Perspectives: Commander's introduction.
Subject: Public health
Author: Volpe, Philip
Pub Date: 10/01/2012
Publication: Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. Army Medical Department Center & School ISSN: 1524-0436
Issue: Date: Oct-Dec, 2012
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Accession Number: 309980587
Full Text: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

That statement is the first of the basic principles enumerated in the preamble to the Constitution of the World Health Organization, adopted on July 22, 1946. * The simplicity and clarity of those 21 words are as true today as 66 years ago, without a single amendment or elaboration. It is as applicable to an organization, a society, or a nation as it is to an individual. The interrelationship of those levels of health is clearly captured in the stated vision of Army Medicine:

In the recently issued Army Medicine Strategy (August 10, 2012), The Surgeon General lays out a shift in perspective for our profession, "from a healthcare system to a system for health." The history of Army Medicine is rich in groundbreaking success in research and proactive efforts in preventive medicine, public health, and health promotion for our forces. Routinely, these achievements are extended beyond the military and greatly benefit the health of people around the world. The transformation of our healthcare system will build on those achievements and expand the perspective to more directly address the health of the individual, indeed, the very lifestyle factors that affect personal health, and, by extension, the health of our Army and our nation.

Since its inception in 1994 by then Army Surgeon General LTG Alcide LaNoue, the AMEDD Journal has been on the forefront, providing information supporting the three basic strategies for of health promotion: advocacy, enabling, and mediation as presented in the WHO Charter for Health Promotion. The Journal presents articles that cover the entire range of health and healthcare. Over the last 7 years, the AMEDD Journal has regularly featured articles dedicated to force health protection and public health, reflecting the diverse skills and expertise of Army medical professionals.

This issue of the AMEDD Journal maintains the standard, incorporating articles on nutrition, personal health responsibility, physical fitness, and drug abuse. It also contains articles on trauma care, operational planning, Army nursing, dentistry, and lessons learned from the combat theaters. Throughout theses pages, the Journal continues to showcase the diversity, sophistication, and talent of medical professionals who accept the responsibility for the health of our military personnel and their families, both today and tomorrow.

EDITOR'S PERSPECTIVE

The Warrior Transition Unit (WTU) program has been very successful in its primary mission, providing extended treatment and/or rehabilitation services to Wounded Warriors to return them to active duty or prepare them for the transition to civilian life. Their wounds are healed, they adapt to losses of limbs and other disabilities, and their psychological and behavioral health issues are addressed and treated. However, even as their bodies are being restored from combat injuries, their lifestyle choices may become detrimental to their overall health, both immediate, complicating the rehabilitation and treatment efforts, and over the long term, with weight-related chronic conditions such as diabetes. In the opening article in this issue, CPT Adam Kieffer and MAJ Renee Cole report on their study of nutrition choices and weight gain among Wounded Warriors assigned to WTUs at four Army medical centers. Their examination revealed that the Warrior recovery process presents a dichotomy in weight management: during healing the major concern is prevention of weight loss; following release to the WTU for outpatient treatment and rehabilitation, weight gain becomes problematic. The article presents detailed data gathered from Warfighters as to their body mass index, the nature of their injuries, and their self-assessments of their lifestyle choices related to nutrition and weight management. Further, the study subjects were asked their opinions of their own weight and physical condition. This article should be of great interest to those charged with assisting Wounded Warfighters through their recovery, rehabilitation, and transition periods, presenting another, more subtle aspect of restoring the health of those who have sacrificed so much.

MAJ Derek Licina opens his article with the following:

According to the World Health Organization, chronic diseases with preventable risk factors have surpassed infectious diseases as the major cause of morbidity and mortality worldwide.

That simple statement frames the ironic reality facing humankind: as successful as medical science has been in discovering and countering diseases, our personal lifestyle choices are becoming increasingly detrimental to our overall health and wellness. MAJ Licina's article explores the quandary facing society, are individuals personally responsible for their negative lifestyle choices? On the surface, a simple question. But as explored in this excellent article, the answers are not so simple. MAJ Licina presents and develops several different, and often conflicting, philosophies of human responsibility. Today, those philosophies are clearly reflected in political perspectives and positions, thus driving the debate as to how healthcare resources (which are undeniably finite at some point) should be financed and allocated across the population as a whole. Who is ultimately at fault: the individual, the society, the environment, a combination? Further, important questions always arise when the discussion turns to public policy to address negative behaviors. Can a free society continue to exist if personal behavior becomes regulated and controlled? Should all potentially harmful nutritional and drug substances be banned, as well as activities which may result in chronic illness or injuries requiring long-term commitment of resources to treat? MAJ Licina's article is a well-developed, thought-provoking examination of questions that are very relevant to the current national debate regarding healthcare and use of medical resources.

It is not easy to become a member of the US military. The physical, intellectual, and ethical standards are high, and strictly applied. Only a small percentage of the age-qualified population can initially meet those standards, and even then, a number of them do not complete training and are eventually separated. The standards and screening process produce a Warrior force comprised of select individuals of the highest character, motivation, and ability, especially in comparison to the population as a whole. However, military people are still products of society, and it is inevitable that a certain percentage bring society's ills into the service with them. Drug abuse is one of the more pernicious of those societal problems that the military must address on a continuing basis. Dr Cristobal Berry-Caban and his coauthors have contributed a sobering article describing one of the latest dangerous drug abuse practices to find its way into the military. New types of synthetic hallucinogenic drugs, popularly known as "spice" and "bath salts," have emerged over the last 8 years. Initially available for purchase in the open market because they purportedly were a mixture of legal herbs, they actually contain added synthetic drugs, a class of sophisticated designer drugs which produce euphoric highs, but also significant adverse effects as well. In their article, Dr Berry-Caban et al detail the composition and effects of these compounds, as well as the efforts of the military to deal with their abuse by service members which has been identified in recent years. This is an important article which should be must reading for leaders and supervisors at all levels.

Presenting the other (positive) end of the behavioral spectrum, the article by LTC Donald Goss and Dr Michael Gross discusses recent trends in running footware (including none), detailing the relationship of various footstrike patterns and injury incidence to footware preferences. Since military personnel must maintain a high level of physical fitness throughout their careers, it is important that those responsible for requiring and supporting their exercise efforts remain current on both the benefits and risks associated with exercise techniques and equipment, especially any potential for debilitating injury. LTC Goss and Dr Gross conducted a detailed study of a cross-section of regular runners to explore the mechanics of various running techniques associated with footware, to determine if there were any injury trends, positive or negative, associated with either the style of running, the footware, runner experience, or a combination of factors. Their article presents the analysis of the extensive data collected during the study, and compares the various injury profiles related to styles and footware. This information contributes to the range of knowledge to support Army medicine's move of emphasis to the achievement and preservation of health for all War fighters.

Although a hemostatic agent may be effective in hemostasis and hemorrhage control, extensive loss of blood may dictate administration of intravenous fluid in resuscitation efforts, whether at point-of-injury or during evacuation. Unfortunately, introduction of such fluid may dislodge newly developed clots with resulting renewed hemorrhage. Dr Don Johnson and his team examined the effectiveness of QuikClot Combat Gauze in maintaining control of serious bleeding in the presence of hemodilution from intravenous fluids. As in the BleedArrest evaluation discussed above, they used the porcine model in a carefully planned laboratory setting to replicate hemodilution conditions, with meticulous data management throughout their procedures. Their article is a clear presentation of the planning, the process, the analysis, and the data supported conclusions. These 2 articles are more excellent examples of the professionalism that is found throughout the Army Medical Department, from the battlefield to the laboratory.

COL Collins Lyons and his coauthors have contributed another excellent article from Army dentistry to join those that have been published in the AMEDD Journal throughout its history. They present a case in which they encountered, diagnosed, and removed a rare, fortunately benign, tumor from a patient's mandible. The article meticulously describes the process from first examination through tumor diagnosis and removal, and clearly articulates the variables and possible alternative diagnoses that should be considered when encountering similar symptom and condition presentations. This is a textbook example of dental professionalism at its best, another indication of the high level of skill, talent, and knowledge that is the standard of the Army Dental Corps.

On July 27, 2011, a 102 year chapter in the history of Army Medicine came to a close. The Walter Reed General Hospital opened in 1909 on the site that developed into one of the most respected medical complexes in the world. The campus of the Walter Reed Army Medical Center provided medical and dental care to many generations of military personnel and their families, including treatment and rehabilitation services for Wounded Warriors from every armed conflict during those 10 decades. It also hosted world renowned research institutes, as well as education and training for medical and dental personnel of the US Army. COL Samuel Passo and Nolan Watson have written a very interesting and informative article chronicling specifically the history of dentistry, including patient care, dental research, and education and training at the Walter Reed campus. The evolution of the dental sciences at Walter Reed closely parallels that of the medical sciences, and the reader will recognize the value of the symbiotic relationships enabled by the collocation of top level resources of the two disciplines. This article captures an important component of the Army Dental Corps' 101 year history, and presents it in a well-written and organized form. It is a good read.

Under the best of circumstances, planning for medical support of combat operations is a difficult and imprecise proposition, based on estimates, assumptions, intelligence reports, and historical data. The level of difficulty is elevated when the planning involves a multinational force, due to the increased complexity of coordination, communication, command relationships, and variations in capabilities and resources. Existing doctrinal approaches and planning models are difficult to apply in such situations, since they often do not address the variables and peculiarities of the force structures. Even more problematic is the fact that most planning tools are classified and/or only accessible by specific personnel. In their article, LTC Soo Lee Davis and Col Martin Bricknell describe the approach they used to develop an operational casualty estimate for a major multinational offensive operation in the area around Kandahar City in 2010. The article is a virtual tutorial on the medical planning process in a deployed combat environment, clearly articulating the necessary attention to detail across a broad scope of research, coordination, resource identification, communication, and timing. It should be of great interest to all operational planners who are anticipating deployment as part of a multinational force, especially when their command will be responsible for the bulk of the deployed area medical resources.

As the deployments into and out of the combat theaters of Iraq and Afghanistan cycled in the years after January 2003, the Army Nurse Corps began to see an alarming trend among the returning Army nurses. More and more of the returning nurses began to express a desire to leave the Army Nurse Corps, the Army, and sometimes the nursing profession altogether. Based on extended periods of combat in our history, the nature of current combat operations is somewhat unusual in that military medical personnel at nondeploying commands, medical centers or facilities can be individually assigned to deploying units (perhaps several times), returning from each deployment to the facility or location from which they departed, and experiencing a "culture shock" at the different environment. COL Denise Hopkins-Chadwick describes a study chartered by the Army Nurse Corps to determine the deployment-related factors that prompt the negative attitudes toward continuing as a military nurse, or even a nurse at all. In her article, COL Hopkins-Chadwick focuses on one part of the study, that of the nurses' experiences upon returning home. From that information, she derives evidence-based support strategies for both the returning nurses and those with whom they work upon return to smooth and ease the transition from the deployed environment back to "normal." This and other results of the study have been integrated into orientation classes and content of the Army Nursing Leader Academy to ensure that current and future leaders, supervisors, and coworkers understand the complexities and stresses inherent in transitioning across such completely different working and living environments.

There is a history of advancements in medical science produced during wars and military conflicts. Unfortunately, as a rule, such progress was usually not realized for medicine in general until cessation of hostilities, as individual medical professionals came back to evaluate and develop the discoveries and techniques that were applied during the conflicts. Usually no formal research or distribution of information was applied in the combat environment, just innovation and trial-and-error to improve the situation of the moment. LTC Laura Feider and her coauthors have contributed an article describing how military medicine has instituted in-theater research teams to provide a formal structure for conducting "there and now" combat relevant medical research to benefit both the theater operating forces in real time, and military medicine over the long term. Their article discusses in detail the role of military nurses in the Joint Combat Casualty Research Team, and presents the variety of nursing research protocols that have been evaluated, as well as those proposed for future investigation. This is an interesting and informative article that reflects both the proactive attitude that frames modern military medicine in deployed combat environments, and the broad scope and very high level of capabilities, skills, experience, and motivation that is the standard of today's Army Nurse Corps.

Articles in previous editions of the AMEDD Journal have discussed at length the evolving capabilities and sophistication of military helicopter medical evacuation (MEDEVAC), and how it can and should be improved. The most recent combat operations have fostered positive changes in where and how stabilization and resuscitation of trauma patients is performed, which has also changed the character of many of the requirements for en route MEDEVAC care of those patients. Those requirements are being addressed in some ways, but MAJ Michael Wisseman and MAJ Christopher VanFossen do not think that those measures are sufficient to provide the ever-increasing level of critical care expertise demanded during transportation of critically injured trauma patients. In their article, they describe the background of the current situation, and provide statistics illustrating the increase in the number of MEDEVAC missions during which critical care interventions were required. They then examine the changes in MEDEVAC medical crewmember training that have been instituted and explain the difficulties inherent in such an approach, especially over the long term outside of combat operations. They develop an approach based on several years of in theater MEDEVAC operations during which nurses, and sometimes physicians, were required to provide the en route critical care necessary to keep the patient stable and/or perform resuscitation. Their proposal is the assignment of Army critical care or trauma nurses as permanent members of Army medical evacuation crews. They lay out the advantages, not only directly to the patients, but also to the professional capabilities of the evacuation unit as a whole. MAJs Wisseman and VanFossen develop their proposal carefully and logically, citing statistics and other documentation in support of their position. This article should be closely read by those charged with developing the doctrine and planning guidance that will create the MEDEVAC structure of the future. This capability has become an absolutely indispensable fixture on the modern battlefield, and it should provide the best capabilities possible to maximize the potential for survival of our Warfighters who must go into harm's way.

MAJ Scott Phillips and his coauthors have contributed an informative article presenting a relatively recent innovation in professional nursing roles which provides advanced generalist clinical skills for a defined group of patients at the unit of care level. The role, the Clinical Nurse Leader (CNL) was conceived and developed by the American Association of the Colleges of Nursing in conjunction with leaders in nursing education and other experts. The CNL is neither administrative nor management, but is intended to be an advanced generalist clinician, the "go to" person at the bedside when knowledge assistance and experienced guidance is required. MAJ Phillips et al build their case for adopting CNLs within AMEDD at the 5 major Army medical centers (at a minimum), not only for the obvious benefits to direct patient care, but also as a key component in meeting the organizational and strategic objectives of both AMEDD and MEDCOM, in particular those articulated in the MEDCOM balanced scorecard approach to organization and function. The article discusses a pilot test of the CNL role within one unit at William Beaumont Army Medical Center to evaluate the various workplace dynamics and parameters that will be involved in any institutional incorporation within AMEDD. The pros and cons of implementing this additional role into the existing manpower and organizational systems are examined and analyzed. This is a thought-provoking look at adopting a beneficial innovation from the civilian sector into the military medical structure. It deserves careful consideration by those defining and shaping military medicine for the future.

It is a familiar occurrence for planning, instructions, guidelines, and important decisions involved in large-scale evolutions of big organizations to be made from the macro perspective--necessarily so, to a point. Therefore, it is no surprise that those involved in executing that evolution at the other end of the spectrum, the smallest units and their individuals, often are mystified at the direction they receive, some of which seems to have no correlation to the reality with which they must contend. This is, of course, the time-honored conundrum of the military member, especially when deploying into a fluid, dynamic combat environment. However, during an extended period of deployment cycles such as those defining the US involvement in Iraq and Afghanistan over the last decade, the big picture aspects of operations should be institutionalized enough to allow inquiry into the "details" to see if attention is warranted, can improvements be made, and if there are any ideas or concerns among those individuals involved which should be addressed. MAJ (Ret) Dave Cannon of the AMEDD Lessons Learned Division describes an effort by Lessons Learned to do just that: upon their return, ask those deployers at the lowest common denominator, the small unit, for their individual feedback regarding their predeployment and operational experiences in theater. The responses were statistically correlated to spot trends, relationships, and outliers within the data to provide perspective and foundation for determining required actions. The article describes the implications of the responses, some corrective actions already completed or in process, as well as several changes to organizational structure to improve flexibility and capability in the combat environment. Of interest are the correlation of some variables such as deployment location and time spent deployed to the resulting responses. Such information, ideas, and insight would likely not become visible at higher levels of the command structure, as the enormous workload of simply getting in and out of theater tends to overwhelm those who are making it happen. Further, when units return and are faced with adjusting to the new garrison environment, and personnel are often dispersed over time, it quickly becomes too late to obtain reliable information. This article is an interesting and insightful snapshot of a large, important effort to see the operational deployment from the perspective of those who make it happen.

* http://www.who.int/governance/eb/who_constitution_en.pdf
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