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Today's commitment: transforming military medicine.

Lt. Gen. James G. Roudebush, Air Force Surgeon General

Remarks at the 2006 Air Force Defense Strategy and Transformation Seminar Series, Washington, Nov. 15, 2006

Thanks for joining us this morning. This is a great opportunity to talk about Air Force medicine. The story of Air Force medicine is really embedded in the story of joint medicine. We in the Air Force are very much in support of the joint warfight, and medical is part of that. What I would like to do this morning is talk a little about Air Force medicine in the sense of where we are today, where we have come from, and where I believe we are going. What I would like to do is refer directly to the QDR, the Quadrennial Defense Review, which I think is more of a Perennial Defense Review now. I think it is going to be ongoing, and frankly I think that is a good thing because we have an enemy that is very adaptive, very clever, totally ruthless and remorseless and willing to engage any weapon in hand, any opportunity to inflict their will upon ours. With that as an enemy before us--not to forget those state actors out there that continue to have agendas, which play perhaps more quietly, but just as persistently in the background--I think it is very important that we do pay attention, obviously to the fight we are in today, but to the fight that we could well be in tomorrow.

So in terms of the QDR, it's been very instructive in terms of laying out those potential threats. The traditional threats we know. We enjoyed a number of years of relative quiescence as we employed a strategy of containment. With a very heavy footprint forward, we can all think back to our installations in Europe and in WESTPAC (Western Pacific) in terms of having large numbers of forces and capabilities forward waiting for that enemy to come forward to meet us on those battlefields. But as the Wall came down, we moved from that strategy of containment to a strategy of engagement. It caused us to think rather differently in terms of how we were configured, in terms of our capabilities and, for we in the Air Force medical service, how we supported our Air Force Line in terms of support of the National Military Strategy objectives. The QDR lays that out very well. And in terms of a mental construct and a way of wrapping our mind around this, I think shifting our weight is a good way to think of that because there are some traditional threats that will continue to be with us as we engage the new and evolving threats before us. As we shift our weight into the irregular, the catastrophic, and the disruptive as well as maintaining that traditional capability, it's a real challenge for us in the medical business to stay absolutely coherent and fully in support of all our Services--Army, Navy, Marine, Air Force--in terms of meeting those threats. For we in the Air Force, our Chief, General Michael Moseley and Secretary Michael Wynne, have been very clear for us. The three priorities are in fact winning the Global War on Terror, taking care of our people, and recapitalizing. And we think those priorities are very much in support of where we are going in the Air Force Medical Service to stay true and coherent with our Air Force Line in support of the Joint mission.

To put the bottom line up front, we in the Air Force Medical Service, in concert with our Army and Navy counterparts, are in fact transforming military medicine. We support a Joint and interdependent operational construct. For us in the Air Force, it's our EMEDS (Expeditionary Medical System)--our modular medical capabilities, and our aeroevac--our ability to move stabilized patients. 'Stabilized' is an important construct. In days gone by we moved stable patients, in fact patients that were well into the healing and recuperative phase. Today we are moving very freshly stabilized patients. And the results really are unprecedented. The disease non-battle injury rate, the rate of illness and injury that occurs with our forces forward, is the lowest ever. And that speaks to a healthy, fit force going forward that is appropriately surveyed and supported in relatively toxic environments, but maintaining their health, maintaining that force, able to do the mission that they have been asked to do. And the lowest died of wounds rate in history. If you look at the chart on the right, it goes back to the Revolutionary War when the died of wounds rate approached 50 percent. Over time we gradually brought that rate down to the point that in the Gulf War it was still up around 25 percent. But in OEF and OIF, in the face of threats and incredibly complex wounds that we are seeing, our "died of" wounds rate now is less than 10 percent. The most recent number is 7.4 percent. So, that is truly transformational and that is a Joint accomplishment.

For us, our Expeditionary Medical System, our EMEDS--which goes all the way from a one pallet capability that we can put into place with a surgical team and the ability to set up within minutes to hours and begin to take care of patients--all the way up to a theater hospital of 75 to 100 beds, and anything in between, allows us to support the full spectrum of threats that we face. This ranges all the way from special operations to major conflict, and in support of our nation being able to respond to homeland security issues, to disasters, to weather of mass destruction, as we saw with Katrina and Rita. So it allows us to respond across those varieties of threats in a way that is light, tailorable, agile, life-saving and able to get there within hours and be taking care of patients within hours of arrival.

So where are we in the Global War on Terror? Right now what it amounts to is we have the theater hospital at Balad (Air Base), which is one of the principal casualty receiving hospitals in Iraq. In January we will pick up the theater hospital in Afghanistan at Bagram (Air Base). We will take that over from the Army. As well as having seven lighter EMEDS strategically placed throughout Iraq and Afghanistan in support of the troops there.

But it's not just the AOR. We are in support of our mission around the world. We are in support of the global airlift mission, which is virtually worldwide. We are in support of our national missions--every time a shuttle is launched, every time we recover a Soyuz capsule we have Air Force medics deployed to support those efforts placed in strategic positions along the flight path and the glide path of those vehicles. We have folks fully engaged, winning the hearts and minds of those around the world, supporting countries in terms of training, supporting countries in terms of humanitarian assistance, and supporting our mission worldwide wherever we find it.

But we also stand ready here at home. We have an EMEDS-25 that is on alert 24/7, 365, which has some advanced capabilities in terms of being able to deal with a variety of circumstances we might be facing. But this was in fact that capability that we used to respond to Katrina. If you recall the rhetoric surrounding that event, the call went out very early for beds. "We need 1,000 beds, we need 2,000 beds, we need 3,500 beds." At some point in the continuum, as we dealt with that disaster--yes, they did need some beds. But what they needed initially was the capability to take care of people who needed to be moved to a place of safety. So we put an EMEDS personnel package into the New Orleans Airport as soon as that runway was open--that was one of the first capabilities that went in. They fell in with our civilian counterparts from the DMAT as well as our other Service counterparts that started to flow in behind that and they took care of those people. They triaged them, they treated the folks that needed to be treated, we moved those who did not need to be immediately treated, and aeroevaced those that did. So we were able to decompress and move those folks to safety within a day or two. And it was a capability--it wasn't an aggregate of beds--it was a capability and that is what the EMEDS brought.

But we have that same capability on alert in Europe (in USAFE) and also in WESTPAC--we are able to respond to whatever contingencies that might arise.

In addition to that, over the last four years we have brought into existence our international health specialist program which identifies those Air Force medics with language or cultural capabilities. And in the 36 specialists assigned to the combatant commands, we have placed those folks in support of the Unified Commands in order to better understand those countries that they are engaged with, to better understand the medical circumstances and capabilities and to provide that medical footprint forward that often allows us to open the door, engage in dialogue and in fact arrive at a very productive interchange with many of those countries. So the international health specialists have been instrumental in helping that move forward. In fact we have a library of 286 Air Force medics with their language skills identified and when we had the earthquake in Pakistan we had individuals who were fluent in the local languages and we deployed those in with the Army capability that went in--the MASH--and they were in fact very helpful and very useful in providing the medical support that was so important to those folks at that time. Our Defense Institute for Medical Operations is a Joint capability with the Navy. They are training as we speak around the world in disaster response, in dealing with AIDS, and in dealing with local endemic medical issues. In fact, we have trained literally thousands of individuals from over a hundred countries now in terms of supporting our strategies forward and making those people better able, better capable to deal with the circumstances as they find them on their home turf.

And with medics as the tip of the spear, Secretary Wynne asked us to put together a capability, and it is referred to as the Humanitarian Relief Operation (HUMRO) Operational Capability Package (OCP). So in good bureaucratic military acronym-ese it is the HUMRO-OCP. But what this is--it's a 25-bed EMEDS. In addition, we have placed a base operating support capability with that, with civil engineers, with food services and security forces. Not in an offensive construct, but in a perimeter security and basically just a stability construct to go forward literally on a moment's notice in support of disaster relief, in support of humanitarian activities to be put in place within hours up and running again within hours. But over the 60 to 90 days following the placement, we begin to transition this hospital capability to either the host nation or to the NGO. And at the 90- or 180-day point, we begin to back out and we leave enduring capacity. We leave that EMEDS now run by the host nation or the NGO, leaving that in place for the foreseeable future. So we are leaving that enduring capacity. So this has not been utilized yet. It is on the books, it is available today, but Secretary Wynne thought it important that we are able to put that capability into place in order to support operations today, but to leave that enduring capacity for the use of those who will need it in the future.

(60 minutes video clip shown) [Editor's note: video not available]

What I want you to do is think about what that clip just told us. I described our EMEDS capability. That is the foundation for our en route care of providing that initial stabilization forward. When you combine that capability with our aeroevac capability then you begin to see what the Air Force brings to the Global War on Terror, which is en route care. Now the important thing to note is this is one of the very best examples of a truly joint and interdependent capability. It starts on the ground with that Army medic, or that Navy medic in support of the Marines, saving the life. They are very well-trained. They have pharmaceuticals in terms of hemostatic bandages, one-handed tourniquets--capabilities that have not been available in the past. They are literally saving lives at the point of injury in order to clear the battlefield and get that individual to the next level of care where that initial battle damage surgery is accomplished, which is where they enter into the Air Force en route care.

So the Air Force does not clear the battlefield. The Army and the Navy do not do that strategic and operational en route care. This is a leveraged interdependent capability and it starts with that medic on the helicopter, "That person is not going to die on my time. My time is going to save that life." That is the attitude up front and that is where it starts.

Then they get to the first battle damage resuscitation, could be at the 10th CSH (Combat Support Hospital) in Baghdad, or it could be at the 332nd in Balad. Life saving surgery is accomplished there, but then those individuals are literally packaged and prepared for en route care with all the life support, with all those capabilities in place. And as Dr. Dorlac, who is an Air Force pulmonologist stationed at Landstuhl (Germany), points out very clearly, their condition is improved en route. Very important concept: their condition is improved en route in the back end of that C-17, or it could be a KC-10 or it could be a KC-135, it could be the best tail in the flow. But the fact is their condition is improved. Their condition is improved. That is en route care. That is leveraged interdependent en route care: starting with that Army medic, with that Navy medic at the point of injury, entering into our system, and then moving back to more definitive care ultimately back to Walter Reed, Bethesda, Brooke Army, Wilford Hall, Navy-Balboa--where truly amazing care is available and employed every day as General Reimer (former U.S. Army Chief of Staff) pointed out. It is truly uplifting what we can do there. But the fact is that that casualty has to get there, and that is what the Air Force does. That is what we bring to the fight. It is that en route care. And it starts on the battlefield with the Army and Navy medics, transits through the Air Force en route care, and gets to the definitive care back here in the States.

Now if you think about the economy of force, go back to our strategy of containment when we had huge contingency hospitals far forward that we were maintaining, and large numbers of individuals on the ground. That is economy of force. That is in fact lean--very lean--and very cost effective because we don't need to put those capabilities forward, because we have a system that brings them home. Now in terms of en route care at the moment we have Landstuhl--it is that intermediate stop which is at about the seventh- or eighth-hour point, which in terms of battle damage surgery sequence is about right. Now, the fact that we have Landstuhl where it is, is very good. But it is by chance. What if we were on the southern tip of South America or at a variety of places in WESTPAC? We would not have that intermediate. So that is in fact what the Air Force has in place with our EMEDS. We can flow that theater hospital or that EMEDS into the strategic spot to provide that interim en route care in order to ensure that we are improving the condition as we move back through the system. So that is what the Air Force brings, that en route care.

Clearly, the result of transformational thinking and technology. In the days of our strategy of containment--heavy footprint forward--we had dedicated aircraft, the C-9, the C-141--separately scheduled, separately flown, separately sourced, very effective for the time, but not applicable to today's threat. So we miniaturized, we modularized, we became much more light, lean and life saving, and we evolved to the EMEDS and the CCATT, our Critical Care Air Transport Team Construct. Now it is instructive if you look on the lower left in Desert Storm we had a footprint forward, and this is lighter than certainly during the Cold War; still instructive. Desert Storm: we had nearly 1,000 Air Force beds in theater. We had nearly 5,000 Air Force medics deployed forward. We moved just over 12,000 patients.

Okay. Fast forward. OEF OIF. We have 87 Air Force beds in theater--strategically placed around the theater. When we pick up the theater hospital at Bagram we will increase that somewhat, but not greatly. Air Force medics deployed: add 776 and about 200 aeroevac-ers to that and you have less than 1,000 Air Force medics forward. Patients moved: well over 38,000 and incredibly more complex patients, very much more significantly ill or injured and complex patients. But that, as a compare and contrast, really speaks to where we have come in terms of our Joint support

Aeroevac is part and parcel of global mobility; you cannot separate aeroevac from our global mobility mission. It is woven into that just the same as air refueling, airlift, aeroevac. It is part and parcel, it is the best tail in the flow. It is part and parcel of that mission, it employs modular, AE and CCATT units. It is aircraft independent and it is Total Force, very much Total Force. Average time home in Vietnam was 45 days. Desert Shield/Desert Storm about 10. Today three or less. As I visit those folks at Walter Reed or Bethesda, fairly common story: "I remember the Humvee going up, the smoke, the blast, screaming for the medics and then it gets murky." And when they wake up they are home. That is transformation. And I tell you it contributes greatly to the recovery because having these individuals home with family is incredibly important to their recovery.

As I mentioned it is Total Force. As we move from a Strategic Reserve construct in the Cold War we have very much moved forward to an Operational Reserve. Our Reserves are with us every day. Their volunteerism is truly impressive. Our Guard compatriots are part and parcel of our mission, so truly is Total Force and it is operational, it is aerobic. We are doing it today, we can do it tomorrow, we can do it next year and beyond.

But as the Chief points out, we truly must take care of our people because that is in fact how the mission is accomplished.

For those of us in the Air Force, caring for our airmen is, for us, job one. We know their health when we access them. They are healthy, they're fit. We monitor their health periodically with our preventive health assessments. Before we deploy them we do the pre-deployment assessment to see what their health is to see if anything has changed. We survey them while they are deployed. Before we bring them home we do another post-deployment health assessment. Then 180 days out, we check it again, with that post deployment re-assessment. Cyclically, aerobically, we do it today, tomorrow, days, weeks, months and years to come. But as we do that we take care of the family. Because the individuals volunteer to come in, the families volunteer to stay. Taking care of families is mission critical. Even more so as our deployed folks forward are literally one or two key strokes away from home. So if something is going sideways at home, they will know about it near real time, with mission impact. Because now they are worried about what is going on at home, they can't focus on what is in front of them; that is mission critical. So taking care of families is very, very important as we take care of the individuals. It is important for trust. They trust that we will take care of them at home, deployed, bring them back safely if in fact they are ill or injured. They trust that we will take care of them next year, 10 years, 20 years. That is what allows us to maintain an all-volunteer force, to keep those folks ready to go do our nation's work.

For us, our medical facilities--whether a clinic or a hospital or a medical center--serve two functions. One, it allows us to deliver that health care at the home station but it keeps our medics ready, competent, current and deployable. And it is a power projection platform that allows us to send them forward and then bring them back, re-blue them. Make sure they continue to be current, qualified, ready to go to the mission.

But as we do this for our folks we have to find the balance. The mission can be all encompassing in terms of ops tempo, in terms of supporting business plans, in terms of bringing on new systems such as AHLTA--which is critically important, but does require training. And it does add a bit to the workload as we bring that system into service and of course our disaster response because we need to be ready to take care of the folks at home as well. That expectation is there. The mission can occupy the scope nearly completely, so we have to find the balance for our people. Find the balance with our family, find the balance with our personal health and fitness, with our personal growth. We need to find the balance, because we need folks with us, today, tomorrow, days, weeks, months and years to come.

One of the things we have done to assist in that is making our deployments a bit more predictable. I talked about the theater hospital at Balad. It is about 350 folks, which by the way is Joint--Army neurosurgeons and ICU nurses are with us there at Balad, a critically important part of our team. But we have five copies of that Balad theater hospital embedded at Wilford Hall. So as we cycle through, one is gone, four are at home ready to go, so it allows us to get more predictability into our peoples' lives at a time when predictability is rather important.

And certainly the Chief is right about recapitalizing. We have to recapitalize our equipment. But for we medics, recapitalizing our people is job one. We need to recruit and retain the best and the brightest. We need to force-develop them to be sure that they are able to do what they are asked to do and we need to be very, very attentive to growing our next generation. Because we need to be looking at those folks who will be sitting here generations to come, because we are in this war, I think, for a very long time.

Other targets on the radar: Base Realignment and Closure. I think everyone is aware that we are reconfiguring our platforms here in the National Capital Area, with Walter Reed and Bethesda coming into the same platform. In San Antonio, Wilford Hall (Medical Center) and Brooke Army (Medical Center) are becoming part of the same platform and really having an integrated health care delivery system within San Antonio and the National Capital Regions.

Human system integration. As we are recapitalizing our fleet and looking at weapons system and capabilities to come, there is a human in each system--manned or unmanned. And we need to be very attentive to those interfaces making sure that we leverage, protect, train and make the most of each individual that is chosen to be part of our Service.

Next generation critical care. We are literally re-writing the book on trauma care in Iraq and Afghanistan from a very Joint perspective. The Army Institute of Surgical Research in San Antonio as an important leverage partner in that regard along with the medics at the Tenth CSH and the 332nd in Balad are working hard to capture those lessons. What is working, what works better, how do we improve our equipment, how do we make that next generation critical care what it needs to be? Those lessons are directly translated back into medicine writ large back here in the States. So as we are moving our state of medicine forward, everyone benefits from that.

The Joint Unified Medical Command, there has been considerable discussion about that. The Air Force is identified as the outlier as opposed to that. I think the construct is less that we are opposed, and more what we are for. More of what we bring. Because we bring that Joint capability, that en route care, that global capability to put medical forces right place, right time where it needs to be. So our ability to deliver that capability is absolutely intertwined with our Line. It starts at the wing level, we are inside the commander's circle of trust and influence so that we have the right medical capability at the right place, right time in support of that wing mission. And just as importantly and perhaps more importantly, we are able to prevent casualties if in fact we have the opportunity to influence the planning at a critical point. On a global scale, we are part of the airlift mission; we are inextricably woven into that mission. It is not something that is easily separable and put to the side to be utilized separately. We are part and parcel. We are concerned that the Unified Medical Command would significantly degrade our ability to perform that mission. So it is more that we are for the mission that we think is critically important jointly to the execution of our strategies forward. Now there are a couple of additional positive aspects to that. One is, again, being in the commander's circle of trust to influence the plans for the right capability at the right place and right time. But the second is that we are in fact doctrinally aligned and absolutely coherent with our Line mission and transform with that doctrinal transformation. So as the Air Force moved from that strategy of containment--heavy forward--to globally engaged, we medics transitioned and transformed along with our Line. Much as the Army is transforming with the Army mission and the Navy is transforming with the Navy and the Marine mission. So we think it is important to keep the medics aligned in order to make sure that we are true to our doctrinal requirements.

Now there is a tendency and a danger to position ourselves perfectly to fight the last fight because we have a relatively mature theater. We are certainly making full use of lessons learned. But our concern is if we in fact begin to transition from that which will soon be the last fight, we won't be ready for the next fight. And having three separate medical Services we in fact believe is somewhat of an asymmetric advantage because we are not sure what the next fight is going to look like. And if you have a more homogeneous medical capability, our ability to transit, adapt and make sure that we can meet the mission in the next fight, we feel would be put at risk. So we are for what we bring, we are concerned about what a Unified Medical Command might do in terms of limiting our ability to meet that next mission and staying doctrinally coherent and culturally coherent because taking care of families is something that is culturally important within each of our Services. So we are concerned about putting those things at risk but we are very much for what we bring--so just a word or two about the Unified Medical Command.

Bottom line same as the top line. Winning the war on terror for us, setting the standard in support of our Joint warriors, caring for people, providing that healthy, fit force with a focus on the family, and recapitalizing our medics and finding that balance for the Long War.

So I thank you for your time and attention but most importantly I thank you for what you do every day, each one of you in your own way is serving and frankly we cannot get there without your service as part of our larger capabilities, so thank you all very much.
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Publication:Air Force Speeches
Article Type:Speech
Geographic Code:1U5DC
Date:Nov 15, 2006
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