[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
[H.A.S.C. No. 114-101]
ENSURING MEDICAL READINESS
IN THE FUTURE
__________
HEARING
BEFORE THE
SUBCOMMITTEE ON MILITARY PERSONNEL
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
HEARING HELD
FEBRUARY 26, 2016
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SUBCOMMITTEE ON MILITARY PERSONNEL
JOSEPH J. HECK, Nevada, Chairman
WALTER B. JONES, North Carolina SUSAN A. DAVIS, California
JOHN KLINE, Minnesota ROBERT A. BRADY, Pennsylvania
MIKE COFFMAN, Colorado NIKI TSONGAS, Massachusetts
THOMAS MacARTHUR, New Jersey, Vice JACKIE SPEIER, California
Chair TIMOTHY J. WALZ, Minnesota
ELISE M. STEFANIK, New York BETO O'ROURKE, Texas
PAUL COOK, California
STEPHEN KNIGHT, California
Dan Sennott, Professional Staff Member
Craig Greene, Professional Staff Member
Colin Bosse, Clerk
C O N T E N T S
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Page
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Davis, Hon. Susan A., a Representative from California, Ranking
Member, Subcommittee on Military Personnel..................... 2
Heck, Hon. Joseph J., a Representative from Nevada, Chairman,
Subcommittee on Military Personnel............................. 1
WITNESSES
Caravalho, MG Joseph, USA, Joint Staff Surgeon General, U.S.
Department of Defense.......................................... 3
D'Alleyrand, LTC Jean-Claude G., M.D., USA, Chief, Orthopaedic
Traumatology Service, Walter Reed National Military Medical
Center......................................................... 23
Hogg, Maj Gen Dorothy, USAF, Deputy Surgeon General, United
States Air Force............................................... 4
Lawrence, Col Linda, M.D., USAF, Special Assistant to the Air
Force Surgeon General for Trusted Care Transformation, Office
of the Air Force Surgeon General, United States Air Force...... 20
Mabry, LTC Robert L., M.D., USA, Robert Wood Johnson Health
Policy Fellow, U.S. House Committee on Energy and Commerce..... 22
Moulton, RADM Terry J., USN, Deputy Surgeon General, United
States Navy.................................................... 7
Tenhet, BG Robert, USA, Deputy Surgeon General, United States
Army........................................................... 6
APPENDIX
Prepared Statements:
Caravalho, MG Joseph......................................... 39
D'Alleyrand, LTC Jean-Claude G............................... 99
Hogg, Maj Gen Dorothy........................................ 46
Lawrence, Col Linda.......................................... 78
Mabry, LTC Robert L.......................................... 83
Moulton, RADM Terry J........................................ 68
Tenhet, BG Robert............................................ 59
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
Mr. O'Rourke................................................. 109
Mr. Zinke.................................................... 109
Questions Submitted by Members Post Hearing:
Mr. O'Rourke................................................. 113
ENSURING MEDICAL READINESS IN THE FUTURE
----------
House of Representatives,
Committee on Armed Services,
Subcommittee on Military Personnel,
Washington, DC, Friday, February 26, 2016.
The subcommittee met, pursuant to call, at 9:28 a.m., in
room 2212, Rayburn House Office Building, Hon. Joseph J. Heck
(chairman of the subcommittee) presiding.
OPENING STATEMENT OF HON. JOSEPH J. HECK, A REPRESENTATIVE FROM
NEVADA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL
Dr. Heck. I will go ahead and call this subcommittee
meeting of the Military Personnel Subcommittee to order.
I want to welcome everyone to the hearing of the Military
Personnel Subcommittee to receive views on how best to ensure
our future military medical readiness. This hearing is part of
the committee's ongoing project to comprehensively review the
current state of the Military Health System and military health
care and, based on this information, identify areas that need
improvement.
Our purpose today is to discuss the top priority of the
Military Health System: to ensure the medical readiness of our
military forces, while also ensuring a ready medical force
prepared to deploy in support of combat operations.
Over the past 14 years of conflict, the services have
worked tirelessly to improve medical readiness, ensuring both
service members and medical providers are able to deploy and
accomplish their missions. The medical readiness rates for each
of the services have seen double-digit growth, as commanders
and healthcare providers work together to identify and
eliminate barriers to deployability.
Combat medicine has also seen extraordinary advances,
resulting in service member survival rates that were once
thought unachievable. In many areas, the standards of care have
been redefined as advances in areas ranging from transfusion
medicine to casualty transport care reshape combat medicine.
These crucial advances have not only benefited the military but
civilian medicine as well.
Many of these advances were made possible by the tireless
efforts of military practitioners. Even in peacetime, military
healthcare providers have the complex job of maintaining the
medical readiness of service members at home stations while
also manning, equipping, and deploying medical units with
medical personnel who are trained in both military skills and
specialized medical skills needed for wartime medicine.
The hard-fought advances in combat care over the past 14
years must be preserved. The medical specialties needed during
war are not limited to trauma; however, during periods of
limited deployment, trauma skills can quickly degrade, which is
why we must do everything possible to maintain proficiency in
both trauma and emergency medicine. It is crucial that military
trauma teams have the proper patient volume and case complexity
during times of limited deployment so that they can maintain
the skills needed in combat.
We will hear today from two panels, the first panel
consisting of the Joint Staff Surgeon and service Deputy
Surgeons General who can provide valuable insights regarding
service-wide initiatives, and the second panel comprised of
practitioners who can provide perspectives on the current
challenges facing military emergency medicine and trauma
practitioners.
I look forward to hearing from our panels about the current
efforts underway by the services to ensure we maintain high
service member readiness and provider readiness during periods
of limited deployment. In addition, I am interested to hear how
the services ensure medical providers maintain their
specialties, particularly in areas where patient volume is
limited. Finally, I look forward to hearing the challenges
facing practitioners as they look for innovative ways to
maintain proficiency during periods of limited deployment.
Before I introduce our panel, let me offer the ranking
member, Mrs. Davis, an opportunity to make her opening remarks.
STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL
Mrs. Davis. Thank you, Mr. Chairman. I also want to welcome
our witnesses from both of our panels this morning.
This hearing should afford us the opportunity to hear a
variety of perspectives on medical readiness. And, as you all
know very, very well, nothing that we have to tell you, medical
readiness is the foundation for which the military services'
medical systems are built, not just the readiness of service
members who are trained and proficient but also the readiness
of the providers who ensure those service members are always
fit to perform their mission.
So much of the discussion on military readiness has been
focused on trauma specialties in combat and how to maintain the
skills the medical community has gained over the last 15 years
of persistent conflict. I am interested to follow up on the
discussion in your written statements about the development of
the essential medical capabilities, as well as how each of the
services maintains visibility over provider readiness to ensure
that we have the proper number of trained providers when
needed, and how you manage the trauma specialties, trying to
track that. And I think, for all of us who are not immersed in
this in the way that you are every single day, understanding
how that really occurs has got to be important as well.
I also want to acknowledge and thank the chairman for
mentioning the contribution to civilian medicine that our armed
services have made and the medical providers have made to our
country. Staggering and incalculable, and I appreciate that
greatly.
Thank you, Mr. Chairman, and I look forward to the hearing.
Dr. Heck. Thank you, Mrs. Davis.
We are joined again today by two outstanding panels. We
will give each witness the opportunity to present his or her
testimony and each member an opportunity to question the
witnesses.
I would respectfully remind the witnesses to summarize to
the greatest extent possible the highpoints of your written
testimony in 5 minutes. The lighting system will be green. At 1
minute remaining, it will turn yellow. When it turns red, I ask
you to quickly try to summarize and finish up your testimony so
we can move on through.
Let me welcome our first panel: Major General Joseph
Caravalho, Joint Staff Surgeon, Office of the Chairman of the
Joint Chiefs of Staff; Major General Dorothy Hogg, Deputy
Surgeon General, United States Air Force; Brigadier General
Robert Tenhet, Deputy Surgeon General, United States Army; and
Rear Admiral Terry Moulton, Deputy Surgeon General, the United
States Navy.
I ask unanimous consent that non-subcommittee members be
allowed to participate in today's hearing after all
subcommittee members have had an opportunity to ask questions.
Without objection, non-subcommittee members will be recognized
at the appropriate time for 5 minutes.
With that, Major General Caravalho, you are recognized for
5 minutes.
STATEMENT OF MG JOSEPH CARAVALHO, USA, JOINT STAFF SURGEON
GENERAL, U.S. DEPARTMENT OF DEFENSE
General Caravalho. Thank you, Chairman Heck, Ranking Member
Davis, and distinguished members of the subcommittee. I am
pleased to be seated alongside my colleagues, and I am
especially grateful for the opportunity to discuss medical
readiness with you today.
My written testimony has been submitted for the record.
Today, I would like to highlight three points in my oral
testimony.
However, as this is my first opportunity to meet with this
committee in my capacity as the Joint Staff Surgeon, I would
like to first take a moment to tell you about my role.
Essentially, I have the responsibility to provide the Chairman
of the Joint Chiefs of Staff and other senior leaders with the
best military medical advice in support of the joint force.
In my role as the facilitator for global medical
synchronization, I work with other Joint Staff directorates to
service Surgeons General and the Assistant Secretary of Defense
for Health Affairs to meet the Chairman's intent in delivering
health services to the combatant commanders and the joint
force.
Now, first of all, I would like to say I am extremely proud
of the accomplishments to date of the joint medical force
across the full spectrum of military operations. And with the
Chairman's vision of future security environments, my first
point is military medicine must be better aligned to
continually demonstrate its readiness posture to the
Department's senior leaders.
It is my observation the joint force expects military
medicine to be more than interoperable and, at times, more than
joint. I believe whenever and wherever feasible, while
remaining cognizant of service responsibilities, to best
support the joint force, the services' medical forces must be
interchangeably aligned.
The Chairman's recently published Joint Concept for Health
Services moves us in that direction. Now, this document
describes in broad terms the Chairman's vision for what the
future joint force will need from military medicine to support
globally integrated operations.
To this end, the services have begun work on establishing
core medical specialty requirements that will aid in creating a
more interchangeable joint medical force. Readiness metrics
will then reflect each medical specialty's ability to function
across the full spectrum of military operations.
Next, I have also observed an increasing number of requests
for medical support to smaller, more widely dispersed ground
forces, and I expect this trend to continue. With this, my
second point is the medical community must adapt to new
paradigms of health service support. To meet this challenge, we
have already begun work towards a formalized and disciplined
review to develop new organizations, training, policies, and
doctrine.
My third point is I view military medical centers,
hospitals, and clinics as our home stations' front lines of
care. They provide ready warfighters and medical forces alike,
while delivering quality health care to our valued
beneficiaries. Then, both during and following deployments,
they offer continued high-quality care for those in need.
Now, these platforms should not be compared directly to
civilian healthcare facilities, as we are focused primarily on
readiness.
In conclusion, military medicine has but one mission, and
that is to support the joint force with globally integrated
health services. We will not lose focus on the world-class
health care our service members and families deserve, but it
will be performed in support of our primary mission of medical
readiness.
From home station to operational deployments to evacuation
and post-deployment settings, I feel strongly the military
medical team across all the services will remain relevant,
adaptive, and highly valued members of the joint force.
Thank you for the opportunity to address the committee and
for your enduring support of our service members and their
families.
[The prepared statement of General Caravalho can be found
in the Appendix on page 39.]
STATEMENT OF MAJ GEN DOROTHY HOGG, USAF, DEPUTY SURGEON
GENERAL, UNITED STATES AIR FORCE
General Hogg. Chairman Heck, Ranking Member Davis, and
distinguished members of the committee, thank you for the
opportunity to come before you today to discuss the future of
Air Force medical readiness.
Fielding ready medics is the key to providing world-class
health care at home and in the deployed environment. Let me
illustrate this point.
Last week, Craig Joint Theater Hospital in Afghanistan
admitted a NATO [North Atlantic Treaty Organization] patient
suffering from adult respiratory distress syndrome. The patient
ultimately needed extracorporeal membrane oxygenation, or ECMO,
and aeromedical evacuation to Landstuhl Regional Medical Center
in Germany.
While awaiting evacuation, the patient's oxygen levels
decreased rapidly, leading to a life-threatening irregular
heart rate, resulting in advanced cardiac life support and
kidney dialysis. Craig's critical care medical team jumped into
action to stabilize the patient and prep him for immediate
evacuation.
The complexities of this emergency illustrate the medical
readiness skills required of our medics in managing not only
trauma patients but nontrauma patients as well. This level of
readiness is achieved through caring for complex patients with
similar disease etiologies in our Military Health System.
Every Air Force military treatment facility is a medical
readiness platform aligned with an operational wing that
directly enhances the medical readiness of warfighters and
their families. The care we provide our beneficiaries enables
us to sustain the readiness of our medical force. And our
readiness is directly related to the volume, diversity, and
acuity of our patient population.
The Air Force Medical Service has a broad portfolio of
readiness training programs to prepare individual medical
specialists and deployable medical teams for reliable
performance across the full range of military operations. The
readiness portfolio spans care provided within our MTFs
[military treatment facilities] to specialized advanced trauma
training delivered in our civilian Level I trauma partnership
platforms.
Our Readiness Skills Verification Program establishes
baseline skills required in a deployed environment. These
skills are identified by senior clinical consultants and
enlisted functional area managers based on combatant
commanders' requirements and are updated with lessons learned
and emerging medical evidence.
In tandem, the Sustained Medical and Readiness Trained, or
SMART, program expands training opportunities for skills
requiring a higher volume and complexity of hands-on care than
normally seen in our smaller military treatment facilities,
utilizing local training affiliations or regional currency
sites, such as the University Medical Center in Las Vegas,
Nevada.
For well over a decade, we have also had cadres of
physicians, nurses, and technicians embedded in our Centers for
Sustainment of Trauma and Readiness Skills, known as C-STARS,
located in Baltimore, Cincinnati, and St. Louis. Hundreds of
our medics have received elite trauma and critical care
training and remain prepared to deploy anytime, anywhere.
Similarly, Air Force graduate medical education programs
develop the knowledge, skills, and attitudes of highly
qualified medical personnel while supporting the Air Force
Medical Service missions. These training programs deliver
health care to our military members and other beneficiaries,
ensures the competency and currency of medical personnel, and
contributes to the readiness of medical airmen.
The Air Force Medical Service is committed to preserving
the medical skills obtained in the last 15 years of conflict
and will continue to meet the evolving requirements of
combatant commanders. With your support, we will continue to
provide trusted and reliable health services to our airmen and
their families for years to come.
Thank you, and I look forward to your questions.
[The prepared statement of General Hogg can be found in the
Appendix on page 46.]
STATEMENT OF BG ROBERT TENHET, USA, DEPUTY SURGEON GENERAL,
UNITED STATES ARMY
General Tenhet. Chairman Heck, Ranking Member Davis, and
distinguished members of the subcommittee, thank you for this
opportunity to provide the Army perspective on ensuring medical
readiness now and into the future.
Today's uncertain global environment continues to place
high demands on the Army. Over the past year, the Army deployed
over 190,000 soldiers to more than 140 countries around the
world in support of various operations. Readiness is the Army's
number one priority.
And, as Ranking Member Davis mentioned earlier, our trained
and ready medical force contributed to the highest
survivability rate in the history of warfare despite the
increasing severity of battle injuries. These advances in
combat casualty care are primarily due to the integrated system
of health that currently extends from the battlefield through
Landstuhl Regional Medical Center in Germany to our in-patient
hospitals in the United States.
Today, we are faced with the question of how to sustain the
competency of our medical force, which has performed so well in
the past 14-plus years. During the second panel, you will hear
from two combat-tested Army physicians, Lieutenant Colonel Bob
Mabry, an emergency medical physician and certified pre-
hospital physician specialist, and Lieutenant Colonel Jean-
Claude D'Alleyrand, an Army trauma orthopedic surgeon, who will
discuss challenges in pre-hospital care as well as maintaining
surgical skills.
However, we must not focus exclusively on the sustainment
of combat trauma, surgery, and burn capabilities. Our Army and
soldiers must be prepared for a multitude of contingency
missions: to engage in conventional conflict against large
armies and smaller, as mentioned by our Joint Surgeon; defend
the homeland; and respond to a wide range of crises, ranging
from peacekeeping to disaster relief and humanitarian
assistance.
The Army must maintain a broad range of medical
capabilities to support this full range of military
requirements. The 2014 deployment of 2,500 personnel to support
Operation United Assistance in Liberia demonstrated the value
of non-trauma-related medical specialities. Some argue these
examples are not part of our mission set for ready and relevant
medical support, but, invariably, when the task is unique and
difficult, the Nation leans on its military.
To ensure the readiness of the entire medical team for this
broad range of missions, we must maintain and sustain our
medical centers, hospitals, and clinics as our readiness and
training platforms. This system ensures our medical force is
trained, ready, and relevant to provide primary and specialty
care in the myriad settings and conditions faced around the
world.
We must continue to develop innovative partnerships with
the VA [Department of Veterans Affairs], civilian hospitals,
and other organizations to ensure our entire medical team
continues to be exposed to a varied and complex mix of
patients. This is essential to train, challenge, and to hone
the skills of our entire medical team.
In addition, we must continue to train the next generation
of the Army Medicine team through our graduate medical
education programs. These programs are vital to our ability to
recruit and retain highly skilled medical providers. Most
importantly, these programs are the primary means of
transferring knowledge from this generation of military
providers to the next.
While our system has proven to be very successful over the
last 14 years, we must continue to improve and evolve it to
meet the challenging needs of our Nation's Army. Since the
beginning of our Nation's history, when we send our Nation's
sons and daughters into harm's way, they need to know that the
Army Medicine is there, relevant, and ready.
I am committed to ensuring we maintain and improve the
readiness of our medical force. I look forward to working with
Congress in this endeavor. And I want to thank my partners in
the DOD [Department of Defense], my colleagues here on the
panel, and Congress for your continued support.
[The prepared statement of General Tenhet can be found in
the Appendix on page 59.]
STATEMENT OF RADM TERRY J. MOULTON, USN, DEPUTY SURGEON
GENERAL, UNITED STATES NAVY
Admiral Moulton. Good morning, Chairman Heck, Ranking
Member Davis, distinguished members of the committee. Thank you
for providing me the opportunity to share some perspectives on
Navy Medicine and our most important strategic priority,
medical readiness. We are grateful to the committee for your
leadership and strong support of military medicine.
Force health protection is the bedrock of Navy Medicine. It
is what we do and why we exist. And this mission spans the full
spectrum of health care, from optimizing the health and fitness
of the force, to maintaining robust disease surveillance and
prevention programs, to saving lives on the battlefield.
And on any given day, Navy Medicine is underway and
operating forward with the fleet and the Marine forces around
the globe. We operate in all warfare domains, in all
environments, and must also deliver important specialized
capabilities to the warfighters. Our personnel, whether an
independent duty corpsman, a flight surgeon, an undersea
medical officer serving aboard a submarine, a ship, or
squadron, or a fleet Marine force corpsman in the field with a
Marine unit, must be trained and equipped to execute their
specific mission.
Our readiness posture also requires us to be capable of
meeting critical surge requirements in support of contingencies
and combat operations. And Navy Medicine's expedition medical
capabilities are important as we provide that care through all
the echelons of care, from the battlefield to the bedside of
our military treatment facilities.
This is clearly evident as Navy Medicine continues to
sustain unparalleled levels of mission success, competency, and
professionalism while providing world-class trauma care and
expeditionary force health protection to U.S. and coalition
forces in southern Afghanistan.
It also enables us to support humanitarian assistance and
disaster response missions since our hospital ships have the
capability to provide relief in the wake of catastrophic events
like tsunamis and earthquakes. And our global health engagement
strategy requires us to be ready to support these diverse
missions around the globe.
I cannot overstate the importance of our military treatment
facilities in ensuring readiness of our personnel. The ability
to deliver the full range of medical capabilities to the
operational commander is highly dependent on the training and
clinical currency of our personnel. And our MTFs are critical
to providing these skills and competencies and must remain
foundational to meeting our current and future operational
requirements.
Navy Medicine also continues to leverage our strategic
partnerships with leading civilian trauma centers so our
personnel can hone and sustain their skills, including the Navy
Trauma Center at LA [Los Angeles] and USC [University of
Southern California] Medical Center. And this program has
trained over 2,800 of our deploying medical personnel since
2002 and continues to enhance their combat trauma skills and
medical readiness.
And it is also important to recognize that our GME
programs, graduate medical education programs, at our medical
centers and our family medicine teaching hospitals support
readiness by providing trained physicians to meet our
operational requirements. And these programs rely on our MTFs
having access to robust beneficiary populations and support our
case number and complexity.
The services, along with the Joint Staff and DOD, are
working to identify, define, categorize, and prioritize
essential medical capabilities, or EMCs. These refer to those
health services that are required to deliver comprehensive
health care in support of globally integrated operations and
will provide the framework for maintaining the medical ready
force.
In the last 15 years of war, I have seen unprecedented
advances in military medicine, and this progress was the result
of a highly trained and well-equipped force dedicated to
rapidly deploying the most effective lifesaving skills and
techniques. And all of us in military medicine are committed to
ensuring the lessons learned are sustained and effectively
implemented throughout the MHS [Military Health System], and we
are committed to continuous improvement. And these efforts
require rigorous ongoing assessment of our capabilities,
identification of gaps, and implementation of sound solutions.
And all of us recognize that there is hard work ahead for that,
to maintain medical readiness moving forward.
Again, thank you for your support, and I look forward to
your questions.
[The prepared statement of Admiral Moulton can be found in
the Appendix on page 68.]
Dr. Heck. Thank you all for your testimony.
We will begin the 5-minute round of questioning by members.
A recent study of military medical staff concluded that the
military seems to understaff operationally required specialties
and overstaffs specialties more towards providing beneficiary
care.
So I would ask, how do the services balance maintaining
that mix of having the docs needed or the entire healthcare
spectrum needed to take care of military beneficiaries or to
maintain their combat skills? And I would guess that part of
the EMCs is going to help define that.
For instance, you know, you look at certain facilities and
there seems to be an abundance of OB-GYN [obstetrics and
gynecology] and pediatrics, understanding that in humanitarian
care we have to be prepared to provide those things, but not
necessarily the level or the number of specialists or
specialties required to provide combat casualty care.
So that would be my first question.
And to follow on to that, when we try to maintain the level
of training of, let's say, our teams that are going to provide
combat casualty care, I think, General, you mentioned your
SMART program, and I appreciate the shout-out to University
Medical Center, my former place of employment.
But how do we ensure that the entire team--the
anesthesiologist, the medic, the nurse, everybody--is trained,
as opposed to just rotating out the trauma surgeon to a Level I
trauma center?
So whoever wants to tackle it first, we can just go down
the line.
General Hogg. Yes, sir, I will take that.
So we need to maintain the readiness not only of our Active
Duty members but of our families also. And the OB-GYN and the
pediatric care that we provide help us to maintain that family
readiness so that when that Active Duty member is deployed they
have confidence that their family will be taken care of. And,
also, those specialties will provide some military medical
readiness due to complications that might occur during those
episodes of care.
The ability to get the whole team trained can be
challenging at times. Most of the specialty care that we get
within the Air Force Medical Service, we rely on our civilian
partners to help achieve that. And it is at their mercy whether
they want us to come into their facility. There is nothing
compelling them, per se, to partner with us.
We do have some challenges with our technicians, our
technical specialties, getting them into the civilian
facilities, because they are not equivalent. The civilian
community doesn't really understand their equivalencies. Once
we get them in the door, they are all on board and usually ask
us, do you have more?
And so we try by getting in the physician and the nurse,
and then, once we get them into our partnerships, we tag along
a technician. And once they see the capabilities of our
technicians, usually that helps.
Dr. Heck. Anybody else want to add?
General Tenhet. I will add to General Hogg's comments here.
In a deployed setting, trauma care takes up about 15
percent of the numbers we see in theater, so 85 percent of
those are disease/non-battle injury. In any given camp or FOB
[forward operating base], you may have upwards of 30 percent
females. So just with the OB-GYN, I mean, gynecologists in
theater is not a misnomer.
So, of the evacuations used in the wonderful Strat Air
[Strategic Airlift] that the Air Force has, 80 percent of our
evacs [evacuations] are disease/non-battle injury as well. So
to sustain just within the trauma system itself, we have to
look across the entire spectrum of medicine.
And as you talked about the--or asked the question on the
OR [operating room] piece, we estimate it takes up to 80 staff
members to support 1 OR. So it becomes a convoluted system to
try and train to standard using the team approach and
collective training.
So our forward surgical teams you are probably familiar
with, we do take them into team training, collective training
down at Ryder in Miami. And we are looking to expand that
across the U.S. and maybe even globally as we go into the
interwar years.
Admiral Moulton. Sir, I would just comment to your first
question, you know, about maintaining the balance, how do we
ensure that we are meeting our operational requirements and
then the peacetime care as well, for us, there are priorities
for distribution of our resources.
First of all, we are going to support the operational
requirements. That is 100 percent staffing. And then we would
look to our overseas activities, which are forward-deployed.
And then, lastly, is our MTFs. And then they are augmented by
civilians and contractors to maintain that skill and to build
that credibility before deploying again.
And then the second question, back to the entire team,
rather than just the trauma surgeons or surgeons in general,
you know, we are moving back to a platform readiness. And for
the last 15 years, we have been doing a lot of individual
augmentations, so now, moving back to platform readiness, we
can train the whole unit. You will know where you are assigned,
and you will know what the training requirements are for that
platform, and then you will train as a team before deployment.
Dr. Heck. Okay. Thank you all. My time has expired.
Mrs. Davis.
Mrs. Davis. Thank you, Mr. Chairman.
And I wanted to go back just to the EMCs, the essential
medical capabilities, for a second. Obviously, you have been
working on it very hard, I think, but when do you expect to
complete them? And how long will it take to implement across
the individual force?
General Hogg. Yes, ma'am. So the Air Force Medical Service
supports the development of the EMCs, and we have been actively
engaged in defining what those are.
The timeframe, we will have the beginnings of some
essential medical capabilities, I believe, in October of this
year. And then the implementation, right now I really don't--we
haven't got the timeline for that.
General Caravalho. Ma'am, if I may say that the EMCs are
primarily going to describe what is already being done by the
services now, except that they are using the civilian
healthcare model of are you board-certified, are you
credentialed, licensed, and privileged. The EMCs is going to
put it--I believe is going to be very helpful because it will
put it into the DOD reporting system style so that now senior
leaders can say are my medics ready, just like are my
submariners ready and are my aviators ready.
Mrs. Davis. Uh-huh.
General Caravalho. I will speak--I think it will speak to--
it won't be too high-level, it won't be strategic, in that
``take care of patients,'' of which everything falls within.
And it won't be too tactical, to say what do our
ophthalmologists do and what do our cardiologists do. It is
going to be along the lines of providing hospitalization,
providing patient movement, something along those lines, under
which, then the essential task list will be generated by the
services and the primary skills, attributes that everyone will
need.
And I believe each provider will then be able to say,
regardless of my specialty as an NCO [noncommissioned officer]
or as an officer, what do I bring to this fight. So I may not
be a general surgeon, but I will be asked to be a surgeon; what
are the skills I will need to be a surgeon in any realm that I
am asked to participate, whether major combat operations,
humanitarian assistance, or what have you.
I think that is how that is going to play out. I think we
will start to be, as was mentioned, start to be able to codify
that in a Department's reporting system later this year.
Mrs. Davis. Uh-huh. Do you think, I mean, you have pretty
much described this right now, I think, that--do you see a
major impact on training requirements then? Is that really
going to----
General Caravalho. I think we are going to--we are not
going to create a new system. I think we already, I think the
services already know proficiency and currency using the peer
review, the systems that civilian healthcare industry uses. We
are just going to codify it and report it so that the senior
leaders know that, no matter what I ask you to do, fight
tonight, sustain operation, are you able to do--are you able to
fight. I am hoping then that, whether they ask for Army or Navy
or Air Force, no matter what the Chairman is looking for, it
won't matter because we are using the same codified skill sets.
Mrs. Davis. Uh-huh.
General Caravalho. And if we are truly interchangeable and
one service is short a surgeon, for instance, using EMCs, we
can look to another service and say, okay, you have met the
standard, can you come in and fill, as opposed to it must be
all Army or all Navy or all Air Force every time there is a
requirement.
Mrs. Davis. Yeah.
Could you all respond? I mean, does that make a real
difference?
General Tenhet. So when we get into the KSAs [knowledge,
skills, and abilities]--so you build the EMCs, that is the
overarching codification of this. And we are looking at 10,
primarily, at this point in time. We haven't solidified that
yet, but that is where I think we are going to go with this.
It, oh, by the way, mirrors into the joint concept of health
support, so that is process and progress in that model.
But concomitant with the EMC is the knowledge, skills, and
abilities that we are aligning across the services. And that
gets into both the operational and down to the tactical level
of the individual. So, within that construct, it is going to be
a scorecard, just like the infantry uses in their unit status
reporting; are they green, amber, or red. We are going to apply
that to medicine.
Mrs. Davis. Yeah. But is this going to be on an individual
basis then? Will you know whether one specific physician is
ready?
General Tenhet. Absolutely. Absolutely.
General Hogg. Yes, ma'am.
Mrs. Davis. And is that true, that you don't know today?
General Hogg. No, ma'am, we do know today. In the Air Force
Medical Service, we have, I mentioned in my oral statement
about the Readiness Skills Verification Program. Every medic in
the Air Force Medical Service has a readiness skills
verification checklist, if you will, that identifies the skills
that are necessary for them to be competent in wartime
scenarios or over the full range of military operations.
That is looked at on a regular basis. Some of the training
is knowledge-based, some of the training is didactic, and some
of the training is hands-on. And they are required to complete
those skills, depending on the timeline, in order to stay
current.
Mrs. Davis. Uh-huh. But in terms of, once this is
operational, I understand it is not new to the system, but
there is added value to it.
General Caravalho. Yes, ma'am. If I may give an example of
where we are short now, if you have a general surgeon who goes
on to a fellowship and does plastic surgery and now she is
practicing as a plastic surgeon for 10 years, when we deploy
her, we will need her as a general surgeon, and she may never
have been in someone's belly operating for 10 or 15 years. We
track her as a competent, board-certified, credentialed,
privileged plastic surgeon, and we lose sight of the general
surgery part.
EMCs will say, no matter where you are, when you deploy,
have you met the skills and attributes we are looking for in a
deployed setting.
Mrs. Davis. Okay. Great.
And for our specialty nurses, just a yes or no, is it going
to be the same?
General Hogg. Yes, ma'am, it is the same.
Mrs. Davis. Okay. Thank you.
Dr. Heck. Mr. O'Rourke.
Mr. O'Rourke. Thank you.
Not sure to whom I should address this question, but I am
interested in the IDES, or the Integrated Disability Evaluation
System, that is supposed to ensure that a wounded or disabled
service member is either reintroduced back into Active Duty or
the appropriate Reserve Component or is able to seamlessly
transition out into VA medical care. And, following the
flowchart the Department of Defense has published, it looks
like that process should take about 295 days.
So I guess my first question is: Are we, in fact, returning
service members to Active Duty status in that time or helping
them to separate in that time with a VA disability rating, or
are we at some other mark either above or below 295?
General Hogg. Yes, sir. In the Air Force system, IDES
system, it is a collaborative process between DOD and VA, and
parts of those process are owned by those two entities.
In the part that the Air Force owns, the Air Force Medical
Service owns, we are doing actually very well with getting
members through, but the total process still is a little bit
over the 295 days.
Mr. O'Rourke. Do you know what it is for the Air Force?
General Hogg. No, sir. I would have to get back to you with
that.
Mr. O'Rourke. Okay, for the record.
And for anyone else, if anyone has a specific number, I
would love to hear it now. If not, we would just request that
as a followup question for the record.
[The information referred to can be found in the Appendix
on page 109.]
Mr. O'Rourke. General Tenhet, did you want to add to that?
General Tenhet. I was just going to mention we are at 291.
However, you know, the Army's injuries, we have had some
complex issues that keep that number around that window there.
Working with the VA, we have improved that significantly in
the last 4 to 5 years. And some of that has been from the
pressure from Congress to work more collaboratively together.
And also it is being able to share the documentation through
Legacy Viewer, et cetera. Any and all medical interaction is
now documented and shared across both the VA and DOD.
Mr. O'Rourke. That gets to a followup question I would like
to ask you, which is, I don't know how to gauge whether 295 is
a lot of time or the appropriate amount of time, but there are
certainly several stages, dozens of stages actually, in this
process, some of which the service member has the opportunity
to appeal a decision or make some other decision on his or her
part, and then decisions that are made by the Department of
Defense, decisions that are made by the VA.
Do you see any obvious opportunities to further streamline
this process, gain greater efficiencies, and ensure that the
service member returns to duty or is able to transition out
effectively and be in the care, again effectively, of the VA so
that nothing is dropped?
General Tenhet. There is always room for improvement, as a
learning organization. The medicine peace of that window is
actually a very small piece. It is mostly administrative. And I
think all the services, medically, are meeting their mark. I
think the coordination with the VA and working with our G-1
[Deputy Chief of Staff of the Army] through the administrative
piece of this, we can always continue to tighten that piece up.
But it is back on the soldier. Fifty percent of those just
2 years ago were being returned to service. We are down to
about 40 percent, again, because of the remaining complex
issues that we have.
But the ability to work with the VA, the warm handoff, and
also implementing the case management structure into this has
really enhanced the program.
Mr. O'Rourke. I have another question that may, because of
limited time for you to answer, be appropriate to get for the
record or to have an offline conversation. But in terms of that
warm handoff, anecdotally, in talking to veterans in El Paso
who served at Fort Bliss and were treated at William Beaumont
Army Medical Center, they talk about excellent care at the
military treatment facility, especially when it comes to mental
health. They then say that regimen of care which was so
expertly executed at William Beaumont, once I transitioned to
the VA, it was very hard to see a psychiatrist or a
psychologist or even a social worker to continue that care.
So I understand the goal. It is not happening. I would
love--and there is not time for you to respond right now, but I
would love to get your thoughts, either in writing or offline,
about how we can do a better job and what role specifically the
Army or Department of Defense could play in extending that care
if somebody is already in treatment.
Mr. O'Rourke. With that, I will yield back to the Chair.
Dr. Heck. Mr. Knight.
Mr. Knight. Thank you, Mr. Chair.
I just have some basic questions.
You know, in California, we have opened another medical
school out there because of the deficiency for surgeons and
doctors that we have in California and across the country. Are
we finding that in Army and Navy and Air Force Medicine, that
we are not getting enough applicants, that we are not having
enough surgeons and doctors?
General Hogg. No, sir. We staff to our requirements, and so
we typically have plenty of applicants to attend our military
medical programs.
Admiral Moulton. And for the Navy, I would say, as well,
that our recruiting efforts have been very successful over the
last several years. So we are not facing any shortages there.
General Tenhet. Same for the Army, sir.
I think our challenge is the retention piece of this.
Especially as the wars start to wane, especially in the trauma
medicine arena, the retention portion of this becomes more
challenging as we go forward.
Mr. Knight. Okay.
And as we have been at war now for 15 years, and for some
purposes for the last 25 years, we have seen readiness be the
number one goal. And I think that should always be the number
one goal in the military, is readiness.
But as our young men and women have gone into theater two,
three, four, five times, we have started to see an awful lot of
things that maybe we dealt with in other wars, maybe in Vietnam
and Korea and World War II, but they are very prevalent today.
We have renamed these things. I think in World War II we named
it ``shell shock,'' and today we have ``PTSD'' [post-traumatic
stress disorder] and ``traumatic brain'' and things like that.
They are all an effect of seeing something that normal people
don't ever want to see, and that affects someone.
How are we treating that differently today than maybe we
did 15 or 20 years ago?
General Hogg. Yes, sir. I think that the biggest way that
we are treating that differently is recognizing that it does
exist and that it does have an effect on our members coming
back from being exposed to those kinds of circumstances.
We certainly have increased our mental health care, and we
continually look to practice evidence-based medicine in
relationship to PTSD and TBI [traumatic brain injury]. And we
continue to care for those individuals coming back.
General Tenhet. I will just add to the comments. I think
just admitting that we do have these problems, Congress
supporting the efforts--$184 million in the last 15 years in
research. We are working with the NCAA [National Collegiate
Athletic Association], the NFL [National Football League], with
their programs, making tremendous strides there. I think it is
450 research programs ongoing right now just in our Medical
Research and Materiel Command.
Mr. Knight. Admiral.
Admiral Moulton. I was just going to also talk about the
partnerships that we have had, reaching out to UCLA [University
of California at Los Angeles] and our NICoE [National Intrepid
Center of Excellence] and really approaching it across the
system vice in isolated areas. So I think we are making good
strides in that.
Mr. Knight. And just in my last minute here, recently I
have sat down with some folks that are working on new and
innovative ways of treating our folks on the battlefield. Some
of them are these bandages where you can see if they are
actually healing or if it is not healing and things of that
nature and under-the-skin type of treatments that we can check
and we can monitor if it is working or if it is not working or
if the skin is healing or not healing.
Have we seen that because we have been at war in the last
15 years more? Or is that just because we are getting more and
more advanced in the medical field?
General Hogg. I will take that one too.
It is both. It is both. I think that as you are exposed to
situations and you deliver care, you are always thinking about,
could I do this better and, if so, how could I do that better?
So our research programs are helping us to look at those
specific care issues and figure out how could we do it better
to improve the survivability of our warfighters downrange.
So I think it is both. It is technology is advancing and we
are able to capitalize on that. But the care that we are
providing downrange and the kinds of things that we are seeing
causes us to look inside and go, could we do that better?
Mr. Knight. Thank you, General.
And I yield back.
Dr. Heck. Dr. Wenstrup.
Dr. Wenstrup. Thank you, Mr. Chairman.
I appreciate you all being here today.
I want to talk a little bit about some of the process of
implementing the things that we want to see as far as keeping
the skill levels up and credentialing that, et cetera. And, as
we know, so much of our military medicine is in the Reserve
Component and so not quite as captive an audience to check all
these boxes, if you will.
And, for example, I spent time with CCATT [Critical Care
Air Transport Team] in Cincinnati, and I thank the Air Force
for letting an Army guy go in there and participate in that.
But great training, pre-deployment training, and you really
have to qualify to be able to go and serve on that mission. And
I think, when I was there, everyone was Active Duty. They could
be reservists, as well, to come into that scenario.
But, by and large, too--so I served a year in Iraq at a CSH
[combat support hospital]. And in the OR, I was the only one
there for a year, and you had others rotating in 90 days. For
some, it was been there, done that; you know, not the first
time; they got it. For a young surgeon coming in, it was like,
holy cow, I have never seen anything like this, I have never
done anything like this.
And even in the Reserve Component, as you mentioned,
General, we have general surgeons that may be doing plastics,
but you know what? At that time, that didn't matter, you are
going to do this.
And so how do we get the Reserve Component, in particular,
to be able to check all these boxes, make sure that they are
ready? And do we have enough surgeons to fill that void?
Anyone.
General Hogg. In the Air Force Medical Service, the
training that we provide is opened up to the total force. So
the Reserves and the Guard can attend C-STARS, they can attend
SMART. They have the same requirements that we have, as far as
our Readiness Skills Verification Program, to maintain
competencies and currency.
The professional medics in the Reserve, the physicians, the
nurses, a little less concerning as far as competency, because
oftentimes they are practicing in their specialties. Where we
have a challenge is with our enlisted medics, because
oftentimes they are not practicing within their specialty. And
so they have a very robust program to, during their annual
trainings and whatnots, to try to get them up to speed.
Dr. Wenstrup. Thank you.
General Caravalho. Sir, the intent, I believe, for the EMCs
is going to be across all components. We shouldn't have an
Active Duty standard and a Reserve Component standard. But I
acknowledge that it is going to be difficult on your battle
assembly to get after some of these things.
So we may face an individual who doesn't have the right
clinical mix, acuity, caseload to meet an EMC-type standard. I
am hoping that across the board we are going to say, if you
can't get it clinically, what are the reasonable facsimiles
that you can then show your proficiency and currency? Online
training, modeling; partnering, strategic partnering, with
civilian or VA entities.
I think if we do this correctly, when you mobilize the
reservists, you must institute time. And we have done this with
this war. We have learned that you have to provide some time to
kind of get their mind into a--you are going to see not just a
gunshot wound, not just a knife wound, but you are going to see
blast injury, head injury and a gunshot wound and a knife wound
at the same time--and a burn.
So that is number one. So the Miami's [Ryder Trauma
Center], the Cincinnati trainings of the world before you
deploy is going to be critical.
The second thing is there has to be a critical mass of
expertise resident when the individuals show up. In other
words, we have been successful, I believe, with one burn center
in San Antonio rather than a burn center at every facility to
ensure everyone has burn center skills. And you rotate staff
through there, that that one person, whether it is a nurse, a
tech, or doc, can say, this is the burn standard, everybody get
on board.
And I think we are going to have to use those types of
creative skills to ensure that folks who may not be ready will
get ready. Because we know, on the back end, they want to be
ready. So when they are willing, it doesn't take long for them
to get on board.
Dr. Wenstrup. So maybe that can be their AT [annual
training]?
General Caravalho. Yes, sir. Yes, sir.
Dr. Wenstrup. Thank you. I yield back.
Dr. Heck. Mr. Zinke.
Mr. Zinke. Thank you, Mr. Chairman. I appreciate you
allowing me to talk before the committee.
My background is SEALs [Sea, Air and Land teams]. And I
have seen the evolution of casualty care, which has been
impressive. I still remain a little concerned about the
acquisition part. I don't think we are as fast as the private
sector is at getting new techniques to the front. But my
question really is about the training.
In looking back at my career, with explosive breaching and
TBI, and looking at what has happened in the NFL and all of a
sudden an awareness of concussions over a period of time, I
remember as a SEAL going into facilities, and we would do 400
explosive breaches in a day and then do it continuously.
What are we doing to examine our training regimen based on
what we know today to make sure that we aren't creating, you
know, situations, you know, like long-term concussion damage,
TBI, in our training regimen? Are we looking at it actively? Do
we need to put more resources in it? What can we do to make
sure that it is being done?
Because oftentimes, you know, what I call the meat-eaters,
the frontline guys, don't pay a lot of attention to the support
folks, and I want to make sure that they do. And what do we
need to do to make sure that happens?
Admiral.
Admiral Moulton. Sir, I would have to take that. I am not
familiar with that enough to talk intelligently about it.
[The information referred to can be found in the Appendix
on page 109.]
General Tenhet. You have to look at the force structure
piece of this, as well. So, as we are looking at medicine and
ensuring we sustain skills as we go forward, the interwar
years, the innovation that comes from some of that, applying
this, we are not going to have the capability--this is just Bob
Tenhet speaking about the future, where I see it going--we are
not going to have that capability at our smaller facilities to
have the high-complex, high-acuity-type patients going into
those facilities.
And we have already taken steps just at Fort Sill, Knox,
and Jackson in removing our surgeons and using the surrounding
capabilities there in the community areas and actually moving
those surgeons to higher-acuity platforms, our health readiness
platforms. We are going to have to see more of that as we go
forward to ensure that we have the training capability. And I
will tell you, it is even a challenge at some of the places we
are moving them to look at high-complexity, high-acuity cases
as well.
So I think the sharing agreements, working with the
civilian populace and, I mentioned earlier, even looking at
international programs, we may have to go there. Because the
Miami's, there are only so many of those that exist out there.
So you are looking at individual skills, and you are also
looking at the collective skills training.
Mr. Zinke. Yeah. I guess my point is that, you know, there
are a lot of preventative things that we should be doing up
front rather than waiting until it is an acute problem. And
especially with explosive breach, I assume it is getting very
similar to going into a boxing match. So I just want to make
sure we get ahead of it so we don't have the problems long
term.
General.
General Hogg. Yes, sir. With the recent collaboration that
we have with the sports industry and the academy, I feel that
we will definitely start to see some of those changes coming
out of those studies that will inform us on how to better
prepare and to prevent these kinds of injuries.
General Caravalho. Sir, in my experience with you
carnivores, I agree that generally they don't like to listen to
medical, and our approach has been ``it is easy to be hard but
hard to be smart.''
What I am excited about readiness nowadays is that we are
following some of the soft truths that they are talking about,
that you can't recreate someone overnight, so how do you keep
someone in the fight for the duration of his or her career and
then offer a full life after that career.
So we are getting smarter in our training. The warfighters
are bringing us in, on board, to help them understand how to do
it right. And we are focusing, as well, on how do we prevent
illness and how do we promote wellness so that you are
survivable, agile, and resilient during your time in the
military.
Mr. Zinke. Well, certainly, if we can do anything to
promote some interest and move in that direction, you know, let
us know.
General Caravalho. Yes, sir.
Mr. Zinke. And thank you.
Thank you, Mr. Chairman.
Dr. Heck. Ms. Speier.
Ms. Speier. Thank you, Mr. Chairman.
And thank you all for being here.
I would like to follow up on the questions that Congressman
Zinke just offered up. There is a wealth of information about
chronic traumatic encephalopathy [CTE]. It not the NFL that is
researching it. The NFL is trying to sweep it under the rug.
Boston University has now, I think, examined the brains of, I
don't know, maybe 100 persons who were in the--some in the
military but most in sports.
There is a Dr. Omalu, who is the coroner who first kind of
identified CTE, that is doing research now with a physician at
USC on PET [positron emission tomography] scans of persons who
are alive. And they have just done a number of PET scans on
veterans, and each PET scan they did showed CTE. One of the
problems is it is not just the concussions; it is the
subconcussive hits that individuals receive.
And I really think it is incumbent on us to start to do a
much better job of identifying it and promoting research in
this area as it relates to those who serve in the military. And
I am kind of surprised and a little bit stunned that you
haven't already undertaken this.
I was told by someone very recently that SEALs now are
actually wearing a monitor to determine how many--I don't know
if they are concussions or just hits that they receive. Could
someone speak to that?
General Caravalho. Ma'am, in one of my last jobs in the
medical research community, we were working with DARPA [Defense
Advanced Research Projects Agency], and there were blast gauges
and different types of devices that one could place across
their body and on their helmet that would look at the--it was
an accelerometer to get a sense if there was a rapid
deceleration. And that would then codify how many events you
had.
Knowing that our troopers in general don't want to say,
``Coach, take me out,'' so they will not complain of these
hits, that is number one.
Number two is IED [improvised explosive device]-related TBI
probably represents less than 20 percent of all TBI that at
least the Army has seen. So most of it is just in normal
training, whether it is combatives or parachute jumping or just
normal Army training.
I think you are right that longitudinally we need to
understand these concussive and subconcussive events and its
effect over time. And the military is also looking at doing
pathologic studies of CT. I cannot speak to PET scanning or
pre-mortem studies as you described. But we have a keen
interest in that in the Department, and we certainly want to
partner with any academic center in getting after this. We
don't care who finds out what the answer is; we want to get
after the answer.
Ms. Speier. All right. Thank you.
I yield back.
Dr. Heck. Well, I want to thank you all for your testimony
here today. Again, the purpose for this hearing is that, as we
undertake the reformation of the military healthcare system, we
want to make sure that we keep readiness first and foremost in
our minds and that we don't impede, one, the readiness of our
military medical providers, but certainly that we don't hinder
the medical readiness of our troops. So, again, we thank you
very much.
Mrs. Davis. May I ask a clarification----
Dr. Heck. Certainly, Mrs. Davis.
Mrs. Davis. Thank you.
Thank you all, again, for being here.
I wanted to clarify a little bit, because we were talking
about moving physicians into civilian facilities and back and
forth, and I understand how it important that is. We also know
that a number of our military providers also moonlight for
training.
But if we are doing that--and, as I understand it, you are
basically managing that within individual services. Is that
correct? So don't we need a more centralized way to manage that
and to be able to identify the different skill sets that you
are using where you have a lot of movement of those providers,
of those physicians?
General Hogg. Yes, ma'am. I think as we define those
essential military capabilities, we will be able to partner
with our other services where we are co-located to utilize
those civilian facilities.
The providers that we send there, not all of them are there
full-time all the time. Some are there as their primary duty in
that civilian facility, but many of them, again, go back and
forth. So they provide outpatient care in the MTF, the military
treatment facility, but then provide the specialty care,
because it is not available in the MTF, in the civilian
facility.
But I do believe that as we define what those essential
medical capabilities are, we will find opportunities where we
could collaborate in that area, as well.
Mrs. Davis. Uh-huh.
Admiral Moulton. Ma'am, I would also add, we are doing that
in what we call multiservice markets, where we are working
together in a multihospital system or multiclinic system where
there are larger populations so we can bring in those kind of
cases for us. And then are we adequately staffing, or what is
that number of providers that ought to be in that area so that
they get the amount of workload for their training.
And then we look at more partnerships with the VA or more
partnerships with the private sector. So we are doing some of
that.
Mrs. Davis. Okay. Well, that is good. I am glad. Sometimes
it seems as if, maybe culture, what have you--that there are
obstacles to doing that. And if that is the ideal--and, again,
looking to all of you, is that ideal, is that much better, that
there is that information-sharing so that we know that someone
is at the proficiency level required? And if it is in the Army
but you don't know it in the Navy, it is not going to do all of
us any good, right?
Okay. Great. I am glad that is at least improving. Thank
you very much.
Thank you, Chairman.
Dr. Heck. Again, I thank the first panel for your
participation today.
And if we can now, we will just swap out panels and
continue to move forward.
I would now like to welcome our second distinguished panel.
We heard from the, I think, 30,000-foot view. Now we are going
to bring it down to a little bit more tactical and operational.
With us this morning is Colonel Linda Lawrence, Special
Assistant to the Air Force Surgeon General for Trusted Care
Transformation, Office of the Air Force Surgeon General, but
also past president of the American College of Emergency
Physicians; Lieutenant Colonel Promotable Robert Mabry, who is
here as a Robert Wood Johnson Health Policy Fellow with the
U.S. House Committee on Energy and Commerce but has a long and
distinguished past, beginning as an SF [Special Forces] medic;
and Lieutenant Colonel Jean-Claude D'Alleyrand, Chief of
Orthopaedic Traumatology Service at the Walter Reed National
Military Medical Center.
I appreciate all of you taking the time to be with us this
morning.
Colonel Lawrence, you are recognized for 5 minutes for your
opening statement.
STATEMENT OF COL LINDA LAWRENCE, M.D., USAF, SPECIAL ASSISTANT
TO THE AIR FORCE SURGEON GENERAL FOR TRUSTED CARE
TRANSFORMATION, OFFICE OF THE AIR FORCE SURGEON GENERAL, UNITED
STATES AIR FORCE
Colonel Lawrence. Thank you.
Chairman Heck, Ranking Member Davis, and distinguished
members of the committee, thank you for the opportunity to come
before you today to discuss the future of Air Force Medical
Service readiness.
I am a residency-trained emergency medicine physician with
over 23 years of Active Duty service in a variety of positions,
such as academics, clinical leadership, 5 years as the Air
Force Surgeon General Emergency Medicine Consultant, and in
multiple command assignments, including command positions in
the deployed environment.
As an emergency physician, you learn early it takes more
than your own individual skills to be successful. I like to
look at medical readiness from a tiered approach. The basics
are individual skills, which we assess through our Readiness
Skills Verification Program. For an emergency physician, these
involve many procedural skills common for resuscitation of
patients, both medical and surgical, which ideally includes a
daily practice environment that provides access to sick and
critically ill patients.
The next tier would be how we come together as teams, for
which in emergency physician we have multiple deployable unit
type codes that are found throughout the echelons of care. Just
as any sports team of all-star athletes cannot be a winning
team unless they practice together, the same analogy applies
for our medical teams. On our deployable teams, we need to have
skills around a common set of standards or guidelines which
drive processes, where every member of the team knows their
role as well as the role of others.
We begin to build that capability or teamwork skills
through processes in our day-to-day work in our MTFs. Many
think we need to see the same type of patients--for example,
trauma patients--to build those skills. That is not true. We
build them every time we come together as a team to perform a
procedure, respond to a complication or resuscitation. Even
actions of coordination of care in handoff become critical
skills.
The best care can quickly be compromised by a lack of
shared processes, poor communication and teamwork. Every day in
our MTFs, we are constantly improving our processes, handoffs,
and practicing the art of good communication and teamwork.
Every patient engagement sustains the readiness of the medical
force and an environment that promotes continuous learning and
improvement.
Our commitment to trusted care is based on a set of
principles which promote high reliability and safety. These
principles not only improve the care we deliver to our patients
but also improve the processes and skills we bring to the
deployed environment.
Beyond our daily roles in our MTFs, we need the opportunity
to challenge and assess our individual and team skills, which
is provided through platforms like C-STARS and simulation.
Through these training modalities, we can replicate some of the
unique demands of the operational environment, reinforce the
use of combat care clinical practice guidelines, and assess our
performance as individuals and teams. This type of training is
invaluable, and, while it takes us away from supporting the 24/
7 mission at our military treatment facilities we work in, it
is the price of readiness.
Finally, readiness is more than combat support. It includes
global health engagement and the day-to-day work to maintain a
medically ready force and ready medics. Every day, we support
medical readiness in the care we deliver to our beneficiaries.
I am grateful for your support and the opportunity to speak
with you today and look forward to your questions.
[The prepared statement of Colonel Lawrence can be found in
the Appendix on page 78.]
Dr. Heck. Thank you.
Lieutenant Colonel Mabry.
STATEMENT OF LTC ROBERT L. MABRY, M.D., USA, ROBERT WOOD
JOHNSON HEALTH POLICY FELLOW, U.S. HOUSE COMMITTEE ON ENERGY
AND COMMERCE
Colonel Mabry. Chairman Heck, Ranking Member Davis,
distinguished members of the subcommittee, thank you for the
opportunity to discuss battlefield medical readiness with you
today.
After nearly 15 years of war, the Military Health System
has made tremendous advances. Today, if you are wounded in
battle and arrive alive to a combat hospital, survival is
virtually assured.
Combat casualty care, however, does not begin at the
hospital. It begins in the field at the point of injury and
continues through the evacuation chain. Our research shows that
up to one in four battlefield deaths are potentially
survivable. However, the vast majority of these bleed to death
before they even make it to a doctor. Care delivered on the
battlefield outside of the hospital is the first and key link
in the chain of survival and is the next frontier for making
any significant advances in combat casualty care.
I believe we face five challenges to improving battlefield
survival.
First and most importantly is ownership. Army Medicine
trains and equips the medical force, but line commanders
execute healthcare delivery on the battlefield. We must
determine who is responsible for improving battlefield care
delivery. The axiom, ``When everybody is responsible, no one is
responsible,'' applies.
Second, data and metrics. We can't improve what we don't
measure. We continue to know very little about what happens to
casualties before they arrive to the hospital.
Third, expertise. We have very few clinical experts focused
on care outside the hospital. Out of about 4,500 Army
physicians, there are only 4 board-certified specialists in
this field.
Fourth, research and development. Our R&D efforts are
focused on developing lifesaving drugs and devices, yet very
little research is done on the delivery system or, in other
words, how do you get the right care to the right patient at
the right time.
Finally, culture. Our organizational culture is centered on
caring for military beneficiaries in our fixed facilities. This
is our biggest mission, yet it is our wartime mission that
makes us unique and justifies our cost to the Nation.
I would like to highlight these challenges by briefly
telling the story of the simple tourniquet. The most effective
thing a soldier can do to save another soldier's life on the
battlefield is to stop bleeding.
The strap-and-buckle tourniquet was first issued during the
Civil War, then again in World War I, World War II, Korea, and
Vietnam. In 1993, I deployed to Mogadishu, Somalia, as a
Special Forces medic in one of the most well-equipped, well-
trained units in the world with a strap-and-buckle tourniquet.
We went to war in Iraq and Afghanistan with essentially the
same tourniquet that was issued during the Civil War.
There is only one problem with the strap-and-buckle
tourniquet: It doesn't work.
In 1945, Dr. Luther Wolff, an incredibly experienced Army
surgeon who cared for thousands of patients fighting across
Europe, wrote an article in the Army Medical Department Journal
describing how the strap-and-buckle tourniquet was ineffective
and should be removed from the inventory. That was in 1945.
Yet it remained in the inventory. Death rates from
extremity hemorrhage in Korea and Vietnam ranged from 7 to 9
percent. That means that 7,000 sons, fathers, husbands,
brothers lost their lives because they did not have an
effective tourniquet. In the initial phase of Iraq and
Afghanistan, our death rates from extremity hemorrhage were the
same as the Korean war.
In 2003, a Special Forces medic invented the combat
applications tourniquet. This new tourniquet worked well and
was widely adopted by U.S. forces, driving down deaths from
extremity injury to virtually nothing.
Meanwhile, the strap-and-buckle tourniquet, first issued
during the Civil War, noted not to work during World War II,
was finally removed from the DOD inventory in 2008.
How did this happen? How did the most advanced military in
the world miss this? More so, how do we prevent something like
this from happening again? Ownership, data, expertise,
research, culture.
Thank you again for the opportunity to speak today. I look
forward to your questions.
[The prepared statement of Colonel Mabry can be found in
the Appendix on page 83.]
Dr. Heck. Thank you.
Lieutenant Colonel D'Alleyrand.
STATEMENT OF LTC JEAN-CLAUDE G. D'ALLEYRAND, M.D., USA, CHIEF,
ORTHOPAEDIC TRAUMATOLOGY SERVICE, WALTER REED NATIONAL MILITARY
MEDICAL CENTER
Colonel D'Alleyrand. Chairman Heck, Ranking Member Davis,
and distinguished members of the subcommittee, thank you for
the opportunity to speak today.
During past conflicts, there have been delays in our
ability to provide optimal care for our wounded, particularly
when there have been many years since the previous conflict.
These interwar years are typically associated with the decline
in the funding and infrastructure of our trauma and
rehabilitative systems as well as a lack of training for our
trauma surgeons. Senior surgeons with experience in combat
injuries may no longer be in the military by the time the next
conflict arises, and those that remain have most likely been
struggling to maintain their skills in the peacetime
environment.
In order to adequately care for wounded warriors, trauma
surgeons need two different skill sets. They need to be able to
treat conventional trauma, such as the injuries seen in the
civilian sector, and they also need to be able to treat combat-
related trauma.
Conventional trauma proficiency can be maintained with
adequate exposure to civilian trauma by allowing surgeons and
military hospitals to treat civilian patients and by
facilitating the continuing medical education of trauma
specialists. Combat-related trauma skills, however, can't be
sustained during peacetime because injuries from explosions or
machine guns are, thankfully, almost nonexistent in our
society.
Therefore, our focus should not be on the sustainment of
these skills but, rather, on retention, specifically the
retention of those providers who have the firsthand experience
treating combat casualties, including not only the surgeons but
also the wound care nurses, therapists, prosthetists, and the
other specialists who form the chain between the point of
injury and the final return to function.
It has been only 3 years since the casualty flow slowed to
a trickle, and, already, many, if not most, of the providers
that I worked with during the peak of the war are gone. At this
rate, there will be very few of us remaining when the next
conflict comes around.
I ask now that each of you think about what you would do if
your spouse or child were gravely injured in a traffic
accident. Without exception, each of you would do your research
and you would take them to the best surgeons that you could
find. Our combat-wounded can't choose; they go where we send
them. So it is our responsibility to send them to the best
trauma specialist that we can.
But without aggressively maintaining their skills, who
knows how many patients our specialists can optimally treat?
Maybe 80 percent? Maybe? But 80 percent is a B-minus. And is a
B-minus really the best that we can do for the young men and
women that we send into harm's way to preserve our way of life?
No. Our combat-wounded deserve A-plus trauma specialists, and
we are morally obligated to provide them.
To do so, we need to maximize our trauma specialists'
experience and education and to retain those who have already
been through the steep learning curve that we all face when we
first learn to care for combat-wounded.
Ladies and gentlemen, on behalf of my trauma colleagues and
the wounded warriors who we serve, I thank you for your time
and continued support.
[The prepared statement of Colonel D'Alleyrand can be found
in the Appendix on page 99.]
Dr. Heck. I thank you all for your testimony, and I think
it is great as a follow-on to the first panel.
You know, we all understand that it is the small amount of
care that we provide that is truly trauma care within the
military, and, as was mentioned, 85 percent is disease and non-
battle injury, which we would expect that most physicians or
healthcare providers would be able to take care of through
their daily practice and be competent in.
That is why I tend to focus more on that other 15 percent,
where we potentially see the degradation of skills during the
interwar years. And my greatest concern, as has been expressed
by this panel, is how do we make sure that the lessons learned
over the last 15 years of war don't get lost or we don't lose
those providers who have gained that knowledge as we make sure
we are ready for the hopefully-never-to-come next war.
And part of that answer has been, well, we rotate folks out
to different programs, whether it is C-STARS or down at Miami-
Dade or a university medical center. But I still have the
concern that that is not adequately preparing the team in order
to respond and be ready to perform.
So, as those who, you know, have worked where the rubber
really meets the road, how do you address this issue? How would
you propose we ensure that the entire team, from the trauma
surgeon to the anesthesiologist to the trauma nurse to the x-
ray tech to the phlebotomist, all know how to operate as a team
in the stressful situation of the trauma activation, whether it
is at a FST [forward surgical team] or a combat support
hospital, soon to be a field hospital? How would you address
that problem that I am fearful we will see over the next
decade?
Colonel Lawrence. I think it comes back to do we maintain
robust medical ecosystems in our large military treatment
facilities. And with that, what I am trying to say is we must
maintain hospitals that have a diverse patient population that
is sick, that is complex.
And I hear you, Chairman Heck, that I agree, we need to see
trauma, but, you know, if I put a chest tube in for a trauma
patient or I put a chest tube in for a congestive heart failure
patient, my team gets the same experience, and that procedure
is a procedure.
And so, in order to maintain some of the lessons learned
and have the best, we need to maintain GME [graduate medical
education] hospitals. And sometimes there has been challenges.
Well, that costs too. If we ever consider removing GME, I
believe that will be the death knell to our robust hospitals
maintaining those lessons learned, bringing up the next
generation of researchers and training our own.
I saw the opportunity when I was the Chief of Emergency
Medicine down at Wilford Hall. The research we did was in
collaboration with NIH [National Institutes of Health] and
others, and we taught that to our residents, and we were able
to teach them the lessons learned. But not only did the
residents get it, all the staff would get it.
And so I encourage that we look at those platforms and we
looked at USUHS, our Uniformed Services University, and how do
we strengthen with our academic partners in the outside as
well.
Dr. Heck. You know, Colonel Mabry, you alluded to the
issues of care from the point of injury to the receiving
facility. And so, while it may be easier to address some of the
training needs within a fixed facility because a team is a team
regardless of the procedure or how the procedure is being
performed, how would you address the concerns? Because, you
know, having the 68 Whiskey [combat medic] respond on post to
some medical emergency isn't the same as responding to a
battlefield casualty.
Colonel Mabry. Sir, thank you for the question.
So what you are getting at, Dr. Heck, is one of the
quintessential challenges of military medicine, which is how do
you train providers to deal with horrifically injured combat
casualties when you don't see horrifically injured combat
casualties on a day-to-day basis.
So some of that is going to be simulation. Some of that is
going to be taking care of sick patients with other conditions
like Colonel Lawrence has described. But you have to have that
exposure.
And so one of the challenges with our medics is, under the
current regimen, the first time they are going to see a
seriously injured casualty is when they are on the battlefield.
And it may be dark, they may be being shot at, and it may be
their best friend.
So I think we have to figure out ways to expose our medics
to critically ill patients before that time. One of the bright
spots is the Critical Care Flight Paramedic Program, which we
have instituted. That requires medics to gain a civilian
paramedic credential and hands-on critical care training in the
hospital to be critical care paramedics like you would see in a
traditional air ambulance system in the United States. By
virtue of that training, they are required to do hands-on
patient care and they are required to see sick patients in the
hospital.
So it is going to be some mix of simulation, some mix of,
if you have a civilian credential, you, like some of the
doctors do, can moonlight as an EMT [emergency medical
technician]. But just seeing casualties every day and seeing
patients every day and doing that thinking out in the field
with another medic on the ambulance is very valuable even when
you deal with sick trauma patients.
Dr. Heck. And then, Colonel D'Alleyrand, as an orthopedist,
do you believe that being able to take an orthopedic surgeon
out of a fixed facility, let's say has not previously deployed,
and then all of a sudden throwing them into an FST, how are we
going to assure that that orthopedist is prepared to function
as an FST member in a situation similar to the pre-hospital
care provider that they never may have been put into
previously?
Colonel D'Alleyrand. Well, I think that is a very difficult
question to answer. The majority of, let's put it this way:
There are roughly 130 to 150 orthopods within the Army. Maybe
six of us, seven of us are trauma specialists. So the person
that you are going to deploy is a total joint surgeon, a sport
surgeon, and there really is no effective way to transfer an
entire body of knowledge, a career's worth of knowledge to that
person.
I think that if you retain senior personnel and if these
people go through their residency programs with senior trauma
surgeons who have been there and done that and have had those
experiences, then you can bring them up along the way with
these life lessons so it becomes part of what they know about
orthopedists. Because the military orthopedist programs have
somewhat of a deployment-related slant in some part of its DNA
[deoxyribonucleic acid] regardless of how isolated you are from
the war.
So I think that, you know, that is a key cornerstone. And I
think on a systems level, which Dr. Mabry can speak at length
about, about having a Joint Trauma System that establishes good
clinical practice guidelines and establishes dogma, that they
can at least have an algorithm that may be not the perfect
substitute for being a traumatologist at Walter Reed but at
least can give them a path towards doing the right thing at the
right time.
Dr. Heck. Okay. Thank you.
My time has more than expired. Mrs. Davis.
Mrs. Davis. Thank you, Mr. Chairman.
Again, thank you all very much for being here.
I am going to ask you to do something that is kind of
difficult. Could you respond to what you heard earlier in
terms, particularly, of exactly what you just said, Colonel,
the systems-level organization that is going to give us what is
required? You know, kind of getting at that question, what is
it going to take in order to try and be sure that the skill
sets that are going all the way through the nurse specialties,
all of the people that are involved in trauma, so that we
really maximize what I understand. We actually have 80 trauma
surgeons that are certified in this way across the services? I
am not sure if that is correct.
But you heard, and I tried to ask this question, I am not
sure if I asked it so artfully, but should we be doing more in
terms of that more central organization so that we actually do
get the best use of the, you know, exceptionally well-qualified
people that we have, knowing that they are not getting the
exposure either in the future?
Colonel D'Alleyrand. I think it is beneficial to look at it
at three different levels, the tactical, at the strategic
level.
So myself, as a surgeon, there are certain skill sets that
I need to have to handle the very broad range of injuries that
come back from theater, be it from the upper limits of
survivability in terms of multi-extremity amputee, blast wound,
open pelvic injuries, to things that more resemble what you
would take off the highway. And those sort of ebb and flow over
the years.
So there are things that can be done for me as an
individual, be it working at a civilian trauma center, and
making it easier for me to continue my own education and
ongoing training, which, currently, I mostly subsidize myself.
That only makes me as one member of the team proficient.
Everyone around me, the x-ray techs, scrub techs, ICU
[intensive care unit] nurses, et cetera, basically go from a
civilian setting straight into a war setting with no training,
if I am the only one who is trained.
So I think making key hospitals that might be expected to
see war casualties, making them trauma centers during peacetime
or throughout even in and out of conflict, that makes the whole
team more efficiently trained.
But then, finally, on the system level, which, again, is
Dr. Mabry's wheelhouse, I think that is going to be an
overriding entity that can at least help establish the
evidence-based guidelines to help guide our practice.
Mrs. Davis. Uh-huh.
Dr. Mabry.
Colonel Mabry. So one of the biggest challenges we have,
ma'am, is that, unlike the warfighter, when we are home, we are
providing health care in our fixed facilities day-to-day. The
warfighter is going to the range and training. And so we are
doing our civilian beneficiary mission, for the most part,
whereas the infantry soldier and the special forces soldier are
out training, preparing for the next war.
So we have to figure out how to kind of thread the needle
where we can maintain our healthcare benefit but, at the same
time, go to war ready and prepared for the next set of
conflicts or next war without a learning period, a learning
curve, which is traditionally what happens.
Mrs. Davis. Uh-huh. But the systems piece, though, in terms
of who organizes, who has the oversight to be sure that things
are moving properly. You mention, I thought that was, you can't
approve what you don't measure.
Colonel Mabry. Yes, ma'am.
Mrs. Davis. So to the extent that there is--whether it is
the DHA [Defense Health Agency]--where does that system
organization lie? Is it there today? Is it being utilized the
way that it should? Is it covering, you know, all aspects of
research and development, or at least aware of it?
Colonel Mabry. Yeah, so there is a challenge where there is
some lack of interconnectivity. So, in other words, during the
start of this war, a lot of talented surgeons recognized we
needed a trauma system. We went to war initially in 2001
without a trauma system. And so it took about 4 years to build
the trauma system. That became the Joint Trauma System, the
Joint Theater Trauma System, where we had senior trauma
surgeons deployed in conference and advising and coaching,
developing clinical practice guidelines, which, really, you can
trace the improvement to our battlefield casualty outcomes to
two things; that is one of them.
And so the Joint Trauma System is currently the repository
for the system, but that is only in one command. It is only in
CENTCOM's [Central Command's] AOR [area of responsibility]. And
it is uncertain whether we will continue to have the Joint
Trauma System as the conflict winds down.
Mrs. Davis. Uh-huh.
Yes, Colonel Lawrence.
Colonel Lawrence. I would like to expand on what Dr.
Mabry----
Mrs. Davis. I am sorry, my time is up. Should we go ahead--
--
Dr. Heck. There are just a few of us here, so we can go
further.
Mrs. Davis. Okay.
Colonel Lawrence. Dr. Mabry is correct, that is a very
important part. And the Joint Theater Trauma System, it
encompasses more than the surgeons. And how are we going to
preserve that? There are discussions, I am told, at the senior
level with our MHS senior leaders, and they are discussing
that.
I think, to get back, what you are hearing is there needs
to be a value placed on readiness. And my concern and I have
been in for almost 24 years of Active Duty is, as the conflicts
decline, we are going back to measuring health care competitive
with the civilian sector, and we are going to lose that
quotient of readiness.
And in the healthcare system today, we are shifting away,
too, from looking at productivity to looking at value and
value-based care. And I believe that is what we are getting at.
It is, how do we preserve outcomes not just on the battlefield
but in our MTFs as well? And if we look at the value equation,
which is health and care over cost, where do you put readiness?
I would argue readiness needs to be up on the top with health
and care.
And if we design the system that is going to allow that
because all of us have talked and we heard the panel earlier--
about the need for our people to spend time away. I mentioned
that, that, you know, you will never get everything in our
Military Health System, so we need a synergistic system that is
going to allow us to spend some time at the C-STARS and SMART
platforms. But where do you put that if you are going to
measure our productivity on what we do in the MTFs?
So, as we build that system that has sustained and endured
as, hopefully, the need for conflict declines, we need to say,
where is that value equation?
Mrs. Davis. Yeah. Okay. Thank you.
Dr. Heck. Dr. Wenstrup.
Dr. Wenstrup. Thank you, Mr. Chairman.
It is a pleasure to have you all here today.
You know, a friend of mine is an Air Force trauma surgeon,
a reservist. You may know Dr. Joe Hannigman. And we went to
high school together. But he shares the thought, there was
multiple deployments, and at first he used to say, ``I am going
to try and get you everything here that you would get at
home.'' Now he comes home and says, ``I am going to try to get
you everything here at home that I would get one of our troops
in theater,'' and that is how far we have come in the last 10
to 15 years. And I don't think there has been any greater
privilege for me, in my lifetime, as to be any part of that and
to take care of our troops.
One of the things that I read in my friend Dr.
D'Alleyrand's testimony, what Hippocrates said, ``War is the
only proper school for surgeons.'' And I think there is a lot
to be said for that. It is how do we capture all this knowledge
and maintain it and share it. And I think we all recognize the
dilemma; it is where do we go from here.
First, I would like to ask Colonel D'Alleyrand, I think you
take the opportunity every chance you get when I have seen you
at Walter Reed, with the residents in particular: this is what
you do here, but this is not what you would do downrange.
Because it is a different set of circumstances, right? You talk
about fungal infections, you talk about open wounds, you don't
put a rod in here, and this and that.
So how much of an opportunity do you get to carry that over
and try to make sure that it is sustained in a resident, a new
doctor coming up?
Colonel D'Alleyrand. We do have a it is called the Combat
Extremity Surgery Course, and it is a joint course that we run
with the Navy as well. And so that is taught a couple times a
year, typically with upper-level residents or general orthopods
who are looking at an upcoming deployment.
It is difficult, though. It is a 2-day course, and we teach
a lot of, sort of, doctrine and, sort of, hard-fought lessons,
but, I mean, how good can you be at anything in 2 days if you
have never really been exposed to it?
So it is difficult to communicate that body of knowledge to
anyone, even--you know, I trained at Shock Trauma in Baltimore.
I thought I had seen, you know, the worst energy injuries that
you could have, and it wasn't even remotely in the ballpark of
what we are seeing at Walter Reed.
So I don't think there is any way to truly prepare them,
but I think having senior faculty who have had multiple
deployments, who have had those hard-won life lessons that
don't always work out well when you are operating in a tent in
the middle of the night, having those guys around, especially
during the interwar periods, to impart that knowledge is the
best thing you can get to some sort of corporate memory.
Dr. Wenstrup. And to that point that you have made, there
are opportunities to take those that have left wearing the
uniform to be part of the teaching process, those that have
actually served in combat. I think maybe we need to take a look
at that.
I really would love all of you to weigh in, because we are
talking about different ideas of military just providing trauma
services, like at SAMMC [San Antonio Military Medical Center],
and then also moonlighting. Is there a hybrid out there? I
think we need some guidance in how can we help you here to
fulfill that role.
Colonel Mabry. Sir, I will take a stab at that.
So I was at the Staff College doing a research paper, and I
came across a book where they were addressing some of the same
concerns following World War II. And they were talking about
bonuses for physicians. And then there was a paragraph in there
that talked about the way to keep physicians in the military is
to give them meaningful work. And so, if you have the surgeons
who are doing the kind of surgery they like to do on a high-
volume basis, what they find meaningful, then that is going to
help with retention.
With regard to training in civilian centers, I guess I
would say, if you crash your car and you have to have your
spleen removed, do you want a surgeon that is familiar,
proficient, or expert in removal of the spleen?
And so I think our challenge is how to have on the--toward
the expert spectrum, you know, when we go to the next conflict.
Because, usually, again, there is a learning curve for the
first couple of years, and our challenge this time is to go to
war next time without a learning curve.
Dr. Wenstrup. Colonel.
Colonel Lawrence. And I would say that learning curve is
going to constantly be there. Because, as we have seen the
advances that we have had in these last 15 years, I think that
is what we are all talking about. How do we preserve that
mindset and how do we preserve the system that allows us to
continue to advance?
And so, again, I will go back to the extreme importance,
you have heard, of GME and not just graduate medical education
but our nurse training programs, our technician training
programs. We need to keep that. And that is where we can pass
some of these lessons learned.
But we need money to continue research. And we need to look
at where can we partner with academic institutions and
professional organizations to take these lessons learned and
continue to grow. How do we sustain the Joint Theater Trauma
System? I mean, if we tuck that away in a closet and pull it
out, it is not going to be any good, all right? But if we
continue--there is a partnership right now with the American
College of Surgeons and the MHS. And they are talking about
looking at similar partnership right now with the American
College of Emergency Physicians.
So, you know, when we start to bring in the professional
organizations, we don't only help our military, we are going to
translate those lessons learned into society and vice versa. We
are going to keep that learning cycle going, and we are going
to continue those partnerships.
So those partnerships, though, cost money. Research costs
money. And time away from our clinical practices to engage
costs time.
But that is what I find when I talk to physicians,
particularly emergency physicians. Anything they can do which
shows value of them and that opportunity to go out there and
continue to partner with their colleagues and learn and make
the entire system better, that is going to keep them in the
suits.
Dr. Wenstrup. Thank you.
I yield back.
Dr. Heck. Dr. D'Alleyrand, when was the last time that you
deployed?
Colonel D'Alleyrand. I just got back 2 months ago from a
deployment to East Africa.
Dr. Heck. Okay. So, you know, as one of the handful of, you
know, orthopedic traumatologists within the Military Health
System, now that you are at Walter Reed, which does not receive
civilian trauma, how do you envision the ability to maintain,
just on a personal basis, your trauma-level skills that you
have developed over the past several deployments?
Colonel D'Alleyrand. It is a problem that I have been
struggling with for a number of years now. So I do a number of
things in order to maintain what I consider to be an acceptable
level of proficiency. I spend two of my weekends a month
moonlighting at local trauma centers. I pay my own way to go to
trauma courses. I teach at trauma courses. I basically do
everything that I can just to try to maintain a certain level.
Is it enough? I wish it were more, frankly. It is what it is.
And, you know, certainly, in the deployed setting, those
are always difficult questions because it is always a different
experience. I was at a couple different places in Afghanistan,
and it is very different if you are operating in a rocket-proof
Role 3 facility compared to operating in flip-flops in a tent
that has, you know, helicopter prop wash knocking the tent
around. And Africa was very different entirely.
So I definitely have used my trauma skill set specifically
for blast wounds, et cetera, on deployment, but deployment also
lots of times is where you have intense degradation of your
skill set as well, long periods of just disuse and waiting for
something to happen, too.
Dr. Heck. So, in your opinion, if Walter Reed was
integrated into the civilian EMS [emergency medical system]
system as a receiving facility for civilian trauma, similar to
Madigan or Brooke, would that help you and others like you be
able to maintain your skills to a higher level?
Colonel D'Alleyrand. I think without question. If you look
at any job, any skill that you can think of, a musician, a
professional athlete, et cetera, you would never consider being
excellent in that field by dabbling in that field. You know,
the weekend athlete is, by definition, a weekend athlete.
So, as I said earlier, and it is obviously common sense, if
I were to work full time at a civilian trauma center and be
given the opportunity to do sabbaticals and rotate at other
facilities where there are regional experts in certain
techniques, that would make me, you know, ideally suited for my
profession, but I would still only be one piece in the big
machine. And by opening the doors to key facilities, Walter
Reed being one of them, as difficult an undertaking as that may
be, that at least gets the entire hospital ready for some
measure of trauma.
It is not going to necessarily be ready for blast wound,
open pelvis, fungus-infested--the stuff we were seeing when
Helmand province was really going off in the winter of 2011,
2010 to 2011. But a facility that is used to seeing high-energy
constant flow of trauma is going to be the best-suited that we
could have for that situation.
Dr. Heck. I appreciate that.
And I just want to go back to something that both Colonel
Mabry and then Colonel Lawrence alluded to, which is, you know,
the cost of readiness. And I agree that we cannot compare the
military healthcare system to the civilian healthcare system,
because you have a unique role and mission to fulfill that the
civilian sector does not have.
And, Colonel Mabry, you said it. You know, when you are
back or the medics are back from deployment, they are doing
their job in beneficiary care and not necessarily getting the
ability to go train like the 11 Bravo [infantryman] does, where
their only job is really to train for the next war.
And I appreciate what you said, Colonel Lawrence, about our
move toward value-based care and where do we put readiness into
that equation. You know, earlier this week, we had a briefing
from DHA on how they are trying to look at, you know,
increasing efficiencies and capability in the military
healthcare system by increasing hours, increasing throughput.
So the balance that we have to come up with is, how does
that impact the ability for the military healthcare provider to
be able to go do those other things that they need to do to be
able to execute their military mission?
And so I have always said and will continue to say that
military healthcare readiness comes with a cost, and we have to
be ready to assume that cost if we want to be prepared to go to
war both with a ready medical force and a medically ready
combat force.
So I appreciate you folks being here.
Mrs. Davis.
Mrs. Davis. Thank you, Mr. Chairman.
And just really quickly, and going back to you, Colonel
Mabry, on the ownership issue that you mentioned, is that in
conflict in any way with jointness?
Colonel Mabry. No, ma'am. It is just unique to the
battlefield. So, you know----
Mrs. Davis. And we do jointness on the battlefield. I guess
I am wondering as we move to nothing on the battlefield.
Colonel Mabry. The point being is, outside of the hospital,
outside of the combat support hospital, it is the operational
commander who owns that real estate. It is the operational
commander who owns the medics, the battalion medical officers,
the critical care flight paramedics, the flight nurses. They
work for the combat commander. But yet we defer medical
expertise to the medical departments. But they don't have
ownership of those assets.
And so there is a friction point there, in that we are
responsible for developing the doctrine and the training but
the line commander is responsible for the execution. So who
owns battlefield medicine is kind of one of our quintessential
challenges. And so who is then able to organize the data, the
training, the research to feed back into the system to improve
care?
And, during this war, it has taken a lot of very strong
personalities over a decade to get to those systems in place--
--
Mrs. Davis. But you want the institution to be there to do
that.
Colonel Mabry. So how does the institution do that is going
to be a big challenge.
Mrs. Davis. What do you think?
Colonel Mabry. I think we need to have a senior person in
charge of it. So, in the Army Medical Department, we have a
brigadier general that is in charge of veterinary medicine, the
Veterinary Corps. I think combat casualty care would equally
benefit from senior leadership. Whether that is a line officer
or a medical officer, I think that would have to be worked out.
Mrs. Davis. Uh-huh.
Is there any disagreement with that?
Colonel Lawrence, do you think that is--what would you say?
Colonel Lawrence. I would say one of the things that we
need to realize is it is not either/or. And sometimes we look
at in-garrison health care, what we deliver in our MTFs, and
our training and currency that we need there, to what do we
need in a deployed environment; and, oh, that is our medical
readiness training, and that is over here. And we need to say,
how is it all one part of the system?
Mrs. Davis. Right.
Colonel Lawrence. And I think, you know, there are
different--I can't speak to the Army. I can speak to the Air
Force. We respond to the line, you know. And when I was a
hospital commander, I worked for a wing commander, a line
commander, but they did understand the importance of our
training.
And so getting back to how do we take and have that system,
which is I think what you are saying. We need to stop looking
at readiness is a price over here we pay and health care is
over here, but how are they merged together, and how do we look
at that delivery benefit to have it so that there is a training
piece in there that you do in your day-to-day but there is also
a training piece that you are not going to get there, and how
do you explain that to the mission commander.
Mrs. Davis. Uh-huh.
Colonel, did you just want to add anything to that?
Colonel D'Alleyrand. I have nothing substantial to add.
Mrs. Davis. Okay.
Colonel D'Alleyrand. I think there is definitely precedent
for----
Mrs. Davis. Thank you. I feel like we have asked the same
question many different ways, but we really feel a
responsibility to help and get this right.
Colonel Mabry. Ma'am, in the pre-hospital setting, I can
point to one Army unit that has done this exceptionally well.
That is the 75th Ranger Regiment. When General McChrystal was
the Ranger regimental commander, he added battlefield medicine
or tactical combat casualty care as one of his big four command
priorities.
And, since then, the Ranger regimental commander has owned
that casualty response system, and they have detailed
documentation on what happens to every Ranger casualty. They
are very well-trained. Their line leaders, their squad leaders,
platoon sergeants, first sergeants are trained in the tactical
medical system. And they have been able to demonstrate a
remarkable survival rate and exceptional care to all of their
Ranger casualties because of the commander's ownership of the
system.
Mrs. Davis. All right. Great. Thank you very much. And I am
sure that even when we look internationally to our partners,
our allies, the kind of exchanges that go on, maybe that is
another area to look at more in terms of getting that kind of
experience.
Thank you very much.
Dr. Heck. Well, again, I want to thank you all, both the
first and the second panel, for taking the time to spend with
us this morning to provide us with your views on how we can
help maintain military medical readiness. It is most
instructive. And, certainly, the comments you have made will
help inform this subcommittee's decisions as we move forward.
Again, I appreciate everybody's participation.
There being no further business, the subcommittee stands
adjourned.
[Whereupon, at 11:15 a.m., the subcommittee was adjourned.]
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A P P E N D I X
February 26, 2016
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PREPARED STATEMENTS SUBMITTED FOR THE RECORD
February 26, 2016
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[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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WITNESS RESPONSES TO QUESTIONS ASKED DURING
THE HEARING
February 26, 2016
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RESPONSES TO QUESTIONS SUBMITTED BY MR. O'ROURKE
General Hogg. Together the Air Force and VA have met the 295-day
goal for IDES Active Component members since October 2014 and since
November 2015 for AF Reserve Component members. Active Component Airmen
who completed the IDES in January 2016 averaged 248 days from referral
for disability evaluation to receipt of a VA benefits decision or
return to duty, which was within the 295-day standard. Reserve
Component Airmen averaged 300 days, which was within the 305-day
standard. [See page 13.]
Admiral Moulton. The Department of the Navy (DON) fully supports
the goals behind the Integrated Disability Evaluation System (IDES) and
remains fully engaged with the Department of Defense (DOD), the
Department of Veterans Affairs (VA), and the other Military Departments
to continue to improve and enhance this Service member-centric program
to eliminate the post-separation ``benefit gap'' for wounded, ill, and
injured Service members. For the Active Component (AC), the DON has
approximately 4,383 Service members (roughly 56% Marines and 44% Navy)
enrolled in IDES. This number represents less than 1% of the combined
service end-strengths of the Navy and Marine Corps. For the Reserve
Component (RC), the DON currently has approximately 114 active cases
for the Navy and 120 for the Marine Corps enrolled in IDES.
As of January 2016, AC Sailors spend on average 255 days and AC
Marines spend on average 230 days in IDES, which includes the completed
transition to the VA. As of January 2016, RC Sailors spend on average
204 days and RC Marines spend on average 307 days in IDES. We continue
to explore ways to reduce the time Service members spend in the AC 295-
day goal and RC 305-day goal IDES processes without compromising the
integrity or accuracy of the system. [See page 13.]
General Tenhet. The Army has met the 295 day IDES processing
standards for the past 12 months. The average processing time for total
Army (all compos and appealed cases) is 256 days as of 20 Mar 16.
[See page 13.]
______
RESPONSE TO QUESTION SUBMITTED BY MR. ZINKE
Admiral Moulton. Congressman Zinke, Navy Medicine has a concerted
effort to address how we manage concussions, TBI, and blast energy
effects on our service men and women. As you are all too aware,
cumulative effects of blast exposures can play a critical role in the
longevity of our readiness. We have previous and ongoing studies on
blast research and noise hazards to prevent, track, and monitor the
effect of impact forces. The Naval Medical Research Center has been
working with Marine breachers such as Combat Engineers and Explosive
Ordnance Disposal since 2008 to assess the impact of blast exposures
during dynamic entry training. As a result of the initial observations,
they are now assessing neurocognitive effects in the most experienced
Marine breachers. The Naval Health Research Center, in collaboration
with Walter Reed Army Institute of Research, has conducted a number of
observational studies assessing overpressure exposures during training,
using sensors mounted on combat helmets and body armor for the last
three years. These studies have included communities such as Navy EOD,
Army Special Forces, and civilian law enforcement tactical teams.
Current efforts are examining blast exposure effects in human brain
surrogates. Future studies will longitudinally examine overpressure
exposures on medical outcomes within specific military occupations. The
Naval Submarine Medical Research Laboratory has two ongoing studies to
better understand noise hazards experienced during training evolutions
as they relate to impulse exposure. They are researching why firing
range exposures are causing quickly and dramatically causing hearing
loss despite multiple combat tours without hearing loss. The second
study addresses hearing protection device fit testing at accession
where the initial training environment begins. Most recently, Navy
Medicine established research collaborations with the University of
Pittsburgh's world-renowned Sports Concussion program. Although there
have been no implemented changes in protocol for negating the
cumulative effects of blast exposures, Navy Medicine continues to
collaborate with academic and civilian sector partners for research and
defining best practices. We are grateful for your strong and unwavering
support to our service members and our ability to deliver world-class
care to the best warfighters in the world. [See page 17.]
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QUESTIONS SUBMITTED BY MEMBERS POST HEARING
February 26, 2016
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QUESTIONS SUBMITTED BY MR. O'ROURKE
Mr. O'Rourke. In your opinion, what can be done to ensure that
service members that are receiving mental healthcare from MTFs, under
TRICARE, have the same access and quality of care when they transition
to the VA healthcare system? Do you have any specific ideas on what can
be done to improve the quality of care during and following this
handoff?
General Caravalho. I would like to defer this answer to the
Services, as care at our MTFs is fully in their Title X
responsibilities
Unfortunately, once a Soldier has transitioned into the care of the
VA or another healthcare system the Army loses the ability to effect
the care that is received.
Mr. O'Rourke. 1. Enclosure 8 to Department of Defense Manual
1332.18 (Volume 2), Disability Evaluation System (DES) Manual:
Integrated Disability Evaluation System (IDES), depicts the standard
timeline for IDES. According to the enclosure, the overall IDES process
should take 295 calendar days for Active Component service members and
305 calendar days for Reserve Component service members. The enclosure
also shows that, during the Physical Evaluation Board Phase, the
jurisdiction for the process transitions from the Department of Defense
to the Department of Veteran's Affairs (VA) and that this transition
should occur between the 115 and 190 day mark, depending on whether or
not the service members rebuts the results of the board. Where does
each service component stand in terms of the amount of days, on
average, that it takes to make the transition to the VA? Please include
both cases when the service member rebuts the findings of the Physical
Evaluation Board and when the service member does not.
General Hogg. The Air Force Active component takes 248 days for the
IDES process, which is within the 295 day standard. The Air Force
Reserve component takes 300 days for the IDES process, which is within
the 305 day standard. For the two medical related stages of the IDES
process, referral and MEB stages, both the Active and Reserve
Components have met standards since October 2012. The Air Force Surgeon
General's office does not track cases separately.
Mr. O'Rourke. In your opinion, what can be done to ensure that
service members that are receiving mental healthcare from MTFs, under
TRICARE, have the same access and quality of care when they transition
to the VA healthcare system? Do you have any specific ideas on what can
be done to improve the quality of care during and following this
handoff?
General Hogg. The ``inTransition'' program has been instrumental in
enhancing the continuity and support of service members throughout
their transition from military mental healthcare to the VA. We continue
to make improvements to the process specifically with timely access and
communication. The hallmarks of clinical quality of care are timeliness
of treatment and appropriate follow up intervals which is largely
dependent on access to care. Tracking adherence to appropriate access
standards for behavioral health care is essential. Additionally,
enhancing communication and integration between the military healthcare
and VA systems is vital to ensuring both continuity and quality care.
Utilizing a shared or, mutually accessible electronic health record and
continued open dialogue between DOD and VA facilitates care
integration. Continuing education of DOD and VA medical personnel on
programs, policies and procedures within the other agency will improve
the transition process and allow staff on both sides to address patient
concerns and provide accurate and timely information to transitioning
service members.
Mr. O'Rourke. 1. Enclosure 8 to Department of Defense Manual
1332.18 (Volume 2), Disability Evaluation System (DES) Manual:
Integrated Disability Evaluation System (IDES), depicts the standard
timeline for IDES. According to the enclosure, the overall IDES process
should take 295 calendar days for Active Component service members and
305 calendar days for Reserve Component service members. The enclosure
also shows that, during the Physical Evaluation Board Phase, the
jurisdiction for the process transitions from the Department of Defense
to the Department of Veteran's Affairs (VA) and that this transition
should occur between the 115 and 190 day mark, depending on whether or
not the service members rebuts the results of the board. Where does
each service component stand in terms of the amount of days, on
average, that it takes to make the transition to the VA? Please include
both cases when the service member rebuts the findings of the Physical
Evaluation Board and when the service member does not.
General Tenhet. The Army has met the 295 day IDES processing
standards for the past 12 months. The average processing time for total
Army (all compos and appealed cases) is 256 days as of 20 Mar 16. IDES
consists of three distinct phases, each of which includes involvement
from the Department of Veteran's Affairs (VA).
Phase1 is the Medical Evaluation Board (MEB) which determines
whether a Soldier meets medical retention standards. The Army has 100
days to complete this phase, of which 55 days are allotted to the VA
for claim development and to complete the disability examinations. The
Soldier has an opportunity to request an impartial medical review and/
or to appeal the MEB findings before the case is sent to the Physical
Evaluation Board (PEB) for adjudication. Phase2 is the PEB which
determines if the Soldier's failing conditions make him unfit for
continued Service. The first stage of the PEB is the informal PEB
(IPEB) which determines if the Service member is fit for duty. If the
IPEB determines that a Service member is unfit, the case is transferred
to the VA to be rated by the VA Disability Rating Activity Site (DRAS).
The Service member's first opportunity to appeal the PEB findings
occurs after the ratings are initiated.
Phase3 is the Transition Phase which allows time for the Soldier to
be returned to duty, if found fit, or to process out of the Army, if
found unfit.
The average IDES processing time for those cases with no MEB or PEB
appeal is 250 days. The average processing time is 289 days when
Soldiers appeal only the MEB findings, 381 days when only the PEB is
appeal, and 422 days when the MEB and PEB are appealed.
Mr. O'Rourke. In your opinion, what can be done to ensure that
service members that are receiving mental healthcare from MTFs, under
TRICARE, have the same access and quality of care when they transition
to the VA healthcare system? Do you have any specific ideas on what can
be done to improve the quality of care during and following this
handoff?
General Tenhet. It is critical to ensure that Soldiers with
behavioral health conditions are engaged in care immediately after
leaving active duty. Early engagements with the VA or another
healthcare system reduce the chance that a Soldier's behavioral health
condition will be adversely impacted during transition.
Soldiers with behavioral health conditions leaving the Army are
automatically enrolled in the Department of Defense ``In Transition''
program, which links the Soldier and his/her Family with a care
coordinator. The coordinator assists the Soldier by locating behavioral
healthcare resources in the VA or another healthcare system.
Unfortunately, once a Soldier has transitioned into the care of the
VA or another healthcare system the Army loses the ability to effect
the care that is received.
Mr. O'Rourke. 1. Enclosure 8 to Department of Defense Manual
1332.18 (Volume 2), Disability Evaluation System (DES) Manual:
Integrated Disability Evaluation System (IDES), depicts the standard
timeline for IDES. According to the enclosure, the overall IDES process
should take 295 calendar days for Active Component service members and
305 calendar days for Reserve Component service members. The enclosure
also shows that, during the Physical Evaluation Board Phase, the
jurisdiction for the process transitions from the Department of Defense
to the Department of Veteran's Affairs (VA) and that this transition
should occur between the 115 and 190 day mark, depending on whether or
not the service members rebuts the results of the board. Where does
each service component stand in terms of the amount of days, on
average, that it takes to make the transition to the VA? Please include
both cases when the service member rebuts the findings of the Physical
Evaluation Board and when the service member does not.
Admiral Moulton. The Department of the Navy (DON) fully supports
the goals behind the Integrated Disability Evaluation Department (IDES)
and remains fully engaged with the Department of Defense (DOD), the
Department of Veterans Affairs (VA), and the other Military
Departments, to continue to improve and enhance this Service member-
centric program to eliminate the post-separation ``benefit gap'' for
wounded, ill, and injured Service members. For the Active Component
(AC), the DON has approximately 4,383 Service members (roughly 56%
Marines and 44% Navy) enrolled in IDES. This number represents less
than 1% of the combined service end-strengths of the Navy and Marine
Corps. For the Reserve Component (RC), the DON currently has
approximately 114 active cases for the Navy and 120 for the Marine
Corps enrolled in IDES.
As of January 2016, AC Sailors spend on average 255 days and AC
Marines spend on average 230 days in IDES, which includes the completed
transition to the VA. As of January 2016, RC Sailors spend on average
204 days and RC Marines spend on average 307 days in IDES. While we do
not track cases separately when the Service member rebuts the findings
of the Physical Evaluation Board and when the Service member does not;
we do know approximately 10% of servicemembers request a formal
Physical Evaluation Board which adds 58 days to the process. The 58
days are included in the averages listed within this paragraph. While
this is much faster than the AC 295-day goal or RC 305-day goal for RC
Navy, it is still longer than we would like. We are working diligently
on improving our RC Marines Corps numbers to align closer to the RC
Navy results. We also continue to explore ways to reduce the time
Service members spend in IDES without compromising the integrity or
accuracy of the system.
Mr. O'Rourke. In your opinion, what can be done to ensure that
service members that are receiving mental healthcare from MTFs, under
TRICARE, have the same access and quality of care when they transition
to the VA healthcare system? Do you have any specific ideas on what can
be done to improve the quality of care during and following this
handoff?
Admiral Moulton. Continued efforts to ensure interoperability and
communication between DOD and VA healthcare systems, as well as
TRICARE, are instrumental to ensuring same access and quality of care
for service members when they transition to the VA healthcare system.
Specific efforts which will continue to support the quality of care
during and following this handoff include:
Automatic enrollment in the DOD's InTransition program
for all service members seen for a mental health concern during the 12
months preceding their separation from military service. InTransition
ensures connection with the gaining healthcare provider to introduce
the service member and facilitate appointments; follow up with gaining
providers to ensure continuum of care; and provide the patient with
support and resource location should members encounter a crisis
situation.
DOD and VA electronic health records that are
interoperable and facilitate communication between DOD and VA
providers.
Quick access (5 7 days) to the VA health system for
military personnel leaving active duty.
Assignment of a DOD/VA Lead Coordinator (LC) to any
patient with mental health concerns, not just those with diagnosed
mental health conditions. Currently, the LC serves as the primary point
of contact for the service member and their family or caregiver during
the transition between DOD and VA. The LC ensures that when a patient
with complex care needs a transfer, that a ``warm hand-off'' to another
LC and Care Management Team (CMT) on the receiving end of the transfer
is accomplished.
NDAA 2016, Section 715 requires that DOD and VA establish
a joint uniform formulary that at a minimum includes medications
related to control of pain, sleep disorders, and psychiatric
conditions, including PTSD. While those efforts are underway to
establish a Continuity of Care Drug List, the Report to Congress will
be submitted no later than July 2016. Further, VA issued a directive in
January 2015 that establishes policy to continue mental health
medications initiated by DOD authorized providers for recently
discharged service members.