The pulse of Army medicine
April 25, 2011
As far as the Army surgeon general is concerned, even one patient is one too many.
Lieutenant Gen. Eric B. Schoomaker, who is also commander of the Army Medical Command, said that although Army doctors and medics are among the best in the world, he'd prefer they weren't needed at all. Instead of trying to heal Soldiers and Families after injuries and illnesses, he would rather focus on keeping them healthy in the first place.
However, in the midst of two wars, and rising chronic illness rates nationwide, Army medical professionals must set their sites on both prevention and cure.
"Not only are we focused on protecting health and preventing injuries, whether in combat or back here at home, we are simultaneously providing the very highest quality of care should something happen in spite of our best efforts," he explained.
In Iraq and Afghanistan, battlefield survivability has skyrocketed to about 95 percent, surpassing all previous wars. Most wounded warriors make it back to a major military medical center, like Walter Reed in Washington or Brooke in San Antonio, within days of a serious injury. Schoomaker said he's heard top civilian trauma experts say that "probably the best care that you can get right now anywhere in the world, is in a tent hospital or makeshift facility in Afghanistan or Iraq.
"We have worked very hard to gather the relevant information about the nature of wounding and the nature of care delivered, so that every patient gives us the opportunity to learn how to do it better for the next patient," he continued. "We've modified many, many ways in which the casualty is managed at the point of injury."
That means Soldiers can give themselves and their battle buddies immediate medical care with simple procedures, like tourniquet application, even before combat medics provide more comprehensive lifesaving aid. Every Army medic is a certified emergency medical technician who carries high-tech equipment, such as blood-clotting bandages, previously unavailable to battlefield first responders.
Schoomaker also commended the Air Force medevac system, which enables wounded servicemembers to be flown back to the States in what are essentially intensive care wards under the watchful eyes of Army, Navy and Air Force medical professionals. He also noted changes in the way patients receive blood and fluids, the types of surgeries wounded warriors receive, as well as how they're resuscitated. Most importantly, the military is leading the civilian world when it comes to the treatment of neurologic and severe brain injuries.
"Neurosurgeons in civilian life are now beginning to recognize that things that military neurosurgeons have learned and are applying are changing the survival and long-term recovery and degree of rehabilitation of people who suffer from very severe wounds to the brain," Schoomaker said, pointing out that Congresswoman Gabrielle Giffords has been largely treated by former military neurosurgeons since she was shot in the head in Arizona in January.
After a catastrophic injury, like traumatic brain injury or one that leads to amputation, a Soldier also needs follow-up, rehabilitative care, which Schoomaker said the Army had gotten away from. This led to an "almost civilian" system of care with a focus on providing immediate, top-notch inpatient and outpatient care, but lacked that crucial intermediate step, which left a "cumbersome" and "chaotic" system for some Soldiers and Families who needed more support.
In the wake of the 2007 Washington Post series on Walter Reed, Schoomaker said the Army rediscovered "that this complex process of healing, rehabilitation and transition-either to private life or back into uniform-requires an integrated, interdisciplinary system that centers around teams, and looks at the whole system from when one is injured, to inpatient healing, to how we transition to an outpatient setting.
"In an era in which the majority of our Soldiers are married with Families, we had to learn what the Family required and how to incorporate them into the healing and rehabilitative process. We didn't have the processes and the focus to do that, and we have now integrated them as full partners in this process. When a Soldier is wounded, the whole Family suffers and needs to be a part of the Soldier's rehabilitation and integration."
That realization led to the establishment of warrior transition units (29 hospital-affiliated and nine state-affiliated units, so Soldiers, particularly those in the reserve components, can heal closer to home) and the triad of care. Comprising a primary care provider, nurse case manager and squad leader, the triad is designed to help Soldiers heal, then return to their units or transition to life as veterans. According to Schoomaker, the program has been extremely successful, and continues to evolve and improve, responding to the ever-changing needs of wounded warriors.
"We're really focused now on the plan that gets a wounded, ill or injured Soldier and (his or her) Family to move through the process of healing, rehabilitation and integration. We call that the Comprehensive Transition Plan. We worked a lot on codifying that," Schoomaker said.
"We've even begun to (integrate) electronic forms that the triad of care can use as a tool (to) interact with the Soldier and Family to help chart their way ahead through multiple domains of their lives."
By working directly with Soldiers and their Families, Schoomaker said the care team gets answers to questions like: What education and training will the Soldier and Family require' What kind of financial support is available' How is the housing situation' What special problems does the Family experience as a result of the injury or illness' "We're looking at how we can marry that up with improvements in the Physical Disability Evaluation System," he explained, adding that one of the most difficult things Soldiers must do, with the support of their triads of care, is decide whether they can continue on active duty or need to medically retire.
Improving care is also the impetus behind the Patient-Centered Medical Home initiative, launched last fall. Under the program, the Army is building primary-care-focused clinics that will give Soldiers and their Families better access to immediate, quality health care. Patients will also be able to establish relationships with their primary care doctor, nurse practioner or physician's assistant.
The program will be especially beneficial for patients who have chronic illnesses, like asthma or diabetes, that require close monitoring, Schoomaker said, adding that he believes the program lends itself to improved access, which will reduce the number of emergency room and urgent care visits.
"There's a lot of health care-seeking behavior that's a function of people's anxiety about whether we'll be here when we're needed. If we can show them by our actions that we're going to be there, experience has taught us that they get more comfortable about solving problems themselves and developing a dialogue with their health care team."
Most Army access standards already exceed those in the civilian sector, and Schoomaker said through the Patient-Centered Medical Home initiative, they will continue to improve. The planned 66 clinics, 17 of which will be off post, will be one of the most important ways that Army doctors can connect with and care for their patients, Schoomaker added.
"We're going to do a better job than we have historically in explaining how this system of health care that they (Soldiers and Families) have is unique and precious.... We want to really create for them the very best system of care that they could ever imagine, starting with keeping them as healthy as possible," Schoomaker said. He has a vested interest in maintaining Army health care excellence, because, as he said, he not only runs it, he's also one of its patients.