Veterans Affairs & Military Medicine Outlook Spring 2018

TBI Research Dental Readiness Pain Management

INTERVIEWS Rep. Tim Walz

Ranking Member of the House Committee on Veterans’ Affairs

Lynda Davis

Chief Veterans Experience Officer, Veterans Experience Office

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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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[1] Hayes K, Shepard A, Cesarec A, et al. Cost minimisation analysis of thermometry in two different hospital systems. Postgrad Med J Published Online First: 18 January 2017, doi:10.1136/ postgradmedj-2016-134630 [2] Kumana C. Minimising the costs of temperature monitoring in hospitals. Postgrad Med J Published Online First: 1 February 2017 doi:10.1136/postgradmedj-2017-134795

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2018 SPRING EDITION

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

TABLE OF CONTENTS INTERVIEWS

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REP. TIM WALZ, D-MINN.

LYNDA C. DAVIS, Ph.D.

By Rhonda Carpenter

By Rhonda Carpenter

Ranking Member of the House Committee on Veterans’ Affairs

Chief Veterans Experience Officer, Veterans Experience Office

RESEARCH

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TRAUMATIC BRAIN INJURY: A RESEARCH UPDATE ON THE SILENT EPIDEMIC

By Craig Collins

26

DENTAL HEALTH AND READINESS

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REDUCING NURSES’ INJURIES WITH TRAINING AND TECHNOLOGY

Keeping soldiers deployable and in the fight

By Gail Gourley

By Gail Gourley

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THE NATIONAL CENTER FOR PATIENT SAFETY

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ON THE CUTTING EDGE

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COMMUNITY LIVING CENTERS AND STATE VETERANS HOMES

Creating “an army of patient safety leaders”

By Craig Collins

With its first training program for robot-assisted surgeons, the Air Force leads DOD and VA physicians into the future of medicine.

By Craig Collins

By Gail Gourley

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THE AIRBORNE HAZARDS OF IRAQ AND AFGHANISTAN: AN UPDATE

By Craig Collins

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INFECTION CONTROL

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A NEW ERA IN PAIN MANAGEMENT

From the battlefield to stateside hospitals, DOD and VA are shoring up defenses against drug-resistant microorganisms.

By Craig Collins

How we got ourselves into an opioid epidemic – and how the VA and DOD are helping to chart a way out

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 Editor: Rhonda Carpenter Contributing Writers: Rhonda Carpenter, Craig Collins, Gail Gourley DESIGN AND PRODUCTION Art Director: Robin K. McDowall Designer: Rebecca Laborde ADVERTISING Advertising Sales Manager: ​Steve Chidel Advertising Team Lead: Beth Hamm Representatives: ​Nicole Banfield, Art Dubuc, Kristy Martin, Geoff Weiss OPERATIONS AND ADMINISTRATION Chief Operating Officer: Lawrence Roberts VP, Business Development: Robin Jobson Business Development: Damion Harte Chief Information Officer: John Madden Business Analytics Manager: Colin Davidson FAIRCOUNT MEDIA GROUP Publisher: Ross Jobson

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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

INTERVIEW

REP. TIM WALZ, D-MINN. Ranking Member of the House Committee on Veterans’ Affairs

By Rhonda Carpenter n U.S. CONGRESSMAN TIM WALZ, D-MINN., is currently serving his sixth term representing Minnesota’s First Congressional District. He is the ranking member of the Veterans’ Affairs Committee, and serves on the Agriculture Committee.

Walz was born in West Point, Nebraska, and enlisted in the Army National Guard at the age of 17. He retired 24 years later as a command sergeant major. Walz is the highestranking enlisted soldier ever to serve in Congress.

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■■ Rep. Tim Walz, ranking member of the House Committee on

Veterans’ Affairs.

OFFICE OF U.S. REP. TIM WALZ

Veterans Affairs & Military Medicine Outlook: You served 24 years in the Army National Guard and you’re currently serving your sixth term in the House of Representatives.

What motivated you to serve in the military and also to go into public service?

Rep. Tim Walz: I grew up in a very rural area. I always tell people I graduated with 24 classmates and 12 were cousins in that rural farming community.

My dad and my uncles and everyone had served. My dad was a Korean War-era veteran. He took me down, and as I recall, we drove about 40 miles, and there was a lieutenant in the National Guard who had the ability to swear us in.

So, the day after my 17th birthday I joined the military. So, I think for me, from an early age, it was expected what you would do. I think my father was also the first person in his family to get a college degree, and he got it via the GI Bill.

And that’s exactly what he was thinking for me. He knew he was dying of cancer at the time. So, he got us in, and I’ve said, for me, it was parents looking out for me. It was one of the best decisions that could have been made. I was maybe too young to understand the implications of it, but I’ve always said that I believe I got so much more from the military maybe than they got out of me – that sense of service, that sense of something bigger than yourself. So, [those

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were] kind of the drivers for us – I think like so many families, it’s tradition. It’s the chance to not only serve, but to then have the opportunity to use some of those benefits that are there as part of it.

You sponsored the Clay Hunt SAV (Suicide Prevention for American Veterans) Bill that became law in 2015. Could you explain the issues the act addresses, and what kind of progress is being made with the problem of veteran suicides?

This is … I think personal for so many of us, both military and civilian, this issue of suicide and mental health. When I first came to Congress, we were still debating whether we should bury these warriors with honor if they committed suicide.

There were still those that argued that they should not have military honors, which was just a stigmatization of it. And then for me, it was very personal with Clay [Hunt]. Clay actually came [to Capitol Hill] as part of a group of Iraq and Afghanistan veterans, and they were lobbying us on veterans’ issues. Clay’s issue was an extension of the GI Bill, and making it more friendly to post-911 veterans.

I got to know him during their time up here on the hill. Then I got the call from his parents that he had taken his life. Clay was a central-casting Marine.

He was shot by a sniper and went back and trained for himself to go back – just the consummate professional, the consummate warrior. If someone like that was struggling to get the help they needed … you know we all knew it and it’s all kind of theoretical, but it was just so personal. So, what the act did was we kind of used Clay as an example that seemed to be … typifying what was happening in this epidemic of veteran suicides. It wasn’t just post-9/11. We know that the vast majority are Vietnam veterans.

So, what it tried to do was it increases [the] mental health capacity of the VA. We were grossly short there. We made some changes to make sure that if you serve as a mental health professional, we’ll pay for your education. We’ll make sure that there are programs to pay off your loans, those types of things. We also asked existing programs in the VA to tell us if they are working, did we have data that showed the efficiency, and were there new things coming out. We are seeing every day that things that used to be considered alternative therapies – yoga, long-distance biking – those types of things were working, and we put those in. And then probably the thing for us [was] we found we needed the capacity and the community to be peer to peer, making sure that we had people who had that shared experience. That’s one of the common

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threads that runs through. I’m sure we’ll talk a little bit about it in terms of how do you balance VA care and community care.

One of the things that is so appealing to veterans going to the VA is they feel a sense of comfort there. They feel a sense of cultural competency, and people know what they’re talking about in terms of veteran experience, so making sure we were building capacity in the community to use our veterans who were there to deliver that. And now it is with everything in the VA, continuing to try and see that they’ve implemented fully, continuing to try and follow up if it is working. I think all of us know whether the number is 22-20 or whatever, this is a zero-sum proposition. We may never get there. But our goal is to make sure that every single veteran in crisis has access to life saving care and hopefully prevent that from happening.

Could you describe H.R.4334, the Improving Oversight of Women Veterans’ Care Act of 2017, that you were cosponsoring? Could you explain the intent of that legislation?

It used to be 10 years ago you’d hear the stories of a veteran walking into a VA clinic and being asked if she was there for her husband. No, she was there because she was blown up in Iraq. That’s why she was there. We have now become a little more sensitive to that. But the problem that we have, that we were experiencing, was that we were seeing a massive increase – and it’s a good thing – [of] 2 million women veterans, adding 18,000 a year over the next 10 years. So, we’re going to add an awful lot of folks, and especially a lot of combat veterans of the current conflict. What this bill is really meant to do, like so many things we try and do, is make sure we assess the problem correctly before we try and prescribe or invest money in it. So, the bill was really focused on the fact that we just don’t have data on what they’re doing. We don’t have performance measures of how they’re doing. We’re not sure. I know anecdotally, and we’re starting to gather more data. Phoenix is a really great example. Phoenix, of course, was in the news for its wait times. But there is also a women’s clinic in Phoenix that is absolutely spectacular – sameday appointment mammograms, open from 5 a.m. to 10 p.m., open on the weekends, provides access to childcare, and has same-day results and scheduling if you need surgery or treatment for breast cancer. I mean, for a working veteran mother, it’s incredible. They were finally doing this the right way. But I don’t have data to show how many veterans have access to that type of quality, accessible 7

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

■■ Members from the Student Veterans of America present Rep. Tim Walz with the Sonny Montgomery Student Veteran

ease of care. This bill was really meant to focus on: Are we getting there? Is there an equality of care?

Where are the gaps, kind of a gap analysis. So, this bill isn’t prescribing them to do something at this point other than to be better at assessing where we’re going. So, I think that’s a pretty easy one. We think they should be able to do that and report to the secretary if they are getting it right or not.

You’ve cosponsored H.R.2631 – the Justice for Servicemembers Act of 2017. What shortcomings do you believe the Uniform Services Employment and Reemployment Rights Act (USERRA) of 1994 has that this bill seeks to correct?

Yeah, USERRA is a good bill, and I want to be clear: The vast majority of employers in this nation are absolutely supportive of their warriors, especially our National Guard and Reserve. Especially in smaller rural communities, they accept a real burden. When a guard unit is deployed – and some 8

of my communities are 8[000] to 10,000 people – they’ll lose 130 members of that community. Well, that tells you that it’s going to be a big chunk of the police force. It’s going to be a big chunk of the teachers. It’s going to be a big chunk of some of the private industries that are there [in that community]. I want to be clear that we believe that the vast majority are already following USERRA, which was basically put in place to ensure that you couldn’t deny a veteran employment because you might get deployed. So I don’t want to hire you for this, or any of the issues that come with it. So, I think the vast majority are there. But there has been a phenomenon that has happened, like the forced arbitration clauses that people sign, [they] don’t give our veterans what the intention was; that you were going to be able to be adjudicated if you could make the case that you lost your job or were denied promotion because you were deployed or doing military service. And the forced arbitration clause basically

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Champion Award for his work in passing the biggest expansion of veteran educational benefits in decades, the bipartisan Harry W. Colmery Veterans Educational Assistance Act of 2017, aka the Forever GI Bill.

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

undermined the ’94 law that allowed us these protections. It cut those off, and it forced them to sign things that could then say, ‘Well, I’m certain that you fired me because of this, but there is no way to prove it because of the forced arbitration clause.

So, what this piece of legislation does is it just tries to go back and give service members the ability to pursue their case, to be able to go to court. I mean if anybody in the country has earned the right to due process in the legal system it’s someone who is serving their nation, especially in a time of war. So that is the argument I’m making.

What do you see as the biggest challenges the VA faces today?

Well, I think for us, we understand it’s that internal capacity. The VA, I said I’m their staunchest supporter and their harshest critic when they need it. A lot of times we’ve got shortages. We have capacity as it’s growing. I think most people that are not veterans would assume that the VA wait times and access to getting in are being caused because we’ve been at war now. I believe today [March 20] marks the 15th year in Iraq. It’s not that it’s an aging population, especially of Vietnam veterans. It’s all the people, to [be] very honest, going to the VA because the care is good. That old mantra is that ‘if you can get in the VA, you’re going to leave pretty satisfied.’ So, I think that internal investment and capacity and balancing that with the care in the community – of how do we make sure that veterans and their physicians are making choices for them, and there is an appropriate role of care in the community – I think the fear is always getting those things out of balance.

It’s interesting that the public, they care deeply, and they want to do right by veterans. Those that don’t really know about veterans’ care or think that you should just give them a card, and they should go wherever they want. That’s not what veterans want. They understand the discord that will come with that, of coordinating care. They understand that the VA is the absolute epicenter of research into those traumatic injuries that are only seen in war or in major industrial accidents. So, that piece is balancing out. I know that the secretary made what something I advocated for from the first day I was here: aligning the electronic records between DOD [Department of Defense] and the VA. I am under no illusion that that is going to go smoothly.

I’m under no illusion that that is not going to be a long multiyear process. But we have to stay there on top of that, because that’s more than just having a computer screen with a veteran’s name on it. That

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is a diagnostic tool that smooths the delivery of care. It makes care in the community easier, so we get away from the frustrations that people experience with billings and record transfer.

I think this issue of accountability and leadership … one of the things I’ve always said is to make sure we attract and retain the best employees. I’ll be very clear – you cannot fire your way to excellence in an organization. You certainly should have the capacity to be able to make sure that you have good employees there. But the problem is this focus on firing people isn’t a really great recruiting tool and not a great retention tool. Should we be getting rid of employees? Yes, there are processes in place,

■■ “It’s interesting that the public, they care deeply, and they want to do right by veterans. Those that don’t really know about veterans’ care or think that you should just give them a card, and they should go wherever they want. That’s not what veterans want. They understand the discord that will come with that, of coordinating care.

They understand that the VA is the absolute epicenter of research into those traumatic injuries that are only seen in war or in major industrial accidents.”

and leadership needs to do the things that they are supposed to do. But my concern is about accountability is the flipside. And I would argue the more important side is the accountability to recruit, retain, and make sure we have a culture of positive morale in the VA. That needs to be addressed simultaneously.

We’re trying to modernize claims’ appeals is I can’t look a veteran in the eye seven years later. I saw one last week in Minnesota at a veteran’s rally on the hill in St. Paul [Minnesota’s Capitol building].

And we were talking about RAMP, the ability to use the new claims process. And he echoed exactly what I said in the hearing. He’s been in line for fiveand-a-half years. He said I’m afraid to get out of line and try this program, Tim, because I’m afraid I can’t get back in the line. No veteran should have that. We should get a fair adjudication. But they 9

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■■ Congressman Tim Walz stands with constituents in the Luxembourg dining facility on Kandahar Airfield, Oct. 9, 2011.

PHOTO BY SPC. AMANDA HILS, 319TH MOBILE PUBLIC AFFAIRS DETACHMENT

Walz went to Regional Command South as part of a congressional delegation focusing on developments regarding electronic health records, traumatic brain injury protocols, and behavioral health initiatives.

should expect to have an answer quickly and fairly.

This veteran’s point when he explained his situation I’m absolutely convinced in his case when he gets to make his appeal he’s going to win. But it’s five-and-a-half years later. So, I think those are the major issues facing us, in re-establishing that culture of excellence and morale at the VA. The VA now allows its physicians to discuss state legal medical marijuana use by their veteran patients. Along with nine of your fellow Democrats you inquired whether the VA would conduct research on medical marijuana in veterans suffering from post-traumatic stress disorder (PTSD) and chronic pain. What response have you received?

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Well, the initial response was wholly unsatisfactory. And I have to be honest, totally out of character. The VA’s medical research arm is second to none in the world. I represent the Mayo Clinic [which is in his congressional district]. And those physicians and their research arm would tell you that too. One of the things we’ve seen with chronic pain, with PTSD, and to be very honest, I started working on opioid legislation in 2007 with step pain management. In 2007, we were seeing an over prescription of these pain killers that are valuable tools, but need to be used appropriately. We were looking for alternatives, and one of the alternatives that … has been in the states and has been looked at was medical cannabis. All I asked for was that the VA do what they’ve always done – conduct 11

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

world-class research into the validity of using medical cannabis as a way to treat PTSD amongst our soldiers. Well, what they sent back, and I’ve spoken very openly about this, what they sent back was basically Attorney General [Jeff] Sessions’ vendetta against medical cannibals. And they sent back what has been absolutely destroyed by outside experts on why they weren’t doing it. And so, the response has not been great.

In fairness to [former] VA Secretary [David] Shulkin, he was moving the ball on this. He was being a realist that people are self-medicating. And they are afraid to tell their physician this because they were afraid of losing benefits or being put in a bad position. That’s a dangerous situation. If you have a veteran dealing with either chronic pain or mental health issues and they are hiding something from their people at the VA, you’re creating a situation that could end in tragedy. So, I said you have to take them on. And the VA secretary – again I’m not asking them to do anything on prescription on anything that is not evidenced based – but he made what I thought was a courageous call on a related topic of service dogs. We don’t have a whole lot of research on the correlation and the effect of service dogs on improvement of health amongst veterans.

But he said something very insightful in a hearing.

He said, “I have never seen a veteran who has a service dog whose quality of life hasn’t increased.

So, I’m going to make an executive decision at the department level and just authorize service dogs.” I wasn’t asking him to authorize prescribing medical cannabis without the research. I was just asking him to authorize the research. So, we’re at a point right now where we’re still in ongoing discussions.

We’ve got a lot of allies including the American Legion, millions of veterans who want us to explore is this a viable option for the pain that our veterans are going through.

You mentioned accountability and leadership previously. Is there another thing at the VA that you think would help improve veterans’ care, and if so what would that be?

Yeah, I think again the sense of maybe ending the discussion on it’s either the private sector or the public sector. I think letting veterans have a role in how we do care in the community, making sure that they see it as a unified health care system and letting them know that when it does make sense to do a blood test at a small rural hospital like in Sleepy Eye, Minnesota, we allow them to do that. But because of the use of electronic medical records and a coordinated care system, that blood 12

test will get back to the VA hospital where maybe they will need follow up on a more substantial treatment, but we can do that there. And I think that that is the thing that would take stress off the veterans. Our population in rural areas is disproportionately represented with veterans, and I think that is cultural. I know others have said because of its economics. Either way, with about 15 percent of our population living in rural areas but upwards of 34 percent of our veterans being there, there has to be a system that is not so focused on just the bricks and mortar at the VA, which is critically important and must be there. It has to be an integrated system that lets that care be coordinated, makes sure that the VA internal capacity is there, but also makes it smooth for people to do some of those things with care in the community. It’s not a false choice of privatization versus big government care. It has always been a combination of the two. And I think figuring that piece out, having an honest discussion about funding in the regular order of things not stuck in some big bill, that is the way we could improve care.

You’ve successfully pushed for the audit of the DOD, something that has never previously occurred. Recently you introduced the Veterans Administration Legislative and Objective Review, the Valor Act, H.R.3122, which would require the VA to undergo a biannual independent audit by a nongovernmental entity. Why do you think this is needed and what is the status of the bill?

Yeah, several reasons. One is I think these audits are to reassure people’s faith in the system.

Internally I think the VA’s inspector general and others do a very nice job. But I think it’s really important to give trust to the public about what is happening here, where their money is going.

So, they are willing to pay. If there are things that this country is willing to pay for, it’s for defense and veterans, but they have every right to know where that money is going. I think, to be honest with you, both at the Pentagon and at the VA they are such large organizations it would give them a better idea. We’ve seen some of these independent researchers were showing upwards of nearly $100 billion wasted over at the Pentagon. That is decreasing our national security. It is decreasing our quality of life for our warriors. And it is not serving the taxpayers well. So, I’m a big fan, and I’ve spent my career here on transparency and good government things. I think this makes the agencies more effective. I think it restores faith in the

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â– â– Rep. Tim Walz poses with a member of the Minnesota Army National Guard during their rotation through

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the Fort Irwin National Training Center in California June 19, 2016. Walz enlisted in the Army National Guard at the age of 17, and retired 24 years later as a command sergeant major. He is the highest-ranking enlisted service member ever to serve in Congress.

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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

■■ U.S. Rep. Tim Walz, the ranking member of the House Committee on Veterans’ Affairs, welcomes Blinded Veterans Association National Vice

system, because if you don’t do this the anecdotal Monday morning at the coffee shop thing is “well, hell they’re paying $800 for a hammer and I can’t get in the VA and yet I see these people sitting around so what are they doing?” Tell them what they’re doing. Tell them who is working there.

Tell them where the money is being spent and find the places where there is waste and cut it and find the places where we’re not investing enough and beef it up. That’s what I hope that accomplishes.

With respect to Veteran’s Choice, can you describe your view of private care for veterans versus the care within the VA facilities. I know you kind of touched on this earlier.

Yeah, well first of all it’s that false choice. We’ve always done care in the community. There are those that are 14

convinced that – and they are certainly not veterans because when you see the VFW [Veterans of Foreign Wars] or any outside groups if you ask about their satisfaction with VA care it ranks very high. As I said, again, I represent the Mayo Clinic. So, I have kind of a litmus test on what quality care looks like, and the Minneapolis VA ranks right there. With that being said, the brick-and-mortar delivery system of large 500-bed hospitals like you see that were built after World War II, that doesn’t make sense in many cases.

And we have a fragmented health care delivery system in this country anyway. The way I’ve always seen it is trying to make it easier to have this model that internal capacity in the VA is funded accordingly. The folks who need to be there are there, but with an understanding that using care in the community fee-for-service makes sense. And so, it

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President Paul Mimms to the joint hearing of the House and Senate committees on Veterans’ Affairs March 14, 2018.

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is not a capitulation and saying full privatization.

That’s not what veterans want. But we’re also not saying that it makes sense to ask a World War II veteran to drive 300 miles to have a blood test in Minneapolis when they could certainly do it in their own community.

So, my take has always been to have an honest discussion, an honest funding discussion about where the two are at and making sure that veterans understand, and then educating the public on this, because again, the public has been told, well, just give these guys a card and let them go anywhere. If you ask a veteran, they’ll say no. If you ask a health care provider in these areas, they would say, well, that’s not going to work either, we don’t have the capacity to do what they’re asking to do. And what medical professionals know is that, especially with veterans, you would have fragmented care. When they go in to see a VA doctor they may just randomly say I’ve got this spot on the back of my hand and it’s not healing or whatever. So now they’ll run them through the tests on that. If we’re in the private sector, chances are they would have to come back in another appointment and go through that.

So, my take has always been that this is a model of integrated care. You cannot talk about veterans’ health care in a vacuum from health care in general. Rural communities are losing their providers in the private sector also. So, we’re going to have to figure out how do we leverage our VA. I thought at times it makes sense to have a wing of the VA at the local hospital. Why build two separate buildings? Why not use it? You have a hybrid vision. You have the VA there. You’d have VA integrated care and you would have private sector care that is right on the same campus. Those are some things that I think we approach to get the right size of the VA, the right size of care in this nation. And then start to coordinate amongst themselves.

What legislative achievements with respect to veterans are you most proud of, congressman?

Certainly, I think Clay Hunt, in moving the whole cultural piece on the acceptance of mental health parity. Early on, I think advanced appropriations so that if we ever get into a government shutdown our veterans are protected from that because we budget a year in advance. I think the Forever GI Bill, and an update of a GI Bill that has been a generation in the making, that makes sense. I think those are things that improve lives. They were done with a spirit of collaboration and honest debate.

And I think how those bills came into law reflected how Congress should work, and in respect to what

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our veterans fought for. Our veterans fought and served for the right for us to govern ourselves, to have civilian government and to have this representation. And I think the way we’ve conducted ourselves in the VA brings honor to them. I think those three pieces of legislation showed that we’re not going to allow politics to interfere with your payments. We’re going to update the GI Bill because there is a new reality of who is getting deployed, and we’re going to recognize that those invisible

■ ■ “In 2007, we were seeing an over prescription of these pain killers that are valuable tools, but need to be used appropriately. We were looking for alternatives, and one of the alternatives that … has been in the states and has been looked at was medical cannabis. All I asked for was that the VA do what they’ve always done – conduct world-class research into the validity of using medical cannabis as a way to treat PTSD amongst our soldiers.”

wounds of war are every bit as valid as the ones that we can see, the extremity injuries or whatever else it might be. And I think we’ve changed the entire debate in the country on mental health because of it. So, I think if I’m remembered for my time here of doing those things, that is something I’m grateful to have had the chance to do.

To switch gears, you’ve launched your candidacy for governor of Minnesota. What made you decide to run for the governorship?

I think more than anything Minnesota is a state that has a long reputation of governments working.

I see some of the same patterns starting to develop there of the gridlock. And I was convinced that the big issues facing people are going to be able to be dealt with at the state level, at least in the immediate future. But I think more importantly of bringing a different style, one that I’ve modeled here especially dealing with veterans, that I start to kind of bridge the gap. I’m one of those rare animals – I’m a rural Democrat. I think people who have exploited this idea that we’re a country divided, that we’re all 15

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■■ Rep. Mark Takano, D-Calif., vice ranking member of the House Committee on Veterans’ Affairs, delivers comments

during a press conference with other Democratic members of the Congressional Hispanic Caucus and House Committee on Veterans’ Affairs Nov. 16, 2017. The lawmakers were demanding action to help deported veterans. Also on stage are (left to right) Reps. Nanette Diaz Barragán of California, Tim Walz, Joaquin Castro of Texas, Juan Vargas of California, and Kathleen Rice of New York. During the press conference, Walz said, “The words ‘deported veteran’ should offend the ears of every American.”

HOUSE COMMITTEE ON VETERANS’ AFFAIRS DEMOCRATS TWITTER PAGE PHOTO

a red, blue map. We’re all urban/rural. I’ve kind of straddled both those worlds. And I think bringing that to it can maybe keep our state functioning in a way that I would say used to happen here, but not so much anymore.

Do you have any outgoing comments about veterans that you would like to share with our readers?

I think the biggest thing is those people who serve in the VA and those people who serve our veterans – as a nation this is one thing that really unites us. It is an area of commonality. I think it can help set the tone for how we repair some of the damage that’s been done to the country. And for the veterans I would say belonging to these veterans’ service organizations, I can’t stress how important their voice is up here. It’s very hard for people when they’re scattered across the country, they are working jobs, they are busy, to feel like their voice is being heard. So, I used to always wonder

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what my dues went to when I paid it to the Legion or whoever I was paying my dues to. Being on the other side of this now and seeing that they are able to come in there and articulate and petition their government for those things that were earned benefits or things that make this country stronger, I would encourage folks to get involved with that, to know that it makes a difference. And if you need to just complain about government remember we are government. We are the school teacher and retired sergeant major down the block or the physician from Tennessee like Dr. [Phil] Roe. We’re a hospital administrator like Secretary Shulkin. That’s how this works. And so, in the area of veterans care the public is behind us. It’s a noble thing.

We’re moving things forward. It’s making government work in a way that it’s supposed to. And that all happens because of the accountability of those veteran groups that are here and the individual veterans who speak up. So, I would just encourage them to keep the faith and keep speaking out.

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TRAUMATIC BRAIN INJURY: A RESEARCH UPDATE ON THE SILENT EPIDEMIC

By Craig Collins n IT’S BEEN CALLED THE SIGNATURE wound of the wars in Iraq and Afghanistan: More than 375,000 service members have suffered a traumatic brain injury (TBI) since 2000, according to the Defense and Veterans Brain Injury Center (DVBIC). In recent years, an average of about 20,000 TBIs occur annually among service members, most of them occurring during active duty.

TBI presents a significant and lasting problem for the military and veteran communities. Nearly 20 percent of the service members deployed to Iraq and Afghanistan have sustained at least one TBI, and nearly 8 percent of all Iraq and Afghanistan veterans demonstrate persistent post-TBI symptoms for more than six months after the initial injury.

Especially troublesome is that about 75 percent of all TBIs are classified as “mild” – mTBIs, or concussions, whose symptoms are subtle and often initially unnoticed by the injured person or physicians. A growing body of research suggests that once these symptoms – including headaches, sleep disturbances, forgetfulness, fatigue, irritability, and depression – emerge, they have a tendency to persist. A study published last year in the Journal 18

of Neurotrauma reported that 15 percent of people with mTBI have symptoms that last a year or more.

The Department of Defense’s (DOD) TBI research, aimed at returning service members to duty, focuses on developing battlefield screening tools, combat casualty care, and rehabilitation. Investigators for the Department of Veterans Affairs (VA) work to develop tools for screening and diagnosing chronic TBI-related conditions and for administering therapies, treatments, and coping strategies.

TBI, of course, recognizes no line of demarcation between active-duty and veteran status, and its scope and complexity have compelled the DOD and VA to merge their efforts. As early as 1992, largely in response to the Gulf War, they established the Defense and Veterans Head Injury Program.

Known today as the DVBIC, it operates at 22 sites around the country to prevent and mitigate the consequences of TBI. In response to an Obama administration executive order, a nationwide research effort, the Chronic Effects of Neurotrauma Consortium (CENC), connected researchers from the VA, DOD, and academia to address the long-term effects of mTBI and its diagnosis and treatment. Dr. William Walker, a TBI expert at the Hunter Holmes McGuire

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U.S. NAVY PHOTO BY DEVIN PISNER

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VA Medical Center and Virginia Commonwealth University, is leading the CENC’s centerpiece study, launched last year: an ambitious observational study of more than 1,000 service members and veterans, aimed at learning more about mTBI and how it can be better diagnosed, and perhaps prevented and treated.

In 2011, the DVBIC launched a 15-year set of longitudinal studies aimed at, among other things, explaining why some people recover more slowly from TBI; what kinds of brain changes (i.e., differences in biomarkers or neuroimaging) can account for this difference; and why TBI may or may not be associated with other chronic conditions such as chronic pain, sleep problems, mood disorders, or post-traumatic stress disorder (PTSD).

One of these studies, led by Karen Schwab, Ph.D., a DVBIC researcher and faculty member at the Uniformed Services

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■■ Dante Dobbins, a 2015 summer volunteer at Naval Surface

Warfare Center, Carderock Division (NSWCCD) in West Bethesda, Maryland, helps Philip Dudt, a researcher at NSWCCD, test different applications of an explosive-resistant coating on helmets. According to Office of Naval Research (ONR) scientist Roshdy Barsoum, Ph.D., early research sponsored by ONR identified that a coating of explosive-resistant polymers could mitigate blast exposure to the brain.

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■■ Banyan Biomarkers has the first

U.S. Food and Drug Administrationapproved blood test that can be used by physicians and health​​care​providers to aid in the evaluation of ​patients with a suspected traumatic brain injury.​

University of the Health Sciences (USU), found that nearly 50 percent of about 1,500 recently deployed service members who’d suffered mTBIs in Afghanistan or Iraq reported at least one severe or very severe post-concussive symptom three months after returning from their deployment. The report sheds light on the need for focused medical follow-up after a concussion.

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BLAST INJURY: A UNIQUELY MILITARY PROBLEM

For years now, DOD and VA research communities have been investigating the presence of biomarkers – proteins or enzymes, usually – that may be associated with brain injury. The DOD’s work in this area was instrumental in the development of a long-sought diagnostic, the Brain Trauma Indicator (BTI™), which became the first U.S. Food and Drug Administration-approved TBI screening tool in February 2018. Manufactured by Banyan Biomarkers, the Brain Trauma Indicator is a blood-testing kit that measures levels of two proteins (GFAP and UCH-L1) associated with head injury. The tool – a historic culmination of a collaboration among military, academic, and public- and private-sector researchers – will help health care professionals manage

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patient care and decide whether to perform further diagnosis with neuroimaging, such as a CT scan.

Many active-duty TBIs are caused by something much more complex than a knock on the head: blast injury, the physical trauma resulting from direct or indirect exposure to an explosion. Blast trauma may be caused not only by the blunt or penetrating force of expelled debris, but also by the wave of high pressure, known as blast overpressure, that can travel through tissues and damage cells. When DOD established its Blast Injury Research Program in 2007, it classified blast injuries into five categories, from primary to quinary, based on the mechanism of injury.

Because it often causes harm with no discernible signs of injury, blast trauma is of great concern to DOD researchers, in terms of both military member health and unit readiness.

The Office of Naval Research (ONR) in Arlington, Virginia, is overseeing the development of a portable system that can measure the likelihood of blast injury, resulting in a “go/ no-go” indicator for unit commanders. Timothy Bentley, Ph.D., a program manager with the ONR’s Warfighter Performance Department, describes the system – Blast Load Assessment Sense and Test, or BLAST – as a three-part assessment tool. The first component is a suite of coin-sized 21

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sensors, strategically placed on a service member’s helmet and body armor, that measure three blast forces: linear acceleration, rotational acceleration, and blast overpressure.

Data from these sensors is processed and analyzed using algorithms, the second component of BLAST, to calculate the likelihood of brain injury.

“That’s done on a statistical probability basis,” Bentley said. “If you get hit with a certain force, we can make a prediction that you are likely or unlikely to have been injured.” The algorithms being developed for the system can be adapted to factor in a person’s previous exposures to blast forces, which have been shown to cause cumulative damage.

If the numbers indicate a possible injury, a service member will make use of the system’s third component, the “brain gauge,” which Bentley describes as a “neurofunctional assessment tool.” The size of a computer mouse, the gauge emits vibrations to stimulate the fingertips in a variety of patterns; the military member’s ability to recognize these patterns will inform a corpsman’s or medic’s decision to recommend the person either stay in the fight or stand down.

“By using the mechanoreceptors, the touch receptors,” Bentley explained, “we can send a very clean signal to your brain.” Studies of animal models have demonstrated a predictable set of neurological responses to sensory stimuli. “They are conserved into people, and they are very well understood. So we have a solid medical and neurological basis for these inputs and outputs.”

BLAST, or a system like it, may provide a more empirical means of determining service members’ fitness for duty after a blast exposure. Current DOD doctrine requires everyone within 50 meters of an explosion to stand down for 24 hours and undergo a mandatory medical evaluation. This poses two logistical problems, Bentley said: First, forward bases are usually small. “If you’re at a forward operating base that’s 100 meters across, and the shell lands in the middle, is everybody in the base supposed say: ‘Stop the war; we’re all standing down for 24 hours’? Of course, that can’t happen. … They’re looking to make people take [blast injury] seriously and to protect people. But there is no real medical basis for that.”

Second, 24 hours isn’t enough time for a medical exam to detect signs of mTBI. The BLAST system can provide a focused triaging tool that directs symptomatic service members into a more thorough evaluation period, while optimizing unit readiness.

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■■ The most common physical symptoms of a traumatic brain injury (TBI) are headache, dizziness, tiredness, trouble sleeping, vision problems, and feeling bothered by noise and light. As of September 2017, the VA had screened more than 1.1 million veterans for a possible TBI.

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■■ Dr. Gregory Johnson, Tripler Army Medical Center Concussion

Clinic medical director, has U.S. Army Spc. Andrew Karamatic follow his finger with his eyes during a neurologic exam March 20, 2014.

The Defense and Veterans Brain Injury Center reports that more than 375,000 service members have suffered a traumatic brain injury since 2000.

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U.S. AIR FORCE PHOTO BY STAFF SGT. CHRISTOPHER HUBENTHAL

As a naval researcher, Bentley is particularly interested in evaluating the effects of explosions in enclosed spaces, such as ships, where shock waves can be reflected and amplified. Future assessments of the BLAST system are in the works: tests of the sensors on mannequins aboard ships, for example, and a Navy/DVBIC clinical trial at Landstuhl Regional Medical Center in Germany, to test the brain gauge on ground troops – breachers and sappers – who use explosives during their training in breaking down obstacles such as doors and walls. “The sensors we’re making are just coming out of development,” Bentley said, “and we hope to get those

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into field testing – not on people, but on real explosions – this summer, and by the fall, get them onto people.”

TREATMENTS: THE SHORT AND LONG HAUL

The upcoming brain gauge trials at Landstuhl mirror a group of studies recently undertaken through one of the Army’s primary conduits for investigations of TBI and its aftermath, particularly those caused by blast. At the Center for Military Psychiatry and Neuroscience (CMPN) at the Walter Reed Army Institute of Research, the blast-induced neurotrauma research group works to characterize the effects of blast injury. Those evaluations have traditionally been pre-clinical studies, involving the manipulation of blast wave variables among animal models, but according to Lt. Col. Jeffrey Thomas, who directs the CMPN, the center has recently extended these evaluations to include settings, such as breacher and sapper training, in which service members and other professionals encounter explosions.

“We have a very robust and fairly new capability to do field studies in training environments with breachers and sappers,” Thomas said, “and groups that are exposed, through their occupation in the military, to repeated low-level blast exposure. We’re … working with training doctrine commands, operational units, even law enforcement organizations, to do some of these studies both with military and paramilitary organizations.”

Understanding the variables associated with explosive blasts, and particularly of repeated low-level blast exposure, helps shape the research agenda of another CMPN research group, brain trauma neuroprotection and neurorestoration, which investigates how to protect warfighters from TBI and to aid in healing and recovery. Treating and healing injured brain tissue remain elusive goals for the research community, for two main reasons: First, the blood-brain barrier, the filtering mechanism that blocks most pathogens from the brain, also keeps out most drugs. There’s no magic pill for treating TBI, nor is there likely to be one; most drug therapies are aimed at associated symptoms, such as increased cranial pressure or seizures. A DODsponsored research team at Indiana University-Purdue University Indianapolis recently discovered a compound that may treat hydrocephalus, the overproduction of cerebrospinal fluid that may follow traumatic injury; last spring, a researcher with the VA Pittsburgh Healthcare System reported lab studies suggesting that lithium treatment may be helpful in promoting recovery in the injured brain.

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The second factor complicating TBI pharmacotherapy, Thomas said, is that TBI doesn’t happen in isolation. It often accompanies considerable trauma to the rest of the body. “The drugs used to treat these symptoms,” Thomas said, “may have – and often do have – a deleterious effect on other systems in the body.”

CMPN researchers are looking at ways to overcome both of these obstacles – to escort pharmacological compounds past the blood-brain barrier and to target the systems requiring therapy. “The neuroprotection group is looking at different ways to deliver drug therapies,” said Thomas. “They have an exciting new area of research looking into nanoparticle drug delivery.”

Finding – or creating – a molecule small enough to penetrate the blood-brain barrier, and to deliver medicine where it needs to be, will be an important milestone in TBI treatment.

Another promising area of research, developed in collaboration with the University of Miami, is just beginning to explore stem cell therapies that may help augment and support injured brain neurons. “We’re hoping to start doing the basic research, and eventually getting into a clinical trial setting years down the road,” Thomas said. “That is an exciting new effort.”

The work of another branch of CMPN research – behavioral biology, whose primary focus is on strategies for maximizing unit readiness and soldier effectiveness – has implications for long-term recovery and coping mechanisms following TBI. In particular, the center, which houses a world-renowned sleep laboratory, is examining the effects of sleep on TBI recovery.

The CMPN’s blast-induced neurotrauma research group has produced enough data, over the years, to yield insights into downstream neural degenerative disease, Thomas said, “and what’s happening in terms of neuroinflammation in the brain, and what may lead to poor outcomes in older individuals who have been through military service.” In encompassing this continuum, the center’s research program is aimed at achieving better long-term medical outcomes for service members who’ve suffered blast-induced TBI – a goal that connects it with the VA’s vast infrastructure for helping veterans with TBI to heal and make the most of their lives after active-duty service.

“It’s always important for us to design things that are going to make people better when they go into the fight,” Thomas said. “But coming out of the fight … the focus needs to be on taking care of somebody who’s had a TBI as best we can, for a lifetime. It’s a significant investment and we do owe them that.”

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DENTAL HEALTH AND READINESS Keeping soldiers deployable and in the fight

n WITH THE RECENT ANNOUNCEMENT OF THE Department of Defense (DOD) policy emphasizing reducing the number of non-deployable service members and improving personnel readiness across the force, readiness is an increasingly significant topic.

Dental health is a key aspect of personnel readiness, and the U.S. Army provides a representative example of military branches’ efforts to maintain oral health- and dental-readiness levels among its service members, important not only to their general health status, but also to minimize soldiers’ risk of dental emergencies in theater and to reduce the need for medical evacuation.

In describing the terms “oral health” and “dental readiness,” Col. Georgia Rogers, DMD, MPH, consultant to the surgeon general for dental public health, explained how they differ.

“When you say someone’s in a state of oral health, it means that they don’t have any diseases or problems in the mouth that are going to affect their ability to function or speak,” she said. “For the Army, dental readiness means that the soldier is either in a state of oral health, or they have minor levels of oral diseases or conditions that are not expected to become a dental emergency within the next year. They’re low risk. It doesn’t mean they’re disease free; it just means that we don’t think their problems are going to become serious.”

However, despite best efforts to screen and treat dental conditions as efficiently as possible, sometimes dental emergencies during deployment do occur due to pre-existing disease, postoperative complications arising from last-minute dental treatment at mobilization platforms, new disease, or orofacial injuries, Rogers explained.

Lifestyle differences in deployed environments, including poor oral hygiene, unhealthy diet, or 26

■■ U.S. Army Maj. Alexa Rihani, deployed in support of Combined Joint Task Force-

Operation Inherent Resolve and attached to the 2nd Brigade Combat Team, 82nd Airborne Division, gives 1st Lt. Jose Funes a dental exam at the medical treatment facility at Qayyarah West Airfield, Iraq, July 26, 2017.

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U.S. ARMY PHOTO BY CPL. RACHEL DIEHM

By Gail Gourley

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tobacco use, can exacerbate dental problems such as pain or infection caused by cavities, infected wisdom teeth, or acute gingivitis.

“The reason these dental emergencies are important is because when a soldier has to be transported by their unit for dental care in theater, it’s not just that soldier. You usually lose several people because you have to transport the soldier in a vehicle, sometimes with a convoy,” said Rogers. “So, unless you’re stationed on a forward base that has a dentist, it can be very difficult for the unit. And sometimes the infections and problems are severe enough that the soldier has to be medically evacuated.”

Rogers noted, “Dental disease and non-battle injury data from July 2009 to June 2011 for Operation Iraqi Freedom shows that on average, a soldier is lost for three days each time they seek dental care. This does not include the soldiers that are lost to the unit to transport the soldier who needs dental treatment.”

In order to determine soldiers’ dental readiness and minimize their risk of dental emergencies while deployed, the Army utilizes the Department of Defense Oral Health and Readiness Classification System, assigning their status to one of four classes.

Dental Class 1 indicates the soldier has had a complete dental checkup and cleaning within the past year and requires no dental treatment (dental wellness); Class 2 assignment means the soldier requires some type of dental care, such as a simple filling or dental cleaning, but the treatment needs are unlikely to cause a dental emergency in the next 12 months; Class 3 designation specifies the soldier requires dental care as soon as possible for urgent dental treatment needs that are likely to cause a dental emergency in the next 12 months; and Class 4 means the soldier is in need of an annual dental exam to determine oral and dental health.

Classes 1 and 2 are dentally ready for deployment, while Classes 3 and 4 are considered not dentally ready and non-deployable.

“One of the big highlights in Army dentistry since 2013 has been improvements not only in dental readiness, but dental wellness,” said Maj. Peter Drouillard, DDS, deputy chief, Dental Programs, U.S. Army Medical Command. He cited current numbers for active-duty soldiers showing that 63.3 percent are Class 1, 34 percent are Class 2, 0.8 percent are Class 3 with urgent dental treatment needs, and 1.8 percent are Class 4, in need of an exam. That translates to dental readiness levels at 97.3 percent.

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■■ A Go First Class program image promoting dental readiness. The Go First Class

program combines dental exams, cleanings, and fillings into one visit.

For unit commanders, a color-coded monitoring and reporting system for readiness clearly shows which of their soldiers need dental exams or treatment, said Rogers, so they can ensure those soldiers complete their treatment. “One of the most important things is that the command team stays on top of the issue, and encourages those soldiers to come in for care,” she said.

“Even though a Dental Class 2 soldier is deployable, they still require some type of treatment for an oral disease or condition, so they are at a slightly increased risk for dental emergencies during deployment,” Rogers said. “Studies have shown that a Class 2 soldier is about twice as likely to have a dental emergency as a Dental Class 1 soldier. A Dental Class 3 soldier is about seven or eight times more likely to have a dental emergency than a Dental Class 1 soldier, so I think the classification system works fairly well at predicting emergencies. Ensuring that soldiers do their best to not just attain, but maintain Dental Class 1 status reduces their risk of being taken out of the fight by a dental emergency.”

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Regarding the recent DOD policy changes concerning military retention for non-deployable service members, Rogers said, “The new policy is looking at soldiers who are non-deployable for 12 months or more, and fortunately for the soldiers, there are very few dental conditions that fall into that category. Most Dental Class 3 problems can be treated within 30 to 90 days. A small percent takes longer, but very few last for more than a year.”

Oral health is important for many reasons whether deployed or not, and can have an effect on general health.

“People use their mouth all day long, to communicate and interact socially,” said Rogers, “and yet they don’t really think about how important their mouth is until they lose that function.”

Rogers indicated studies have linked dental problems with cardiovascular disease, diabetes, dementia, and stroke. She added, “Other studies have shown that people in poor dental health are usually less likely to be willing to eat a healthy, high fiber, whole grain diet with fresh fruits and vegetables, tending to prefer processed foods because they require very little or no chewing, so it can affect your nutrition intake.”

Drouillard pointed to another connection between oral and general health. “The mouth can also be used as a diagnostic tool to reflect systemic conditions that are occurring in the body,” he said. “Sometimes findings in the mouth can alert an astute dentist to consult with other medical providers to determine whether the patient’s at increased risk for [other diseases]. So the mouth can also be a window into systemic health.”

Poor oral health can also cause difficulty sleeping and inability to concentrate. “Sometimes people say, ‘I can put up with a little bit of a toothache,’” Rogers said. “But the infections and the pain are usually very distracting, so when you’re out on a mission when you’re deployed, if you’re having a problem concentrating on what’s around you, having difficulty focusing on what people are telling you, you have pain when you try to sleep, you can’t sleep, it runs people down quickly. So that’s usually why they have to end up being medically evacuated even if they try to tough it out.”

To advance oral health and readiness, the U.S. Army Dental Command initiated several programs in a multifaceted effort to improve soldiers’ dental treatment and increase efficiency. Implemented in 2004, the First-term Dental Readiness program provides a dental exam and treatment to recruits, and those with Class 3 problems are identified. “The goal is to complete the dental care that they need so that at least 95 percent of soldiers who graduate from Advanced Individual Training, or AIT, having completed both the initial entry training portion of basic and career training for their specialty, are dentally ready,” Rogers said. “The goal is to get them to their first permanent duty station ready and deployable.”

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Another program, Go First Class, “was a major change in the way that we operate our clinical operations as far as scheduling,” Drouillard explained. “It was implemented across the Army Dental Care System in 2013, and the big change is that it combined a required annual dental exam with a dental cleaning and, if possible, minor restorative care, into one single patient encounter or appointment.”

Previously accomplished at separate times, the new program provided more efficient and cost-effective care, and, he added, “We’ve seen dramatic improvements particularly in dental wellness rates because several of our soldiers only needed a cleaning to be converted from a Class 2 state to a Class 1 state. By addressing that treatment need and/or one or two fillings, we were able to move them to a better classification of dental readiness.”

A third readiness initiative, implemented in 2010, then revised and fully fielded in 2015, is the High Caries Risk Program. “It’s an Army-wide initiative to help soldiers break the cycle of decay-repair-decay,” Drouillard said. “So there’s disease, then you fill it, and then you get disease around that filling, and the cycle perpetuates when dental treatment is performed but the soldier’s individual risk factors are not addressed. You didn’t address the cause of the disease, you just addressed the sequelae. The High Caries Risk Program was developed to provide education and intervention through several factors – nutritional assessment, application of fluoride varnishes to increase that beneficial effect of fluoride in the mouth, tobacco cessation counseling, and practical oral hygiene reminders.”

The Army Dental Care System is supporting other endeavors to improve readiness, including research on the treatment of sleep apnea, a sleep disorder in which breathing stops and starts. “We are using oral appliances for mild and moderate sleep apnea treatment in place of CPAP [continuous positive airway pressure] machines and other devices,” said Drouillard. “For a deploying soldier carrying around [an oral appliance] versus having to both transport and maintain a CPAP machine, it makes a big difference.

There’s been a large push to involve Army dentistry in that aspect of care, and of course, that has a readiness aspect to it as well; if you can improve a soldier’s care for sleep apnea, then potentially they could be more fit to fight.”

Another ongoing effort involves increasing use of CAD/CAM (computer-aided design/computer-aided manufacturing) technology. Rogers explained that if a soldier in a stateside setting needs a crown, for example, they could transmit a digital image of the prepared tooth from a handheld scanner to a dental facility with CAD/CAM capability where a crown could be milled and shipped. “Theoretically if you have that on site, the patient goes home with the crown the same day. And if you’re nearby, you could have their crown back in 24 to 48 hours,” she said. Without this technology, it can take weeks for the same process, so this improves readiness because when a patient is waiting for a 29

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■■ Dr. Charles Wiseman​,​DDS, performs a dental exam on Spc. Christopher Ruocco, of the Trenton, N​ew Jersey-​based 445th Quartermaster

U.S. ARMY PHOTO BY SGT. 1ST CLASS JASON HUDSON, 91ST TRAINING DIVISION PUBLIC AFFAIRS

Battalion, June 8​, 2016,​at a Periodic Health Assessment (​ PHA) ​held on Fort Hunter Liggett during the 91st Training Division’s Combat Support Training Exercise​. The PHA helped hundreds of soldiers maintain their medical and dental readiness.

crown, they’re usually considered Dental Class 3, and nondeployable for that time.

Drouillard added, “In theater care, you would reduce how far the soldier would have to be evacuated back if there were something that happened that required a dental prosthesis if you could mill that at a combat support hospital, for example, instead of evacuating them all the way back to a higher level of care in the United States or somewhere in Europe. It gives us a little bit more versatility to address dental treatment needs at a lower level. We’re not quite there yet, but it’s certainly something that’s been discussed.”

Regarding hurdles encountered in dental health and readiness efforts, Rogers said, “I always say that the big challenge we have in the Army isn’t attaining dental readiness; it’s maintaining it. We can treat soldiers into Dental Class 1 and treat their disease, for the most part. But the challenge is keeping them there.”

With soldiers having access to dental care, but only about 63 percent currently dentally healthy, or Class 1, Rogers said,

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“It reinforces the fact that dental treatment is not the biggest determinant of oral health. Personal habits are.”

Drouillard noted that it’s also crucial to keep Army dentistry readiness programs fresh and to educate new dentists coming into the fold about those programs as personnel changes occur. “The military is renowned for moving the pieces around; soldiers move around the country and the world, so as you transition, it’s important to sustain the gains that you’ve accomplished through successful dental programs,” he said.

“Our job as dental leaders is to educate line commanders on not only the benefits of oral health, but the potential risks that they’re susceptible to if they find themselves in an austere environment and the soldier develops a toothache,” Drouillard concluded. “That is a challenge and something that we deal with, both as dental providers and military officers – educating our leaders working as a team, the same way our medical colleagues do, to get information to the fighting force.”

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REDUCING NURSES’ INJURIES WITH TRAINING AND TECHNOLOGY

By Gail Gourley n PATIENT SAFETY DURING HOSPITALIZATION is a constant concern, given the possibility of infections, errors, or accidents. But hospitals can also be a hazardous work environment for nursing staff – one of the most perilous, in fact. Bureau of Labor Statistics data show that U.S. hospitals recorded more work-related injuries and illnesses causing employees to miss work days than the construction or manufacturing industries. Injury causes include slips, trips and falls, contact with objects such as needle sticks, and violence, but the majority of nursing injuries are caused by overexertion and bodily reaction from motions like lifting, bending, or reaching related to moving or transferring patients who have limited mobility.

The Department of Veterans Affairs (VA) has been at the forefront of an effort to protect nurses and reduce the incidence of those injuries. The Veterans Health Administration (VHA) implemented a Safe Patient Handling program in all VA medical centers a decade ago, and has since seen a dramatic reduction in nurses’ injuries.

“Before the 2000s, there was little happening in the VA or around the country to protect nurses from injury,” said Jill A. Earwood, MSN-HCQ, CSPHP, RN, VHA Office of Nursing Services liaison for Safe Patient Handling and Mobility and the Asheville VA safe patient handling and mobility coordinator/nursing quality manager. “In the 1990s, a nurse researcher, Audrey Nelson at the Tampa VA [Patient] Safety Center, saw a need to protect nurses from injuries. She led the way with Dr. Michael Hodgson, at that time the VA chief consultant for occupational health and safety, and ergonomist Mary Matz. They created pilot sites to demonstrate the role of technology with bedside nurses and how the solutions would hopefully be successful in reducing nursing injuries.”

The pilots were highly successful, said Earwood, and in 2008, a VHA “Executive Decision Memo” and funding of more than $200 million signaled the national roll-out of the Safe Patient Handling program in 153 VA medical centers.

The program to reduce injuries focused on patient-handling because, with approximately 47 percent of injuries resulting from mobilizing patients, it is the most common work-related injury to nursing staff, which includes registered nurses, 32

licensed practical nurses/licensed vocational nurses, and nursing assistants.

The program has made a significant difference. “Since the implementation of Safe Patient Handling in the VA, nursing injuries overall have decreased 40 percent, and specific injuries related to patient-handling have been reduced by 50 percent,” Earwood said.

The program is now identified as Safe Patient Handling and Mobility (SPHM), adding the word “mobility,” Earwood explained, “because we recognized that the technology we use to move our patients also contributes to their early mobilization.”

Caregivers regularly reposition and transfer patients who have limited mobility as an integral part of their care, traditionally using manual techniques that emphasized using proper body mechanics but too often resulted in musculoskeletal injury. “Nurses mobilize patients; we know that’s risky,” Earwood said. She pointed to research estimating that “in an inpatient setting, nurses will lift, push, pull, tug approximately 1.8 tons in an 8-hour shift if they use manual techniques alone,” adding that most nurses work 12-hour shifts.

“If nurses are injured and working, hurting and working, taking medications to alleviate pain, our patients are at risk and the quality of care suffers,” said Earwood. Additionally, “nurses sometimes have their careers ended and have to seek other ways to contribute to the mission rather than direct care. That’s why the VA focused on patient-handling injuries in particular.”

To reduce the risk of injury, the SPHM program utilizes a wide array of technology to mobilize patients. Overhead fullbody lifts using slings mounted on ceiling tracks assist with transferring patients out of bed and into a chair, for example.

Earwood said when the program was instituted, the goal was for all facilities to have full-body lifts in at least 75 percent of their direct-care areas within the first years of the program, and that has been successful.

Other technology includes powered standing-assist devices and non-powered stand aids. “We have air-assisted technology [that] helps us move patients from one surface to another or even from the ground up, because we know a lot of individuals sustain life-altering injuries from trying to lift someone

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■■ Brooke Army Medical Center nurses complete annual training on patient restraint techniques during Nursing Skills Validation Nov. 19,

PHOTO BY ROBERT SHIELDS

2014, at the San Antonio Military Medical Center.

up off the floor who is unable to get up,” said Earwood. “We also have many devices for hygiene, like shower chairs that are powered and powered lift devices for toilets; and we have specialty beds and specialty stretchers that are powered.”

And, she added, they have technology to help patients when they arrive at the hospital and need assistance getting out of a vehicle, when the previous method was “all hands on deck, do the best we could.”

The use of technology also promotes the beneficial aspects of early mobilization for patients. One example Earwood cited is “a patient in an ICU that is on a ventilator for supportive breathing and we help that person ambulate using a floor-based lift, and subsequently they are able to come off that ventilator, whereas before they were dependent on the ventilator and weren’t able to be weaned off it.” While the SPHM program and the technology utilized protect nurses from injury, she said, “This doesn’t just benefit the nurse. It benefits the patient.”

The increased focus on the benefits of early patient mobilization has heightened the need for assessment tools. “We

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know as nurses,” said Earwood, “if we move people, they get better, so we mobilize our patients earlier and earlier. That can create risk for both patient and nurse; the patient can fall more easily, and the nurse is trying to catch the falling patient.”

While the SPHM program provides algorithms to help nurses choose equipment based on the patient’s mobility status, she continued, “What we haven’t had until recently was an objective tool that helps us assess a patient’s mobility status.”

To aid in assessing the mobility status of patients, Earwood said the VA Office of Nursing Services recently signed a national licensing agreement to utilize the industry-developed Bedside Mobility Assessment Tool, an instrument that “gives a nurse an objective way to do an assessment on a patient, and that assessment then indicates what equipment is needed to move the patient safely so the patient is protected from falling and the nurse is protected from being injured.

We’re excited about this. This is new, and we’re hoping this is going to help us reduce not just our nurses’ injuries but also our patients’ injuries from falls.”

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The VHA’s strong support for the SPHM program extends from the national level to the regional Veterans Integrated Service Networks (VISNs) to individual hospitals and units. A national program manager leads a network of facility coordinators to manage the programs at the local level, Earwood explained, with each facility having its own SPHM coordinator and program. Unit peer leaders are the “unit-level champions and the cornerstone of the culture change to prevent injuries,” said Earwood. “They step in to remind co-workers about using the technology and they help with training.”

Earwood said many facility coordinators from across the country also participate at the national level in technical advisory groups that work on finding solutions to specific challenging issues, such as maintaining a safe environment of care for nurses and patients in mental health or perioperative environments.

These groups provide an opportunity to share information. “I can assure you that I have taken ideas from others and implemented them here in Asheville,” said Earwood. “We are a network of individuals who want to see one another succeed and have solutions that work.”

In an effort to share best practices with the private sector, a number of facility coordinators participate in a group called Universal Safe Patient Handling and Mobility, “working with private partners and even internationally to share ideas. There are private-sector facilities that have excellent programs; we want to learn from them, and they’re learning from us,” Earwood said.

Collaboration also occurs at SPHM national conferences that include the VA and private sector. And some facility coordinators are partnering with schools of nursing and the American Association of Colleges of Nursing to assist them in connecting with vendors, for example, in an effort to augment the technology in their simulation labs.

Training for SPHM increasingly highlights utilization of simulation technology, according to Earwood. “We have simulation coordinators throughout the VA and it’s definitely becoming more of a focus area for all types of training,” she said, adding that simulating specific scenarios regarding new and emerging patient mobilization challenges was highlighted at a recent VA-hosted SPHM conference.

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■■ In a demonstration of safe patient-handling techniques, Kelsey McCoskey, U.S.

Army Public Health Command Joseph A. Lovell award winner, uses a repositioning sheet and ceiling lift to reposition a volunteer in August 2013.

Despite the commitment to reduce injuries, they do still occur, in part because culture change and adoption of technology can take time, Earwood said. “We encourage [the] reporting of injuries, no matter what the cause, so injured nurses can receive treatment and we can process claims in a timely manner,” she said. “The VA is committed to those employees. There is a continuation-of-pay system and a liberal leave policy. We provide light-duty assignments to prevent re-injury during a time when they may not be well 35

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enough to take care of patients, following their physician’s recommendation. If a nurse cannot return to direct clinical care, every effort is made to assign them to a nonclinical role, but still able to contribute their expertise on patient care, because we don’t want to lose that nurse.”

In addition to the health implications of nurse injuries, the monetary cost can also be significant. “In theory, if we decrease the injuries, we decrease the cost,” said Earwood. “What we do know is that hospital workers’ compensation claims are between $9,000 and $12,000. The average cost of a low back injury in the U.S. is about $40,000. The average cost in the VA to replace a nurse injured so badly that he or she cannot return to direct care is between $40,000 and $80,000 depending on location. But the indirect costs outweigh the direct cost about 5-to-1, according to the U.S. Department of Labor, because there’s just so much involved in putting a nurse at the bedside. So, we believe as we reduce nursing injuries we certainly reduce costs and lost time.”

In expressing an even broader view, Earwood said, “In my role working with the Office of Nursing Services and nurse leaders in the VA, we are all fully aware that we have an emerging trend with a shortage of nurses in the coming decade, because a lot of ‘baby boomer’ nurses will be concluding their careers. So, it’s beneficial to the VA to do everything we can to keep nurses healthy and to support their vitality.”

Noting another trend, Earwood said while the overall and patient-handling injury rates for VA nurses continue to decrease, injuries from assault have increased approximately 31 percent over roughly eight years. “Even though the rate of injuries from assault is still lower than the rate of injuries from patient-handling, it is an increase, and we recognize that needs to be an area of focus,” she said.

Assaults can occur either by patients who act deliberately or by those who exhibit poor impulse control, such as a patient with dementia, Earwood explained, adding, “Each situation can pose a unique risk to the nurse.”

The VA’s Prevention and Management of Disruptive Behavior program provides

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■■ VA nurses Heather Frank (left) and Jill Jefferson, along with Simulator SAM, during ICU

simulation training at the VA Central Iowa Health Care System in Des Moines, Iowa.

education and training to address those risks. “But we’re finding that those programs are somewhat ineffective for that category of dementia,” she said, “so the VA has programs that are fairly new and being introduced in the facilities, that help give our nurses tools in how to approach those patients better.”

Earwood identified other challenges in their efforts to reduce nurses’ injuries.

“Our schools of nursing, even though they have some of the most amazing simulation spaces, are still teaching our students body mechanics as the primary way to prevent injury from moving patients. So, our schools are behind, unfortunately. That’s probably one of biggest challenges we face,” she said.

Access to training can be difficult because nurses need to be able to come away from patient care to be trained, Earwood explained. “That’s been the age-old problem in nursing: How do we have time to take care of the patients and to also take the needed time for training? We accomplish it, but it’s always a challenge in organizing.”

Additionally, she pointed to the need to support facilities’ efforts to replace SPHM technology and equipment as it ages, and to promote design aspects that enhance SPHM components in facility renovation and construction.

Earwood emphasized that the VA is committed to providing a safe working environment through access to technology across all settings, through construction and design, and through training. She referred to a 2015 National Public Radio feature highlighting the VA’s SPHM program development as an example of innovation and leadership regarding reduction of nurses’ injuries.

“Those of us who are VA employees are committed to veterans. That’s why we work at the VA,” Earwood concluded, and with a predicted upcoming critical shortage of nursing staff, added, “The VA is committed to keeping nurses safe and healthy so that we’re able to support veterans into the future.”

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THE NATIONAL CENTER FOR PATIENT SAFETY Creating “an army of patient safety leaders”

By Craig Collins n DR. DOUGLAS E. PAULL, acting chief officer of the Department of Veterans Affairs’ National Center for Patient Safety (NCPS), is good at offering examples, real and hypothetical, that illustrate the many ways things can go wrong in a health care setting – while also demonstrating the value of his center’s work. “Let’s say there is a nurse taking care of a sick patient in an intensive care unit,” he said. The nurse wants to flush the patient’s intravascular catheter with a blood thinner, heparin, a routine procedure, and he/she finds two vials in the cabinet: one a relatively weak solution, and another that’s considerably stronger.

The nurse wants to use the weaker one. “But the two vials in the cabinet look nearly identical,” Paull said. “They both have a blue label on them. They both have a similar cap. Yes, there’s writing in a small font that spells out the concentration. It’s clearly there. And yes, the unit has policies and rules for checking medicine. But that nurse is a little fatigued. Maybe it’s his or her second shift. Maybe they’ve been taking care of several sick patients. Maybe they’re distracted for just a moment. And maybe they flush the line with the wrong medicine.”

In 1999, when the Institute of Medicine (IOM, now the National Academy of Medicine) published “To Err is Human: Building a Safer Health System,” the report was a wake-up call for health care organizations and professionals. Between 3 and 3.5 percent of patients admitted to U.S. health care facilities suffered an adverse event during their stay, the report reads, and more than half these events were preventable. This meant that avoidable adverse events in health care were a leading cause of death in the United States.

A year earlier, in 1999, the Department of Veterans Affairs (VA) had established the NCPS to lead patient safety efforts throughout its health care system, the Veterans Health Administration (VHA). Located in Ann Arbor, Michigan, with a field office in White River Junction, Vermont, the NCPS, with a staff of about 60 38

people, leverages its expertise and works to improve patient safety in every facility that treats American veterans.

Since NCPS’ inception, its patient safety experts have studied the principles of what are known as highreliability organizations (HROs), such as the aviation and nuclear power industries, where daily operations are a matter of life and death – and where mistakes are exceedingly rare. Today, Paull said, the center’s tools for analysis and outreach help embed these principles, some of which may surprise outsiders, in VHA facilities. For example, leaders within the most effective HROs are engaged and sensitive to what’s going on at the front lines – they want to discover bad news and fix what caused it, rather than hide from it – and defer to others not because of their title, but because they have the skills and knowledge to solve problems. For all the talk of “accountability” in the working world, HROs often have a different way of establishing it: They don’t target the “who” – the people who make mistakes – but the “why.” The “whys” are key to beginning the process of making sure a mistake isn’t repeated, and that a more resilient and “fault-tolerant” health care organization results.

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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

■■ Patient safety is the prevention of inadvertent harm or injury to patients, including the identification and control of hazards and

vulnerabilities that could cause harm to patients. In March 2017, the NCPS stated it had contributed to an 82 percent decrease in deaths from suicide in VA inpatient mental health; helped reduce major fall-related injuries by five per month since 2012; fostered a strong culture of safety throughout the VHA; and created a five-step process for ensuring correct surgery procedures.

In the 1970s, Paull said, when the aviation industry began to study itself and discover the reasons for plane crashes, it found these reasons went far beyond mechanical failures; they extended to cockpits and control towers. “It was the conversations that weren’t happening, the lack of communication, the lack of planning or situational awareness or interaction. It was the things that weren’t said. In any health care organization, communication is one of the most common contributing factors [to mistakes]. When something bad is happening, usually somebody knows about it, and yet there is something that prevents them sometimes from speaking up about their concern. We’re really talking about creating a culture of safety.”

VA PHOTO

TOOLS FOR PROTECTING PATIENTS: DISCOVERING THE “WHY”

The programs and initiatives offered by NCPS are aimed at creating this culture. In Paull’s example of the nurse who mistakenly used the wrong concentration of heparin to flush a patient’s catheter, a response favored by some people would be to discipline the nurse, even fire her, especially if

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the patient were harmed. This, however, would do nothing to assure such a mistake didn’t happen again. The center’s most proximate tool for preventing recurrent harm is the Root Cause Analysis (RCA), a team approach involving professionals from the appropriate disciplines who meet to find out what happened and why; to make sure it doesn’t happen again; and to follow up by measuring whether corrective actions have made a difference.

RCA teams develop flow diagrams of the events that occurred prior to an adverse event. “That tells you what happened,” Paull said. “But then we start to ask the deeper questions, the whys. We’ve developed what we call a causal statement.” The causal statement must be precise – it can’t simply state, for example, that a person didn’t follow policy. “You have to ask why didn’t they follow policy,” said Paull. “Did they even know there was a policy? Were they trained in that policy? When was their training? Maybe the training was three years ago. Do they have recurrent training? Is anybody providing oversight? … When you start to frame these causal statements you find out that for most things that go wrong, there are multiple contributing factors. In fact, we probably 39

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shouldn’t call it Root Cause Analysis, because there is very seldom, in my opinion almost never, a single root cause.” The example of the nurse and the blood thinner, if explored by an RCA team, might discover issues associated with staffing, fatigue, or an ill-timed distraction. “And of course, there are two look-alike medications, so that’s a big problem. Why isn’t one a different color – or why aren’t they otherwise separated? Anyone in a hurry might have picked the wrong one.”

This isn’t to say the organization is completely blind to blameworthy acts that cause harm. Criminal or deliberately unsafe acts – such as a surgeon willfully ignoring a mandatory “time out” between procedures – are subject to disciplinary action in the VHA, as in any other health care setting.

RCAs are used not only to examine adverse events, but also close calls or near misses – mistakes that were caught and corrected before they could cause harm. They occur much more often than adverse events, and addressing mistakes in this way not only results in a safer system, but also focuses the attention of everyone involved on continually identifying and correcting potential problems.

■■ In keeping with the center’s emphasis on proactive measures, many of its initiatives focus on instilling a culture of safety in the emerging generation of health care professionals through education and training.

An RCA is, by definition, reactive in nature; it happens after an adverse event or a close call has occurred. The center’s primary tool for proactively analyzing new procedures or medical devices is a process called Healthcare Failure Mode and Effects Analysis (HFMEA), a risk-assessment method adapted from the engineering profession. It’s a more technical process, involving a bigger team than an RCA, but it’s a useful tool for gaming out the consequences of proposed changes to the health care environment – say, the introduction of a new or updated electronic health record. “Imagine the unintended consequences of introducing staff to a completely new software program,” Paull said. “All kinds of things could happen. So instead of just introducing it, we do things like HFMEA to look at the process. Where are the potential failure points, where are the hazards? And then we can start to prevent those things from happening during a pre-implementation phase.”

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AN ORGANIZATIONAL CULTURE OF SAFETY

The NCPS is world famous for designing these two processes for answering questions – What happened and why?

What might happen and why? – that seem deceptively simple, but are anything but simple in health care settings. The RCA and the HFMEA are the backbone of the center’s work, but they are far from comprising all that NCPS does. The staff in Ann Arbor and White River Junction aren’t just a bunch of health care nerds, crunching numbers in cubicles. They are, like Paull, passionately dedicated to protecting veteran patients from harm. They work to spread the gospel of patient safety to every corner of the VHA, and beyond – and their work has measurably improved outcomes within the VHA. The center’s outreach to VHA medical professionals takes many forms. The Daily Plan®, a patient-centered document template designed by NCPS staff, is a means of prompting communication between patients and providers. Each month, more than 75,000 veterans use this document to review with their providers what they can expect on a specific day of hospitalization – medications, tests, imaging orders, and future appointments, for example – as a way of identifying and preventing potential errors. Through its webbased Patient Safety Assessment Tool (PSAT), which allows VHA managers and staff to conduct a detailed assessment of their patient safety program according to guidelines and best practices, and the Patient Safety Centers of Inquiry, which develop and disseminate relevant innovations (such as new protocols for reducing hospital-acquired infections), NCPS teams up with frontline providers to enact HRO principles.

The NCPS sometimes aims its expertise at a specific problem. The leading category of adverse events in the RCAs submitted to the NCPS’ internal, confidential patient safety reporting system, for example, is patient falls. In response, NCPS created the Falls Toolkit, an online package of resources that helps facilities design their own comprehensive fall prevention programs. Still one of the most frequently downloaded items on the NCPS website, the Falls Toolkit has helped reduce major fall-related injuries in VHA facilities.

Another program, first implemented in 2007, has helped to substantially reduce the number of suicides completed by inpatients at VHA mental health facilities. NCPS designed and distributed the Mental Health Environment of Care Checklist as a tool for these facilities to survey and recognize environmental hazards – items or conditions in patients’ rooms and living areas – that could increase the likelihood of a completed suicide. The checklist was deployed throughout VHA’s inpatient facilities, and a follow-up review of RCA data from 2000 to 2015 found that after its 2007 introduction, the completed suicide rate dropped 82 percent at these facilities.

In keeping with the center’s emphasis on proactive measures, many of its initiatives focus on instilling a culture of safety in the emerging generation of health care professionals through education and training. Thousands of VA

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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

■■ Medical personnel from the Eisenhower Army Medical Center conduct a procedure in the operating room on Aug. 17, 2015. Surgeons within

DOD PHOTOGRAPH BY JOHN CORLEY, EAMC MEDICAL PHOTOGRAPHER, U.S. ARMY

the Veterans Health Administration are required to take a “time out” between operations.

personnel nationwide have received training though the NCPS’ Clinical Team Training (CTT) program, which improves patient safety by facilitating clear, timely communication among multidisciplinary teams. Modeled after the aviation industry’s crew resource management training, CTT has demonstrated measurable improvements in patient safety outcomes, including fewer medication errors, surgical mortality, hospital-acquired pressure ulcers, and “failure to rescue events” among groups trained in CTT methods.

Two other NCPS programs reach back to the earliest stages of medical education. The center has worked with leaders at VA medical centers and their affiliated university schools of medicine to create patient safety curricula for faculty development and resident education, and since 2002, dozens of workshops, customized to fit the needs of host facilities, have been conducted for thousands of faculty and residents across the nation. In partnership with the VA’s Office of Academic Affiliations (OAA), NCPS offers a one-year fellowship in patient safety to applicants from both clinical and non-clinical disciplines. Another NCPS/OAA collaboration offers

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chief residents a one-year program of learning and teaching about quality and patient safety while improving safety at their home facilities. Today, more than 80 Chief Residents in Quality and Patient Safety are learning and leading at more than 55 VA facilities.

The effects of this work are accumulating not only throughout the VHA, Paull said, but also throughout American medicine. “There aren’t enough people on faculty in the United States who have expertise in quality and safety, who know how to do a root-cause analysis, how to create control charts, how to use that data,” he said. “I’m meeting young people who were Chief Residents in Quality and Safety 10 years ago, and now they’re assistant chiefs of staff. They’re making decisions for our nation’s veterans. They’re teaching junior residents. So we’re forming an army of patient safety leaders, and each of them is creating an army – and by the way, 70 percent of all U.S. physicians and nurses train at VA facilities in their lifetime. So we’re getting to most of the people in the country who will be taking care of you and me.

We’re force-multiplying.”

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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

INTERVIEW

LYNDA C. DAVIS, Ph.D. Chief Veterans Experience Officer, Veterans Experience Office

By Rhonda Carpenter

Veterans Affairs & Military Medicine Outlook: Can you explain the mission of the Veterans Experience Office (VEO) and how it carries out that mission?

Lynda C. Davis: VEO is VA’s veteran “Customer” Experience Office [CXO that] reports directly to the VA [Department of Veterans Affairs] secretary.

[Its] mission is carried out through VEO’s application of industry best-practice CX capabilities for data, tools, technology, and engagement.

For CX data, VEO captures and analyzes the voices of veterans, and their family members, caregivers, and survivors using human-centered design; real-time customer experience surveys using a platform employed by the leading CX organizations in the private sector; and veteran-experience data analytics to understand and detect trending topics.

With respect to CX tools, VEO has built and delivered tools and products for VA, starting with our partnership with the Veterans Health Administration [VHA], that are customer driven and industry informed, including CX Patient Experience [Directorate] training, personal facility navigation services, and Journey Maps.

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■■ Lynda C. Davis, Ph.D., Chief Veterans Experience Officer,

Department of Veterans Affairs.

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COURTESY VETERANS EXPERIENCE OFFICE

n LYNDA C. DAVIS, Ph.D., serves as the chief veterans experience officer for the Department of Veterans Affairs. She is a former U.S. Army signal officer and has worked at the departments of Navy and Defense.

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

For CX technology, VEO focuses on delivering easy, effective, and emotionally resonant veteran experiences through all communications channels including online, by phone, and in person.

Finally, for CX engagement, VEO supports veterans through enhanced outreach and involvement and the better coordination and integration of VA and non-VA services and resources at the local level through collaboration with Community Veteran Engagement Boards, Federal Advisory Committees, and other strategic partners.

You are a former Army signal officer. How has your military service prepared you for this job?

My Army time reinforced my commitment to service and gave me critical leadership and management skills needed to be effective in the execution of policy and programs that meet mission requirements.

How is the VEO organized and what are the responsibilities of each of the directorates?

VEO is organized in six directorates: 1) Portfolio Management manages project development and resources including program evaluation and accountability reporting oversight; 2) Insights and Analytics captures and analyzes the voices of veterans, their families, caregivers, and survivors through the application of best-practice tools and technology; 3) Multi-channel Technology, delivers easy and effective veteran experiences through all communications channels, which includes vets.gov; 4) VA Patient Experience builds and delivers veteran experience tools and products for the Veterans Health Administration and staff offices; 5) VA Benefits Experience builds and delivers veteran experience tools and products for the Veterans Benefits Administration, National Cemetery Administration, Board of Veteran Appeals, and VA Central Office; and 6) Community Engagement supports veterans through coordination and integration of local VA and non-VA services that includes our Community Veterans Engagement Boards, Veteran Friendly Communities, and our federal advisory committees’ work.

■■ “For CX data, VEO captures and analyzes the voices of veterans, and their family members, caregivers, and survivors using human-centered design; real-time customer experience surveys using a platform employed by the leading CX organizations in the private sector; and veteranexperience data analytics to understand and detect trending topics.”

What is your role at the Department of Veterans Affairs?

As a direct report to the secretary and an assistant secretary equivalent, I am part of the VA leadership team. I have a responsibility to not only lead the unique and important new Office of CX but to ensure that the policies and practices across the VA are designed and implemented with leaders, managers, and all VA employees to successfully meet the commitment we all have to serve veterans and assist the family members, caregivers, and survivors who support them with the best possible care and benefits experience based on their voice.

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On a personal level, what were some of the veterans’ issues you wanted to take on when you knew you were going to be appointed to the job?

Having served in the military myself, being the mother of a veteran and also the caregiver of a disabled veteran and of a veteran’s widow, I knew I wanted to apply my personal experience and my treasured time with my peers to ensuring that their voices were heard.

Thus, my first pledge to the secretary was that the CX capabilities of VEO would be hardwired across the department to support the delivery of all care and benefits services across VA and to inform service recovery and program improvement through policy and operations. My second act was to recommend the formation of a federal advisory committee for veterans’ families, caregivers, and survivors.

My management of the Choose Home Initiative in support of VA’s delivery of comprehensive services to aging and seriously wounded, ill, or injured veterans in their homes and communities enables me to support this important VA-wide commitment to enhance VA case management and to better integrate supplementary community-based resources.

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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

What are some of the challenges you’ve faced since your appointment to lead the VEO? The challenges in the first year on the job were twofold: 1) to help VEO, as a new office modeled on industry practices with unique capabilities, to communicate its value-add to the department, specifically the administrations with responsibility for delivering service to our special customers, the veterans and families, caregivers, and survivors they serve, and 2) to help the VA administrations understand and apply that value-add to their operations.

I am delighted to report that significant progress has been made. VEO and its emphasis on CX is now recognized as a permanent part of the VA culture; its value has been proven through projects like Patient Experience, under which VEO and the VHA are implementing private-sector customer service best practices at all VA hospitals and are testing the use of a major customer feedback program that will enable our veteran patients to tell us about their specific experience. It will also empower our employees to take action to improve the veterans’ experience.

■ ■ “I am delighted to report that significant progress has been made. VEO and its emphasis on CX is now recognized as a permanent part of the VA culture.”

How does the VEO measure success for a veteran?

VEO measures success based on the industry standards of CX ease, effectiveness, and emotional resonance, all of which contribute to the overall experience of trust in the VA and its delivery of care and benefits services. We use multiple channels [websites, call centers, the White House VA Hotline, real-time service-line surveys, comment cards, personal interactions, and more] to listen to veterans’ concerns, compliments, and recommendations about their needs and those of their peers. They are the source of information on both individual need and requirements for service recovery and common needs, and the opportunity for program improvements. We listen, determine appropriate action,

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and then receive feedback on how our actions have addressed the needs we heard. As VA’s CXO, VEO is working across the VA to hardwire the voice of the veteran into policy and operations decision-making for the improved benefit of the veteran.

You’ve also been charged with improving the work experience for VA employees. Could you provide an example of how the VEO is leading this charge? And how would you identify its success?

Through the CX data capabilities VEO brings to the department, VA leaders, managers, and providers will be empowered with concrete customerexperience feedback from veterans. This feedback will better inform their responsibility for service recovery and their opportunity for performance improvements. VEO is providing its employees at all levels with CX training and tools and technology.

For example, in VHA medical facilities, we are implementing a collaborative Leadership Rounding program, a standard Red Coat Ambassador program, and other CX best practices. Across all CX efforts, we are integrating back-end data systems so employees have more complete information on the veteran’s experience and can see the impact of their actions.

What has the response been to the White House VA Hotline?

The response to the White House VA Hotline has been overwhelming. Since becoming a 24/7 contact center on Oct. 15, 2017, the hotline has received more than 53,000 calls, which have been answered by a dedicated team of agents – more than 90 percent of whom are veterans or from a military family.

Of the calls received, 59 percent of the callers are reporting concerns with a VA program or process.

The remaining 41 percent of calls are either compliments, general inquiries, or directory assistance.

The feedback received through the White House VA Hotline not only allows us to address veteran concerns, but also helps us understand the overall veteran’s experience. Veterans express their pleasure [about having] the ability to contact the White House VA Hotline. They call back to relay the timeliness of responses from medical centers for resolving their issues quickly or simply to say what great care they get at their specific VA medical center.

It has been an honor, and the culmination of my personal and professional experience, to continue to support our veterans and their families, caregivers, and survivors as the chief veteran experience officer.

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ON THE CUTTING EDGE

With its first training program for robot-assisted surgeons, the Air Force leads DOD and VA physicians into the future of medicine.

n A COUPLE OF YEARS AGO, when Air Force Maj. (Dr.) Joshua Tyler discovered a surplus in the research budget of his unit – the 81st Surgical Operations Squadron at Keesler Air Force Base, Mississippi – he asked his superiors if he could buy a robot. And not just any robot: a da Vinci Xi® surgical system, the most sophisticated of its kind, the fourth-generation version of the first and only robotic system approved by the Food and Drug Administration (FDA) for general laparoscopic surgery.

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Tyler, a colorectal surgeon at Keesler Medical Center, saw an opportunity to train Air Force surgeons – and surgeons throughout the Departments of Defense (DOD) and Veterans Affairs (VA) – in robot-assisted surgery, which he thought was important for two reasons: first, the growing significance of robotic surgery in performing certain procedures. “I would argue that robotics is the standard of care for urology, especially for prostate surgery,” said Tyler.

“Laparoscopic prostatectomy never really took

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©2018 INTUITIVE SURGICAL

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

■■ OPPOSITE PAGE: The da Vinci Xi robotic surgical system

demonstrates its four arms.

off in the United States, or really worldwide.” He also estimated that more than 80 percent of gynecological cancer surgeries are performed today using robotic systems. “For those two specialties, it’s ubiquitous.”

It’s reasonable to expect that today’s surgeons have been exposed to robotics in their residencies or fellowship programs, because urology and gynecology embraced the technology early in the 21st century.

It wasn’t until 2010 or later that other types of procedures, such as hernia repair or colorectal procedures, were adopted for robot assistance. This is partly due to the fact that the Xi, which allows access to multiple quadrants of the abdomen, didn’t hit the market until 2014. “General surgery has been later to the party,” Tyler said. “Most of our surgeons have not had exposure to robotics in their training programs.”

The costs and complexities of training on the da Vinci system comprised Tyler’s second reason for wanting the Air Force to have its own surgical robot.

Becoming credentialed in robotic surgery begins with a computer-based orientation course, followed by a hands-on orientation, and finally surgeon-tosurgeon training in basic single-site or multi-port surgical skills. It’s a rigidly defined curriculum, and out of necessity, military and VA surgeons who’ve sought certification have traveled to training sites operated by the da Vinci’s manufacturer, Intuitive Surgical® Inc., to receive their instruction.

The federal government has invested hundreds of millions of dollars in the acquisition of surgical robots, but has been slow to establish its own training and credentialing programs. Intuitive offers its credentialing course for a $3,000 training fee, and offers to cover candidates’ travel and accommodation costs – which VA and military physicians, as federal employees, can’t accept. “So suddenly that $3,000 training becomes a $4,500 or $5,000 [cost] for a federal servant,” said Tyler, “and in the current fiscal environment, that’s not really a sustainable model.”

Within Keesler’s Clinical Research Laboratory, Tyler and his colleagues established their training facility, the Institute for Defense Robotic Surgical Education (InDoRSE), for military and VA surgeons to become credentialed operators of the da Vinci system. It’s the first, and so far only, DOD medical facility to offer training with the da Vinci Xi, the

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latest and most advanced system. The InDoRSE is essentially a federal satellite of Intuitive’s Atlanta training facility, saving taxpayers about $3,000 per trained surgeon. So far, at a rate of about four per month, the facility has trained 41 surgeons from 21 different facilities across the DOD and VA, from among five different surgical specialties. “And those surgeons have gone back to their home hospitals and performed more than 200 robotic cases,” said Tyler. Last spring, a Keesler team performed the Air Force’s first robotic surgery, a ventral hernia repair conducted by members of the 81st Surgical Operations Squadron.

ROBOTIC SURGERY: THE BASICS

Robotic surgical systems, first developed in the 1980s, are today used primarily to overcome the limitations of minimally invasive surgical techniques – which, by definition, limit the size of incisions and rely on precise placement and manipulation of an endoscope and surgical instruments.

They’re also used to sharpen the capabilities of surgeons performing open procedures, such as a kidney removal or transplant.

The DOD medical establishment, including the InDoRSE, now uses 24 robotic systems at 16 different facilities, all of them either third- (Si) or fourth-generation (Xi) versions of the da Vinci system. The Xi, a versatile multi-port system capable of accessing multiple abdominal quadrants, is composed of three core elements: • A moveable cart with four mounted overhead arms. One arm is equipped with an endoscopic camera that’s been inserted into the patient through a small opening, while others are equipped with articulated or “wristed” instruments that can bend and rotate beyond the capability of the human hand.

• A vision system consisting of the endoscope, cameras, and a display offering a magnified, high-definition, three-dimensional view of the surgical site.

• A surgeon console, where the primary surgeon is seated and looking at a magnified view of the surgical site while operating the robotic arms. The system translates the surgeon’s hand movements electronically into scaled-down manipulations of the instruments, and is capable of filtering out any shaking or tremors for natural, steady movements.

The da Vinci system has been approved by the FDA for use in urological surgeries, general laparoscopic procedures, non-cardiovascular thorascopic surgeries, and thorascopically assisted cardiotomy.

The obvious advantage associated with the robotic system is that it can access hard-to-reach places.

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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

“Laparascopic instruments are rigid, and they give you kind of awkward linear motions,” Tyler said. In the narrow confines of the pelvis, that’s a severe limiting factor, which is why more than 90 percent of prostatectomies are now performed robotically. “It’s the same for rectal cancer surgery,” said Tyler. “There are times when I’ve got a margin of error of a couple of millimeters in a cancer operation with a big tumor, so the precision of having your wrists coupled with extra visualization is incredible.”

The ultimate measure of robotic surgery, of course, is not the surgeon’s ease of use, but outcomes for both the patient and provider. Robotic surgery is a young field, and the developing research picture is unsettled and sometimes contradictory – but misinterpretations often aren’t the fault of researchers themselves. For example, a recent retrospective Stanford University study comparing robotically assisted kidney removal surgeries to those performed by human surgeons found that the robotic procedures tended to take longer and cost more, but that there was no statistical difference in patient outcomes or length of hospital stay. The article reporting on these results, in the British daily The Telegraph, was decidedly less nuanced: “Humans still make better surgeons than robots, study shows.”

Make no mistake: Surgical robots are expensive.

A single da Vinci system costs between $1.5 and $2.2 million, and its operation involves an annual service contract that’s usually in the low six figures. Many of the surgical attachments fitted to its arms are disposable, ranging in cost from $600 to $1,000 each – and a single procedure can use between three and eight separate instruments. The Stanford study calculated that robotic nephrectomies cost, on average, $2,600 more than conventional surgery.

But Tyler, a published outcomes researcher, rejects the idea that robotic procedures take longer and cost more – and he’s not alone in his thinking. Studies making those assertions, he said, tend to rely on limited data and variables, such as a single procedure or time frame. The time it takes to perform a given procedure can vary widely based on the institution and where the surgeon is in his or her learning curve.

When weighing the benefits of robotic surgery, Tyler said, it’s important to look at the individual procedure. Kidney removal, studied by the Stanford team, isn’t a particularly tricky operation for a qualified surgeon, and therefore probably not the most appropriate application for robotics. “If we talk about hernia surgery, I think the benefit is less pain than laparoscopy,” said Tyler. “For colon procedures, the benefits are smaller incisions, quicker recovery, and quicker discharge. And we all know those are benefits, 56

but we rarely put a dollar amount on them. A single hospital day costs about $1,500. So, if you can save one single event of surgical site infection, it’s a savings of about $21,000.”

Studies comparing the costs of robot-assisted and laparoscopic or open procedures often focus on operating room costs, and don’t factor costs over the continuum of the patient’s surgical stay. Tyler’s records of his own surgeries over the past few years, more than 200 open, laparoscopic, and robotic cases, reveal that his robotic procedures are associated with lower rates of surgical site infection and shorter hospital stays.

Dr. Amir Bastawrous, a Seattle colorectal surgeon, has published data suggesting robotic surgery is actually faster and more cost-effective when the costs of the center’s overall care, and not just the operating room costs, are captured by the study.

Over the longer term, significant differences in outcomes are more difficult to determine. A study of robotic and open prostate cancer surgeries, published in the journal The Lancet in the summer of 2016, found that patients who underwent the robotic procedure generally spend less time in the hospital – but there was no difference in urinary or sexual function among patients in a three-month followup. The key question – whether there’s a difference in cancer recurrence – may soon be answered in a twoyear follow-up, but at least one comparison of open and robot-assisted prostatectomy, an investigation reported in European Urology in 2014, has suggested that the microscopic precision of robot-assisted cancer surgery may produce better longer-term outcomes. “Robot-assisted surgeries,” the authors wrote, “have fewer instances of cancer cells at the edge of their surgical specimen,” reducing the likelihood that those patients would need additional treatments.

BEYOND THE HOSPITAL

It may be that the wariness of robotic surgery’s critics is in part due to the fact that there isn’t yet an FDA-approved competitor for the da Vinci system – it’s hard for some experts to view a proprietary monopoly as cost-effective. Tyler admits that Keesler’s acquisition of its da Vinci systems was a combination of luck and grassroots advocacy. “This certainly wasn’t a top-down program, where the Surgeon General determined that we develop the program,” he said. “That would have been a lot more costly.”

Up-front costs and limited mobility are the chief barriers to expanding the horizons of robotassisted surgery within the military medical system.

Interestingly, the da Vinci was born from a joint

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U.S. AIR FORCE PHOTO BY SENIOR AIRMAN JENAY RANDOLPH

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

DARPA/NASA project in the 1980s, an effort to develop a “telesurgical” robot capable of performing surgery remotely on the battlefield or in other remote environments. One of the chief stumbling blocks for this application was latency – the delay between the surgeon’s actions and the robot’s responses – but information technology has since largely bridged this gap. In the famous “Lindbergh Operation” of 2001, a team of surgeons in New York, using high-speed telecommunications, performed a successful cholecystectomy on a patient in Strasbourg, France, with the use of a ZEUSTM surgical robot.

DARPA sponsored another investigation into medical battlefield robotics in 2005, an unmanned “trauma pod” designed to perform full scalpel-and-stitch surgeries on wounded service members in forward locations, but the project wasn’t completed, and many challenges remain for such an application.

It was the Army that initially sponsored, in 2002, the investigation of a less-expensive open-source surgical robot, now known as RAVEN, aimed at providing a more practical alternative to an expensive proprietary system. Based on freely available hardware designs and software, a more fully evolved

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■■ Members of the 81st Surgical Operations Squadron perform the

first robotic surgery in the U.S. Air Force at Keesler Air Force Base in Mississippi. Using robotic surgery decreases risk of surgical site infections while giving the surgeon better visibility and dexterity during an operation, which improves the overall surgical procedure.

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RAVEN, or an open-source system like it, may someday result in a smaller, cheaper, more durable surgical robot that can be used in more extreme environments.

In the meantime, the military’s surgical robots are on the move – not at forward locations, but at least far beyond the continental confines of the DOD’s medical establishment.

According to Tyler, there are plans to introduce da Vinci systems in military medical facilities in Baghdad, Iraq, and Kandahar, Afghanistan. In March 2018, the USNS Mercy, the world’s largest floating hospital, departed Pearl Harbor for its 13th annual Pacific Partnership voyage with a da Vinci robot on board. The days of the trauma pod may be far off – but maybe not as far as we think. “In my opinion, there’s very little role for robotics in the damage-control/trauma setting, where a recently injured patient is in danger of bleeding to death,” Tyler said. “But once those patients are stabilized and resuscitated and back to an appropriate level of care … there are reconstructive options that may be better served with robotics. There’s a lot we don’t know yet, but I think getting robots to some of these facilities is a step in the right direction for us to start answering that question.”

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■■ A surgeon’s view through a 3-D imaging system displays

articulating instrumentation during an operation using the latest state-of-the-art robotic surgical system at William Beaumont Army Medical Center (WBAMC) in El Paso, Texas, May 2, 2016. WBAMC performed the first robotic surgery in the Department of Defense using the robotic system. The surgeon-manipulated system allows surgeons to operate with articulating instruments that bend and rotate with far greater freedom than the human wrist through an incision smaller than a centimeter.

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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

COMMUNITY LIVING CENTERS AND STATE VETERANS HOMES

By Gail Gourley n THE DEPARTMENT OF VETERANS AFFAIRS (VA) offers numerous options for extended-care services to eligible veterans, providing them and their families abundant flexibility in making choices about their care. These options fall into two general categories: home- and community-based services, which help chronically ill or disabled veterans remain in their homes, and the residential or nursing home option.

The home- and community-based options include adult day health care, home-based primary care, homemaker and home health aide care, hospice, palliative care, respite care, skilled home health care, telehealth care, and veterandirected care. Veterans can simultaneously receive more than one of these services, with these choices offering veterans a range of alternatives to support their desire to receive care at home.

The residential and nursing home category includes community residential care in settings such as group living homes or medical foster home care, which serve as options for veterans who qualify for nursing home care but prefer an alternative residential setting and who are able to pay for these VA-monitored programs.

For eligible veterans whose needs require nursing home care, VA-contracted community nursing homes serve a significant number. Two other options are VA community living centers (CLCs) and state veterans homes (SVHs).

For some, the thought of a nursing home evokes images of an institutional facility with doors on either side of a hallway, a rigid care schedule, and an uninviting place for residents’ family and friends to visit. However, within the VA and around the country, that picture is changing to a more homelike physical environment and a veteran-centered care model.

The CLCs, owned and operated by the VA, demonstrate the organization’s commitment to transform its nursing home care.

According to Lisa Minor, RN, MSSL, director, FacilityBased Program Operations, Veterans Health Administration (VHA) Office of Geriatrics and Extended Care, the VA’s 134 CLCs are located across the country in every state except Alaska, Rhode Island, Utah, and Vermont, with operating 60

beds numbering approximately 13,391. Last year, Minor said, the VA treated 41,344 unique veterans in the CLCs. Most CLCs are located within VA medical centers, although some are in separate buildings on the medical center campus while others are completely detached to serve a wider geographical area.

“The VA has been keeping pace with changes in nursing home care in the community at large,” explained Marianne Shaughnessy, Ph.D., CRNP, director of Facility-Based Programs Policy, VHA Office of Geriatrics and Extended Care. “In the late 1990s and early 2000s, a trend emerged toward creating more homelike atmospheres in community nursing homes. This movement became known as cultural transformation. In 2005, the VA committed to this movement,” she said, and changed the designation from VA nursing home care units to VA CLCs. “The cultural transformation movement is characterized by moving from traditional nursing homes, which were designed to look and function like institutions, into more residential environments,” Shaughnessy said. “The interiors were redesigned to create a more homelike atmosphere with comfortable living spaces and communal dining areas and kitchens, because these are the centers of activity in most homes.”

Because most CLCs are within existing medical centers, transforming the facilities from institutional to more homelike requires renovation in some cases and new construction in others. This utilizes the “small house” model, incorporating small groups of living units with common central spaces.

The movement went beyond changing the physical structure, Shaughnessy added, extending into care practices redesigned to revolve around the veteran’s preferences.

“Mealtimes are flexible, and snacks and drinks are available throughout the day. Activities, therapy, and sleep schedules are built around the veteran’s choices. The focus is on the veteran and providing care in his or her home, rather than a veteran residing in an institution where schedules are dictated by the institution.”

Shaughnessy emphasized, “We really make an effort to involve the veterans and their families in care planning.

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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

PHOTO BY LUKE THOMPSON

■■ Garden and visiting area on Main Street in the community living center at W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina.

The veterans have a voice. Their families have a voice. They have choices, and we work with them to honor their choices around the care that they’re receiving.”

Dr. Mark Heuser, FACP, associate chief of staff, Geriatrics and Extended Care at W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina, described multiple services available to veterans at CLCs, categorized as shortstay programs of 90 days or fewer and long-stay programs of more than 90 days.

“The goal of the CLC is to maximize the veteran’s physical and cognitive functioning,” said Heuser, adding that in some cases, with physical therapy, for example, or an adjustment of medications, “a veteran can actually reach a higher level of functioning than when he or she came in.”

Short-stay programs include hospice and palliative care for veterans with life-ending diseases. This can also involve respite care, when “veterans on home hospice may come into our facility to give their caregiver a break or rest from their

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daily care,” Heuser said. “Or they may come from home hospice to the CLC hospice for a pain crisis or other crisis, for treatment of their symptoms, often then returning to home hospice.”

Other short-stay programs include: rehabilitation, for example, following a hip fracture; skilled nursing care, for treatments such as wound care or IV antibiotics; dementia care when exacerbated by associated acute problems, such as recent hospitalization for urinary tract infection; continuing care short stay, such as for weakness following hospitalization to build stamina and endurance; and geriatric evaluation and management.

Long-stay programs, Heuser said, include dementia care. “A veteran that has dementia and requires assistance with activities of daily living [ADL] – bathing, transferring, toileting, grooming, feeding – and meets [VA service-connected] eligibility criteria would be eligible to stay in a VA community living center for an indefinite period of time,” he said.

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Long-stay programs also include: continuing care for veterans who have normal cognition but require assistance with ADL due to physical issues, such as spinal cord injury or severe arthritis; or mental health recovery, for veterans who have chronic mental illness and are unable to live in a community setting.

Emphasizing the transformation from institution to become more veteran centered and homelike, Minor said, “The CLC is where they live; whether they come for short stay or long stay, that is their home for that time period. They don’t come to live where we work. We actually work where they live.”

Regarding CLC eligibility, Shaughnessy said, “Generally, the VA is responsible to provide or pay for long-term nursing home care for veterans that require that level of care and have a 70 percent service-connected disability, or a 60 percent service-connected disability and are unemployable. Veterans can qualify for short-term rehabilitation in a VA CLC if they require such care for a service-connected condition. And veterans who do not meet the criteria may also be admitted for short- or long-stay services if the resources allow at the site.

We encourage veterans and their families to consult with the VA health care team to talk about available options.”

State veterans homes provide another nursing home option for veterans. These 156 facilities, located in all states and Puerto Rico, are state owned, operated, and managed, and the VA must formally recognize and certify SVHs to participate in the program and ensure they meet VA standards. Similar to the CLCs, these facilities provide shortand long-term skilled nursing care and rehabilitation.

According to Minor, SVHs provide one or more of three separate programs: nursing home (148 programs, 25,685 beds); domiciliary care (54 programs, 5,894 beds); and adult day health care (three programs, 109 participant slots).

Each state determines eligibility and admission criteria for its facilities, although, Minor said, “There are some overarching federal regulations that determine who is eligible.

But the state sets their admission criteria.”

Although SVHs are not required to adhere to the design guidelines that the VA has adopted for the CLCs, Minor noted that several states have adopted a model that resembles a more homelike and less institutional facility.

To assist in navigating the numerous choices, Shaughnessy highlighted the shared decision-making portion of the VA’s Geriatrics and Extended Care Services website (www.va.gov/ geriatrics) that helps educate veterans, family members, and caregivers about what options are available for home- and community-based services as well as residential care facilities. Detailed worksheets, available to download, assist with considerations about the type and amount of care that’s needed, as well as the veteran’s preferences. “It also provides them with questions that they can take with them to their next health care visit so they can have an informed discussion with their doctor,” Shaughnessy said. “A great thing

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■■ Occupational therapist Griselle Rivera Ortiz observes how Vietnam

veteran Angel Martinez performs his routine at the VA Caribbean Healthcare System’s San Juan Community Living Center, Jan. 21, 2016.

about the shared decision-making site is that it also provides questions for families to speak with each other about what the veteran’s preferences are. Sometimes those conversations with families can be difficult to start, but it’s worked into this information on the website so nicely that it hopefully will initiate some of those conversations among the veteran and family members before they even get to the VA. Our goal is to honor the veteran’s wishes for care that they receive and the setting in which they receive it.”

Minor echoed that concept. “Veterans have many choices for long-term care services and support,” she said. “Our goal is to provide the right services at the right time in the right setting.”

Shaughnessy addressed future trends and the scope of need for VA nursing home services. “Current estimates suggest that the number of veterans who are going to require nursing home care at some point in their lives is expected to reach 1 million by 2023. And as the Vietnam-era cohort ages, the VA is providing services to this growing group,” she said.

“This group of veterans was the first to benefit from a shifting paradigm in trauma care called ‘scoop and run,’ which decreased transit time to a trauma care setting,” Shaughnessy continued. “While the casualty rates dropped, many veterans returned with significant physical disability.

Further, the group was not generally welcomed home after their service, so many have suffered psychological trauma and never sought formal treatment. Over the years, these veterans may have received care at local VA medical centers or through private insurers. However, as they age, their health care needs are growing, and the VA estimates a significant number will seek out extended care services from the VA.” 63

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Minor identified this trend as a future challenge.

“Regarding the cohort of Vietnam veterans and the complex issues that this veteran group has, and the CLC program, we’re trying to evolve to meet the needs of our veterans. And with that group aging over the next five to 10 years, we expect that many of these men and women are going to require extended care resources to manage these complex medical, cognitive, and psychosocial issues. We’re preparing to help the veterans meet these challenges with additional training and innovative programs to identify and build on strengths to help them live as they would wish to.

But that’s also one of our challenges, because these veterans are complex in so many areas. We have to evolve to be able to care for them.”

Given that challenge, Shaughnessy emphasized the importance of continuing to develop services for veterans who live in the community. “If we can create a safety net for veterans

utilizing home- and community-based resources and residential care programs, that would be a significant goal in the next decade,” she said.

Shaughnessy reinforced the value of the VA’s commitment to cultural transformation, recognizing that “veterans who are living in extended care settings become an extended family. They share a common bond and a common experience; it doesn’t matter what era they’re from. They value the camaraderie that comes with being with other veterans and being in a place that honors them and their service. Adding that cultural transformation aspect and creating more homelike atmospheres goes right along with the extended family that’s already there,” she said, concluding, “I feel that it’s our responsibility to provide the best quality care that we can for these veterans who have served their country honorably, and treat them with the dignity, respect, and love that they’ve earned.”

COMMUNITY LIVING CENTERS: NURSING HOMES TRANSFORMED The community living center (CLC) at W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina, illustrates the cultural transformation emphasis on veteran-centered and homelike care in VA nursing homes.

The 124-bed facility includes a separate 12-bed hospice and palliative care building.

New construction and renovations to the existing CLC began in 2011 and are mostly complete, according to Dr. Mark Heuser, FACP, associate chief of staff, Geriatrics and Extended Care. “Our team was able to work with the architect designers from the beginning, which was key,” Heuser said. “Veterans who live in our CLC need to feel like it’s home, and they need the ability to continue to have activities that they would have in their communities.”

In the former facility, “there might have been three or four veterans in a room, with a congregate bathroom down the hall,” Heuser said. “What we have now are all single bedrooms, each with a private bath.” While this increased privacy for all residents, he added, it especially enhanced the ability to care for the increasing number of women veterans.

The facility is arranged into seven “neighborhoods” with access to a common “Main Street” area. “It’s a central, very open space with a glass roof and muted-sun natural light,” Heuser said. “In the evening, street lights come on and the ambience is wonderful.”

The central gathering space includes a café, movie theater, and barber shop. The town hall is the monthly meeting site of the resident council. This group, with a peer-elected mayor and neighborhood representatives, considers topics ranging from which movies they’d like to see in the CLC theater to outside events such as a holiday light tour, picnic in a city park, or local area baseball game.

They also plan activities within the CLC such as a recent

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dress-up affair with music and dancing. And it’s not only recreational matters, said Heuser. “It can be a change in medical practice that we think is important.” For example, staff presented a newly developed infection control program to the resident council; the residents were able to become informed by asking questions and agreed that it was important.

Another key characteristic of the CLC is a focus on food, including not only the nutritional aspect but also the social component – “the coming together of family and friends,” Heuser said. “It’s important that food continues to be a major attraction and source of happiness in [residents’] lives, so in working very closely with food services, we’ve expanded not only our menus but also where we provide food,” he said. Each neighborhood has an area for cooking and serving, enabling residents to watch meal preparation and sense the aromas, improving their appetite and enhancing their enjoyment.

Other features include an indoor urban garden with areas conducive to visiting with family, said Heuser, “in an intimate environment among plants and wooden furniture and natural lighting.” Outside, a healing garden with a water feature and gazebo also includes raised beds where veterans can plant and tend vegetables.

Another notable element is a pond that provides not only a peaceful view from the hospice house, Heuser said, but also a dock where a railing folds down, allowing residents to cast a fishing line from a wheelchair in a safe and sun-protected location. “We have veterans that love to fish,” Heuser said, “and we have this for them. It’s rare that they go out and not catch something.”

These qualities of the CLC reinforce the vision of the cultural transformation. Heuser said, “The whole idea is, ‘How can we help you live better?’”

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THE AIRBORNE HAZARDS OF IRAQ AND AFGHANISTAN: AN UPDATE n FOR MORE THAN A CENTURY NOW, American service members who have gone to war have found themselves in dynamic, often chaotic surroundings, far different from the familiar and well-regulated environment of home – and many have suffered health problems as a result. World War I veterans, after exposure to poison gas weapons on the European front, returned home complaining of respiratory problems. Atomic-era veterans who’d either participated in weapons tests, been prisoners of war in Japan, or occupied the cities of Hiroshima and Nagasaki after 66

their bombing encountered ionizing radiation. Vietnam veterans who came into contact with the herbicide Agent Orange have reported a variety of health problems, and a quarter-of-a-million veterans of the Gulf War of 1990-1991 complained of a chronic multisymptom disorder known as Gulf War syndrome, which is still being studied today.

In each of these cases, the departments of Defense (DOD) and Veterans Affairs (VA) have worked to determine causes and improve health outcomes for returning veterans – but their efforts have often progressed more slowly than veterans

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PHOTO BY CPL. ALFRED V. LOPEZ

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

■■ OPPOSITE PAGE: U.S. Marine Lance Cpl. Nathanial Fink (left), a

light armored vehicle driver with Alpha Company, 1st Light Armored Reconnaissance Battalion, and Lance Cpl. Garrett Camacho, a food service specialist with Headquarters and Service Company, dispose of trash in a burn pit in Khan Neshin District, Afghanistan, March 3, 2012.

and their advocates would have wanted. The deliberate pace of ex post facto data-gathering, research, and resulting clinical practices is often criticized, most notably in the cases of Agent Orange and Gulf War syndrome.

The modern version of the VA’s environmental health effort, the Post-9/11 Era Environmental Health Program within the Office of Public Health, represents a joint effort to begin this data-gathering effort as early as possible to better understand differences in service member health before and after deployment. As soon as veterans began separating from wartime service in Afghanistan and Iraq, the DOD’s preventive medicine experts began providing their VA counterparts a list of who’d been deployed, and to where. The VA gathered health care data from these personnel and prepared quarterly reports. Environmental health coordinators were (and continue to be) stationed at VA medical centers to help returning veterans understand and receive care for any health problems that might have arisen from hazards – chemical, physical, or environmental – they might have encountered during their deployment.

More than a decade of data and anecdotal reports from Iraq and Afghanistan are increasingly suggesting that the air itself has been one of the signature hazards of the Southwest Asia theater. A number of returning veterans have reported respiratory illnesses, and outside the VA’s own research system, several experts have suggested these illnesses, along with other symptoms such as chronic fatigue and recurrent headaches, might be linked to hazardous materials in the air – either borne on the dusty desert winds or emanating from one of the hundreds of open-air burn pits used to dispose of waste at forward installations. Beginning in 2003, Navy Capt. Mark Lyles, chair of medical sciences and biotechnology at the Naval War College, studied dust particles sampled from the air in Iraq and Kuwait and found 37 different metals, including aluminum, lead, chromium, manganese, and tin. According to existing research by the Environmental Protection Agency, these metals have been linked to neurological disorders, respiratory ailments, depression, and heart disease. The dust also contained 147 different kinds of bacteria and several fungi that could cause disease.

Another early indicator of a potential link between particulate matter and service members’ respiratory illness was a study reported in the New England Journal of Medicine in July 2011, which revealed diagnoses of constrictive bronchiolitis (CB), a rare and incurable lung disease, among soldiers

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– most of them from the 101st Airborne Division, Fort Campbell, Kentucky – who had returned from deployment and were no longer able to meet the Army’s physical fitness standards due to shortness of breath. Bob Miller, a pulmonologist at Vanderbilt University Medical Center, examined 80 soldiers, many of whom had long-term exposure to a fire at a sulfur mine near Mosul, Iraq, in 2003. Fortynine of these soldiers agreed to an invasive lung biopsy after X-rays and other tests failed to reveal a cause. All 49 tissue samples were judged to be abnormal, and 38 resulted in a diagnosis of CB – a scarring and thickening of the walls of the smallest lung passages. Miller and colleagues concluded from these biopsies that CB could be linked to service in Iraq and Afghanistan; the biopsies also revealed dust particles in the patients’ lungs.

In a 2006 memo, and in 2009 testimony before the U.S. Senate, then-Air Force Lt. Col. Darrin Curtis, a bioenvironmental flight commander at Iraq’s Joint Base Balad, warned that open-air burn pits represented an “acute health hazard for individuals,” citing a number of possible toxic contaminants in the smoke, such as arsenic, benzene, cyanide, toluene, and formaldehyde. The types of waste burned in these pits varied widely until 2009, when the military updated its policies to prohibit the burning of toxic materials such as solvents, batteries, jet fuel, tires, and some medical wastes.

To learn more about the issue of burn pits and service members’ health, the VA commissioned a study by the Institute of Medicine (IOM, now the National Academy of Medicine), which reported in 2011 that while there was evidence that exposure to smoke from burn pits may cause short-term reductions in lung function, there wasn’t enough data to draw any conclusions about long-term respiratory health consequences. On the heels of this report, then-Secretary of Veterans Affairs Eric Shinseki directed the Veterans Health Administration (VHA) to conduct long-term prospective studies on all adverse health effects that might be related to deployment in Iraq and Afghanistan, including those that might be related to exposure to airborne hazards and burn pits.

The VHA’s Office of Public Health created the Airborne Hazards and Open Burn Pit (AH&OBP) Registry, an effort mandated by law in 2013 and launched in summer 2014 to gather data to feed into the studies suggested by the IOM. The registry is open to anyone, veteran or active-duty military, who served in Iraq or Afghanistan; was stationed in Djibouti after Sept. 1, 2001; or who served in the 1991 Persian Gulf War and may have been exposed to oil fires and dust.

Registrants may also request a free medical exam.

The VA also views the registry as an online tool for increasing veterans’ access to information. Visitors to the site can connect with resources to help them learn more about their health concerns, schedule an examination, or file a compensation claim. It also provides a channel for the VA to reach back to registrants if new developments arise.

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As of April 2018, more than 140,000 service members and veterans had signed up for the registry, and several studies were under way within the VA, the DOD, and the Joint Pathology Center, including comparisons of cardiopulmonary function and other health measures during and after deployment to burn pit and non-burn pit sites; birth outcomes among service members after burn pit exposure; molecular indicators (biomarkers) of burn pit exposure; analysis of more than 20,000 biopsy samples (including about 500 cancer tissues) from deployed service members; and the effects of pulmonary exposure to particulate matter among animal models.

Within the VA, much of this research is coordinated by the War-related Illness and Injury Study Center (WRIISC) in East Orange, New Jersey. “They focus on lung injury and deployment-related lung disease,” said Dr. Patricia Hastings, DO, MPH, FACEP, RN, a retired Army colonel who now serves as deputy chief consultant for the VA’s Post-deployment Health Services. “A lot of the really important research that’s going on has been done there by their pulmonary physiologist.”

The WRIISC also serves as a kind of center of excellence, a site for specialty care related to environmental exposures that often receives cases from other VA facilities, where providers may be encountering cases they haven’t seen before.

The research foundation for this specialty care is admittedly in need of growth, and both DOD and VA have been battered, in recent years, by news stories profiling veterans who’ve suffered serious health problems – neurological disorders, strange rashes, rare and aggressive cancers – that they and their family members claim were linked to burn pit exposure. In February 2017, for example, Amie Muller, a 36-year-old wife and mother of three who served in the Air National Guard as a photojournalist during two (2005 and 2007) tours in Iraq, died of pancreatic cancer, which her family attributed to burn pit exposure. In response, Sen. Amy Klobuchar, D-Minn., from Muller’s home state, co-sponsored a bill that would compel

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■■ An airman tosses uniforms into a burn pit at Balad Air Base, Iraq, in 2008. The

military burned unusable uniforms so they didn’t end up in enemy hands. In 2009, the military prohibited the burning of batteries, tires, and certain medical waste as well as other toxic materials. As a result of health problems service members experienced after deployment to the Middle East, the VA released its post-9/11 report “Report on Data from the Airborne Hazards and Open Burn Pit (AH&OBP) Registry.”

the VA to create a center of excellence dedicated solely to accelerating and improving its understanding of the health effects associated with burn pits, and to treat veterans who become sick after exposure. That provision passed the Senate, but the final defense authorization for 2018 contained watereddown language directing the VA to “coordinate efforts related to furthering understanding of burn pits, the effect of burn pits on veterans, and effective treatments relating to such effects, including with respect to research efforts and training of clinical staff on related matters” – which the VA already does, using the WRIISC as its center of excellence.

Klobuchar and her bill’s co-sponsor, Thom Tillis, R-N.C., aren’t alone, however, in believing the federal bureaucracy needs to move faster to respond to what may be a war-related health crisis. In September 2016, the Government Accountability Office issued a report to Congress that implored the agencies to redouble their efforts at assessing the health effects of burn pit exposure. “Although DOD and the Department of Veterans Affairs have commissioned studies to enhance their understanding of burn pit emissions,” the report stated, “the current lack of data on emissions specific to burn pits and related individual exposures limits efforts to characterize potential long-term health impacts on service members and other base personnel.”

After a 2015 report indicated that nearly 40 percent of those who began filling out the AH&OBP Registry questionnaire didn’t complete it, the VA turned again to the National Academy of Medicine to look over and offer advice on the first phase of its data-gathering efforts. The academy’s evaluation, released in February 2017, contained several recommendations for improving the administration and use of the registry: recommending, for example, that the VA evaluate whether and how registrants who did not complete the questionnaire differ from those who did; analyze why some registrants didn’t complete 69

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it; and use this information to develop strategies that encourage registrants to finish and submit their responses. At the same time, the academy pointed out that self-reported data isn’t the best resource of information on interrelationships between exposures and health outcomes. “It’s important to understand,” the authors wrote in an overview of the report’s highlights, “that even a well-designed and executed registry would have little value as a scientific tool for health effects research compared to a well-designed epidemiologic study.”

Hastings said the VA has taken the academy’s recommendations to heart and streamlined the questionnaire – its online format has been shortened from 17 pages to two – but has been cautious about making drastic changes now that there are already tens of thousands of registrants. To do so would risk producing two distinct research cohorts, rather than one large one. “Changing the questions midstream makes it less valid,” she said. “Keeping the questions very similar overall is more helpful to the studies we’re doing.”

Epidemiological research that can conclusively prove or disprove a cause-effect relationship between airborne hazards and illness is particularly challenging because of the diffuse and varied experiences of service members. So many different items were burned, at different times, in different burn pits, that the creation of a framework for studying their effects seems difficult, if not impossible.

It’s also likely that the particulate matter causing respiratory disease among service members might come not solely from burn pit smoke, but from ground surface dust, as Lyle’s study suggested. A few years ago Dr. Anthony M. Szema, a physician at the VA Medical Center in Northport, New York, performed lung biopsies of veterans who’d been deployed to Camp Victory, near Baghdad, Iraq, and were complaining of shortness of breath.

Every one of Szema’s biopsies revealed

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■■ U.S. Air Force aircraft of the 4th Fighter Wing fly over Kuwaiti oil fires set by the

retreating​Iraqi army during Operation Desert Storm in 1991.​​Researchers began using the term “Iraq/Afghanistan War-Lung Injury” to describe some war-related respiratory illnesses​ in Gulf War veterans.​

microscopic metal particles, including titanium, that had formed crystals in the patients’ lungs. Dozens of patients at the clinic have also been diagnosed with constrictive bronchiolitis. Szema and colleagues coined a new term for this particular war-related respiratory illness: Iraq/Afghanistan War-Lung Injury.

Right now, all that’s known about the dust inhaled at Camp Victory is that it’s far more metal laden than what service members would normally encounter; nobody knows why. Szema has speculated a few possibilities: It could have been borne on the air from other burn pits at nearby installations. It may have been produced by the 1991 Gulf War, when U.S. bombs and Iraqi missiles hammered the desert soil and fused dust and metal. Or it may be naturally occurring.

As difficult and complicated as these questions are, the families of sick service members are demanding answers, and clearly the VA, the DOD, and their research partners have much work to do in determining the relationships between wartime exposures and long-term illness. In the meantime, Hastings, who sees the AH&OBP Registry as much more than a research database, said the VA wants service members to maximize the likelihood of good health outcomes by taking advantage of the free medical exam offered through the registry program.

“We don’t have great participation in the exam right now,” she said, despite the fact that it’s available to all veterans who have served in Southwest Asia since 1991, whether they’re enrolled in VA care or not. “The exam is, of course, free – no co-pay,” said Hastings, “and it can be done by their own practitioner if they’re not enrolled in VA health care. They can have it done by the environmental health coordinator at the VA medical center. And they’ll get the results of the exam afterwards.” The exam is a small, relatively easy step, which Hastings hopes will establish a lifelong relationship between veterans and dedicated professionals who – while they don’t yet have all the answers – are veterans’ best hope for receiving the care they need.

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INFECTION CONTROL From the battlefield to stateside hospitals, DOD and VA are shoring up defenses against drug-resistant microorganisms.

By Craig Collins n FOR THE MILITARY AND VETERAN medical communities, the field of infection control – preventing infections acquired during health care delivery – has been challenged on two fronts in the post-9/11 era: the emergence of infectious diseases, such as the bacterium Acinetobacter baumannii (A. baumannii or “Iraqibacter”) in military treatment facilities in Iraq and Afghanistan, and the spread of multidrug-resistant organisms (MDROs) across global health care networks.

In 2014, Dr. Eli Perencevich, a professor of internal medicine and epidemiology at the University of Iowa and director of the Center for Comprehensive Access & Delivery Research and Evaluation (CADRE) at the Iowa City VA Health Care System, co-wrote an overview of the problem in the journal Infection Control & Hospital Epidemiology. About 10 percent of hospitalizations, he wrote, are complicated by health care-associated infection, and up to 75 percent of those infections are from organisms that resist first-line antimicrobial treatment.

At least part of the reason for this, according to Perencevich, has been worldwide complacency among the infectious disease community. “It used to be that we always had a new antibiotic,” he said. About 30 years ago, laboratories and pharmaceutical companies stopped developing such new drugs, probably because other drugs were more profitable.

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The drug-resistant superbugs that have gained ground as a result of this lapse include A. baumannii, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), Klebsiella pneumoniae, Clostridium difficile (C. difficile), and others. These organisms have a tendency to hang around in health care settings; according to the Department of Veterans Affairs (VA), C. difficile can persist on inadequately cleaned surfaces for up to five months, and MRSA can survive for more than nine months.

Department of Defense (DOD) and VA professionals have developed strategies and tactics – and established institutions – to fight these organisms. When A. baumannii began spreading to patients in stateside military hospitals in 2003, medical staffs implemented strict protocols – screening every single incoming patient, isolating infected patients, and using personal protective equipment (PPE). The Defense Health Agency required infection control officers (ICOs) at each of its combat support hospitals, created or expanded infection control curricula at military medical schools and training centers, and established the Multidrug-resistant Organism Repository and Surveillance Network (MRSN) at the Walter Reed Army Institute of Research. MRSN collects and characterizes MDROs at medical facilities throughout the military in order to inform best clinical practices, influence policy,

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■■ Under a high magnification of 12,960X, this colorized scanning electron microscope (SEM) image revealed some of the morphologic details

CDC PHOTOGRAPHER JANICE HANEY CARR

displayed by a number of joined, Gram-negative, rod-shaped, Escherichia coli bacteria.

and enhance infection prevention and control efforts.

The Veterans Health Administration (VHA) – the nation’s largest integrated health care network – has undertaken similar efforts throughout its medical and residential facilities.

Its National Infectious Diseases Service launched a prevention initiative that, in its first five years, drove health careassociated MRSA infections down 69 percent in acute care facilities, 81 percent in spinal cord injury units, and 49 percent in long-term care facilities. These infection rates continue to fall. The VHA built on this success by expanding the program into an MDRO Prevention Initiative targeting multiple organisms, in different modes of care. The initiative involves commonly used prevention protocols – screening, environmental management, hand hygiene, and contact precautions – tailored to setting and circumstances.

Infection control is a concept now firmly embedded, both culturally and institutionally, throughout the VHA and the military medical system – and yet, despite dramatic reductions in infection rates, health care-associated infections remain a persistent problem, often flaring up in particular

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environments and circumstances. The military and VA remain hyper-vigilant, crafting joint plans and responses to drug-resistant infections for patients in their care.

BATTLEFIELD TRAUMA: OPENING THE DOOR TO INFECTIOUS DISEASE

Military medical providers wage the infection control fight on the same fronts as other professionals, attempting to minimize infections resulting from contact with medical equipment such as catheters, intravenous lines, and ventilators, but their work is complicated by several factors. Many warfighters admitted to forward medical facilities have open wounds that make them more susceptible to infection, and trauma itself is known to disrupt the immune system and predispose patients to infections and inflammatory complications. When the emergence of A. baumannii was first tracked among military casualties, it was initially thought that the organism had been introduced – inoculated, in epidemiological parlance – bluntly, by the penetrating force of 73

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improvised explosive devices, bullets, or debris.

According to Dr. David Tribble, DrPH, science director of the Infectious Disease Clinical Research Program at the Uniformed Services University of the Health Sciences, this idea was first dispelled by epidemiologists from the Walter Reed Army Institute of Research, who found that the outbreak was largely due to another signature characteristic of military medicine: the different echelons of care, at different locations, received by wounded service members during the casualty-evacuation process.

Walter Reed researchers, said Tribble, “provided evidence that a lot of these cases are health care-associated infections acquired through the chain of medical evacuation, where people are coming from a downrange facility, usually what we call the ‘Role 2’ forward surgical hospitals, or from the larger field hospitals like Bagram or Kandahar. And they were frequently air evacuated to Landstuhl, in Germany, and then sent for definitive care in the United States. And of course, many of them would then go on to VA hospitals for care. So there’s a lot of opportunity for health care-associated infection transmission among these very seriously injured personnel.”

About nine years ago, Tribble and colleagues with both DOD and VA developed a project for tracking shortand long-term infectious disease outcomes following deployment-related traumatic injuries among service members. The resulting Trauma Infectious Disease Outcomes Study has yielded even more data about the considerable burden trauma-associated infections place on the military health system.

Around a quarter to a third of wounded service members, they found, were contracting trauma-associated infections. Interestingly, researchers found geographic differences among the organisms causing these infections. In Afghanistan, trauma-associated infections are more likely to be caused not by A. baumannii but by Escherichia coli and the group of organisms known as the

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■■ Human neutrophil interacting with MDR Klebsiella pneumoniae (in pink).

ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species), which are the leading cause of health care-associated infections worldwide.

These pathogens – primarily gram-negative bacteria, whose outer membranes protect them from many antibiotics – create most of the problems for forwarddeployed medical providers.

Tribble and colleagues are still investigating the problem of trauma-associated infection. “We’re trying to better understand what leads to an increased risk of these infections, and how best to prevent them,” he said. “We look at some of the measures, in medical and surgical care, used to prevent them. And we’re also studying how to get optimal results: When you do get an infection, what’s the best way to treat it?”

ATTACKING THE UNKNOWNS

Over the past decade or so, DOD facilities reduced infection rates with two main tactical adjustments: pre-deployment training specific to infection control for 75

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health care professionals, and stationing infection control practitioners farther forward in Iraq and Afghanistan, up to “Role 3” hospitals.

“We saw some very dramatic declines in ventilator-associated pneumonia rates,” Tribble said, “as there was kind of a re-emphasis of proper techniques, and trying to apply them as best as possible in a forward setting. We saw the Acinetobacter infections that were so common in those earlier years in Iraq go down to very low rates.”

Despite all the medical community has learned and applied so far in the 21st century, Tribble said there are important things practitioners still don’t know about health care-associated infection that need further investigation. Health care providers still don’t have a good handle on how to use antibiotics in a way that’s both effective and doesn’t increase an already virulent organism’s resistance. “There’s not a lot of guidance out there on managing some of these complex types of patients, like these combat trauma patients who’ve suffered polytrauma and are injured at different sites,” said Tribble.

“When we see wound infections, the majority of them are polymicrobial.”

We know that using broad-spectrum antibiotics against these infections is a bad idea, Tribble said, but we don’t have a lot of better ones yet.

Another area in need of further research is how pathogens are transmitted from one patient to another in health care settings. “In today’s world, people often don’t stay in the hospital long,” Tribble said. “They move in and out. There’s a lot of mobility in health care – and because of that, the organisms have mobility too, and that increases risk.”

A recently unveiled vision for the future of the VA’s infection control research echoes Tribble’s concerns.

In 2016, Perencevich and about three dozen of his VA colleagues – infectious disease experts, epidemiologists, implementation experts, operational partners, and leaders such as Dr. Martin Evans, director of the MRSA/MDRO

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■■ Medical illustration of methicillin-resistant Staphylococcus aureus.

Program – convened in Iowa City to chart a course for research into existing “knowledge gaps” in preventing and treating MDRO infection. The four areas of research they determined to be most necessary for exploration were: • Transmission dynamics. VA experts cited a lack of data about how MDROs are transmitted in acute-care settings, and future studies should investigate the best and most cost-effective strategies for reducing transmission, such as hand hygiene, environmental cleaning, isolation measures, and active surveillance.

Some future studies should also examine adherence issues – not only policies and protocols, but also whether these practices are universally adopted.

• Antimicrobial stewardship. Every VA facility has an antimicrobial stewardship mandate: a specific plan for reducing unnecessary use of antibiotics, which can strengthen a pathogen’s drug resistance. But not every VA facility has an infectious disease specialist. VA experts are calling for studies examining optimal strategies in both inpatient and outpatient settings, and the establishment of 77

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standard metrics that can assess, in the absence of expert judgment, changes in resistance and appropriate prescribing. “We’re definitely reducing prescribing, but we don’t have the ideal target yet,” said Perencevich. “There are really no standard ways to monitor antimicrobial stewardship.

There is no metric. So, our colleagues here in Iowa City are developing automated ways to monitor prescribing.”

• The microbiome. It’s a new concept – the human organism as an ecosystem comprising interacting microorganisms – and research in this area is in its infancy. The VA anticipates ways to manipulate the human microbiome to eliminate or prevent colonization by MDROs, but also recognizes there’s no existing framework for such research, nor criteria for prioritizing study designs such as longitudinal studies or clinical trials. VA experts recommend further exploration of the effectiveness of fecal transplants as therapy (some studies have shown transplants to be effective at eradicating C. difficile), and of additional research into microbiota outside the gastrointestinal tract.

• Special populations. Many of the VA’s first MDRO initiatives were aimed squarely at the acutecare setting: large VA medical centers serving vast numbers of inpatients. The success of these early efforts has allowed VA researchers to drill down to different settings, populations, and variables that may complicate a one-size-fits-all approach. For example, a study reported last year in the American Journal of Infection Control revealed that while hospital-acquired cases of C. difficile continued to decrease throughout the VHA from 2003-2014, the infection rates in long-term care facilities actually increased over the same period. VA experts envision research into specific care settings or circumstances that should be prioritized, including long-term care, spinal cord injury, rehabilitation, mental health care, ambulatory care, and homebased care.

The work of professionals in these settings has shown that an infection control approach adapted to patients and their circumstances can yield remarkable results. In 2012, residents of the 120bed community living center at the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina, were experiencing an unprecedented prevalence of MRSA: 70 percent of residents had been colonized by the bacteria, meaning they had the organism on their skin or in their noses.

Nineteen residents were infected.

Long-term residents differ from hospital patients, of course, in several ways, and the center adopted 78

a program to supplement the existing MDRO prevention protocols while maximizing interaction and mobility. Residents were screened and then “decolonized” with both a topical antiseptic and a nasal antibiotic, every day for five days, and then tested again a week later. Rooms were cleaned thoroughly with antiseptic and ultraviolet light.

Lanette Hughes, RN, the center’s MDRO prevention coordinator, said the program’s success was due to the staff’s decision to play offense. “We were monitoring this MRSA, but we weren’t really stopping it because we were continuing to get new patients in. We weren’t doing any decolonization.”

Over the next four years, the MRSA infection rate among residents dropped 89 percent – and not only that, said Hughes, but rates of infection from every other drug-resistant organism decreased, including Klebsiella, E. coli, VRE, C. difficile, and the Enterobacter genus known as CRE/CPE. A VA/CDC PARTNERSHIP

As the Salisbury program demonstrates, the failure or success of infection control isn’t necessarily determined by the mode of attack, but by how well, and how consistently, that attack is implemented. Five years ago, the VA, a leader in implementation science, established a 10-hospital Infection Control Research Network, which focused exclusively on studies of strategies to prevent the spread of MRSA in VA facilities.

This network was recently expanded in several important ways: In fall 2017, the VA and U.S. Centers for Disease Control and Prevention (CDC) announced their partnership to fund a practicebased network of 15 hospitals (the original 10, plus five) and their associated community-based outpatient clinics.

Several research initiatives, aimed at the knowledge gaps recently identified by VA experts, will be implemented among these facilities to compare infection control processes and outcomes. Heather Reisinger, Ph.D., the implementation specialist who works with Perencevich as associate director of the CADRE, traveled with an implementation research team that visited each of the original 10 facilities in the network, observing and interviewing staff, but said this new partnership will allow the VA to build capacity and train research teams at each of the sites. “Right now we’ve established that we’re going to be looking at the environmental services in the VA, the staff who do the cleaning of patient rooms, and looking at how different places do that – and then how we can standardize that across the

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U.S. AIR FORCE PHOTO BY TECH. SGT. CHRISTOPHER PARR

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board.” Other studies are likely to look at transmission dynamics and the use of antibiotics. These implementation studies will be funded and designed by the VA, Reisinger said, while “the CDC is covering the nuts and bolts – research coordinators and people gathering statistics and pulling data from the VA electronic medical records.”

The new partnership is an exciting new phase in infection control research, said Reisinger, a holistic attempt to not only gather data on who’s infected, and where, and when – but also how and why. “What we’re trying to do now is not only perform that data collection process, but to actually try to understand the implementation process and get a better sense of what the barriers are, specific to facilities, so that we can help them overcome those barriers. There has been work with infection control nurses, determining what types of interventions are best, but there really hasn’t been a focus on the science of implementation, and how we get that integrated into infection control practices. This is kind of the first step in trying to see if we can do that.”

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■■ Medical personnel from the U.S. Navy, Army, and Air Force work

together to move patients from a forward operating base to the main medical care facility located near Young Air Assault Strip, Fort McCoy, Wisconsin, during exercise Patriot Warrior, Aug. 19, 2017. As wounded troops are transported from downrange to a major medical facility, their susceptibility to infection is of concern along all levels of care.

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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

A NEW ERA IN PAIN MANAGEMENT How we got ourselves into an opioid epidemic – and how the VA and DOD are helping to chart a way out

By Craig Collins n BY NOW, MOST AMERICANS are familiar with the term “opioid epidemic,” but fewer have a detailed understanding of what it means. The rapid increase in the use of prescription and non-prescription opioid drugs – substances that act on the brain’s opioid receptors to produce morphine-like effects – began in the late 1990s and has reached a crisis point.

According to the Centers for Disease Control and Prevention (CDC), drug overdose has become the leading cause of death among Americans younger than 50, with two-thirds of those deaths caused by opioids. The increase in overdose deaths in the United States has been dramatic – from 1999 to 2014, opioid deaths increased 369 percent, from 4,030 to 18,893 – and continues at an alarming rate. Today, the CDC estimates that more than 115 people in the United States die every day after overdosing on opioids.

Opioids are a class of painkillers that include oxycodone (OxyContin® and Percocet®) and hydrocodone (Vicodin®).

Some are “opiates” – substances derived from the sap of the opium poppy – but the term “opioids” is a broader term used to include the synthetic and semi-synthetic substances that now comprise most of the drugs designed to act on opioid receptors. All opioids today are considered drugs of high abuse potential. According to the National Institute on Drug Abuse (NIDA), about 21 to 29 percent of patients prescribed opioids for chronic pain – pain lasting more than three months, or past the time of normal tissue healing – misuse them, and about 8 to 12 percent develop an opioid-use disorder.

Given these numbers, it’s reasonable to ask: Why have opioids ever been prescribed for chronic pain? There’s no better person to answer the question than Dr. Jack Rosenberg, an anesthesiologist with the VA Ann Arbor Healthcare System who began his career in the early 1990s, before most of the long-acting “extended release” opioids had hit the market. Rosenberg was a pain management fellow at the University of Michigan Medical School in 1992 and 1993 – a time when opioids were occasionally 80

prescribed in primary care for short-term indications, such as post-surgical pain or fractures, but were not prescribed for long-term pain, such as back or neck pain, because of the belief that morphine or methadone carried a clear risk of recreational use and addiction. At the same time, there was a growing belief that patients who needed help for chronic pain weren’t being helped enough.

Opioid therapies, involving medications such as hydrocodone, were designed and prescribed cautiously for select pain clinic patients who were resistant to other methods of treatment. “We weren’t as sophisticated as we are now,” Rosenberg said. “But it seemed as though, in these select patients, it [opioid therapy] was helpful.”

Around this time, a rapid increase in opioid prescriptions began. One of the primary justifications for this increase, used by researchers, physicians, and pharmaceutical companies, was a letter published in the January 10, 1980 issue of The New England Journal of Medicine.

The letter, written by Hershel Jick (MD) of Boston University Medical Center and his assistant, Jane Porter, was headlined “Addiction Rare in Patients Treated With Narcotics.” Citing their analysis of 11,882 patients who had received opioids for pain, Jick and Porter concluded that “despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” This letter was cited by various publications, including at least one medical textbook, well into the 2000s. The increase in opioid prescriptions gathered more steam in mid-1990s when other opioids, such as OxyContin, were developed and marketed as modified-release substances that delivered the opioid over an extended period of time – thereby eliminating the euphoric effects that led to recreational use.

Interestingly, while there was peer-reviewed evidence yet that proved the efficacy of opioids in treating pain lasting up to three months, there was no evidence that they worked for longer periods. Physicians, including VA

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■■ Hydrocodone acetaminophen tablets lying on a prescription form. Hydrocodone is a prescription semi-synthetic opioid that is used to treat

NIH PHOTO

moderate to severe pain. For some patients who suffer from chronic pain, opioids may increase the severity of the pain in the long run. Today, hydrocodone is said to be one of the most common recreational prescription drugs in America.

doctors – such as Rosenberg, who, in the early years of combat in Iraq and Afghanistan, were seeing a growing number of veterans suffering from chronic pain – felt a moral imperative to provide relief.

By then it was well known that pharmacology wasn’t the only way to treat chronic pain; multidisciplinary approaches that involved teams of specialists such as neurologists, rheumatologists, orthopedists, physiatrists, anesthesiologists, and psychiatrists were proven to be effective. “But multidisciplinary clinics were very expensive,” Rosenberg said, and many insurers wouldn’t pay for them. “Pain was this untreated demon … and it seemed as though we had an instant solution to the chronic pain problem.”

Rosenberg co-chaired the development of the first “VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain,” which was released in 2003. “There, we took the position that we have all this untreated pain in our veterans,” he said, “and I distinctly remember strategizing how we could get primary care doctors more comfortable with chronic opioid therapy, because the research had come out suggesting that the risk of addiction in pain patients was very small.” After publication of the 2003 guideline, VA physicians across the country prescribed opioid therapy for chronic, noncancer-related pain at increasing rates.

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A TURNING POINT

By 2010, when the VA and the Department of Defense (DOD) issued a new clinical practice guideline, evidence regarding opioids was coming into clearer focus. In prescribed doses, the potentially harmful side effects of opioids, such as respiratory depression, were minimal, and modified-release products were effective when swallowed whole, but patients who misused these tablets – crushing, chewing, or dissolving them – could rapidly release and absorb potentially harmful, even fatal doses. Used correctly, delivering the opioid over an extended period of time, modified-release substances still increased the risk of overdose and death, due to the larger amount of opioid present in the patient’s system.

The VA and DOD faced two growing crises: first, the clear evidence, documented in a growing body of newspaper and magazine articles and medical research, that long-term opioid therapy carried risks. The number of opioid prescriptions – and dosage strengths – had risen steadily throughout the 2000s. Overdoses were dramatically on the rise. “Pill mills” began sprouting up around the country, particularly in Florida, in which doctors or pharmacists were prescribing or dispensing opioids inappropriately, or for recreational 81

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purposes. In 2010, the CDC reported oxycodone caused 1,516 deaths in Florida, more than four a day and more than any other drug.

At the same time, Rosenberg said, “We still had all these veterans, now coming back with terrible injuries. … Fifty percent of them had substantial pain.” Weighing one crisis against another, VA and DOD issued a new guideline for opioid therapy in 2010, based on clinical studies or systematic reviews up to March 2009. The guideline called attention to the risks associated with, and contraindications for, opioid therapy for chronic pain, but deferred to the decisionmaking of providers and their patients. “At that point,” said Rosenberg, who also co-chaired the development of the 2010 guideline, “our guidance was: If nothing else works, then you can use chronic opioid therapy.”

Nationwide, opioid prescriptions and dosages began to drop after a 2012 peak. States began implementing prescription drug-monitoring programs and databases, tracking prescriptions of controlled substances such as opioids. The 2010 VA/DOD guideline mirrored guidance from other government and private organizations, such as the CDC, but addiction and overdose rates continued to increase, for several reasons. For one thing, doctors who prescribed opioids for shorter durations, or in lower doses, had no way of verifying whether patients were using prescriptions written by other doctors, either for opioids or for other drugs, such as benzodiazepines, that increased the risk of overdose when taken with opioids.

The VA began publicly releasing data on opioid prescribing rates at its facilities nationwide, and in 2014, launched its Opioid Safety Initiative, an education-focused program providing resources for doctors to educate patients and each other about opioid safety and the use of state monitoring programs. VA medical providers were able to discern, and take into account, non-VA prescriptions when considering their own patients’ medical care.

Over the next few years, as opioid prescription rates steadily declined at VA facilities around the country, studies began demonstrating that non-pharmacological therapies, such as psychotherapy and behavioral therapy, could reduce pain and improve function in chronic pain patients. A 2014 report by the VA’s Office of Inspector General found that these nonpharmacological options were an underutilized resource for chronic pain patients who’d been prescribed opioids. The medical community still lacked any evidence that opioids were an effective long-term therapy for chronic pain.

In 2016, as Rosenberg and his colleagues were preparing their own revisions to the VA/DOD opioid therapy guideline, the CDC published its revised recommendations for prescribing opioid pain medications to adults. The new CDC guideline differed from the previous version in significant ways, recommending lower dosages and the use of risk assessment tools, such as state prescription monitoring programs, for all patients, rather than focusing on high-risk patients.

The guideline provided more specific recommendations for

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■■ Alyson Rhodes, right, a yoga therapist at the Intrepid Spirit Center

on Fort Bragg, North Carolina, leads patients through a therapeutic yoga session Dec. 14, 2017. Pharmacology isn’t the only treatment for chronic pain. The VA offers complementary treatments for pain management such as yoga, physical therapy, and cognitive behavioral therapy.

monitoring and discontinuing the use of opioids when risks and harm outweighed benefits. In July 2016, Congress passed the Comprehensive Addiction and Recovery (CARA) Act, requiring VA and DOD to consider the CDC opioid guideline in its new opioid therapy guideline, which was already in development.

TOWARD A NEW NORMAL

The new “VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain,” based on evidence received through December 2016, contained a total of 18 recommendations in four areas: initiation and continuation of opioid therapy; risk mitigation; type, dose, follow-up, and tapering of opiods; and opioid therapy for acute pain.

Rosenberg, who again co-chaired the effort, said he and his colleagues took an assertive stance: “The evidence is overwhelming now that chronic opioid therapy is harmful,” he said, “and we’ve said that opioid therapy should not be used for chronic pain, because the risks overwhelm the benefits.”

It’s important to note that the guideline recommends strongly against “initiation” of opioid therapy for chronic pain; many VA and DOD patients already receive and are doing well with opioids, and select patients may, after a careful examination of risks and benefits, still initiate opioid therapy as the best available alternative. The guideline does not support the abrupt termination of opioid therapy, nor abrupt dosage reductions, for patients who are already managing chronic pain with opioids. Research suggests these practices may increase the risk of other harmful consequences, such as drug-seeking behavior or even suicide.

Instead, Rosenberg said, the guideline recommends a watchful regimen that makes use of all available risk mitigation strategies and re-evaluates the benefits and risks of 83

■■ Charles Brill, a physician assistant who works at the Intrepid Spirit

Center on Fort Campbell, Kentucky, inserts needles into Spc. Arthur Barlow, an automated logistical specialist assigned to Headquarters and Headquarters Company, 101st Special Troops Battalion, 101st Airborne Division Sustainment Brigade, 101st Airborne Division, as part of an acupuncture session to relieve Barlow’s pain, at the center March 20, 2017. For many of Brill’s patients, acupuncture is a way to treat chronic pain without the use of opioids.

continued opioid therapy at least every three months. When appropriate, the guideline recommends tapering – slowly decreasing the dosages over time, to a reduced dose or discontinuation. Overall the guideline’s message is clear: The first choice for long-term pain management should be selfmanagement strategies or other non-pharmacological treatments, or non-opioid drugs. If opioids are chosen as a chronic pain treatment, the choice should be made after a careful assessment of risks and benefits for the particular patient – and those assessments should continue throughout the duration of the patient’s treatment.

The new guideline demonstrates a radical change in thinking – a 180-degree reversal – since the VA and DOD issued their first guideline, 15 years ago, recommending the use of opioids for long-term pain management. After the guideline’s publication, two studies offered fresh insights: One validated the guideline, and another suggested much work to be done to ensure its implementation.

The first study, published in the March 6, 2018 issue of JAMA, was conducted by a team at the Minneapolis VA Center for Chronic Disease Outcomes Research, led by Dr. Erin Krebs, MPH. The subject group included 240 veterans with chronic pain – back pain or osteoarthritis of the knee or hip – that was ongoing and intense. Half these veterans were treated for a year with opioids, and the other half with non-opioid drugs, either over-the-counter drugs such as acetaminophen or prescriptions drugs such as lidocaine.

The study revealed that over time, the non-opioid group had slightly less pain intensity, while the opioid group had more side effects, such as fatigue, constipation and nausea.

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Interestingly, Krebs and her colleagues eliminated any possibility that patient expectations might play a role in these outcomes: Though most of the subjects, Krebs said, began the study believing opioids were far more effective than nonopioid treatments, all were told which group they were in.

The Minneapolis study is a landmark in opioid research, Rosenberg said. “They looked, in a very rigorous and scientific way, at opioid therapy over a long period, and found that it was not efficacious.” It’s now known, with a high degree of certainty, that the harm associated with opioid therapy, including side effects and the risk of addiction, far outweighs the benefits.

Another recent study, published in the April 2018 edition of Journal of General Internal Medicine, was conducted by a team at the VA Eastern Colorado Health Care System’s Center of Innovation for Veteran-centered and Value-driven Care.

Investigators surveyed the care provided to 1.1 million veterans at 176 VA medical centers between 2010 and 2015, and found that opioid prescription for chronic pain varied widely among these centers – at some, as many as a third of veterans seeking care for chronic pain began long-term opioid therapy; in others, as little as 5 percent. Dr. Joseph Frank, MPH, lead author of the study, described it as “a first step in understanding the institutional cultures that may contribute to the use of opioids to treat chronic pain.” Frank’s team found, unsurprisingly, that veterans were less likely to begin long-term opioid therapy at facilities where a wider range of treatment options were available – an indicator that available resources are a key determinant of institutional culture.

For patients at more remote rural centers, options will always be more limited, but Rosenberg said the VA, with its Whole Health Initiative and other programs, has been working to change the way veterans and health care providers think about pain management – to extend a holistic, patient-centered culture throughout the enterprise. For many veterans, particularly those who’ve suffered serious injuries, opioids may continue to be an option for long-term pain management, though evidence increasingly suggests they’re unlikely to be the best option. For other veterans, said Rosenberg, we may be entering a post-opioid era, one in which reaching for a pill shouldn’t be the first impulse of anyone treating chronic pain.

“We have to re-educate our nation that that kind of thinking is not wise,” Rosenberg said. “If you have back pain that has taken you 20 years to get, and now it becomes so severe that it’s impeding you, you need to stop looking for the instant solution. You need to know that it might take some work. You may have to do daily exercises. You may need to eat better. You may need to quit smoking.”

While the damage of the opioid epidemic can’t be undone, the growth of this culture throughout the veteran and military medical communities – a culture that doesn’t zero in on pain, but focuses on the overall wellness of a patient – may help future service members and veterans feel better, and avoid further harm.

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PHOTO BY LEEJAY LOCKHART

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