m2va 18 2 final

Medical Oxygen O Infant Security O Creative AdvancesPhysician Assistant Programs O Wound Care Training

Pilot Doctor

Lt. Gen. (Dr.) Thomas W. Travis

Surgeon GeneralU.S. Air Force

June/July 2014Volume 18, Issue 2

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Air Force Medicine

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auG 18.3

q&a

Dr. Jonathan Woodsonassistant Secretary of Defense for Health affairs

Special Sectioncombat casualty care Simulation

featureSMasters in public Health

Burn care

Defibrillators

information Sharing

WHo’S WHoDefense Health agency

traDe SHoWSMHSrS/ataccc

Modern Day Marine

cloSing Date7/29

oct 18.4

q&a

lt. gen. patricia Horohoarmy Surgeon general

Special SectionSexual assault in the Military

featureSMobile Health it

traumatic Brain injury

careers in Health

WHo’S WHoarmy Medicine

traDe SHoWSauSa

Joint forces pharmacy

cloSing Date9/30

noV/dec 18.5

q&a

col. peter J. Bensoncommand Surgeon, u.S. army Special operations command

Special SectionDavid Bowen DHa cio

featureSptSD treatment

telemedicine

Biosurveillance

Health care analytics

pharmacy automation

WHo’S WHoWilford Hall ambulatory Surgical center

traDe SHoWSSoMa

i/itSec

cloSing Date11/17

Lieutenant GeneraL (Dr.) thomas W. travis


16

Departments Industry Interview2 eDitor’s PersPective3 ProGram notes4 PeoPLe14 vitaL siGns27 resource center

roy DeaL, m.D. Medical Director and Service Director for Military Resiliency UnitEmerald Coast Behavioral Hospital

5ProtectinG the most vuLnerabLeAbductions of infants from maternity wards are a relatively rare occurrence in the United States, but when they do occur they make headlines. Hospitals have seen it necessary to implement electronic systems that make abductions almost impossible.By Peter BuxBaum

10WounD care traininGThe kinds of aid available for wound care training range from the very low tech to the very high tech.By Peter BuxBaum

21DeeP breathsIt doesn’t take any sort of formal medical training to comprehend how crucial oxygen is when treating wounded warriors, whether that treatment needs to takes place right on the battlefield or happens back at a basecamp hospital unit.By J.B. Bissell

24From veteran meDic to Physician assistantPhysician assistants are among the most highly paid individuals with master’s degrees. According to the most recent surveys, in 2012 the annual median salary for the profession was $90,930.By Chris mCCoy

June/July 2014Volume 18, Issue 2Military Medical & Veterans affairs foruM

Features

28

“To enhance our competency in the ground expeditionary

and air evacuation missions, we

must ensure that our providers

continue to have robust

opportunities to practice their skills and that

we continue to pursue critical research and

modernization initiatives for the

future.”

—Lieutenant General (Dr.)

Thomas W. Travis

8creative aDvancesWhat if a single needle prick cured post-traumatic stress? Or an ancient remedy stopped suicidal thoughts? Or virtual reality replaced traditional therapy? All of these methods are showing signs of success in recent studies.By Dana CruDo

18A pictorial spread detailing Air Force Medicine’s command structure and senior leadership.

Who’s Who: air Force meDicine

Cover / Q&A

A lot has happened at the Department of Veterans Affairs over the past two months in the wake of the VA backlog scandal. Secretary of Veterans Affairs Eric K. Shinseki has resigned and been replaced by Acting Secretary of Veterans Affairs Sloan D. Gibson.

In his farewell message to VA employees, Shinseki stated: “I have been privileged to have served as your secretary and am deeply grateful to the employees and leaders who have placed the interests of veterans above and beyond their own self-interests; who are serving with dignity, compassion and dedication; and who live by VA’s core values of integrity, commitment, advocacy, respect and excellence. I know that you will provide your support and loyalty to Acting Secretary Sloan Gibson, who is now your leader. In fact, I expect it.”

Acting Secretary of Veterans Affairs Sloan D. Gibson released this message upon assuming office. “Not all veterans are getting the timely access to the health care that they have earned. Systemic

problems in scheduling processes have been exacerbated by leadership failures and ethical lapses. I will use all available authority to swiftly and decisively address issues of willful misconduct or mismanagement.

“VA’s first priority is to get all veterans off waiting lists and into clinics while we address the underlying issues that have been impeding veterans’ access to health care. The president has made clear that this is his expectation.”

Contrary to the opinion of many in Congress, who are stating that the VA has a bloated budget, I think that the VA is in need of greater funding to better address the backlog of veterans needing health care. It is my hope that more funds are appropriated by Congress for the VA to hire more medical staff in its clinics and hospitals.

The demand for veterans care and health care costs in general are rising. As veterans grow older in the oncoming decades, the costs of their care will rise. One solution to deal with the rising cost of health care would be for the U.S. government to finally negotiate with the pharmaceutical industry for lower prescription drug prices.

As usual, feel free to email me with questions or comments for Military Medical & Veterans Affairs Forum.

Christopher McCoyeDitor

editor’s PersPectiVe


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U.S. Army Medicine released a preview of its new concussion/mild TBI awareness training materials for all DA personnel.

Armywide TBI training is mandatory per HQDA EXORDs 242-1 and 165-13, and training materials are currently available on the Traumatic Brain Injury Training support page on Army Training Network.

The new concussion/mild TBI training mate-rials will provide a unique blend of organic training technology and cinematic scenario-based training, in-product filmed facilitators and interactive practical exercises. These will replace the existing training materials and will be available on ATN in August 2014. Separate products will be available for soldiers and leaders, medics, primary care providers and specialty care providers.

The Army’s Warrior Concussion/Mild Traumatic Brain Injury Campaign (HQDA EXORD 242-11), published in 2011, seeks to change the Army’s cultural attitude regarding concussion and reduce the impact of concussion on individual soldier health and well-being. Education is the overarching line of effort to increase awareness, promote prevention, and decrease the stigma of seeking care for concussion. HQDA EXORD 242-11 mandates TBI education for all Army personnel.

The Army will continue to inform and educate every soldier and leader about the effects of a concussion and actions required to be taken following events that may cause a concussion. Every medic and medical provider will be provided understanding of the process for evaluating, treating and tracking soldiers exposed to a poten-tially concussive event as well as those diagnosed with a concussion.

Through educating the force, the Army hopes to affect a cultural change about better understanding of concussions. This will help ensure that soldiers and leaders understand the impor-tance of a check-up and subsequent rest for recovery, following a potentially concussive event. This is in support of the NFL practice, “It’s better to miss one game than the whole season.”

Since 2000, a total of 294,172 Department of Defense service-members worldwide have been diagnosed with a traumatic brain injury, of which 58 percent are U.S. Army soldiers. While much of the popular media focuses on those concussions/mild TBIs that occur in the deployed setting, approximately 78 percent of all Army TBIs from 2000-2013 were non-deployment associated and occurred in garrison. Therefore, concussions will continue to be a challenge for DoD.

Compiled by KMI Media Group staffProGraM notes

New Army TBI Training Program

Researchers at the University of Adelaide say addictive behavior such as drug and alcohol abuse could be associated with poor development of the so-called “love hormone” system in our bodies during early childhood.

The groundbreaking idea has resulted from a review of worldwide research into oxytocin, known as the “love hormone” or “bonding drug” because of its impor-tant role in enhancing social interactions, maternal behavior and partnership.

Dr. Buisman-Pijlman, who has a back-ground in both addiction studies and family

studies, said some people’s lack of resilience to addictive behaviors may be linked to poor development of their oxytocin systems.

She said the oxytocin system develops mainly based on experiences.

“The main factors that affect our oxytocin systems are genetics, gender and environment. You can’t change the genes you’re born with, but environmental factors play a substantial role in the development of the oxytocin system until our systems are fully developed.”

She said studies show that some risk factors for drug addiction already exist at

four years of age. “And because the hard-ware of the oxytocin system finishes devel-oping in our bodies at around age three, this could be a critical window to study. Oxytocin can reduce the pleasure of drugs and feeling of stress, but only if the system develops well.”

Her theory is that adversity in early life is key to the impaired development of the oxytocin system. “This adversity could take the form of a difficult birth, disturbed bonding or abuse, deprivation, or severe infection, to name just a few factors,” Buisman-Pijlman said.

Can ‘Love Hormone’ Protect Against Addiction?

www.M2VA-kmi.com M2VA 18.2 | 3

Colonel Bertram C. Providence has been selected for the rank of brigadier general, commander, 1st Medical Brigade, Fort Hood, Texas, and will become command surgeon, U.S. Army Forces Command, Fort Bragg, N.C.

Major General Joseph Caravalho Jr., commanding general, U.S. Army Medical Research and Materiel Command and Fort Detrick, Fort Detrick, Md., is to be assigned as

deputy surgeon general/deputy commanding general (Support), U.S. Army Medical Command, Falls Church, Va.

Major General Brian C. Lein, deputy surgeon general/deputy commanding general (Operations), U.S. Army Medical Command, Falls Church, is to become commanding general, U.S. Army Medical Research and Materiel Command and Fort Detrick.

Brigadier General Barbara R. Holcomb is to become commanding general, Brooke Army Medical Center, Joint Base San Antonio, Texas. She most recently served as command surgeon, U.S. Army Forces Command, Fort Bragg.

Colonel Robert D. Tenhet, executive officer to the surgeon general, Office of The Surgeon General, Washington, D.C., has been selected for the rank of brig-adier general and is to become commanding general, Northern Regional Medical Command, Fort Belvoir, Va.

Rear Admiral (lower half) Christopher J. Murray is to be assigned as commander, Naval Safety Center, Norfolk, Va. Murray is currently serving as assistant chief of staff, operations, Allied Joint Forces Command, Naples, Italy.

Air Force Colonel Lee E. Payne has been nominated to the rank of brigadier general. Payne is currently serving as deputy assis-tant surgeon general, health care

operations, Office of the Surgeon General, Headquarters U.S. Air Force, Falls Church.

Rear Admiral Bruce A. Doll has been assigned as director, research and development, Defense Health Agency, Falls Church. Doll is currently serving as deputy chief, Navy medicine research and development, M2, Bureau of Medicine and Surgery, Falls Church.

Compiled by KMI Media Group staffPeoPle

Compiled by KMI Media Group staffProGraM notes

Acting Secretary of Veterans Affairs Sloan D. Gibson announced immediate actions to improve access to care for veterans in Fayetteville, N.C. The visit to the Fayetteville VA Medical Center (VAMC) follows the VA’s release of results from its Nationwide Access Audit, along with facility level patient access data.

“Far too many veterans in Fayetteville—and across this country—are being told they have to wait in line. I’m here today to say that no veteran should ever have to wait for the care they have earned through their service and sacrifice,” said Gibson. “The data we released this week [6/12/14] shows the extent of the problems we face. As the president has said, we must work together to fix the unacceptable, systemic problems in accessing quality health care. And that starts by addressing and solving the problems right here in Fayetteville.”

In addition to the system-wide actions taken in response to the audit findings and data, Gibson outlined actions to accelerate access to care for veterans in Fayetteville:

• The Fayetteville VAMC is reaching out to all veterans identified as waiting longer than 30 days for care to discuss individual medical needs and schedule appointments—more than 2,000 veterans have been contacted.

• Gibson directed that the Fayetteville VAMC receive an additional $7.4 million from within VA’s budget specifically to accelerate access to care.

• Fayetteville VAMC has expanded hours—adding mornings, evenings and weekends—and deployed a mobile care unit to see patients.

• Gibson directed that the Fayetteville VAMC use temporary staffing measures, along with clinical and administrative support, to ensure these veterans receive the care they have earned through their service.

• Gibson directed that the Fayetteville VAMC increase the use of established contracts with community partners to schedule veterans waiting to be seen by a doctor.

Maj. Gen. Joseph Caravalho Jr.

Rear Adm. Bruce A. Doll

VA Acting Secretary Gibson Announces Immediate Actions to Improve Access to Care in Fayetteville

www.M2VA-kmi.com4 | M2VA 18.2

Abductions of infants from maternity wards are a relatively rare occurrence in the United States, but when they do occur they some-times make headlines. Hospitals have seen it necessary to implement electronic systems that make abductions almost impossible.

There are a number of reasons for implementing infant abduc-tion prevention systems. One is to obviate the catastrophic emo-tional toll that abduction takes on its victims, both parents and babies. Another is to mitigate the hospital’s legal liability in case the unthinkable happens. Implementing infant abduction systems is now considered a standard procedure for hospitals offering maternity services.

Thanks to advances in technology, health care facilities are able to install systems that are simple to use and effective in prevent-ing infant abductions. And these systems are improving. The latest iterations make use of a hospital’s existing Wi-Fi infrastructure to make system implementation less expensive while improving its performance.

According to the National Center for Missing and Exploited Chil-dren, 288 infant abductions have been perpetrated by non-family members in the last 30 years in the United States while eight abductions took place in 2012. Of the 288, 12 victims are still missing. A little less than half of these incidents, 132, took place at health care facilities, four in 2012. Five of the 132 are still missing. Most of the babies snatched from health care facilities, 77 percent, are taken from their mothers’ rooms and 11 percent of the incidents involved violence against the mother.

The center has developed a profile of the infant abductor from an analysis of the 288 cases occurring between 1983 and 2012. Abductors are usually females of childbearing age. They frequently have lost a baby or are incapable of conceiving. The abductor is usually married or cohabiting with a partner and wants to provide her companion with a desired child. She usu-ally plans the abduction, but doesn’t target a specific infant, instead seizing any opportunity to abduct an infant. She frequently impersonates a nurse or other health care personnel. The woman will often fake a pregnancy for the benefit of her partner and then, in a state of panic, abduct a child in furtherance of her plan to start a family.

“The problem came to light 25 years ago and we started to pay more attention to abductions within health care facilities,” said

Diane Hosson, director of security solutions at Stanley Healthcare Solutions.

“Maternity wards have an open atmosphere. People aren’t com-ing there because they are sick. They are coming to rejoice over a baby being born and they want to have a welcoming environment. Potential abductors can mix with other guests during visiting hours.”

The Joint Commission, an independent accrediting body for health care facilities and programs, started recommending the deployment of electronic security systems to prevent infant abduc-tions in the 1990s. Since the installation of these systems has become widespread, the incidence of infant abductions has been reduced.

“Installing infant abduction systems is a way to protect our infants,” said Captain Jennifer Rhoades, an element leader at the Family Birthing Center at Keesler Air Force Base, Miss. “We haven’t had that issue here, but there has been an increase in infant abduc-tions. It is standard procedure in infant delivery to protect the babies.” The Keesler unit uses the Hugs system from Stanley Healthcare Solutions, a system which has been installed at Keesler for around

seven years.“Infant abductions by non-family members are a

very low probability threat,” said Mark Kosloski, presi-dent of McRoberts Security Technologies Inc., “but when it does happen, it makes the news.”

The key technology used in most infant abduction prevention systems is radio-frequency identification (RFID). A monitor that emits a radio signal is placed on the infant and communicates with RFID readers that can tell if the infant has been removed from its room or if the radio tag has been tampered with.

“Active radio-frequency identification technology has been used for infant security for over 20 years,” said Zahir Abji, president of GuardRFID. “There have been a handful of high-profile abductions at health care facilities every year. These can have a significant impact on the facility in terms of liability and its public perception, as well as the emotional toll these incidents take on family members and hospital staff. Another reason to use the technology is that it reduces the amount of time staff spends on monitoring the whereabouts of infants.”

“Active RFID means the tag is in communications with a reader every seven to 10 seconds,” said Paul

Constant, director of sales and marketing at Secure Care Products Inc. “It squirts out a heartbeat saying that it is working properly.”

By Peter BuxBaum, m2Va CorresPondent

How tHe military PreVents infant aBduCtions from its maternity wards.

Zahir Abji

Paul constant


The system looks for that signal, and if it fails to materialize the system may take any of a number of different measures, depending upon the system and the preferences of the facility. It can send an audible alarm to the nursing station, it can send text alerts to smart-phones and pagers and it can automatically lock doors, elevators and corridors. Exactly what happens next depends on the policies and standard operating procedures of the hospital.

“When you look at infant security, there are many things that need to be in place,” said Constant. “It’s not just the infant security system. It is also people, processes, procedures, training and practice. A lot has to do with being able to act in case of an abduction.”

“The most important thing for an infant security system is to be able to alert staff that an infant is going near a door that can lead it out of the department,” said Hosson. “With the Hugs system, once the tag is applied, mother and baby can move around within the protected area. But if someone tries to take that baby with the tag toward an open door, the system goes into alarm and the staff is alerted.”

Each facility that uses Hugs can decide how the alarm is to be delivered. “It can be set to go to pagers and mobile phones,” said Hosson. “The system can be programmed to stop all elevators. They have many options and they can decide what is right for them to make sure the infant doesn’t get out of the hospital and that the abductor is apprehended.”

GuardRFID offers both perimeter security systems as well as real-time tracking of RFID tags.

“We can create fields in doorways to detect tags as they approach,” said Abji. “This can be adjusted to detect tags up to 20 feet away. The other way is to have tags transmit beacon messages every few seconds. These are tracked in real time so that if there has been an attempt to tamper with a tag or to remove an infant, the system can detect exactly where that event is occurring.”

Secure Care protects infants by installing exit panels at doors where infants should not pass. “That way we create a safety and detection zone,” said Constant. “Doors can be locked in the event an infant is removed. If the tag fails to report into the system, it provides a warning so that staff can check on the baby, replace the transmitter, or do whatever else has to be done. If a tag has been tampered with, the system can lock down all doors and send a report that a certain baby is in trouble. The system is not computer dependent. If a computer, a server, or a virtual server goes down, the system can still issue alarms locally and lock doors.”

At Keesler Air Force Base, maternity staff place a monitor on each child once it is born and an alarm sounds if the infant is taken off the unit. The tags communicate with RFID readers that are posi-tioned near doors and by exit ways. The alarm activates once a baby is taken past an armed door.

“We have a Code Pink, which is pretty standard for infant or child abductions,” said Rhoades. “We have staff members who man the doors and exit ways until we determine where the baby is.”

If the infant is being taken off the ward for a legitimate reason—to radiology, for example—the tag can be de-activated so that an alarm does not sound. “But if we forget to take the monitor off the baby or it is tampered with in the room, the alarm will sound,” said Rhoades. “The alarm will tell us what room and which baby so that we can go to room to make sure the system was not accidentally alarming and we go from there. There are a number of reasons the alarm can go off and it just tells us the system is working properly.”

The alarm is an audible sound that is transmitted to the nurse’s sta-tion and that can be heard throughout the unit.

Different systems offer different types of tags. GuardRFID offers a tag that clamps to an infant’s umbilical cord and a tamper-resis-tant tag that sits within a band and can be placed around the baby’s thigh, upper arm, or ankle. “The umbilical tag sits within a clamp so that it is fairly unobtrusive,” said Abji. “It remains on the infant until the umbilical cord falls off or the infant is discharged from the hospital within 24 to 48 hours.”

Some hospitals and staff prefer the umbilical tag despite the fact it is not tamper resistant because the thought is that an abductor will not interfere with a device attached to an umbilical cord. The motivation of the abductor, after all, is not to harm the baby.

“It is a very quiet system, which means you don’t get false alarms, which a lot of staff members prefer,” said Abji. “Nuisance alarms tend to desensitize staff members and they don’t pay atten-tion after a while. The band can always be placed on the infant if the umbilical cord falls off.”

McRoberts offers three types of infant tags for its MyChild infant protection system: an umbilical tag, a wrist/ankle tag and a skin-sensing tag. “The umbilical tag is attached to the infant’s umbilical cord clamp, deterring potential abductors from removing the tag,” said Kosloski. “The standard wrist and ankle tag is easily applied with any one of a number of tamper-resistant bands. The skin-sensing tag is attached to the infant’s wrist or ankle and has the ability to sense if it has been removed from the infant. We provide three tags to provide customers with choices and, more than that, so that they can use the solution that makes the most sense for each patient.”

The key recent innovation to electronic infant security systems has been the migration of traditional, proprietary systems to the Wi-Fi infrastructure already in place in most hospitals. “The new systems snap onto the Wi-Fi environment that is already well deployed,” said Kosloski. “Leveraging Wi-Fi reduces the time and cost to implement the solution.”

Traditional infant protection systems are based on proprietary RFID architectures, which require the deployment of special receiv-ers that are specific to that system. As a result, the protected area of a facility is physically limited to where the technology is staged.

“Because Wi-Fi is already typically deployed enterprise-wide,” said Kosloski, “there is the ability to extend the utilization of an infant protection system without having to buy specialized com-ponents. There is not really any difference in performance between the two.”

McRoberts recently introduced a Wi-Fi-based, campuswide infant security solution. “Infants are monitored 100 percent of the time and can be quickly located even during transport, transfer and treatment in ancillary departments,” said Kosloski. “Protected infants continue to be visible to staff and secured by the system at all times. The hybrid system takes advantage of our expertise in providing RFID lockdown security at exit points while leveraging a hospital’s Wi-Fi network to easily and cost-effectively expand the coverage area without the cost and installation of a facilitywide pro-prietary RFID network.”

MyChild for Wi-Fi uses a small, lightweight, single-use Wi-Fi tag. “We provide a sterile, eco-friendly security tag for each newborn,” said Kosloski. “The software enrolls and deletes the single-use tags automatically, eliminating the need for manual tag management.”


MyChild also includes an integrated closed-circuit television option which provides a live video feed from cameras that monitor exits supervised by the MyChild system. “In the event of an alarm, live video of the area and a photo of the patient appear in a pop-up window,” said Kosloski. “Another unit feature allows users to con-figure the system so that individual units see only the patients and alarms that are associated with their areas.”

McRoberts intends to continue to support both its new Wi-Fi and its traditional solution. “Some customers will continue to prefer the traditional proprietary solutions,” said Kosloski, “because there may be security or coverage weaknesses in their current Wi-Fi infrastructure.”

Stanley Healthcare’s coming Wi-Fi solution works on an open architecture, noted Hosson. “It works throughout the hospital to protect the infant not just in the maternity ward,” she said. “Once a baby is out of the protected area, there is not as much visibility to location with a traditional system until the baby is back in the pro-tected area. With Wi-Fi, a tag can be found anywhere in the hospital. This provides a much larger layer of protection than ever before.”

Secure Care has added a mother-baby matching feature to its system. “There are many reasons to have this kind of system,” sad Constant. “You want to make sure that a baby doesn’t go home with the wrong parent. You want to make sure that a baby isn’t breastfed by a mom with AIDS.”

When a baby is entered into the system, the system is aware of where the baby is supposed to go. A wireless matchmaker unit is

installed outside of the room and gives a red light or a green light as a baby approaches the room. When the baby is discharged, its identification number is automatically removed from the system.

Secure Care also recently enhanced its technology with two-way communications between the software and the exit panels located at the doors. “This allows users to change exit codes and the size of the detection zone from a central location,” said Constant. “Before, they would have to go to each door unit and change them manually.”

GuardRFID is working on enhancements that improve user interfaces. “Our customers don’t want to spend time on security issues,” said Abji. “They want to be delivering services to patients. Until recently user interaction was all done at the nurse’s desk. But nurses aren’t always at their desks. So we have developed smartphone apps to allow nurses to visualize their areas, admit and discharge patients, and accept alarms, all from their mobile devices.”

At Kessler Air Force Base, the folks at the birthing unit are currently discussing upgrading the system they have. Rhoades explained: “It is a system that will allow seeing exactly where the baby is, as opposed to just receiving a report that it is off the unit.” O

For more information, contact M2VA Editor Chris McCoy at [email protected] or search our online archives for related stories at www.m2va-kmi.com.

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What if a single needle prick cured post-traumatic stress? Or an ancient remedy stopped suicidal thoughts? Or virtual reality replaced traditional therapy?

What may seem like far-fetched ideas now could become viable treatment options not too far into the future.

These are just a few of the cutting-edge approaches mili-tary researchers are exploring to better treat post-traumatic stress and suicidal ideation that Robert McLay, research director for the Naval Medical Center, San Diego, shared during the 2013 Warrior Resilience Conference. The virtual conference was held in August.

“It sounds like fantasy,” McLay said. “But this stuff looks really promising.”

PTSD can develop after a traumatic or life-threatening event and is characterized by ongoing nightmares or flash-backs of the event, feelings of fear, guilt or shame, jumpiness or alertness, and trouble sleeping. The National Center for PTSD estimates that 11 to 20 percent of veterans of the Iraq and Afghanistan wars live with PTSD. Suicide risk is higher in people with PTSD.

According to the July 2013 Medical Surveillance Monthly Report by the Armed Forces Surveillance Center, mental

disorders are the leading cause of hospital bed stays and the second leading cause of medical encounters for active-duty servicemembers, largely due to increases in hospitalizations for PTSD and depression.

Although troops have left Iraq and the conflict in Afghanistan is winding down, PTSD will continue to be a problem. Several studies of veterans suggest that while PTSD symptoms usually start soon after the traumatic event, they also may not appear until months or years later.

Help and hope are available. There are many evidence-based treatments such as

cognitive processing therapy, prolonged exposure therapy and selective serotonin reuptake inhibitors available to treat PTSD and related problems. Cognitive processing therapy provides new skills to handle distressing thoughts and to process traumatic events. Exposure therapy helps decrease distress about trauma through repeated exposure to trauma-related feelings to help reduce the power they have to cause distress. Selective serotonin reuptake inhibitors are antide-pressants that treat some symptoms of PTSD.

McLay cautioned that these current interventions should be tried first, before the more innovative interventions.

By dana Crudo

military researCHers are adVanCing treatment studies for Ptsd and dePression.


“We know these current treatments really work, but we also know there are servicemembers out there who are not helped by them,” he said. “We need to look at new technology and options. We need to give these servicemembers a helping hand.”

Here are a few of the latest research endeavors happening at the Naval Medical Center, San Diego.

Stellate ganglion block. This procedure involves injecting a local anesthetic into the stellate ganglion, which is a ball of nerves in the neck where the “flight or fight” signals from the brain go out to the body. Stellate ganglion block has been used for a long time to ease pain, but now researchers are learning that it also seems to reduce post-traumatic stress. In a pilot study by the center, patients experienced significant drops in post-traumatic symptoms; however, effects faded with time. Research on dosage amounts continues.

Transcranial magnetic stimulation. Brain scans show changes in brains with PTSD. The brain is a neurochemical circuit and post-traumatic stress disturbs this circuit, resulting in changes based on the electrical charge of the brain. Transcranial magnetic stimulation is a new technology that can change the brain’s charge. It already has been approved for use in treating depression. Early studies by the center showed a significant drop in post-traumatic stress symptoms in half of the patients in the study. The improve-ments gained from the noninvasive method wear off, but they are not completely reversed. Research into this technology continues.

Attention retraining. This computer-based method focuses on how patients look at and respond to different stimuli. The goal is to train patients not to focus on anxiety-inducing or negative thoughts, events or situations. This method is used to treat other anxiety conditions and may be effective for PTSD. The center showed in a recent study that although patients improved with attention retraining, they often did not continue the treatment as directed, and the gains were lost.

Virtual reality assisted exposure therapy. This intervention builds upon exposure therapy, which is considered currently to be the most effective treatment for PTSD. This therapy creates a realistic, anxiety-provoking simulation that teaches patients to overcome their fears by facing them and talking about them. It

aims to make exposure therapy more engaging and effective by using virtual reality as an alternative to traditional methods. Clini-cal trials at the Virtual Reality Medical Center in San Diego showed that 50 to 75 percent of patients got better and stayed better with this therapy.

Caring letters project. This suicide prevention program sends brief, caring emails and reminders of available treatments to servicemembers following psychiatric hospitalization. Previous studies suggest that repeated, caring communication helps reduce suicide in high-risk patients. The center is conducting a two-year, multisite study of 4,730 patients to study the effect the caring let-ters project has on suicide rates.

Ketamine. This ancient remedy has been used in developing countries as an anesthetic for years. It also has been touted as a miraculous, short-term antidepressant. The center’s researchers have shown that ketamine may be able to help people who are at their very lowest feel better, resulting in reduced suicide and improved long-term outcomes. They studied the use of ketamine with patients with suicide ideation in emergency rooms. Research results so far have shown that most patients who received ketamine felt better almost immediately and that these improvements lasted at least two weeks. These patients experienced reduced feelings of hopelessness, depression and suicidality. The center is conducting more ketamine clinical trials.

Time will tell which of these studies will prevail and lead to successful treatments that can be used at the home front and at the frontline. Regardless, these latest advances in technology and research show more innovative, life-saving treatments are around the corner.

“We have shown that we can do something,” McLay said. “There is hope.” O

Dana Crudo is a staff writer for www.health.mil.


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m2Va CorresPondent

BreaktHrougHs in wound simulation are making wound Care training more realistiC.

The kinds of aid available for wound care train-ing range from the very low tech to the very high tech. Low-tech tools include teaching by show-ing students pictures and diagrams of wounds and their proper care. Low-tech simulations include properly weighted manikins on which trainees can practice applying pressure and dressing wounds.

Hi-tech, or high fidelity, simulations avail-able for wound care include manikins that breathe, bleed and sweat and whose vital signs respond to trauma and to treatment. The high-est-end manikins are made out of artificial tissue that has been designed and developed to emulate human tissue in every way. Beyond that, there are also immersive virtual reality environments that duplicate locations such as emergency rooms, and mentoring systems that monitor a student’s every move, map those against the techniques used by established experts and provide feedback.

Wound care doesn’t always take place on the battlefield or in the emergency room. At the U.S. Army Burn Center in Fort Sam Hous-ton, Texas, arriving nurses are trained on the routines of wound care for patients that may be hospitalized for long periods of time. The approach taken by the burn center is decidedly low-tech: They train on static manikins, practicing the application of pressure and the dressing of wounds without even a depiction of the wound itself. Burn center personnel say that their decisions are based on budgetary realities: These days they have to answer for every dollar that they spend.


Lieutenant Colonel Jodelle Schroeder, commander of the 126th Forward Surgical Team based in Fort Hood, Texas, believes that the greater the level of realism, the better the efficacy of the training. Few will disagree with that assertion, especially not the companies that make the more sophisti-cated simulations. “The more realistic we can make the train-ing, the better,” said Schroeder. “This gets the attention of train-ees as to what they are doing well and also where improve-ment is needed.”

Schroeder’s unit uses a combination of simulations in its training. “We sometimes use manikins with wounds affected on them with moulage kits for things like amputations, skel-etal injuries, cuts and burns,” she said. “Sometimes we also use moulage kits on actual per-sonnel and practice washing and dressing wounds on them.” Moulage refers to the art of simulating wounds often used in film and the theater.

“High fidelity simulations include an electronic compo-nent,” explained Sarah Shingle-ton, a wound care clinical nurse specialist at the U.S. Army Burn Center. “The manikin is connected to a com-puter which enables it to breath, cry, urinate and sweat. We would use high fidelity simula-tions for things like burn resuscitations and cardiac arrest. Trainees can apply chest com-pression and the heart rate changes based on the scenario. For wound care, we have found that level of high fidelity not to be necessary.”

“We mainly use high fidelity simulations for more complex scenarios,” agreed Major Scott Phillips, chief of clinical education and a senior clinical nurse specialist at the Burn Center. “Although we could use high fidel-ity simulations for wound care training, we think that the low fidelity alternatives are

good enough to get the point across of how to clean and dress a wound.”

Industry types argue that the more immersive the train-ing, the more effective it is. “The deeper the immersion, the better the learning experience and the longer that experience stays with the trainee,” said Eric Rohde, chief strategist, Medi-cal Simulations for Intelligent Decisions. “They pick up the skills better and quicker with immersive training methods.” Intelligent Decisions developed virtual reality environments for a variety of medical and surgical training scenarios.

SynDaver Labs developed a product line originally designed to simulate healthy human tis-sue for educational purposes and to replace the use of animals in studies. The company has since branched out to creating trauma simulations in aid of training. “Our trauma models include applications for bullet wounds, severed limbs and soft tissue injuries,” said Christo-pher Sakezles, the company’s president and chief technology officer. “The trauma models are always made according to the specific needs of customers. For

military customers, we have made models with a femur shattered by an AK-47 round or a trau-matic amputation from an IED.”

Some of the more recent developments added to wound care simulations include add-ing pressure sensors to the simulated wound, according to Bob Buckman, vice president of sales and marketing at Operative Experience Inc. “This assures that the student is apply-ing the appropriate amount of pressure to the wound and that it is properly packed,” he explained. “Another important innovation has been the simulation of coagulated blood. This also is a sign that the wound has been properly packed and dressed.”

christopher Sakezles

Maj. Scott Phillips

Sarah Shingleton


Immersive medical simula-tions are analogous to military training simulations that provide after-action reviews to the train-ees, according to Rohde. “A host of analytics follow on the train-ing that can be used to better ‘Monday morning quarterback’ the actions of the medical personnel,” he explained. “The Holy Grail for training, especially in the military, is to quantify what soldiers or med-ics are learning and then improve performance in the next round by educating them on where they are missing something.”

The mentoring approach to simulated training developed by SimIS uses the Microsoft Kinect camera used in gaming systems to compare the actions of a trainee in a given situation against those of an expert performing the same procedure. “We developed the software to compare the two sets of actions,” said Justin Mae-stri, product manager for health care simulations at SimIS. “The system provides a readout that compares everything from how the instruments were handled to body mechanics.”

The Army Burn Center hosts 800 trainees annually from all branches of the military who learn wound care as part of a broader burn treatment mission in an eight-week intern-ship. “Simulations allow our students to make mistakes and to learn from experience before dressing the wounds of actual patients,” said Phillips. “This is especially important for harder procedures such as applying dressings that go around the shoulder. The students can work on that in a fault-free zone using simulations.”

“It is all about learning the correct procedures and tech-niques,” added Shingleton. “The students can take as much time as needed without worrying about the patient being in pain.”

The course provided for nurses and medics at the Burn Center follow the classic formula of crawl, walk, run, said Shingleton. “Like any other kind of training, we first have to provide the stu-dents with knowledge,” she added. “We teach them about the lev-els of skin and how to differentiate superficial from deep wounds. The students start out in the classroom with a combination of lectures and interactive training. After that they will typically be given some bedside time, where they can see real wounds being treated.”

Back in the classroom, the students then get to practice wound care on the manikins. “They get dressed up in mask and gown and learn to take dressings off as in real life,” said Shingle-ton. “They learn how to clean the wound, how much pressure to apply, and how to hold the patient’s limbs while these procedures are being done.”

The Burn Center doesn’t use high fidelity manikins and doesn’t simulate wounds on the manikins. But the manikins must be properly weighted and flexible so that pressure can be applied and they can be manipulated like an actual patient. “There may be some use in manikins that display more anatomical features such as muscle and bone,” said Phillips. “The main thing that we accomplish is to establish the muscle memory involved in getting the procedures done in the right way. More sophisticated simula-tions cost a lot more money. We need justification for spending money these days.”

The Army Burn Center does go high tech with its use of a robot to provide images of wound care on actual patients to students sitting in a classroom. These images are used in training students not only locally, but also remotely by teleconference.

“One technology we use daily is a wound flow mapping sys-tem,” said Phillips. “This allows us to upload actual photos of patients and incorporate those into teaching. We can show stu-dents the progression of wounds from real patients rather than from a computer or a manikin.”

Around 90 percent of wound patients admitted to the Army Burn Center are now photographed, according to Shingleton. “They are photographed again whenever there is a major change in their condition and also as close as possible to discharge,” she said. “As a result, we have a vast repository of pictures that we can use to educate students on wound progression.”

The latest developed packing gauze on an Operative Experience model is applied. [Photo courtesy of Operative Experience]

Justin Maestri


“These ongoing pictures of patients are a good representa-tion on the progress of wounds,” said Phillips. “Sometimes we take down dressings fairly often, especially if we are suspicious of infection. But lots of times we might go three to five days between dressing changes.”

Higher tech simulations tend to be used for training com-bat medics at lower-level, pre-hospital stages of care. Operative Experience Inc. (OEI) developed its combat trauma skills training simulators with a Small Business Innovation Research grant from the U.S. Army. OEI created training courses using high fidelity and anatomically correct simulators with pathology and wound patterns representative of combat injuries. The simulators consist of artificial tissues, including skin, bone, muscle, fascia, blood vessels and nerves, that can be operated on with standard combat surgical instruments.

OEI point-of-injury simulators emphasize training in dam-age-control and operative management of high velocity gunshot wounds. They enable instruction in, among other things, the vascular control of blood vessels, damage-control shunting of arteries and veins and amputations.

“We have simulations for use in training wound packing for pre-hospital treatment, such as packing hemostatic dressings on wounds resulting from high velocity gunshots,” said Buckman. “We are developing a new product with a substance that simulates blood and can show when hemorrhaging stops in response to the application of tourniquets, surgical sponges and gauze. We also provide training video with some of our models.”

CAE Healthcare has developed a series of sophisticated manikins with features designed to facilitate different types of training. “Our highest fidelity manikin, HPS, breathes, exchanges real gases, and has a physiology so that it can be used for anesthesia and other higher-end training programs,” said Richard Low, a group leader at CAE Healthcare Academy. “Other manikins, such as our iStan and METIman, are still high fidelity although not quite on the level of HPS. They were developed for more generalized medical training.”

CAE’s Caesar manikin was developed for the Army’s tactical combat casualty care course, although not specifically for wound care. “Caesar comes out of the box with an amputated leg and with a fully-functional airway for training on trikes, inserting needles in the chest and other such procedures,” said Low.

The manikin can be ordered with different types of injuries such as traumatic amputations so that it can be used to practice wound care. “The manikins can also be altered with a simulated wound kit that can portray bullet wounds and lacerations,” said Low. “The physiology of the manikin can be adjusted to mimic trauma and students can learn how to treat that. The manikins will respond differently when 500 units as opposed to 1,000 units of fluids are administered. Vital signs will change differ-ently depending on whether the patient is treated immediately or whether there was a five-minute delay.” One of the biggest technology innovations in recent years, Low added, has been the ability to allow the manikin to wirelessly communicate with its controlling computer.

The original mission of SynDaver Labs was to develop artifi-cial tissues that not only look and feel like real human tissues,

but work like the tissue as well. “We attacked the subject from the inside out,” said Sakezles. “We now have 100 kinds of tissue, everything from mucous to bone, corneas and muscles, every-thing that goes into the makeup of the human body.”

SynDaver’s bodies are used primarily in classroom settings, both in the military and civilian sectors. “There is no analog with our products other than cadavers,” said Sakezles. “They are more expensive than cadavers, but they also bleed and breathe and have no biohazards associated with them.” The artificial bodies have been used with surgical simulators but are mostly used in research facilities.

Intelligent Decisions creates virtual reality environments that are accessed by users through a head-mounted display. The com-pany is now working on a hybridized environment that integrates the virtual with the real in creating a medical training simulation.

So, for example, a wound care simulation could incorporate a virtual emergency room with an actual manikin simulating a wound and lying on a gurney. In this way the student would expe-rience not only working on a simulated patient and perceiving the patient’s responses to treatment, but also the people, activ-ity, noise and even the panic associated with the environment in which this treatment may be taking place.

“The virtual reality environment could include everything from people moving around to machines beeping to people screaming,” said Rohde. “It duplicates the increased stress of the real environment.”

“The camera and the software take into account that people come in different sizes,” noted Maestri. “The system is also manikin agnostic. It can use any manikin as long as our stickers are put in place to provide the tracking information we need.” The company develops specific mentoring simulations at the request of its customers.

Future simulation systems are likely to become all the more sophisticated. SynDaver is working on a new set of simulated tissues. “They will have their own internal embedded physiology thanks to a new electromechanical component,” said Sakezles. “Wireless controls can also be used to change the training sce-nario.”

Intelligent Decisions’ virtual reality environments will likely benefit in the future from holographic capabilities. “We are look-ing at ways to cultivate holographic media,” said Rohde. “Train-ees will be able to practice tasks in a virtual environment using images from actual patients.”

“There are some really good simulations out there,” said Schroeder. “I’m not sure they are being used to the fullest extent. What I’d really like to see is people using them more. And I’d like to see the people who develop the simulations to really keep push-ing the limit on them.

“Leadership has to be adamant that the use of simulations and moulage is important,” she added. “It serves the education and training of our caregivers and it also serves our patients well.” O

richard Low



Vital siGns

Soft Tissue Regeneration Inc. announced that enrollment has been completed for a clin-ical trial of the company’s L-C Ligament, a biore-sorbable scaffold for soft tissue regeneration of the anterior cruciate ligament of the knee.

The clinical trial is a prospective, multi-center, non-randomized trial to evaluate the safety profile of the L-C Ligament in 15 males and females with acute ACL injuries. The outcome by which the effectiveness of treat-ments is evaluated in this study is the rate of revision surgery in treated patients. The trial will also measure the patient’s radiographic, clinical and subjective outcomes.

The trial is being conducted at Isala Klinieken in Zwolle, The Netherlands, by Dr. Kees van Egmond and at Martini Hospital in Groningen, The Netherlands, by Dr. Reinoud Brouwer. A larger, randomized clinical trial in Europe is anticipated to begin September 2014.

“The first patient was implanted on June 18, 2013, and is now out more than 10 months,” said Joseph Reilly, president and chief execu-tive officer of Soft Tissue Regeneration. “All 15 patients are doing extremely well and are following a normal course of physical reha-bilitation. This is the first step in a process that will help improve patient outcomes on so many levels.”

The U.S. Food and Drug Administration allowed marketing of the first device as a preven-tive treatment for migraine headaches. This is also the first transcutaneous electrical nerve stimulation device specifically authorized for use prior to the onset of pain.

“Cefaly provides an alternative to medication for migraine prevention,” said Christy Foreman, director of the Office of Device Evaluation at the FDA’s Center for Devices and Radiological Health. “This may help patients who cannot tolerate current migraine medications for preventing migraines or treating attacks.”

Migraine headaches are characterized by intense pulsing or throbbing pain in one area of the head, accompanied by nausea or vomiting

and sensitivity to light and sound. A migraine can last from four to 72 hours when left untreated. According to the National Institutes of Health, these debilitating headaches affect approximately

10 percent of people worldwide and are three times more common in women than men.

Cefaly is a small, portable, battery-powered, prescription device that resembles a plastic head-band worn across the forehead and atop the ears. The user positions the device in the center of the forehead, just above the eyes, using a self-adhesive electrode. The device applies an electric current to the skin and underlying body tissues to stimulate branches of the trigeminal nerve, which has been associated with migraine head-aches. The user may feel a tingling or massaging sensation where the electrode is applied. Cefaly is indicated for patients 18 years of age and older and should only be used once per day for 20 minutes.

First Medical Device to Prevent Migraine Headaches

Enrollment for L-C Ligament Clinical Trial Completed Aptima is developing ACLAMATE—the

Automated Cognitive Load Assessment for Medical Staff Training and Evaluation. Funded by the U.S. Army Medical Research and Materiel Command and managed by the Telemedicine & Advanced Technology Research Center, ACLAMATE is a system that unobtrusively collects and analyzes data about team workload during the simulation, giving trainers the ability to monitor and modify the scenarios to maximize individual trainee and team learning.

While medical simulator technologies have advanced, methods to measure training effective-ness have lagged. Currently, trainers use pencil-and-paper-based assessments that are limited to coarse high-to-low rating scales. In complex medical exer-cises where personnel each perform a different role, such broad evaluations don’t adequately reflect the learning experience for individuals and the team.

ACLAMATE closes that gap by analyzing data across several dimensions during the medical scenario, measuring the cognitive workload of each team member as well as the interpersonal dynamics and communications occurring amongst the group.

“Relying on a simple ‘1-5’ rating to evaluate training effectiveness can result in a gross over-simplification of whether learning objectives have been met. And more importantly, if not, why not?” said Jeff Beaubien, ACLAMATE principal investi-gator for Aptima. “You may have two teams that each received the same rating, but for entirely different reasons. One may have been under-chal-

lenged and bored, doing the minimum, while the other may have been overloaded with the scenario’s complexity, barely passing.”

During a simulation, unobtrusive sensors collect each member’s heart rate, brain activity and other neuro-physiological signals to assess individual and team workload. The team, comprising a surgeon, anesthesiologist, nurses and technicians, also wears Sociometric Badges, which use wireless microphones and accelerometers to record who’s talking to whom, turn taking, speech volume and pitch over time.

ACLAMATE’s algorithms analyze these data streams in real time. Instructors are automatically alerted to changes in cognitive load, allowing them to modify the scenario to ensure learners stay within the zone of proximal development throughout the exercise.

“Optimal learning occurs when trainees are kept in a sweet spot of proper cognitive load, where members of the health care team are pushed just beyond their limits, yet not overwhelmed,” said Scott Pappada, ACLAMATE project manager. “For example, if the scenario progresses to include complications, such as a sudden bleed, the trainer would be alerted before the team becomes overloaded; he or she could then modify the scenario accordingly,” added Pappada.

Aptima is developing ACLAMATE in partnership with Ohio State University’s Wexner Medical Center and Sociometric Solutions Inc.

Jeffrey M. Beaubien; [email protected]

Medical Simulation Technology to Improve Training


Compiled by KMI Media Group staff

MediCortex, a start-up pharmaceu-tical company focused on the treatment of neurodegenerative conditions, is devel-oping therapeutic drugs that will limit the long-term effects of brain injury, including the types of severe brain trauma that veterans have received in combat.

MediCortex, currently in the proof-of-concept stage, is seeking an investment

to support synthesis and initial in-vitro tissue culture studies for assessing the biological activity and lack of toxicity of its pipeline compounds.

TBI is an extremely serious and, unfortunately, increasingly common condition which for combat veterans is in most cases the direct result of close proximity to the concussive force of improvised explosive devices, mortars,

rocket-propelled grenades and other explosive ordnance. The symptoms of TBI which occur as a result of repeated head trauma include sleep disturbance, problems with concentration, ringing in the ears, nausea and seizures. When left untreated, these symptoms can develop into more severe neurodegenerative conditions, including Alzheimer’s and Parkinson’s.

An Orau-developed mobile application, CSEPP Ready, is a featured element in the inaugural 2013-2014 Prepare Pueblo emergency prepared-ness campaign in Pueblo, Colo., which is in its final phase from June to August 2014. Both the campaign and the app are intended to assist residents living in communities surrounding one of the last two active U.S. Army chemical warfare agent stockpiles with preparing for a potential chemical-related emergency.

Even though an accident is unlikely, FEMA and the Army work together to ensure the local communities are prepared through the Chemical Stockpile Emergency Preparedness Program (CSEPP). Through CSEPP, Orau experts provide hands-on technology courses to train public affairs

professionals and emergency managers to develop and deliver timely public information in an emergency event using the latest technology tools, including mobile apps, cloud technology and social media. Specifically, CSEPP Ready, which can be downloaded free in both Android and iPhone/iPad mobile formats, provides checklists for family disaster kits, information on how to respond to emergency sirens and directions for sheltering in place.

The Prepare Pueblo campaign focuses on talking about emergency preparedness with family, friends and coworkers, knowing residents’ emer-gency zones, and listening for alerts and notifications. The campaign was created by Pueblo-based public affairs professionals and emergency managers who had been through Orau-led CSEPP courses.

Among the various neurointerventional devices that have been developed for challenging indications, such as intracranial aneurysms and acute ischemic stroke, flow diverters and stent retrievers have shown particular promise as viable treatment alternatives, although they have yet to prove their long-term effectiveness, said an analyst with research and consulting firm GlobalData.

Priya Madhavan, M.S., GlobalData’s analyst covering medical devices, stated that following the success of stent-based technologies in the interventional cardiology and endovascular therapy fields, flow diverters, such as the Pipeline Embolization Device, and stent retrievers, including Solitaire, have attracted attention from the neurointerventional community.

Madhavan said: “Flow diversion techniques can be employed to treat complex intracranial aneurysms, including wide-neck, large and giant aneurysms, which remain difficult to treat due to high recanalization and recurrence rates. Flow diversion devices aim to reduce the need for inserting multiple coils and using stent- and balloon-assisted devices.”

Meanwhile, the development of novel mechanical thrombectomy devices, such as stent retrievers, has been fuelled by the limitations of intravenous thrombolysis with recombinant tissue plasminogen activator.

Stent retrievers provide a one-step technique for device deployment and clot retrieval, which increases ease of use and patient safety. With

the development of innovative stent-retriever technologies, market sales of mechanical throm-bectomy devices, such as the Merci clot retrieval system, have decreased significantly. GlobalData forecasts the stent retriever market to achieve revenues of over $50 million by 2020 and gain the largest share in the mechanical thrombec-tomy devices arena.

Novel Stent-based Technologies for Aneurysm and Stroke

Therapeutic Dugs for Severe Brain Trauma Under Development

Emergency Preparedness Mobile Application


Pushing Air Force Medicine Forward in a Constrained Fiscal EnvironmentQ&AQ&A

Lieutenant General (Dr.) Thomas W. Travis


Lieutenant General (Dr.) Thomas W. Travis is the surgeon general of the Air Force, Headquarters U.S. Air Force, Wash-ington, D.C. Travis serves as functional manager of the U.S. Air Force Medical Service. In this capacity, he advises the sec-retary of the Air Force and Air Force chief of staff, as well as the assistant secretary of defense for health affairs, on matters pertaining to the medical aspects of the air expeditionary force and the health of Air Force people. Travis has authority to com-mit resources worldwide for the Air Force Medical Service, to make decisions affecting the delivery of medical services, and to develop plans, programs and procedures to support worldwide medical service missions. He exercises direction, guidance and technical management of a $6.6 billion, 44,000-person inte-grated health care delivery system serving 2.6 million beneficia-ries at 75 military treatment facilities worldwide.

Travis entered the Air Force in 1976 as a distinguished graduate of the ROTC program at Virginia Polytechnic Institute and State University. He was awarded his pilot wings in 1978 and served as an F-4 pilot and aircraft commander. The gen-eral completed his medical degree from the Uniformed Services University of the Health Sciences School of Medicine, where he was the top Air Force graduate, and in 1987 he became a flight surgeon. For more than three years, Travis was chief of medical operations for the Human Systems Program Office at Brooks Air Force Base, Texas. He later served as the director of operational health support and chief of Aerospace Medi-cine Division for the Air Force Medical Operations Agency in Washington, D.C.

Prior to his current assignment, Travis served as deputy surgeon general, Headquarters U.S. Air Force, Washington, D.C. The general has commanded the U.S. Air Force School of Aerospace Medicine; 311th Human Systems Wing at Brooks AFB; Malcolm Grow Medical Center and 79th Medical Wing, Andrews AFB, Md.; and the 59th Medical Wing, Wilford Hall Medical Center, Lackland AFB, Texas. He also served as the command surgeon, Headquarters Air Force District of Wash-ington, and command surgeon, Headquarters Air Combat Command, Langley AFB, Va. He is board certified in aerospace medicine. A command pilot and chief flight surgeon, he has more than 1,800 flying hours and is one of the Air Force’s few pilot-physicians. He has flown the F-4, F-15 and F-16 as mission pilot and the Royal Air Force Hawk as the senior medical officer and pilot.

Q: As surgeon general of the Air Force, what are your priorities?

A: My top priority, and that of the Air Force Medical Service, is focused on supporting the line of the Air Force mission—our ‘true north’—maintaining a medical force that is trained and ready to deploy at a moment’s notice, but also aligned with our wings in support of their operational missions. Our mis-sion is to enable medically fit forces, provide expeditionary medics and improve the health of all we serve to meet our nation’s needs.

We have completed over 194,000 patient movements since 9/11, including transporting 7,900 critical care patients. We pro-vided ‘care in the air’ to more than 5,000 patients in 2013 alone, including almost 300 critical care air transport team (CCATT) missions for the most seriously ill and injured.

In addition, we are now providing enhanced support for our ‘deployed in place’ airmen who man systems such as remotely piloted aircraft, or who are executing intelligence, surveillance and reconnaissance missions. These airmen are projecting air power in ways we have never done before. In different ways, our ‘outside the wire’ airmen, such as special operations forces and explosive ordnance disposal specialists, require a different type of prevention and care. The types of injuries or stresses—both visible and invisible—these members face are causing us to

Pilot Doctor


adapt and innovate to provide medical support in different ways than we have in the past to address the expanding definition of ‘operators’ and step up to our role as human performance practitioners, assuring airmen are always able to perform their missions effectively. Not only will access and care be customized for the mission, but so will prevention. We are now working to institutionalize how we are doing it now and how it will need to be done in the future.

Q: What are some challenges that the Air Force Medical Service currently faces?

A: The foremost challenge will be to stay ready, even as we come home from the current long war. Our military forces have benefited from the vast achievements Air Force, Army and Navy medics have made in deployed and en-route care since the beginning of the current war. Yet with this war winding down, even with fiscal challenges, we now have a clear responsibility to make sure military medics are well-trained and well-prepared for whatever contingency the future brings, to include combat operations, stability operations, humanitarian assistance or disaster relief.

To enhance our competency in the ground expeditionary and air evacuation missions, we must ensure that our providers continue to have robust opportunities to practice their skills and that we continue to pursue critical research and modernization initiatives for the future. We have very successfully leveraged civilian partnerships to maintain trauma skills readiness, and as this war subsides, I am convinced we will rely even more strongly on these relationships to help us train and to conduct research. Our Centers for the Sustainment of Trauma and Readiness (C-STARS) partnerships in Baltimore, Cincinnati and St. Louis provided critical trauma and critical care air transport team training to our deploying medics during the war and will remain significant platforms. We believe we will need to expand our training opportunities in the pause between hostilities to ensure all of our personnel remain ready and current.

To that end, we are transitioning to a layered, centrally man-aged platform emphasizing hands-on patient care, called Sus-tained Medical and Readiness Training, or SMART. This program establishes a three-tiered approach where personnel at facilities of all sizes will train with a standardized curriculum using organic training opportunities, local training affiliation agree-ments with partnering hospitals, and, when necessary, regional currency sites to ensure required skills are preserved and staff is sustained in a trained and ready status. We anticipate our first class at a regional SMART site to begin in September at Nellis Air Force Base, Nev.

With a focus on the future, we are involved in some amazing state-of-the-art research in our major thrust areas of en route care, force health protection, expeditionary medicine, human performance and operational medicine. As an example, we are collaborating with the Battlefield Health and Trauma Research Institute and the San Antonio University Health System to conduct research on spinal fractures, blood transfusions, sepsis, burns, hemorrhagic shock and compartment syndrome.

In support of human performance and en-route care, our C-STARS faculty and civilian partners are studying the tim-ing of aeromedical evacuation on the clinical status of combat

casualties to help medical teams determine the best timing of evacuation to optimize health outcomes. While we have been very proud of our success in quickly returning patients to higher levels of care when required, the decision of when to move a patient must be data-driven, and our experience in the current long war should help guide such decisions in the future.

Q: How is the Air Force Medical Service managing to maintain force health protection in this time of steep budget cuts?

A: As always, the focus of the AFMS is the readiness of our air-men. We continue to invest in prevention measures, such as immunizations, targeted routine health assessments and force health protection research initiatives. These will pay huge divi-dends down the road in keeping our airmen healthy. Additionally, we are committed to working with our sister services in shaping the newly established Defense Health Agency. We are hopeful that collaborations over the coming months and years will result in efficiencies, as well as cost savings, across our force health protection programs.

Q: Could you discuss some examples of Air Force Medicine’s role in providing expeditionary combat casualty care in support of joint operations?

A: Our CCATT have been a vital component during the war in saving lives by transporting stabilized patients to the next level of care. Our ‘care in the air team’ capability has been instrumental in advancing our practice of transporting only stable patients to a paradigm of en-route patient treatment that has become integral to health service support in joint doctrine.

As we strive for even greater survival rates, we’ve evolved our CCATT capability point-of-injury response. This gives us more capable care further forward and more sophisticated in-transit support. Our tactical critical care evacuation teams deliver dam-age control resuscitation on rotary wing, forward-deployed fixed wing, and tilt wing aircraft, and have accomplished more than 1,600 critical care patient movements since we began the pro-gram in June 2011, many from point of injury.

In addition to our CCATT capability, the expeditionary medi-cal support health response teams are successfully deployed as a part of our continuous evolution in medical response capabili-ties anywhere in the world. They deliver immediate emergency care within minutes to hours of arrival—surgery and intensive critical care units in place within six hours, and full capability established within 12 hours of deployment arrival.

Working side by side with Army and Navy medics, we have executed joint en-route care that is historic in achieving unprec-edented survival rates.

Q: How does the Air Force Medical Service maintain the right workforce to deliver medical capabilities across the full range of military operations?

A: The AFMS prioritizes and funds our manpower requirements based on meeting the readiness mission we provide to the war-fighters. In addition to ensuring we have correctly funded the right manpower requirements, we take deliberate actions to maintain those skill sets.


Air ForCE MEdiCinE

Maj. Gen. Dorothy Hogg(SG3)

Medical Force Development

Farah Sarshar(SG8)

Medical Plans & Programs

Col. Michael Loverling(SG5)

Research & Acquisitions

Brig. Gen Charles Potter(SG1)

Health Care Operations

Col. Billy Cecil(SGY)

Chief Financial Officer/FM

Brig. Gen. James McClain

(AFMSA)AF Medical Support

Agency

Col. Richard Terry(SG6)

Chief Information Officer

Brig. Gen. Sean Murphy

(AFMOA)AF Medical Operations

Agency

Lt. Gen. Thomas W. Travis

Surgeon General

Command Sgt. E. Jason Pace

Chief Medical Enlisted Force

Maj. Gen. Mark EdigerDeputy Surgeon

General

2014

Legal Advisor to the Surgeon General

Congressional and Public Affairs

In addition to this work, the AFMS faces keen human resource competition from the private sector and other federal agencies. To mitigate this challenge, we have pursued an aggres-sive two-pronged approach specifically targeting expanded edu-cation opportunities and enhancements to quality of life/practice to attract and retain qualified health professionals. Beginning in 2006, we expanded officer and enlisted education opportuni-ties as a cornerstone of a ‘grow our own’ strategy. This included expanding the Health Professions Scholarship Program, funded residency training opportunities and instituting several new enlisted commissioning and certification programs such as the Enlisted to Medical Degree Preparatory Program (first selection board in fiscal year 2015).

By levying active duty service commitments to these pro-grams, the AFMS was able to lengthen decision point timelines and guarantee a sustained force cohort for the future. These programs have proven to be the most successful avenue of acces-sion for the AFMS.

In efforts to enhance quality of life and practice, we engaged clinical specialty consultants to balance the force and spread the deployment load more evenly among members. This effort con-tinues to be key for high-demand, low-density medical specialties with high wartime deployment rates.

The successful implementation and execution of our two-pronged approach has resulted in a 10-year high in overall AFMS retention and average career lengths.

Q: Within Air Force Medicine, is there a growing trend towards more personalized care?

A: Yes, we are moving in that direction. As an example, we continue to embrace the principles of patient-centered medical home (PCMH) to improve patient care, access and outcomes. We have attained all-time-high levels of provider and team continuity throughout 2013, while reducing emergency room utilization rates. And we developed standardized support staff protocols to promote evidence-based practice, reduce variation and enhance reliability by using PCMH teams to their fullest capabilities. The protocols have also helped to improve cur-rency of our medics while creating access opportunities for our patients.

Likewise, we have achieved enhanced access through the continued deployment of secure messaging. This technology has now been launched throughout the AFMS and includes more than 305,000 enrolled users sending over 41,000 messages per month. This leading-edge communication tool provides an additional venue to meet patient needs without face-to-face appointments, and helps our patients partner with providers in the management of their care.

Q: Much has been made of the ‘tyranny of distance’ in the Pacific region. How does that impact Air Force Medicine?

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A: In recent years, the Air Force has become accustomed to moving patients from Iraq and Afghanistan to definitive care in Germany and the United States relatively quickly, but the ‘tyranny of distance’ in the Pacific region does not allow that luxury. While we can depend upon the health care infrastructure of some Pacific countries to provide support to our patients, it is not available in all areas of the Pacific. Thus, the vastness of this region presents challenges to Air Force Medicine, most notably in our ability to provide rapid life-stabilizing care at dispersed operating locations, as well as responsive joint casu-alty evacuation from these locations to definitive care in the United States.

Additionally, potential adversaries in this region may prevent the access we have been accustomed to in recent wars, which could exacerbate the problem and result in even higher casualty rates. As the armed forces collaborate on new integrated war fighting concepts to ensure U.S. access and freedom of action in denied environments, Air Force, Navy and Army medics must also collaborate to ensure optimal warfighter performance and survival. Greater transport distances and times create a necessity for longer hold times for patients, which can increase the mortal-ity rate for casualties.

Accordingly, the AFMS has partnered with Navy and Army medics to develop integrated solutions for medical operations in denied environments. New capabilities must employ lighter, more autonomous medical teams enabled by miniature medical devices and telemedicine, yet more resilient to survive during forward operations in a hostile environment. Our aeromedi-cal evacuation system must be capable of moving casualties using integrated medical teams. An example is an ongoing Air Force-Navy collaboration to develop a way to move casualties from land to ship to land using integrated Air Force and Navy capabilities in support of hostilities in the Pacific. The Air Force and Navy are also exploring the potential use of unmanned aircraft for medical resupply and patient movement in denied environments.

We are also focusing on global health engagement activities to set the conditions for success in future wartime scenarios. We must give health engagement priority to the partner nations that play a critical role in our success in denied environments, first as a deterrent to war and second to ensure access to needed local infrastructure and resources in war. In order to quickly provide medical care, we must build relationships and share capabilities with partner countries in the region. The value of this type of engagement was recently proven in the Philip-pine tropical cyclone response. While U.S. Air Force medics were postured to support disaster relief efforts, the Philip-pine Air Force used training provided by Air Force medics to successfully move patients from the disaster area to receive medical care.

Q: How important are international partnerships to the Air Force Medical Service?

A: International collaboration is essential to our mission. International health specialists forge partnerships with nations around the globe, which help us address our critical challenges and meet theater combatant commanders’ end-state objectives. We are working to improve health conditions and regional

stability to decrease the risk of conflict, and also to become more interoperable partners, able to effectively respond as a team across the full spectrum of operations—from humanitar-ian disaster response to combat casualty care. As an example, we recently signed a terms of reference agreement with the Israeli Defense Force to reaffirm our mutual commitment to collabora-tion between our two organizations. The agreement will expand cooperation in such areas as aerospace medicine, mental health, training, academics and medical research.

Q: Are there any new special programs or initiatives within Air Force Medicine that you’d care to share with us?

A: I’m excited about the life-saving advancements in medicine—and the many initiatives now underway in the AFMS to ensure we remain on the leading edge into the future. I will give you a few examples.

We made history recently, when the lung team and one of our CCATTs transported the wife of a servicemember in need of a lung transplant on an Extracorporeal Life Support (ECLS) machine from Landstuhl, Germany to Joint Base Andrews, Md.—the longest-ever successful transport for a critically-ill patient on ECLS. Further research into use of the ECLS for the compre-hensive treatment of combat casualties with single- and multi-organ failure is now underway at the Joint Battlefield Health and Trauma Institute by Air Force investigators.

In addition, last year we launched our telehealth initia-tive, called Project ECHO (extension for community health outcomes), with one specialty (complicated diabetes manage-ment) serving three military treatment facility pilot sites. Now in our second year, we have added chronic pain management, traumatic brain injury, behavioral health, dermatology, ear, nose and throat, and acupuncture for a total of seven live ECHO spe-cialty series, and are on track to add four more specialty areas (addictions, infectious disease, neurology and dental) this com-ing year. We have expanded participation to include all services and the Department of Veterans Affairs. Added to this capability, continuing medical education accreditation was granted for six of the seven ECHOs. Participating provider response has been overwhelmingly positive, with a 17 percent increase in provider knowledge and confidence level in their management of these complicated patients, and an overall 95 percent approval rating in the ECHOs’ value to their practice. Project ECHO is postured for MHS-wide adoption under the new Defense Health Agency, which was established on October 1, 2014.

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

A: During my 37-year career, I have never seen a time when it was more evident how important military medicine is to the operational capability of this nation. We have learned much and our medics have performed magnificently. The AFMS will con-tinue to focus hard on providing operational support and high quality care around the globe, in-garrison and deployed, on the ground or in the air—that’s what we mean when we say ‘trusted care anywhere.’ I am honored to lead and serve with Air Force medics during this important time, and to partner with my Army and Navy colleagues as we move forward together to build an even better Military Health System. O


It doesn’t take any sort of formal medical training to comprehend how crucial oxygen is when treating wounded warriors, whether that treatment needs to takes place right on the battlefield or happens back at a basecamp hospital unit. It’s a cornerstone of life on Earth, after all, and, as Scott Brady said, “Supplemental oxygen is typically provided on the battlefield during hemorrhage, pneumothorax, and for open or penetrating chest wounds.” In other words, oxygen is used for nearly every kind of typical combat-zone injury.

Brady, a biomedical engineer for the U.S. Army Medical Material Agency at Fort Detrick, Md., went on to explain that “the Department of Defense has invested research and development dollars to fulfill the require-ment for unlimited oxygen from a small, lightweight device.”

Smaller and lighter, yes, but without sacrificing performance. Increased flow rates, improved reliability, and higher safety standards also are on DoD’s wish list. “Those would all be welcome advancements for providing supplemental oxygen on the battlefield,” Brady added.

The people at On Site Gas Systems have been work-ing on those exact types of advancements for nearly 25 years, and on armed-forces-specific solutions since 2001. “The military came to us years ago with this need,” said Robert Wolff, the company’s vice president of sales. “We had already been making oxygen genera-tors for a long time, but the question was, ‘Okay, can we now take this and make it so that the military can transport it and set it up easily, use it, have it be reliable and withstand getting banged around in the back of a truck, and have it stay operational in the desert when it’s over 100 degrees?’ We took the concept that we had been using for a number of years and brought that to meet the military’s standards.”

That concept is to separate the molecules of existing air. As Wolff said, “It’s not terribly complicated, but it’s not exactly easy.

“The air you breathe is about 21 percent oxygen. What we do is pull out a good amount of the balance, mostly nitrogen, and end up with a concentration of USP93 medical-grade oxygen, which is 93 percent oxygen, plus or minus 3 percent. It’s just a separation of molecules. It’s a physical process, not a chemical one.”

Perhaps then the more complicated process was to imbed that science into a battlefield-ready contraption. “That’s our expertise, though,” said Guy Hatch, chief executive officer at On Site Gas. “Our company is built around finding a solution that meets our customers’ specific needs. In this case, it was to take existing technology and make it small enough and robust enough to oper-ate anywhere in the world.”

Ultimately, location can be one of the biggest chal-lenges. “The extreme environments encountered on the battlefield make sustainment of oxygen generators difficult,” explained Brady. “The Army performs envi-ronmental tests before selecting equipment to ensure the devices are not only effective and safe, but also suitable for the environment to which they will be deployed.”

Hatch, Wolff and their colleagues were up to the task. “It took a lot of engineering and design work, and then there was a lot of trial and error and testing that was involved with prototypes,” said Wolff. “These things have to withstand being dropped, withstand the cold and heat. They have to go from storage to being deployed on trucks, planes and helicopters, and then set up in the field—all without heavy equipment to move it.”

The end result of all the brainstorming and blueprints was their Portable Oxygen Generation System (POGS), a self-contained,

mediCal oxygen Comes in many forms for ameriCa’s military.

Guy Hatch

robert Wolff

By J.B. Bissell, m2Va CorresPondent


man-portable, FDA-approved unit that can generate up to 33 liters per minute of medical-grade oxygen.

“That oxygen can then be put either directly into patient care—you can hook a patient directly up to our unit—or into a distribution system for a facility, or you can fill cylinders and have those for trans-portation and back up,” Wolff said.

Those three options mean that POGS essentially solves one of the military’s biggest oxygen-related problems. “In a medical situation, whether it’s non-critical or critical care, oxygen is required and used everyday,” said Wolff. “The dilemma, especially for the military, is the ability—or lack thereof—to have oxygen when you need it at all times.”

But since POGSs simply make use of the ambient air wherever they’re deployed, they can supply much-needed oxygen 24 hours a day, seven days a week if needed. “It’s an on-demand system,” Wolff explained. “We’re creating oxygen and it’s being used or filling cylin-ders at the same time. Logistically, we don’t have to rely on anybody else bringing cylinders or tanks in. We just take the air and run it through our generator. You control your oxygen.

“So, with our equipment, as long as it’s provided air—and minor maintenance over the course of time—the oxygen never goes away. You don’t have to replenish anything. It’ll just keep on running for years and years.”

easy oxygen on tHe go

Oxygen cylinders—a necessity for medical transfers and certain other emergencies—do need replenishing. “That need presents a logistics issue when transporting across a battlefield,” said Brady. “The Army reduces the logistical burden by using large oxygen generators at combat support hospitals.”

Cobham’s Deployable Oxygen Generation System–Medium (DOGS-M) is one of the devices that can help ease that particular bur-den. It produces 93 percent pure oxygen at the rate of 120 liters per minute, and in addition to “providing medical-grade oxygen directly to patients at field based hospitals, it can fill various sized cylinders,” said the company’s business development manager, Craig Case.

“Our ground-based systems have been qualified to meet the U.S. Air Force medical oxygen generator standards for large vol-ume systems,” added Case. “Still, the Cobham DOGS-M has rela-tively small physical dimensions (among large-volume generators) so more units can be transported on a single pallet, reducing transportation costs.”

As a matter of fact, each DOGS-M weighs in at about 2,250 pounds, but their slim profile, measuring just 28 by 60 by 76 inches, allows up to four to be loaded on a single standard 463L pallet.

At the other end of the size spectrum, Cobham also manufac-tures oxygen generators specifically for medical helicopter transport groups. The Advanced Medical Oxygen Generating System (AMOGS) is “designed for the Sikorsky HH-60L/M medical evacuation helicop-ter,” said Case. “It’s a unique system in that it provides USP93 oxygen directly to patients en route or via an integrated storage bottle.”

Since onboard medics and crewmembers already have plenty to be thinking about, Cobham made sure that the AMOGS was as plug-and-play as possible. It comes with dedicated system software and a modular design to ease maintenance issues. The valves are simplified and the status panel is particularly straightforward. Furthermore, “Cobham offers training programs for operation and service of all our units,” added Case.

Ease of use also was one of the main considerations when Oxy-Sure Systems started the development of their Model 615 Portable Emergency Oxygen System. “It’s an on-demand, emergency-duration device that’s suitable for layperson use,” said Julian Ross, OxySure’s chief executive officer.

Not only is it easy to use, but it’s an entirely different kind of product. “It’s a unique technology,” Ross continued. “Medically pure oxygen is created instantly when needed from two dry, inert powders inside a specially designed dispenser made of lightweight and thermo-plastic materials [the Model 615].”

It may seem like something out of a futuristic science fiction movie, but the three-step process really is nearly effortless. All anybody in the immediate vicinity must do to begin oxygen delivery is insert a powder cartridge, turn the Model 615’s obvious knob, and outfit the victim with the mask. That’s it, and then the system will push six liters of medically pure oxygen per minute for at least 15 minutes. If addi-tional oxygen is required, a fresh cartridge can be employed.

Two technical sergeants connect oxygen tanks to a cylinder bank at a undisclosed Southwest Asia location. [Photo courtesy of the U.S. Air Force/by Technical Sergeant Michelle Larche]

A liquid oxygen filling diagram. [Photo courtesy of Essex Industries]


Because it is so easy and utterly portable—the dispenser weighs just 11 pounds—it can “greatly improve access to emergency oxygen that positively affects the survival, recovery and safety of individuals in numerous areas, especially military applications,” Ross added.

liquid oxygen

Essex Industries supplies the military with yet one more type of product: liquid oxygen (LOX). But they didn’t decide to do it on a whim. “The design and development of the Essex products was driven by customer request,” explained Tim Bannister, vice president of sales and business development, Essex Industries. “The United States Air Force Special Services called on us, with our experience in LOX sys-tems, to solve their problems of medical oxygen delivery. We were able to devise a system of products [the Battlefield Oxygen Sustainment System, or BOSS] for battlefield applications.”

Put simply, BOSS is a complete collection of products that were designed specifically to generate, liquefy, store, fill and deploy liquid oxygen. The system currently features four products (which are also available separately): the Oxygen Generator and Liquefier (OGL), Back-pack Medical Oxygen System Filling Station (BMOS-FS), Mounted Medical Oxygen System (MMOS), and Backpack Medical Oxygen System (BMOS).

As impressive as this range of products is, it’s Essex Industries’ fundamental difference from other companies in the same industry that remains their standout quality. “LOX systems inherently provide several advantages over gaseous systems in medevac applications,” explained Bannister.

“Liquid oxygen increases in volume 860 times as it converts from a liquid to a gas. That means a smaller amount of LOX will produce a large volume of gas, eliminating heavy storage cylinders. This reduces both the weight and space required, resulting in portable units that are easier to carry without sacrificing capability. Fill time also is much faster: It takes only 10 percent of the time to refill these units than comparable high pressure gaseous systems.”

As Brady indicated, logistics is one of the greatest challenges associated with field-based oxygen generation and delivery. But incon-venient emergencies happen all the time, and the oxygen absolutely must arrive where it’s needed. “Our OGL helps solve this issue by providing a more compact, mobile means to generate LOX in the field, and thereby provide a practical method for refilling field and medevac equipment,” Bannister said.

These are truly portable solutions, too. The BMOS is a lightweight LOX storage and gaseous delivery system that can be carried or worn by parachutists and ground support personal to administer oxygen to a patient in the field. The BMOS-FS, a portable LOX storage device that is designed to fill multiple BMOS or MMOS systems, can be carried by two ground-support personal or mounted in an aircraft, helicopter, or ground vehicle.

“In addition, our products feature several benefits that overcome obstacles or challenges found in the field,” Bannister continued. The BMOS, MMOS, BMOS-FS and Next Generation Portable Therapeutic Liquid Oxygen System do not require a power source for operation. They are more reliable, with no moving parts and no requirements for periodic testing, and also provide versatility. For example, medics can use the BMOS to run a ventilator.”

The bottom line is that “our system enables the military to provide and generate medical oxygen wherever it is needed,” Ban-nister said. And sometimes it’s needed in places beyond the battlefield.

“These products have been well received by all branches of the military. Their deployment has brought life-saving medical oxygen to soldiers on the battlefield and in medevac transport. But their usage has extended to civilian medevac and disaster response applications, too. The generators and filling stations enable all emergency personnel to keep the equipment ready for any crisis situation.”

Guy Hatch also emphasized non-military applications. “Disaster management requires medical oxygen,” he agreed. “We sent a bunch of POGS down to New Orleans after Katrina because the infrastruc-ture for this particular need was unusable for about two weeks. Our machines were essentially set up as an oxygen filling station for the cylinders that went out to the airport and other places where they had taken folks. POGS were used in Haiti after the earthquake, too; in the field hospitals and make-shift clinics.”

Indeed, whether it’s in the field or in a helicopter—and supplied by separating molecules from the air or taking advantage of the liq-uid form—oxygen isn’t only a cornerstone of life, it’s a cornerstone of medical treatment and disaster management. Fortunately, these companies and others like them are making it easier than ever for this essential gas to get where it needs to be, when it needs to be there. O

The ship’s certified registered nurse anesthesiologist provides an oxygen mask for a patient during surgery in the operating room on board the aircraft carrier USS Ronald Reagan. [Photo courtesy of the U.S. Navy/by Oliver Cole]



Physician assistants (PAs) are among the most highly paid individuals with master’s degrees. According to the most recent sur-veys, in 2012 the annual median salary for the profession was $90,930. The profession has its roots in the military as well.

The first PA program was started at Duke University in 1965. This class was formed entirely of former U.S. Navy hospital corpsmen.

Many universities today still reach out to veterans for their programs. A number of them go the extra mile and provide generous benefits to veterans seeking a transition into a new civilian career.

georgia regents uniVersity

The Georgia Regents University (GRU) PA Program is ranked number 25 by U.S.

News and World Report out of all the accred-ited PA programs in the country. GRU’s PA Program also has the lowest tuition of all PA programs in Georgia. Furthermore, GRU PA graduates’ board pass rate is consistently higher than the national average on certifica-tion exam scores. The class of 2013 achieved a 100 percent pass rate on the PA National Certification Exam (PANCE) on their first attempt. Ninety percent of GRU PA graduates have jobs before they graduate. Forty percent of the faculty and adjunct faculty are veterans who have served in the armed forces prior to their careers as PAs.

“In 2012, GRU’s PA Department devel-oped its ‘Green to Grad’ program with specific focus to attract veterans to Geor-gia Regents University by utilizing the Health Research Services Administration Grant awarded to the GRU PA Program,”

said Associate Professor Rebecca Rote. “Our program goal is to strategically advance the physician assistant profession by encour-aging experienced prior service military personnel to pursue the PA profession as a second career. We believe increasing the number of veteran personnel enhances our profession by transitioning mature, depend-able, life-experienced leaders into our com-munities, [individuals] who will provide outstanding patient care and who will men-tor current and future PA professionals into experienced providers and leaders.”

The Green to Grad Program supports veterans by identifying, recruiting and men-toring active duty and reserve personnel and veterans who are interested in pursuing a Master of Physician Assistant (MPA) through Georgia Regents University. The program is working to increase veteran application

By CHris mCCoy, m2Va editor

many uniVersities reCruit Veterans for tHeir PHysiCian assistant Programs.From Veteran Medic to Physician Assistant


submission, veteran interview selection and veteran acceptance by approximately 10 per-cent. This equates to increasing acceptance of prior servicemembers from an average of one to two veterans per class per year to four to five veterans per class per year.

Green to Grad also works to reduce mili-tary/veteran specific obstacles often encoun-tered by current and past servicemembers pursuing undergraduate and graduate level education. The program enhances student education opportunities, encourages student commitment to pursue the MPA degree, and decreases prerequisite course workload by offering transfer credit flexibility for military specific courses completed during a service career.

“Green to Grad utilizes military medical experience and deployment experience in lieu of shadowing experience, medical expe-rience, or volunteer experience if medically related,” said Rote. “The GRU PA department along with GRU’s Office of Military and Vet-erans Services has identified and worked to eliminate many of the barriers to enrollment that veterans interested in pursuing the PA profession face.”

The consolidation of Augusta State Uni-versity and Georgia Health Sciences Uni-versity into Georgia Regents University has provided an additional opportunity for vet-erans to receive education assistance that is streamlined to support a more efficient enrollment process at GRU. It also allows vet-erans, active duty servicemembers and their dependents the opportunity to complete prerequisite coursework on an as-needed basis prior to submitting the PA Program application.

“Through this effort GRU continues to develop community growth and rapport, expand the operational relationship between federal and state government installations, and provide an opportunity for GRU admin-istrators, faculty and staff to recognize and demonstrate our appreciation to enrolled veterans for their military service,” said Rote. “This effort has cultivated an environment of mutual respect and teamwork between GRU, Fort Gordon Army Installation, Vet-erans Administration Hospitals and the Georgia War Veterans Home, who have all agreed to serve in the recruitment and edu-cational activities during the mobilization phase, as well as the PA didactic and clinical academic years.”

In a continuing effort to support the mil-itary, the Georgia Board of Regents passed a resolution on April 20, 2012, to waive

the $235 institutional fees for active duty military at University System of Georgia Institutions. Georgia Regents University also offers credit by examination and has an online transfer equivalency guide for cur-rent and prior military servicemembers to evaluate if their prior military training may be able to transfer into college credit. This enhances the student’s education opportu-nities, encourages student commitment to pursue a degree, and decreases prerequisite course workload by offering transfer credit flexibility for military-specific courses com-pleted during the student’s military service career.

Moreover, Georgia Regents offers an out-of-state tuition fee waiver to all full-time military personnel stationed in Georgia and to their dependents.

“Dependent children of active duty servicemembers may also qualify for the Hope Scholarship if they graduate from a Georgia high school,” said Rote. “The Army ROTC Green to Gold Division Commander’s Hip Pocket Scholarship Program provides selected soldiers the opportunity to complete their baccalaureate degree requirements and obtain a commission.”

soutH College

Tennessee-based South College’s Vet-Up Program is designed to offer medics and corpsmen that have provided life-saving health care skills in the U.S. armed forces the opportunity to continue their profes-sional education with the goal of becoming a physician assistant.

The program focuses on adding to the extensive military training and real-world experience these veterans have by bridging the gap between military health care experi-ence and the civilian graduate medical edu-cation of a PA program.

“These men and women will have a unique opportunity to continue to serve others as ‘lifesavers then, caregivers of the future,’” said Ken Harbert, Ph.D., MHA, PA, DFAAPA. “Our country is in dire need of primary health care providers and they will be the ‘best of the best’ with the latest emergency medical training that often far exceeds that of civilian trained health care providers.

“These men and women who have mili-tary health care experience are dedicated to providing high quality patient care to the citizens of Tennessee and will make excellent physician assistants,” said Harbert.

“Our program offers mentorship, advice and partnering with a veteran faculty member to assist each veteran in their path to become a physician assistant. These men and women will have a unique opportunity to continue to serve others above themselves.”

drexel uniVersity

The Drexel University PA Program appre-ciates that many servicemembers gain valu-able patient contact during their service. Navy corpsmen and Army medics are obvi-ous examples, but many other postings allow someone the experience of patient contact.

“We take that into consideration dur-ing application. Teamwork is a huge part of being a PA and we also realize that it is a skill honed during service. Our program is a good fit because we look at each application that meets our prerequisites on an individual basis—we don’t only consider GPAs, patient contact or other requirements alone,” said Adrian S. Banning, MMS, PA-C. “We really look at the whole picture that an applicant brings to the table. We continue that indi-vidual attention in regards to students of the program as well.”

The student to faculty ratio within the program is eight to nine students per each faculty member.

“While we are the first PA program in Pennsylvania, one of the first in the country and have one of the largest classes in the country, we also have a large and very com-mitted faculty,” said Banning. “The faculty knows your name right away. We get to know you and are there to help you become the best PA you can become. The program is student-centered.”

The faculty has an open-door policy at Drexel and strives to meet student needs. All students are paired one on one with a faculty advisor who they can access as a resource. All students are also paired one on one with an upperclassman student mentor as another resource.

“Our program has 90 credit hours of pre-requisites, and while that’s no small amount, we don’t require a bachelor’s degree at this time. Most applicants do have one, but if you were deployed and moving and traveling, we recognize that finalizing a degree could have been a challenge,” said Banning. “In addi-tion, the classroom (or didactic) portion of our program can be taken over two years at a slightly lesser pace than full time. This is a flexible option for veterans. The clinical por-tion is full time. Our graduates report that


they feel they were trained well and we have excellent PANCE pass rates.”

Banning explained that Drexel University is very veteran-supportive and has consis-tently been recognized for its outreach to military servicemembers. Drexel features an Office of Veteran Students Services to pro-vide campus-wide support. There is a student veteran association and a veteran lounge and email list.

“We’re very proud that U.S. News and World Report recently ranked Drexel as number 12 on the inaugural Best Col-leges for Veterans List out of 234 schools,” said Banning. “In addition, Victory Media, G.I. Jobs and Military Advanced Education have each named Drexel a Military Friendly School for 2013-2014. Drexel is also a Yellow Ribbon school, offering financial assistance to veterans-more on that below.”

Since Drexel University is a Yellow Rib-bon school, the VA and the university will match the contribution of the government to a student’s education for those who are eligible. Tuition and fees are covered 100 percent, there is an allowance for books, and there is no cap to the number or participants that Drexel will support. All programs at the university, including the PA program, fall under this benefit.

“This is part of the GI Bill,” said Ban-ning. “So while the base tuition is not differ-ent, this is a great benefit that might make a huge difference to a person. In addition, we have a great office in Drexel Central that will help you through each step of the financial aid and Yellow Ribbon process individually.”

uniVersity of wasHington medex nortHwest

University of Washington (UW) MEDEX Northwest also has a history of supporting former servicemembers in their PA program. The first class started in 1969 with 14 former corpsmen and medics. The first five classes were all military veterans.

“MEDEX has always included veterans in its classes, and in 2014, one-third of the approximately 2,000 MEDEX graduates had been in the military prior to entering the program,” said Keren H. Wick, Ph.D. “Over the last several years, between 20 and 33 per-cent of the entering class has been from the veteran (or Guard or Reserve) population.”

All students are required to have at least two years of clinical experience; most have more than this. This contributes to an

average age of 34 to 35, which is higher than in most PA programs.

“This means that our veteran students are in the classroom with others who also have a few years of life experience after high school,” said Wick.

MEDEX includes veterans on the faculty, with at least one veteran faculty member at each of its four classroom locations. MEDEX includes military hospitals and clinics as well as VA facilities in the roster of clinical sites used for student rotations.

“MEDEX provides applicant information sessions on or near military installations where we have classrooms and attends edu-cation fairs hosted by different branches of the service,” said Wick. “The missions of both the UW medical school and MEDEX include educating clinical providers who will serve rural areas within our five-state north-west service region (Washington, Wyoming, Alaska, Montana and Idaho, or WWAMI). MEDEX also places emphasis on increas-ing access to health care for the medically underserved.”

MEDEX considers the whole application when potential students apply to the pro-gram. This includes grades, but also outlines a candidate’s rural, disadvantaged, or mili-tary background. The curriculum includes topics specific to special populations, such as culturally appropriate care for minority groups. Medical conditions that veterans may encounter, such as PTSD and traumatic brain injury, are also covered in the program.

The UW Veterans Center employs staff who can conduct official reviews of the vet-eran’s status to determine eligibility for the GI Bill. They also offer confidential referrals or veteran-specific counseling if needed. The veterans center serves as a hub for student groups seeking social interaction.

“Veterans can often apply medically related training as shown on the military transcript to MEDEX program prerequisites. Admissions staff screen the military tran-script for potential matches with prerequisite courses,” said Wick. “Students seeking a bachelor’s degree as part of their PA educa-tion can receive up to 30 transfer credits (from the military transcript) at the UW toward the general education requirements. Students must complete the UW general requirements for a bachelor’s degree in addi-tion to the MEDEX coursework.”

The bachelor’s option will be retired when all PA programs are required to be at a master’s-only level in 2021. The master’s degree option is a stand-alone program that

does accept transfer credit (all students take all courses).

The UW and all state institutions allow veterans to use the in-state tuition scale if they separated from a base in the state. However, MEDEX was given self-sustaining status in the mid-’80s, which means that the program does not receive state funds. All stu-dents, in-state or not, pay the same tuition. The program retains that tuition, which provides operating funds for the program. MEDEX accepts GI Bill tuition support for its veteran students, and also tuition assis-tance as allowed by each branch for Guard or Reserve members.

MEDEX has four classroom locations: Seattle, Spokane and Tacoma, Wash., and Anchorage, Alaska. All four locations offer easy access to cultural and recreational activities.

“Seattle’s campus is in the middle of the urban core. The flagship campus of the UW could qualify as its own city within Seattle (almost 44,000 enrolled students plus faculty and staff),” said Wick. “The campus is next to Lake Washington. Major nearby military bases include Naval Station Everett, Naval Air Station Whidbey Island, Navy Base Kit-sap, and Joint Base Lewis-McChord.”

The Spokane class meets at the inter-collegiate campus shared with Washington State University and Eastern State University. The campus is easily accessible just next to downtown. Fairchild Air Force Base is near Spokane.

The Tacoma classroom is on the Univer-sity of Washington-Tacoma campus, which is located in the city center in a refurbished warehouse district. UWT enrollment is much smaller than main campus, a size that fosters a sense of campus community. Joint Base Lewis-McChord is just 13 miles away, and Navy Base Kitsap is across Puget Sound to the west.

The Anchorage site, in collaboration with University of Alaska-Anchorage, uses classroom space in the UAA health sciences building. Sometimes students remain in base housing on nearby Joint Base Elmendorf-Richardson.

Since their start, PA programs have focused on training veterans, and it is refresh-ing to see that so many modern universities are continuing that tradition. O

For more information, contact M2VA Editor Chris McCoy at [email protected] or search our

online archives for related stories at www.m2va-kmi.com.


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Medical Simulation Technology to Improve Training


Roy Deal, M.D. Medical Director and Service Director

for Military Resiliency UnitEmerald Coast Behavioral Hospital

Q: Could you tell our reader about some of the solutions Emerald Coast Behavioral Hospital offers to the military and other government contractors?

A: Emerald Coast Behavioral Hospital provides a military-specific inpatient psy-chiatric unit that is part of the Patriot Support Program of UHS Inc. This dedi-cated unit serves active duty and retired military suffering from a wide variety of mental health issue ranging from PTSD/trauma, depression and anxiety to addic-tion/chemical dependency.

Q: What unique benefits does Emerald Coast Behavioral Hospital provide its customers in comparison with other companies in your field?

A: The Emerald Coast Behavioral Hospi-tal Resiliency Unit provides a temporary duty station to military servicemembers in their greatest time of need. These men and women who have served our country valiantly are able to receive evidence-based treatment alongside their brethren that will allow them to find their new ‘normal’ and in most cases return back to duty. We provide comfort in crisis and strength through healing.

Q: What are some interesting new programs or initiatives at Emerald Coast Behavioral Hospital?

A: At Emerald Coast Behavioral Hospital we are providing proven, evidence-based treatment for individuals suffering from a broad spectrum of mental health dis-orders. Our treatments include cogni-tive behavioral therapy, cognitive process therapy and prolonged exposure, and [we] have recently undergone a facility wide implementation of dialectical behavior therapy.

Q: How is Emerald Coast Behavioral Hospital positioned in the market for expansion?

A: As Emerald Coast Behavioral Hospital’s Resiliency Program continues to provide positive treatment outcomes, our reputa-tion of success has required our unit to be expanded. We do not ever want a wounded warrior who is seeking our help to be turned away due to capacity issues. So as the need for civilian assistance to active/retired military grows, we too had to grow with it. We are dedicated to providing excellent patient care to our active/retired military and adjusting to the growing demands of the military installations we proudly serve.

Q: Can you provide a few success stories?

A: Story 1: We treated a Marine Lieuten-ant Colonel with 20 years of distinguished service. He started as a tank operator in Desert Storm. His PTSD had caused stress to produce several severe medical problems. He completed the program for PTSD and was able to return to duty. He remained in contact with me to let me know most of his medical problems resolved and he was promoted to full colo-nel before his retirement from the Marine Corps. He invited me to his promotion ceremony and retirement party and stated he was well, enjoying his family and retir-ing with honor with a renewed outlook on life because of our staff’s dedication to his recovery and discussed our program at his promotion ceremony as the reason for his success and recovery.

Story 2: An active duty E-5 with nine years of flawless service was admitted

to me. She had been diagnosed with schizophrenia and had been admitted to a DoD facility twice and another pri-vate hospital. She had custody of her infant removed due to her continued psychosis and failure to respond to treat-ment. She had a restraining order issued by her husband. She presented to our facility catatonic and unable to com-municate her needs or symptoms and refusing treatment. I got her mother, a psychiatric nurse from Miami, involved in her treatment. We had three three-hour sessions, with her mother driving from Miami for two of them. With her mother encouraging her and filling me in on family history, it was determined she had PTSD from childhood trauma and severe post-partum depression with psychotic features. These issues had never been diagnosed or treated. With proper medication and psychotherapy from the therapy staff, her condition responded to treatment with 100 percent remission of symptoms, return to duty, return to her husband and child, and a very emotional, joyful reunion. A family and career saved.

Q: How are Emerald Coast Behavioral Hospital’s solutions customized to meet the needs of the government?

A: Emerald Coast Behavioral Hospital’s Resiliency Unit has a staff that is specially selected to work with the military and government. We understand military cul-ture and provide military culture training to all of our civilian employees. Most of the employees working with our active/retired military are in the National Guard, Reserves, or are themselves veterans. We provide consistent communications to all the military installments and the VA regions we serve. We adhere to military/VA formularies for medication manage-ment, provide 24/7 access for command visits, have dedicated parking for military/VA members, a special waiting area in our intake area, and can organize transporta-tion when needed. O

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NEXT ISSUE


Cover and In-Depth Interview with:

Dr. Jonathan Woodson

Insertion Order Deadline: July 22, 2014 • Ad Materials Deadline: July 29, 2014

FeAtures

August 2014Vol. 18, Issue 3

Master’s in Public HealthA master’s degree in public health can be an attractive way into formulating health care policy for veterans who have left the services and are interested in a career in government.

Burn CareAmong the worst battlefield injuries are severe burns. The term fourth-degree burn has even been coined to describe those burn injuries that go to the bone.

Information sharingThe electronic health record system for DoD has been a centerpiece of reform.

DefibrillatorsDespite their near ubiquitous nature, only a few companies manufacture defibrillators for the military and civilian world.

sPeCIAl seCtIOn: Combat Casualty Care simulationSimulating battlefield injuries provides crucial experience to the men and women involved in military medicine.

WHO’s WHO: Defense Health AgencyA pictorial chart depicting the leadership and command structure of the Defense Health Agency.

Assistant secretary of Defense for Health Affairs

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