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Commander's introduction.

In my remarks introducing the previous issue of the AMEDD Journal, I pointed out the distinct, symbiotic relationships of healthcare services across the military and civilian settings. Those invaluable links include education, certifications, delivery practices and experiences, facility design, and research and development. Understandably, the availability of easily identifiable and accessible information from both types of healthcare systems is vital to stimulating and advancing the practice of medical science for everyone. Again fulfilling its important and unique role as a resource for such information from military medicine, this issue of the Journal contains a number of articles on subjects which have direct corollaries in civilian medical science and healthcare delivery.

The first article is an ideal example of the exploitation of the broad range of available information sources to develop a focused look at what is arguably military medicine's most important responsibility, battlefield trauma care. LTC Kyle Remick led an impressive group of highly skilled, broadly experienced Army surgeons in an extensive literature review to evaluate available information on multiple aspects of trauma care. The review parameters were carefully defined in focus and scope, and rigorously followed, ensuring study results are scientifically sound, balanced, and evidence-based. The article presents the extensive information derived during the review in a carefully organized, easily understood structure which supports 5 specific recommendations for transformation of Army trauma care. The concept development, design, execution, and analysis presented in this study once again demonstrates the exceptionally high caliber of talent, skill, and dedication that is typical of our military medical professionals. Their study results should absolutely be a part of the ongoing development of protocols, procedures, organization, and training which will define trauma care in combat environments of the future.

Number 4 on the recently promulgated list of The Army Surgeon General's top 10 issues is "Implementation of mild Traumatic Brain Injury (mTBI)/Concussive Injury Protocols." As is so often the case, our military medical professionals in the combat theater have recognized the import of an increasingly encountered serious condition, and are directly addressing it within the capabilities of their environment and resources. LTC Ralph Caldroney and Navy CAPT James Radike have contributed a timely, important article describing their experiences in Afghanistan (2009-2010) in the development and implementation of protocols and guidelines for recognition, screening, evaluation, and management of mTBI at the Kandahar hospital. Their article presents well-researched, detailed information about the presentation of symptoms of brain injury, and the various screening techniques and tools that are used to gauge the severity of indicated TBI. They explain the various approaches to treatment that were adopted at Kandahar. Perhaps most importantly, they detail their focus on repetitive brain injuries as a vital factor in determining a patient's potential susceptibility to more severe, perhaps permanent, damage from further exposure. This article is a valuable contribution in support of one of The Surgeon General's most urgent priorities.

The historically high survival rate of wounded US Warriors from current conflicts has resulted in a proportionally larger number of combat Veterans who require extended follow-on care as their external wounds heal and they seek to return to as normal a lifestyle as possible. Loss of limbs is one of the more common of the conditions faced by these valiant Warriors. Lead author Brad Issacson and a group of highly qualified orthopaedic and rehabilitation professionals from the Department of Veterans Affairs, Walter Reed, and university medical schools have contributed a timely, important article which clearly synopsizes the major concerns involved in the recovery and rehabilitation of military amputees. Their extensively-researched article consolidates data and experiences from a broad range of sources to present the latest information concerning amputation wound care, residual limb complications, prosthesis technology, and approaches to physical and occupational therapy which are available for recovering Warriors. This article is yet another example of the wide range of dedicated healthcare professionals who collaborate time and again to advance the state-of-the-art of care for our Warriors who willingly go into harm's way in defense of our freedom and way of life.

It is obvious that the extended nature of the current combat operational tempo has taxed our Warriors, both physically and psychologically. Throughout these commitments, military medicine has continued to make tremendous advances with trauma injuries, saving lives and restoring the injured to amazing levels of recovery. The behavioral and mental health professionals have worked tirelessly to develop techniques and approaches to care for those Soldiers suffering from mental and psychological disorders. One of the undesirable consequences of the psychological pressures and stresses that affect Soldiers in a combat environment is the negative impact they can have on the Warrior's family relationships. Dissolutions of marriages and family breakups following return from deployment are far too common. At the extreme, we see the reports of physical abuse, including the death of one or both spouses, and sometimes children. The family advocacy approach to address the stresses of military life on the family was developed in the 1980s. It is by necessity an evolutionary methodology as the nature of combat changes, while at the same time the very character and structure of American society itself are constantly in flux. COL Derrick Arincorayan teamed with Dr Larry Applewhite and Dr Rene Robichaux to look at an adaptation of the family advocacy approach to address the domestic stresses inherent in an multiple deployment environment. Their article makes a very strong case for providing (in effect extending) family advocacy support to the forward operating areas with deploying units, and ensuring such support is closely coordinated with each unit's home station. The availability of such resources accomplishes many things, most importantly ensuring continuity of support for those deploying personnel who were already receiving family advocacy services, and providing immediate, onsite services for those encountering difficulties, either from home or at the deployed location. This article is another indication of the dedication and commitment of our healthcare professionals to the "whole" Soldier, proactively adapting to the times and places as required.

Of the many benchmarks with which we gauge the quality of military medicine, perhaps the one most widely discussed by healthcare beneficiaries is access to care. This is nothing new, access to healthcare services by dependents and other beneficiaries has long been a major concern for military medical planners and policy makers. Indeed, efforts to directly address dependent healthcare began with the Dependents Medical Care Act in 1956, which evolved into CHAMPUS in 1966 and is now TRICARE, which serves all eligible beneficiaries. The program functions well within the United States, but the biggest challenges for military healthcare providers are overseas. This issue of the Journal contains 3 articles dealing with the difficulties presented in Europe by the reduction of forces permanently assigned there, combined with the demands of the ongoing combat operations in Afghanistan and Iraq. In the first article COL Robert Smith provides a manager's overview of the circumstances which complicate the ability of the military to meet the demands, and expectations, of the eligible beneficiary population. His discussion examines the difficulties presented by not only the operational and resource reduction requirements, but also the internally imposed demands on the time of providers, which directly translates into less time for patient care. He offers suggestions to mitigate the problems and increase access, most of which will have to be addressed at the policy level because they would be applicable across the entire Military Health System. COL Smith's article is a clear, well-reasoned look at the realities of providing healthcare services to our eligible beneficiaries around the world.

Next, LTC Ivan Speights and his coauthors describe the actions they implemented at the Army Health Clinic, Mannheim, in 2008 to address the combined challenges of the transformation of the US forces in Europe, combat theater deployments, and the normal personnel turbulence of a military medical organization. The first step was a statistical analysis of the users of the clinic's services, segregated by type of beneficiary and the nature of services used, which was then used to adjust service and resource assignment schedules. They implemented a telephone screening and consultation process to focus provider appointments towards those for which actual caregiver contact was necessary. The clinic itself was remodeled after an analysis determined the optimum, standardized layout to support the processes and services required by the user community. Finally, since nothing in the provision of medical services is static, the clinic's operational data are reviewed every quarter to adjust schedules and resources as necessary. This is a wonderful example of the initiative and resourcefulness of our military medical professionals as they face a challenge head-on, roll up their sleeves, and make it work for the benefit of their supported population.

In the earlier two articles, access to care was discussed from a broad perspective, then it was considered in the efforts of a single clinic to optimize its operations to ensure access was not compromised. LTC Raymond Gundry and MAJ Christoph Hillmer have contributed an excellent article discussing the challenges of realigning medical assets across an entire region of responsibility in response to the reduction of forces and other resources in Europe. Unfortunately, strategic planning for the reduction of support services, including medical support, was not detailed as part of the overall planning of the force transformation. Further, there was no documentation or lessons-learned available from the last major force downsizing in the early 1990s. Adding to that mix was the turmoil of the constant deployment rotations of medical personnel and resources into the combat theaters. Consequently, the realignment of medical support across their area of responsibility was initially reactive, but was successful because of the skill, knowledge, and sheer hard work of those responsible for making it happen. LTC Gundry and MAJ Hillmer describe the numerous considerations and problems, many unexpected of course, they encountered as they contended with the myriad of responsibilities involving personnel, logistics, facilities, budget, host nation concerns, and transportation involved in this enormous undertaking. At the end of the article, they have provided 5 points of planning guidance derived from their experience to assist future, similar efforts. The experiences detailed in this article, and especially the invaluable planning guidance, should be incorporated as part of contingency planning process for future realignment of overseas medical support assets.

Throughout history, advances in medical science have been the result of scholarship, experimentation, and technology, elements which themselves are absolutely interdependent. Indeed, great strides in one area drive the other areas, and the cycle builds momentum. Over the past century, the accelerated breakthroughs in various areas of technology have stimulated stunning advancements in medical science as researchers and engineers quickly developed medical applications, which then redirected technological development in entirely new directions. However, sometimes the assumed omnipotence of technology may lead to unwise decisions with detrimental results. In his well-researched article, LTC Lee Bewley investigates an area of technology that is one of those assumed mainstays of American business success, and focuses on its actual efficacy in healthcare organizations. Some form of information management is absolutely essential for any successful enterprise, and, unquestionably, digital technology has revolutionized our ability to organize, analyze, research, archive, and access information--but management should understand that technical expansion can reach a point of diminishing returns. LTC Bewley presents a strategic analysis of the investment and productivity returns for investment in information management technology, and develops some cautionary perspectives for those charged with responsibility of such systems. His clearly presented analysis of a complex subject, along with the detailed findings and recommendations are yet another indication of the high level of scholarship and expertise which is characteristic of our military medical professionals.

Previous issues of the AMEDD Journal have presented articles discussing various aspects of the provision of healthcare services to prisoners and detainees in the combat theaters of Iraq and Afghanistan. LTC Beverly Patton has contributed an interesting and informative article which details an important, related consideration of detainee management which is much more complex than it may appear on the surface. The provision of nutritional meals in keeping with the customary diet of internees is not just the obligation of a civilized nation, it is also specified in the 1949 Geneva protocols. However, it is not as straightforward as distributing pallets of military rations among the detainees. Not only should the dietary patterns of the general internee population be understood and followed, but the specific dietary considerations for those with certain health conditions must be addressed. The article discusses the efforts made to ensure pregnant, diabetic, or injured detainees, as well as infants, malnourished children, and hospitalized internees were provided nutrition suitable to their conditions as much as possible. Further, provision of special meals was hampered by the forced segregation of the population by ethnic groups (to minimize tension and conflict), and the separation of adolescents from the adults. LTC Patton has not only done an excellent job of describing the difficulties and complexities involved in this effort, she has also cited the governing regulations and helpful references, and presented a valuable list of lessons-learned for planners of future, similar operations.

This issue of the AMEDD Journal closes with a collection of abstracts prepared by the 2011 class of doctoral students of the US Army-Baylor University Doctoral Program in Physical Therapy. The 9 abstracts report the results of the students' research projects which were conducted as part of their curriculum and in support of the Neuromusculoskeletal Injury Prevention and Rehabilitation Research Program. These abstracts are representative of the outstanding opportunities for professional education and career enhancement available in military medicine.
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Author:Rubenstein, David A.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Jul 1, 2010
Words:2248
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