers who were given one or more opioid prescriptions.

The Army Comprehensive Pain Management Program [CPMP] focuses on education, training, guidelines, and tools for providers and patients in order to accelerate the evolution of pain management practices to impact the national trend of over-reliance on opioid treatment of pain. Central to this initiative is the adoption and implementation of the Stepped Care Model for Pain. The model provides a standardized approach to pain care that emphasizes self-care and healthy lifestyle habits. Within the primary and secondary care levels, the model leverages primary care pain champions as well as internal behavioral health consultants and clinical pharmacists to assist providers in managing acute and chronic pain while minimizing the use of opioids. At the tertiary level of care, interdisciplinary management pain centers deliver holistic, multimodal pain management through the co-location of interventional, rehabilitative, and complementary and integrative health therapies. The combination of education and interdisciplinary care allows providers and patients to address pain with non-pharmacologic therapies such as physical therapy, acupuncture, movement therapy, biofeedback, and manual manipulation more, rather than reliance on opioids.

To improve access, continuity, and quality for substance abuse treatment, Army Medicine recently integrated substance abuse clinical services within our behavioral health system of care. This allows us to address co-occurring mental and physical illnesses with effective and evidence-based early intervention and therapy, including the use of MedicationAssisted Treatment [MAT].

This approach brings substance use, behavioral health, and primary care providers together to form teams organized around the patient. All providers now use the electronic health record to share information and coordinate

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care. Teams can better identify early and address co-occurring behavioral health conditions and physical illnesses in patients who are at risk of developing substance use disorders, such as becoming addicted to prescription opioids.

Substance Use Disorder [SUD] treatment integration has allowed Army Medicine to begin tracking patient risk and treatment outcomes targeted specifically for those with [an] SUD. Patient-reported assessments are collected as a part of routine care to inform clinical care, assist in multi-disciplinary planning, assess clinical progress throughout, and monitor treatment outcomes to include a decrease in addictive symptoms, such as physical cravings, and monitoring the potential for relapse.

Could you talk briefly about the Medical Hands-free Unified Broadcast, or MEDHUB, technology that is being tested at Regional Health Command-Atlantic?

The MEDHUB is a revolutionary capability increasing medical readiness through automated patient visibility.

MEDHUB automatically collects and transmits patient data and estimated time of arrival, over the DOD tactical network in real time, from the ambulance to the hospital, allowing the facility to alert, rally, and prepare providers for incoming patients. Developed by the U.S. Army Medical Research and Materiel Command [USAMRMC], this hands-free, voicefree medical device automatically documents and transmits, thus enabling the medic to spend more time treating patients.

The MEDHUB is being tested by the 44th Medical Brigade at Fort Bragg, informing medical providers at Womack Army Medical Center. The new Womack Emergency Room [ER] “Big Board” provides early and accurate trending vitals, drug doses, and mechanism of injury information to the staff, resulting in faster triage and seamless care upon reception. This developmental system is being designed for tactical evacuation units and hospitals supporting large-scale combat operations. Results from these tests and demonstrations will inform the final product decisions in FY 19. This program fills two gaps: providing accurate knowledge of incoming patients and providing accurate patient documentation prehospital for the patient’s electronic health records.

In a July 10 press release, the Food and Drug Administration (FDA) stated it supports the Defense Department’s emergency use of freeze-dried plasma (FDP) to initially control hemorrhage from battlefield trauma.

How will FDP usage affect frontline casualty care?

Freeze-dried plasma is a medical combat multiplier for frontline casualty care, and United States Army Medical Research and Materiel Command is pursuing a two-pronged approach to provide freeze-dried plasma to the battlefield.

FDP produced by a French military manufacturing facility is available to Special Operations Command under an Emergency Use Authorization [EUA] granted by the FDA on 10 July, filling the near-term gap for service members 37

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■■ Lt. Gen. Nadja Y. West, U.S. Army surgeon general and U.S. Army Medical Command commanding general, and others met at Fort Hunter

Liggett, California, to tour the 528th Hospital Center, Sept. 6, 2018.

U.S. ARMY PHOTO BY STAFF SGT. JUSTIN GEIGER

currently in harm’s way. To replace the French product, a commercially viable, U.S.-manufactured [Vascular Solutions Inc.] FDP is on schedule to be approved by the FDA in early calendar year 2019 for use where fresh-frozen plasma is unavailable [e.g., battlefield use], with full-use approval to follow upon completion of an additional clinical trial. The FDA’s decision will lead to the widespread availability of FDP, which is a significant step in addressing the leading cause of preventable battlefield deaths: uncontrolled bleeding.

The FDA has granted a “priority review designation” for the new antimalarial drug tafenoquine. What is the significance of the drug?

Tafenoquine [ARAKODA] was recently approved by the FDA on 8 Aug. It is the first new FDA-approved drug to prevent malaria in 20 years. Not only is it effective against all stages and species of malaria, but after a three-day loading dose, the drug only requires a weekly dose rather than a daily dose. No other FDA-approved anti-malarial drug can provide this protection, which is a substantial improvement over the current therapies and has the potential to contribute to

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malaria eradication. Availability of this drug will have significant impact on malaria worldwide.

Also, could you talk briefly about the roles the USAMRMC and the Walter Reed Army Institute of Research played in attaining this determination?

Tafenoquine [WR238,605] was first discovered and underwent pre-clinical testing in the Division of Experimental Therapeutics of the Walter Reed Army Institute of Research [WRAIR], a subordinate laboratory of the U.S. Army Medical Research and Materiel Command. Much of the clinical testing of the drug was conducted at or through WRAIR units outside of the continental U.S. Management of the advanced development of the drug to licensure was executed by the U.S. Army Medical Materiel Development Activity, another USAMRMC subordinate command, in partnership with 60 Degrees Pharmaceutical LLC., the ultimate sponsor and commercializer of the product. USAMRMC also played a significant role in assisting GlaxoSmithKline in achieving recent FDA approval of tafenoquine for the radical cure of Plasmodium vivax malaria [Krintafel] to replace primaquine.

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WEARABLE TECHNOLOGY On the threshold of clinical care

By Craig Collins n IT’S A STRANGE-SOUNDING NAME for a medical outfit, but the Penn Medicine Nudge Unit is just that: a unit that nudges. Director Mitesh Patel, M.D., MBA, M.S., and colleagues at the University of Pennsylvania’s Perelman School of Medicine design interventions that align patient behaviors and decision-making with long-term health goals: making the right choices obvious to patients, and making those choices easier to select.

As a primary care physician at the Corporal Michael J. Crescenz Veterans Affairs Medical Center in Philadelphia, Pennsylvania, Patel realizes that nudging patients – many of whom he sees only once or twice a year – toward healthy behavior is no simple task. “One of the challenges we often have,” he said, “is that we’re talking to patients about how they should be more physically active or lose weight, and about changing their behavior. But then they leave our office, and we don’t see them for six months or a year – or some longer period. And we don’t have any way to interact with them outside of the visit.”

Patel’s recent research has focused on monitoring patient activity and weight – often with the use of consumer fitness wearables from manufacturers such as Apple®, Fitbit, or Samsung – combined with incentives for behavior change.

“In most cases,” he said, “just giving someone a device and a smartphone is not effective in changing their behavior. But if you combine it with the right behavior change strategy, it can be really effective.”

In recent studies Patel led for the University of Pennsylvania, his team issued activity monitors to recently discharged heart patients and monitored their progress toward a target goal of activity. His studies have used both financial incentives – setting up a modest account and subtracting money when goals aren’t met – and “gamification” incentives, aimed at families who earn or lose points based on whether family members meet their goals.

His studies have shown that these structured behavior modifications, followed closely with wearable activity 40

monitors, can sustain behavior changes for up to six months, a vast improvement over patients who are simply given the monitors. “There’s a lot of good evidence to show that half of the people who get a wearable device stop using it within a couple of weeks to a month,” Patel said. He’s in the process of launching his first study to compare the effectiveness of these incentives among veterans who are overweight or obese, with a body mass index (BMI) of 25 or greater. His team will track step counts and minutes of moderate to vigorous physical activity among groups of veterans working with each incentive scheme, and compare outcomes.

Step counts and rates are fairly simple data for measuring physical activity, but Patel said that among consumer wearables, those are the only two measures he trusts for his purposes. “We’ve found they’re fairly good at tracking step counts,” he said. “But other studies have found that their monitoring of other things, like sleep and heart rate and calories, is actually not that great. The technology isn’t there yet.

You have to really trust the data in order to make use of it.”

It’s one of the biggest issues facing wearable technology today: Stories abound of wearable technologies on the threshold of revolutionizing treatments for certain diseases or disorders, but we’re not there yet, particularly in the area of medical-grade wearables designed to inform clinical decision-making. There are a few at work today: The Zio® wireless patch, a small adhesive patch that can be worn on the chest to monitor heart arrhythmias for up to two weeks, was cleared in 2011; four continuous glucose monitors (CGMs) have been cleared by the federal Food and Drug Administration (FDA) for use in monitoring diabetes. Last year KardiaBand, manufactured by AliveCor, became the first medical device accessory approved for the Apple Watch by the FDA, and several other devices – including a blood pressure monitoring smartwatch, a sleep apnea-monitoring Fitbit, and a wristband that will monitor a wider range of biometric information such as blood oxygen saturation and respiratory rate – are on the near horizon.

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■■ An Apple Watch®. In 2017, the KardiaBand became the first medical device accessory approved for the Apple Watch by the Food and

FANCYCRAVE1 VIA WIKIMEDIA COMMONS

Drug Administration. The device is a clinical-grade wearable EKG band that replaces the Apple Watch band, providing access to an EKG anytime, anywhere.

In the meantime, Department of Veterans Affairs (VA) researchers continue to explore how wearable devices might be used to improve patient care. At the VA’s Advanced Platform Technology (APT) Center in Cleveland, Ohio, clinicians and IT engineers work together to study how remote sensing can be used in rehabilitative medicine. Applications currently being developed by teams at the APT Center include: • A wearable sensor, part of a smoking cessation intervention, that captures hand-to-mouth smoking motions and is sophisticated enough to differentiate them from other movements (i.e., answering a phone call or drinking). The sensor cues the sending of tailored intervention video content to the relapsed smoker.

• A customizable cloth-like pressure sensor that can be inserted between the end of a residual amputated limb and a prosthetic. The sensor maps the pressure distribution, sends that data to a visualization system, and allows for prostheticians to redistribute forces that might lead to skin ulceration.

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• A “smart” wheelchair cushion that senses how hard and how long pressure is distributed over itself. With the use of algorithms that analyze pressure data, the cushion will alter its shape and stiffness in response.

• A wearable gait laboratory, an insole array of sensors that monitors slips and trip and falls in everyday environments through analysis of gait parameters, balance controls, and body postures.

APT investigators include Case Western Reserve University faculty members Rahila Ansari, M.D., M.S., an assistant professor of neurology, and Ming-Chun Huang, Ph.D., assistant professor of electrical engineering and computer science. Ansari is also a practicing neurologist at the Louis Stokes Cleveland VA Medical Center. According to Huang, a technology such as the wearable gait laboratory may be a useful tool for clinical evaluation, whether the data is gathered in the hospital or at home. “With the research and the data, we’re gathering,” he said, “we’re trying to accumulate 41

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■■ A Zio XT monitor in

knowledge to see how wearables might trigger effective interventions after an injury.”

An important distinction between many APT projects and most of the wearables available today, said Ansari, is that APT investigators hope to design “closed-loop” systems that take measurements, transmit that data into a control system that analyzes it using algorithms, and activate a mechanism that can take the necessary action. “For example,” she said, “if we’re dealing with a prosthetic limb or a wheelchair, then in order to prevent a breakdown or ulceration, we measure what the forces are, and then we’ll continuously adjust for all those things in real time, so we know we’re preventing problems.”

CLOSING THE LOOP: ALGORITHMS AND ANALYTICS

It’s these next-generation wearable sensing technologies – not devices but systems, of which devices are a component – that signify a transformation in the way doctors and patients interact. Their artificial intelligence will indicate not only what the data say, but what should be done in response.

Josef Stehlik, M.D., MPH, a professor at the University of Utah School of Medicine and cardiologist at the VA Salt Lake City Health Care System, specializes in patients with heart failure, a condition that involves high readmission rates among patients discharged from hospitals. In spring 2018, Stehlik’s research team reported the results from their study of a wearable monitoring system: “a Band-Aid-like patch,” he 42

said, “containing several sensors that detect patients’ physiological parameters.” One hundred veteran patients from four different VA medical facilities wore the monitors, which transmitted data using Bluetooth technology to their smartphones and tablets – which, in turn, uploaded the data to a secure VA server in Sacramento, California.

From there, data from Stehlik’s 100 veteran heart patients, including parameters such as heart rate, respiratory rate, posture, and activity, were fed into an algorithm that compared them to a previously established baseline for each patient. “This predictive algorithm was very accurate in identifying which patients were likely to get in trouble with heart failure exacerbation,” said Stehlik. For patients whose data were heading into dangerous territory, the analytics triggered an alarm that notified the research team. “We’ve also shown that this alarm would come approximately seven to 12 days before the readmission would happen,” Stehlik said. “So presumably, there would be sufficient time to do an intervention: contact the patient, change medications to treat the patient before the exacerbation progresses, on time to prevent a readmission.”

Now that his team has established the ability of the analytics to predict exacerbation for heart patients, Stehlik hopes to show how the data can be integrated usefully into cardiologists’ clinical workflow. “As you can imagine, a lot of clinicians have been bombarded by lots of different data.

It’s not just important to make data available – it needs to

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place on a woman’s chest and the Zio XT monitor. The wireless patch can be worn to monitor heart arrhythmias for up to two weeks.

IMAGE COURTESY OF DR. MING-CHUN HUANG, EECS CWRU

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be processed into an output so that clinicians can respond to it and provide the benefit of that information to the patient. That’s where I think a lot of research is necessary.” He hopes to conduct a trial among VA patients in which he can measure the clinical efficacy of the wearable monitoring system: whether the device paired with a predictive algorithm can reduce readmissions or shorten hospital stays for heart patients.

At the Daroff-Dell’Osso Ocular Motility Laboratory at the Cleveland VA Medical Center, neuroscientist Aasef Shaikh, M.D., Ph.D., a professor at Case Western Reserve University, is examining how sensors can be used to aid in diagnosing and differentiating among different tremor disorders that often present similarly. In the laboratory, Shaikh and his colleagues fit patients with sensors – wearable magnetometers with gyroscopes capable of taking fine 3-D positional readings.

Just as with Stehlik’s heart patients, this data has been fed into specifically formulated algorithms to distinguish one type of tremor – for example, cervical dystonia, essential tremor, or Parkinsonian tremor – from another.

These assessments currently happen in Shaikh’s lab, but he and his team are developing mobile versions of the sensor that will be able to transmit data wirelessly. “The key thing here,” he said, “is that now we can use wearable technology and machine learning, artificial intelligence, to analyze the output of those wearables to provide better diagnostics – and better care – for the patient.”

Shaikh’s ambition is to develop a closed-loop system that may become directly involved in providing care for tremors. Deep brain stimulation (DBS), a method of dampening muscleactivating signals from the thalamus, is achieved among tremor patients through surgery, in which electrodes are implanted into the thalamus and connected to a generator – Shaikh describes it as a “pacemaker for the brain” – that can block tremor-inducing impulses.

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■■ A graphic depicting an interpretation of the “Internet of Wearable Things.”

With a wearable sensor that can detect the tremor, and an algorithm that can distinguish the tremor type, the system would be capable of applying DBS to relieve the patient’s symptoms.

THE FUTURE: THE INTERNET OF WEARABLE THINGS, BIG DATA, AND DOCTORS

Closed-loop systems with wearable technology may be the key to offering real-time interventions for patients with burdensome conditions that require constant vigilance. Huang, Ansari, and their colleagues at the APT Center, for example, are looking to close the loop for patients at constant risk of having their skin integrity compromised: patients who wear prosthetics or use wheelchairs. If Shaikh can close the loop for tremor patients, he can offer them a degree of relief they’ve never known.

For nearly two decades, people with insulin-dependent diabetes have been

using continuous glucose monitors (CGMs): Wearable sensors that detect glucose levels in the intracellular fluid just under the skin, transmit readings wirelessly to receivers or smartphones, and cue patients to take steps such as adjusting insulin or boosting their blood sugar levels. The CGM loop was closed in the fall of 2016, when the FDA approved the first hybrid closed-loop CGM system, Medtronic’s MiniMed670G, that collects and analyzes glucose data with sophisticated algorithms that determine both the timing and amount of insulin needed by the patient. When the system is placed in auto mode, data is used to trigger a small insulin pump for calculated delivery of insulin.

Brian Layden, M.D., Ph.D., associate professor of medicine at the University of Illinois at Chicago and an endocrinologist with the Jesse Brown Veterans Affairs Medical Center, said the closedloop CGM is useful for people with 43

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Type 1 diabetes, the autoimmune form that often requires patients to inject insulin several times daily. “Type 1 diabetes is increasing, but not dramatically. It only represents about 5 percent of our diabetes cases now.” The vast majority of Layden’s patients, particularly older veterans, have the more lifestyle-dependent Type 2 diabetes, which is often treated with oral medications.

Casual observers may notice an important element missing from this loop: the physician. But when clinicians such as Ansari and Shaikh talk about closing the loop, they’re not talking about making themselves obsolete; they’re acknowledging the impossibility of monitoring and delivering health care around the clock. Layden spends plenty of time with patients – both those with Type 1 and Type 2 diabetes – and is intimately involved in their care. Said Huang: “We don’t want patients to feel as if, once they’re given a technology, they’ll rely on that and never meet with the doctor anymore or do therapy.”

Ansari foresees the next generation of wearable monitors, and even closedloop systems, as complementary to physicians’ care. “My thought as a physician,” she said, “is that it will help improve patients’ relationships with their doctors.” Her migraine patients, for example, often have difficulty documenting symptoms in their prescribed headache diaries. “If there were a way to automatically sense that, or if we were able to find a way to have patients input data with the click of a button, all of the sudden that improves the doctor/ patient relationship and makes it so much easier for us to give the advice they’re going to need to improve their migraines, or whatever else is going on.”

When he looks to the future, Huang, the computer scientist, envisions an “Internet of Wearable Things” that not only assists in the care of individual patients, but also forms pools of data that can be studied and mined by research physicians – essentially combining the data collected by wearables with environmental context to improve clinical care in the same way map applications crunch

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■■ This hybrid insulin pump/glucose sensor closed-loop device collects and analyzes glucose

data and self-adjusts to keep sugar levels for the wearer in range.

constant streams of user data to recommend the best routes for other users.

Such an approach, he realizes, raises important questions about the security of patient data, particularly when it’s being processed by an artificial intelligence to perform big-picture analyses. “That makes it more complicated to protect the data itself,” he said. “Of course, some people say we should never share that data, but that contradicts our vision of the Internet of Wearable Things – that we can use that data from sensors to improve other people’s lives.”

When the next generation of wearables begins to affect patient care – and perhaps collect data that can be aggregated for big-picture analysis – this concern will become paramount, Ansari cautions. If doctors and researchers are collecting mountains of data about

patients, there will need to be safeguards in place to keep patient-specific data out of the hands of third parties with other motivations, such as employers or insurers. “These are some questions we don’t necessarily have the answers to right now,” she said, “but I think we’re going to have to sort [them] out as time goes on.”

Still, she sees the next generation of wearables as inevitable – and welcome – tools for improving patient care, which is why she’s devoted so much time and effort to investigations at the VA’s Advanced Platform Technology Center. “As these technologies grow and we get even a better understanding of how we’re able to use them,” she said, “I think we’re going to be able to get a lot more holistic and well-rounded care provided to our patients.”

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PTRUMP16 VIA WIKIMEDIA COMMONS

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

■■ An X-ray of the right knee.

Knee and shoulder cases represent a high percentage of VA orthopedic clinic visits.

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

ORTHOPEDICS

By J.R. Wilson n ONE OF THE FASTEST-GROWING medical specialties is orthopedics, with growing public awareness since the war in Southwest Asia began at the start of the century. That war’s signature improvised explosive devices (IEDs), combined with advanced body armor protecting the warfighter’s torso – but not arms and legs – has led to both tremendous advances in the saving of severely damaged limbs and a stunning revolution in prosthetics for those whose limbs could not be saved.

But advances also have been seen in non-prosthetic-related orthopedic surgeries and treatments, within military medicine but even more substantially within the Veterans Health Administration (VHA) and the nation’s growing population of veterans. While bolstered by some 3.5 million mostly young veterans from nearly two decades of combat in Iraq and Afghanistan, it is the aging Vietnam-era cohort of more than 2 million veterans that is increasing the demand on VHA orthopedic care.

“In FY 17, we performed 815,000 surgical clinic visits and 56,116 non-surgical orthopedic cases; 21,000 of those – 38 percent – were in-patient. Probably 25 percent of what we do is joint replacements – hip replacements totaled 4,639 last year, along with 9,628 knee replacements. The other 75 percent are largely arthroscopy of the knee and shoulder,” noted Dr. William Gunnar, the VHA’s national director of surgery.

“It’s really a remarkable amount of surgery. The median wait time from scheduling to completion was 26 days for hips; 49 percent of knees were performed within 30 days of scheduling, which is when the patient and doctor are ready to move forward. We’re not trauma centers. We have an older patient population compared to the DOD [Department of

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Defense] and tend not to have traumatic injuries; we deal primarily with degenerative joint disease.”

Gunnar said the Department of Veterans Affairs (VA) is well resourced to provide timely and high-quality orthopedic surgery, whether at one of approximately 100 facilities or authorized in the community at non-VA centers.

“People forget how large we are; the statistics are stunning. The VHA surgery program is located at 137 facilities; 110 are in patient and the rest ambulatory. We see 6.5 million clinic visits, perform 3.2 million consults, and, in our 870 ORs [operating rooms], perform 420,000 surgical procedures a year,” he said.

In 1996, the VA performed a total of 5,423 hip and knee replacements at 97 facilities. In 2017, that number had ballooned to 14,267 carried out at 98 facilities.

“So, there has been a tripling of the case volume in the last two decades, treated by the same number of facilities,” he remarked. “In FY 17, we outsourced 5,000 cases for community care services in orthopedic surgery for in-patient procedures, presumably joint replacements. From a surgical perspective, we outsourced about 20 percent of our caseload in 2014, bumped up to 26 percent, then returned to 20 percent within a couple of years. Of the 56,000 cases we did in FY 17, 21,298 were in patient.”

The number of women in combat situations, fighting wars with no defined front lines, also increased significantly since 9/11, leading to a corresponding increase in female veterans.

However, Gunnar reported the number of women the VA sees for joint replacement surgery is still small, with 93 percent of all hip and knee replacement patients being male, with an average age of 65.

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

PHOTO BY DERRICK CRAWFORD, 5TH MEDICAL RECRUITING BATTALION

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

The older age of VHA orthopedic patients means there are more complications due to other medical conditions and a longer recovery time, both of which increase the demand on VHA medical centers and clinical personnel.

“Older patients may need a considerable workup that requires various medical specialists, typically including cardiologists, to prepare them for the OR to ensure the risk can be optimized and known. That time is variable. The Choice Act requires whenever we can’t provide services within 30 days, it is referred to community care,” he explained.

“That said, we hold ourselves to once the individual is ready to be scheduled, the clock starts for us. Often the veteran will not want to be scheduled, especially for an elective, within 30 days but perhaps three months from now. We still track and include those in our median time.”

The Veterans’ Access to Care through Choice, Accountability, and Transparency Act of 2014 provided primary care, in-patient and out-patient specialty and mental health care for eligible veterans when the local VA health care facility could not provide the services due to a lack of available VA specialists, long wait times, or extraordinary distance from the veteran’s home. Due to run out of funds, it was replaced in June 2018 when President Donald Trump signed the VA Mission Act, which also expanded caregiver assistance to the families of disabled veterans, extended

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■■ U.S. Army Reserve Col. Paul Phillips III (left), a member of the

orthopedic surgery team at Hill Country Memorial Medical Group in Fredericksburg, Texas, explains X-ray results to patient Don Huston and his wife, Alice, during a clinic visit March 14, 2018.

coverage to all veterans (not just those with post-9/11 medical needs), and eliminated the Choice Act’s 30-day/40-mile restrictions.

Although DOD is responsible for the health care of activeduty military personnel and the VA for veterans, the two massive care systems cooperate and share physicians and facilities in a number of locations around the country.

“Once someone transitions to veteran status and is enrolled in the VA and signed up at one of our facilities, depending on the environment, there may be some cross-collaboration. Those are managed locally between the VA and DOD facilities,” Gunnar said. “For instance, [the] Sacramento VA [Medical Center] has a relationship with David Grant Medical Center at Travis AFB [Air Force Base], where clinicians from both DOD and the VA operate together. Orthopedic care at our Anchorage VA [Healthcare System] is done by a collaboration of DOD and VA orthopedists at Elmendorf AFB. That also is true in Honolulu.”

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DOD’s top medical care center is the Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland, which both treats military patients and conducts research into new approaches to care and rehabilitation.

Walter Reed’s Orthopedics and Rehabilitation Center offers a wide range of services, including: • physical medicine and rehabilitation • occupational therapy • physical therapy • amputee care • orthotics and prosthetics • orthopaedic surgery • traumatic brain injury • chiropractic “Board-certified, trained specialists address the full spectrum of orthopedic musculoskeletal concerns, from pain management and sports medicine to total joint replacement. … State-of-the-art equipment, facilities, and techniques are used in arthroscopic and open musculoskeletal repair, reconstruction, and joint replacement,” the facility’s website states. “WRNMMC also participates in research in the advancement of orthopedic care, evaluating cartilage growth and transplantation to arthritic knees.

“Specialists in hand, upper extremity, and microvascular surgery treat common and complex conditions, including traumatic, degenerative, congenital, and overuse/repetitive

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■■ Aging Vietnam veterans are one cohort that is driving the increase

in demand for VHA orthopedic care, particularly orthopedic surgeons.

motion injuries. Foot, ankle, and adult-reconstructive surgeons perform joint reconstruction, replacement, and revision. Physical therapists and technicians provide expert knowledge, resources, and guidance in the treatment and prevention of recurrent injuries.

The nationwide doctor shortage (see “Staff Shortages” on page 52) is most severe among specialists, including orthopedic surgeons, and has added to the pressures on VA facilities to meet patient needs in a timely manner.

“Obviously, any given environment or any of our 137 programs may struggle with hiring. There are processes to work through that, whether hiring full-time employees with benefits or through a contractual relationship. There is a host of options for hiring surgeons,” Gunnar said. “That doesn’t mean there may not be challenges at any given facility.

“But, as a whole, I see a rising number of cases at the facilities we have and our timeliness standards are reasonable, so if I lose an orthopedic surgeon at one facility, I have the option to outsource that care to the community and the patient can either wait or be referred to the community. Often they stay with the VA, because they like their doctors.”

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

STAFF SHORTAGES VHA faces a unique set of recruitment and retention challenges.

By J.R. Wilson n THE VETERANS HEALTH ADMINISTRATION (VHA) is the nation’s largest health care provider, servicing millions of veterans ranging in age from late teens to late 90s – nearly 5 million of whom live in rural and highly rural areas. With a nationwide shortage of doctors and nurses, VHA also holds the numerical lead in shortages of primary care physicians, mental health professionals, registered nurses, licensed practical nurses (LPNs), etc.

But raw numbers can be deceiving.

“Our recruitment challenges mirror private-industry health care. There is an overall shortage in physicians and nurses, [and] our hiring needs are greater than anyone else’s.

Due to our sheer size, our vacancy numbers do appear large, but there is always a shortage because everyone is competing for the same pool of people,” according to David Perry, acting chief officer for VHA Workforce Management & Consulting.

“Each year we identify the staffing shortages, both clinical and non-clinical. And every year, nurses, LPNs, pharmacists, and especially diagnostic radiology technicians are the ones we focus on as primary hiring needs. These shortages are in both full- and part-time staff. So, recruitment is our primary challenge. But our vacancy numbers are just one piece of a larger puzzle.”

For the VHA, that challenge is more complicated than just competing with all other health care groups, especially when it comes to finding enough of the right specialties to deal with their far-flung rural cohort.

“It’s hard to find [specialists] in the rural areas or to get those we recruit to work in those areas. There also are challenges in the higher urban areas as we compete against 52

universities, large health care providers, etc., with a limited resource from a budget perspective in terms of what we can pay,” he explained.

“Our pay scales are comparable until you get into some highly specialized disciplines, such as cardiology, so we look at ways to share resources, such as interim staffing providers and shared resources. We just can’t get to what they can make in the private sector, so we have to be creative in other ways. We can use the Mission Act to leverage community care to help offset some of those gaps.”

The VA Mission Act of 2018 provides for community care for veterans otherwise entitled to VA care that cannot be scheduled in a timely manner to avoid lapses in health care services and ensure continuity of care, to provide care where traditional VA services are more than 40 miles away, or if a veteran’s referring clinician believes furnishing care or services in the community would be in the veteran’s best medical interest.

Another partial solution to the problem of serving patients in rural areas is a technology in which the VA has been a leader: telemedicine, wherein patients are introduced to easy-to-operate equipment to check blood pressure and perform other basic monitoring tasks at home, the results of which are then transmitted to a doctor who could be anywhere in the country. In some cases, doctors also can consult with patients by phone or computer video while checking those vitals in real time.

“It helps in areas where we’re having difficulty recruiting, so someone in a bigger population center can provide telehealth to a rural area,” Perry explained. “That compensates where we are not able to put people in remote physical locations.”

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

■■ According to a VHA annual report, psychologist, medical technologist, medical officer, nurse, and physician assistant are the top five

most-needed clinical occupations.

Another issue that may be a problem in the future is getting young people to take the difficult path of medical school – and the more difficult one of specialization. While medical school enrollments have been on the rise, funding shortages have been reducing the number of available residencies for more than 20 years.

That compounds another growing problem – nearly half of all physicians practicing today are 55 or older. Given that it takes a decade or more to complete undergraduate pre-med, then medical school, then an internship and a residency, even if only half of those doctors retire at age 65, there would not be enough new doctors in the pipeline to replace them. As a result, a study released this summer by the Association of American Medical Colleges predicts that by 2030, the United States will face a shortage of between 42,600 and 121,300 physicians.

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“The Mission Act, in particular, was set out to help us come up with different ways to increase the number of people enrolled in medical school. However, from our perspective, there’s nothing I’m aware of that is helping drive medical students into specialty areas, and we’re not in a position to steer that conversation. But there does need to be some thought put into that, perhaps through our affiliate program, but that is a broader question than just the VA; it’s impacting health care nationwide,” Perry said.

“Another thing we’re leaning on is the increased utilization of our affiliates and leveraging their staff at some of our larger facilities as another stop-gap measure. We’re also looking at our J1 [non-citizen medical providers] population. There are two segments: foreign-born doctors who are citizens, and those in our J1 program, who are considered for employment after all other efforts to recruit have not been successful.”

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Since 2014, the VHA’s Office of Inspector General has issued an annual report – “Determination of Veterans Health Administration’s Occupational Staffing Shortages” – in an effort to determine the status of staff shortages across the VHA’s various medical centers. While the FY 18 report followed a different set of rules than the four previous studies, the top five critical-need clinical occupations – especially the top two – have remained relatively consistent: medical officer, nurse, psychologist, physician assistant, and medical technologist.

Despite overall shortages, especially in rural areas, the VHA also has the nation’s highest growth rate for physicians and other clinical staff. Their reported vacancies in all sectors total about 10 percent, which Perry said is good compared to the private sector, where vacancy rates can run as high as 30 percent.

“For primary care, I have a 1 percent vacancy rate, which is incredible. Our specialties are the highest vacancies, but that varies by region,” he added. “Our nurse vacancy rate is about 9.4 percent out of 100,000 RNs, LPNs, CRNAs [certified registered nurse anesthetists], etc., so that’s a pretty good rate, as well.”

The VHA also is more susceptible to changing demographics in their patient population than most health care providers. The largest population in VA history – World War II veterans – is almost gone; of 16 million Americans who served in World War II, only about half a million were still alive in mid-2018. The largest group today are those who served in the post-9/11 military; the VA projects that veteran population will be just under 3.5 million by 2019 – and still growing. They have now surpassed the surviving veterans of the Vietnam War (1961-1975), estimated at more than 2 million.

“We are growing every year in terms of the number of veterans we have to care for, plus an aging population with increasing care needs. And as you age, you go to a more geriatric focus, which shifts the demographics of the workforce we need from other specialties. But we are not seeing the same growth in the resources we need,” Perry said.

“In the last 10 years, we’ve grown by 100,000 employees and average 2 to 4 percent growth every year. During that same period, the number of veterans also has increased. Our veteran enrollment projection right now is 3 percent between now and 2026, especially long-term services and support and priority 1-A enrollees. The driver there is the Vietnam veteran population as they age and what gets covered and is considered a service-connected disability.”

Despite growth and shortage rates Perry said compare favorably to the overall health care industry, the VA continues to seek ways to improve its recruitment and retention numbers.

“About 70 percent of doctors receive their residency training in a VA facility, which is our biggest pipeline. Those medical schools are our affiliates, and we work with them to

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■■ Beverly Buchanan, a nurse educator at the William Jennings Bryan

Dorn VA Medical Center in Columbia, South Carolina, prepares to instruct staff. Buchanan was selected as one of the spokespersons for the 2017 Go Red for Women® “Real Women” by the American Heart Association. An Army veteran, she is also a heart disease survivor, having undergone open heart surgery in 2012.

maximize recruitment. We have a targeted focus on mental health and this year have had a positive gain of more than 500 mental health professionals. [From January through August 2018], we have hired 2,400 mental health professionals, including those 500 that are a positive increase. That’s new positions in a very tough recruitment market. In other areas, the number of total hires to new position growth is roughly 2- or 3-to-1.

“We try to maximize salaries, our relocation incentive, our Education Debt Reduction [EDR] program – which increased from $120,000 to up to a $200,000 loan reimbursement. The results of the EDR have been outstanding, one of our best recruitment and retention tools. In FY 18, we had a little 55

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The first study, “Cost minimisation analysis of thermometry in two different hospital systems [1] ,” was conducted at University Hospital Centre Zagreb (UHCZ) and University of Michigan Hospitals (UMH), each of which used the Exergen TAT-5000 to evaluate cost savings. Results dramatically favored TAT over tympanic thermometry at UHCZ, where the cost of consumables per measurement would be more than 10 times cheaper for TAT, leading to considerable budget savings within a year of hospital-wide implementation. The UMH study concluded that routine use of Exergen TAT-5000 would lead to cost savings over three years at UMH. The second study, “Minimising the costs of temperature monitoring in hospitals [2] ,” revealed that Exergen TAT-5000 savings exceeded $1.7 million when there were 10 beds per device used for five years. In addition, the study indicated that other forms of thermometry such as oral, axillary and rectal are not favored by hospital staff due to numerous factors including time commitment needed from the healthcare provider, patient discomfort and the potential to wake a sleeping patient.

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

■■ Seen here is the Department of Veterans Affairs Ann Arbor Healthcare System medical facility. Nationwide there is a shortage of doctors

PHOTO BY SUSAN MONTGOMERY

and nurses. Each year the VHA’s clinical and non-clinical hiring needs are greatest among nurses, licensed practical nurses, pharmacists, and diagnostic radiology technicians.

more than 1,200 participating and our forecast for FY 19 is about 1,500. The program applies to clinical physicians, but any categories that are in the top 10 critical occupations are eligible. That includes mental health, nurses, etc., so long as they are involved in patient care. We do nationally targeted advertising campaigns, are expanding our efforts in telemedicine, and are working to transition medical professionals coming out of the military to work in the VA.” In recent years, the VA has come under fire for long wait times for veterans to see doctors or schedule procedures, but Perry said a lot of progress has been made in the past five years, thanks to changes in how care is gauged.

“Staffing shortages are not an indicator of performance or impact on wait times,” he said. “Outcomes for access, quality, and satisfaction scores we see are the areas we focus on. For 2018, through June, our average wait time for primary care was 4.5 days, 8 days for specialty care, and just 3.7 days for mental health care. Same-day service in urgent care is not included, just normal scheduled appointments.

“The data we were looking at five years ago had lots of variations, and we were not held to consistent standards or monitoring, so the numbers varied widely by area. In 2014, there

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was a concerted effort to make access a key driver and priority; the results we see today are because of that.”

Perry has a very positive outlook on the VHA’s future in terms of both the speed and quality of care it will be able to provide a still-growing and diverse veteran population and the number of physicians and other clinical care professionals the organization will be able to field, although the raw numbers, taken out of context, still may cause concern and criticism. And if it does begin to see truly negative results, “we will look for ways to deal with those.

“If we continue on the trajectory we’re on now with our growth, I think the vacancy numbers will correspond to that growth. If I add another 10,000 physicians next year and have a 10 percent vacancy rate now, I can expect to see that vacancy rate grow as well. My focus is on looking at the outcomes on which we measure true success,” he concluded.

“How we focus on the care we deliver is the most important issue. We have a shift in demographics, with an aging population, and a shift in care coverage. Making sure we focus on the right measures is the best way to deliver on how we provide the care and services expected of us.”

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A PATH TO INDEPENDENCE The U.S. Army Wounded Warrior Program

By Eric Tegler n THE U.S. ARMY’S WOUNDED WARRIOR (AW2) program has continually evolved over the years. From an initiative to help severely wounded combat casualties of the wars in Iraq and Afghanistan access support services, to a broader effort aimed at all critically wounded, injured, or ill soldiers, AW2 has been a model of America’s commitment to its warfighters.

It’s a model that needs continuous tweaking, said Reginald Coffey. Coffey is the chief of Recovery Care Division for AW2 and he views the program as a tool to foster soldier progress.

“When I first came to AW2, clients were basically here for life,” he explained. “We had a motto, ‘AW2 for Life.’ It’s a phrase I disliked, because it was a duplication of the role, mission, and purpose of the Department of Veterans Affairs [VA].

“Our mission is to be a transitional facilitator, to get individuals back into the fight or to transition them to civilian life as smoothly and seamlessly as possible – today we say we have a ‘path to independence.’”

WHAT IS AW2?

For critically wounded, injured, or ill soldiers, the Army Wounded Warrior program is akin to being one of two lanes on the path to independence.

One lane is the broadly medical treatment and recovery of the soldier, managed and administrated by Army Medical Command and its medical facilities.

AW2 is the other lane, in which the non-clinical needs of the soldier or veteran – financial support, adaptive living equipment, education, and career transition support – are addressed

by AW2 recovery care coordinators (RCCs) whose role is to ensure that these non-clinical needs are met, for both soldiers and their caregivers.

“This is the Army’s effort to take care of those most critically injured in combat and beyond,” says AW2 Director Col. Terrance J. Johnson. A career infantry officer with senior positions at U.S. Africa Command in Germany and with the U.S. embassy in the Democratic Republic of the Congo, Johnson took over as AW2 director in July 2017.

“Over 95 percent of these soldiers will never return to the line. Most will transition to veteran status. We take care of their transition, ensuring that it is smooth by taking care 58

of the individual’s non-clinical case management needs, working in conjunction with the Veterans Administration,” Johnson said.

AW2 is essentially a passage for critically wounded, injured, or ill soldiers that bridges their separation from active-duty support (if necessary) to long-term VA support.

Though the two are often confused, AW2 is not connected with the private-sector Wounded Warrior Project charity.

Rather, AW2 is one of four appropriated Department of Defense (DOD) wounded warrior programs established in 2004 to transition critically wounded service members from the wars in Afghanistan and Iraq from military service to civilian life. Its counterparts are the Marines’ Wounded Warrior Regiment, the Navy’s Safe Harbor, and the Air Force Wounded Warrior Program (AFW2).

The Army’s program began life on April 30, 2004, as the Disabled Soldier Support System Initiative. A little over a year later, it became known as AW2. Initially, AW2 was limited to those who suffered disabling wounds in combat, many of whom were returning from U.S. theaters of operation in the mid-2000s. Over time, the Army realized that soldiers face significant risks – and consequently severe injuries and illness – outside of combat.

“It became apparent that a soldier who endures an amputation as a result of combat or from a training accident, or even a car accident, still has the same requirements,” Reginald Coffey said. “So, we changed the rules of eligibility, which now allow us to treat all soldiers the same.”

Coffey, who joined AW2 in 2009 after serving as an Army patient administration officer, emphasizes that AW2 is a dynamic program, constantly evolving based on demand, soldier input, and other influences.

“In 2007, I was at Walter Reed [Army Hospital] with the honor and privilege of being in the military leadership group that was escorting President [George W.] Bush,” Coffey said.

“He was talking to some wounded warrior amputees. He said to one, ‘How can I help you?’ The soldier replied, ‘Sir, I’d like to stay in the Army.’ Now traditionally, amputees were transitioned out, very few got to stay. But with a vocal [directive] the president changed our policies. We incorporated

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AW2 PHOTO

■■ COAD soldier Staff Sgt. Oscar Guerra meets with his AW2 Advocate, Command Sgt. Maj. (Ret.) Timothy Battle.

this guidance into the existing Army regulation on Active Duty or Active Reserve (COAD/COAR) status – continuation which allows soldiers with those types of critical conditions to apply to stay on active duty status or active reserve status.”

The inclusion of these types of severe wounds and injuries into AR 635-40 COAD/COAR was not only a departure from the early stages of AW2, but from decades of pre-9/11 policy under which critically wounded soldiers were almost automatically separated from the service. It has paid dividends in numerous cases. A great example is Col. Greg Gadson, a double above-the-knee amputee who lost his limbs to an IED in Baghdad in 2007. Gadson returned to serve the Army effectively, both as the third director of AW2 and later as the commanding officer of the Army garrison at Fort Belvoir, Virginia.

AW2 has undergone further changes over the years, including re-framing itself in 2016 as a transition organization rather than a long-term support service that duplicated the VA.

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“At one point we had an unsustainable number [of wounded],” Johnson said. “There was a directive to take care of soldiers for life, to contact every single wounded warrior – tens of thousands – every month. Unfortunately, that required a structure too large to sustain. The biggest change has been the development of the phased approach to care, which began about two years ago.”

HOW IT WORKS

The Army Wounded Warrior program is a directorate, subordinate to the service’s Warrior Care and Transition Program (WCT), which reports to the Army Medical Command commander and surgeon general, Lt. Gen. Nadja Y. West.

“We’re like the WCT line unit,” Johnson explained. “We have the folks who touch the wounded warriors on a daily basis. They’re in the Warrior Transition Battalions, they’re in 59

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■■ Spc. (Ret.) Emmanuel Adame with his spouse, Monique, and daughter, Luna. Spc. Adame was nominated to Operation Homefront, a nonprofit

every major VA medical center in the country. We have an advocate in Landstuhl, Germany, one in Puerto Rico, two in Hawaii. They give one-on-one counseling to our clients and their families about their non-clinical needs.”

Wounded, injured, or ill soldiers typically (though not universally) move through stages including notification/evacuation, medical care and medical board evaluation, and reintegration with or transition from the Army.

Soldiers going through the process may go to one of the Army’s warrior transition units (WTUs). WTUs are organized much like Army battalion units, but soldier medical care and healing is their core mission. There are 14 WTUs at Army bases and medical facilities in the continental United States and Hawaii. Each WTU has a resident AW2 recovery care coordinator (RCC), or Advocate. Advocates are also stationed at major VA medical centers and a number of Army bases.

Once admitted to a WTU, each soldier is assigned an AW2 RCC. While RCC is the formal nomenclature, “RCC” and “Advocate” can be used interchangeably. Each of AW2’s 136 specialists truly “advocates” for the soldier and their family/ caregiver.

To be considered eligible for AW2, a soldier must be expected to receive at least a 30 percent Army disability rating from the Integrated Disability Evaluation System (IDES) for 60

one of the following conditions: • Blindness or severe loss of vision • Loss of limb • Hearing loss or deafness • Burns or permanent disfigurement • Paralysis/spinal cord injury • Traumatic brain injury (TBI) • Fatal and incurable disease with limited life expectancy of one year or less Soldiers who receive a 30 percent IDES disability rating for any other combat-related condition or condition caused by an instrumentality of war like post-traumatic stress disorder (PTSD) or other behavioral health conditions are eligible too. Likewise, those who receive a combined 50 percent disability rating for any other combat-related conditions or conditions caused by an instrumentality of war can be admitted to AW2.

AW2 Advocates ensure that soldiers and their families/ caregivers leverage the financial and other services available to them. Naturally, soldiers and their families are not experts in an array of services, including Servicemembers Group Life Insurance, combat pay or Social Security benefits. Johnson also points out that while the soldier’s priority is to heal, many can’t devote their focus to it unless their

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AW2 PHOTO

organization, by his AW2 Advocate, Paul Sanchez, and received a much-needed new automobile for he and his family.

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“If a service member has a family without a car or a reliable place to stay, they are very concerned about the family.

They’re going to take care of family first. The Army medical system takes care of all of the patient’s needs. Who’s taking care of the family?”

AW2 Advocates do it, proactively. If a soldier qualifies for AW2, his/her Advocate identifies resources like the Special Compensation for Assistance with Activities of Daily Living (SCAADL) program, which provides payments to caregivers while the service member is still active, then transitions them to the VA Caregiver program.

It’s worth pointing out that the needs of a particular soldier and the needs of the Army may not always coincide. AW2 is noteworthy because its advocacy is trained solely on the soldier. “Our objective is to facilitate that soldier identifying and achieving his/her identified goals and objectives. To live their lives to the fullest extent possible based on their new norm,” Coffey said.

“We’re in the trenches doing what’s best for the soldier, his/ her family, or caregiver,” Coffey said. “That’s not always what the Army wants, but it’s what the soldier needs. The Army may want to keep the soldier active, but the individual wants to move on to something else. It’s all about assisting the soldier or veteran in achieving their goals and objectives. If those include continuation of service, we say ‘Hooah!’ If he or she decides it’s time to transition and become a productive member of the civilian community, we say ‘Hooah!’ and facilitate that process.”

The AW2 process works in stages, formally called the lifecycle case management phase (LCMP). LCMP is broken into four stages, which hinge on assessment, engagement, and time. In LCMP 1, the soldier and advocate have an initial consultation/assessment, typically while the soldier is an in-patient. Advocates follow up every 30 days. In LCMP 2, contact and assessment are made every 90 days. The third stage mandates contact/assessment every 180 days, and finally, soldiers enter LCMP 4, the lifetime or alumni phase of AW2.

Case management is broken down in this fashion both to facilitate a solder’s path to independence and to account for the inevitable differences in progress among individuals and their support systems.

“Two soldiers with the exact same injury or illness can have recovery and transition needs that are totally different,” Coffey said. AW2’s goal is to get soldiers back into the force or facilitate their transition to civilian life within 365 days or as soon as possible based on their condition and needs, although Advocate support lasts beyond that period.

On average, soldiers spend 18 months in the program, during which AW2 makes sure the soldier has no core disruptive issues (housing, income, health care, VA benefits, community integration).

“If they are on that path to independence, they have to go through at least two lifecycle phases before we put them in

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the Alumni program,” Johnson said. “That’s when we stop bothering them. They have a reasonable level of independence, but they can always reach back to us.”

Part of that independence includes gainful employment, and AW2 works to help transitioning soldiers find training, internships, and employment, along with broader DOD transition programs like Operation Warfighter. Along the way, AW2 also educates potential employers about the specific talents and needs of wounded warriors.

“America is a country where the spirit of goodwill is unending,” Coffey said. “Employers want to give, but we have to educate them about what they’re signing up for.”

While employed, soldiers may have to take time off for continued medical care. Some, with conditions like PTSD, may need special accommodation, like non-cubicle workspaces or temporary quiet spaces.

“You’d be amazed at how flexible employers will make themselves for these wounded warriors,” Coffey added.

“That’s what allows our program to do what I think is the best job any generation has experienced with post-injury care for our soldiers.”

Once a wounded warrior has entered the Alumni phase of AW2, they have medically retired and transitioned to the VA system. But veterans can always reach back to an AW2 Advocate for additional support.

READINESS, NOW AND IN THE FUTURE

You might think that the Army Wounded Warrior program really only affects soldiers who’ve left the line – but you’d be wrong.

Johnson points out that the AW2 director position is a combat-arms dedicated billet. In part, that helps wounded warriors recognize that AW2 leaders have also been on the line, and in several cases, wounded themselves. In addition, it lends gravitas to the outreach that AW2 does with the active Army.

“Any time I’m on an installation, I try to engage at the brigade combat team level. We meet over lunch or coffee and I tell them that, while they may not be familiar with it, this program is great. It goes back to the Army’s No. 1 priority: readiness. It gives confidence to healthy soldiers on the line because if something happens, they’re aware of a program that takes care of them and their families. It improves morale, which is critically important.”

While boosting morale, AW2 simultaneously takes the burden of post-injury non-medical support off the operations, logistics, or support unit from which a soldier came. In the past, such a burden distracted from core readiness.

Johnson and AW2 Sgt. Maj. Thomas C. Abbott Sr., set out last year to reach AW2 locations in 40 states and three overseas posts during their tenure with the program. Whether they’re at an Army installation, a hospital, or a community institution, 61

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■■ Sgt. Steven Wurth, a participant in the Warrior Games, tests the route during course orientation, Colorado Springs, Colorado, May 28, 2018.

U.S. ARMY PHOTO BY STAFF SGT. KALIE FRANTZ

The DOD Warrior Games is an adaptive sports competition for wounded, ill, and injured service members and veterans. AW2’s objective is to support wounded soldiers in living their lives to the fullest extent possible based on their situation.

they’re seeking to raise awareness of AW2 and how it serves wounded warriors, the service, and American society.

As noted, AW2 is a continually evolving program. As its emphasis and processes have changed, so too has the environment in which it operates. When the program launched in 2004, America had just begun its hard-fought campaigns in the Middle East. Over time, the intensity of U.S. military engagements has thankfully decreased.

That has implications for AW2, which is adjusting to meet demand.

“We started with a handful of Advocates supporting 340 severely wounded soldiers,” Coffey said. “By 2012, we had 247 Advocates supporting 25,000-plus wounded, ill, and injured.

Now, we’re down to about 12,000, so as my population draws down, it allows us the opportunity to reset our force structure to meet our mission requirements.”

Current projections put the AW2 population at 8,000 to 9,000 in the next couple years. While the decline in demand from injuries stemming from combat operations or preparation for combat is notable, it hasn’t reduced the AW2 population in a linear fashion. That’s because not all wounds are physical.

“What you’re seeing now is those who deployed and came back physically uninjured, but three to five years later, something is wrong with them,” Coffey said. “It’s what we call an ‘above the shoulder’ injury. In every war there’s an initial wave of casualties, but five or 10 years later, you see the residual effects of that war, which are usually behavioral health-related.”

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Though PTSD and similar conditions have sustained demand for AW2, the program is ready to scale itself appropriately as the need hopefully wanes.

“As long as the case numbers go down, we will continue to shrink,” Johnson said.

AW2 aims for a 60-1 soldier-Advocate ratio to provide the best service, and will seek to maintain that ratio as it contracts.

The program has a base number of 72 government-employed Advocates. The remainder are contract Advocates drawn from the private sector. Their number has decreased over the past two years, and will continue to as conditions warrant.

The geographic distribution of the AW2 population, which tends to live in a horseshoe pattern around the country, has allowed for further consolidation, according to Johnson. The scalability of the private contract is an asset, and if needed, more Advocates can be hired in a timely fashion. AW2’s leaders stress that while it may be getting smaller, its case management quality will stay at the same high level.

That level will be maintained as the active Army program merges with the Army Reserve program under the Army Enterprise Recovery Coordination Program (AERCP), providing one seamless service for wounded, injured, or ill soldiers. As Johnson says, AW2 will continue to march along with our most critically wounded warriors.

“If you qualify for AW2, you don’t have to find information and resources yourself.”

To learn more about the AW2 Program, contact the AW2 Contact Center at 1-877-393-9058.

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COMBAT CASUALTY CARE Advances and lessons for the next war

By Craig Collins

n THROUGHOUT 21st CENTURY combat in Afghanistan and Iraq, American military medicine achieved an unprecedented survival rate.

By 2016, more than 90 percent of U.S. warfighters wounded in battle had made it home alive, compared to about 75 percent for each of the wars in Korea, Vietnam, and the Persian Gulf. The highest survival rate in the history of warfare was achieved in spite of the increasing severity of battle injuries inflicted by the weapon of choice for counterinsurgents: improvised explosive devices (IEDs) planted in the ground or delivered by vehicles or suicidal attackers. Up to two-thirds of American service members killed or wounded in Iraq and Afghanistan were victims of IEDs. Military experts have documented the litany of improvements in trauma care, from points of injury to stateside hospitals, that contributed to this improvement. Last year, in the journal Current Problems in Surgery, six military physicians – including Eric Elster, M.D., chair of the Department of Surgery at the Uniformed Services University of Health Sciences (USU) and a captain in the Medical Corps of the U.S. Navy – documented these advances in an article, “Combat Casualty 64

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PHOTO BY MASTER SGT. MATT HECHT

Care and Lessons Learned from the Past 100 Years of War.” The innovations mentioned by the authors included improvements in: • Point-of-injury care. In Iraq and Afghanistan, the revised Tactical Combat Casualty Care guidelines, developed in 1996, were conveyed via training not only to medics and corpsmen, but to all warfighters. The effective use of extremity tourniquets and hemostatic agents, some of them newly developed, helped slow rates of hemorrhage, which studies revealed to be the cause of 90 percent of preventable battlefield deaths.

• Care during prehospital transport. Blood transfusions and hypothermia prevention measures helped to sustain wounded warfighters, and toward the end of the war in Afghanistan, critical care flight paramedics from Army National Guard units were providing a high level of care during helicopter transports to in-theater medical facilities.

In 2009, Secretary of Defense Robert Gates issued a mandate based on the “golden hour” standard of care that had been developed for civilian trauma systems, requiring prehospital transports of critically injured casualties in 60 minutes or less. According to Michael Davis, M.D., director of the U.S. Army Medical Research and Materiel Command (USAMRMC) Combat Casualty Care Research Program (CCCRP) at Fort Detrick, Maryland, and a colonel in the U.S. Air Force Medical Corps, the golden hour mandate “is likely the greatest thematic breakthrough relative to our medical successes in the most recent overseas conflicts.” According to a 2015 report in the Journal of American Medicine, the mandate saved a total of 359 lives.

• Surgical care in theater. The use of “damage control” resuscitative and surgical measures focused on stabilizing patients for transport to definitive care. Previous resuscitation protocols, developed before advancements in the storing and transport of blood products, had involved generous intravenous infusion of crystalloid solutions, such as normal saline or Ringer’s lactate solution. “They would get 2 liters of that salt-based solution regardless of how sick they were,” Elster said, “and then if that didn’t work, they would get two units of packed red blood cells.”

Pumping high volumes of fluid into patients, however, increased the incidence of several adverse complications, including acute respiratory failure, and in 2006, the military medical community transitioned to the “hypotensive resuscitation” strategy developed by Col. John Holcomb, an Army trauma surgeon, which involves a balanced infusion

■■ OPPOSITE: New Jersey Army National Guard combat medics

move simulated casualties during a tactical trauma care course on Joint Base McGuire-Dix-Lakehurst, New Jersey, Sept. 28, 2018. The Brigade Combat Team Trauma Training (BCT3) consisted of tactical combat casualty care, care under fire, and tactical field care.

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of platelets, plasma, and packed red blood cells. While whole blood transfusions remain the ideal method of resuscitation, it’s not always possible on the battlefield, and Holcomb’s ratiodriven method improved survival and decreased the incidence of acute respiratory failure among severely injured patients.

• Intercontinental casualty transportation. 21st century combat medicine saw the transformation of fixed-wing transport aircraft into airborne intensive care units. Wounded patients being flown to upper-echelon medical facilities in Germany or stateside were accompanied by critical care air transport teams (CCATTs), which include a critical caretrained physician, a critical care-trained nurse, and a respiratory therapist.

The Iraq/Afghanistan survival rate is remarkable not only in that it was an improvement over previous conflicts, but also because it improved on itself through the duration of the war, despite the fact that the severity of injuries increased overall among U.S. warfighters. In the first decade of Operation Enduring Freedom and Operation Iraqi Freedom, the combat injury case fatality rate decreased from 18 percent to 5 percent.

This improvement points to advances in logistics as much as in medicine, said Elster, who last year published Out of the Crucible: How the U.S. Military Transformed Combat Casualty Care in Iraq and Afghanistan, a book he co-edited with Arthur Kellermann, M.D., M.P.H., dean of USU’s School of Medicine. The Joint Trauma System (JTS), pioneered by Holcomb beginning in 2003, established lines of communication and a tri-service trauma care system that, by design, continues to be refined today. More than any medical innovation, Elster said, the most important contributor to historic combat survival rates “has been the establishment of a Joint Trauma System as a learning health care system. The thing that ties all the advances together and provides the opportunity or ability to disseminate those advances, and then to measure their effectiveness, is the Joint Trauma System.”

CLOSING THE GAPS

In June 2016, the lessons learned in forming and operating the JTS were the focus of a report issued by the National Academies of Science, Engineering and Medicine titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” The report articulated a vision for “a national trauma care system driven by the clear and bold aim of zero preventable deaths after injury and minimal trauma-related disability to benefit those the nation sends into harm’s way in combat as well as every American.”

Elster sees three major steps that need to be taken in order to move combat medicine closer to zero preventable deaths – and those steps are currently underway. First, the JTS must be embedded throughout the entire military medical system. Established and developed post-9/11, the JTS, 65

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Elster said, evolved into a theater-based system, particular to circumstances presented by Iraq and Afghanistan, but “has been maturing over the last several years to become an enterprise-level solution.” Originally administered by the Army’s Institute of Surgical Research, the JTS was recently established in the Defense Health Agency’s Combat Support Agency, where it serves as the reference body for all trauma care in the military health system, sets standards for trauma care, coordinates the translation of research, and incorporates lessons learned from trauma education and training partnerships into clinical practice.

At this scale, the success of military medicine won’t depend on where the next war is fought. “You need the ability to practice this focused empiricism,” Elster said, “which is taking the best data you have, developing practice guidelines, disseminating those guidelines, measuring their effectiveness, and measuring outcomes.”

A second step will be to ensure that all members of combat casualty care teams are proficient in the skills needed in the expeditionary environment. The Defense Health Agency’s Clinical Readiness Program, which divides JTS clinical practice guidelines into expeditionary domains, provides training, practice, and assessment of the knowledge and skills necessary for each.

The third driver toward keeping combat casualties at their lowest possible level, Elster said, will be continued investment in a requirements-driven research program: “The ‘requirement,’” said Elster, “is whatever the military identifies as a

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■■ Combat medic soldiers with the 230th Brigade Support Battalion

conduct lifelike combat casualty care training with soldiers injured on the battlefield. Soldiers trained on medical techniques and medical intervention at a training area near Fort Bliss, Texas, during the 30th Armored Brigade’s eXportable Combat Training Capability (XCTC) exercise, Aug. 6-21, 2018.

need to take care of patients in the expeditionary environment, whether it’s a new tourniquet or an advanced resuscitative strategy. We need to make sure we continue robust investments, because if we don’t do it, no one else will.”

Several of the requirements that surfaced during the Iraq and Afghanistan wars were met with innovations from military clinicians and researchers, including the requirement for safe and faster-acting anticoagulants and hemostatic dressings; for tourniquets able to stop bleeding with compression at the armpit or groin; for a device that forward surgical teams could use to stop aortal bleeding; and for standardized high-level care during helicopter evacuations.

At Fort Detrick, the CCCRP and other elements of the USAMRMC help lead the effort to meet further requirements – and anticipate future needs. In an email interview, Davis said these requirements generally involve time (the ability to do things faster, automating them where possible) and distance (the ability to push lifesaving capabilities as far forward into the expeditionary environment as possible). For example, Davis said, automated vascular access – the use of 67

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miniaturized robotics, equipped with ultrasound and artificial intelligence, to deliver resuscitative fluids into an injured warfighter’s bloodstream – is likely only one to three years away from being used on the battlefield. These same scanning technologies could be used for non-invasive hemorrhage detection in cases where warfighters aren’t overtly bleeding or visibly symptomatic.

One of the most potent lifesaving technologies being investigated at the CCCRP, said Davis, is the extracorporeal life support (ECLS) tool for combat trauma – essentially a bypass system for severely injured warfighters that can do the work of the heart, lungs, liver, and kidneys for hours or days in forward locations. Working versions of the ECLS tool exist today, Davis said, but “the current generation of ECLS systems will need to be improved upon, then miniaturized and ruggedized for the future battlefield.”

The coalescence of automation, robotics, data integration, and artificial intelligence, Davis said, “could allow for the care of multiple casualties at once, allowing for more casualties to be treated at a faster rate.” The CCCRP and other USAMRMC laboratories, such as the Medical Simulation and Information Systems Research Program and the Telemedicine & Advanced Technology Research Center, are investing in autonomous medical interventions to integrate into future battlefield systems. Among the most promising solutions are autonomous unmanned vehicles for delivering lifesaving supplies and technologies. With the ability to move faster and farther than current rotary-wing aircraft, and without the potential cost of further human casualties,

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■■ Air Force Lt. Col. (Dr.) Jeremy Cannon (right) and Dr. Jeremy

Pamplin place a patient on extracorporeal membrane oxygenation, or ECMO, in September 2012 at San Antonio Military Medical Center in Texas. ECMO is a heart-lung bypass system that circulates blood through an external artificial lung and sends it back into the patient’s bloodstream. ECMO is one part of the extracorporeal life support tool for combat trauma.

these platforms, Davis said, “could bring blood, sterile water, and other medical supplies faster and farther into the battlespace than current technology allows.”

While point-of-injury care remains a top concern for the CCCRP, said Davis, the military medical establishment is looking at ways to integrate medical evacuation or casualty evacuation capabilities into vertical-lift platforms – which may be manned or unmanned, but may still be equipped with some degree of robotic or automated lifesaving technology.

“Imagine a future scenario,” said Davis, “where militarygrade drones – with their ability to carry substantial weight and deliver medical supplies – can also carry up to six casualties on the return flight without the need for piloted flight.”

COMBAT MEDICINE IN THE FUTURE BATTLESPACE

A new term appeared last year in the updated Army Field Manual: Multi-Domain Battle. It’s a term military scholars and policymakers use to describe what they imagine warfare 69

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■■ The Joint Trauma System (JTS) provides “bookends” for the CCCRP. On the left side, the JTS and clinical community provide observations

GRAPHIC COURTESY OF COL TODD E. RASMUSSEN, USAMRMC CCCRP

and questions that the research program endeavors to answer with knowledge and materiel solutions. On the right side, the JTS and clinical community take, hone, and integrate the results of that research to develop best practices and clinical guidance for combat casualty care.

will be like for American combatants in the future – and what it’s already beginning to look like in places like eastern Ukraine and the Middle East. This type of conflict, combining traditional forms of kinetic military warfare with psychological, cyber, and economic attacks, is increasingly practiced by peer- or near-peer adversaries looking to challenge American military dominance in all domains: land, sea, air, space, and cyberspace.

Over the longer term, it will become increasingly unlikely that American warfighters will be engaged in a protracted counterinsurgency campaign against non-state actors whose most dangerous weapons are IEDs. They’ll more likely be organized into small, “light footprint” expeditionary units, according to Davis. “The combat zone of the future will likely take place in densely populated, cramped cityscapes where smaller, more agile teams of warfighters will replace the large contingents seen in conflicts of the past.” This battlespace, described in battle doctrine as dense urban environment, presents combat medicine with new challenges.

A warfighter who suffers a head wound in the Middle East can expect to be in a stateside hospital within 24 hours today, as the United States and its allies enjoy near-complete control of the air and seas. A forward surgical team can rely on communicating directly with experts back home, who may in some cases walk them through a difficult procedure step by step via videoconference. In multi-domain peer-topeer battle, these advantages are likely to be challenged; air transports, including medical evacuations, may be curtailed and communications jammed, using either conventional or cyber weapons. U.S. and allied combatants likely will have to provide medical support in an anti-access/area denial environment – or prepare to do without medical support for much longer periods of time. “The ability of medical providers in the forward battlefield to engage with higher echelon support,” Davis said, “will likely be severely eroded … the mindset of the golden hour approach will have to change.

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In the future, instead of evacuating the casualty to another higher role of care, we’ll instead need to focus on providing medical support to the casualty at or near the point of injury.”

Today’s harbingers of multi-domain battle explain the urgency Davis and the CCCRP are applying to automated systems such as robotic vascular access and the ECLS tool. But whatever technical advances future warfighters might enjoy, multi-domain battle is likely to demand more from medics, corpsmen, and warfighters who act as first responders.

Advances in telehealth and information technology, such as wearable medical sensors and secure communications technologies that can deliver virtual medical services, may also play a significant role. As the golden hour gives way to a new paradigm of prolonged field care, each of these factors – automation, greater forward expertise, and telecommunications – is likely to change the way combat medicine is practiced.

As Elster pointed out, however, the basic science of medicine remains unchanged, and military trauma medicine learns not just from war to war but also, because of the JTS, during ongoing operations. “Remember,” Elster said, “Iraq and Afghanistan evolved from the beginning, which involved more traditional armaments and injury patterns toward … dismounted IEDs becoming more prevalent. The biology is always the same. The logistics are what change, and you need to train for that.”

The JTS-enabled “learning health care system” Elster credits with boosting combat survival rates in Iraq and Afghanistan will be of critical importance in this future battlespace, Davis said, for one simple reason: No matter how accurately his program predicts the challenges multi-domain warfare might present, American combat medicine is likely to encounter something unexpected. “For this research program and, indeed, the entire military,” said Davis, “it is clear that the future battlefield will be a test of not only our current and future capabilities, but also how we apply those capabilities across new and unfamiliar terrain.”

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DEPARTMENT OF DEFENSE PHOTO BY REESE BROWN

Female surgeons of the Belvoir Hospital take a moment to re-create a recent image from The New Yorker magazine as a display of price and diversity.