m2va 16-5 (aug. 2012)

August 2012Volume 16, Issue 5

www.M2VA-kmi.com

Dedicated to the Military Medical & VA Community

Medical Developer

Maj. Gen. James K. Gilman

CommanderU.S. Army Medical Research and Materiel Command

Tactical Combat Casualty Care O Interoperable EHRs Medicine on the Go O Medevac O Tissue Injury

PERSONNEL RECOVERY ROUNDTABLE

Experience CountsZOLL, with over 25 years of experience

manufacturing resuscitation technologies

for the military, understands that to meet

today’s demands, you require more than just

the best monitoring technology available. The

ZOLL Propaq M, in addition to providing the

trusted and proven vital signs you have come

to expect from Propaq, now has significantly

enhanced data communications allowing you

to capture patient care data from the point of

injury through definitive care.

© 2012 ZOLL Medical Corporation, Chelmsford, MA, USA. ZOLL is a registered trademark of ZOLL Medical Corporation. Propaq is a trademark of Welch Allyn.

For more information, call 1-800-804-4356 or visit us at www.zoll.com/nextgen.

Propaq:The Standard

You’ve asked, we’ve delivered.Your next-generation Propaq® is here. The standard in vital signs monitoring, now with advanced capabilities for all levels of care.

PropaqM_Encore_MMT_AD__0612_v4.indd 1 6/21/12 11:47 AM

Military Medical & Veterans Affairs Forum August 2012Volume 16 • Issue 5

FeAtures CoVer / Q&A

16

DepArtments

2

3

4

14

27

Editor’s Perspective

MC4

Program Notes/People

Vital Signs

Resource Center

InDustry InterVIew

28

Major General James K. Gilman Commander

U.S. Army Medical Research and Materiel Command

Joe RobinsonSenior Vice President

Government and Enterprise SolutionsPhilips Healthcare

Aerial Medical Evacuation (MEDEVAC)Since the Korean War, the advancement of aerial medical evacuation has transformed battlefield medicine beyond our expectations. However, we must continually improve and evolve to make it even better.By Colonel Robert Mitchell

22

Mastering the Basics The immediate traumatic effects of battlefield injury may have changed in character or intensity over the centuries, but the need to speedily intervene to maximize the survival and recovery of casualties has not.By Colonel (Dr.) Peter J Benson

12

More Training, Better Bandages Dealing with battlefield wounds requires both skilled people and the best equipment. U.S. military forces are pushing for better training and improving dressings that stop bleeding, which is often the first requirement of lifesaving care.By Henry Canaday

9

Interoperable EHRs Congress has been after the Department of Defense and the Department of Veterans Affairs for years to make their respective electronic health records systems interoperable. In other words, the legislators want data from one system to be viewable and usable in the other.By Peter Buxbaum

6

Medicine on the Go Saving the lives of wounded soldiers is always a challenge, even in a military medical facility equipped with the latest state-of-the-art technology. Expeditionary medicine has become a critical part of keeping soldiers alive, with each branch of the military using its own unique methodology for delivering that critical care.By Kenya McCullum25

Personnel recovery operations are part of each military branch’s capabilities. While the Air Force and Navy conduct combat search and rescue operations, the Marines conduct tactical recovery of aircraft and personnel, and the Army conducts medical evacuation operations, the goal is the same: to get the warfighter back home.

20

Experience CountsZOLL, with over 25 years of experience

manufacturing resuscitation technologies

for the military, understands that to meet

today’s demands, you require more than just

the best monitoring technology available. The

ZOLL Propaq M, in addition to providing the

trusted and proven vital signs you have come

to expect from Propaq, now has significantly

enhanced data communications allowing you

to capture patient care data from the point of

injury through definitive care.

© 2012 ZOLL Medical Corporation, Chelmsford, MA, USA. ZOLL is a registered trademark of ZOLL Medical Corporation. Propaq is a trademark of Welch Allyn.

For more information, call 1-800-804-4356 or visit us at www.zoll.com/nextgen.

Propaq:The Standard

You’ve asked, we’ve delivered.Your next-generation Propaq® is here. The standard in vital signs monitoring, now with advanced capabilities for all levels of care.

PropaqM_Encore_MMT_AD__0612_v4.indd 1 6/21/12 11:47 AM

Special Section PERSONNEL RECOVERY ROUNDTABLE

The Department of Veterans Affairs (VA) recently announced a new partnership to use health information exchange technology. The goal is to improve the quality of care to local veterans in Western New York. This is one of 13 communities in the United States selected by VA to participate in the Virtual Lifetime Electronic Record (VLER) Health Communities Program. The providers participating, including physicians from VA, private practices and hospitals in Western New York, will be able to access veteran’s health information electronically through HealtheLink, Western New York’s clinical information exchange.

“The VLER program is aimed at creating a more convenient and comprehensive medical, personnel and benefits record for all veterans, in addition to creating a seamless transition from military to civilian life,” said Brian G. Stiller, director of VA Western New York Healthcare System. “One of our priorities is to eliminate the need for our veteran patients to carry paper copies of their health records to private providers. The information will be accessible with a veteran’s consent from military to VA to private-sector health care.”

This is a success story. Now the Department of Defense, (DoD) and VA need to do this on a much larger scale by integrating the separate DoD and VA electronic health record systems, one of the prime components of President Barack Obama’s promise of a Virtual Lifetime Electronic Record that would capture full health care histories on individuals, including private sector care.

Senior leadership at both the DoD and VA have been grilled on the progress of VLER integration. House committees on armed services and veterans affairs held a joint hearing recently and committee members said they were disappointed to learn that full integration of the DoD and VA health record systems won’t occur until 2017. Defense Secretary Leon Panetta and VA Secretary Eric Shinseki were even skeptical about meeting that deadline.

There is a lot of money involved and a lot of veterans that need quality care. Every expert from the DoD and VA I have spoken to on this matter wants to get this done as much as lawmakers and the public do, and tell me they are doing the best they can. This is going to take some time to be done correctly. The last thing veterans need is an integrated system that does not work properly. I believe when it is all said and done it will have been worth the wait. If you have any questions concerning Military Medical & Veterans Affairs Forum, feel free to contact me at any time.


eDItorIAl

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U.S. Coast Guard Forum

Colonel Carol Pierce, chief of clinical operations at the U.S. Central Command (CENTCOM) Surgeon’s Office, oversees the development of telebehavioral health (TBH) policies for CENTCOM. TBH is becoming an increasingly popular tool for deployed medi-cal personnel and soldiers alike to connect across battlefields. As a nurse who deployed in 2008 with the MC4 system, Pierce recently provided input into pre-deployment train-ing requirements for the electronic medical record (EMR) system.

Q: Telebehavioral health has been really effective in helping providers connect with soldiers at remote locations. What guidance has CENTCOM delivered to the field regard-ing this capability?

A: In 2011, telebehavioral health was already being utilized in Afghanistan somewhat. It was our hope to standardize policy in Afghanistan and other clinical operations across CENTCOM to expand the use of this capability.

Around January of this year, Major Gen-eral William E. Rapp, deputy commander for support, United States Forces-Afghanistan, signed a policy for telebehavioral health in Afghanistan. The policy directed the use of TBH applying a hub-and-spoke concept that virtually connected locations where behav-ioral health providers were located to far-forward, remote sites. The policy included measures of effectiveness and delineated standards of care. In March 2012 the U.S. CENTCOM administrative guidance for use of TBH, titled Medical Tele-Behavioral Health Care Services within the USCENTCOM area of responsibility [AOR], was published. The

guidance encouraged services to consider TBH as a behavioral health modality in other areas within the CENTCOM AOR.

Q: Why was it necessary to standardize the use of the TBH capability?

A: The issue became one of processes. When there is a TBH encounter, questions about whether a consent form is necessary or deter-mining if there are enough providers cre-dentialed in each facility arise. We needed to standardize the processes for CENTCOM to ensure consistency and uniformity.

The CENTCOM general administrative guidance is already in the field. We also dis-seminated to our service counterparts to include the Army Central Command, Air Force Central Command, Marine Forces Central Command and Navy Central Com-mand and the medical treatment facilities that would most likely use TBH in a theater of operations. Right now, we’re working closely with Army units in Kuwait on using TBH. They’ve had the capability, but it’s not neces-sarily exercised as much as it could be.

Q: What efforts have been made to synchro-nize International Classification of Disease, 9th Revision [ICD-9] codes with TBH for documentation purposes?

A: When we have an initiative like TBH, we want to have the ability to evaluate how we are actually using the system. In other words, if we put infrastructure in place we need to make sure we have a perspective of how often TBH is being utilized. Looking at it from a higher headquarters perspective, it would be ideal to do a query in MSAT [Medi-cal Situational Awareness in Theater] for TBH encounters so we could see how we’re using it and where it’s being used most often in theater.

To get that theater-level view, we looked at how we should be documenting TBH in the EMRs. When we first started looking at this in Afghanistan, the policy that was cur-rently in place stated that the first diagnostic code entered would be for TBH; the second would be the disorder the patient was seen for, such as depression. The problem with

this practice is that TBH is a modality, not a medical diagnosis. We provided new instruc-tions that a provider should always use what-ever the patient’s diagnosis was as the first code. Other information and the modality such as TBH should be identified by a specific V-code, or user code, following the diagnosis code. This now allows us to use MSAT to build a report that shows how the capability is being used.

Q: What changes will the Army consider making based on the TBH encounter data?

A: The TBH data will be part of our decision-making process, especially in Afghanistan where forces are very widely distributed. In remote locations, access to in-person behavioral health practitioners is very limited because of time and safety concerns. What Afghanistan has done to overcome these chal-lenges is establish a hub-and-spoke concept so that a provider may be in a larger location and will meet with patients at smaller loca-tions via TBH on a scheduled basis.

We recognize that while our medical forces expanded during the force surge efforts, they will need to be significantly reduced as forces draw down. We want to make sure that we have enough behavioral health providers available. If we can show that we can effectively use our behavioral health providers using this TBH capability, we will be able to use a hub-and-spoke concept to connect several sites and maximally use our behavioral health personnel.

Telebehavioral health is not a substitute for in-person consultations; it’s simply an encounter using a different modality. I think TBH has been successful because the younger generations are comfortable using communi-cation technologies.

We continue to emphasize in CENTCOM that all patient encounters and medical care is to be documented using the EMR. I feel strongly that every encounter be an EMR encounter. With MC4, we’ve been able for the most part to ensure that the EMR is being used. O

This article is also available on The Gateway at www.mc4.army.mil.

By Colonel Carol PierceChief of Clinical Operations

U.S. Central Command Surgeon’s Office

Institutionalizing Telebehavioral Health Practices

Medical Communications For Combat Casualty Care

www.M2VA-kmi.com M2VA 16.5 | 3

DARPA and NIH to Fund ‘Human Body on a Chip’ Research

Researchers in the Department of Biological Engineering at MIT will receive up to $32 million over the next five years from the Defense Advanced Research Projects Agency (DARPA) and the National Institutes of Health (NIH) to develop a technology platform that will mimic human physiological systems in the laboratory, using an array of integrated, interchangeable engineered human tissue constructs.

A cooperative agreement between MIT and DARPA worth up to $26.3 million will be used to establish a new program titled “Barrier-Immune-Organ: Microphysiology, Microenvironment Engineered Tissue Construct Systems” (BIO-MIMETICS) at MIT, in collaboration with researchers at the Charles Stark Draper Laboratory, MatTek Corp. and Zyoxel Ltd. The BIO-MIMETICS proposal was one of two award winners selected as part of the Microphysiological Systems (MPS) program at DARPA, and will be led by MIT professor Linda Griffith in collaboration with MIT professors Steven Tannenbaum, Darrell Irvine, Paula Hammond, Eric Alm and Douglas Lauffenburger. Jeffrey Borenstein and Shankar Sundaram will lead the work at Draper Laboratory, Patrick Hayden will lead the work at MatTek, and David Hughes will lead the work at Zyoxel.

The BIO-MIMETICS program will combine technologies developed at MIT, Draper Laboratory, MatTek and Zyoxel to create a versatile microfluidic platform that can incorporate up to 10 individual engineered human microphysiological organ system modules in an interacting circuit. The modules will be designed to mimic the functions of specific organ systems representing a broad spectrum of human tissues, including the circulatory, endocrine, gastrointestinal, immune, integumentary, musculoskeletal, nervous, reproductive, respiratory and urinary systems. The goal of the program is to create a versatile platform capable of accurately predicting drug and vaccine efficacy, toxicity and pharmacokinetics in preclinical testing. The BIO-MIMETICS team anticipates that the platform will be suitable for use in regulatory review, amenable to rapid translation to the

biopharmaceutical research community, and adaptable for integration of future technologies (such as advances in stem cell technologies and personalized medicine).

Program Notes

Army Brigadier General Joseph Caravalho Jr. has been nominated for appointment to the rank of

major general. Caravalho is currently serving as commanding general, Northern Regional Medical Command, Fort Belvoir, Va.

Air Force Major General Thomas W. Travis has been nominated for appointment to the rank of lieutenant general and for assignment as surgeon general of the Air Force, Headquarters U.S. Air Force,

Pentagon, Washington, D.C. Travis is currently serving as deputy surgeon general, Office of the Surgeon General, Headquarters U.S. Air Force.

Brigadier General Norvell V. Coots, special assistant to the surgeon general, Falls Church, Va., was appointed to surgeon general, U.S. Forces-Afghanistan/medical

advisor, International Security Assistance Force Joint Command, Operation Enduring Freedom, Afghanistan.

Colonel Jeffrey Clark assumed command of the Europe Regional Medical Command from Brigadier General Nadja West May 8 at Patton Barracks in Heidelberg. Army Surgeon General Lieutenant

General Patricia Horoho presided over the ceremony. Clark was previously the Landstuhl Regional Medical Center commander, while West has been selected to become the Assistant Surgeon General for Force Sustainment in the Falls Church, Va., office of the Army Surgeon General. The ERMC commander is also the U.S. Army Europe command surgeon.

Compiled by KMi Media Group staffPEOPLE

Combat Medical Systems Buyout of Z-Medica

Combat Medical Systems (CMS) extended its distribution agreement for Combat Gauze, the DoD-approved hemostatic, as a part of its buyout of former partner Z-Medica Corporation’s ownership interest in the company effective June 21, 2012. CMS, a distributor and developer of medical solutions that simplify tactical medicine, will remain the exclusive government distributor of the Combat Gauze line through 2014.

To date, Combat Gauze has been fielded to every servicemember in DoD. It is authorized in every Individual First Aid Kit (IFAK), Combat Life Saver and medic/corpsman medical bag.

According to a recent DoD Tactical Combat Casualty Care survey, in 1,895 documented battlefield uses of Combat Gauze, 90.7 percent of respondents agreed/strongly agreed that Combat Gauze was “effective at stopping severe external bleeding.”

“CMS and Z-Medica worked closely to field Combat Gauze, one of our first servicewide successes,” said Corey Russ, president and founder of CMS. The development of Combat Gauze offers the medic a simple, cost-effective hemostatic product to treat severe external bleeding, especially in areas where a tourniquet cannot be applied. “The buyout will let CMS further focus on being a veteran-owned, DoD medical solutions provider.”

Jason Cauley; [email protected]

Brig. Gen. Joseph Caravalho Jr.

www.M2VA-kmi.com4 | M2VA 16.5

Program Notes

Replacement Medical Clinic

Contract Awarded

Satterfield & Pontikes Construction Inc., Austin, Texas, is being awarded a $19,096,000 contract for construction of the medical clinic replacement at Naval Construction Battalion Center Gulfport. Work to be performed provides for the construction of a new branch clinic patient care facility, which includes a medical clinic and a dental clinic. Buildings 295 and 369 and the existing car wash, located on the project site, will be demolished as part of this project. A new car wash will be designed at a new location. Work will be performed in Gulfport, Miss., and is expected to be completed by August 2014. Contract funds will not expire at the end of the current fiscal year. This contract was competitively procured via the Navy Electronic Commerce Online website with eight proposals received.

Personalized Lymphoma Vaccine a Step Closer to Approval

Biovest International Inc., a majority-owned subsidiary of Accentia Biopharmaceuticals Inc., recently announced that the European Medicines Agency (EMA) has notified Biovest regarding the official designation of the Rapporteur and Co-Rapporteur for BiovaxID, a personalized cancer vaccine for the treatment of follicular non-Hodgkin’s lymphoma.

The Rapporteur and Co-Rapporteur are members of the EMA’s Committee for Medicinal Products for Human Use (CHMP). They are supported by a team of assessors from their national authority. The Rapporteur and Co-Rapporteur have been assigned with the primary responsibility of preparing and delivering an approvability evaluation report under the EMA’s centralized procedure. Under this procedure, a registration of BiovaxID throughout all EU-member countries can be obtained simultaneously via a single application. Upon approval, BiovaxID would be the first cancer vaccine available in Europe for lymphoma patients.

Biovest’s EU regulatory advisor, Adriaan Fruijtier, stated, “This is another key milestone as

part of the formal EMA process and a precursor to the upcoming filing of our marketing authorization application for BiovaxID. The role of our Rapporteur and Co-Rapporteur is to perform the scientific evaluation for BiovaxID and to prepare an assessment report for the EMA’s CHMP. We look forward to meeting with our selected reviewers, as we will work closely with them, providing the necessary support for a comprehensive submission.” Fruijtier serves on the Biovest Scientific Advisory Board and as the managing director of CATS Consultants GmbH in Germany. He has extensive EU regulatory experience, having held positions with the EMA, Bayer, Glaxo, Micromet and Novartis.

The EMA has granted Orphan Medicinal Product designation to BiovaxID for the treatment of follicular lymphoma and mantle cell lymphoma, which are B-cell subtypes of non-Hodgkin’s lymphoma. Orphan Drug status gives Biovest a 10-year period of market exclusivity for BiovaxID upon approval for each indication in the EU, thereby offering competitive protection from similar drugs of the same class.

National Association of Emergency Medical Technicians Testimony

On behalf of military veterans, and representing the National Association of Emergency Medical Technicians (NAEMT), Ben Chlapek, deputy chief, Central Jackson County Fire Protection District, Blue Springs, Mo., recently testified to the Committee on Energy and Commerce, Subcommittee on Health at a hearing entitled “Helping Veterans with Emergency Medical Training Transition to Civilian Service.”

The focus of the hearing was on H.R. 4124, the Veteran Emergency Medical Technician Support Act of 2012, legislation that would assist states in streamlining their certification requirements for veterans with military medic training who want to continue their career as EMTs or paramedics in the civilian workforce.

Chlapek is a paramedic and retired U.S. Army Lieutenant Colonel who served 36 years, with tours in Afghanistan, Kosovo, Central America, and multiple other countries. He holds undergraduate degrees in chemistry and fire science and two

master’s degrees in public administration and homeland defense and security. He has served as faculty at Louisiana State University. He serves on numerous national, state, and local committees including the Missouri Governor’s Advisory Council for EMS and as the Chair of NAEMT’s Military Relations Committee.

In his testimony, Chlapek stated that the hearing is extremely important in developing policies that honor the training of military medics so they can smoothly transition into the EMS civilian workforce and provide their valuable medical skills to communities across the U.S. “Military veterans receive some of the best medical training and experience available when serving our country. Their sacrifices, commitment to duty, and ability to get the job done in austere environments make them exceptionally well suited for working as EMTs and paramedics in our communities upon their release from the armed services,” Chlapek said.

Chlapek detailed cases of work-ready veterans being stymied by varying and prohibitive requirements even though they are more than qualified to serve as civilian EMS professionals. Congressmen Adam Kinzinger of Illinois (R-11th) and Congresswoman Lois Capps of California (D-23rd) introduced the bipartisan bill H.R. 4124 this past March to address veteran transition issues. The legislation continues to achieve bipartisan support of 13 Democrats and 17 Republicans. H.R. 4124 provides demonstration grants to states with shortages of EMS practitioners to help streamline state requirements and make allowances for returning veterans to enter the EMS workforce without unnecessary duplication of their training by determining the extent to which the state requirements for education and training of EMTs and paramedics are equivalent to that of the military, and identifying methods, such as waivers, for qualified military medics to forego duplicative requirements.


Compiled by KMi Media Group staff

The United States Congress has been after the Department of Defense and the Department of Veterans Affairs for years to make their respec-tive electronic health records systems interoper-able. In other words, the legislators want data from one system to be viewable and usable in the other.

The rationale behind this demand, which became a legislative mandate in 2009, was to make the DoD and VA health care systems more efficient and to save the taxpayers money. Since the two health systems have overlapping beneficiaries, and since many patients transition from the military to the veterans’ health system at some point, it made sense for the electronic records they used to be able to work together.

The approach the two departments decided to take to fulfill their obligations was to develop an integrated electronic health record (iEHR). The iEHR, which will replace DoD’s AHLTA and VA’s VistA, is now being developed under the auspices of an Interagency Program Office (IPO). The iEHR is expected to be rolled out in two pilot programs beginning in 2014.

If it were easy to develop an iEHR, it would have been done already. As it stands, there are two major obstacles to sharing medical information between DoD and VA systems: the divergent architectures of the systems and the different data ontologies that they employ. To achieve interoperability, both agencies must standardize how data is defined, structured and communicated, and agree on interagency code sets for domains such as pharmacy, allergy, chemistry, radiology and others. All of this remains a work in progress.

But that doesn’t mean that data from AHLTA and VistA are still separated by a Chinese wall. The two departments have been working on making some categories of data viewable and sometimes computable in the other system. There are also two other projects that in some ways are helping the iEHR along: the Virtual Lifetime Electronic Record (VLER), a presidential mandate, and the related development of personal health records (PHRs), which allow the patient to supply information to the health record, both of which are key to connect-ing government health data with data generated by private sector health providers.

VA And dod working together to shAre dAtA.

Elizabeth McGrath

George Mahler

By Peter BuxBAum

m2VA CorresPondent


“There is still a lot of founda-tional work that needs to be done to make sure both organizations are working on a common approach and architecture for the iEHR,” said Elizabeth McGrath, DoD’s deputy chief management officer.

Much of the remaining work involves the nuts and bolts of the busi-ness rules surrounding data fields, according to George Mahler, senior program manager at CCSi, which is

working with the VA on personal health records. “There need to be rules, for example, on what is required if a field is left blank,” he explained, “or what other data is required for an interoper-able exchange of information between systems.”

The data approach is one of the key challenges associated with the development of the iEHR, agreed Mark Davis, program director for informatics at DRC, a company that is working with both departments on certain aspects of the electronic records project. “Another is the application development challenge,” he added, “and a third is how to jointly incorporate innovation.”

On the architecture side, the departments have opted for a service-oriented architecture (SOA) that is different from the approach either organization takes today. “We are both moving away from our legacy platforms to a new place,” said McGrath. “The IPO has procured an enterprise service bus which is the key piece of the communications ability” that will unite the two sets of data.

SOAs develop software capabilities through the integration of loosely coupled, reusable components, as opposed to the point-to-point integration between stand-alone systems. An enterprise service bus or service broker, which is able to extract data from one application and present it in another, is key to creating this interoperability.

The decision to go with an SOA dates back to November 2008, after DoD and VA accepted the recommendations made by government consultant Booz Allen Hamilton. The Booz Allen analysis demonstrated that there was a 97 percent overlap of requirements among the two departments with respect to inpa-tient care electronic health records. The SOA will enable the IPO to develop common services for both systems.

“The common architecture becomes the single platform that the iEHR rides on,” said Barclay Butler, the IPO director. “As new capabilities come into play, both departments are in a position to adopt them without changing the underlying infrastructure.”

On the data side, “We have made decisions on using a com-mon data standard and health data dictionary and are taking other very deliberate approaches to make sure that we are com-ing together,” said McGrath. While the new architecture is being developed, “we will continue to share as much data as possible. As we evolve to more data-driven standards based on a common approach, we will rely less on some of these mechanisms we have in place today.”

To date, the DoD and VA have taken an incremental approach to information sharing, efforts that include the Bidirectional Health Information Exchange (BHIE) and the Clinical Data Repository/Health Data Repository (CHDR). The BHIE provides a real-time interface between AHLTA and VistA to provide viewable

Barclay Butler


data to health care providers in either system. The CHDR software synchronizes data between DoD and VA repositories to enable the exchange of specific categories of information, such as allergy information and lists of medical problems, for shared patients.

The DoD and VA have some prior experience developing joint systems and processes at the James A. Lovell VA-DoD Federal Health Care Facility in North Chicago, Ill. That facility represents a merger of the North Chicago Veterans Administration Medical Center and the Naval Health Clinic Great Lakes and created an integrated organization that treats servicemembers and veterans alike through the same system.

At the IT level, the merged facility operates a single medical record system that draws on existing integration efforts. “The capabilities we have put in place in North Chicago enable better communication and transparency,” said McGrath. “We have a single sign on to both systems and a common patient identifica-tion function. We are learning from this experience and plan to continue with some of these capabilities into the future.”

The VLER project is also relevant to the development of the iEHR, as “VLER will have access to AHLTA and VistA data, as well as data from private sector providers,” said McGrath. Over half of the medical care provided to servicemembers and veterans is done in the private sector.

VLER was initiated by President Obama in April 2009 and calls for the development of a system that will include comprehensive administrative and health information on members of the armed

services during the course of their military careers and after they leave the military. The project requires that DoD, VA and private health care providers be able to exchange information among their electronic records.

“The key is a standards-based information exchange mecha-nism that requires data to be passed in a certain format,” said McGrath. “In the future, we view the iEHR as replacing AHLTA and VistA as the information sources that would feed the VLER.” VLER development is also being managed through the DoD-VA IPO.

VLER is also related to the proliferation of patient-controlled personal health records. Both VA and DoD have PHR programs—known as MyHealtheVet and MiCare, respectively—which are seen as another effort to bridge the digital divide between the depart-ments and private providers. Users of these programs authorize the agencies and/or private health networks to feed data to their PHRs.

“The PHR will be part of VLER,” said Butler. “It will allow patients to report their own data. Clinicians can see and review documents but the patient has the control. They can add docu-ments to their own records and share these with health care providers.”

CCSi is supporting two PHR efforts for the VA. One allows MyHealtheVet PHRs to access VistA data and make them elec-tronically available to patients through middleware called Medical Domain Web Services. The other project, called blue button, pro-duces text and PDF documents based on DoD and VA health data that can be read by multiple programs.

“All of this is a precursor to building the iEHR,”said Mahler. Davis advocates that the IPO adopt an agile application devel-

opment model for the iEHR that relies on input from users to develop functionality. He also advises to embrace third-party inno-vations that can be easily integrated into the iEHR architecture.

“Innovations can be incorporated through an app store model,” said Davis. “Adopting an open source architecture encour-ages entrepreneurs to develop apps that work within the health management platform that meet the needs on the ground.”

Butler agreed that interaction with open source development community will be important for the iEHR and that the integrated record will rely on commercial off-the-shelf technologies to the greatest extent possible. There are also proven government tech-nologies, including aspects of AHLTA and VistA, that may be pulled into the iEHR.

“We are also very focused on what we call the 2.0 capabilities,” said Butler. “We recognize the need to be able to operate in mobile and wireless environments while protecting the security of private health information.

“This effort involves a clinical transformation,” Butler added. “The IPO is a unique organization sitting between both depart-ments and both department secretaries have strenuously supported it. They have given us the responsibility to create an iEHR for the purposes of improving the quality of health care while reducing costs. This is a tremendously exciting time for us. The IPO is in a position to improve health care for our beneficiaries. O

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Dealing with battlefield wounds requires both skilled people and the best equipment. U.S. military forces are pushing for bet-ter training and improving dressings that stop bleeding, which is often the first requirement of lifesaving care.

The Army Medical Department Center and School (AMEDDC&S) believes recent experience in Iraq, Afghanistan and domestic support shows need for the addition of advanced pre-hospital critical care skills in the medical evacuation mis-sion. “A requirement exists to provide specialized advanced trauma management at or near the point of injury and thus improve patient outcomes,” AMEDDC&S spokesman Phillip Reidinger said.

The center has concluded the best course of action is to certify paramedic flight medics with advanced critical-care training. Cur-rently, these flight medics receive only four weeks of training and are trained at the emergency medical technician (EMT) basic level. EMT-basic is the training and certification all combat medics are required to achieve. EMT-paramedic is two levels more advanced.

The Army Medical Command plans to change training requirements for 68WF3 soldiers assigned to air-ambulance units. This program will enable flight medics to provide advanced critical en-route care to trauma and medical patients and suc-cessfully prepare medics to pass the National Registry Emer-gency Medical Technician-Paramedic examination. AMEDDC&S and the University of Texas Health Science Center at San Antonio partnered in November 2011 to establish this Army Flight Medic Paramedic program.

Two pilot classes will be conducted at Fort Sam Houston, Texas, in fiscal year 2012 and will be limited to existing pre-qualified flight medics.

Classes will be conducted in three phases over nine months. There are four weeks of flight training, six months of paramedic training, and eight weeks of critical-care skills training, which provides flight-medic candidates with critical-care skills and experience to perform direct hands-on patient care. All students will undergo a rigorous and demanding field validation exercise at the conclusion of the critical-care clinical course.

The first pilot class began in February 2012 and the second pilot class takes place in July 2012. Current enrollment in the two pilot courses is 30 students.

Staunching blood flow immediately on the battlefield is essential and must often be done under dangerous or extremely difficult conditions. The Army’s Tactical Combat Medical Care (TCMC) trains on use of wound dressings and provides advice on improvements in dressings and the testing of future battlefield medical products, noted Captain Don Merrill, master of physi-cian assistant studies at AMEDDC&S’s Center for Pre-Deploy-ment Medicine.

Merrill said the most important advance in battlefield hemorrhage control has been rapid placement of the Combat Application Tourniquet (CAT) and Special Operations Forces Tactical Tourniquet (SOFTT). “CAT can be applied with applied with one hand, is compact in size, and performs an excellent job of hemorrhage control. SOFTT is a little bulkier and wider, but

reCent ConfliCts show need for CritiCAl CAre skills. By henry CAnAdAy

m2VA CorresPondent


seems to be more rugged. Both tourniquets do an excellent job of hemorrhage control, but we have noticed that on patients with thin arms, women and children, CAT works better.” For patients with thick legs, TCMC prefer SOFTT for greater circumference, size and durability.

Closely following the tourniquet has been the development of Combat Gauze. “This is gauze impregnated with kaolin, which is clay,” Merrill explained. This accelerates the clotting cascade in blood, thus making it thicker and easier to clot. Combat Gauze is used for arterial bleeding in non-compressible areas, such as the groin, auxiliary and inguinal regions of the body.

When a patient has a wound in one of these areas, a medic is trained to pack that wound with gauze, apply direct pressure over the site for three minutes and check to see if hemorrhage control has been achieved. “If it has not, he must remove the bandage and start the process over,” Merrill said. “It is time consuming, but with proper training it has had success on the battlefield.”

Another dressing is an occlusive chest seal. “If a patient has suffered a penetrating wound to the chest, we want to completely cover that wound so no air can enter or escape,” Merrill said. “There are many different chest seals on the market; they all work similarly and we feel that all work well.”

Once a chest wound has been identified, the medic should immediately cover the wound with their hand or other item. They then do a blood sweep of the wound to try and remove blood and debris from the surface of the wound. The next step is to apply the dressing, adhesive side directly on top of the wound. “The medic should then apply 3-inch tape to all four sides of the dressing to aid in securing the dressing. It typically takes 30 to 40 minutes to develop a tension pneumothorax.”

Finally, the emergency field dressing has elastic tails and a com-pression device that allows it to apply a significant amount of direct pressure over a wound. “This works very well for all types of venous bleeding and can be utilized in a variety of ways,” Merrill said.

Z-Medica makes Combat Gauze. Combat Gauze has been fielded to every servicemember in DoD, and it is the only authorized hemo-static. It is authorized in every IFAK, Combat Live Saver, and medic/

corpsman medical bag. Z-Medica’s Combat Gauze is the number-one combat gauze for U.S. armed forces, said Marketing Manager Christina Guman. Combat Gauze comes in a vacuum-packed, easy-tear pouch. It is used, in conjunction with manual pressure, for temporary control of traumatic external bleeding.

The company cites several peer-reviewed clinical studies proving the safety and efficacy of combat gauze and comparing it favorably with other hemostatic dressings.

A study in The Journal of Trauma looked at the safety of Combat Gauze, another hemostatic agent, and Kerlix gauze as a control, and concluded that Combat Gauze was as safe as Kerlix. Another Jour-nal of Trauma study evaluated efficacy of five different hemostatic dressings, including Combat Gauze, HemCon, Celox, TraumaStat and a placebo gauze, and found Combat Gauze the most effective.

Regular Combat Gauze is a 3-inch by 4-yard strip of non-woven hemostatic gauze, impregnated with kaolin, which promotes clot-ting without animal or human proteins. Z-fold format makes it easy to pack a wound and Combat Gauze has an X-ray strip for easy detection. Combat Gauze XL is similar, but is 2-ply, 4-inch by 4-yard gauze.

In the DoD’s TCCC Equipment Evaluation survey are 1,895 documented battlefield uses of Combat Gauze, of which 90.7 per-cent of respondents agreed/strongly agreed that Combat Gauze was the most “effective at stopping severe external bleeding.”

Combat Medical Systems recently introduced Combat Gauze XL, which has 2.7 times the gauze in the same-sized package as the older Combat Gauze Z-Fold LE. Both versions are used for massive traumatic wounds caused by improvised explosive devices, land-mines and gunshots.

Packaged, XL is 6 by 5 by 1 inches and weighs just two ounces. “That’s important if you have a limited amount of space,” said Presi-dent Corey Russ.

Russ said Z-Fold or and XL are easy to pack. “It is very intuitive to use. Other dressings require special applications.”

CMS also makes Battle Wrap, a compression wrap that allows visualization of bleeding and pressure with no slipping. Bat-tle Wrap is clear, flexible, strong and self-adhering. Its unique

Combat Gauze is used for arterial bleeding in non-compressible areas. [Photo courtesy of Combat Medical Systems]


adhesive properties will not leave a residue on skin and it is free from latex.

A different approach is available from U.K.-based Medtrade Products, which offers Celox, a hemostat whose purpose is to stop bleeding as fast as possible. “It deals with life-threatening bleed-ing,” explains Chris Marsden, head of marketing for hemostats. “You can use a tourniquet or a hemostat, or a combination of both.”

Celox is especially suitable for severe high-pressure bleeding, hemorrhages, arterial bleeding, application to strong blood flows and to bullet, blast, knife and shrapnel wounds.

Unlike standard gauze, Celox granules are high surface-area flakes that swell, gel and stick together to make a gel-like clot when they come in contact with blood. The granules stop bleeding by bonding with red blood cells. Celox thus does not set off a clot-ting cascade, but only clots the blood it comes directly in contact with. “It does not depend on natural clotting, it is purely physical,” Marsden said.

This clotting method has several benefits. For example, Celox clotting ability has been proven to work in the presence of common

anti-coagulants such as warfarin. Moreover, when soldiers have started to lose blood, they can get cold with hypo-

thermia, which interferes with clotting. “We have tested Celox with blood at so low a temperature

that you would be dead, but it still works,” Marsden said.

And conventional hemostats require pres-sure for three minutes, after which medics check

to see if bleeding has stopped before binding up the wound. Marsden said Celox can clot blood in as little as one

minute. “This is important on the battlefield, where you do not want to spend more time than is necessary.”

For safety, Celox is made from chitosan, derived from shellfish, a natural material that breaks down in the body. Chitosan is digested by an enzyme that is present in tears, saliva and mucus. It breaks down to a sugar already present in the body.

Marsden said there is very good test data on Celox, and the dressing has had a 100 percent success rate in treating gunshot injuries in Afghanistan. “It has also been used successfully by the Dutch, both on the battlefield and in civilian emergencies at home.”

Celox is now used by all U.K. forces, some NATO forces and some U.S. special operations units. “We are marketing it to other U.S. forces,” Marsden said. “One advantage of all using one type is that you can standardize training.”

Celox recently introduced Z-Fold gauze, which offers the same performance as its roll gauze but in a smaller and lighter form. Z-Fold ensures simple application and makes it easier to carry mul-tiple packs. Medtrade said 5 feet of Z-Fold Celox work as effectively as other 12-foot gauzes. Z-Fold weighs only 34 grams in a slim-line pack. O



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Celox Rapid hemostatic Z-fold gauze. [Photo courtesy of Z-Medica]


“Medic!” That cry from the battlefield unfailingly evokes the image of a selfless corpsman charging to the side of a wounded com-rade to begin lifesaving treatment. The immediate traumatic effects of battlefield injury may have changed in character or intensity over the centuries, but the need to speedily intervene to maximize the survival and recovery of casualties has not. Dr. Nicholas Sin’s famous statement from the Spanish American War, “The fate of the wounded soldier is determined by the hand which applies the first dressing,” is just as true today as it was over 100 years ago. Since that time, it is only in the last decade that the U.S. has realized the first substantial improvement in the overall survival of wounded soldiers and a decrease in soldiers killed in action. The case fatality rate in World War II was 19.1 percent and in Vietnam, 15.8 percent. Today in Afghanistan, the case fatality rate is 10.2 percent, almost halved since World War II and the lowest since the U.S. tracked such statistics. So what brought about this amazing improvement in survivability in our most recent combat?

Certainly, some measure of improvement has resulted from technological improvements in ballistic and blast protection, like the universal wearing of improved body armor; advances in medicine like broad-spectrum antibiotics; and advances in surgical technology and practice. What has changed most significantly is the paradigm of what constitutes immediate battlefield trauma care, the response of the combat unit and chain of command, and the technical con-tinuum of medical care. Following the Vietnam conflict, a number of

pioneering researchers and medical theorists began to examine the data related to the distribution of combat wounds, wound lethality and the duration from wounding to when soldiers died as a result. Synthesizing data from the World Wars, the Korean and Vietnam conflicts as well as operations in Grenada, Panama and Somalia, several comprehensive patterns became evident. Among those killed in action—those who died before reaching a dedicated medical facil-ity and surgical care—certain proximately fatal wounds were found: penetrating wounds to the central chest and head, and large solid organ injuries. More importantly, a group of injuries was also found among those killed in action. These injuries were amenable to simple and easily trained battlefield treatment interventions: extremity hem-orrhage, tension pneumothorax and airway obstruction.

Multiple landmark articles by Bellamy, Hagmann, Bulter, Hol-comb, Kotwal and others set the stage for how immediate trauma treatment would change for the better and ultimately lead to lives saved. These works put forward the concept that civilian-based pre-hospital treatment protocols and advanced trauma life support principles were not adequate for the modern combat environment. What was evident was a mismatch between the pathology of battle-field trauma and the standard temporizing measures of civilian pre-hospital or emergency care. The overwhelming preponderance of penetrating and complex multi-trauma injuries in combat is mark-edly different from the demography of civilian trauma emergencies. The important gap revealed in these studies pointed to a subset of

the unherAlded AChieVement of tACtiCAl ComBAt CAsuAlty CAre.

By Colonel (dr.) Peter J Benson


combat wounded that had died before reaching treatment facilities due to potentially preventable causes. Historical data has proven that over 90 percent of those who die in combat die before reaching a medi-cal treatment facility. This then became the focus for revamping the approach to the initial interventions for those wounded in battle. The rapid intervention for those potentially preventable causes of death could provide the greatest potential to save lives.

The drive to innovate a new strategy to decrease combat deaths became codified in what is now known around the world as tactical combat casualty care (TCCC). Beginning in 2001, a committee, the Committee for TCCC (CoTCCC) was established and sponsored by U.S. Special Operations Command in order to review and update TCCC pre-hospital trauma care guidelines. Later the committee was moved to the sponsorship of the Army and Navy surgeons general, the U.S. Army

Institute of Surgical Research and the Joint Theater Trauma System. In 2007, the CoTCCC was aligned as working group of Trauma and Injury Subcommittee of Defense Health Board to advise and guide the Secretary and Department of Defense regarding a standardized meth-odology for the immediate treatment of combat injuries. The guiding principles were to define and establish effective training based on the medical evidence to treat the known major causes of preventable com-bat death, beginning with uncontrolled extremity hemorrhage, ten-sion pneumothorax and airway obstruction. This was allied with the drive to foster an organizational environment that supported a team or command approach to dealing with casualty events.

Several U.S. military units were early adherents of this approach. U.S. special operations forces, especially the 75th Ranger Regiment, made the greatest mark in codifying TCCC in its operating procedures. Beginning in 1996, the emerging TCCC protocols were made standing operating procedure for the regiment’s medical personnel. Addition-ally, medical training was made a command priority for all personnel. All personnel were trained in TCCC principles as first responders, and select non-medic soldiers were trained as emergency medical technicians to enhance capability. The regimental commander, then Colonel Stanley McChrystal, put medical training on par with other regimental imperatives as one of the “Big Four,” along with physical fitness, marksmanship and small unit tactics. The regiment also devel-oped a command and training stratagem: casualty response for ranger leaders, which cemented the response to a casualty event as a leader’s and unit responsibility, and not just something a medic performs. Any casualty event in combat creates a command and leadership issue, communications requirements and transport issues, all in addition to the need for urgent medical treatment. The modern system of “unit-centric TCCC” versus “medic-centric TCCC” grew from this beginning to be the accepted standard practice as now exists.

The concept of TCCC breaks down battlefield trauma care into sev-eral phases: care under fire, tactical field care and tactical evacuation. This serves to concentrate unit and medical assets to a mental model to achieve the maximum effect in eliminating preventable combat deaths with swift and effective intervention with the proper assets and coor-dination. Care under fire is limited only to immediate life-threatening hemorrhage and airway obstruction; tactical field care interventions provide treatment for redress and stabilization of both penetrating and blunt trauma, burns; and the evacuation phase involves preparation for and monitoring during patient movement. Each of these phases has specific medical treatment tasks and performance measures associated with them. The TCCC protocols sponsored by the CoTCCC can be found on several open websites: www.health.mil/education_and_training/tccc.aspx, and www.naemt.org/education/phtls/tccc.aspx; as well as in published form as the Military Version of the Pre-Hospital Trauma Life Support manual published by the National Association of Emergency Medical Technicians. This systematic approach to casualty response has become the established worldwide standard for tactical emergency medical response for both military and tactical law enforcement.

The TCCC concept is taught to every U.S. servicemember prior to deployment and has become a cultural norm. This effect cannot be minimized as the result of the forward thinking of the original authors who researched preventable combat deaths. By changing the very nature of how initial battlefield care was provided, they brought about the means to close the gap where potentially salvageable casualties were previously lost—before they even arrive at a medical treatment ele-ment. The TCCC framework provides a common mental model of what effective care an individual soldier is not only capable of but is expected to perform, but also how that effort fits into the actions of the combat medic, the advanced tactical provider, unit medical officer and the unit’s leadership. By creating a system to train and standardize the skills and knowledge required to save lives, which is based on solid medical principles, TCCC has clearly demonstrated its effectiveness. The estab-lishment of TCCC as a practice has been a major factor in thousands of lives saved in Afghanistan and Iraq, in both U.S. and coalition forces.

The goal to set for the future is to ensure that the lessons learned at such great cost in past conflicts will not be forgotten. It is common for each new generation of warriors to painfully re-learn the combat wisdom of the past. With regard to the precepts of TCCC, perhaps this will not be repeated. Based on sound research and accepted medical principles, TCCC has been widely accepted by not only the military medical community, but those in command. Continued stress on the simplicity and soundness of TCCC in individual and collective training will ensure that these bedrock casualty response capabilities will not be lost. Ongoing research and development will serve to further refine medical devices and techniques, but the basics of combat trauma treat-ment will remain immutable. During World War I, British surgeon Arthur Anderson stated, “The future of very many battlefield injuries depends on the first treatment received…” Anderson’s words are as true today as in 1916 during the Battle of the Somme, and will ring true for as long as soldiers march to battle. O

Colonel (Dr.) Peter Benson is deputy chief of staff and command surgeon for the United States Army Special Operations Command.

Medics with the 82nd Airborne Division’s 1st Brigade Combat Team retrieve wounded paratroopers from a Black Hawk medevac helicopter operated by the 101st Airborne Division’s 159th Brigade Jan. 23, 2012, at the Joint Readiness Training Center, Fort Polk, La. [Photo courtesy of U.S. Army/Sgt. Michael J. MacLeod]




USAMITC’s ERS Supports MEDCOM WorldwideTo provide near real-time metrics or statistics

for information management and information technology (IM/IT) enterprise operational readiness displayed in various dashboards, charts and reports around the world, the U.S. Army Medical Information Technology Center (USAMITC) created the Enterprise Reporting Service (ERS). The ERS was built to show all medical treatment facilities (MTFs) a snapshot of how their environment looks while also showing views of metrics from a regional and enterprise perspective for all IM/IT leaders and staff. “Clearly, the statistics we provide on the ERS can give any Information Management Division staff pertinent information that is actionable,” said Ryan Birdsell, USAMITC’s Core Technology Business Intelligence and Integration Team Lead. “We’re moving toward a self-service business intelligence platform where our data users will be able to create their own reports and dashboards.”

The ERS is managed out of the business analytics and performance management cell within USAMITC’s core technology division, plans and technology branch. The ERS program supports the entire U.S. Army Medical Command (MEDCOM) worldwide, which includes every Army MTF and everyone within the MEDCOM chain of command from the chief information officer on down.

“In the beginning, the data was just numbers and overall quantities. Now we have laid the foundation to move toward a performance management style platform which measures strategy, compliance and end user device health,” said Birdsell. “We’ve defined the different types of reports to show them and assist senior leadership in making business decisions.

“The ERS consists of over four terabytes of data and has the ability to sort through thousands of rows of data in seconds,” said Birdsell. “This data warehouse can hold an entire fiscal year of metrics to support trending analysis allowing the sites to track their progress towards IM/IT goals and objectives.”

“Through 2012, more than 35 percent of the top 5,000 global companies will regularly fail to make insightful decisions about significant changes in their business and markets,” according to Gartner Research, an IT research and advisory firm.

“Business intelligence throughout the MEDCOM is practically nonexistent,” said Tim Engler, ERS business intelligence designer. “The ERS drives strategy, tracks progress towards benchmarks and

supports smarter IM/IT business decision-making.” One of the many reports found on the ERS is the desktop standardization compliance report.

Birdsell said that moving toward a standard desktop is essential to any enterprise IT management operation. A standard desktop means a computer has all the required software, correct versions and updates. “Once we determined what a standard desktop was, then we could baseline the environment and measure forward progress toward the benchmark,” said Birdsell.

By Kenneth Blair Hogue, USAMITC Public Affairs

Cutting-edge Tool to Track Battlefield Traumas

Minutes on the battlefield can mean the difference between life and death. In fact, 90 percent of combat wound fatalities occur before a soldier reaches a medical treatment facility.

To make those minutes count, the Texas A&M Health Science Center (TAMHSC) Rural and Community Health Institute joined forces with the 75th Ranger Regiment, U.S. Army Special Operation Command and Altarum Institute to build the Pre-Hospital Trauma Registry (PHTR). This registry tool allows medics to quickly record and track trends of injuries on the battlefield without revealing their location to enemies. The PHTR was also later modified for use by the U.S. Army’s 2nd Brigade Combat Team of the 101st Airborne (Air Assault) Division.

“The system we designed allows them to capture information about the patient from pretty much the first moment,” said Peter Yu, Ph.D., associate research scientist at the TAMHSC-Rural and Community Health Institute.

Because information is entered immediately, medics working on a patient can easily access data telling them what equipment to apply, what kind of medicine to administer if any, should be given.

A few years ago, the Army approached the TAMHSC-Rural and Community Health Institute requesting a tool that would not only allow for the easy communication of data but also could be used when deploying on

the front line. They wanted real-time data in an easy-to-use system on limited bandwidth.

The PHTR was designed based on these needs. It’s modeled after the Tactical Combat Casualty Care (TCCC) card, a paper form currently used on the battlefield by the Army. Entering data using the PHTR eliminates the risk of handheld devices that give off backlight and increase the risk of being seen by the enemy.

Medics carry the TCCC cards and note very basic information upon approaching the patient, including the soldier’s name, rank, wound site, administration of fluid and necessary drugs. Then, they evacuate to a safe place with an Internet connection to upload these details into the PHTR.

The tool can use any platform, portable computer, working station or handheld device to allow medics to connect to the server. This enables information to be instantly documented and helps the Army keep all of its records in one spot. Before the registry was implemented, information on Army casualties was scattered throughout several offices.

In addition to real-time feedback, it’s compatible with the Joint Theater Trauma Registry, a giant database storing casualty information. With medics able to browse any server, they can easily access the PHTR to analyze reports and readjust treatment strategies.


VITAL SIGNS

New Training Model Yields Faster, More Accurate

Claims Processing

A report recently released by the U.S. Department of Veterans Affairs reveals that new training initiatives for VA employees who process and evaluate veterans’ disability claims are yielding faster, more accurate decisions for veterans.

“Our training and technology skills programs are now delivering the knowledge and expertise our employees need to succeed in a 21st-century workplace,” said Secretary of Veterans Affairs Eric K. Shinseki. “We have improved and are expanding training practices to better equip our staff to handle today’s difficult cases.”

In the face of dramatically increasing workloads, VA is vigorously pursuing new and better ways to train its employees in the complex regulations governing VA’s disability compensation program.

Designers of the revamped “Challenge” training model for new decision-makers overhauled the previous curriculum and more than doubled classroom instruction time to eight weeks. Extensive supervised and hands-on learning was added to enable employees to rapidly achieve critical skills and competencies.

Students of the new model completed 150 percent more claims per day, with a 30 percent increase in accuracy, when compared to student performance under the previous program. To date, more than 1,300 employees have taken the training, which is now in place for all newly appointed or reassigned employees who handle disability claims.

VA has completed a record-breaking 1 million claims per year the last two fiscal years, and is on target to complete another 1 million claims in fiscal year 2012. Even so, too many veterans have to wait too long to get the benefits they have earned and deserve. That is why VA is aggressively building a strong foundation for a paperless, digital disability claims system—a lasting solution that will transform how VA operates and eliminate the backlog. This plan will help VA achieve Secretary Shinseki’s goal: claim completion in less than 125 days with 98 percent accuracy in 2015—delivering faster, better decisions for veterans.

Redesign of the Challenge program is just one part of VA’s comprehensive investment in its people. VA has also added quality review teams at each of its 56 regional offices to quickly identify any processing errors made by its employees and provide on-the-spot remedial training at the earliest possible stage in the claims process.

Members of the quality review teams are trained by VA’s national quality assurance staff to ensure local reviews are performed according to national standards. Team members are also certified in management and leadership approaches. Since implementation earlier this year, the teams have already conducted nearly 60,000 in-process reviews, and decision quality levels are showing significant and steady increases as a result.

Troops with Tinnitus Could Find Relief

Troops suffering from tinnitus developed after encountering explosions during battle could one day be treated by a drug delivery technology now being developed at Draper Laboratory.

Tinnitus, which can be debilitating, is the single largest cause of disability in veterans who have served in Iraq and Afghanistan, according to the U.S. Department of Veterans Affairs. One recent study found that 40 percent of returning troops suffered from this condition.

There are no specific tinnitus drugs available today, so doctors may prescribe off-label anti-depressants or painkillers for troops suffering from tinnitus, which offers temporary relief in some cases, but may result in severe side effects or require repeated, painful injections.

Draper envisions its drug delivery device as providing extended, painless delivery to the middle ear, where the drug can diffuse across the round window membrane to gain access to the cochlea. The lab is developing a system based on novel electronic properties of polymers and wireless communications to give patients the ability to control the dosage if they choose to do so.

The project is taking place under contract to the Department of Defense through the Peer Reviewed Medical Research Program. The research team includes Jeff Borenstein, who leads Draper’s work in tissue engineering and drug delivery, and Jane Wang, a Draper Lab Fellow whose research at the Massachusetts Institute of Technology is supervised by Professor Robert Langer.

After the device finishes delivering its supply of drugs, it would dissolve harmlessly into the body. In addition to medical applications, this dissolvable electronics technology could also be applied to sensors for environmental observations in oceans, forests and other areas that do not result in pollution when the work is over.

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Cathey Hayes; [email protected]


Compiled by KMi Media Group staff

Major General James K. Gilman is a 1974 graduate of Rose-Hulman Institute of Technology with a degree in biological engineer-ing and received his M.D. degree from Indiana University School of Medicine in 1978.

Following a categorical medicine internship and residency in internal medicine at Brooke Army Medical Center (BAMC), Gilman served as the chief resident in medicine there and then as staff inter-nist and chief, Internal Medicine Service, U.S. Army Medical Depart-ment Activity, Nurnberg, Germany. He then returned to BAMC where he completed a fellowship in cardiovascular diseases and served as a staff cardiologist. In 1991, Gilman completed a fellowship in clinical cardiac electrophysiology at the University of Texas Health Science Center at Houston. He then served as chief of Cardiac Electrophysiol-ogy and assistant chief of the Cardiology Service, Brooke Army Medi-cal Center. From 1994 until 1997, he served as chief of Cardiology and Cardiology Fellowship Program director at BAMC. In 1995, he deployed to Haiti with the 2nd Armored Calvary Regiment in support of Operation Uphold Democracy.

Subsequent assignments include: deputy commander for Clini-cal Services, Darnall Army Community Hospital, Fort Hood, Texas; deputy commander for Clinical Services, Madigan Army Medical Center; commander, Bassett Army Community Hospital, Fort Wain-wright, Alaska; acting assistant surgeon general for force projection, Office of the Surgeon General (OTSG); director, Health Policy and Services, OTSG; and commander, Walter Reed Health Care System. Before coming to the U.S. Army Medical Research and Materiel Com-mand, Gilman served as commander, Brooke Army Medical Center and Great Plains Regional Medical Command in San Antonio.

Gilman is a graduate of Command and General Staff College and the Army War College. He is board certified in both Internal Medicine and Cardiovascular Diseases. He is a fellow of the American College of Cardiology. Military awards and decorations include the Distinguished Service Medal, Legion of Merit (3 OLC), Meritorious Service Medal (2 OLC), the Army Staff Badge, and the Expert Field Medical Badge. He also is the recipient of The Surgeon General’s “A” Proficiency Designator and a member of the Order of Military Medi-cal Merit.

Q: What is MRMC’s strategy for managing acquisition by integrat-ing diverse functions and communities, such as users, laboratories, commercial industry, resource management, U.S. Food and Drug Administration [FDA] regulatory affairs and logistics?

A: USAMRMC has implemented Decision Gate, which incorporates all the required DoD 5000 acquisition management elements with industry best practices along with the FDA’s requirements for devel-opment of medical products. This is our tailored Acquisition Frame-work for managing the business of medical product development and acquisition that helps us ensure effectiveness and efficiency in executing DoD’s medical product investment that is entrusted to USAMRMC.

We use a variety of agreements to work with academia and industry. Our personnel stay current with what’s going on in the commercial marketplace through execution of market research activities to ensure that we know what commercial medical innova-tions and technologies are emerging that may be used/incorporated or are complementary with our development efforts. This allows us to maintain close contact with various medical communities as well as maintain awareness of issues and challenges that our industrial base may experience in supporting our military-unique medical products we have in development.

We also maintain very close coordination and working relations with the user representatives at Directorate of Combat and Doctrine Development and the Joint Project Management Office: Chemical Biological Medical Systems under the Joint Program Executive Office Chemical and Biological Defense.

Major General James K. Gilman Commander

U.S. Army Medical Research and Materiel Command


Medical DeveloperFrom Discovery and Innovation to New Capabilities

Q&AQ&A

Q: Can you describe the process by which an emerging technology becomes a usable product by MRMC after it has received FDA approval?

A: Through market research and technology watch efforts, USAMRMC scientists, project managers and other staff maintain awareness of new medical products that are in develop-ment as well as those that gain FDA approval and become available to us through the open market.

For an in-house product, USAMRMC is required to do the same testing, identification, scale up, etc. processes as a private pharmaceu-tical company. The main difference is that once a drug, vaccine, or device has been shown to be safe and efficacious for a commercially viable product [treat, prevent or diagnose] we transfer the technology to a commercial partner and they complete the necessary clinical trials and manufacturing to get it approved, licensed or cleared through the FDA. However, if the prod-uct is primarily for military use the government pays for the whole thing and uses commercial pharmaceutical manufacturing companies to make the product.

Q: How are technologies being developed from the ground up in MRMC laboratories?

A: The USAMRMC laboratories form the bed-rock for innovation and discovery that eventu-ally results in new capabilities for the Army, DoD, and in many cases, for global health. Our laboratory-conducted activities align their research with the medical needs of warfighters and their families. Central to this challenge is finding solutions for malaria, dengue, bacterial diarrhea, and a variety of other infectious dis-eases our troops may face during a deployment. The survival and recovery of wounded soldiers provide a wide spectrum of new challenges. Some examples include non-compressible hemorrhage, traumatic brain injury and post-traumatic stress. Military medical researchers are engaged in a relentless pursuit for solutions that start in the laboratory. We focus on results and good business practices, so that many of the great challenges of today will get resolved for the next generation.

USAMRMC, as the Army’s medical materiel developer, operates under the regulations and policies of the DoD acquisition system. This system’s business practice helps ensure the USAMRMC operates in an environment where the benefits and the costs are well managed and the resulting product provides true value and utility. The use of integrated product teams

enables the laboratory scientist, who con-ducted the initial research toward a solution, to remain involved in the development of the new capability through advanced develop-ment and initial fielding.

Q: How do you balance the development, testing and fielding of technologies so that by the time they are approved the technology is not obsolete?

A: To make sure that we develop, test and field technology before the technology is obsolete, we evaluate three things.

USAMRMC does the early research and then looks for a commercial partner to help bring products to market in the U.S. and overseas, where a commercial market may exist. This approach works especially well when the products have broader appli-cation, such as anti-malarial drugs and casualty vital signs monitoring systems. This strategy enables the USAMRMC to pro-vide our soldiers and civilians much-needed medical capabilities, while strengthening our partnerships with commercial partners around the world.

What we develop at USAMRMC is based on enduring requirements. The Army has a very sophisticated process for identifying gaps in our health care capabilities. In some cases the challenge is a worldwide threat, such as malaria or HIV. In other cases the threat is unique to military life, such as adenovirus. The conflicts in Iraq and Afghanistan brought the issues of traumatic brain injury and post-traumatic stress to the forefront of medical concerns.

To speed the development and delivery of products to the field, the USAMRMC partners with the best in industry and academia. We leverage the knowledge and experience of scientists who are on the frontiers of discov-ery and create partnerships that advance and enhance the development process. At the same time, we continually conduct market research to determine if there is a better solu-tion than the one in which we are invested. In fact, we acquire over 90 percent of our medi-cal products from industry—their idea, their science, and our market research—to choose the best solution to the medical capability gap. In the end, we quickly but efficiently identify medical solutions, regardless of the source, to provide the warfighter a defense against an enduring threat.

Q: What are the challenges of conduct-ing operational logistics and single


integrated medical logistics management in peacetime and during contingencies?

A: Health care in all environments drives significant requirements for medical supplies, equipment and specialized logistics services. Operational medical logistics, which is the support of deployed medical forces, involves a number of challenges. Peacetime support is primarily focused on fixed military treatment facilities that are close to suppliers, have excellent communications and have fairly well established requirements. Operating forces, which also have very sophisticated medical capabilities, operate far from support organizations. They have relatively austere communications, mini-mal logistics staff, and can carry very limited amounts of supplies. Nonetheless, they must respond effectively to whatever health risks and patient conditions are encountered, and must adapt quickly to changes in mission or supported populations. Medical logistics sup-port must be anticipated and delivered to dispersed hospitals as well as medical elements at brigade, company, platoon and team level. This requires focused planning for support to medical operations, careful positioning of medical supplies and maintenance resources, and close coordination with medical commanders as well as sup-porting transportation and distribution organizations. Because it is designed to support a land force, the Army Health System has these medical logistics capabilities within its operational medical force structure, and is therefore often tasked by the combatant com-mander to support all services. This mission for Single Integrated Medical Logistics Management [SIMLM] adds complexity in plan-ning and establishing support relationships with medical units that are organized, controlled and equipped differently than Army units. Army medical logistics organizations have successfully provided SIMLM support for several years in EUCOM, CENTCOM and U.S. Forces Korea [USFK].

One of the strengths of Army SIMLM operations is the enduring capability provided by USAMRMC’s medical materiel centers in Europe and Korea, USAMMCE and USAMMC-K. These are multi-functional organizations for medical logistics support to both institutional [i.e., ‘peacetime’] and operating theater medical forces. They provide medi-cal supply, medical equipment maintenance, optical fabrication, and medical set assembly and reconstitution. Most important, they work closely with their supported commands in theater medical logistics planning and conduct robust customer support operations. These medical materiel centers leverage habitual supplier relationships and support to peacetime health care operations to respond quickly to con-tingency operations in the EUCOM, AFRICOM, CENTCOM and USFK areas of responsibility. They have both been designated by the chair-man, Joint Chiefs of Staff, as theater lead agents for medical materiel in recognition of their role in supporting joint forces. In many cases we support interagency partners of our own federal government as well as international partners from our enduring hubs.

Q: What is the core strategy of maintaining modernization and tech-nology improvements as part of life cycle management?

A: We use different strategies. As the medical materiel developer, we maintain constant con-

tact with the Directorate of Combat and Doctrine Development and directly to some user communities to ensure that we build a portfolio or product that will deliver needed medical capability while anticipat-ing for the DoD’s medical needs 10 and 20 years into the future.

We partner and leverage. Our relatively small budget for medical research, development and acquisition requires us to partner with industry, academia, other government agencies, and even non-govern-mental organizations to gain maximum efficiency from every dollar invested by DoD to deliver new medical capability for substantially lower direct investment than industry benchmarks.

Q: In what ways is MRMC conducting research to improve medical simulation and training and health information sciences?

A: USAMRMC’s Joint Program Committee-Medical Training and Health Information Sciences and the Telemedicine and Advanced Technology Research Center are working closely with TRICARE Man-agement Activity staff to investigate ways to move health care forward, implement best practices into the MHS enterprise, and perform risk mitigation within the enterprise. Health information sciences covers the whole spectrum of care from point of injury on the battlefield to our military health care facilities all over the world.

Mobile health and health care delivery has been a major focus for the command. At USAMRMC, our goal is to improve care through enhanced training technologies and systems, and medical simulation technologies are in the forefront of improved training within the mili-tary. We believe it has great value and can change the way health care is taught, trained and delivered.

One major area we study is the training of combat medics and medical providers. We are researching and developing more effective, objective and cost-efficient ways in which medics can be trained.

As home-based health is becoming a trend within the MHS, our medical simulation team is looking into how we can bring health and rehabilitation into the home. We are doing this through controller-less game technologies that make rehabilitation more engaging, by utiliz-ing current technologies to perform cognitive and physical rehabilita-tion in an interactive environment.

Q: How is MRMC exploring and employing innovative methods to meld automated information technology with logistics and transpor-tation’s best business practices?

A: USAMRMC developed and recently fielded an enterprise resource planning solution called the Theater Enterprise Wide Logistics System [TEWLS]. This state-of-the-art system pro-vides a single, web-enabled solution supporting the total life cycle management of medical assemblages as well as theater medical supply operations. All Army medical assemblages, which are the building blocks for medical capabilities in operating medical units, are managed in TEWLS from their initial design through their acquisition, production, fielding and maintenance. All Army theater-level medical supply operations in EUCOM, CENTCOM, AFRICOM and USFK are managed in TEWLS by their supporting medical materiel center. This means that medical units of all services send their Class VIII orders into this single application, which determines the optimum source for meeting the requirement, based on customer location and stock availability. TEWLS also provides a web portal that allows customers to obtain supply information and place orders much as they would through Amazon or other familiar websites. TEWLS is linked with standard DoD transportation systems to facilitate movement and in-transit visibility. TEWLS was developed by USAMRMC, but has since transitioned to the Defense Health System Support [DHSS] office for management as a standard DoD medical logistics system.


TEWLS marks a fundamental shift from reliance on legacy sys-tems that are characterized by local, client-server-based applications and data. It uses modern, commercial off-the-shelf software that emulates industry best practices and leverages commercial invest-ment for technical improvements over its life cycle. TEWLS enables an enterprise approach to managing medical materiel and its associated data. USAMRMC is currently working with the user community and DHSS to incorporate functions performed by Army medical logistics companies into TEWLS, as well as medical supply support provided by the Army MEDCOM to NORTHCOM units operating in the United States in defense support to civil authority operations. The enterprise capabilities provided by TEWLS will enable innovation in medical logistics business for global support to military health care.

The Army Medical Logistics Enterprise [AMLE] is shaped by four main ideas—total life cycle management of medical materiel; develop-ment of enterprise architecture to network organizations, processes and information; innovation in business processes to take advantage of enterprise architecture; and strength of strategic partnerships with our sister services and with the Defense Logistics Agency [DLA]. As I mentioned, TEWLS provides a technology foundation for networking Army medical logistics. Another key enabler is the governance process we have established to collaborate across organizations and commands to achieve a shared vision and unity of effort. We use this governance structure for strategy management following the balanced scorecard methodology that is used throughout the Army Medical Command. In this way we ensure that medical logistics innovation supports the

strategic goals and objectives of the surgeon general/MEDCOM com-mander. Finally, we recognize that military health care is inherently a joint endeavor. The AMLE is a key component of a broader Defense Medical Logistics Enterprise that promotes interoperability, efficiency and operational excellence. In addition, the AHS has a formal partner-ship with DLA that is vital to medical supply chain support for deploy-ment and sustainment of operational forces. This enterprise approach to medical logistics is consistent with concepts emerging from the joint logistics community, and will be a significant contribution to the delivery and sustainment of military medical technology supporting the nation’s warfighters.

Q: How does MRMC work with private industry to achieve its goals?

A: As compared to the commercial medical R&D sector, the USAM-RMC operating budget is much, much smaller. As such, the USAM-RMC seeks out R&D partnerships with industry to leverage their financial resources and technical expertise, as well as their established manufacturing, marketing and distribution capabilities. Additionally, the USAMRMC seeks to procure commercially-available medical prod-ucts in the first instance. This often requires minor product modifica-tions and the development of military-unique training packages to make commercial products suitable for military use. The end goal of these government/industry partnerships is the fastest possible develop-ment and delivery of required medical capabilities to our soldiers, at the lowest possible cost to the U.S. government. O

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Part of the U.S. military creed is to never leave a fallen comrade behind to fall into the hands of the enemy whether wounded, captured or dead. Personnel recovery (PR) operations are part of each military branch’s capabilities. While the Air Force and Navy conduct combat search and rescue operations, the Marines conduct tactical recovery of aircraft and personnel and the Army conducts aerial medical evacuation operations, the goal is the same: to get the warfighter back home. Experts from the Air Force, Navy and Marines answer one question in regards to the future of PR.

Lieutenant Colonel Stephen A. Goodman is chief, personnel recovery branch, Headquarters United States Air Force. He oversees policy, guid-

ance and resource support for all Air Force personnel recovery programs, including Guardian Angel, fixed-wing and vertical lift weapon systems. He is the Guardian Angel Functional Area Manager, Combat Rescue Officer Air Force Specialty Manager, and Guardian Angel Program Element Monitor.

in 2009, the Air Force became the only service component with person-nel recovery as a core function. Combat search and rescue (CSAr) is the primary mechanism whereby dedicated Air Force rescue forces accomplish Pr in uncertain or hostile environments. it’s rooted in the American warrior ethos and our resolve to bring every one of our men and women home from combat, regardless of service branch. Preserving and evolving our Air Force CSAr capability is central to meeting combatant commander requirements today and in the foreseeable future.

dedicated Air Force rescue forces include the triad of HH-60 and HC-130 aircraft, along with Guardian Angel ground recovery forces. Additionally, a vari-ety of combat aircraft and support personnel maintain CSAr training and quali-fications together, these professionals comprise a CSAr task force (CSArtF).

the past 10 years have been unprecedented for rescue forces. the requirement to support the combined forces air component commander with on-call CSAr teams did not go away, but the necessity to support special operations forces and casualty evacuation missions increasingly shaped the capability and culture of the force. Since 2001, over 12,000 lives have been saved by Air Force rescue; more than 400 have been saved so far this year.

in Afghanistan, this combat record is defined by the “golden hour” stan-dard for recovery mandated by the Secretary of defense. through effective forward positioning of forces, the Air Force has been able to reach more iso-lated and injured personnel faster than ever before, even in heavily contested environments. With the anticipated drawdown of forces in Afghanistan, rescue forces are likely to be some of the last to leave. As the support structure draws down, many of the original challenges related to distance and relative isolation must be accounted for all over again.

While an obvious area of emphasis, Afghanistan is not the exclusive model for future CSAr engagement. other stress points in the Middle East, Africa and the Pacific require renewed emphasis on the CSArtF. As a data point, operation Unified Protector demanded alert coverage for 9,700 coali-tion strike sorties and required the CSArtF to be ready to cover consider-able distances, using a combination of land and sea-based assets, while penetrating an integrated (albeit degraded) air defense system. it’s highly likely that our next operating environment will pose similarly challenging conditions.

Future Air Force CSAr operations will present more complex basing and staging decisions, longer infiltration distances, increasingly lethal surface threats, longer patient treatment timelines, and highly complex command and control relationships. these challenges are driving realistic training, particu-larly to combat anti-access strategies and area denial operations; procure-ment to leverage existing technology, in many cases to gain and maintain tactical information superiority; and force management initiatives that will ensure a ready force for years to come.

AWRCS(NAC/AW) Michael C. Ousley, senior chief naval aircrewman tactical helicopter (naval aircrew warfare/aviation warfare). His current

assignment is Helicopter Sea Combat Weapons School, U.S. Pacific Fleet (HSCWSP). His current billet is senior enlisted advisor/qualification cur-riculum model manager for all helicopter sea combat enlisted aircrew. His HS Squadron background on CVNs are eight Western Pacific deployments to Arabian Gulf (USS Kitty Hawk, USS Carl Vinson, USS Abraham Lincoln).

His flight experience includes SH-60F (HS-4/HS-2), HH-60H (HS-4/HS-2), and MH-60S (HSCWSP).

CSAr is one of the many U.S. Navy helicopter primary mission areas. discussions about any and all future capabilities should start from the les-sons learned files and check the number of times someone’s “good idea” has come up in the past. developmental stages of aircrew qualification bring with them different perceptions as to what would be a need for future CSAr development.

PERSONNEL RECOVERY ROUNDTABLESpecial Section

How do you think combat search and rescue will evolve over the next year?By Lt. Col. Steve A. Goodman

How do you think combat search and rescue will evolve over the next year?By Senior Chief Michael C. Ousley

U.S. Air Force

U.S. Navy


Navy Commander Martha A. Cutshall, clinical subject matter expert for headquarters Marine Corps (HQMC), Combat Development Command,

and Marine Corps Major Michael Akselrud, is the section head for personnel recovery, Special Operations Directorate, HQMC.

the Marine Corps views Pr as an implicit requirement in all combat operations. All elements of the Marine air-ground task force (MAGtF) pos-sess the ability to support Pr operations, or participate in the recovery of isolated personnel. the MAGtF commander may, or may not, elect to dedicate forces to perform this mission; however, additional capability to perform self-supporting recovery operations and external Pr support is provided through a concept known as tactical recovery of aircraft and personnel. Aviation, ground or waterborne assets, or any combination of these, may conduct a trAP mis-sion. trAP assets may also be employed in the conduct of other non-recovery missions, and called upon to perform a recovery as it becomes necessary. the trAP concept emphasizes detailed planning and the use of assigned and briefed personnel for the specific purpose of recovering personnel and/or aircraft. the MAGtF commander may utilize the trAP force when an immedi-ate recovery is impractical, or the tactical situation necessitates the additional capabilities a trAP force provides.

the mission of trAP is the expeditious recovery of downed aircrew, aircraft, or other evaders and equipment under a wide spectrum of threats, without the further loss of friendly forces, and is normally planned as a raid type mission. Mission success will depend on thorough pre-mission planning, accurate intelligence, known isolated personnel identification and location, flexible and redundant command and control, and highly trained trAP forces. A typical trAP force has three elements. they are as follows: HQ element, search element and security element.

Corpsmen are included in the trAP force—typically, at least two. they are responsible for treating the isolated individual(s) and all casualties, ensur-ing that they and other medical personnel have the appropriate medical gear,

ensuring medical kits are set up in the same manner as per the trAP force’s standard operating procedures, getting as much information as possible on the condition of the isolated individual(s) (i.e. types and extent of injuries, blood type etc.) and for conducting triage on scene and administering first aid accordingly.

When the isolated individual(s) comes under U.S. control, the trAP force will begin the process of collecting intelligence information while at the same time ensuring the physical and mental health of returnees in order to return them to normal life and duty. Some personnel may have spent time in harm’s way after an incident/mishap occurs without any contact with enemy person-nel or other hostile entities. Some may have been captured and confined in a hostile environment in which they were maltreated, while still others may have been detained for some period of time in a more neutral or benign setting. trAP forces have to be prepared to medically deal with returnees from across this spectrum of experiences.

the trAP mission continues to evolve. With the recent addition of the MV-22 to the MAGtF’s air element, trAP forces can travel longer distances and do this much faster, allowing them to get to the isolated individual(s) quicker and return them to a higher level of medical care faster ensuring a much better physical and psychological outcome for the isolated individual(s). All post-rescue activities of the trAP force will ensure continued support of the physical and psychological rehabilitation to manage recovered personnel in a fashion to maximize probability of returning healthy personnel to duty while gathering information to improve tactics, techniques and procedures for forces operating in a similar environment. O



A dedicated CSAr is a “sneak in, recover the survivor/s, sneak out” operation. orient any and all future developments to enable those tasks to be accomplished without fail. if all branches of dod are trained using similar doctrine, the reaction time for a successful recovery, with the ability to capital-ize asset capabilities already on station, gives fleet commanders the positive edge in mission success.

Mission planning and intelligence distribution are the critical phases of a CSAr that can be the causal factor in which the absolute best flight crews are equipped, rehearsed and prepared for a CSAr and the entire mission is aborted due to lack of detail. “Eighteen hours of preparation for eight minutes of brilliance in the terminal area” is a quote often heard during mission plan-ning at NSAWC airwing evolutions in Fallon, Nev.

For the U.S. Navy, the most recent development to the flight crew require-ment in the past 10 years has been the addition of SAr medical technicians (SMt). SMts provide a level of trauma and cardiac care previous crews composed of rescue swimmer/gunners could not provide. Updating medical care capabilities to those matching Naval special warfare advanced tactical practitioners are in line with joint requirements and could further bridge a gap between dedicated NSW support and CSAr.

CSAr will always depend on the capabilities and the proactive nature of the survivor. Following an event in which they find themselves surviving in territory we do not control, it’s entirely up to them to initiate a recovery. Professional aircrews and quality training in environments that best simulate hostile intent develop the reactions and responses to ensure mission success.

PERSONNEL RECOVERY ROUNDTABLE

How do you think tactical recovery of aircraft and personnel (TRAP) will evolve over the next year?

By Cmdr. Martha A. Cutshall and Maj. Michael Akselrud

U.S. Marines


By Colonel roBert mitChell

future AdVAnCed CAPABilities trAnsforming BAttlefield mediCine.

Since the Korean War, the advancement of aerial medical evacu-ation (Medevac) has transformed battlefield medicine beyond our expectations. If you are picked up by an Army medevac aircraft in today’s fight, you have a 92 percent chance of survival. This statistic is the highest in the history of modern warfare. However, we must continually improve and evolve to make it even better. Conventional rotary wing aircraft have lacked a technological leap in speed and endurance for decades. Make no mistake, the Army and defense industry have made dramatic improve-ments in our current fleet, but the conventional heli-copter is limited in speed by the law of physics. On the other hand, technology is rapidly advancing in vertical lift aircraft design and development. Advanced aircraft systems will provide vastly improved performance, much greater speeds and ranges, and allow for increased lift capacity. There are several platforms flying today that have substantially bet-ter speed, range and lift capabilities than traditional helicopters. The Army should capitalize on these advances to increase efficiencies for the medevac role; save life, limb and eyesight; and to provide the best dedicated medical evacuation system possible for the soldier.

BACkground

Visionary leaders recognized the need for more efficient methods of conducting aviation missions, with greater capabilities, more

flexibility, more commonality, reduced costs, reduced logistics tails and reduced training requirements. Numerous aviation vertical lift

studies were commissioned over the past several years, all with very similar findings:

The current fleet of Department of Defense rotorcraft cannot continue to merely be incre-mentally improved to meet future operational requirements. Significant increases in range, speed, payload, reliability and reduced logistical footprint are all required and can only be met through the application of new technologies, which are best developed through a joint multi-role (JMR)/com-monality approach.

An investment strategy based on joint programs, versus single service programs, will provide signifi-

cant life cycle cost savings and efficiencies.Investments in science and technology (S&T) are essential to

develop required technologies to maintain a technological edge over adversaries.

In 2008, Secretary of Defense Robert Gates directed the services to conduct a comprehensive evaluation of all vertical lift requirements. He specifically tasked the Joint Advanced Concepts Directorate, Office of the Under Secretary of Defense for Acquisition, Technology and Logistics, to lead a joint approach to the future development of verti-cal lift aircraft for all military services. The Joint Staff, in conjunction with the U.S. Transportation Command and the services, developed

Col. Robert Mitchell


a strategic plan to meet the needs identified in the capabilities-based analysis (CBA), with the emphasis on common service requirements. The Joint Staff is working with the Deputy Under Secretary of Defense for S&T to develop a detailed S&T plan in support of this strategic plan, including the resources required for implementation. The Army estab-lished the JMR study to identify and provide a mission-based assess-ment of how Army aviation may obtain synergies between multiple function areas. The study will further seek to establish a roadmap for existing Army aviation fleets to transition to those common roles, or determine if planned improvements to the current aviation fleets will provide the appropriate capabilities to support current and projected warfighter needs. Specific medevac requirements will be logically inte-grated into these future capabilities rather than being added ad hoc.

Future vertical lift platforms will have significantly greater perfor-mance in speed, range and payload, while operating much more effi-ciently. Currently, certain platforms flying today have much greater capabilities than current Army rotary wing assets.

Greater speeds and payloads substantially enhance aerial medical evacuation operations by facilitating timely evacuation to the appro-priate role of care, over greater distances, and with more efficient use of forces.

With greater ranges, vertical lift aircraft could operate from more secure locations, with more efficient logistical support lines, a more efficient ground medical footprint, and provide evacuation to better care facilities for injured soldiers.

Platforms with cabin space sufficient to allow medical providers to operate in a stand-up environment and, with appropriate equipment and interior lighting, could facilitate improved en-route resuscitative medical capabilities that far exceed our current capabilities.

ConCePt

The Joint Future Vertical Lift (JFVL) working group is comprised of the Future Vertical Lift Study Team; Marine Corps [MC], Navy and Army, the Joint Multi-Role Aircraft Study Team, special operations personnel, various science and technology representatives, and key DoD personnel. Goals are to develop capabilities-based strategies and concepts toward defining joint vertical lift aircraft needs for the 2025 timeframe and beyond, similar in purpose as the Joint Strike Fighter program. The working group will develop and capture the service/ Special Operations Command (SOCOM)/Coast Guard concerns, capa-bility needs and gaps, so that the JFVL effort can merge them into common and service-unique lists of capabilities, metrics and eventu-ally technology development initiatives.

The industry is currently developing innovative aviation technol-ogies for vertical lift platforms. These vary in concept and design from tilt-rotor and tilt-wing, to counter-rotating advancing blade rotary wings and compound designs with both rotary wing and fixed wing structural components. Some prototypes now flying will reach speeds well above 200 knots. Today, the MC and Air Force apply tilt-rotor technology in the form of the V-22 Osprey in missions requiring verti-cal lift performance, over long ranges, with the additional capability to aerial refuel. Each concept affords various advantages and disad-vantages. However, increased speeds above 250 knots, with increased lift and range capabilities are within reach, even today. Medevac can and should capitalize on these capabilities to mitigate the risks of extended evacuation times required by slower, performance-limited helicopters. Below are examples of vertical lift technology that are currently being explored.

Infrascanner Technology – How it worksExtra-vascular blood absorbs NIR light more than intra-vascular blood since there is a greater concentration of hemoglobin (usually 10 fold) in an acute hematoma than in the brain tissue where blood is contained within vessels. The Infrascanner measures the difference in NIR light absorption at corresponding locations on the left and right sides of the head. The detection depth is superfi cial (within 3.5 cm of the skin sur-face), where blood migrates in most cases of bleeding.

Infrascanner Detection Abilities:• Patient measurement is completed within 2-3 minutes.• Can detect hematomas greater than 3.5 cc in volume.• Detects hematomas up to 2.5 cm deep from the surface of the

brain (or 3.5 cm from the skin surface).• Accuracy: In patients with Epidural, Subdural and Intracerebral

hematomas: Sensitivity = 88% / Specifi city = 90.7%*

Infrascanner Military ApplicationThe Infrascanner has a very specifi c application in detecting TBI on the battlefi eld and in routine military settings where timely triage is critical. The United States Navy and Marines have invested signifi cantly in Infra-scanner development and have successfully fi eld tested it in Iraq. Early hematoma detection can contribute to saving lives and in planning an adequate evacuation priority of the injured.

The Infrascanner is a portable screening device that uses Near-Infrared (NIR) technology to screen patients for intracranial bleeding, identifying those who would most benefi t from immediate referral to a CT scan and neurosurgical intervention. In the triage of head trauma patients, the Infrascanner can identify patients most likely to have intracranial bleeding.

© 2012 ADS, Inc. The ADS logo is a registered trademark of ADS, Inc. A0257 5/12

855-819-4276ADSINC.COM/MEDICAL

HANDHELD BRAIN HEMATOMA SCREENINGINFRASCANNER

“Time Lost is Brain Lost”

The Infrascanner is a portabl(NIR) technology to screen pathose who would most benefi

i l i t ti I

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INFRASCANNERMODEL 2000

*C. Robertson, E. Zager, R. Narayan, N. Handly, A. Sharma, D. Hanley, H. Garza, E. Maloney-Wilensky, J. Plaum, and C. Koenig, “Clinical Evaluation of a Portable Near-Infrared Device for Detection of Traumatic Intracranial Hemato-mas,” Journal of Neurotrauma, vol. 27, pp. 1597-1604, 2010.


future VertiCAl lift And Joint multi-role study Progress

U.S. JFVL Strategic Vision: Over the next 40 years, the Department of Defense will transform the depart-mentwide vertical lift fleet through the development and fielding of families of next generation, joint, vertical lift aircraft that provide the advanced capabilities to the joint force required to meet future operational requirements across the spectrum of conflict.

Goals for the future vertical lift working group:

• Set conditions for joint capabilities integration and development system process.

• Refine critical attributes areas by variant and weight class.

• Initial Capabilities Document (ICD): Methodology for working groups will begin development of a draft joint ICD by spring of 2012.

The DoD-directed future vertical lift study developed a CBA designed to outline a joint approach for future development of vertical lift aircraft and rotorcraft. It relied on subject matter experts from all the services to evaluate the joint requirements for vertical lift, and used the Army Aviation CBA as a foundation. The FVL strategic plan formalizes the strategic vision of DoD for the next generation of vertical lift aircraft and rotorcraft, establishes joint requirements for the next generation, and empha-sizes development of common service requirements. Speed, lift capacity and range were all addressed in the gap determination, but within the larger scope of joint mission requirements. Civil industry concurrently formed a vertical lift consortium to provide input on new technologies and new and innovative concepts for DoD vertical lift platform consideration.

imProVed medeVAC CAPABilities PotentiAl

Having the capability to rapidly project medical evacuation and medical supply delivery over long distances to locations without operational landing strips offers the ability to strategically impact world disaster and humanitarian relief efforts. For example, when Haiti suffered a severe earthquake in January 2010, the airport was nonfunctioning and shut down, as were virtually all emergency and rescue services. Supplies and medical treatment were almost non-existent. Designated V-22s could have been dispatched immediately, landing at key locations to deliver essential medical and rescue supplies and equipment, with the ability to provide on-site medi-cal care and medical evacuation of critically injured personnel. The world would certainly have taken notice. Aircraft with vertical lift capability bypass airstrips or airports, allow for shipboard operation and provide flexibility in response to almost any situation. Range, speed and lift capacity increase projection distances, while reducing the critical element of a timely response. Tsunamis, earthquakes, floods and manmade disasters can strike anywhere, at any time, often restricting or prohibiting conventional air support. Delivery of essential medical support, supplies and key medical personnel while evacuating critically injured personnel is paramount.

With extended ranges of 400 to 600 nm, the number and loca-tions of combat support hospitals necessary to support the fight

could be significantly modified, with much more flexibility in locat-ing medical support facilities.

Designing a new family of platforms presents an opportunity to integrate some niche features. Some nations on the international scene have already introduced successful on-board surgical interven-tion on the battlefield, saving soldiers’ lives under extreme conditions. Although intended as an emergency fallback, this capability could be designed into a platform by ensuring adequate size, space, lighting, stability and equipment interface are included in requirements devel-opment. This capability could additionally be tailored to support a mobile surgical team that could be rapidly deployed to a critical loca-tion and quickly be set up to conduct surgical intervention.

Aerial medical evacuation, as currently performed, uses existing rotary wing aircraft for evacuation from the point of injury through Role III. Army helicopters typically perform this role in combat with considerable success, achieving survival rates of 92 percent. However, aerial evacuation with existing helicopters, with inher-ent technological limitations, has operational gaps in range, speed and payload capacity. These gaps are particularly evident in aerial evacuation from Role II to Role III and above. Strategic implications reveal that we also do not have the ability to rapidly project medical capabilities to hard hit disaster areas when conventional airports and airstrips become inoperable or are not available. Future vertical lift platforms will be critical in mitigating existing capability gaps. Speed is life in the medevac business and the future vertical lift will no doubt be a game-changer. Time is of the essence when life-saving situations arise around the world. O

Colonel Robert Mitchell is the director, medical evacuation pro-ponency at Fort Rucker, Ala. He is rated as a master army aviator and former aviation consultant to the Army surgeon general (June 2008 to June 2012).



Soldiers from Headquarters and Headquarters Company and Alpha Company, 1-125th Infantry Regiment, 37th Infantry Brigade Combat Team, practice medical evacuation during training at Camp Shelby Joint Forces Training Center, Miss. [Photo courtesy of U.S. Army]


how exPeditionAry mediCine PlAys An imPortAnt role in sAVing liVes.By kenyA mCCullum, m2VA CorresPondent

Saving the lives of wounded soldiers is always a challenge, even in a military medical facility equipped with the latest, state-of-the-art technology. But when you take medicine outside of the hospital, and move it closer to the battlefield, that challenge increases exponentially. Nonetheless, expeditionary medicine has become a critical part of keeping soldiers alive, with each branch of the military using its own unique methodology for delivering that critical care.

exPeditionAry mediCine in the Air forCe

According to Major Brandi Ritter, a physician assistant and deputy of the Operational Medicine Division of the 711th Human Performance Wing at Wright-Patterson Air Force Base, expeditionary medicine for the Air Force is considered any medicine that is practiced outside of the controlled environment in a medical center. Ritter said that this does not only apply to saving wounded soldiers, but also the work that the Air Force does during disaster relief missions—such as the work they did in the wake of Hurricane Katrina.

ChAllenges in the Air forCe

One major challenge that medics in the Air Force face when prac-ticing expeditionary medicine is related to equipment—namely when they are working with other branches of the military, the differences in equipment can make it difficult to treat patients during a mission.

“If your buddy next to you gets blown up and he’s in the Army, you may have no idea what he’s carrying and you’re supposed to use his equipment to treat his injuries, so that can be a challenge,” said Ritter.

In order to deal with this challenge, the Department of Defense’s Committee on Tactical Combat Casualty Care has created guidelines that outline standards for first responder medical care across the services. As a result, there is an agreement among each branch of the military about the minimum equipment that should be carried by first responders—such as tourniquets and hemostatic agents. In addition, each piece of equipment has been defined across the forces, so that everyone knows what a piece of equipment should minimally be able to do and what kinds of materials these supplies should be made of.

There has also been extensive research conducted to ensure that these devices are indeed the best quality products on the market.

After extensive research, the 711th Human Performance Wing has found that another major challenge that the Air Force faces in expeditionary medicine is monitoring and prioritizing treatment, par-ticularly when several patients need help at the same time.

Similarly, there is a challenge when it comes to the flow of infor-mation during these types of missions, because medics don’t neces-sarily know exactly what has been done to a patient at any given time in the process. The Air Force has become a victim of its own success in that regard: They have been able to push medical capabilities so far forward, and treat patients so efficiently, that documentation often falls through the cracks along the way.

“We don’t necessarily know, as the patient flows through the process, what was done at each stage because you’re trying to do it so efficiently and effectively—so would you rather go ahead and make sure a tourniquet is on correctly, or fill out the tag that says the tour-niquet’s on?” said Major Courtney M. Lee, who is a physician assistant specializing in emergency medicine. “In the process of what falls off the wayside, documentation falls off. It doesn’t necessarily matter in the sense of whether or not we save that individual, but in the long-term scheme of things, when they get back to a medical facility and a surgeon is trying to figure out what was done to a patient to decide what to do next, the documentation becomes an issue.”

AdVAnCements in the Air forCe

Ritter said that the Air Force is always looking for ways to push its capabilities even further, and one area that they are currently explor-ing is the ability to transmit information from the battlefield back to emergency medical facilities, which allows combat medics to receive the guidance they need to save lives in real time.

“I think you’re going to see real-time telemedicine, where you can have a video camera in the back of your HMMWV ambulance and the team back in the operating room can take a look at the patient and see what you’re doing to treat them in the back of the ambulance,” she said. “Telemedicine is really going to be big as we move forward.”


As telemedicine develops, it comes with its own unique set of chal-lenges, namely that as servicemembers use this robust technology to save lives, transmitting any information runs the risk of giving away their mission’s location. As a result, the military is charged with ensur-ing the safety of soldiers using this technology.

the mArine CorPs

According to Rear Admiral Michael H. Anderson, the director of the Medical Corps of the Marines, expeditionary medicine for this branch of the military is an all-encompassing proposition, which he describes this way:

“When we talk about expeditionary medicine, it goes along with everything that the Marine Corps does. The Marine Corps is expedi-tionary by definition, therefore when we look at our medical capabili-ties, we look not only just from the point of injury, we start looking at prior to the point of injury, and how we can build a resiliency within the system to take care of a Marine that is severely wounded or ill on the battlefield.”

In order to ensure that medics in the Marines are able to work efficiently, initial preparation, which is centered on training in tactical combat casualty care, is done before the servicemembers are even sent into theater. This training is based on the premise that first respond-ers need to be able to treat hemorrhaging and blockages to a soldier’s airway in order to keep that patient alive.

The Marine’s second piece in expeditionary medicine is the devel-opment of technology that can be used in theater to treat trauma patients. In order to do this, they monitor the injuries of patients from the point of injury on the battlefield and as they travel through the lev-els of care until they arrive at a military medical facility in the United States. As a result, the Marines are able to design equipment that will

not only allow soldiers to do their jobs effectively, but also eliminate some of the points of injury that they have observed.

One example of this is a protective undergarment that was devel-oped when the Marine Corp discovered an increase in the genital/uri-nary injuries of soldiers. As a result, this product has made a significant difference in the occurrence of penetrating injuries to male genitalia, and the Marines are currently looking for ways to further develop the technology to provide higher levels of protection for men, as well as women, who are in combat.

The next area of concern is actually on the battlefield, and the Marines have worked to use forward surgical units so that they can provide immediate surgical resuscitative care as close to the point of injury as possible—which goes a long way toward keeping soldiers alive as they travel back to the United States for more advanced care.

“This is a significant shift in doctrine from say, combat in Vietnam, where we had the large surgical hospitals that patients would stay in for weeks at a time until they were deemed stable enough to transfer back to the United States,” said Anderson. “Because our capabili-ties have been so refined and so successful, we’re finding that those Marines who would have previously died on the battlefield with their quadruple amputations, are being kept alive, such that our survivabil-ity rates approach 95 to 98 percent.”

ChAllenges in the mArine CorPs

As Marines find themselves in smaller and more austere environ-ments, the challenge becomes to create smaller and smaller medical capabilities that are still effective enough to keep patients alive and stabilize their condition.

Another challenge that the Marine Corps is currently working to solve is the use of blood products, because in order to ensure the best outcomes for patients, blood must be administered as quickly as pos-sible. In order to address this challenge, they have created a distribu-tion system for blood products, which allows blood to get to theater quickly, since research has shown that blood is at its best when it’s used within two weeks of being drawn.

AdVAnCements in the mArines CorPs

In order to address the Marine Corps’ concerns about keeping wounded soldiers stable as they are transported to medical facilities, they have developed pain control methodologies that are used in lieu of traditional morphine injections. By using an oral lollipop made of fentanyl, medics are able to control the administration of pain medica-tions in a way that they would not be able to when using morphine.

“The difference is, with the morphine injection, if someone is in shock, it depends upon a good blood flow to all the extremities, and that’s where the Marine is going to be given the injection of the morphine. Giving the technology of the fentanyl lollipop allows for additional, or more rapid, administration of the pain relieving medica-tion,” Anderson said. “In addition, if the corpsmen determine that the pain relieving medication is perhaps contributing to a lowering of the blood pressure too far, they can just remove it from the mouth and essentially stop the dosage, whereas an injection is an injection—you can’t pull out the medication.” O




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M2VA RESOURCE CENTER

CAlenDAr

August 13-16, 2012Military Health System Research Symposium (ATACCC)Fort Lauderdale, Fla.www.ataccc.org

September 9-12, 2012NGAUSReno, Nev.www.ngausconference.com/12NS/

September 25-27Modern Day MarineQuantico, Va.www.marinemilitaryexpos.com

October 22-24, 2012AUSAWashington, D.C.www.ausa.org

December 15-18, 2012Special Operations Medical Association Conference (SOMA)Tampa, Fla.www.specopsmedassociation.org

February 11-14, 2013Military Health System ConferenceWashington, D.C.www.health.mil/2012mhsconference.aspx

Vice Admiral Matthew L. NathanSurgeon GeneralU.S. Navy

Cover and In-Depth Interview with:

October 2012Vol. 16, Issue 6NEXTISSUE


Insertion Order Deadline: September 6, 2012 • Ad Materials Deadline: September 13, 2012

FeaturesField Hospitals An in-depth look at the technologies and solutions making field hospitals the lifesaving facilities they are today.

Leadership Insight Rear Admiral Michael H. Anderson, Medical Officer to the Marine Corps

Cloud Computing Sharing data is critical to delivering superb health care.

Special Section:Shipping Container Review

Emergency Communications When disaster strikes, maintaining communications is vital to saving lives.

Organization Profile:U.S. Army Corps of Engineers


Joe Robinson Senior Vice President

Government and Enterprise SolutionsPhilips Healthcare

Q: Describe your role at Philips.

A: I’m responsible for enterprise business and central marketing for Philips Health-care North America and Philips cross sec-tor businesses—health care, lighting and consumer lifestyle—in the public sector in the United States.

Q: Can you provide an overview of what Philips Healthcare offers to the U.S. military?

A: We offer a comprehensive portfolio of health care solutions, from magnetic reso-nance imaging [MRI] systems to patient monitoring and informatics solutions. We also supply innovations in sleep therapy, combat-ready defibrillators and much more.

Q: What new cross-sector products are available to the Department of Defense and the Department of Veterans Affairs?

A: We have the opportunity to provide lighting solutions that will allow the VA and DoD to meet the tough energy reduc-tion standards currently in place. We have delivered high-tech imaging in the battle-field such as our mobile MRI, which assists in diagnoses to help enhance patient care. We also offer oral care products, as well as products to support mother and child care such as fetal monitors and obstetrical information management systems.

Q: How can Philips’ experiences with the U.S. military translate to solutions for the VA?

A: Having diagnostic equipment on-site, like our mobileMRI in theater, may lead to earlier detection of traumatic brain injuries, and that could have a long-term impact on how veterans may be treated in the future. Capturing images is only the

beginning. Data transfer, storage, utiliza-tion and research over the long term will likely change care plans for veterans and enhance quality of care.

Q: How can VISN 23’s implementa-tion of Philips IntelliSpace Critical Care and Anesthesia [ICCA] benefit the other Veteran Integrated Service Networks [VISN]?

A: ICCA brings together the critical care patient’s monitoring and care information and provides the opportunity for clinical decision support and improved workflow. When paired with our eICU Program, the VISN has the ability to monitor Intensive Care Unit [ICU] beds in multiple hospitals from a single location staffed with critical care specialists. This is one of the few tech-nologies that the VA is looking to deploy across VISNs. ICCA has been viewed as an innovative way to provide quality health care to our veterans and is looked at as the new standard of care.

Q: What are your thoughts about the cur-rent DoD/VA collaboration on electronic health records?

A: I believe their efforts will be closely watched by the private sector. The medical diagnostic imaging support project in the early ‘90s was groundbreaking for work in the realm of a picture archiving and

communication system, and the lessons learned found their way quickly into pri-vate sector health care.

Q: What sets Philips apart from other government vendors?

A: Philips has a long history of working with many government agencies including the VA and DoD. We have earned their trust by consistently delivering on difficult spec-ifications under challenging timeframes. Philips’ ability to design, build and deliver three first of their kind mobile MRIs to the Afghan theater speaks to this. These systems became operational in October 2011 and are being used to assist in the diagnosis and treatment of mild traumatic brain injury.

Q: Can you tell us about one of your recent successes?

A: Philips recently received CMS Innova-tion Grant funding to work with the Mayo Clinic to help reduce errors in acute care hospitals, which often result in measurable harms and significant CMS costs. It is our hope that what is learned here will trickle down to the VA/DoD care facilities.

Q: Can you tell us about your military hir-ing program?

A: Philips continually hires veterans. In addition we partner with the following veteran recruiting programs: Hire Heroes, Joining Forces Initiative, Milicruit, RecruitMilitary.com, Employer Partner-ship and the Wounded Warrior Project.

Q: Is there anything else that you would like to add?

A: We remain eager to meet the needs of our government customers by providing solutions that address their evolving chal-lenges. O

INDUSTRY INTERVIEW Military Medical & Veterans Affairs Forum

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