Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

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JulySeptember2006Perspective1MGRussellJ.CzerwMedicalOperationsintheStrykerBrigadeCombatTeam3LTCEdMichaud,MC,USA;MAJMikeHelwig,MC,USA;LTCJohnGlorioso,MC,USA;LTCKeithSalzman,MC,USAMedicalProcessingofPatientsfromOperationsEnduringFreedomand10IraqiFreedom:TheDeployedWarriorMedicalManagementCenterMAJBrentJohnson,BSC,USAFCaringforContractorsinOurMidst:LessonsLearnedfromOperationIraqiFreedom17MAJAndrewDoyle,MC,USAThumbOppositionRestoration:ACaseStudy22CPTDavidAdmire,SP,USAMedicalSupportandBasketball-RelatedSportsInjuryofUSSoldiersinAfghanistan27LTCJamesFrizzi,MC,USA;MAJPeterRay,MC,USAR;CAPTJohnRaff,MC,USNRImprovingSoldierCareThroughOutcomesResearch:30TheAccessionScreening&ImmunizationProgramCPTRemingtonNevin,MC,USA;LTCDavidNiebuhr,MC,USA;KevinFrick,PhD;COLJohnGrabenstein,MS,USAMultidisciplinaryCrisisManagementSimulation-BasedTrainingProgram39KevinCoonan,MD;LTCJosephMiller,MC,USA;MichelleMartinez;COLPatKelly,MC,USAElementsofLeadershipfortheSuccessfulOrganization47COLGeorgeTuriansky,MC,USAMentorsandProtgs:SimpleRulesforSuccess50COLMarkMelanson,MS,USAAValidationStudyofaCommonlyUsedMilitaryAssessment59ofPersonalityInteractionalPatternsSusanWalley,MSW;COL(Ret)KylePehrson,MS,USAR;PatrickPanos,PhD

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LTGKevinC.Kiley TheArmySurgeonGeneral Commander,USArmyMedicalCommandMGRussellJ.CzerwCommandingGeneral USArmyMedicalDepartmentCenterandSchool JulySeptember2006 TheArmyMedicalDepartmentCenter&School PB8-06-7/8/9 0615605 PETERJ.SCHOOMAKER General,UnitedStatesArmy ChiefofStaff DISTRIBUTION:Special AdministrativeAssistanttothe SecretaryoftheArmy ByOrderoftheSecretaryoftheArmy: Official: JOYCEE.MORROW Onlineissuesofthe AMEDDJournal areavailableathttps://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 AProfessionalPublication oftheAMEDDCommunity The ArmyMedicalDepartmentJournal [ISSN1524-0436]ispublishedquarterlyfor TheSurgeonGeneralbytheUSArmyMedicalDepartmentCenter&School,ATTN: MCCS-DT,2423FSH-HoodST,FortSamHouston,TX78234-5078. CORRESPONDENCE: Manuscripts,photographs,officialunitrequeststoreceive copies,andunitaddresschangesordeletionsshouldbesenttothe Journal atthe aboveaddress.Telephone:(210)221-6301,DSN471-6301 DISCLAIMER: The Journal presentsclinicalandnonclinicalprofessionalinformation toexpandknowledgeofdomestic&internationalmilitarymedicalissuesand technologicaladvances;promotecollaborativepartnershipsamongServices, components,Corps,andspecialties;conveyclinicalandhealthservicesupport information;andprovideapeer-reviewed,highquality,printmediumtoencourage dialogueconcerninghealthcareinitiatives. Viewsexpressedarethoseoftheauthor(s)anddonotnecessarilyreflectofficialUS ArmyorUSArmyMedicalDepartmentpositions,nordoesthecontentchangeor supersedeinformationinotherArmyPublications.The Journal reservestherighttoedit allmaterialsubmittedforpublication(seeinsidebackcover). CONTENT: Contentofthispublicationisnotcopyrightprotected.Materialmaybe reprintedifcreditisgiventotheauthor(s). OFFICIALDISTRIBUTION: ThispublicationistargetedtoUSArmyMedical Departmentunitsandorganizations,andothermembersofthemedicalcommunity worldwide.

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JulySeptember20061ItismydistinctpleasuretoreviewmyfirstissueoftheAMEDDJournalasthenewCommandingGeneral,USArmyMedicalDepartmentCenterandSchoolandFortSamHouston.Ilookforwardtoeverysubsequentissuewithenthusiasmasweread,learn,andbroadentheknowledgeofourWarriorMedics.TheAMEDDJournalexistsforthespecificpurposeofreflectinggeneralperspectivesontheconductofourcorebusiness.Itservestostrengthentheconceptsandapplicationofclinical,research,operational,andadministrativeArmymedicine.Furthermore,theAMEDDJournalprovidesusgreatbenefitsasapeer-reviewedpublication.First,reviewingarticlesinyourfield(andingeneral)keepsyouabreastofdynamicresearchandideas.Secondly,theAMEDDJournalprovidesyouanexcellentvenuetocontributeideasandinformationforthoseofuswholooktotheAMEDDJournaltostrengthenoureducation,research,andservice.Toourreadersandcontributors,allofusattheCenterandSchoolthankyouinadvanceandsincerelyappreciateyoursupportandencouragementasyoucontinuetoconductandreportonyourresearch,experiences,andlessonslearned,whilewedoourverybesttoexpandtheknowledgebaseofourWarriorMedics.IknowyouwillfindthiseditionoftheAMEDDJournalparticularlyusefulandinformative.Itcontainssomegreatresearch,observations,andideasthatcoveramyriadofdiversetopics,allveryapplicabletopresent-dayAMEDDglobaloperations.ThiseditionbeginswithanarticletitledMedicalOperationsintheStrykerBrigadeCombatTeam(SBCT)authoredbyagroupofmilitarymedicalprofessionalsledbyLTCEdMichaud.TheydoasuperbjobhighlightingtherealitythatthecontemporaryoperationalenvironmentdictatesthenecessityforfurtherrefinementsintheSBCTmodifiedtableoforganizationandequipment.TherearesometrulysmartcomparisonshereregardingmedicalsupportinthelegacybrigadecombatteamandthecurrenttransformedSBCT.TheauthorsconcludethattheBrigadeSurgeonSectionshouldbemorerobustandself-sufficient,thuseliminatingtherequirementforcriticalaugmentation.Thearticlebringstolightahostofotherissueswithsomeverysupportiveobservationsinthisveryeasyread.MedicalProcessingofPatientsfromOEFandOIF:TheDeployedWarriorMedicalManagementCenter(DWMMC)byMAJBrentJohnson,USAFexplorestheoperationsoftheDWMMCatLandstuhlRegionalMedicalCenter.HearticulatestheDWMMCsmanychallengesandsuccessesincopingwiththecomplexitiesofoutpatientmanagementacrossthespectrumofmultipleoperations.TheDWMMCatLandstuhlisthemodelforourplannerswhentheyconsiderthehighdemandofoutpatientcareforfutureconflicts.CaringforContractorsinOurMidst:LessonsLearnedfromOperationIraqiFreedombyMAJAndrewDoyle,takesagoodlookatthedilemmaofprovidingthepropercareforourUScontractorsinPerspectiveMajorGeneralRussellJ.Czerw

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2ArmyMedicalDepartmentJournalOIF.Henotesthatthepresenceofcontractorswithourforcesisnothingnew,howeverourArmyfieldmedicalunitsarestructuredtoprovidecombatcasualtycaretoamostlyhealthy,young,adultpopulation.OurcontractorsareoftenolderandmayhavemedicalconditionsthataredramaticallydifferentthanthoseoftheaveragefrontlineSoldier.Heconcludesthatourdeployingmedicalunitsmusttakethisintoaccountandplanandexpandtheirserviceaccordingly.Itistothebenefitofourdeployedwarriorsthatwekeepourcontractorshealthywhiletheyareservingwiththem.ThumbOppositionRestoration:ACaseStudybyCPTDavidAdmireintricatelyexaminesthesuccessfuloutcomeofathumbinjurysustainedbyanF-16pilot.Aftertwosuccessfuloperations,combinedsuccessfuloccupationaltherapyandintensiverehab,thepilotwasabletoreturntoduty,savingenormousamountsoftimeandmoneywhilecontinuingtomaintainoperationalreadiness.MedicalSupportandBasketball-RelatedSportsInjuryofUSSoldiersinAfghanistanbyLTCJamesFrizzietaldutifullyremindsusthatalthoughourSoldierstrulyenjoyandbenefitfromtheimprovedathleticandsportsfacilitiesatfar-forwardareas,thepresenceofsuchfacilitiesinevitablyleadstoanincreasedrequirementforcrutches,casts,andcoldcompresses.Ourmilitaryshouldcontinuetoprovidesuchfacilities.However,medicalsupportprovidersmusttakeintoaccounttheattendantimpactonsuppliesandcapabilitiesduringtheplanningprocess.ImprovingSoldierCareThroughOutcomesResearch:TheAccessionScreening&ImmunizationProgram(ASIP)byCPTRemingtonNevinetalprovidesagreatlookattheASIPprogramasanapplicationofmedicaloutcomesresearch,improvingSoldiercarewhileprovidingevidenced-basedforecastedcostsavings.HecontendsthatimplementingserologicscreeningwouldmostcertainlychangecurrentArmyaccessionimmunizationpracticesforthebetter;eliminatinginnumerableunnecessaryinjections,reducingneedlestickinjuriesandsavingbigdollars.Perhapswecanallsaygoodbyetothedaysofmassimmunization.MultidisciplinaryCrisisManagementSimulation-BasedTrainingProgrambyDrKevinCoonanetalisagreatread.Itreinforcesthatsimulationtrainingisofgreatvalueacrossthespectrumofhealthservice.FromthefoxholetotheICU,simulationisaninvaluabletoolforenhancingpatientcareteamperformance.Thearticlealsoemphasizesthatfurtherstudiesanddocumentationarerequiredtooptimizethattraining.Moretocomeinthedynamicfieldofsimulationtraining.ElementsofLeadershipfortheSuccessfulOrganizationbyCOLGeorgeTurianskyisanabsorbingessayonasubject,leadership,whichcanneverbeoveremphasized.COLTurianskythoughtfullysharesthepillarsofhisleadershipphilosophy:vision,communication,courage,developingsubordinates,knowingyourself,andpassion.Thisarticleisaneasyandimportantreadbecauseweallhaveroomforimprovementinourroleasleaders.MentorsandProtgs:SimpleRulesforSuccessbyCOLMarkMelansonisaclear,structuredpresentationonanoftenoverlookedtoolthatorganizationshaveavailabletonurtureandgrowtheirpeople.COLMelansondelineatestenruleseachforthementorandtheprotginamentoringrelationship.Thisconciseapproachtothesubjectofferssomegreatpearlsofwisdomonhowmentoring,whenusedcorrectly,canbeofgreatbenefittoourmedicalprofessionals,augmentingtheirskillsandknowledgewhileoptimizingthetimeandresourcesinvestedintheeffort.Finally,AValidationStudyofaCommonlyUsedMilitaryAssessmentofPersonalityInteractionalPatternsbyMsSusanWalleyetalisacomprehensivestudytoevaluateifuseofthePersogenicsPersonalityProfileisaneffectivemethodofenhancingmissionaccomplishment.Originallydevelopedforcivilianuse,ithasbeenincorporatedasatrainingsupporttoolwithinthemilitary.ThisstudylooksagainatMyers-Briggsandotherpersonalityevaluationinstruments,describesthemethodologies,andpresentstheanalysisofdata.Theauthorsconcludethat,althoughcertainsimilaritiesdoexistbetweenourcivilianandmilitarypopulations,furtherstudiesareneededtoassessdirectandtangiblebenefitstomilitarypersonnelfromuseofthePersogenicstool.Again,itismypleasuretocomeaboardandIlookforwardtoyourcontinuedsupport.Allofyouhavemysincerethanksforwhatyoudoeveryday!Perspective

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JulySeptember20063Armytransformationinvolvesacombinationofstructuralchangesandtheincorporationofnewtechnologies.Theimplicationsofinformationagetechnologyhavespecialimportanceforthemilitary,notonlyintheever-expandingcapabilitytorecognize,understand,andadapttotheenemysresourcesandactions,butalsointhebasicunderstandingofthecurrentconditionandcapabilitiesofourresources.AsSunTzuwroteover2,000yearsago,Ifyouknowtheenemyandknowyourself,youneednotfeartheresultofahundredbattles.1ThetransformationofArmymedicinewithnewinformationtechnologiesisamajorcomponentinacommandersabilitytobetterknowthecurrentconditionofthatmostimportantresource,theSoldier.Suchexpandedcapabilityisbecomingespeciallyimportantinthenewoperatingenvironmentpresentedbythenonlinearbattlefield.ThedesignationofcombathealthsupportundercombatservicesupportisarelicofthelegacyArmy.Inthecontemporaryoperatingenvironment,medicalcompaniesarenolongerclusteredinthebrigadeordivisionsupportareas.Theyaredispersedtofarforwardoperatingbasessupportingthemaneuverunitswithminimalcontactwiththesupportbattalion.Assuch,medicalassetsshouldnolongerfallunderlogisticsbattalions,commandedandcontrolledbylogisticians.Thebrigadesurgeonsectionistaskedtoprovidethebrigadecommander,battalioncommanders,andthebrigadecombatmedicswiththemostrobustmedicalsupportpossible,includingrealisticmedicaltraining,medicalinformationmanagementimplementation,currentandaccuratemedicalintelligence,carefulhealthservicesupportplanning,responsiblecoordinationforClassVIIIsupport,andcompetentexecutionofmedicaloperations.TheSoldiersandmedicsofthemaneuverplatoonsmustbepreparedtostabilizeatraumapatientathispointofinjuryandevacuatehimtoalevelIIIhospitalassoonaspossible.Further,preservationofahealthyforcerequiresthatSoldiersmustbeeducatedtokeepthemselveshealthy,fromthebasicsofhygienetothefoodthattheyeat.ThisrequiresbothacentralizedunityofeffortwithinthemedicalcommunityandadecentralizedexecutiondowntothemedicalplatoonsandtheindividualSoldier.TherolesofthebrigadesupportmedicalcompanyandmedicalsupportoperationsofthebrigadesupportbattalionhaveevolvedunderthenewStrykerBrigadeCombatTeam(SBCT)structure.Thesecellsdolessmedicalplanning,operations,treatment,andevacuationsthaninlegacyforcestructures.Themedicalstaffstructureisalreadybeingmodifiedbynecessity,bothingarrisonandindeploymentstoOperationIraqiFreedom,toreflectthenewparadigm.Thebrigadesurgeonsectionisrobust.Themaneuverbattalionmedicalplatoonsandbrigadesupportmedicalcompanyaremoreindependent,yetmoreinterconnectedbymultipleinformationsystems.Soldiersaregivenincreasedtraininginfirstaidandpreventivemedicine.Themodifiedtableoforganizationandequipmentoftheobjectivebrigadecombatteamshouldbestructuredtoreflectthoselessonslearned,similartothemoderndivisionwhichhasanindependentmedicalcompanyandarobustsurgeonsection.BRIGADESUPPORTMEDICALCOMPANY:ASEPARATECOMPANYHistorically,CharlieMedhasbeenlocatedinthebrigadesupportareawithallofthecombatservicesupportelements.Becauseofthistraditionalcollocation,itmadesensetotaskorganizethemedicalcompanyundertheumbrellaoftheforwardsupportbattalion.ItwasaveryappropriateorganizationforthelegacyArmyfightingonalinearbattlefield,eg,todefendtheFuldaGap.Theenemyhaschanged.Thebattlefieldhaschanged.TheArmyhastransformed.MedicalOperationsintheStrykerBrigadeCombatTeamLTCEdMichaud,MC,USAMAJMikeHelwig,MC,USALTCJohnGlorioso,MC,USALTCKeithSalzman,MC,USA

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4ArmyMedicalDepartmentJournalThemedicalcompanyassetsaredispersedontodaysnonlinearbattlefield.Forexample,duringanOperationIraqiFreedomdeployment,the296thBrigadeSupportMedicalCompany(BSMC)supportedoperationsofthe3rdBrigade,2ndInfantryDivisionSBCTfrom6forwardoperatingbasesbothwithinandoutofthebrigadeareaofoperations.SomeoftheBSMCmedicspatrolledwithandgavedirectmedicalsupporttoinfantrysquadsandcompaniesincombatoperations.Onlyasingleteamwasleftwiththebrigadesupportbattalion(BSB)toprovidelevelIcaretothebattalion.ThebrigadesurgeonsectionrarelyinvolvedtheS4whenplanningcombatoperations.ThemedicalplansofficerdevelopedthemedicalplaninconjunctionwiththeS3planningsection.Whentheplanwasexecuted,coordinationwasdonewiththeS3operationssection,theairoperationsofficer,andthefiresandeffectscellfordeconfliction.Themediconthelineorthetreatmentteamaugmentingabattalionisafarforwardcombatmultiplier.Themedicispartoftheteamofaninfantrysquadassaultinganobjective.Theforwardaidstationistherewhenabattalioncordonsavillage.Thesearenotlogisticsupportfunctions.Medicalsupportincombatisacombatsupportfunction.Thisisnottoarguethatthereisnotalogisticselementtocombathealthsupport.Ofcoursethereis.However,medicallogisticsistocombathealthsupportasmovingClassI,III,andVsupplyistoaninfantryoperation.Underthecurrentstructure,theeffectivenessofcombathealthsupportisfartoodependentoncommandphilosophies,preferences,andindividualpersonalities,asillustratedinthedeploymentexperiencesoftwodifferentSBCTs.Duringthedeploymentdiscussedearlier,the296thBSMCsupportedthebrigademagnificentlyinspiteofthetaskorganization,notbecauseofit.TheBSBattemptedtomaintaincontroloverallofitsSoldiersdispersedover28,000squaremilesinsupportofthemaneuverbattalions.Thisattempttomaintaincommandandcontrolrenderedthedispersedmedicalassetslessresponsivetotherapidlychangingneedsofthemaneuverbattalions.Boththebrigadeenvironmentalscienceandmentalhealthofficersperformedsuperbly,buttheireffortsweresometimeshamperedbecausetheycouldnotresponddirectlytorequestsfrombrigadeheadquarters,ortheindividualbattalionstowhichtheywereattached.ThisoccurredbecauseallrequestsrequiredapprovalbytheBSBcommander.Further,thesehealthprofessionalswererequiredtosubmitreportsoftheirassessmentsofmaneuverbattalionstotheBSBcommanderforapprovalbeforeprovidingtheinformationtothebrigadesurgeontobriefthebrigadecommander.Indeed,theroutingofsupportrequestsandtheflowofreportinformationthroughtheBSBwasdoctrinallycorrect,butthemissionoftheBSMCisthatofamedicalforceandserviceprovidertothebrigade,nottotheBSB.Duringtheirdeployment,the1stBrigade,25thInfantryDivisionSBCTenjoyedanexcellentrelationshipwiththe25thBrigadeSupportBattalion.ThiswasduetoacombinationofstrongandextremelycompetentCaptainsatboththehealthsupportserviceofficerandmedicallogisticsofficerpositionsintheBSMC,andareversemigrationofofficersfromthebrigadesurgeonsection(BSS)totheBSMCwheretheybroughtabrigadelevelperspectivetotheirbrigadesupportrole.TheBSMCcommanderhadbeentheBSSplanner.WhileinIraq,the25thBrigadeSupportBattalionwasabletocollectmedicalsituationreportsandsendthemtothebrigadesurgeonviatheNIPRNET,*andwasalsoveryresponsivetorequestsfromtheBSS.AnotherpositivefactorduringthedeploymentwasthattheSBCTwasoverstaffedwithtwoMedicalServiceCorpsofficersinthebrigadesurgeonsection,andtheBSMChadanExecutiveOfficer.However,thissituationwasuniqueforthisdeploymentandcannotberelieduponforfutureoperations.ThefactthatthesuccessofthatdeploymentwasnotexperiencedinpreviousdeploymentsbythisSBCT,orduringotherSBCTdeployments,demonstratesthatthecurrentorganizationcanbemadetoworkwithexperiencedstaffinggreaterthantheallocationofthemodifiedtableoforganizationandequipment.Unfortunatelythatistheexceptionratherthantherule.TheusualsituationundernormalstaffinglevelsalmostalwaysinvolvesLieutenantsinCaptainsbilletsandmedicalofficersdivertedintononmedicalroles,witharesultingnetdecreaseinmedicalplanningandoperationaleffectiveness.InlightofthechangesintheArmy,theenemy,andthebattlefield,combathealthsupportshouldberemovedfromthelogisticsumbrella.TheBSMCshouldbeaseparatecompanyfallingdirectlyunderthebrigade.MedicalOperationsintheStrykerBrigadeCombatTeam *Nonclassifiedinternetprotocolrouternetwork

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JulySeptember20065TheBSMCsdeployedoperatingenvironmentisnodifferentthanthatoftheMilitaryPoliceandCivilAffairsdetachments,andtheSignal,MilitaryIntelligence,Antitank,andAirDefenseArtillerycompanies,allofwhichhaveSoldiersdispersedacrosstheforwardoperatingbasesinthebrigadeareaofoperationsunderthebrigadetroopbattalion.AseparateBSMCatthebrigadelevelcanbeusedbythebrigadecommanderandstafftomeettheneedsoftheentirebrigadewithouttheperceivedthreattobattalionoperationsandintegrity.CURRENTMEDICALOPERATIONSIntheArmyofExcellencelegacybrigadecombatteam,themedicalcompanywasthehubofmedicaloperations.BrigademedicalplanningwasbasedprimarilyoninputandforcehealthprotectionestimatesprovidedtothebrigadeS3throughtheforwardsupportbattalion.AllpatientswereevacuatedfromlevelItolevelII.Allmedicallogisticswerecoordinatedthroughthebrigadesupportbattalionmedicalsupportoperations,andallcommunicationswentthroughthemedicalcompany.Asdiscussedearlier,thatparadigmhaschanged.Patientsarenowstabilizedneartheirpointofinjuryandmostareevacuateddirectlytotheclosestmilitarytreatmentfacility(generallylevelIII)foroptimalmedicalcare.TheBSSperformsbrigademedicalplanning,coordinateswithmedicalforcesinthoseechelonsabovebrigadelevel,andcoordinateswithhostnationandnongovernmentalorganizations.Medicalinformaticsandimplementationofthetacticalelectronicmedicalrecord,bothcriticaltotransformationofmedicalsupportintheSBCT,aretwoofthenewrolesperformedbytheBSS.Brigadelevelmedicalevacuationsarecoordinatedandmanagedbythebrigadetacticaloperationscenter(TOC).ThebrigadesurgeonsectionhasassumedthesenewresponsibilitiesoutofnecessityduetothecommandandcontrolstructurewhichdirectsandsupportsSBCToperations.TheSBCTbrigadeTOCisaremarkablepowerhouseforboththeplanningandexecutionofthecombatteamsmissions.TheS3battlecaptainandthebrigadestaffmonitoroperationsaroundtheclock.Allformsofcommunicationsaremonitored,evendowntotheindividualvehicle.UnmannedaerialvehicleimageryandintelligencedatacanbepresentedonmonitorsintheTOC.RadardataonenemymortarpositionsarefedtotheForceEffectsCommandCenter(FECC)wherequickreactionforcesarealertedtodealwiththeidentifiedthreat.TheairspacecontrollersitsnexttotheAirForceAirLiaisonOfficer(ALO)whocontrolsallrotaryandfixedwingairmovementinthebrigadeareaofoperations.MedicalevacuationandnonstandardcasualtyevacuationflightsarecoordinatedintheTOCamongtheintelligence(S2)section(safetyoflandingzones),theFECC(clearanceoffriendlyandenemyfire),theALO(assignmentofflightcorridors),andtheBSSwhichensuresthatpatientsarepreparedforpickupatthedesignatedlandingzones.TheBSSreceivesmedicalsituationreportstwicedailyandsendspatientstatusinformation,medicalintelligence,andoperationalguidancetomedicalplatoonsusingtheTOCstacticalcommunicationsresources.Responsive,effectivecombathealthsupportwouldbeimpossibleintodaysbattlefieldenvironmentwithoutclose,activeinterfacebetweentheBSSandthebrigadesTOC.Ontheotherhand,theBSBshealthservicesupportofficerandmedicallogisticsofficerarerelativelyisolatedfromthebrigadesongoingcombatoperations.TheydonotparticipateinbrigademedicalplanningoroperationsattheTOC,butratherconfinetheirresponsibilitiestoBSBmedicaloperations.Unfortunately,theyaretypicallyassignedtononmedicalcombatservicesupportfunctions,tothedetrimentoftheirforcehealthprotectionresponsibilities.Themisuseofthesehealthcareprofessionalsisespeciallyegregiousinviewofthefactthatthemodifiedtableoforganizationandequipment(M-TOE)assignsonly3medicalofficersand2enlistedpersonneltothebrigadesurgeonsectiontoperformthesectionsextensiveplanningandoperationalfunctions.Fortunately,aslessonslearnedfromactualcombatoperationshavebeenconsideredindeploymentplanning,atleast2SBCTcommanderssupportedamorerobustBSS.Thosesuccessessupporttheideathatcombathealthsupportofbrigadecombatoperationswouldbebetterservedbyapermanentchangetothestructure,ie,changetheM-TOEtomovethehealthservicesupportofficerandtheenlistedassistanttothebrigadesurgeonsection.PREVENTIVEMEDICINEIn2000apreventivemedicinesection,consistingofanenvironmentalscienceofficerandapreventivemedicinespecialist,wasaddedtothebrigadesupport

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6ArmyMedicalDepartmentJournalmedicalcompanyoftheSBCTtoaffectcollectionandanalysisofmedicalthreatintelligence.ThenewsectionprovidestheSBCTadditionalresourcesduringtheintelligencepreparationofthebattlefield(IPB).TheyworkcloselywiththebrigadeS2todevelopspecificenvironmentalandenemymedicalthreats.Suchthreatshavebecomeevermoreimportantincurrentoperationalenvironments.Anticipatinganenemysdecisionprocesshasalwaysbeenvitaltosuccessincombat.Forcommandersoftodaysfastmoving,extremelyflexible,andrapidlyreactiveSBCToperations,suchanticipationisofcriticalimportance.DuringtheIPB,thepreventivemedicine(PRVNTMED)sectionproducesaPRVNTMEDestimatewhichissubmittedthroughthebrigadesupportbattalionforthebrigadesurgeon.2,3TheEnvironmentalScienceOfficerwillalsodirectlyparticipateinthepreparationofthePRVNTMEDormedicalannexinallbrigadeoperationsorders.ThePRVNTMEDsectionisresponsibletothebrigadecommanderforensuringpreventivemedicinemeasuresareimplementedtoprotectSoldiersagainstfood,water,insectbornediseases,andenvironmentalinjuries(eg,weather).Thescopeofthisresponsibilityincludesthebrigadesupportareaandunitsinforwardareas.Thesectionsactivitiesaregovernedbytheunitemploymentandforcehealthprotectionplansandcoordinatedbythebrigadesurgeonsection.ThePRVNTMEDsectionprovidesconsultationandadviceintheareasofenvironmentalsanitation,epidemiology,andentomology.Itconductsoccupationalandenvironmentalhealthsurveillanceandprovideslimitedsanitaryengineeringandpestmanagementservices.Thesectionischargedwithmedicalsurveillance,ie,monitoringthemedicaltreatmentrequirementsofbrigadeSoldierstoidentifyinjuryanddiseasetrends.SuchinformationiscriticalforboththeSBCTsurgeonandcommandersatalllevels.ItisvitaltothecombateffectivenessofthefightingforcetoidentifyanyconditionoractivitythatisdetrimentaltothehealthoftheSoldiersassoonaspossible,andinstitutecorrectiveaction.Medicalsurveillancehasbecomemuchmoreefficientwiththeadventofthetacticalelectronicmedicalrecord,4,5whichallowstheuseofdataminingtoolstoquicklyidentifytrendsandpatternsintreatments.Datamustbeobtainedandreviewedduringvisitstoaidstations,senttothebrigadesurgeon,analyzedforactionableinformation,thentransmittedtounitsfortheiruse.ThePRVNTMEDsectionhasthecapabilitytotrainandsupervisethebrigadefieldsanitationteamsandensurethoseteamseffectivenessintheircriticalmissionofensuringsafedrinkingwaterandfood,sanitarywastedisposal,enforcementofhandwashingrequirements,diseasevectorcontrol,andothermeasurestoensurethehealthandcombateffectivenessofthebrigadesSoldiers.Aboveall,thePRVNTMEDsectionprovideseducationandtrainingtoallSBCTSoldiersinpreventivemedicinemeasures,ie,howtostayhealthy.Unfortunately,theconceptualanddoctrinalapplicationandutilizationofpreventivemedicineresourcesdidnotmaterializewiththefirsttwoSBCTs.TheenvironmentalscienceofficerandpreventivemedicinespecialistwereassignedtothebrigadesupportmedicalcompanyintheBSBwheretheywereemployedintheinspectionoffieldfeedingteams,rodentcontrol,andotherBSBgeneralresponsibilitiesasassigned.AssuchthePRVNTMEDsectionsskillsandtrainingweremarginalized,bothdoctrinallyandpractically.Thesectionshouldhavetrainedandsupervisedbrigadefieldsanitationteamstoperformthosefunctions,amongothers.ThebrigadesurgeonischargedwiththecoordinationofallPRVNTMEDfunctionsandserviceswithinthebrigade,justasthedivisionsurgeondoesatthedivisionlevel.6Therealityisthatforgeographic,political,orpersonalreasonsthePRVNTMEDsectionmemberswereoftentaskedbytheBSMCandtheBSBwithnonmedicalresponsibilitiesandassignments.Consequently,fewofthebrigadelevelpreventivemedicinefunctionswereimplemented.The1stBrigade,25thInfantryDivisionSBCTdidnotexperiencethesamemisuseofthePRVNTMEDsectionduringtheirdeployment.Thebrigadesupportmedicalcompanycommander(whohadwrittenthebrigadepreventivemedicinepolicywhileassignedtothebrigadesurgeonsection)ensuredthatthePRVNTMEDsectionperformeditsdoctrinalfunctionsandsubmittedregularreportstothebrigadesurgeon.Theabovedescribedproblemshavealsobeennotedinlegacydivisions.ThedivisionPRVNTMEDsectionisdoctrinallyemployedbythedivisionsurgeon.Inmanycasesthesectionisassignedtothedivisionsupportcommand,therebyeliminatingtheirintegrationwithdivisionmedicalplanning,operations,andtraining.ThissituationisbeingcorrectedasthePRVNTMEDMedicalOperationsintheStrykerBrigadeCombatTeam

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JulySeptember20067sectionisassignedtothedivisionsurgeonsectionindivisionreorganizations,7thusensuringdoctrinalapplicationofthisresource.Similaractionshouldbetakenwithinthebrigadestructuretoensurethatthebrigadesurgeonhastheresourcesnecessarytomaintainthehealthoftheforce,assessandestimatethehealthandmedicalconditionsoftheenemysforces,andassistthehostnationwithhealthissuesamongtheirpopulationtotheextentpossible.COMBATSTRESSCONTROLAcombatstresscontrol(CSC)section,usuallyfoundonlyindivisions,8isanothernewadditiontotheSBCTsmedicalresources.Similartothepreventivemedicinesection,theCSCsectionisresponsibleforpreparingtheCSCestimate3forthebrigadesurgeon.TheteamalsoischargedwithmonitoringthementalhealthofbrigadeSoldiersanddevelopingrecommendationsastoactionsthatmaybetakentomitigatestressrelatedinjuryandimprovetheoverallmentalhealthsituation.TheCSCofficermustworkcloselywiththebrigadechaplainandthecommandsergeantmajortomaintainasenseoftheattitudesandmoraleofthetroopsandidentifydetrimentaltrendsorpatterns.Asdiscussedpreviously,thetacticalelectronicmedicalrecordallowsuseofdataminingtoolstoresearchtreatmentrecords.TheCSCsectionalsovisitsaidstationsandconductsinterviewswithindividualSoldierswhotypicallyhavebeenreferredfromtheircommandorhealthcareproviders.TheCSCofficer,whetherapsychologistorsocialworker,musttrainSoldiersandleadersatalllevelsinindividualandcollectivetasksthatareusedtoavoidstressinjuries.TheymusttrainhealthcareprovidersandsupervisorsintreatmentmethodswhicharemostconducivetoreturningdysfunctionalSoldierstoduty.Atthecompletionofdeployment,theCSCsectionmustbeintegralinplanningredeploymentscreeningandfollowupforSoldierswhohavebeentraumatizedbycombat.Theymustworkcloselywiththechaplaintodevelopandimplementasuicidepreventionprogram.Theymustcoordinatewithfamilyadvocacyprogramsathometohelpstrengthenfamiliesandprovidecrisisintervention.TheCSCteammustalsocoordinatecloselywiththeArmySubstanceandAlcoholProgramtoidentifyandassistSoldierswhoareabusingalcoholanddrugs.TheCSCsectionshouldmanagethecasesofallbrigadeSoldierswithmentalhealth,substanceabuse,orsignificantfamilyproblemsandadvisethecommandersontheirconditionsandtheassistancetheyrequire.LEVELIICAREINTHESTABILITYANDSUPPORTOPERATIONSThedoctrinallevelIIfacility(brigadesupportmedicalcompany,legacyforwardsupportmedicalcompany),wastraditionallytheevacuationdestinationafterinitialstabilizationwasperformedatlevelI(pointofinjury,aidstation).AtthelevelIIsite,patientswerefurtherstabilized,thenmovedtoalevelIIIfacility(hospital).TheBSMCalsoprovidedmedicalreinforcementtomaneuverunitswithaugmentationtreatmentteamsandevacuationassets.Thistreatmentandevacuationmodelisseldomusedinthenonlinearbattlefieldenvironment.PatientsarenowtakendirectlyfromeitherthepointofinjuryorlevelIcaretothelevelIIItreatmentfacility.Thisisthestandardmethodofpatientevacuationintheciviliansectorandisonlylogicalforthemajortraumainjuriessustainedincombat.DependingonthelocationofthelevelIIIfacility,evacuationisdoneeitherwithorganicmedicalevacuationvehiclesorhelicopterairambulances.Initially,forwardsurgicalteamswereenvisionedtoaugmentmedicalcompaniesatlevelII.Withaugmentationofx-ray,laboratory,andpatientholdcapabilitiesonthemodifiedtableoforganizationandequipment,theseteamscouldbefullyfunctional,andcollocatedwithanybattalionaidstationiflocatedagreatdistancefromalevelIIIfacility.InIraq,theunitshaveevacuatedtheirowncasualtiestolevelIIIfacilitiesasdiscussedpreviously.Inthatdangerousandunstableenvironment,evacuationconvoysareimpracticalbecauseroutesgenerallycannotberehearsed,andambulanceexchangepointsaredifficulttoestablish,coordinate,andsecure.AregisterednurseinsteadofthelicensedpracticalnurseisassignedtotheSBCT.Theintentisforthesenursestoassistwithtrainingofmedicsandotherbrigademedicalpersonnel.ThebrigadenursehasbeenaneffectiveeducatorforBSMCmedics.Unfortunately,similartrainingisnotextendedtobrigademedicsassignedtocombatmaneuverbattalions.Thebrigadenursehasproventobeavaluableorganizerandimplementationmanagerformedicalreadiness,clinicorganization,andpatientcare.Thenurseshouldbeconsideredashared

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8ArmyMedicalDepartmentJournalresource,asaretheenvironmentalscienceandmentalhealthofficers,toaddressplanningandtrainingrequirementsacrossthebrigade.BRIGADEMEDICALTRAININGOurphysicians,nurses,physicianassistants,andmedicsarebettertrainedthaneverbeforeandareexpectedtomaintaintheirproficiency.Ensuringthattheymaintaintheirskillsandaccreditationsisadauntingchallenge,eveninunitswithsufficientresources.Medicshavearealworldmissionofpatientcare,areexpectedtoprovidemedicalcoverageforallunittraining,maintaintheirequipment,andstayproficientintheirnonmedicalmilitaryskills.ThemedicsmustpasstheEMT(emergencymedicaltechnician)class,obtainEMTcertification,passTraumaAimsandprehospitaltraumalifesupportcoursesintheirMOS91Wtransition.AtFortLewis,SBCTspooledtrainingresourceswithMadiganArmyMedicalCenterattheJointMedicalTrainingCenter.Medicsattachedtothebrigadesurgeonsectiontrainedtheunitmedicsintheirrequirementsquarterly,resultinginover90%conversionof91WmedicsintheMedicalOperationalDataSystems.Medicsmustalsotakethesemiannualskillsvalidationtrainingwhichwasconductedatthemedicalplatoonlevel.TheStrykerbrigadeshavegiventheirmedicsandotherprovidersadditionaltraumatrainingtoensuretheyarepreparedtocareforourmostseverelywoundedSoldiersonthebattlefield.Thetrainingwascentrallycoordinatedbythebrigadesurgeonsection(BSS).ThetrainingwasconductedbyBSSstaffaugmentedbyexternalmedicalpersonnel,withinvaluablesupportfromMadigantocreaterealistictraumatrainingduringabrigadelevelexercise.Thetrainingevolutionwasrepeatedjustpriortodeployment.The1stBrigade,25thInfantryDivisionandthe3rdBrigade,2ndInfantryDivisionSBCTsinstitutedanefforttotrain100%oftheirSoldiersincombatlifesavingproceduresandtechniquesbecausetraumacanoccurtoanyoneatanytimeonthebattlefield.Trainingeveryoneincombatlifesavingskillsdramaticallyincreasestheprobabilitythattherewillbesomeoneavailabletoinitiatefirstaidandstabilizationofinjuriesimmediately.Muchofthistrainingisconductedatthebattalionlevel,butsomerequireacentralizedeffortforimprovedqualityandefficiencyofdelivery.Alloftheindividualtrainingmustbesupervisedanddocumented.ADDITIONALSTRYKERMEDICALEVACUATIONVEHICLESStrykerMedicalEvacuationVehicles(MEV)haveproventobeefficientandquietwhileeffectivelyprotectingtheoccupants.TheseMEVsallowamoreaggressivemedicalpostureonthebattlefield.EachSBCTmobiletreatmentteamshouldhaveatreatmentandevacuationMEVvariant.MoreMEVswouldallowtreatmentteamstosupportmaneuvercompaniesatthefight,aswellasmakeadditionalvehiclesavailabletomeetanyincreasedrequirementsonthedynamicbattlefield,ortoreplacelostvehicles.TheArmyMedicalDepartment(AMEDD)submittedtherequestforsuchachangetotheArmyReviewTeamwhenthefirstSBCTwasformed.Thechangewasnotsupportedduetocostlimitationsandairliftconstraints.Theneedforthechangeismoreacutenow,andsolidlyjustifiablefrommanymonthsofcombatexperience.Inaddition,itisnowclearthatthefrontlineambulancesshouldbereplacedwith4to8MEVstoaugmentevacuationcapabilitiesthroughoutthebrigadeareaofoperations.CONCLUSIONArmytransformationcontinuesapaceasthe172ndSBCTcompleteditstransitionatFortWainwrightanddeployedtoIraq,andafourthStrykerbrigadeformedatFortLewis.MedicaltransformationrequirescloseworkbetweenStrykerunitsandtheirsupportingmilitaryhospitals,alongwithcontinuedassistancefromtheAMEDD.ThechangestotheSBCTmodifiedtableoforganizationandequipment(M-TOE)whichdistinguishitfromlegacybrigadesareappreciated,butfurtherrefinementsarenecessary.TheM-TOEshouldbemodifiedtomaketheBSSmorerobustandself-sufficient,eliminatingtheneedtoaugmentitwithpersonnelwhoarebadlyneededelsewhere.TheBSSmustbeabletoconductcurrentandfuturemedicaloperationswhilebeingresponsivetomedicallogisticsdemandsaroundtheclock.Itmustalsobeabletoimplementmedicalinformatics,analyzeandpreparedetailedmedicalintelligence,overseemedicalreadinesslevels,organizeacomprehensivetrainingprogramformedicalcaregivers,andworkcloselywithhostnationandothernongovernmentmedicalelements.In1795,asurgeoninNapoleonsarmy,DominiqueJeanLarrey,perfectedtheuseofthebattlefieldMedicalOperationsintheStrykerBrigadeCombatTeam

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JulySeptember20069ambulancehehaddeveloped3yearsearlier.TheambulancevolantwasoneoftheinnovationsinmilitarymedicalsupportdevelopedandimplementedduringtheNapoleonicwars.Duringthesecampaigns,Napoleonsmilitaryalsodevelopedtheconceptsoforganized,sophisticatedlogisticssupportofanarmyincombat.Sincetheirinception,thetwosupportfunctions,medicaloperationsandlogistics,havebeenseparateentities,bothconceptuallyandpractically,andshouldbesotoday.TheSBCTbrigadesupportmedicalcompany(BSMC)shouldbemovedfromthebrigadesupportbattalion(BSB)tothenewbrigadetroopsbattalion.TheBSMCwouldthenapplytheirresourcestobrigadelevelmedicalsupportandavoidtheprovincialconcernsoftheBSB.Armymedicineshouldbeconsideredacombatsupportfunctionratherthanacombatservicesupportoperation.LessonslearnedfromSBCTcombatdeploymentscanbeusedtodemonstratetheneedandjustificationforsuchrealignment.REFERENCES 1.SunTzu.ChapterIII,AttackByStratagem.In:GilesL,trans.TheArtofWar.1910.Availableat:http://classics.mit.edu/Tzu/artwar.html.2.FieldManual8-55:PlanningforHealthServiceSupport.Washington,DC:USDeptoftheArmy;9September1994:chap11,sect1.3.FieldManual4-02:ForceHealthProtectioninaGlobalEnvironment.Washington,DC:USDeptoftheArmy;13February2003:chap2,sect2-3.4.FieldManual4-02.16:ArmyMedicalInformationManagement;Tactics,Techniques,andProcedures.Washington,DC:USDeptoftheArmy;22August2003:chaps2and3.5.OnleyDS.Electronicmedicalrecordsgointocombat.GovtComputNews[online].November222004.Availableat:http://www.gcn.com/print/23_33/27923-1.html.6.FieldManual4-02.17:PreventiveMedicineServices.Washington,DC:USDeptoftheArmy;28August2000:chap3.7.FieldManual4-02.21:DivisionandBrigadeSurgeons'Handbook(Digitized);Tactics,Techniques,andProcedures.Washington,DC:USDeptoftheArmy;28August2000:chap1.8.FieldManual8-51:StressControlinaTheaterofOperations;Tactics,Techniques,andProcedures.Washington,DC:USDeptoftheArmy;29September1994:chap2,sect1. AUTHORS LTCMichaudhasrecentlyreturnedfromdeploymentastheCivilMedicalAffairsDirectorforCombinedJointTaskForce76inAfghanistan.PreviouslyhewastheBrigadeSurgeonforthe1stBattalion,25thInfantryDivisionStrikerBrigadeCombatTeam.MAJHelwigiscurrentlytheCommanderoftheUSArmyHealthClinic,Friedberg,Germany.Whenthisarticlewaswritten,hewasthe3rdBrigade,2ndInfantryDivisionSBCTSurgeon.FromJulytoNovember2004whiledeployedtoOIF,hewastheAreaofOperationsNorthSurgeon/TaskForceOlympiaSurgeon,responsibleforprovisionofhealthcareto19,000coalitiontroopsandcivilians,evacuation,andmedicalreconstructionoveranareaof28,000squaremilesinnorthernIraq.LTCGloriosoistheChief,FamilyMedicineService,TriplerArmyMedicalCenter,Honolulu,Hawaii.PreviouslyhewastheBrigadeSurgeonofthe3rdBrigade,2ndInfantryDivisionStrikerBrigadeCombatTeam.LTCSalzmanistheChief,InformaticsattheMadiganArmyMedicalCenter,FortLewis,Washington.PreviouslyhewastheBrigadeSurgeonforthe3rdBattalion,2ndInfantryDivisionStrikerBrigadeCombatTeam.

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10ArmyMedicalDepartmentJournalINTRODUCTIONOperationEnduringFreedom(OEF)began7October2001againsttheTalibanregimeinAfghanistan.LandstuhlRegionalMedicalCenter(LRMC),thelargestAmericanmilitarymedicalcenterinEurope,becamethesolereceivingfourth-echelonmedicalfacilityforpatientsfromOEFcombatoperations.TheDeployedWarriorMedicalManagementCenter(DWMMC)atLandstuhlwasestablishedtomanagetheprocessingofpatientsbeforearrivalandduringtheirtimeatLandstuhl.TheDWMMChandlestaskssuchasidentificationofincomingpatientairlifts,billetingarrangements,patientmovement(fromDWMMCtogeographically-separatebilletingandtotheaeromedicalstagingfacilitiesatnearbyRamsteinAirBase),accountability,anddatainputtotheDWMMCdatabase,theDefenseEnrollmentEligibilityReportingSystem,theCompositeHealthCareSystem,andtheArmysPatientAccountingandReportingReal-TimeTrackingSystem.Thesetaskspreparepatientstoeitherreturntodutyorbesenttotheirhomestationforadditionalcare.Patientnumbersdramaticallyincreasedinthemonthsprecedingthe20March2003startofOperationIraqiFreedom(OIF)andremainedsignificantthrough2004.ThispaperfocusesonthemedicalsectionsroleandhowtheDWMMCinterfacedwiththemedicalstaffofLRMCtopreparefor,treat,andmanagethedispositionofpatientsarrivingfrombothOEFandOIFoperations.ACTIVECOMBATPHASEAccordingtoCOL(nowBG)D.A.Rubenstein(writtencorrespondence,March2004),ChiefofStaff,EuropeanRegionalMedicalCommand,priortoOIF,DWMMCprocessedadailyaverageof2to3newpatientsfromUSCentralCommand(CENTCOM),arrivingon3to4flightsperweek(maximumof32patientsonanyflight).InformationaboutincomingpatientswasmonitoredthroughtheUSTransportationCommandsRegulatingandCommand&ControlEvacuationSystemwebsite.ThewebsiteprovidesaPatientMovementRequest(PMR)foreachpatientmanifestedonagivenmission.ThePMRcontainsthepatientsdiagnosis,abriefclinicalsummary,medications,allergies,andadministrativeinformation.ThePMRswereprintedanddistributedtotheDWMMCmedicalsectionforcoordinationwiththeLRMCmedicalstafftodetermineinpatientversusoutpatientstatus,treatingservice,andinpatientbedlocationifthepatientwastobeadmitted.Duringthe MedicalProcessingofPatientsfromOperationsEnduringFreedomandIraqiFreedom:TheDeployedWarriorMedicalManagementCenterMAJBrentA.Johnson,BSC,USAFABSTRACTTheDeployedWarriorMedicalManagementCenter(DWMMC)atLandstuhlRegionalMedicalCenter,Germany,hasplayedapivotalroleinpatientmanagementfromOperationsEnduringFreedomandIraqiFreedom.TheDWMMCpreparesforthearrivalandmanagementofthesepatientswhiletheyaretreatedatLandstuhl,andcoordinateseithertheirreturntodutyorevacuationtotheUnitedStates.DWMMCoperationsandscopechangeddramaticallyfromtheearlydaysofOperationEnduringFreedomwhenanaverageof2.5newpatientsperdaywerereceivedfrom3or4flightsperweek(maximumof32patientsonanyflight),tothepeakofOperationsEnduringFreedomandIraqiFreedom,whenanaverage57newpatientsarrivedondailyflightsaveraging30to40patientsperflight.PlannersforthenextmajortheaterwarshouldconsiderthehighdemandofoutpatientcareevidencedbyLandstuhlRegionalMedicalCentersexperienceandincorporateplansforaDWMMCtomanagepatientflow.

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JulySeptember200611earlyperiodofDWMMCoperation,oftenlessthan5patientswouldarriveonanygivenflightsothemedicaldirectorcouldpersonallyvisiteachclinicanddeliverthePMRstotheon-callphysicians.Asthenumberofarrivingpatientsincreasedproportionallywiththeincreasingnumbersofin-theaterpersonnelinthefewmonthspriortoOIF(duringtheperiod20Marthrough6May2003,LRMCreceivedanaverageof24patientsperday(ibid)),dailymeetingstomakesuchdecisionsandassignmentsbecamearequirement.Thedailymeetingswerenormallyconvenedat1300,withadditionalmeetingscalledtoaddressanyflightswithmorethantenpatientsthatwerescheduledtoarrivebeforethefollowingdaysregularsession.Theregularmeetingswereattendedbythedivisionchiefsforsurgeryandmedicine,apsychiatry/psychologyrepresentative,thebedmanager,theDeputyCommanderforClinicalServices(DCCS),thereceivingDWMMCdoctor,andtheDWMMCchief.EachpatientwasreviewedandthedivisionchiefsdecidedonICU,inpatientoroutpatientstatus,andacceptingservice.DetailsaboutflightarrivaltimeswerepresentedbytheDWMMCdoctor,andanyadditionalrelevantinformationwaspassedamongdivisions,DCCS,andtheDWMMCchief.ThedispositionofpatientswasdeterminedbasedontheinformationavailableonthePRMs.Forexample,severeneurosurgerypatients,someocularinjuries,andothersevereacutepatientsthatweredeemedtorequirecareoutsideofLRMCscapabilitiesweretriagedtothenearbyGermanuniversityhospitalatHomburg.DuetotheoftenincompleteclinicalpicturepresentedbythePMRs,arrivingpatientswereoccasionallydirectedtotheemergencyroomwheretheon-callphysicianfortheacceptingserviceprovidedanassessmentanddisposition.PatientsevacuatedtoLRMCformentalhealthreasonswereeithertriagedtoinpatientstatusortotheemergencyroom,wheretheywouldbeevaluatedbytheon-callpsychiatristorpsychologist.Ifconsideredsafe,thosepatientswouldbesenttooutpatientstatus.DWMMCphysiciansrotatedthe24-hourreceivingandreportingcall.ThereceivingphysicianwasresponsibleforobtainingPMRsandflightinformationforarrivingpatients,organizingandpreparingforthedailymeetings,andrecordingarrivalinformationforeachpatientatthemeeting(inpatientoroutpatientstatus,receivingservice,andbedlocationforinpatients).PatientinformationwasrecordedonamasterspreadsheetthatwasemailedtoDWMMCstaff,theLRMCcommander,andinpatientwards.Thereceivingphysicianoversawpatientarrival,ensuredmovementtoassignedlocations,andevaluatedoutpatientstoensuretheycouldremainasoutpatientsuntilthenextdutydaywhentheywouldbeseenintheoutpatientclinics.PatientsweretransportedtoLRMCfromRamsteinAirBasebyambulanceorbus.WhenpatientsarrivedattheDWMMC,thereceivingphysicianwasbriefedonanyin-flightchangesbyeithertheairevacuationcreworthecontingencyaeromedicalstagingfacilitypersonnel.Manpowerpoolmembersthentransportedinpatientstotheirwards.Outpatientsweresenttotheirrespectiveclinicsiftheyarrivedduringdutyhours.OutpatientsarrivingatnightoronaweekendweretakentotheFamilyPracticeclinicwheretheywereinprocessedbyDWMMCenlistedstaffandthenevaluatedbytheDWMMCdoctor.Whenthereweremorethan10outpatients,thereportingDWMMCdoctor,theon-callfamilypracticephysician,andtheon-callpediatricianwerecalled-inincrementallytoassistintheevaluations.Ifthereweremorethan30outpatients,asfrequentlywasthecase,allfourphysicianscouldbeinvolved.EvaluationofoutpatientswasperformedtoensuretheirconditionsmatchedtheclinicalinformationdiscussedatthedailyDWMMCmeeting.Occasionallyapatientwasmoreacutethanpreviouslyindicatedoronintravenous

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12ArmyMedicalDepartmentJournalantibioticsoranalgesics.InsuchsituationstheDWMMCdoctorcoordinatedwiththebedmanageranddivisionchiefforthepatienttobeadmitted.Followingevaluation,theoutpatientswouldbeprocessedforbilleting.Someweretransportedtogeographically-separatebilletingwhilemoreacutepatientswerekeptinon-postbilletingor,initially,asin-hospitalboarders.Suchpatientshadtobemobileenoughtogettothediningfacilitywithoutassistanceandrequirenonursingcare.Patientsassignedtothistypeofbilletingwerethosewhocouldnotambulategreatdistancesorupstairs,whohadminoreyeinjuriesthatimpairedtheirvision,andrenalstonepatients.ThereportingphysicianpreparedadailyreportonLRMCsCENTCOMpatients.DuringtheearlyphasesofOEF,theDWMMCmedicaldirectorrecordedinformationaboutthe4or5OEFpatientsthatwereintheLRMCsystematanyonetimeforin-theatercommanderswhodesiredinformationabouttheirevacuatedSoldiers.Astheoperationaltempoofthetwomajoroperationsincreased,distributionofthereportalsoincreasedtomultiplerecipientsthroughoutEuropeandCentralAsia,includingunitcommanders;theheadquartersoftheEuropeanRegionalMedicalCommand,theUSEuropeanCommand(EUCOM),CENTCOM,theUSArmyMedicalCommand,andtheArmySurgeonGeneral.DuringtheperiodApriltoJuly2003,withapproximately250-350outpatientsandinpatientsatanyonetime,thereporthadexpandedintoahand-generateddocumentof30pagesormore.EachdayoneoftheDWMMCdoctorswasresponsibleforthemanualrecordingofallnewarrivals.ThemanifestsforallairevacuationmissionsleavingforthecontinentalUnitedStates(CONUS),inpatientbedreports,andseveralotherreportswerecarefullyreviewedsodepartingpatientscouldbemanuallydeletedfromtheLRMCreport.Thereportingdoctoralsoconductedroundsontheinpatientsandcollectedupdatesoneachindividual.ThosecommentswereenteredintotheDailyUpdate.LOW-INTENSITYCOMBATPHASEAftertheendofactivegroundcombaton1May2003,thepatientloadarrivingatLRMCsteadilyincreasedthroughthesummerandearlyfall.SomeofthisincreasewasduetotheclosureandredeploymentofNavalFleetHospital,Rota,Spain.Asanevacuationhospital,thisfacilityhadmanagedapproximately20%oftroopsevacuatedfromCENTCOM.Theclosureoccurredatatimeofincreasingpatientloadsandcontinuinglow-intensitycombat.Therefore,LRMCabsorbedtheadditionalpatientload.Itisalsoprobablethataportionoftheincreasewasduetothefactthatsometroopsignoredtheirsub-acuteinjuriesorcomplaintsduringthebuildupandactivecombatphaseofOIF.OncethecombatmissionwasdeclaredcompleteandtheenvironmentalconditionsintheGulfbegantotakeaphysicalandemotionaltoll,thesecourageouswarriorsbegantopresentthemselvesforcareandeventuallyarrivedatLRMC.Fortheperiodof7Maythrough30June2004anaverageof33patientsperdayarrivedatDWMMC.Therateclimbedtoanaverage42newpatientsperdayduringperiod1Julythrough15September2004.1Atthepeakofpatientflow(anaverageof57newpatientseachday)duringthis75-dayperiod,upto5airevacuationflightsarrivedeachdaywithapproximately30to40patientsperaircraft.Duringone2-weekperiodinparticular,dailyarrivalsoflessthan100patientsoccurredonly3times.AccordingtoLRMCsstatisticsprovidedbyCOLRubenstein(writtencorrespondence,March2004),thelargestnumberofnewpatientsreceivedina24-hourperiodwas168.SeveralkeyfactorsallowedDWMMCandLRMCtomeettheincreasedmissiondemandsofthisperiod.DWMMChadadatabaseforaccountabilityandpatienttracking.Overtimeincreasedemphasiswasplacedonitsuse,eventuallyresultingintheproductionofanautomateddailyreportinlieuofthemanuallygenerateddocumentthatpreviouslyconsumedanentiredayofaphysicianstimeforpreparation.TheDWMMCdatabasewasusedtodevelopwhatarguablybecamethemostimportantreport,theAgingReport.Thisdocumentlistedthepatientsbynameindescendingorderbylengthofstaywiththelongeststayatthetop.Thereportallowedearlyidentificationandscrutinyofpatientsreachingthe14-daylimit.Asisalwaysthecase,thereweresomepatientswhopurposelydelayedthemedicaldisposition,casemanagerappointment,ordersgeneration,andairevacuationprocessandstayedinGermanylongerthannecessary.TheAgingReportallowedrapididentificationanddispositionoftheseindividuals.DevelopmentoftheDWMMCdatabasetoadapttotheneedsofthereal-worldoperationaltemporesultedinanexcellenttoolthatallowsDWMMCstafftoselectanameandviewarrivalinformation,medications,appointmentdates,billetinglocation,andTheDeployedWarriorMedicalManagementCenter

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JulySeptember200613disposition.Allinformationiscarefullypassword-protectedandmeetsHIPPAstandardstoensurepatientprivacyandcodedsothateachsectiononlyseesinformationappropriatefortheiruse.Electronicairevacuationformscanalsobegeneratedfromthissystem.Soon,itwillbepossibletoprocesspatientselectronicallyfromdoctorcompletionthroughairevacuationnurse/flightsurgeonapprovaltoinclusionontheflightmanifest.OutpatientsrepresentedasignificantpercentageofarrivalsduringallphasesofOIF.Asoutpatientnumbersclimbedto40or50ormoreperflight,threeorfourphysiciansrequiredincreasinglengthsoftimetopersonallyevaluateeachpatientwhoarrivedafterdutyhours.Tomitigatethissituation,theDWMMCimplementedaself-evaluationquestionnaire,illustratedonpage14,thateachpatientcompletedafteraninitialbriefing.Thequestionnairewaslaterredesignedsothatappropriateyesandnoanswersmandatinganimmediatevisitwereinthesamecolumnforeaseofidentification.Thelargenumberofoutpatientswhowerearrivingforchronicmusculoskeletalcomplaintsandminorinjurieswerestableandcouldsafelyremainasoutpatients.Arrivingpatientswhoindicatedaneedforpainmedicinerefills(themostcommonreasontoseeaproviderimmediately),hadintravenousmedicationrequirements,orcouldnotgetthemselvesaroundinanoutpatientsettingwereidentifiedandtheirproblemsaddressed.Patientswhohadsuddenonsetofchestpainorotherseriousnew-onsetconditionsweresenttotheemergencyroomforwork-up.Thisexpeditedsystemsavedmanysignificanthoursandreducedmedicalstaffrequirementswithnocompromisetopatientsafety.Asthesummerof2003passed,themobilizedorTDYphysiciansassignedtotheDWMMCnearedtheendoftheirrotationsatLRMC.ItsoonbecameclearthatreplacementphysicianswouldnotbeavailableforDWMMCassignmentandasignificantgapinstaffingwouldoccur.Atonepointthisstaffingshortfallresultedintwophysiciansalternating24-hourcallforreceivingmissions.InlateJuneandearlyJuly2003thetaskofpreparingandreceivingairevacuationmissionswastransitionedtoastaffofnursesandmedicaltechnicians,thusallowingalargerstaffofmoreavailablecareerfieldstohandlethisvitalcomponentoftheprocess.Italsoallowedsubsequentphysicians,physicianassistants,andnursepractitionersdelegatedtotheDWMMCtobemoreappropriatelyusedinthePost-DeploymentClinicatLRMC.Theseprovidersrotatedcalltoassistwithafter-hoursevaluationofarrivingoutpatients.Theyalsoevaluatedsecondarycomplaintsandmadespecialtyconsultswhenappropriate.Thiscombinationofshiftingnursingintothereceivingmission,puttingcredentialedprovidersbackintothePost-DeploymentClinictocleararrivingoutpatients,andusingthequestionnairetoreducethetotalnumberofoutpatientsneedingimmediateattentionresultedinasafe,stablesystemthathadbeeninplaceforapproximately14monthsattheendofmytour(June2004).Theneedforon-callfamilypracticephysiciansandpediatricianstoassisttheDWMMCmissionwas,forthemostpart,eliminated.Theimportanceandsuccessofthenursesassumptionofthereceivingmissioncannotbeoverstated.Consummateprofessionals,theyenthusiasticallyadaptedtoanextremelydemandingandcomplexmission,makingthewholesystemwork.DISCUSSIONTheEUCOMin-theaterpolicyallowed14daysbeforepatientseitherhadtoreturntodutyorproceedtotheirdutystation.CENTCOMsin-theaterpolicywas5to7days.Neitherperiodwasenoughforpatientstorecoverfromchronicoracuteinjurieslikemeniscaltears,shoulderinstability,footandankleproblems,

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14ArmyMedicalDepartmentJournalbackpain,etc.Althoughstatisticsarecurrentlyunavailable,theLRMCstaffanecdotallynotedthatasignificantpercentageofchronicinjuriespresentedbypatientsexistedpriortodeployment.Somepatientswithchronicinjuriesordiseaseswithinitiatedmedicalboardactionsweredeployedandunderwentsignificantexacerbationwhileintheater,andsubsequentlyrequiredevacuation.Theseoccurrencesreflectthedifficultdecisionscommandersareforcedtomakepriortodeployments.OurexperienceshowedthatitwasnotuncommonforcommanderstotakeaSoldierwithaninjuryandusethatindividualfortheshortterm,onlytohavetheSoldiersconditionworsentotheextentthatheorshebecomesnon-mission-readyinthelongterm.TheEuropeanRegionalMedicalCommandmandatedthatallpersonnelenteringtheDWMMCsystemfromCENTCOMcombatoperationswhowouldnotreturntodutywouldgothroughapostdeploymenthealthevaluation.Thisevaluationincludedblooddraw,HIVlabs,TBtest,andevaluationformalariaprophylaxisandexposuretodepleteduranium.Bydoctrinethismissionistheresponsibilityofthehomeunitwhentroopsreturn.ItwasconfirmedthatMTFsinCONUSwereactivelyconductingpostdeploymentprogramsandtroopswerereportingthattheMTFswererepeatingblooddrawsandotherinterviewsalreadydoneatLRMC.ThisduplicateeffortatLandstuhlinvolvedsignificantadministrativeandpersonnelsupport,andundoubtedlyconsumedresourcesthatcouldhavebeenbetterusedelsewhere.TheTheaterPatientMovementRequirementsCenter,Europe(TPMRC-E)wasthevalidatingandapprovingcenterforallairevacuationsenteringandleavingEUCOM.AnAirForceactivitylocatedatRamsteinAB,theTPMRC-Ewasresponsiblefordisseminationofairevacuationpolicyandregulations,approvingrequestsforindividualpatientevacuation,arrangingadditionalflightsinresponsetoincreasedpatientnumbersorunusualpatientcareneeds,suchasspecialmissionstotheBurnCenteratBrookeArmyMedicalCenter,CriticalCareAirTransportTeammissionsforSelf-evaluationquestionnaireforevacuatedoutpatientsarrivingattheLandstuhlRegionalMedicalCenterfromOperationEnduringFreedomandOperationIraqiFreedom. PatientsName(Last,First) SSN Rank Whatmedicalproblemareyouherefor?___________________________________Pleasecircle DoyouhaveamedicalproblemthatneedstobeseenYESNOrightnowinsteadofatyourdoctorappointmentnextdutyday?Duringtheflightornowdoyouhavechestpain?YESNODuringtheflightornowdoyouhavetroublebreathing?YESNODuringtheflightornowdoyouhaveafever?YESNODuringtheflightornowareyoubleeding?YESNODoyouhavediabetes?YESNODoyouhaveanIVorneedleinyou?YESNOAreyoucurrentlyhavingthoughtsofinjurytoselforothers?YESNOIfyouhavepain,doesyourpainmedicinerelieveit?YESNOIfyouhavepain,doyouhaveenoughpainmedicineYESNOtolastuntilyourclinicappointmentnextdutyday?Canyouwalk100yardsonfootorYESNOwithcrutchesifyoucurrentlyhavethem?Areyouabletoeatanddrink?YESNODoyoufeelsafetobeanoutpatientandseennextdutyday?YESNOAreyoustationedinGermany?YESNODonotwritebelowtheline.Thissectionisforprovidersuseonly.Thisformhasbeenreviewed,andthispatient: Isstabletobeanoutpatient Needstobeseenbyaprovider TheDeployedWarriorMedicalManagementCenter

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JulySeptember200615ICUpatients,etc.TheDWMMCstaffconsultedoftenwiththeTPMRC-Eforairevacuationissuesortoexpediteindividualpatientmovement.TheDWMMCcoordinatedwiththemonthemovement(instandbycontingencystatus)toCONUSofseveralspecial-interestIraqicivilianswhowereacceptedbyUScivilianhospitalsforcare.TheDWMMCalsowasthecoordinatingactivityforwoundedalliednationtroopswhowerebroughttoRamsteinfortransfertoanotheraircraftfortransporttotheirhomecountry.TheDWMMCwaspreparedtoacceptthosepatientsifaflightdelayoccurredduringsuchtailswapmissions.TheaeromedicalstagingfacilitywasavitalcomponentinboththetransportationofpatientstoLRMConarrivalandthepreparationofpatientsfortheirflighttoCONUS.Acontingencyaeromedicalstagingfacility(CASF)wasactivatedandsenttoRamsteinpriortothebeginningofOIF.TheCASFestablishedoperationsintheSouthsideGymatRamsteinAirBaseandaugmentedtheRamsteinholdingcapacitywith100beds.MidwaythroughtheactivecombatphasetheCASFcommanderinitiatedaweeklyprocess-improvementmeetingthatincludedLRMC,theCASF,TPMRC-E,andvariousotherunitsthatwereinvolvedinthepatientmovementprocess.Thesemeetingscontinuedduringtheperioddiscussedinthisarticleandprovedabsolutelyinvaluableforstreamliningthiscomplexmultidepartmentmission.Numerousproblemsweresolvedonthespot,andtheprofessionalrelationshipsthatwereestablishedallowedsimplephonecallstoquicklyresolvemanyotherproblems,allofwhichaidedthemissiontremendously.Itisstronglyrecommendedthatsimilarinteragencystructuresandproceduresbeestablishedattheoutsetofanyfuturemajormilitaryconflicts.Asmentionedpreviously,theEUCOMin-theaterpolicyforpatientcarewas14days.However,someconsiderationwasgivenforpatientswithahighreturn-to-dutypotential.Duringthefallandwinterof2003,CENTCOMcommandersbeganexpressingconcernatthelowreturn-to-dutyrateduringthefirst6monthsofOIFitwaswellunder5%.Inresponse,theDWMMCstaffworkedwiththeLRMCmedicalstafftoplaceemphasisonthereturnofpatientstoduty.Thisresultedinsomepatientsbeingkeptlongerthan14days.GeneralSurgerydevelopedaprotocolforherniorrhaphyandcholecystectomypatientsthatinvolvedalastfollow-upat2.5to3weekspost-opandreturntodutyonalight-dutyprofileforrecovery.Patientsevacuatedforbiopsy-relatedissues(skinlesions,Papsmears,etc)wereroutinelyheldoverthe14-daylimittoallowfinalizationofbiopsyresults.LRMCsreturntodutyraterosetoapproximately30%bytheearlyspringof2004.However,returningapatienttotheateronaprofileforanongoingmedicalproblemisacomplicatedissue.WithmaturemedicalassetsinplaceinIraq,clinicalsituationsarosewhichallowedsubspecialtyevaluationatLandstuhl(forexample,achronichandinjury),afterwhichpatientsweregivenaplan,instructedonbracewearandrehabilitation,andreturnedtodutyonprofilelimitations.Follow-upwasthenperformedintheater.Althoughnotabletofunctionatthesquadlevel,aprofiledSoldiercouldperformsomefunctionatthebattalionlevelorhigher(monitoringradios,administrativetasks,etc),replacingaSoldiertoreturnthesquadlevel,thusconservingunitstrength.Unfortunately,wediscoveredthatitwasverydifficulttocoordinatewithcommandershighenoughinthechaintoformalizesuchaprogram.Thecommandlevelthatcouldusuallybecontactedwaslimitedtotheplatoonleader/companycommanderwho,whengiventheoption,wouldrejecttheprospectofthereturnof

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16ArmyMedicalDepartmentJournalanySoldierthatcouldnotperformthesquad-levelmission.Thein-theaterbattalionanddivisionsurgeonsmustbecomeveryproactiveandaggressivelycommunicateandcoordinatewithhigherlevelcommanderstodeterminewhatlimitationscanbesupported,presenttheoptionsandavailablesourcesofinformation,andensureallcommandlevelsunderstandthebenefitsofsuchareturn-to-dutyprogram.Theendtomajorcombatoperationswasdeclaredon1May2003.Fourteendayswereaddedtothetimeframeofthestudy1toensureallcasualtiesoftheactivecombatphasehadreachedLRMCandwereincluded.Ofthe1,236identifiedandtrackedpatientsthatarrivedfromOIFduringthisperiod,20.7%werebattlecasualties,41.3%sustainednon-battleinjuries,and38%werediseasepatients.Thispatientpopulationaccountedfor620inpatientadmissionsand616personneltreatedasoutpatients.Ofthe620inpatients,77weredischargedtooutpatientstatuspriortoairevacuation.Therefore,56%ofthesepatientswereoutpatientsatsomepointintheirstay.AsnotedindiscussionswithEUCOMmedicalplannersfollowingcompletionoftheactivecombatphase,outpatientsaccountedforasignificantportionofourcareresponsibilities.Previously,medicalplanningwasdiscussedintermsofinpatientbeds,butasmedicalcareintheUScivilianandpeacetimemilitaryworldhasshiftedtoanoutpatientparadigm,sotoohasmilitarywartimecare.CONCLUSIONManagingoutpatientsisfundamentallymoredifficultthanmanaginginpatients,bothintermsofmedicalcareandadministrativetrackingandprocessing.FuturemedicalplannersmustanticipatealargeoutpatientmissionandplanscalabledepartmentssimilartotheDeployedWarriorMedicalManagementCentertomanageoutpatientsandassistinthepre-arrivalplanning,receiving,processing,andevacuationofinpatientsandoutpatients.LandstuhlRegionalMedicalCenterwasthefirsthospitaltodevelopaDWMMC.Itshouldserveasthemodelforotherevacuation-chainMTFsinfuturecombatoperations.ACKNOWLEDGEMENT ThisarticleisdedicatedwithmyprofoundthanksandbestwishestothestaffoftheLandstuhlRegionalMedicalCenterandtheDeployedWarriorMedicalManagementCenter.Yourincrediblyhardworknotonlyexceededmissionrequirementsbutgavegreatcomfortandaidtotheapproximately15,000patientsfromOperationsEnduringFreedomandIraqiFreedomwhopassedthroughourdoorsduringmytenureasmedicaldirector.Itwasmypleasureandhonortoworkwithallofyou.REFERENCE 1.JohnsonB,CarmackD,NearyM,TenutaJ,ChenJ.OperationIraqiFreedom:theLandstuhlRegionalMedicalCenterexperience.JFootAnkleSurg.2005;44;No.3:177-183.AUTHOR MajorJohnsoniscurrentlyassignedtotheHumanEffectivenessDirectorateoftheUSAFResearchLaboratory,Wright-PattersonAirForceBase,Ohio.Previously,hewasthemedicaldirectoroftheDWMMCattheLandstuhlRegionalMedicalCenterfromlateApril2003untilJune2004. LANDSTUHLREGIONALMEDICALCENTERTheDeployedWarriorMedicalManagementCenter

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JulySeptember200617INTRODUCTIONInrecentcontingencyoperations,USArmymedicalunitshaveincreasinglyabsorbedexpandedresponsibilitiesbeyondthoseoftheirdoctrinalcombathealthsupportmission.Thesenewresponsibilitiesincludetheneedtoperformwidespreadhumanitarianassistancetolocalpopulations,theprovisionofhealthcaretoUSArmydetainees,andsupplyingthehealthsupportforDepartmentoftheArmyciviliansandcontractedpersonnelonthebattlefield.Inthatthesemissionsextendbeyondtheirdoctrinalconstruction,medicalunitsareatadisadvantageintermsofsupplies,personnel,andpracticalexperiencewhenattemptingtomeetthesenewrequirements.1Thissituation,inturn,mayresultininadequatecaretothesespecialpopulations.Onespecific,increasingdemandbeingplacedonArmymedicalunitsdeployedinOperationIraqiFreedom(OIF)isthegrowingpresenceofUScontractorsonthebattlefield.Thiscanbeanespeciallydifficulttaskforaunittotackle.Armyfieldmedicalunitsareprimarilystructuredtoprovidecombatcasualtycareand,toalimitedextent,ongoingprimaryhealthsupporttoamostlyhealthy,young,adultpopulation.Incontrast,deployedcontractorsdonoteasilyfitintothesecategories.Contractorsareoftenolderandmayhavemedicalconditionsvastlydifferentthanthoseoftheaveragefrontlinesoldier.Toaddtothedifficultiesinsupportingthedeployedcontractor,thereareamyriadofrulesregulatingwhichgovernmentsuppliedhealthsupportdeployedcontractorsare,andoftenarenot,eligibletoreceive.Ontheotherhand,unitsarehardpressednottoprovidehealthsupporttocontractorsintheirmidstwhentheypresentforcare.Toovercometheseconflicts,medicalunitshavehadtoadapttheirnormalwaysofdoingbusinesstomeettheseneeds.Unfortunately,theseadaptationsusuallyoccuradhoc,afteraunithasdeployedtotheater,andwithoutthebenefitoflearningfromtheexperiencesofothers.ThisarticleattemptstooutlinesomeofthelessonslearnedbypreviousunitsdeployedtoOIFastheyhavestruggledtoprovidehealthsupporttodeployedcontractors.Todoso,itisnecessarytopresentabriefbackgroundofcontractorsupporttotheUSArmy,bothitshistoryanditsregulatoryprocesses.Followingthisoverview,thereisadiscussionoflessonslearnedbymedicalunitspreviouslydeployedtoOIF.ItshouldbenotedthatthisarticleonlyaddressesUScontractors,notthird-countrynationalshiredtosupportUSarmedforces.HISTORICALBACKGROUNDTheUSArmyhasrelieduponcontractedciviliansupportsincetheRevolutionarywar.Civilianshavebeenhiredtoprovidetransportationoftroopsandsupplies,buildmajorengineeringprojects,andtosupportcommunicationsequipment.Inrecentdecades,asactivecomponentforceshavedecreasedinsize,themilitaryhasbecomeincreasingdependantuponciviliancontractorsforsupport.2FromtheRevolutionaryWarthroughOperationDesertStorm,therewasonecivilianonthebattlefieldsupportinganywherefrom50to70militarypersonnel.BythetimeoftheBosnianconflictthisratiowas1:10.3WhilethecurrentnumberofcontractorsinvolvedinOIFisunknown,itislikelythatthenumberofcontractorsonthebattlefieldisgreaterthanever.WiththeincreasinglytechnologicalnatureofUSarmedforces,contractorsareinvolvedinalmosteveryaspectofsupportingdeployedtroopsandcanbefoundimbeddedwithUSarmedforcesateverylevelofthebattlefield.Thisincreasedpresenceisevidencedbyseveralmeasures.Currentreportsandafteractionreviewsarefilledwithanecdotesconcerningtheincreasingdemandsciviliancontractorsareplacingupondeployedmedicalunits.Furthermore,attheFortCaringforContractorsinOurMidst:LessonsLearnedfromOperationIraqiFreedomMAJAndrewDoyle,MC,USA

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18ArmyMedicalDepartmentJournalBlissCONUS(continentalUnitedStates)ReplacementCenter,civiliansnowaccountforover60%ofthepersonnelprocessedfordeploymenttoOIF.4REGULATORYISSUESThefirstissueamedicalunitmusttackleisthatofeligibility.Isthecontractoreligibleforcareintheirfacility?Asmentionedpreviously,theregulatorycontrolsgoverningdeployedUSciviliancontractorsarevast,andattimescontradicting.Contractorsareemployeesoftheircivilianemployer,notthegovernment,andthusaregenerallynoteligibleforgovernmentprovided,nonemergencyhealthcare.Traditionally,thispolicyhasappliedtocontractorsdeployedwiththeforce.CurrentDepartmentofDefensepolicyholdsthatcivilianemployersareresponsibleforprovidingallofthehealthsupportrequiredbytheiremployees,includingthatrequiredwhiledeployedwithUSarmedforces.Theemployerhastheoptionofeitherprovidingthatsupportdirectly,contractingwithnon-USfacilities,orthroughanegotiatedcontractwiththeUSgovernmentformilitarysuppliedhealthcareforwhichtheemployerreimbursesthegovernment.5,6Thatbeingsaid,otherregulationsandpoliciesmayspecifythattheciviliancontractoriseligibleforgovernmentsuppliedhealthcare.WhileUSpolicydeclaresemployersareresponsibleforprovidingforthehealthcareoftheiremployees,italsostatesthatciviliancontractorsdeployedwithUSforceswillreceivethesamelevelofcareavailabletomilitarypersonnel.Incontingencyoperations,oftentheonlyhealthcarethatmeetsthisstandardisthatprovidedbythelocalmilitarymedicalunit.Inthiscase,Armypolicyimpliesthatciviliancontractorsmayhavemilitarysuppliedhealthcaremadeavailabletothem.Additionally,certaincontractorsareeligibleforcarebasedonthetypeofservicetheyperform.Forexample,civilianflightinstructorsandfoodserviceemployeesareeligibleforphysicalexaminations.Finally,manyciviliancontractorsareeitherretiredUSmilitarypersonnelorveterans.Whiletheyarenoteligibleforgovernmentprovidedhealthcareascontractors,theyareeligibleforcareduetotheirpreviousmilitarystatus.7Additionalregulationsapplytoemergencyandevacuationcarefordeployedcontractors,beyondthesettingofroutinehealthsupport.Emergencycareisalwaysavailableandrendered,consideredtobeareimbursableservice.Itshouldbenoted,though,thatforwarddeployedmedicalunitsareneitherequippednororganizedtoprocessbilling.Thus,emergencyservicesinthesesettingsarenotcaptured.8Thesamestandardsapplytoemergencyevacuation,atleasttotheLevelIVmedicalfacility(eg,LandstuhlRegionalMedicalCenter)anduntilthecontractorismedicallystable.However,ifthecontractorpatientthenmustbereturnedtothecontinentalUnitedStatesforongoingcare,transportisdependantuponthecontractbetweenthegovernmentandtheemployer.Tofurthercomplicatetheissueformedicalpersonnel,thepresenceofcontractorswithUSforcesissubjecttointernationallaw.IncountriesthathaveStatusofForcesAgreementswiththeUnitedStates,contractorsaccompanyingthemilitaryarealsosubjecttothoseagreements.Incontingencyoperations,contractorsareciviliannoncombatantsandmayfallundertheauspicesoftheGenevaConventionsandotherLawofWarregulations.Thetimetodetermineeligibilityofcareisnotwhenthecontractorpresentstotheaidstation.AsmedicalunitsdeployingtoOIFcanexpecttocareforciviliancontractors,proceduresforthiscareshouldbeinplacepriortodeployment.However,theinterpretationofthelegalobligationsandrequirementsisnottheresponsibilityofthemedicalunit.Themedicalunitshigherheadquartersshouldsortthroughthislegalmorassanddeveloppoliciesandproceduresforthecaregivers.Ifthisdoesnotoccurpriortodeployment,theunitshouldrequestguidanceassoonaspossible.Thecontractorseligibilityforcareshouldbeestablishedpriortotheirarrivalintheater.Thiswillincludearrangementsforcare,bothroutineandemergency,andwillbestipulatedinthecontract.Thisstatuswillbeannotatedontheindividualcontractorsidentificationdocuments.AlldeployedcontractorsareissuedaUniformedServicesIdentificationandPrivilegeCard(DD1173).Thiscardshouldclearlydeclarethoseservices,includingmedical,towhichthecontractorisentitled.Inaddition,thecontractorwillreceiveaLetterofAuthorization(LOA)fromthecontractingofficer.TheLOAshouldalsoindicatethoseservicestowhichthecontractorisentitled,andhowreimbursement,ifindicated,ishandled.9InlieuofCaringforContractorsinourMidst

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JulySeptember200619thisorotherguidance,themedicalprovidersarelefttotheirbestjudgment.LESSONSLEARNEDIdeally,contractorsdeployingtoOIFwillundergopre-deploymentprocessingwiththeunitinwhichtheywillbeimbedded.However,contractorsoftendeployasindividualsandjointheirrespectiveunitsinthefield.Inthesecases,contractorsdeployingtoOIFwillusuallyprocessthroughaCONUSReplacementCenter(CRC)priortodeployment.AttheCRC,theywillundergothesamemedicalanddentalscreeningasactivedutysoldierspriortodeployment.Thesescreeningswillbeperformedbymilitaryphysiciansanddentists.Thescreeningprocessshouldincludeareviewofthecontractorsmedicalrecord,identificationofanydisqualifyingmedicalanddentalconditions,andtheadministrationofanyrequiredimmunizations.Furthermore,thecontractorsshoulddeploywithatleasta90daysupplyofanymedications,andadditionalpairsofeyeglasses,asneeded.Whilethisistheprocess,anddeployedmedicalproviderscanreasonablyexpectcontractorshavegonethroughthisprocess,nevertheless,thereareseveralareasthatthemedicalunitmustconsiderinpreparationstoprovideroutinecareforeligiblecontractors.MedicalRecords.Onceaunitisidentifiedasthesupportingmedicalunitforaneligibleciviliancontractor,certainadministrativerecordsshouldbekeptbytheunit.Primarily,theunitshouldbeprovidedacompletemedicalsummaryforthecontractor.Thesummaryshouldincludeadescriptionofallunderlyingmedicalconditionsandrelevantpastmedicalhistory,currentimmunizationstatus,allexistingprescriptions,toincludeeyeglasses,anddocumentationofDNAsampletestinganddentalpanographicradiograph,forfutureidentificationpurposes.Inaddition,copiesofthecontractorsLOA,emergencycontactinformation,employerandinsurancecontactinformation,andthenameandcontactinformationofthecontractorsprivatephysicianshouldalsobekeptonfilebythemedicalunit.Pharmacy.Thecareofcontractorsisanexpandedmissionresponsibilityresultinginagreaterpopulationofcare.Consequently,medicalunitsmaynothavetheClassVIIIsuppliestomeetthisneed.Themostsignificantdeficiencyislikelytobeintheunitspharmacy.Intermsofoverallpatientworkload,contractorsrepresentanadditionaldrainonaunitsalreadylimitedpharmacy.Furthermore,thecontractormayrequirechronicmedicationsthattheunitdoesnotpossessandmaynotbeabletoobtain.Assoonasacontractorisassociatedwithamedicalunitforcare,theunitshouldidentifyanychronicconditionmedicationsthecontractorrequires,especiallyifthisincludesmedicationsnotcarriedintheunitspharmacy.Arrangementsmustthenbemadetoeitheracquirethesemedications,orchangethemedicationstoonestheunitpossesses.Also,theunitmustbegintoarrangefortheacquisitionofrefillmedications,longbeforetheyareneeded,duetothesubstantialamountoftimeitmaytakeforthemtoarriveintheater.MedicalEvacuation.Thecontractormayrequiremedicalevacuationinthecaseofsevereinjuryorillness.TheusualevacuationrouteistothecombatsupporthospitalandthentoLandstuhlRegionalMedicalCenter(LRMC).OnceatLRMC,thecontractormaybetransportedtoCONUSforfurthercareasnecessary.Whethertheycontinuetobecaredforinmilitarytreatmentfacilitiesbeyondthispointisdependentuponthecontractorseligibilityformilitarybenefits.Oncetheneedforevacuationisrecognized,initiatealogtotrackalleventsandmovementofthecontractor.Maintainalistofallcontactinformation,includingmedicalunitsandfacilitiesandthecontractorsfamily.TofacilitatefurtherevacuationfromLRMCtoCONUS,acopyoftheLOAmustaccompanythepatient.EnsurethatacopyoftheLOAissentwiththecontractorsmedicalrecordsduringevacuation.Notification.Notificationofsevereinjury,healthissues,ordeathfollowstwomainpaths;thefirstforcommandandcontrol,thesecondtofacilitatecareand

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20ArmyMedicalDepartmentJournalevacuation.Initially,notificationmustbemadetothesupportedunitscommandandalsotheregionalcommand.Theseelementswillprovideofficialnotificationtotheemployerandnext-of-kin,ifnecessary.Themedicalunitshouldhaveapre-setplanfornotificationoftheunitschain-of-command.Beyondnotifyingthechain-of-command,thecontractorsfamilymustalsobenotified.Whilethiswillnotbedonebythemedicalunitdirectly,theunitsmedicalstaffshouldbepreparedtogivedetailedinformationtothechain-of-commandforcommunicationwiththefamily.CONCLUSIONMedicalunitsdeployingtoOIFfacemanyexpandedresponsibilitiesbeyondthoseoftheirtraditionalcombathealthsupportmission.ChiefamongtheseexpandedresponsibilitieshasbeentheprovisionofcaretociviliancontractorsdeployedalongsideUSarmedforces.However,thehealthcaresupportneedsofdeployedcontractorscanbevastlydifferentthanthosewhichtheunitisdoctrinallypreparedtoprovide.Also,theincreasingnumbersofciviliancontractorscaneasilyexhaustthecapabilitiesofastandardcombat-equippedmedicalunit.Itisobviousthatcontractorswillcontinuetobeaneverincreasingpresenceonthemodernbattlefield.Consequently,USArmymedicalunitsmustbepreparedtocareforthem.Ideally,thispreparationoccurspriortoaunitsdeployment,andinvolvesadjustmentintheunitsoperatingprocedures,anticipatedworkload,andneededsupplies.Thispreparationshouldalsoinclude,ataminimum,acursoryknowledgeoftherulesregulatinggovernmentsuppliedhealthsupporttodeployedcontractors.Toaccomplishthesegoals,deployingunitsshouldlearnthelessonsfromexperiencesofpreviouslydeployedunits.Theselessonsincludetheneedtomaintaincompleteandrelevantrecords,expandClassVIIandpharmacysupplies,andestablishproceduresformedicalevacuationofdeployedcontractorpatients.Previousexperiencesshowthatthesesimplesteps,iftaken,willdramaticallyimproveaunitsabilitytocareforcontactorpersonneldeployedalongsideUSforces,andresultinamoresuccessfulmissionoverall.Pre-deploymentPreparationPlanforneedtocareforcontractorsEstablishprocedurestodeterminecontractorseligibilityforcareBepreparedtoincreaseClassVIIItomeetneedsofcontractorsRoutineCareDuringDeploymentGathernecessarymedicalandadministrativeinformationforallcontractorscaredforbytheunitProactivelyplanforre-supplyofchronicmedicationsInCaseOfMedicalEvacuationImmediatelyinformchainofcommandInitiatealogofallactionsperformedMaintainadatabaseofcontactinformationSendacopyofLetterofAuthorizationwiththecontractorsmedicalrecordsBepreparedtoprovidedetailedinformationtocommandandthecontractorsfamily CaringforContractorsinourMidst

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JulySeptember200621 REFERENCES1.DavisLM,etal.Armymedicalsupportforpeaceoperationsandhumanitarianassistance[abstract].RANDCorporation;1996.Availableat:http://www.rand.org/pubs/monograph_reports/MR773/.AccessedDecember2,2005.2.MankerJE,WilliamsKD.Contractorsincontingencyoperations:panaceaorpain?AirForceJLogist[serialonline].2004;28(3):14-22.Availableat:http://www.aflma.hq.af.mil/lgj/Vol%2028_No3_WWW.pdf.AccessedDecember2,2005.3.HammontreeG.Contractorsonthebattlefield.InRaineyJC,ed-in-chief;ScottBF,ed.2003LogisticsDimensions:Strategy,Issues,andAnalysis.MaxwellAirForceBase,AL:AirForceLogisticalManagementAgency;December2002.Availableat:http://www.aflma.hq.af.mil/lgj/LogDim2003_3.pdf.AccessedDecember2,2005.4.ReeceB.Deploymentpreparation;destination:Iraq.Soldiers.2005;60;No.2:30-33.5.DoDInstruction3020.41,ContractorPersonnelAuthorizedtoAccompanytheUnitedStatesArmedForces.Washington,DC:USDeptofDefense;October3,2005.6.DAPamphlet715-16,ContractorDeploymentGuide.Washington,DC:USDeptoftheArmy;February27,1998.7.ArmyRegulation40-400,PatientAdministration.Washington,DC:USDeptoftheArmy;March12,2001.8.FieldManual3-100.21,ContractorsontheBattlefield.Washington,DC:USDeptoftheArmy;January3,2003.9.ArmyContractorsAccompanyingtheForceGuidebook.Washington,DC:USDeptoftheArmy,OfficeoftheAssistantSecretaryoftheArmy;September,2003.AUTHOR MAJDoyleiscurrentlytheMedicalAnalystattheCenterforArmyLessonsLearned,FortLeavenworth,Kansas.

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22ArmyMedicalDepartmentJournalINTRODUCTIONBurkhalteretal1statedthatthelossofoppositionofthethumbtothefingersisthemostsignificantactivemotionlossassociatedwithaninjurytothemediannerve.Itisdifficulttooverstatethevalueofthumboppositionineverydayactivities.ThisisespeciallytruetothepilotofanF-16.Thepilotistaskedtoperformmanyintricateoperationswiththelefthand,usingavarietyofcontrolsthatrequireprecise,strong,andtrueopposition.Thedefinitionofoppositionvariesdependingonauthorandphysician.In1938Bunnellstatedinhismuchreferencedarticle2that,inopposition,thethumbnailisparalleltothepalmandthepulpofthethumbfacesthepulpofthefingers.Cooney,Linscheid,andAnintroducetheideasofabduction,flexion,androtationofthethumbcarpometacarpaljoint(CMCJ)andmetacarpaljoint(MCPJ).3Thisnotionofthethumbmovingawayfromthefingers,supinatingoverandcomingfacetofacewiththefingers(trueopposition)insteadofjustflexingattheinterphalangealjoint(IPJ)andMCPJisrequisiteforflyingtodaysjetfighteraircraftandcountlessotherroutinedailytasks.ThisarticlereportsonacaseoflowmediannerveinjurysustainedbyanF-16pilotandhisrapidandcompletereturntothecockpit.Surgicalrepair,rehabilitationcourse,andrequirementstoperformhisjobwithemphasisonleftthumboppositionarehighlighted.CASEREPORTThePatientInlateMarchof2001,a28year-oldactivedutymaleUSAFF-16pilotfellwhiledescendingawet,poorlylit,shallowstaircase.Heattemptedtobreakhisbackwardsfallwithhisdominantlefthandwhileholdingaglasscontainer.Thecontainershattereduponimpact.ThepilotsustainedseverelacerationstoZoneIIIofhisleftpalm.AfterexaminationatthelocalmilitarymedicalfacilitythepatientwastransportedtoanearbycivilianKoreanhospitalwhereheunderwentmicrosurgerytorepairseveredtendonsandnerves.Surgicalrepairwasperformedon:1.leftthumbflexorpollicislongus(FPL)100%lacerated;2.leftindexfingerflexordigitorumprofundusandsuperficilias(FDPandFDS)both100%lacerated;3.leftmiddlefingerFDP-50%laceratedandFDS100%lacerated;4.leftaductorpollicis(AP)60%lacerated;5.leftflexorpollicisbrevis(FPB)100%lacerated;6.leftopponenspollicis(OP)50%lacerated;7.leftabductorpollicisbrevis(APB)50%lacerated;8.commondistalnervebranchesfromthemediannervetothethumb,index,andmiddlefingerswerealsofoundtobesevered. ThumbOppositionRestoration:ACaseStudyCPTDavidAdmire,SP,USAABSTRACTAcaseofthumboppositionrestorationbyextensorindicisproprius(EIP)opponensplastyandrehabilitationispresented.ThepatientwasamaleUSAirForce(USAF)F-16pilotinSouthKoreawhosustainedaninjurytohisleftpalmseveringmultipletendonsandnerves.SuccessfulsurgicalrepairoftheflexortendonswasaccomplishedatacivilianKoreanhospitalwithoutrepairoftherecurrentmotorbranchofthemediannerve.Afterasuccessfulcourseofoccupationaltherapytorestorefingerfunction,asecondprocedurewasperformedatWalterReedArmyMedicalCenterinvolvingthetransferoftheEIPtendontotheextensorpollicuslongusandabductorpollicisbrevisinthethumb.Intensiverehabilitationatthe121stUSArmyGeneralHospitalinSeoulKorearesultedinearlyfullrestorationoffunction.Upondischargefromoccupationaltherapy,evaluationfromUSAFaeromedicalpersonnelandreturntotheUnitedStates,thepilotreturnedtoflightstatus.

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JulySeptember200623Duringtheprocedure,therecurrentmotorbranchofthemediannervetothethenarmusclescouldnotbelocated.This4-hourprocedurewasperformedwithoutcomplicationandthepatienthadanunremarkablepostoperativerecovery.TwoweekslaterthepatientreportedtotheOccupationalTherapy(OT)clinicatthe121stUSArmyGeneralHospitalatYongsanGarrisoninSeoul,Koreatobeginaperiodofrehabilitation.ThepatientwasplacedinacustomdynamicflexionsplintandamodifiedKleinertprotocolwasbegunasStewartdescribesinStanleyandTribuzi.4Thesplintusedforthistreatmentprotocolutilizesrubberbandtractiononthefingernailstoprovidepassiveflexiontothefingerswhileallowingactiveextensionandisdesignedtoachievepassiveglideoftheinjuredtendonstopreventscaradhesionsandjointcontractures.4DuringthiscourseoftherapythepatienttraveledtotheUnitedStatesforaperiodofconvalescentleave.UponarrivalhereportedtoWalterReedArmyMedicalCenter(WRAMC)inWashington,DCtocontinuehisrehabilitation.RecoveryoffunctionatWRAMCwasrapidandwithoutcomplication,exceptforthepersistentinabilitytoopposehisleftthumb.RepeatelectrodiagnosticmotornervestudiesrevealednodefiniteresponseintheAPBsuggestingasevereifnotcompletemediannerveneuropathyatthewrist.TheSurgicalRepairInlateJuneof2001thepatientwastakenintotheOR(operatingroom)atWRAMCforexplorationofthemediannerveandpossibletendontransfertorestoreopposition.Whiledissectingtheleftmediannerveproximallythemotorbranchwasnotvisualizedandexplorednofurther.Theattendingsurgeonthendecidedtotransfertheextensorindicisproprius(EIP)tendontothethumbtorestorethumboppositionmotion.Severaltendenousoptionsareavailablefortransfertorestoremotion.ThemechanicalandanatomicalbenefitsofeacharewelldocumentedasinRoach,Short,WernerandFortino.5Literaturealsoexistsdocumentingtheobjectiveresultsfromcomparisonsofdifferenttypesofoppositionrestoringtendontransfers.6,7Thechoiceofdonortendon/muscleiscontroversialandnoteverytendontransferprocedurewillproducethesameresult.Factorstobeconsideredincludethepatientsfunctionalrequirements,anyassociateddeficits,tendon/muscledonoravailability,surgeonpreference,andas,inthiscase,previousinjuryandsurgicalhistory.8AlsoasDavisandBartonstateinGreen9andasBurkhalter1outlines,EIPtendontransfersaremanytimesfavoredbecausethereisnosubsequentweakenedgraspandnoresultingfunctionaldisabilityassometimeshappenswithopponensplastysusingdonatedflexortendons.Thispatienthadrecentlyundergonerepairtotheflexortendons,necessitatingusinganalternativedonortendontorestoreoppositiontothethumb.IntheOR,withthetendontransferdecisionmade,theEIPtendonwaslocatedthroughanincisionmadedorsallyoverthemetacarpalphalangealjoint(MCPJ)oftheleftindexfinger.Theidentifiedtendontobetransferredwascutfreeandanotherincisionwasmadeoverthedorsoulnaraspectoftheleftwrist.ThroughthiswoundtheEIPwasagainidentifiedandcarriedbacktothemusclebelly.Next,atunnelwasmadebetweenthemoredorsalincisionandanincisionmadeoverthepisiformbone,andtheEIPwasdeliveredintothis.Anadditionalincisionwasmadeoverthedorsoradialaspectoftheleftthumbandthetendonwasthenbroughtintothisopening.Throughthislastincision,theEIPwaspassedthroughthecenteroftheAPBtendon,underneaththedorsoradialdigitalnerveandthroughthemiddleoftheEPLtendon.Thepatientswristwasthenplacedin20degreesofflexion,withthethumbinmaximumpalmarabductionandahorizontalmattresssuturewasusedtosecurethetransferredEIPtotheEPL.TheEIPwasthenpasseddownandanotherstitchwasusedthroughthisdonatedtendonandtheAPB.Finally,theEIPwasagaintransferredunderneaththedigitalnerve,throughtheAPB,andsuturedagain.Afterirrigation,allthewoundswereclosedandasplintappliedwiththewristin20degreesofflexionandthethumbinmaximumpalmarabduction.Thepatientwastransferredtorecoveryinsatisfactorycondition.PostoperativeRehabilitationPostoperativerehabilitationafterthisopponensplastywasmodeledafterthethree-phaseapproachasStanleyoutlinesinHunter8:PhaseIisaperiodofimmobilization,duringPhaseIIthepatientbeginsactivemotion,andPhaseIIIisstrengthandcoordinationtraining.Thetimingofinternalhealingdictatestheorderandtimingofthesephases.8Ofcoursecompleteimmobilizationisinitiallyrequiredtoallowthetendonjuncturetodevelopcollagensufficienttowithstandfuturestresswithmotion.ThepatientwasmaintainedinthepositionwiththeactualsplintthatwasutilizedintheORuntilfollowupwith

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24ArmyMedicalDepartmentJournalOTinKoreaatapproximately3weekspostoperativecare.UponarrivalattheOTclinicatthe121stGeneralHospitalinKorea,theexistingsplintwasremovedandacustommoldedhandbasedthermoplasticsplintwasappliedapproximatingthesamepositionaswasusedinthepostoperativesplint.Thepatientshandwasevaluatedandthepatientwasinstructedinactiverangeofmotionforalluninvolvedjointsaswellasgentlescarmassage.Althoughthispatientwasextremelymotivatedandwishedtobeginactivemotiontothethumbearly,immobilizationwasemphasizedasitisextremelyimportanttotheoverallsuccessoftherepair.JacobsandThompson10identifiedlackofsufficientpostoperativeimmobilizationasamajorcauseoffailureafteropponensplastyproceduresandrecommendafull6weeksbeforeattemptingactiveoppositionoftheinjuredthumbandtoday.Mostprotocolsrecommend3to4weeksofcompleteimmobilization.1,8,9Afteranotherweekofcontinuousimmobilizationofthethumbintheremovablesplint(uptoweek5aftersurgery),thepatientbegangentlesupervisedactivemotionofthethumbinterphalangealjoint(IPJ),MCPJandcarpometacarpaljoint(CMCJ)withsplintwearatnightandbetweentherapysessions.ActivemovementwasemphasizedthatwouldbothretraintrueoppositionusingthenewdonatedEIPtendonandalsotominimizescaradhesionsthatmightpotentiallylimitfinalmotion,withoutover-stressingthetendonrepairsite.Goaldirectedactivitiessuchaswholehandgraspingandtrueoppositionalpinchwiththethumbandsmallfingerusingputtyandsmallflatobjectswereusedinsteadofroteexercisetoholdthepatientsattentionandintrinsicallymotivatehimtoreachhisgoalsofreturningtoflying.Atthistimemoreaggressivescarmanagementtechniqueswerebegun.DeepscarmassagewasincorporatedintothedailytreatmentregimenattheOTclinicandalsoathomeaspartofthepatientshometreatmentprogram.LanolinandvitaminEwereusedtobothmoisturizethesurfaceskinandcombinedwithdeeppressuretosoftensubcutaneousscar.11Researchislimitedontheeffectsofmassageonscartissuebutisthoughttoaltercollagenthroughacombinationofmechanicalandthermaleffects.8,11Mechanically,collagenorganizationisassistedbythephysicalmovementbetweenthescarandsurroundingtissuesandalocalthermaleffectiscreatedresultinginincreasedtissueextensibility.8Ultrasoundandparaffinbathswerealsousedinthiscasetoeffectivelyincreasethetemperatureofsofttissuespriortomovementtoincreasetheextensibilityofthetissuesandincreasethepotentialforactiverangeofmotion(AROM).Massageandtissuemobilizationmayalsoaidbycompressingtheinterstitialfluidcontenttherebyincreasingextensibility.8Massagewasperformeddailyintheclinicandreportedbythepatienttoberepeated3-4timesdailyoutsideofOT.Elastomerpolymerinsertswerecustommolded,andwornunderneaththesplintatnightandalsowithcompressionwrapsandCobantapethroughouttheday.Theseinsertsprovidedanothermeansofcompressionandtissueextensibilitymaximization.Althoughthesetechniquesarenotstronglysupportedintheliterature,anecdotalclinicalreportssuggesttheirefficacyandusefulnessinmanagingscarformationandmaximizingpostoperativeAROMandfunction.Gentlepassiverangeofmotion(PROM)wasalsoinitiatedtogentlystressthesofttissuessurroundingthethumb.Specifically,effortswerefocusedonthumbIPJandMCPJextensionandflexion,thumbCMCJabductionandextension,andwristextensionandflexion.TheemphasisonPROMwasgentle,pain-freestretchesafterheatapplication,usuallyaccomplishedwithparaffinbathimmersion.ThepatientwasinstructedtoonlyperformactivemotionexercisesathomeandrelyonOTclinicalstafftosuperviseanyPROMtopreventpossibleattenuationorstretchingoftherepair.Byweek7followingsurgery,thepatienthaddiscontinueddaytimeuseofthesplintinfavorofactiveuseofhishand.Thepatientwascontinuallycautionedagainstoveruseandoverstressingthenewlytransferredtendontopreventrupture.Heshowedrapidprogresswithreturnofactivemotionofthethumbandverylittlescaradhesionformation.Initially,whenattemptingoppositionthethumbflexorswouldoverpowerandpullthethumbonaplaneparallelwiththepalmtowardsthesmallfinger.Thiswouldplacethepulpofthethumbperpendicularwiththepulpofthesmallfingerwithouttherotational,abduction,orpronationcomponentsoftrueopposition.Atthispointtheemphasisshiftedfromquantitytoqualityofmovement,focusingonsupinationandThumbOppositionRestoration:ACaseStudy

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JulySeptember200625abductionofthethumbinanefforttotraintrueopposition.Thepatientwasencouragedtoperformoppositionactivitieswithbothhandstomatchthumbmovements.Healsoperformedcountlessrepetitionsofgrossgraspingactivities,andfinemotortasksthatrequiredtrueoppositiontobesuccessful.Thepatientcontinueddailytherapysessions,showingexceptionalmotivationbytravelingfromanoutlyingArmycampnorthofSeoultothe121stGeneralHospitalwhichhastheonlyUSmilitaryOTclinicinKorea.Overthenext5weeks,oncetrueoppositionwasestablished,resistancewasslowlyintroducedandgraduallymoreaggressivestretcheswithcontinuedaggressivescarmanagementwasperformed.Therapysessionswerecutdownto3andthento2sessionsperweek,withmoreemphasisplacedonhomeself-treatment.Variouscommerciallyavailablehandstrengtheningdeviceswereissuedwithacontinuingfocusonqualityofmotion.Atlessthan14weeksaftersurgery,thepatientwasabletodemonstratefull,trueoppositionwiththumbpadtosmallfingerpadcontact,includingallpreviouslydiscussedcomponentsofthumbrotationandabduction.Healsodemonstratedtheabilitytomaintainthumbpadcontacttothebaseofthesmallfingerand,witheffortandstretch,tothedistalpalmarcrease.Intheclinicthepatientproducedagripstrengthaveraging65poundsfortheaffectedhand.ItwasatthispointthatthepatientwasdischargedfromOTwithperiodicfollow-upstomonitorhiscondition.Within2weeksofdischargefromOT,thepatientwasevaluatedinaflightsimulatorandwasrecommendedforconsiderationforreturntoflightstatusbyobservingofficials.Aftersubsequent,numerousphysicalevaluationsandapermanentchangeofstationbacktotheUS,hewasgivenapprovaltobeginrequalificationtraininginpreparationforreturntothecockpit.JobRequirementsInordertobesuccessfulinthecockpitoftheF-16,thepilotmustperformmanyoperationswiththelefthandrestingonthethrottleandmanipulateswitcheswiththehandonapanelaswell.Onthethrottleandpanelareswitchesandbuttonsthatrequiretwistingandturningmotionsutilizingtheleftthumbinalateralpinchwiththethumbpadpressedagainsttheradialsideoftheindexfinger.Also,onthethrottleitselfarebuttonscontrollingnumerousradarfunctionsthatrequirethethumbtoriseupoffthesideofthecontrol(abduction)andselectivelyslideorpushabuttonwiththepulpofthethumbinaplaneperpendicularwiththepalm.Theseoperationswouldbeimpossiblewithouttherotationalandabductioncomponentsoftrueoppositionofthethumb.SimpleflexionofthethumbMCPJwouldnotprovidethenecessaryrangeofmotionthatisrequiredtoflyandoperateeffectivelythecontrolsoftheF-16aircraft.Itissafetosaythatwithoutthisoppositionrestoringprocedureandanexcellentoutcome,thispilotwouldbeunabletoreturntothecockpitandflytheF-16.DISCUSSIONThemajorityofdocumentedcasesofopponensplastysreportgoodtoexcellentresults.Unfortunately,classificationofresultsfromopponensplastyproceduresisnotconsistentintheliterature.Factorssuchasstrength,positionofthethumbIPJandmobilityaregivendifferingprioritiesinvariousstudies.Thepatientinthisstudywouldrateexcellentinanysystemofclassification.UsingJacobsandThompsons10criteria,heachievedatleast75%ofnormalfunctionandhad<20degreesdifferencebetweentheplanesoftheopposedthumbnailandthepalmwithgoodpower.UsingcriteriasetbySundararajandMani,12thispatientachievedanexcellentresultwiththeabilitytoopposethethumbtosmallfingerwiththethumbIPextended.Whatislackinginareviewoftheliteratureisthefactoroftimeoffunctionalreturn.AndersonandSundararaj13monitoredresultswithEIPopponensplastypatientsouttooneyear.Burkhaltersstudy1hasnomentionofrateortimingofreturnoffunction.Futurestudiesofopponensplastyprocedureswoulddowelltobeginmeasuringthespeedoffunctionalreturnaswellastheoverallabilityofthetransferredtendontoopposethethumbovertime.Withawellexecutedopponensplatyprocedure,intensivepostoperativeoccupationaltherapy,adetailedandcloselymonitoredself-careprogram,andamotivated,hardworkingpatient,thiscasewasbroughttoasuccessfulclosureinlessthan14weekswithexcellentresults.Thelessthanoptimalresultofthepilotbeingunabletoreturntothecockpitwas

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26ArmyMedicalDepartmentJournalaverted,savingtheenormousamountofmoneyalreadyinvestedinthisindividualinhisextensiveandtimeconsumingflighttraining.REFERENCES 1.BurkhalterW,ChristensenRC,BrownP.Extensorindicispropriusopponensplasty.JBoneJointSurg.1973;55A:725-732.2.BunnellS.Oppositionofthethumb.JBoneJointSurg.1938;20:269-284.3.CooneyWP,LinscheidRL,AnK.Oppositionofthethumb:ananatomicandbiomechanicalstudyoftendontransfers.JHandSurg.1984;9A:777-786.4.StewartKM.TendonInjuries.In:StanleyBG,TribuziSM,eds.ConceptsinHandRehabilitation.Philadelphia,PA:FADavis;1992:353-3945.RoachSS,ShortWH,WernerFW,FortinoMD.Biomechanicalevaluationofthumboppositiontransferinsertionsites.JHandSurg.2001;26A:354-361.6.BindraRR,BhandarkarDS,TaraporvalaJC.Opponensplasty-anexperienceoftwenty-threecasesusingthreetechniques.JPostgradMed.1990;36:9-12.7.MehtaR,MalaviyaGN.Evaluationoftheresultsofopponensplasty.JHandSurg.1996;21B:622-623.8.StanleyBG.Preoperativeandpostoperativemanagementoftendontransfersaftermediannerveinjury.In:HunterJM,MacklinEJ,CallahanAD,eds.RehabilitationoftheHand:SurgeryandTherapy.4thed.StLouis,MO;CVMosby;1995:765-7789.DavisTRC,BartonNJ.Mediannervepalsy.In:GreenDP,ed.GreensOperativeHandSurgery.Philadelphia,PA;ChurchillLivingstone;1999:1497-1525.10.JacobsB,ThompsonTC.Oppositionofthethumbanditsrestoration.JBoneJointSurg.1960;42:1015-1026.11.WalshM,MuntzerE.Woundmanagement.In:StanleyBG,TribuziSM,eds.ConceptsinHandRehabilitation.Philadelphia,PA;FADavid;1992:171-175.12.SundararajGD,ManiK.Surgicalreconstructionofthehandwithtriplenervepalsy.JBoneJointSurg.1984;66B:260-264.13.AndersonGA,LeeV,SundararajGD.Extensorindicispropriusopponensplasty.JHandSurg.1991;16B;334-338.AUTHOR CPTAdmireisanOccupationalTherapistattheOccupationalTherapyClinic,GeneralLeonardWoodCommunityHospital,FortLeonardWood,Missouri. 18THMEDICALCOMMAND 121STGENERALHOSPITALSEOUL,KOREAThumbOppositionRestoration:ACaseStudy

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JulySeptember200627INTRODUCTIONIntheGlobalWaronTerrorism,theUnitedStateshasdeployedthousandsofathleticSoldiers,Sailors,AirmenandMarinestothird-worldnations.Partofsustainingmilitaryoperationsintheseareasrequiresconstantimprovementintheareaofoperations.Medicalassetshavebeenreconfiguredintosmallersubunitstosupportthesemissions,ofteninforwardoperatingareas.DeployedSoldiersstrivetomaintaintheirstrength,flexibility,andpeaceofmindinitiallybydoingroutinephysicaltrainingorusingmake-shiftweightsandgymequipment.Eventually,organizedsportssuchassoccerandbasketballappearonbase.Participationinorganizedcompetitivesportsintheatre,justasingarrisonathomebases,carriesanincreasedriskofinjury.Therearefewriskassessmentguidelinestohelpacommanderwiththedecisionastowhethertoallowsuchactivities.ForwardOperatingBase(FOB)SalernoisaUSmilitaryinstallationinsoutheasternAfghanistan,nearthePakistanborder.TheFOBismedicallysupportedbyaforwardsurgicalteamaugmentedwith14additionalpersonneltoallowadditionalmedicalholdingcapacityforinjuredSoldiers.TheausterelocationofFOBSalernochallengescurrentmedicallogisticsupportsystems.ThemajorityofsuppliesmustbebroughttoFOBSalernobyair.Suppliesandpersonnelshortagesoccurwithchangesintheweatherand/orenemyactivity.OnewaytoimprovemoraleinsuchanaustereenvironmentistocontinuallyincreasetherecreationaloutletsforSoldiers.InMay2004,thecommandofFOBSalernowelcomedtheopeningofaconcretebasketballcourttoimprovebothphysicalfitnessandthementalwell-beingoftheSoldiersontheFOB.Basedonstatisticalevidence,1thephysiciansontheFOBpostulatedthatanewbasketballcourtmayleadtoanoverallincreaseinkneeandankleinjuryduetothenatureofthesport.Previousstudiesdoneintheciviliansectorhavedocumentedaninjuryrateof18.3per1,000participants,withthemostcommoninjurybeingtheanklejoint.2ThispaperdocumentsthemedicalimpactofopeningabasketballcourtonaforwardoperatingbaseandprovidescommandersandmedicalplannersdatawithwhichtoperformriskassessmentandlogisticalplanningifsuchprojectsarepursuedinareassupportedbyEchelonII/III(-)MedicalTreatmentFacilities.3DATAANALYSISAretrospectivereviewofemergencyroomconsultationsfortheperiod24Marchthrough26June2004wasconductedforalldiagnosesofkneeand/orankleinjuryoccurringonForwardOperatingBase(FOB)Salerno.Thepatientdatawasfurtherdividedintotwogroupsthoseinjuriesoccurringpriorto10May2004(thedatethebasketballcourtopenedforuse),andthoseinjuriesoccurringonorafter10May2004.Eachsubgroupthussampled47daysofemergencyroomadmissiondata.OnlyUSSoldiersstationedontheFOBwereincludedinthisstudy.Fifty-twopatientssustainedkneeand/orankleinjuriesontheFOBfrom24Marchthrough26June(Table1).Thenumberofkneeinjuriesincreasedfollowingintroductionofthecourt,althoughonlytoaminordegree(n=11vsn=13).Thenumberofankleinjurieswentuptoamuchgreaterdegree(n=9vsn=19).Asshowngraphicallyinthechart,theproportionofkneeandanklenonbattleinjury(NBI)increasedaswell(25%vs44%).Thus,duringthesecondtimeperiod,2outofevery5NBISoldierswerebeingseenforeitherankleorkneeinjury.Thisrapidincreasewastheimpetusforthispaper.ThesubgroupanalysisbymonthispresentedinTable2.MedicalSupportandBasketball-RelatedSportsInjuryofUSSoldiersinAfghanistanLTCJamesD.Frizzi,MC,USAMAJPeterD.Ray,MC,USARCAPTJohnB.Raff,MC,USNR

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28ArmyMedicalDepartmentJournalDuringthereviewperiod,theoverallSoldierpopulationonFOBSalernoremainedconstant;thetempoofmilitaryoperationsunderwentnosignificantchanges.Asidefromthebasketballcourt,therewerenoothernewsportsfacilitiesconstructed(soccerfields,gymnasiums,etc)onFOBSalernoduringtheperiod24March-26June2004.DISCUSSIONKneeandankleinjuriesareagivenintheactiveandathleticpopulationtypicallyassignedtoaFOB.GiventhatfootballandbasketballcontributetothehighestratesofinjuriesinmaleSoldiers,4wepropose,andthedatasupport,thattheincidenceoftheseinjuriesincreasedwhenbasketballwasintroducedonthisforwardoperatingbase.Establishingthedegreetowhichtheseinjuriesaffectedoperationalcapabilityisbeyondthescopeofthispaper.However,apreviousstudyoftheArmedForcesdatabasewhichreviewed13,861hospitaladmissionsovera6yearperiodforinjuriesrelatedtosportsorArmyphysicaltrainingdidconcludethattheseinjuriesaccountforasignificantnumberoflostdutydaysandhaveanimpactonmilitaryreadiness.4ThereisnointentbytheauthorstosecondguessthedecisiontobuildtheconcretebasketballcourtonFOBSalerno.ItwasanoperationaldecisionthattookmultiplefactorsintoconsiderationandconcludedthatthepresenceofthecourtsupportedtheoverallFOBmission.Ourintentistoprovideinputthatwillassistcommanderswiththerisk-benefitanalysisthatispartofmakingthatdecision.Inthiscase,theincidenceofankleinjurydoubledafterthebasketballcourtwasconstructed.Theneedformedicalsupplies(ClassVIIIsupplies),namelycrutches,ankleorthoses,andkneeimmobilizersincreasedcommensurately.PerhapsthisscenariohadgreatermeaningtothemedicalprovidersComparisonofkneeandankleinjuriesaspercentagesoftotalnonbattleinjuriesforthe47dayperiodsimmediatelyprecedingandfollowingtheopeningoftheconcretebasketballcourtatForwardOperatingBaseSalerno,Afghanistan. 0%10%20%30%40%50%60%70%80%90%100%47DayPeriodPriorto10May0447DayPeriodBeginning10May04 T o t a l N o n b a t t l e I n j u r i e s OtherNonbattleInjuries Knee&AnkleInjuries MedicalSupportandBasketball-RelatedSportsInjuryofUSSoldiersinAfghanistanTable1.NonbattleKneeandAnkleInjuries asa PercentageofAllNonbattleInjuries IncurredatFOB Salernoin PeriodsImmediatelyBeforeandAfter OpeningoftheBasketballCourton10May2004TimeframeTotalInjuriesKnee&AnkleInjuriesPercentofTotal 47dayperiodpriorto05/10/04772026%47dayperiodstarting05/10/04723244% Table2.MonthlyTabulationofKneeandAnkleInjuriesOver94DayReportingPeriodMarchAprilMayJune Kneeinjuries19410Ankleinjuries17911Percentoftotalknee&ankleinjuriesforthe94dayperiod(n=52)4%31%25%40%Daysinperiod(percentoftotalreportingperiod)7(7%)30(32%)31(31%)26(28%)

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JulySeptember200629 asthefacilityssupplyofcrutchesandanklebootswasdepleteduntilnewsupplyarrived.FOBSalernowasultimatelyabletocontinuethewartimemissionuninterruptedbutadjustmentsinsupplyandpersonnelassignmentswereabsolutelynecessary.CONCLUSIONWhileimprovementsintheathleticandsportsfacilitiesatfar-forwardareasoftheUSGlobalWaronTerrorismarelaudedbySoldiersandcommandersalike,themedicalimpactofthesefacilitiesmustbeaddressedpriortoconstruction.WhileabasketballcourtmayinvokememoriesofhometoaSoldier,tothedeployedphysicianthepresenceofthecourtmeansaneedforcrutches,casts,andcoldcompresses.Ifthebasecommandersdonotassignprioritytomedicalsuppliesneededtoaddresssportsinjuries,theymayfindtheirmedicalcaregiverslackingthosesamesupplieswhenfacedwithbattleinjuriestothelowerextremities.WehopethatourexperiencewiththeintroductionofabasketballcourtonaFOBwillinfluenceothercommandstotaketheimpactonmedicalsupportintoaccountduringthedecision-makingprocess.WerecommendthattheUSmilitarycontinuetoconstructsportsfacilitiesforitsdeployedtroopsandaugmentthemedicalfacilitiesandsuppliesatbaseswheresuchfacilitiesexist.Inthisfashion,theUSSoldiermayremainphysicallyfit,mentallysharp,andaffordedthefinestcareAmericahastooffer.REFERENCES 1.MeeuwisseWH,SellmerR,HagelBE.Ratesandrisksofinjuryduringintercollegiatebasketball.AmJSportsMed.2003;31;No.3:379-385.2.McKayGD,GoldiePA,PayneWR,OakesBW,WatsonLF.Aprospectivestudyofinjuriesinbasketball:atotalprofileandcomparisonbygenderandstandardofcompetition.JSciMedSport.2001;4;No.2:196-211.3.FieldManual4-02.10:TheaterHospitalization.Washington,DC:USDeptoftheArmy;29Dec2000:chap1,sect1-3.4.LauderTD,BakerSP,SmithGS,LincolnAE.SportsandphysicaltraininginjuryhospitalizationsintheArmy.AmJPrevMed.2000;18(3suppl):118-128. AUTHORS LTCFrizziisassignedtotheGeneralSurgeryServiceattheEisenhowerArmyMedicalCenter,FortGordon,GA.MAJRayisanassociateprofessorintheDivisionofPlasticandReconstructiveSurgery,UniversityofAlabamaSchoolofMedicine,Birmingham,AL.CAPTRaffiswithAppalachianOrthopedicAssociatesinKingsport,TN.

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30ArmyMedicalDepartmentJournalCURRENTARMYACCESSIONIMMUNIZATIONPRACTICESThetransformationfromciviliantoSoldierintodaysall-volunteerArmyisacomplexone.TheprimaryresponsibilityforprocessingandmanagingnewSoldieraccessionsfallstotheUSArmyAccessionsCommand(USAAC).TheUSAACprocessesover130,000enlistedaccessionsannuallyforassignmentsintheActiveArmy,ArmyReserve,andNationalGuard.Armyaccessionsareprocessedthroughadecentralizednetworkof5AdjutantGeneralCorpsReceptionBattalions(AGBN):30thAGBNFortBenning,GA43rdAGBNFortLeonardWood,MO46thAGBNFortKnox,KY95thAGBNFortSill,OK120thAGBNFortJackson,SCThesesiteseachprocessfrom10,000toover40,000accessionsannually.The120thAGBN,thelargestArmysite,processesavolumeofaccessionssimilartothatoftheentireUSNavyorAirForce(USAF),whicheachprocesstheirenlistedaccessioncohortatasinglelocation.ASoldierstransformationtakesplaceover3to4days,duringwhichtimenecessaryadministrativeandmedicalprocessingareperformedinpreparationforthestartofintensiveBasicCombatTrainingorOne-StationUnitTraining.ImmunizationofnewSoldiersagainstcommonvaccine-preventableinfectionsisanimportantpartofaccessionmedicalprocessing.TheUSArmyMedicalCommand(MEDCOM)supportsthemissionofUSAACbyprovidingnecessaryvaccines.MEDCOMpersonnel,underthecontroloftheinstallationmilitarytreatmentfacility(MTF),administerthesevaccinesindesignatedclinicsfortheAGBNs.SoldiersprocessingthroughAGBNclinicsareimmunizedagainstupto10separatediseases.Thecorrespondingvaccinesincludemeasles-mumps-rubella(MMR),hepatitisB,inactivatedpoliovirus,quadrivalentmeningococcalA/C/Y/W-135,tetanus-ImprovingSoldierCareThroughOutcomesResearch:TheAccessionScreening&ImmunizationProgramCPTRemingtonL.Nevin,MC,USALTCDavidW.Niebuhr,MC,USAKevinD.Frick,PhDCOLJohnD.Grabenstein,MS,USAABSTRACTTheUSArmyAccessionScreeningandImmunizationProgram(ASIP)isanapplicationoftheemergingfieldofmedicaloutcomesresearchtotheimprovementofSoldiercareandtheoptimizationofbusinesspracticesintheUSArmyMedicalCommand(MEDCOM).Informedbytheresultsofmathematicaldecisionanalysis,theASIPbusinessplanprovidesanevidence-basedforecastofthecost-savingsexpectedtobederivedthroughreductionsinunnecessaryvaccineadministrationbyusingserologicscreeningtoassesspreexistingimmunity.BeginninginFY2006,theASIPwillimplementrapidserologicscreeningforpreexistingimmunityamongArmyaccessions,fundedviathe$4.7millioninprojectedinitialcostsavingsfromavertedvaccineadministration.Overthefirst6yearsoftheprogram,theASIPwillaverttheunnecessaryadministrationofapproximately$40millioninvaccineproducttoaccessionswithserologicallydemonstrableimmunity,eliminateoveronemillionunnecessaryinjections,andpreventapproximately100occupationalneedlestickinjuriesamongclinicstaff.Theevidence-basedinformationprovidedtoArmydecisionmakersthroughthemethodsusedintheASIPbusinessplanarguesforexpansionoftheroleofoutcomesresearchacrosstheMEDCOM.

PAGE 33

JulySeptember200631diphtheria(Td),influenza,andvaricellavaccines.Influenzavaccineisadministeredseasonally,andvaricellavaccineisadministeredtoasmallnumberofrecruitsonthebasisofmedicalhistory.AtsomeAGBNs,hepatitisAvaccineisadministered;oftenincombinationwithhepatitisBvaccineasthebivalenthepatitisAhepatitisBvaccine,currentlyTwinrix(GlaxoSmithKline,Philadelphia,PA,8888255249).Soldiersreturnonemonthlaterduringtheirtrainingforanadditionalmedicalencountertoreceiveneededvaccineboosterdoses.ThethirddoseofhepatitisBvaccineisgenerallyadministeredatthenextdutystation,6monthsaftertheinitialinjection.REDUCINGUNNECESSARYIMMUNIZATIONTHROUGHSEROLOGICSCREENINGThepracticeofgivingsimultaneousimmunizationsatfirstentryintomilitarytrainingisreferredtoasmassimmunization.1ThepracticeofmassimmunizationdatesbackatleasttoWorldWarII,whenthetechniquewasdevelopedtoquicklyfacilitatetheadministrationofvaccinetolargegroupstopreventoutbreaksofdisease.2AlthoughessentialtopreservingthehealthofSoldiers,standardmassimmunizationpracticesmayfailtoaccountforpreviouslyadministeredimmunizations.SerologicconfirmationofimmunityisoneoptionthatcanbeusedinmassimmunizationtoreliablyassessaSoldierspersonalneedforagivenimmunization.Indeed,inanApril,2004memorandum,theArmedForcesEpidemiologicalBoardconcludedthatserologicscreeningwaspreferredoverimmunizationrecordreviewforthispurposeandspecificallyrecommendedserologicscreeningforpreexistingimmunitypriortoimmunization.Basedonthecurrentavailabilityofcommonserologictests,theadministrationof4vaccinescouldbeselectivelyreducedthroughserologicscreeningpriortoimmunization.ThesevaccinesarehepatitisA,hepatitisB,MMR,andvaricella.Underapilotprogram,theGeneralLeonardWoodArmyCommunityHospitalatFortLeonardWoodbeganconductinguniversalserologicscreeningforpreexistingimmunitytohepatitisBinMayof2005.3All5AGBNsalsoperformtargetedvaricellascreeningbasedontheresultsofamedicalhistoryquestionnaireadministeredtonewSoldiers.Thosewhoendorseanegativeorunknownhistoryofchickenpoxreceiveserologicscreeningforvaricella,andthosefoundsusceptiblebytiterareimmunized.TheUSAF,whichconductsconsolidatedaccessionprocessingatLacklandAFB,TX,successfullyimplementedauniversalserologicscreeningprogramtoreducetheadministrationof3vaccines:MMR,varicella,andhepatitisB.TheUSAFbenefitsfromeconomiesofscaleandlimitedfixedcostsbyperformingallofitsenlistedprocessingatasinglefacility.INVESTIGATINGTHEPOTENTIALFORARMYACCESSIONSCREENINGAlthoughtheUSAFhaddemonstratedthatuniversalserologicscreeningofaccessionswascost-effectiveatasinglemassimmunizationsite,littlewasknownaboutthefeasibilityofimplementingsuchapolicyacrosstheArmysdecentralizedaccessionprocessingsystem.Theconventionalwisdomheldthatimplementingsuchapolicywouldbeimpracticalandcost-prohibitiveacrossprocessingcenterswhoseprocessingvolumesvariedsignificantly,andwherethetraditionallyhighcostsofserologictestingwerethoughtnottobenefitfromtheeconomiesofscaleachievedthroughcentralizedtesting.Additionally,thenecessaryfixedcostsandstaffingexpensestoimplementscreeningwerethoughttoexceedthepotentialsavingsinvaccinethatwouldresultfromsuchascreeningprogram.AtthedirectionoftheProponencyOfficeforPreventiveMedicine,adetailedresearchprojecttoexaminethoseissueswascommissioned.BetweenOctoberandNovember2004,sitevisitswereconductedatthe5Armytraininginstallationsthatreceiveenlistedaccessionstogatherdataonactualcosts,outcomes,practices,procedures,andcapabilities.WiththeassistanceofahealtheconomistatJohnsHopkinsBloombergSchoolofPublicHealth,arigorouscost-effectivenessanalysisforimplementingserologicscreeningatthese5siteswasalsoperformed.TobestcomplywiththeArmedForcesEpidemiologicalBoardsrecommendationstomaximizereductionsinunnecessaryimmunizations,modelswereconstructedofthepotentialcostsavingsthatwouldbeobtainedthroughscreeningforpreexistingimmunitytoasmanydiseasesaspossibleforwhichcommonscreeningtestswerereadilyavailable,includinghepatitisA,hepatitisB,measles,

PAGE 34

32ArmyMedicalDepartmentJournalrubella,andvaricella.4Althoughimplementationofscreeningwouldincurbothfixedandvariablecosts,onlythemarginalcostsassociatedwiththescreeningofanindividualaccessionwereexamined.Forthepurposesofthisanalysis,thosecostsincludethecostofvaccineproductandofalltheserologyreagentsusedtotestforimmunity.Cost-effectivenessanalysiswasfacilitatedthroughthecreationofamathematicalmodel,implementedusingtheindustryleadingdecision-analyticsoftwaretoolTreeAgeProHealthcare(TreeAgeSoftware,Inc.,Williamstown,MA,413-458-0104).ThroughtheuseofMonteCarlostochasticsimulation,themodelthuscreatedpermittedcalculationofmultipleeconomicandnon-economicoutcomesofinterest,toincludetotalvaccinecostsavingsandvaccinecostsavingsperinstallation.Themodelalsocalculatednoneconomicoutcomesofinterest,toincludereductionsininjections,probabilityofmissedimmunizationduetofalse-positivescreeningtests,andprobabilityofcompleteseroconversionfromeachvaccineproduct.ThemodelautomaticallyfactoredintheeffectsofSoldierattrition,andoftheage-specificdosingstrategiesnecessaryfortheuseofthebivalentvaccineTwinrix,whichisnotlicensedforusein17-yearolds.Inaddition,throughtheuseoffirst-andsecond-ordersensitivityanalysis,therobustnessoftheoutcomestochangesininitialassumptionscouldbemodeled.Themodeltookasitsinputtheratesofpreexistingimmunitytoeachofthesediseasesobtainedfromreviewofexistingsurveillanceandresearchstudies,includingarecentstudyofhepatitisBimmunityamongmilitaryrecruits.5TherewaslimitedavailabilityofreliableseroprevalenceinformationforpreexistingimmunitytohepatitisA.Toconfirmthemathematicalanalysis,adetailedseroprevalencestudyofhepatitisAantibodiesamongapproximately2,800recruitswasperformedinJanuary,2005usingbankedfrozenserumobtainedonaccessionsduringcalendaryear2004.6CostsofvaccineproductwereobtainedfromanexhaustivereviewofactualpharmacypurchasingrecordsattheMTFssupportingArmyAGBNs.Ratesofseroconversionforeachvaccine,aswellasthesensitivityandspecificityofscreeningandserologictests,wereobtainedfromliteraturereview.RatesofattritionwereobtainedthroughareviewofUSAACdata.THEECONOMICBENEFITSOFSEROLOGICSCREENINGDuetohighratesofpreexistingimmunitytomeasles,rubella,varicella,hepatitisAandhepatitisBamongArmyaccessions,ourmodeldeterminedthat,onaverage,$43ofunnecessaryvaccineswereadministeredtoeachnewaccessioninFY2004.ThesevaccineswereunnecessaryinthattheywereadministeredtoSoldierswithserologicallydemonstrableimmunitytooneormorescreeneddiseases.Althoughthisamountmayseemsmallperaccession,duetothelargesizeoftheannualaccessioncohort,thisrepresentsasignificantcumulativesum:over$5.3millionworthofunnecessaryvaccineswereadministeredtoArmyaccessionsduringFY2004.Thisannualamountisequivalenttoover$100,000worthofunnecessaryvaccinesweekly,thecostsofwhichcouldotherwisebeusedtofundimprovementsinmedicalprocessingandimmunizationdelivery.Asratesofpreexistingimmunityrise,duetotheArmyenlistingrecruitswhoareincreasinglylikelytohavereceivedhepatitisBvaccinebeforeaccession,thesepotentialcostsavingsincrease,toover$6millionannuallybeginninginFY2006,and$7millionannuallybeginninginFY2009.THEUSARMYACCESSIONSCREENINGANDIMMUNIZATIONPROGRAMTheendresultofthesitevisitsandthecost-effectivenessmodelingwastheformulationoftheUSArmyAccessionScreeningandImmunizationProgram(ASIP)businessplan.7Followingalengthystaffingprocesswheretheprojectedvaccinecostsavingswereindependentlyconfirmedandtheinputofthe5servicingMTFswasobtained,theArmySurgeonGeneralapprovedtheASIPproposalandissuedimplementationinstructionsinamemorandumdatedNovember18,2005.Fundedentirelythroughprojectedvaccinecostsavings,theASIPhasdevelopedintoacomprehensiveTheAccessionScreeningandImmunizationProgram

PAGE 35

JulySeptember200633strategyforimprovingthequalityofaccessionmedicalprocessingandimmunizationdelivery.TheASIPimplementstherecommendationsoftheArmedForcesEpidemiologicalBoardtoinstituteserologicscreeningforpreexistingimmunityamongArmyenlistedaccessions,andprovidesnumerouseconomicandnon-economicbenefits.Beginningwithimplementationacrossall5ArmyAGBNsinFY2006,theASIPwillimplementrapidserologicscreeningforpreexistingimmunityamongArmyaccessionstohepatitisA,hepatitisB,measles,rubella,andvaricella,fundedviathe$4.7millioninprojectedinitialcostsavingsfromavertedunnecessaryvaccineadministration(Figure1).TheASIPwillalso Figure1.ImmunizationinjectionschedulefornewlyaccessedpersonnelundertheAccessionScreeningandImmunizationProgram. UniversalSerologicScreeningforpresenceofantibodiesforVZV,rubella,measles,HAV,andHbSAb IPV,FLUMGC,TDPCN In-processingVaricella non immunesonly VZV#1 MMR#1 Measles/Rubellanon-immunesonly HepatitisA* non immunesonly A#1 HepatitisB* non immunesonly B#1 1Month MMR#2 VZV#2 B#2 I m m u n i z a t i o n s ReceptionBattalion(AGBN)/BasicCombatTrainingTrainingPhase Timeline AdvancedIndividualTraining/SoldierReadinessProgram B#3 6to12Months A#2 KEYTOABBREVIATIONSAHepatitisAvaccineBHepatitisBvaccineFLUInfluenzavaccineHAVHepatitisAvirusHbSAbHepatitisBsurfaceantibodyIPVInactivatedpoliovirusvaccineMGCMeningococcalA/C/Y/W-135vaccineMMRMeasles-mumps-rubellavaccinePCNBicillin-LA(administeredat3of5AGBNs)TDTetanus-diphtheriatoxoids(Td)VZVVaricella-Zostervaccine*Note:HepatitisAandBvaccinedeliveredinbivalentformtothose18andoldernon-immunetoboth.

PAGE 36

34ArmyMedicalDepartmentJournalinstituteotherneededimprovementsinenlistedaccessionmedicalprocessing.Overthefirst6yearsoftheprogram,theASIPwillaverttheunnecessaryadministrationofapproximately$40millioninvaccineproducttoaccessionswithserologicallydemonstrableimmunity(Figure2),eliminateoveronemillionunnecessaryneedleinjections,and,basedoncurrentestimatesofinjuryrates,preventapproximately100occupationalneedlestickinjuriesamongclinicstaff.8TheASIPwillenablethefundingofhigh-qualitymedicalprocessingandimmunizationclinicsunderthedirectcontrolofthecommanderoftheinstallationMTFateachofthe5AGBNs.BeginninginFY2006,withthehiringof29.5full-timeequivalents(FTEs)andcontinuingwiththehiringofanadditional30FTEsthroughFY2010,theASIPwillfreeexistingmilitarypersonnelbyfundingfullcivilian(civilservice)staffingofASIPclinicswithtrainednurses,phlebotomists,andclericalstaff,underthesupervisionofon-scene,credentialedmedicaldirectors.TheASIPwillprovidefordedicatedserologicscreeningequipmentwithinexistinglaboratoriesatthese5installationMTFs,staffedwithdedicatedtechnicians,providingthereliableandrapidturnaroundofresultsneededforsuccessfulprogramimplementation.TheASIPwillprovidefundsfortraining,capitalimprovementsandequipmenttoassurecompliancewithregulatorystandardsandtoimprovetheefficiency,reliability,andqualityofmedicalprocessingoftheArmysnewestSoldiers.TheASIPwillalsofullyfunduniversalglucose-6-phosphatedehydrogenase(G6PD)deficiencytestingataccession.Undertheproposal,AGBNswillshipwholebloodspecimenstotheBrookeArmyMedicalCentercentralreferencelaboratory,wherecentralizedtestingandpermanentelectronicdocumentationofresultswilloccur,precludingtheneedforlatercostlyandrepeattesting.9UniversalscreeningforG6PDataccessioniswarrantedgiventhehighrateofdeploymentofUSArmypersonneltoareasofmalariaendemicityforwhichterminalmalariaprophylaxismayberequired.TheASIPwillprovidecentralizedoversightandmanagementoftheaccessionmedicalprocessingandimmunizationprogramthroughtheestablishmentofaProgramManagementOffice(PMO)locatedattheMilitaryVaccineAgency,responsibleforoverallcoordinationanddirectionoftheprogram(Figure3).TheASIPPMOwillcoordinateandsynchronizepolicyguidancefromtheUSArmyTrainingandDoctrineCommand,theOfficeoftheSurgeonGeneral,andtheMEDCOMforaccessionmedicalprocessingandimmunizationissues,andwilldirecttargetedanalyticeffortstowardfurtherimprovingmassscreeningandimmunizationprogramsandexpandingtherangeofdiseasesforwhichscreeningisfeasibleThefirst6yearsoftheASIPprogramwillresultinatotalcumulativecostsavingstotheMEDCOMofover$10.4million.TheASIPprovidesthesesignificantcostsavingswhileimprovingthequality,reliability,andefficiencyofenlistedaccessionmedicalprocessing,andincreasingtheconfidenceandtrustofnewSoldiersinArmyimmunizationpolicies.AsshownintheTable,theASIPbudgetassumesmultipleFigure2.CumulativevaccinecostsandpotentialvaccinesavingsrealizedfromimplementationoftheAccessionScreeningandImmunizationProgram. $0$10,000,000$20,000,000$30,000,000$40,000,000$50,000,000$60,000,000$70,000,000$80,000,000$90,000,000200620072008200920102011FiscalYear C u m u l a t i v e V a c c i n e C o s t s NecessaryVaccine PotentialVaccineSavings TheAccessionScreeningandImmunizationProgram

PAGE 37

JulySeptember200635conservativecostestimates,includingaperaccessionserologicscreeningcostof$14inFY06,decreasingto$12insubsequentyears;andconservativecost-savingsfigures,includingtotalvaccinecostsavingsperaccessionof$49inFY2006,increasingto$63peraccessionbyFY2011.InrecognitionofthehighcostofperishablevaccineproductkeptonhandatASIPclinics,theASIPbudgetcontainsfundstopurchaseredundantvaccinerefrigerationandfreezerequipment,properlyequippedwithremotealarmsthatwillalertclinicstaffofequipmentmalfunctionorpowerfailures.ASIPclinicThesavingspernewSoldierrealizedwitheachimmunizationseriesandatcompletionoftrainingundertheAccessionScreeningandImmunizationProgramwhencomparedtothestatusquo.FY2006FY2007FY2008FY2009FY2010FY2011 VaccineCostperImmunizationSeries($) In-processingStatusquo565656565656ASIP282726252423Difference(28)(29)(30)(31)(32)(33)1MonthStatusquo282828282828ASIP181615141312Difference(10)(12)(13)(14)(15)(16)6to12MonthsStatusquo282828282828ASIP171817161514Difference(11)(10)(11)(12)(13)(14)TotalVaccineCost($) Statusquo112112112112112112ASIP636158555249Difference(49)(51)(54)(57)(60)(63)SerologyCost($) Statusquo111111ASIP141212121212Difference131111111111TotalCost($) Statusquo113113113113113113ASIP777370676461Difference(36)(40)(43)(46)(49)(52)

PAGE 38

36ArmyMedicalDepartmentJournalFigure3.TheUSArmyAccessionScreeningandImmunizationProgramestablishedastandardizedstructureandmethodologyacrossthe5receptioninstallationsunderthecentralizeddirectionoftheOfficeoftheSurgeonGeneralandtheArmyMedicalCommand. OfficeoftheSurgeonGeneralUSArmyMedicalCommand MilitaryVaccineAgency ASIPProgramManagementOffice GreatPlainsRegionalMedicalCommand SoutheastRegionalMedicalCommand NorthAtlanticRegionalMedicalCommand GeneralLeonardWoodArmyCommunityHospital ReynoldsArmyCommunityHospital BrookeArmyMedicalCenter ASIPReferenceLaboratory MartinArmyCommunityHospital MoncriefArmyCommunityHospital ASIPLaboratory 43rdAGBNASIPClinic 30thAGBNASIPClinic 46thAGBNASIPClinic 95thAGBNASIPClinic ASIPLaboratory ASIPLaboratory 120thAGBNASIPClinic ASIPLaboratory IrelandArmyCommunityHospital ASIPLaboratory TheAccessionScreeningandImmunizationProgram

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JulySeptember200637budgetfiguresalsoincludefundstoprovidefortheprovisionandinstallationofemergencypowergenerationequipmentthatwouldensurethecontinuedoperationofvaccinestorageequipmentintheeventofanemergencythatwouldthreatenvaccinepotency.ExperiencehasdemonstratedthatplanstomovelargevaccinestockpilestoMTFstoragefacilitiesintheeventofequipmentmalfunctionorpowerfailureareimpractical,necessitatingtheprovisionofbothredundantequipmentandemergencypowersupplies.FUTUREDIRECTIONSFOROUTCOMESRESEARCHTheASIPrepresentstheapplicationofthefieldsofoutcomesresearchanddecision-analyticmodeling10toimproveSoldiercareandtooptimizebusinesspracticesacrosstheMEDCOM.Thepracticeofoutcomesresearchrequiresaccesstolargeamountsoflinkedmedicaldata.MuchofthisdataisalreadyavailableintheDefenseMedicalSurveillanceSystem(DMSS),operatedbytheArmyMedicalSurveillanceActivity.11DMSSalreadycontainsrelevantmedicaloutcomesandhealthcareutilizationdataonmembersofthearmedforces.Theadditionoflinkedpharmacy,laboratory,andradiologydatawouldprovideadditionaloutcomesresearchcapabilitytothealreadyrobustmedicalsurveillancefunctionsofDMSS,improvingtheMEDCOMsabilitytoplanforandevaluateotherlarge-scalepublichealthinterventions.TheAccessionScreeningandImmunizationProgramhasdemonstratedthatmoderateinvestmentsinoutcomesresearchprovidesignificantreturnsoninvestment.Therefore,itisrecommendedthatoutcomesresearchcapabilitiesbeincorporatedaspartoftheconsolidationofmilitarypublichealthandmedicalsurveillancefunctionsattheplannedArmedForcesHealthSurveillanceCenter. REFERENCES1.GrabensteinJD,NevinRL.Militarymassimmunizationprograms:Principlesandstandards.In:PlotkinSA.MassImmunization.Inpress.2.BenensonAS.Immunizationandmilitarymedicine.RevInfectDis.1984;6:1-12.3.PabloK,RooksP,NevinR.BenefitsofserologicscreeningforhepatitisBimmunityinmilitaryrecruits.JInfectDis.2005:192:2180-2181.4.NevinRL,NiebuhrDW,FrickKD.Cost-minimizationanalysisofserologicscreeningpolicyoptionsforUSArmyaccessionimmunizations.[PosterPHP47].In:ContributedPosterPresentations.ValueinHealth.2005;8;No.3:436.5.ScottPT,NiebuhrDW,McGreadyJB,GaydosJC.HepatitisBimmunityinUnitedStatesmilitaryrecruits.JInfectDis.2005;191:1835-1842.6.NevinRL,NiebuhrDW.SeroprevalenceofhepatitisAantibodiesamongnewenlistedaccessionstotheUSmilitaryin2004.[Poster1026].Presentedat:43rdAnnualMeetingoftheInfectiousDiseasesSocietyofAmerica;October8,2005;SanFrancisco,CA.7.NevinRL.TechnicalGuide#310:TheUSArmyAccessionScreeningandImmunizationProgram.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine;November18,2005[limiteddistribution].8.NevinRL,NiebuhrDW,FrickKD.MathematicalmodelingofoccupationalneedlestickinjuryreductioninaUSArmymassimmunizationprogramthroughuniversalserologicscreeningforpreexistingimmunity.AmJInfectControl.2005;33;No.5:e139-e140.9.DoDInstruction1645.1,HemoglobinSandErythrocyteGlucose-6-PhosphateDehydrogenaseDeficiencyTestingProgram.Washington,DC:USDeptofDefense;July29,1981.10.WeinsteinMC,O'BrienB,HornbergerJ,JacksonJ,JohannessonM,McCabeC,LuceBR.Principlesofgoodpracticefordecisionanalyticmodelinginhealth-careevaluation:reportoftheISPORTaskForceonGoodResearchPracticesModelingStudies.ValueHealth.2003;6:9-17.11.RubertoneMV,BrundageJF.TheDefenseMedicalSurveillanceSystemandtheDepartmentofDefenseserumrepository:glimpsesofthefutureofpublichealthsurveillance.AmJPublicHealth.2002;12:1900-1914.

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38ArmyMedicalDepartmentJournalAUTHORSCPTNevin,iscurrentlyassignedtotheArmyMedicalSurveillanceActivity,USArmyCenterforHealthPromotionandPreventiveMedicine,Washington,DC.LTCNiebuhrisonthestaffoftheDivisionofPreventiveMedicine,WalterReedArmyInstituteofResearch,SilverSpring,Maryland.DrFrickisanassociateprofessorintheDepartmentofHealthPolicyandManagement,JohnsHopkinsBloombergSchoolofPublicHealth,Baltimore,Maryland.COLGrabensteinisonthestaffoftheMilitaryVaccineAgencyOfficeoftheUSArmySurgeonGeneral,FallsChurch,Virginia.TheAccessionScreeningandImmunizationProgram USARMYCENTERFORHEALTHPROMOTIONANDPREVENTIVEMEDICINE USArmyMedicalResearchandMaterielCommand

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JulySeptember200639INTRODUCTIONSimulationhasprovenusefulinawiderangeofapplicationswhereerrorsinhumanjudgmentorperformancecanresultincatastrophicconsequences.Itisubiquitousinaviation,nuclearpowerplantoperations,andmodernmilitarybattlefieldtraining.Overthelastdecadetheanesthesiologycommunityhasadaptedtheprinciplesofcrisismanagementintoastandardcurriculum,withglobaladoption.1,2Severalcentersaredevelopingprogramsthatfollowasimilarpattern,includingarecentlywelldescribedadaptationforemergencymedicine.2-5Mostoftheseprogramsfocuson1or2physicianornurseanesthetistswithouttheinvolvementoftherestoftheirusualhealthcareteam.However,inmosthealthcareenvironmentscareisdeliveredbydisparateteams,withoutcomesandperformancelargelyaffectedbytheinteractionsoftheteammembers,ratherthantheisolatedresponsesofasinglepractitioner.1,2Wereportontheparticipantresponsetothemultidisciplinaryteam-basededucationprogramatamilitarymedicalcenter.Thisprogramhasbeenadaptedforawiderangeofoffice,hospitalandprehospitalproviders,includingcombatfieldconditions,weaponsofmassdestruction,andacutepatientdecompensationduetoiatrogeniccomplicationsusingtheSimManpatientsimulator(LaerdalMedicalCorporation,WappingersFalls,NY,877-523-7325).METHODSThesimulatorconsistsofasemiautomatedmanikinthathasvisiblerespirations,variableairwayconditions,modifiableauscultationfindings,palpablepulses,andtheabilitytorepresentmanualbloodpressures.Asimulatedmonitor,usedtodisplaypulseoximetrywaveforms,oxygensaturation,andheartratewhenthefingerprobeisattached,isusedwithallgroups.Cardiacrhythm,heartrate,exhaledcapnography,arterialwaveformwithbloodpressure(BP),centralvenouswaveform,respiratoryrate,cyclicnoninvasiveBP,coretemperatureandcardiacoutputarevariablydisplayeddependingonthemonitoringcapabilityandpreferencesoftheindividualteams.Inaddition,thesimulatorcanbeattachedtoastandardcardioverter/defibrillatorvialimbleadsorthechestelectrodesusedforelectricaltherapydelivery.Thesimulatorandthemonitorarecontrolledbysoftwarethatisprogrammedtomodeldiseaseprocessesandrespondtointerventionsorcomplicationswithalterationsinthevitalsigns,physicalexamination,oraudiocues(suchaspatientvomiting).Participantsweregivenasummaryofthecapabilitiesofthesimulatoraswellassomebasicinformationonfacetsofcrisismanagementpriortoparticipation.Thegroupswerethengivenachancetofamiliarizethemselveswiththeavailableequipmentandobtain MultidisciplinaryCrisisManagementSimulation-BasedTrainingProgramKevinM.Coonan,MDLTCJosephP.Miller,MC,USAMichelleMartinezCOLPatKelly,MC,USAABSTRACTThisreportdescribesourexperienceswithasimulation-basedcrisismanagementprogramusedtotrainexistingteamscomprisedofphysicians,nurses(LPNandRN),respiratorytechniciansand/ormedics(EMT-BandEMT-P).The579participantsweretrainedusingscenariosreflectingtheirclinicalenvironment,includingbattlefield/prehospital,ambulatoryclinic,emergencydepartment,fieldhospital,medical-surgicalnursing,andintensivecaresettings.Scenariosincludediatrogenicdecompensation,riskmanagementissues,weaponsofmassdestruction,andinitialpresentationofcriticalillness.Theparticipantsoverwhelminglyfoundthetrainingvaluable.Simulationcanbeadaptedto,andisusefulfor,trainingarangeofhealthcareprovidersworkingtogetherinvastlydifferingsettings.

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40ArmyMedicalDepartmentJournalhands-onexperiencewiththesimulatortoestablishbaselinefunctionandphysicalexaminationfindings.Theparticipantsweregivenapatienthistorytailoredtotheirworkenvironment,andoftensupportinginformation,suchaselectrocardiograms,radiographs,prehospitalreports,laboratoryvalues,priornursingandphysiciannotes,nursingflowsheets,andanesthesiarecords.Equipmentandmedicationswereprovidedinamannertoreplicatetheirpractice,eg,astandardhospitalcrashcart.Prehospitalteamsareencouragedtousetheirownequipmentandsupplies.Theteamswerecomposedofarangeofhealthcareworkersincludinginterns,residents,staffphysicians,practicalnurses,medical-surgicalregisterednurses,criticalcareandemergencynurses,respiratorytherapists,paramedics,andemergencymedicaltechnicians-basic,whooftenwerefunctioninginaroleofmedicalornursingassistant.Theteamsweredrawnfromexistingpatientcareunitsandclinics.Table1listsseveraloftheteamsandthetypesofscenariosused.Followingthesimulation,weconductedadebriefingsessionwiththegoalofhavingteamparticipantsrelaytheeventsastheyperceivedthem.Eachscenariowasdesignedtohave7criticalactionsthatmustbetaken,and4specificpitfallswhicharedetrimentalorilladvised.Participantsweregivenalistingoftheeducationalgoalsandbriefsummariesoftheproblemsencounteredandexpectedmanagement,withcurrentreferences.Weencouragedinvestigationofthedifferinginterpretationsoffindingsandtreatmentsusedinthesimulation.Thedebriefingsfocusedonbothmedicalcareandteamdynamics.Weadaptedapreviouslyvalidatedteamperformancetooltoserveasatemplate,presentedintheAppendixtothisarticle,forourreviewandfuturestudies.9Table1.Settings,TeamCompositions,andTrainingScenariosusedinSimulationTrainingExercisesSettingTeamCompositionScenarios MedicaloncologywardMed-surgicalwardStep-downunitInternalmedicineresidentsNurses(RNandLPNs)AidesRespiratorytherapistsAnaphylaxistoIVantibioticsNarcoticinducedrespiratorydepressionVentriculartachycardiaduetoacuteMIHyperkalemiaHemolyticreactiontoblood EmergencydepartmentEmergencyphysiciansEMT-PNursesEMT-BExsanguinatingextremityhemorrhagePrehospitalesophagealintubationHeatstrokeNerveagentintoxicationNeckinjuryAcuteMIwithRVextensionMultipletraumaHypothermia Austerefieldenvironment(battalionaidstation)PhysiciansPhysicianassistantsMedics(EMT-BandsomeEMT-P)CombinedgunshotwoundandnerveagentintoxicationAirwayburnsTensionpneumothorax CriticalcareunitPhysiciansNursesRespiratorytherapistsSepticshock,anaphylaxisinpatientwithpneumoniaARDSwithacuterespiratoryfailureTensionpneumothoraxMassivepulmonaryembolus PrimarycareclinicPhysicianNurse(RN)MedicalassistantorLPNAnaphylaxisAcuteMIAsthma MultidisciplinaryCrisisManagementSimulation-BasedTrainingProgram

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JulySeptember200641RESULTSOvera12-monthperiod,weprovided1,616person-hoursofteam-basedsimulationto579healthcareproviders.Avarietyofteamsparticipated,withmixedgroupsofprovidersfromvariousdisciplinesandtrainingasgraphicallydepictedintheFigure.Wepolledaconveniencesampleof100ofthe579users,94ofwhichelectedtocompleteasurvey(3surveyswerediscardedastheycircledthevalue10foreveryaspectofthesimulation)ontheirassessment.TheresultingdataispresentedinTable2.DISCUSSIONCrisismanagementisdifferentfromroutinecare.6Weassumethatperformanceinacrisiscanaffecttheoutcome,possiblypreventingadverseeffectsorminimizingpatientinjury.However,thisrequiresoptimalproviderperformance,decision-makingskills,andoverallintegrationandcommunicationwithintheteam.SpecificaspectsofthecrisismanagementprocesshavebeenquantifiedanddescribedasshowninTable3.Theseelementscanbetaught.1-4Thesimulationprogramprovidedtraining,oftenconcurrently,onmultiplelevels.Itallowedtherehearsalandintegrationofalgorithmiccare,whichimprovesretention.7,8Awidevarietyofprocedureswereemployed:endotrachealintubationsurgicalorneedlecricothyrotomychestcompressionmaskventilationchest-tubethoracostomyintravenousaccessIVdriptitrationcardioversion/defibrillation/pacingTraininginthoseproceduresdevelopednotonlythetechnicalskills,butalsotheintegrationofthoseskillswithanoverallpictureofpatientmanagement.9,10Patientcareteamsmaybefacedwithcriticallyillordecompensatingpatientswithoutthebenefitofextensiveexperience.Thoroughlyconsideredandwell-rehearsedplansforspecificclinicalemergencies TeamCompositionbyTypeofTrainingPA(16,4%)RT(13,3%) EMT(189,45%)LPN(33,8%) RN(111,26%) MD/DO(58,14%) Table2.UserAssessmentofMultidisciplinaryCrisisManagementSimulationsQuestion*MeanSD Thesimulationwasrealistic8.51.7Thescenariowasclinicallyapplicabletomyfield8.81.3Therewassufficienttimetoperformcriticalactions8.81.3Responsestointerventionswereappropriate8.51.6Thesimulationwillhelpmeinfuturecriticalsituations9.01.2Thesimulationwillhelpmepreventerrors8.81.4Thesimulationreviewed/taughtsomethinguseful9.11.1*Responsescale:1=disagreestrongly,10=agreestronglyStandarddeviation

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42ArmyMedicalDepartmentJournalarecrucialtosuccess.Manycriticaleventsmayoccursoinfrequentlythatmembersoftheteamhavenopersonalexperienceorrecallofcurrentmanagementoptions.Althoughtypicallyconsideredaproblemfacedbythemilitaryheathcaresystemduringconflict,civilianpractitionersinalldisciplinesarefacingthegrowinglikelihoodofprovidingcareforvictimsofweaponsofmassdestruction.Coursesemphasizingexperience-basedlearning,suchastheAdvancedCardiac,AdvancedTrauma,andPrehospitalTraumaLife-Support(ACLS,ATLS,andPTLS),offersomesupport.Theyprovideacommonframeworkandanapproachthatislikelytobenefitmostpatientsinagivensituation.Experiencefromthecoursesandhands-onpatientcaresolidifylearning,unlikereadinginstructionsfromacoursemanual.Experienceinevaluatingandtrainingaircraftpilots,combatvehiclecrewmembers,anesthesiapersonnel,andnuclearpowerplantoperatorshasledtoasharedmodelfordealingwithcriticalincidentsorcrisis.Somekeybehaviorshaveemergedfromanalysisofairlinecrashes,battlefielddisasters,andmedicalmalpracticecases.Theseskillshavebeenidentifiedandcanbetaughtandimproved.2,11Ourapproachhasbeentoprovideasharedexperience,viaasimulatedpatient,tomembersofahealthcareteam.Thesearebrief,butintense,criticalevents(eg,acuterespiratorydistress)whichrequireactiveinterventionbymultipleproviders.Errorsareallowedtooccur,andthesoftwarecomponentmodelsthepatientsresponsetotheerrors.Forexample,administrationofparenteralverapamiltoapatientwhohadalreadyreceivedparenteralbeta-blockersresultsinprofoundbradycardiaandhypotension,whichmayrespondtoappropriatetherapywithatropine,calcium,andglucagon.Thekeygoalofusingapatientsimulatorisasafe,flexibleenvironmentforlearningatavarietyoflevels.Theadultlearnersbasicdidacticknowledgeisenhancedbycase-basedlearning.Inaddition,proceduralskillscanbetaughtinasafe,controlledenvironment,withoutrisktopatientsfromincorrectperformance.Itallowstheapplicationoflearningtonewclinicalsituations.Inaddition,thehands-onnatureofthesimulatorenhancestheeducationoftheteamasateam.Itisnotonlycriticalthatindividualsknowtheirspecificskillsandcanperformtheirroles,Table3.AspectsoftheCrisisManagementProcessBEPREPARED.Anticipateandplanformedicalcrisis.Knowyourenvironment.Conductsituationalplanning.Havesharedplans,policiesandproceduresforemergencies. COMMUNICATION.Beclearandprecise.Ensurereceptionoftheintendeddata.Keepeveryoneintheloop.Bepolite.Leteveryoneknowwhichplanisinuse.Uselowvoices.LEADERSHIP.Establishroleclarity.Delegate.Makesuretasksarecomplete.Singlepersoncallstheshotsandgivesorders.Addressprofessionalconcernsdirectly.RESOURCEAWARENESSandoptionsforimplementation.Everyoneofferssuggestions.CALLFORHELPearly.Distributeworkloadandmobilizeadditionalresources.Declareanemergency/callacode.Entireteamsharedindecisionmaking.RE-EVALUATIONofsituationisanongoingprocess.Focusonbigpicture,consideralternativeapproaches.TEAMAWARENESSandutilizationofallavailableinformation.Avoidfixationerrors.Calloutcriticalinformationduringevents.Crossmonitorothersactionsandbehaviors.Notifyteamofslips,lapses,andmistakes.TRIAGEANDPRIORITIZATION.Focusonkeygoalswhichmaychange.Triageisanongoingassessmentofthedynamicneedsofpatientsagainstresourcesavailable.EFFICIENTMANAGEMENTofmultiplepatients.Thesickestpatientmaystillbeinthewaitingroom.Useappropriateprovidersforspecificproblems.COPEWITHDISRUPTIONSANDDISTRACTIONS.Reacttonewinformationbutfocusonthecritical.BEPREPARED.Anticipateandplanformedicalcrisis.Knowyourenvironment.Conductsituationalplanning.Havesharedplans,policiesandproceduresforemergencies.COMMUNICATION.Beclearandprecise.Ensurereceptionoftheintendeddata.Keepeveryoneintheloop.Bepolite.Leteveryoneknowwhichplanisinuse.Uselowvoices. MultidisciplinaryCrisisManagementSimulation-BasedTrainingProgram

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JulySeptember200643butalsoforindividualstorecognizethattheserolesareonlyperformedinconjunctionwithothersofdifferingtrainingandlevelsofexpertise.Allteammembersperformcriticalactionsthatarebothessentialtoanddependentupontheactionsoftheothermembers.Itisthistimespenttogetherworkingtowardssharedgoalsthatallowsindividualstorealizewhatistrulymeantbyperformingasateam.CONCLUSIONSimulationappearstobeaveryusefultoolforimprovingpatientcareteamperformanceinawidevarietyofsettings,rangingfromthemudfloorsofamilitaryaidstationtotheintensivecareunitofafixedfacilityhospital.Thismodalityshouldbeavailableforactivedutyandreservemilitaryhealthcareteams,otheragenciesprovidinghomelanddefense,andcommunityhospitalsandclinics.Studiesvalidatingtheimpactofsimulationbasedtrainingonoutcomeareurgentlyneeded.12Wide-spreadadoptionislikelytooccurpriortodefinitiveproof.Carefuldocumentationandconsiderationoftheoptimizationoftrainingandtheimpactonoutcomeswillrequireongoingefforts.REFERENCES 1.InstituteofMedicineCommitteeonQualityofHealthCareinAmerica.In:KohnLT,CorriganJM,DonaldsonMS,eds.ToErrIsHuman:BuildingaSaferHealthSystem.Washington,DC:TheNationalAcademyPress;2000.2.RisserDT,RiceMM,SalisburyML,SimonR,JayGD,BernsSD.Thepotentialforimprovedteamworktoreducemedicalerrorsintheemergencydepartment.TheMedTeamsResearchConsortium.AnnEmergMed.1999;34;No.3:373-383.3.ReznekM,Smith-CogginsRS,HowardS,KiranK,HarterP,SowabY,GabaD,KrummelT.Emergencymedicinecrisisresourcemanagement(EMCRM):Pilotstudyofasimulation-basedcrisismanagementcourseforemergencymedicine.AcadEmergMed.2003;10;No.4:386-389.4.SmallSD,WuerzRC,SimonR,ShapiroN,ConnA,SetnikG.Demonstrationofhigh-fidelitysimulationteamtrainingforemergencymedicine.AcadEmergMed.1999;6;No.4:312-323.5.ReznekM,HarterP,KrummelT.Virtualrealityandsimulation:trainingthefutureemergencyphysician.AcadEmergMed.2002;9;No.1:78-87.6.SempowskiIP,BrisonRJ.Dealingwithofficeemergencies.Stepwiseapproachforfamilyphysicians.CanFamPhysician.2002;48:1464-1472.7.SchwidHA,RookeGA,RossBK,SivarajanM.Useofacomputerizedadvancedcardiaclifesupportsimulatorimprovesretentionofadvancedcardiaclifesupportguidelinesbetterthanatextbookreview.CritCareMed.1999;27;No.4:821-824.8.WillyC,SterkJ,SchwarzW,GerngrossH.Computer-assistedtrainingprogramforsimulationoftriage,resuscitation,andevacuationofcasualties.MilMed.1998;163;No.4:234-238.9.HolcombJB,DumireRD,CrommettJW,StamaterisCE,FagertMA.ClevelandJA,DorlacGR,DorlacWC,BonarJP,HiraK,AokiN,MattoxKL.Evaluationoftraumateamperformanceusinganadvancedhumanpatientsimulatorforresuscitationtraining.JTrauma.2002;52;No.6:1078-1086.10.MarshallRL,SmithJS,GormanPJ,KrummelTM,HaluckRS,CooneyRN.Useofahumanpatientsimulatorinthedevelopmentofresidenttraumamanagementskills.JTrauma.2001;51;No.1:17-21.11.PatelRM,CrombleholmeWR.Usingsimulationtotrainresidentsinmanagingcriticalevents.AcadMed.1998;73;No.5:593.12.CoonanK.ComparisonofComputerBasedandPatientSimulatorBasedCrisisManagementPrograms.AnesthAnalg.2003;96:1236.AUTHORS Whenthisarticlewaswritten,DrCoonanwasonthestaffoftheAndersenSimulationCenter,MadiganArmyMedicalCenter,FortLewis,Washington.LTCMillerisStaffAnesthesiologist,DepartmentofAnesthesiaandOperativeServices,attheMadiganArmyMedicalCenter,FortLewis,Washington.Whenthisarticlewaswritten,hewastheMedicalDirectoroftheAndersenSimulationCenter.MichelleMartinezistheAdministratorofSimulationPrograms,AndersenSimulationCenter,MadiganArmyMedicalCenter,FortLewis,Washington.COLKellyisamemberoftheStaff,DevelopmentalPediatrics,MadiganArmyMedicalCenter,FortLewis,Washington.Whenthisarticlewaswritten,hewastheChief,DepartmentofClinicalInvestigation.

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44ArmyMedicalDepartmentJournalAPPENDIX.TeamEvaluationForm TeamEvaluationTool ScenarioTimeanddateTotalscore(of80possible) Teamcomposition(circleleader,indicateleveloftraining/specialty) Score:0=standardofcarenotmet,1=marginal,2=optimal Leadership Repeatvitalsigns Nodelegationorinstructions,multipleconflictinginstructions,severaldisjointedefforts,chaotic0None0 Leaderloosestrackorcontrolofeventsbutoveralldirectscare1Oneset,orincomplete(i.e.notemperature)omitted,ordeterioratingpatientwithoutrepeatBP,HRmeasurements1 Clearlydefinedleadermaintainedcontrolofsituation,delegatesandinstructsthroughout,organized2Morethanonecompletesetfollowinginitialvitalsigns,ongoingwithfrequencyasdeterminedbypatientstability2 Examfindingsandvitalsignscommunicatedto team Useofinformationfromothersources Nodiscussionofpertinentfindings0Ignored0 Somefindingsannounced1Notsought1 Clearannouncementofsignificantfindingswithacknowledgmentbyleader2Reviewed2 Interventionsclearlyannounced Abdominalexamination Noannouncementofcompletionofproceduresorotherinterventions0Notdone0 Someinterventionsannounced1Donebutincomplete1 Allinterventions(IVstarted,bleedingcontrolled,etc.)announcedclearly2Done,includingflanks2 Communication Repeatchestexamination Yellingtobeheard,arguments,orcriticalinformationnotcommunicated0Notdone0 Teamleadermissesanycommentsordoesntusecheck-backsystem1Donebutincomplete1 Calm,quite,professionalwith2waydiscussionofsignificanteventsandfindings2Done,includingCXR2 Workloaddistribution Neckexamined Membersnotused,orboggeddownbyserialtasks0Notdone0 1Incomplete1 Allmembersinvolved,taskscoordinated,handleddistractionsandredistributedpersonnelasneeded2InspectionforJVD,trachealdeviation,c-spinetenderness,bruits,hematomas,pulses2 Teamwork Documentation Memberswaitingonothersforcompletiontoinitiatecriticaltasks,unawareofwhatwasneeded0Notcompletedornotsentwithpatients0 1Incomplete,illegible1 Membersanticipatedothersneedsandactions,workedinparalleltowardscommongoals2Completeandlegible2 MultidisciplinaryCrisisManagementSimulation-BasedTrainingProgram

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JulySeptember200645 Assessrisktoteam Choiceoftransferchosen Failedtorecognizehazardexistedtoteam,failuretouseuniversalprecautions,leavingsharpsout0Dangerous0 1Wastefulorsuboptimal1 Recognizedandmanagedhazards2Correct2 Triageandprioritizationofinjuries Patientstabilizedpriortomovement Failuretoaddresslifethreats,futileresuscitations,prematureterminationofefforts0Unstableorlikelytolooseairwayenroute,incorrectlevelofprovideraccompanying0 AddressA-B-Csseriallyandinorder1Stablebutwithminimaladditionalinterventioncouldbemademorestable1 Simultaneousmanagementoflifethreats,rapidinitiationofcriticalinterventions2Stableandsafefortransport,appropriateproviderinattendance2 Assessairwaypatency Administrationofanalgesia Noassessment0None,orexcessive0 Notedpatientisbreathingorcantalk1InadequatedosingoruseofIM/SQ/POroutesforseverepain1 Look-listen-feel,talktopatient,assessforstridorandpoolingsecretions2Titratedtoeffect2 Oxygenapplied ScenarioSpecificCriticalaction#1 >60sbeforeinitiation0Notdoneorprotracted,detrimentaldelay0 30-60s1Donewithsomedelayorincompletebutadequate,techniquelackingbutgoalaccomplished1 <30stoinitiation2Donepromptly,efficientlyandcorrectly2 Auscultation ScenarioSpecificCriticalaction#2 >60s0Notdoneorprotracted,detrimentaldelay0 30-60sornotsufficient,missedfindings1Donewithsomedelayorincompletebutadequate,techniquelackingbutgoalaccomplished1 30s,bilateral,twolocationseachside2Donepromptly,efficientlyandcorrectly2 Neurologicevaluation ScenarioSpecificCriticalaction#3 None0Notdoneorprotracted,detrimentaldelay0 Pupils,GCS,movementx41Donewithsomedelayorincompletebutadequate,techniquelackingbutgoalaccomplished1 ROSandcompletescreeningexam2Donepromptly,efficientlyandcorrectly2 Assessedcentralpulses ScenarioSpecificCriticalaction#4 Notdone0Notdoneorprotracted,detrimentaldelay0 1Donewithsomedelayorincompletebutadequate,techniquelackingbutgoalaccomplished1 Done2Donepromptly,efficientlyandcorrectly2 Assessedperipheralpulses ScenarioSpecificCriticalaction#5 Notdone0Notdoneorprotracted,detrimentaldelay0 Delayedorunilateral1Donewithsomedelayorincompletebutadequate,techniquelackingbutgoalaccomplished1 Bilateralanddeterminedinconjunctionwithcentralpulses2Donepromptly,efficientlyandcorrectly2 APPENDIX.TeamEvaluationForm(continued)

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46ArmyMedicalDepartmentJournal Determinedcardiacrhythm ScenarioSpecificCriticalaction#6 Notdone0Notdoneorprotracted,detrimentaldelay0 Delay>60sinapplyingmonitororinterpretation1Donewithsomedelayorincompletebutadequate,techniquelackingbutgoalaccomplished1 Cardiacmonitorappliedandrhythmdeterminedin<602Donepromptly,efficientlyandcorrectly2 InitialHRandBP ScenarioSpecificCriticalaction#7 Notdoneor>1minutedelay0Notdoneorprotracted,detrimentaldelay0 30-60s1Donewithsomedelayorincompletebutadequate,techniquelackingbutgoalaccomplished1 <30s2Donepromptly,efficientlyandcorrectly2 Fullsetofvitalsobtained ScenarioSpecificPitfall#1 Notobtained(includingtemperature)0Encounteredortriggeredandnotmanaged0 >5minutes1Encounteredortriggeredbutmanaged1 <5minutes2Notdone2 ECGobtained ScenarioSpecificPitfall#2 Notobtained0Encounteredortriggeredandnotmanaged0 >5minutes1Encounteredortriggeredbutmanaged1 <5minutes2Notdone2 ECGinterpretation ScenarioSpecificPitfall#3 Notinterpretedormissedsignificantdiagnosisorerroneousdiagnosiswithinitiationofdangeroustherapy0Encounteredortriggeredandnotmanaged0 Incompleteinterpretation1Encounteredortriggeredbutmanaged1 Complete,fullinterpretationwithrecognitionofpathologicfindingsandinitiationoftherapy2Notdone2 ObtainedAMPLEhistory ScenarioSpecificPitfall#4 Notattemptedorincomplete(e.g.forgettingtoaskaboutdrugallergies)0Encounteredortriggeredandnotmanaged0 Unabletoobtainandothersourcesnotsought1Encounteredortriggeredbutmanaged1 Completeaspossible2Notdone2 MADIGANARMYMEDICALCENTERAPPENDIX.TeamEvaluationForm(continued)MultidisciplinaryCrisisManagementSimulation-BasedTrainingProgram

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JulySeptember200647ArmyFieldManual22-100definesleadershipasinfluencingpeoplebyprovidingpurpose,direction,andmotivationwhileoperatingtoaccomplishthemissionandimprovingtheorganization.1Myleadershipphilosophyemphasizessixareasthatarecriticaltoachievingsuccessinanyorganization:vision,communication,courage,developingsubordinates,knowingyourself,andpassion.Leaderswhosuccessfullytapthesefactorsintheirpersonalandprofessionallifearerolemodelsfortheirorganizations.Visioniskeytoleadership.Withoutvision,thepeopleperish.2(p94)Visionistheleadersroadmapoftheorganizationsfuture.Itprovidestheorganizationwithdirectionandasenseofpurpose.Anorganizationneedstoknowtheplanforitsfutureandthemilestonesthatwillbeusedtoattainsuccessfulresults.Peoplewhoworkinanorganizationwithoutavisionhavenosenseofbelongingandfeelthereisnohigherreasonfortheirexistence.Workisnotmeaningfulwithoutavision.Visionisthusthekeyingredientthatstokesthefireofcreativityandtransformsanorganization.Anintellectualimageofthefutureisaprerequisiteforchangeandmustprecedeanyphysicalchange.Organizationalchangeisundirected,unfocused,andunproductivewithoutaunifyingvision.Communicationisparamounttoleadership.Awell-formedvisionforanorganizationisnotenough.Goalsareuselessifmembersofanorganizationdonotunderstandwhattheyare.Aleadersvisionmustbecommunicatedtotheorganizationinaclearandsuccinctmannersothatitiseasilygraspedbyorganizationmembers.Communicatingthevisioninvolvespersuadingpeopletobuyintoit.Toachievesuccess,subordinatesateveryleveloftheorganizationmustbeabletotranslateandapplytheleadersvisiontotheirdailyjobs.Leadersmustwidelyarticulatetheirvisioninfrequentinteractionswithorganizationmembers.Communicationcanbeverbalorwrittenandwithinformalorinformalsettings.Newsletters,emailcommunications,andsmallandlargegroupforumsareeffectiveandpracticalwaysofdisseminatingthevision.Everycontactwithamemberoftheorganizationisanopportunitytoreachoutandspreadthevision.Communicatingthevisionisonlyoneofmanymessagesthatmustbeconveyedthroughoutanorganization.Stressingtheneedforconstantimprovementkeepstheorganizationfocusedonattainingfuturegoals.Disseminationofresults-basedlearningaboutwhatisworkingandwhatneedsimprovementwithinanorganizationiscritical.Givingpraise,credit,andpositivereinforcementforajobwelldoneisessential.Bythesametoken,counselingandconstructivecriticismisalsoimportantinthepursuitofthevision.Aleaderisafacilitatorandmoderatorwhoinfluencesthebehaviorofindividualsandteamswithintheorganization.Effectivecommunicationfostersgroupproblemsolvinganddecision-making.Itencouragesaclimateofopennessandtruthfulnessforfreeinteractionsaboutcommonlysharedproblems,errors,andlessons.Anopendoorpolicyandawillingnesstolistenareintegralcomponentsofeffectivecommunication.Listeningisjustascriticalasspeaking.Opennesstonewideascapitalizesonanorganizationscreativity.Beingaccessiblesendsamessagethattheleadercaresandisapproachable.Nonverbalcommunicationthroughbehaviorandgesturessendsapowerfulmessagetoorganizationmembers.Leadersshouldnotunderestimatetheextenttowhichtheirfollowersobservethem.Asimplegestureofintegrityorcompassioncanbeworthathousandwordsandcanencouragerole-modelingbehaviorwithintheorganization.Conversely,aleaderwhosendsinconsistentandcontradictorymessagesbynotlivinguptotheexpectationsthathesetsforhisorganizationbreedsmistrustanddisrespect.Courageisathirdelementofleadership.ItisoneofthesevenArmyvaluesformingtheacronymLDRSHIPthatallSoldiersareexpectedtopossess.ElementsofLeadershipfortheSuccessfulOrganizationCOLGeorgeW.Turiansky,MC,USA

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48ArmyMedicalDepartmentJournalCouragecanbesummarizedbythephrase,Whenincharge,beincharge.2(p39)Aleadermusthavecouragetofollowhisvision,takeaction,andinitiatechange.Hemusttranslatehisvisionintoreality.Thisinvolvesawillingnesstotakeapublicstandonhisbeliefsandsometimestochallengethestatusquo.Aleaderwhotakesactiondoeswhathesaysandthenmore.Hespeaksthetruthanddisplaysintegrity,anotherofthesevenArmyvalues.Acourageousleadertakesrisksandsearchesforsolutions.Heistoughenoughtoensurethattheorganizationexecutestheactionsnecessarytotransformvisionintorealityandtoachievethedesiredendresult.Hedelegatesresponsibilitytoempowerhissubordinates.Healsostandsupforsubordinateswhennecessary.Couragealsomeanstakingresponsibilityfordecisionsandacknowledgingmistakes.Throughpersonalreflection,aleaderusesmistakesasalearningtoolinthelifelongprocessofself-improvement.Aleaderwithcourageembodiesthevalueshecultivatesinhisorganizationandlivesbythem.Aleaderconsistentlyconductshispersonalandprofessionallifeinamannerthatwillbringcreditnotonlytohimself,butalsotohisorganization.Thisencouragessubordinatestofollowthepathtosuccessbyemulatingtheleadersbehavior.Developingandmentoringsubordinatesisessentialtoeffectiveleadership.Leadershipconceivedasthelonewarriorisreallyheroicsuicide.3Aleadercannotcommandinavacuumdisregardinghisstaffsinput.Aleaderneedssubordinatestoadviseandchallengehimandtohelphimidentifyhisweakandblindspots.Aleaderrecognizesthatdevelopingandmentoringhissubordinatesenhanceshisowneffectiveness.Buildingleadershipintothegeneticcodeofanorganizationistheultimatecompetitiveadvantage.4AccordingtoCharanandTichy,GeneralElectricattributesitsabundanceofchiefexecutiveofficertalenttoitsfocusonnurturingandgrowingleadersfromwithintheorganization.4Thismeansmakingtimeforpeopleissuessuchasencouraging,mentoring,coaching,andadvising.Aneffectiveleadergivesbothpositiveandnegativefeedbacktohissubordinates.Aleaderrewards,recognizes,andcelebratestheaccomplishmentsandsuccessesoftheirsubordinates.Aleaderprovidesguidanceandsuggestspathwaysforproblemsolving.Aleaderalsoencouragesreflectionasatoolforself-improvementandemphasizesthatpeoplelearnfrommistakes.Anintegralpartofsubordinatedevelopmentisthecreationofaworkenvironmentinwhichpeoplecansucceed.Thisisdonebyearmarkingresourcesforlearninginareassuchastrainingandeducation,pilotprojects,anddevelopmentalassignmentsandensuringtheavailabilityofbasicresourcessuchasfinancialsupport,tools,materials,andfacilitiessosubordinatescanexcel.Anenvironmentforsuccessencouragesteamworkandcollaborationateachleveloftheorganization.Aleaderdevelopssubordinatesbyestablishingandmaintaininganethicalclimate,whichemphasizesthatracism,sexism,andprejudiceareunacceptable.Subordinatedevelopmentalsomeanscaringdeeplyaboutyourpeople,bothpersonallyandprofessionally.Respectandrecognitionareessential.Providingresourcestoremedysocialissuessuchasmaritaldiscordandalcoholabuseisimportantforharmoniousandeffectiveworkperformance.Afairandcaringcommandclimatefostersrolemodelemulationandsubordinatedevelopment.Effectiveleadershipmeansknowingyourselfbyrecognizingyourlimits,abilities,shortcomings,andvalues.Thisalsoinvolvessearchingdeeplywithinyourselftounderstandyourownassumptions,biases,prejudices,andbeliefs,aswellasthoseofothers.Aneffectiveleaderexploreshowhediffersintheseareasfromothersandrealizestheimplicationsofthesedifferencesonhisbehaviorandinteractionswithorganizationmembers.Itisimperativethataleaderlookinwardandexplorefeelingstowardrace,gender,rank,andsexualandreligiousorientation.Theimplicationsofnotrecognizingdifferencesbetweenyourfeelingsandthoseofyourorganizationmemberscanbeimmense.Inaddition,aleadermustrecognizethatothershavevaryingdecision-making,learning,andinterpersonalstylesandthatthesestylesmaybejustaseffectiveasanyofhisown.Beforeyoucanleadothers,beforeyoucanhelpothers,youhavetodiscoveryourself...Andnothingismorepowerfulthansomeonewhoknowswhotheyare...ifyouknowwhoyouare,thenpeopletrustyou.5Aleaderwhoknowshimselfultimatelycontributestoacommandclimateoffairnessandtrustwhichcanonlyspurrolemodelbehaviorinsubordinates.Effectiveleadershipispassion.Passionistheinnerfiretoinspireandmotivatepeople.Passionisbornofempathy,theabilitytoconnectwithpeople...Withpassionateleadership,thepulseofaninstitutionanditsElementsofLeadershipfortheSuccessfulOrganization

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JulySeptember200649peoplebeatsfaster,itbreathesharder,itrunsstronger.6Passionateleadershipinvolvesinstillingoptimism,highmorale,enthusiasm,andanespritdecorpsintheworkenvironment.AccordingtotheBlairHousePapers,onewaytomaximizepeopletalentistoraisethespiritoftheworkforceEmpoweringandenergizingthefrontlines...7Aleadermustcreateaworkclimateinwhichpeoplefeelgoodabouttheirjobsandtheircontributionstotheorganization.Aleadercaninstillenthusiasmforhisvisionbyhismerefrequentpresenceandpersonalinteractionswithorganizationmembers.Thisshowspeoplethatyoucareenoughtoseehowthingsaregoing,tomakesurethatpoliticalredtapedoesnotbogpeopledownintheirjobs,andtomakepeoplefeelthattheyreallydomakeadifference.Aneffectiveleaderinspirespeopletofocustheirenergyonspecificgoalsdirectedtowardthevision.However,aleadermustbewiseenoughtobalanceappropriateoptimismwiththerealitiesthatfacetheorganizationmembersonadailybasis.Inspiringsubordinatestoattaintheirgoalsgeneratesfeelingsoffulfillment,self-esteem,andjobsatisfaction.Byvirtueoftherolemodelstatus,apassionateleaderbreedsenthusiasminsubordinates.Toachievetheendresultaneffectiveleadermustcreateaclimatethatstimulatespositivechangewithinhisorganization.Hemusthaveavisionthatisclear,succinct,andunderstoodbyhissubordinates.Hemusthaveexcellentcommunicationskillsasaspeaker,listener,facilitator,andmoderator.Hemusthavecouragetobeatrueleader.Asmartleadernurturesfutureleadersforhisorganizationandbecomesapeoplesleaderbymentoringanddevelopinghissubordinatesanddealingwithpeopleissues.Aleadercanbefaironlywhenheknowsdeepinsidewhohereallyis,howthiscompareswithothers,andhowtheactionsofhissubordinatesaffecthisownbehavior.Passionateleadershipignitestheorganizationinpursuitofthevision.AllsixoftheseelementsarecriticaltoeffectiveleadershipandmakealeaderallthathecanbeintodaysArmyofOne.ACKNOWLEDGEMENT TheauthorgratefullyacknowledgesLieutenantRussellA.Baum,Jr.,SupplyCorps,UnitedStatesNavalReserve,forhiscriticalreviewandeditorialcomments.REFERENCES 1.FM22-100ArmyLeadership:Be,Know,Do.Washington,DC:USDeptoftheArmy;31August1999:1-4.2.SullivanGR,HarperMV.HopeisNotAMethod.NewYork:BroadwayBooks;1996.3.HeifetzR.Quotedby:GaryL.Theworkofamodernleader:aninterviewwithRonHeifetz.HarvardManageUpdate.April1997:4-6.4.CharanR,TichyN.NeedaCEO?Hereshowtogrowone.USAToday.October20,1997:21A.5.JaworskiJ.Quotedby:WebberAM.Destinyandthejoboftheleader.ChangeAgentJune/July1996:40-42.6.RodinJ.Quotedby:TraffordA.Leadingmedicineintothefuture.WashingtonPost.November4,1997:HealthSection:6.7.ClintonWJ,GoreA.BlairHousePapers.January1997:PartIII,Section1.Availableat:http://govinfo.library.unt.edu/npr/library/papers/bkgrd/blair.html.AUTHOR COLTurianskyistheProgramDirectoroftheNationalCapitalConsortiumDermatologyResidencyattheWalterReedArmyMedicalCenter,Washington,DC.HeisalsotheDermatologyConsultantfortheDiLorenzoTRICAREHealthClinicatthePentagon.

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50ArmyMedicalDepartmentJournalMentorsandProtgs:SimpleRulesforSuccessCOLMarkA.Melanson,MS,USAMentoringisapartneringrelationshipwhereasenior,moreexperiencedofficerprovidesguidanceandadvicetoajuniorofficerinordertofosterprofessionalgrowthinthesubordinate.Speakingfrompersonalexperience,mentoringhasbeenandremainsthesinglemostimportantfactorinmydevelopmentandgrowthasanofficerandaleader.ThefollowingaresomekernelsofwisdomforthementoringrelationshipthatIhavediscoveredduringmynearlyquartercenturyofexperienceasbothmentorandprotg.Ihavedistilledthisexperienceintotwosetsof10commonsense,yetremarkablyoftenoverlookedrulesoneseteachforthementorandtheprotgrespectively.TenSimpleRulesforMentorsWheninitiatinganydiscussiononmentoring,anaturalquestiontoaskiswheretobegin?Doyoustartwiththementorortheonebeingmentored(protg)?Whilethecontributionsofbothparticipantsareimportant,mentoringsuccessesorfailuresmostoftendependupontheskillsofthementor.Ifthementorisnotpreparedtodohisorherjob,thentheentirementoringprocessmaybeineffectiveand,consequently,discouragetheprotgfromanyfuturementoringopportunities.Itishopedthatbyconsideringthese10simplerules,mentors,presentandfuture,willbebetterpreparedtoassumethisveryimportantrole.MENTORRULE#1ItsNotAboutYou!Beingchosentobesomeonesmentorisapowerful,potentiallyintoxicatingexperience.Notsurprising,itiseasytoletitgotoyourhead.However,ifyousimplyengageinmentoringtosatisfyyourownego,youwillultimatelyfail.Atbest,yourprotgwillrecognizethatyouarejustdoingthisforyourselfandnotforhimorher.Atworst,youwillmodelaself-centeredbehaviorthatyourprotgmayemulateandthenperpetuatewhenheorshebecomesamentor.Whilementoringdoesofferbenefitstothementor,suchasself-validationandestablishingalegacy,theprimaryfocusofmentoringisontheindividualbeingmentored,theprotg.Sincenotallattemptsatamentoringrelationshipwillbesuccessfulandnotallofyouradvicewillnecessarilybefollowed,youshouldbehumblewhilementoringandcheckyouregoatthedoor.Itisalsoessentialthatyoudonotusethementoringrelationshipasavehicletoexploittheprotgforyourownpersonalgain.Forexample,avoidgivingbusyworkthatyoudonotwanttodotoaprotgundertheguiseofitbeinggoodforhimorher.Chancesareyourprotgwillseerightthroughthisveiledattemptatexploitationandunderstandablygrowtoresentit.

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JulySeptember200651 MENTORRULE#2AlwaysMaintainConfidencesTrustiscriticalinahealthymentoringrelationship.Hence,mattersdiscussedbetweenamentorandaprotgmustremainconfidential(aslongastheissuedoesnotinvolveviolationsofArmyregulationsortheUniformCodeofMilitaryJustice).Itisinthissafeenvironmentthataprotgcanopenlysharemistakesoranylackofself-confidence.Italsoallowsthejuniormentoringpartnertotakeriskswithoutfearingnegativeconsequences.Giventhat,thementorshouldnotsharetheprotgsmistakesandsetbackswithothers.Ofcourse,maintainingconfidencesgoesbothways.Thistrustingenvironmentallowstheseniormentoringpartnertosharelessonslearnedfrompersonalmistakesandfailureswithoutthefearoftheseblundersbecomingcommonknowledge.Alwaysremember,trusttakesalongtimetobecomefullyestablished,yetitcanbedestroyedinamatterofmoments. MENTORRULE#3SetandEnforceBoundariesThisruledealswithavoidingoneofthedarkeraspectsofamentoringpartnershipthedevelopmentofaninappropriaterelationship.Throughoutthecourseofmentoringajuniorofficer,itiseasytodevelopalikingoraffinityforyourmentoringpartner.But,itisimperativethatthementorkeeptherelationshipprofessional.Asamentor,youmustalwaysinsistonmaintainingmilitarycourtesywithnoexceptions.Asapersonalexample,Icalledmymentorofmorethan20years,Siruntilthedayheretiredasacolonel.Ifyouareasupervisortoyourprotg,youmustneverletyourroleasamentorcompromiseyourdutiesandresponsibilitiesasarater.Youmustavoidlettinganyhintofcronyismorfavoritismtocreepintoyourdecisionmaking.Ofcourse,aromanticrelationshipwithyourprotgisstrictlyforbiddenandwillprobablyadverselyaffectbothofyourcareers.Afinalnote:youshouldneverallowyourmentoringrelationshiptocircumventthechainofcommand. MENTORRULE#4KnowYourLimitationsOnceyouhavegainedthetrustandconfidenceofyourprotg,youmayfindyourselfaskedforguidanceinareasaboutwhichyouknowverylittle,or,perhaps,nothingatall.Thatiswhyitissoimportantthatyouacknowledgeanysuchlimitationswhenprovidingadvice.Theremaybethetemptationtoprovideguidance,anyguidance,justsothatyoudontloseface.Admittingalackofknowledgeonasubjectmayseemlikeaweaknessandthreatentoundermineyourstandingwiththeprotg.But,inactuality,acknowledgingyourownlackofexpertiseorexperiencewillfurtherstrengthenyourmentoringrelationship.Thosebeingmentoreddonotexpecttheirmentorstoknoweverything,but,rathertosharetheirexperiencesandpointthemintherightdirection.So,ifyouareaskedtoprovideadviceonasubjectaboutwhichyourknowledgeislimited,youshouldguidetheprotgintheproperdirectionand,ifpossible,tothebestpersonwhocangivethemthenecessaryguidance.

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52ArmyMedicalDepartmentJournal MENTORRULE#5KeepYourPromisesMentoringtakestime,yourmostvaluableresource.Beforeenteringintoamentoringpartnership,itiscrucialthatyoudeterminewhetherornotyoucanmakethetimetodedicatetosuchanendeavor(Istronglybelievethatifyoutrulythinkthatmentoringisimportant,youwillmakethetimeforit!).Ifyoucannotdedicatethetime,thenIsuggestthatyoudonotevenattemptit.Onceyouhavedecidedtocommittoamentoringrelationship,youmustfollowthroughwithyourpromises.Forexample,ifyouagreetoweeklymeetingswithyourprotg,youmustkeeptheseappointments.IfyoupromisetoreviewajuniorofficersOERSupportForm,thendoitandprovideyourfeedbackinatimelymanner.Apatternofbrokenappointmentsandunfilledpromiseswillsendaclearmessagetoyourmentoringpartnerthatyouarenotreallydevotedtohisorherdevelopment.So,dowhatyousayyouaregoingtodo,whenyousayyouaregoingtodoit. MENTORRULE#6ListenandAskQuestionsAcommonmisconceptionaboutmentoringisthattheprotgsimplybringsproblemstothementorandthementortellstheprotgwhattodo.Althoughthismaybetemptingforbothmentoringpartners,itshouldbedonesparingly.First,donotassumethatyouautomaticallyknowwhatyourmentoringpartnerneedsfromyou.Youneedtotrulylistentothequestionsthattheprotgisasking.Practiceeffectivelisteningtobesureyouaregivingtheactualhelporadvicethatisrequired.Interestinglyenough,ahighlyeffectivewaytoimpartwisdomisbyaskingquestionsthatleadtheprotgtodiscovertherightanswerforhimorherself.Iknowfirsthandthatthiscanbeveryfrustratingtotheprotgwhousuallysimplywantsaquickanswer.However,inthelongrunitteachestheonebeingmentoredhowtothinkthroughproblemsandindependentlydevelopsoundsolutions. MENTORRULE#7ReachOuttoJuniorOfficersItisessentialthat,asaseniorofficerandpotentialmentor,onemustremainapproachable.IntheArmy,rankcanbeveryintimidating.RememberhowyouwereintimidatedbyseniorofficerswhenyoufirstjoinedtheArmy.Giventhatfact,weasseniorleadersneedtobreaktheice.ApracticethatIlearnedfromanotherofmymentorsistoinitiateconversationswithjuniorofficerswhomIdonotknow.Iintroducemyselfandaskwheretheyarefromandtrytolearnalittleaboutthem.Thissimplegesturepaysbigdividendsinthelongrun.Itgreatlyincreasestheprobabilitythattheseofficerswillseekmeoutforguidanceinthefuture.MentorsandProtgs:SimpleRulesforSuccess

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JulySeptember200653 MENTORRULE#8DontSugarcoatFeedbackHonestfeedbackisveryimportantinaneffectivementoringpartnership.However,theremaybeatemptationtosoftenconstructivefeedbacksoasnottooffendtheprotgorruinthementoringrelationship.Typically,whenhandledcorrectly,suchcorrectivefeedbackisusuallysomeofthemostimportantmentoringthatyoucangiveayoungofficer.Now,Iamnotcondoningdegradingorbelittlingtheindividual.Negativefeedbackneedstobespecific,givenjudiciouslyandunemotionally.Ofcourse,ithelpsifsuchfeedbackissandwichedbetweenpositivecomments.Aswithallcounseling,itshouldbedoneimmediatelyandinprivatetohavethegreatestimpact.Thefeedbackshouldalsoproviderecommendationsonhowtoaddressshortcomingsorareasthatneedimprovement.Itisimportanttoalwaysseparatetheindividualfromtheundesirablebehavior.Finally,oncethematterisdiscussed,itshouldnotbebroughtupagainunlessthebehaviorormistakeisrepeated. MENTORRULE#9BeYourselfSincementoringisarelationshipbetweentwouniqueindividualsthereisnosingleguaranteedrecipeformentoring.Therelationshipwillnaturallyreflectthedistinctpersonalitiesofthepairofindividualsinvolved.So,itisimportantthat,asamentor,youareauthentic.Yourdeedsshouldmatchyouractionsoryourwalkshouldmatchyourtalk.Ifyouareanintrovertbynature,tryingtocomeacrossasanextrovertwillseemphony.Onethingthatmayhelpyouindevelopingyourownstyleistodosomeself-reflection.Thiscanhelpyouidentifythekeyelementsofyourleadershipstyleandhowyoucanusethesetraitstobecomeamoreeffectivementor.Thegoodthingaboutmentoringisthemorethatyoudoit,thebetteryouwillbecome.Sotakeprideinbeingamentoranddoityourownway,withbothpassionandconviction. MENTORRULE#10CommittoContinuousLearningWhateveryourmilitaryspecialty,youshouldbededicatedtomaintainingyourtechnicalcompetencyandstayingabreastofadvancementsinyourfield.Thisisalsotruefortheleadershipandmentoringskillsrequiredtobeaneffectiveofficer.Awaytodothisistosetasidesomequiettimeforreadingprofessionaljournals,thoserelatingtoyourmilitaryspecialtyandthoserelatedtoofficership.Whileyouareprobablyawareofprofessionalreferencesforyourtechnicaldiscipline,youmaynotbeawareofjournalsforleaderdevelopment.ArmyjournalsthatmaybeofhelpareMilitaryReview,publishedbytheUSArmyCombinedArmsCenteratFortLeavenworth,KS,andParameters,fromtheUSArmyWarCollegeatCarlisleBarracks,PA.Bothinstitutionssupportwebsitesfromwheretheirarticlesmaybedownloaded:MilitaryReviewhttp://usacac.leavenworth.army.mil/CAC/milreview/index.aspParametershttp://carlisle-www.army.mil/usawc/Parameters/Thispublication,theAMEDDJournal,isanothervenueforstayingcurrentindevelopmentswiththeArmyMedicalDepartment.Finally,ifyouareseriousaboutgrowingasamentor,youshouldavidlyreadallthatyoucanonthesubjectofmentoring.Foralistofsuggestedreadingmaterial,IhaveincludedabibliographyofbooksandarticlesthatIhavefoundhelpfulinmypersonalgrowthasamentor.

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54ArmyMedicalDepartmentJournalSUMMARYThekeypointsoftheaboverulesincluderememberingthatmentoringisabouttheprotg,notthementor.Confidencesmustalwaysbemaintainedtoensuretrust.Thementorneedstosetandenforceboundariesintherelationshiptoensureprofessionalism.Amentormustknowhisorherlimitationswhengivingguidanceoradvice.Promisesmadebythementorneedtobekeptiftherelationshipistolast.Duringthementoring,theseniorofficermustuseeffectivelisteningandshouldrefrainfromsimplytellingtheprotgwhattodoinordertodevelopproblem-solvingskillsintheprotg.Potentialmentorsmustbeapproachableifjuniorofficersaretofeelcomfortableinseekingthemoutasmentors.Feedbackneedstobespecificand,whennecessary,includeconstructivecriticism.Mentorsmustunderstandthemselvesanddevelopamentoringstylethatisauthenticandconsistentwithwhotheyreallyare.Finally,mentorsneedtodedicatethemselvestocontinuouslearning,technically,tactically,andasmentors.Itismysincerehopethat,byconsideringthesekeypoints,mentorswillbebetterpreparedtofocusontheindividualizedneedsoftheirrespectiveprotgs,therealgoalofanysuccessfulmentoringrelationship.TenSimpleRulesforProtgsWhiletheskillsofthementorarecriticaltomentoring,theprotgalsosharesresponsibilityforensuringthattherelationshipissuccessful.Unfortunately,somenewprotgsmaynotbeawareoftheirresponsibilitiesasamentoringpartner.Hence,thefollowing10rulesforprotgsarepresentedtohelpthemrealizethegreatestbenefitfromtheirmentoringrelationships. PROTGRULE#1CherishyourMentorsTimeItisimportantthatasaprotgyoutrulyvalueyourmentorstime.Yourmentorissettingasidetimeexclusivelyforyourdevelopmentandgrowth.Consequently,youoweittoyourmentoringpartnertoalwaysbeontimeandfullypreparedformeetingswithhimorher.Ifheorsheassignsyouhomeworktodo,suchasreadingassignments,thenyoumustbesuretocompleteyourtasksbeforetheyaredue.Tonotdosomaybeviewedbyyourmentorasacavalierattitudeandwilllikelyhurttherelationship.Yourmentormayreasonablyconcludethat,ifyoudonottakeyourprofessionaldevelopmentseriously,whyshouldheorshe? PROTGRULE#2AlwaysMaintainConfidencesOneofthecornerstonesofasuccessfulmentoringrelationshipistrust.Itiswithinasaferelationshipthattheprotgisabletofreelyaskquestions,expressconcerns,andtakeriskswithoutthefearofnegativeconsequences.Oneofthemosteffectivewaysformentorstoimpartwisdomisbysharingpersonalchallengesandsetbacksandwhatlessonsthementorhaslearnedfromthem.Sinceitisunlikelythatanyonewouldwanttheirmistakeswidelyadvertisedtoothers,thesameisprobablytrueforthosewhomentor.Therefore,whenyourmentortellsyouthingsinconfidence,youmusthonorthatspecialtrustandnotsharetheinformationoutsideofthementoringrelationship.Simplyput,genuinetrustonlydevelopsovertimeandcanbedestroyedinaninstant.Consequently,itisimperativethatyoualwaysmaintainconfidences.MentorsandProtgs:SimpleRulesforSuccess

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JulySeptember200655 PROTGRULE#3LearnfromYourMistakesGoodmentorsdonotexpectperfectioninthosetheymentorandfullyexpecttheirprotgstomakemistakes.Interestinglyenough,itisusuallyfromourmistakesandfailuresthatwelearnourgreatestlessons.So,bewillingtotakerisksandtrynewthings;itisessentialforyourgrowthasanofficerandaleader.Also,acceptthatyouwill,fromtimetotime,makemistakes.Ifandwhenyoudofallshort,reflectuponthosesetbacksandgleanwhateverlessonthatliesattheheartofyourfailure.Now,whileamentorshouldbetolerantofmistakes,aneffectivementorwillnottolerateaprotgrepeatingthesamemistake.Suchbehaviordoesnotshowpersonalgrowthandmaturity.Besuretolearnfromyourmistakesandnotrepeatthem. PROTGRULE#4BeReceptivetoFeedbackOneofthemosteffectivetoolsinsuccessfulmentoringistheuseoffeedback.Oftenfeedbackispositiveandencouraging.Itcanbejustwhataprotgneedsduringtryingordifficulttimes.But,sometimesthefeedbackismorecritical.Thekeytobeingagoodprotgistoacceptthegoodwiththebad.Ifyouexpectyourmentortoonlyshoweryouwithpraise,youwillbemissingthefullbreathanddepthofmentoring.So,keepyouregoincheckandlistenobjectivelytoanyconstructivefeedbackfromyourmentor.Whileitmightnotseemsoatthetime,suchwisdomandinsightcanoftenbesomeofthemostimportantmentoringthatyouwillreceive. PROTGRULE#5KeepYourPromisesMentoringrequiresyourmostvaluableresource,namelyyourtime.Beforeenteringintoamentoringpartnership,besurethatyoucandedicatetimetosuchanendeavor.Ifyoucannotsetasidethetime,thenIsuggestthatyoudonotenterintoamentoringpartnership.Thatbeingsaid,ifyoudocommittoamentoringrelationship,youmustfollowthroughwithyourpromises.Forexample,ifyouagreetoweeklymeetingswithyourmentor,youmustkeeptheseappointments.IfyoupromisetoprovideyourOERSupportFormtoyourmentor,thendoitpromptly.Brokenappointmentsandunfilledpromiseswillclearlydemonstratethatyouarenotseriousaboutbeingmentored.Toavoidthiscommonpitfall,keepyourpromisestoyourmentor.Bydoingthis,youwillalsobekeepinganimportantpromisetoyourself,namelytomakethemostofbeingmentored.

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56ArmyMedicalDepartmentJournal PROTGRULE#6GenuinelyConsiderAdviceGivenOneofthemostvaluablebenefitsofmentoringistheopportunitytofreelyaskforadvice.Guidancecanrangefromthetechnicalaspectsofgettingthejobdone,tosuggestionsaboutchoosinganassignment,orwhetherornottocontinuepursuingamilitarycareer.Asacourtesytoyourmentor,youshouldthoughtfullyconsideranyadvicethatisgiven.Now,thisdoesnotmeanthatyousimplydowhateverthementorsuggests.Rather,itisbesttolistentothesuggestionsgivenandthencarefullydecidewhetherornottofollowtheadvice.Aself-confidentmentordoesnotexpecttheprotgtofolloweverybitofadvice.However,ifyouareconstantlyseekingadvicefromyourmentor,butneverfollowhisorherguidance,thenchancesarethatyourmentorwillstopgivingyouanyadvice.(ThishappenedtomewithonejuniorofficerIwasmentoring.Thisrecurringbehaviorultimatelyendedthementoringrelationship.)So,genuinelyconsideranyguidancethatisgivenand,ifyouchoosenottofollowit,explaintoyourmentorwhyyouelectednottofollowtheadvice.Thiskindofopendialoguewillhelptoensurethatyourmentordoesnotfeelthatheorsheiswastinghisorhertime. PROTGRULE#7ClarifyYourExpectationsSincethefocusofthementoringisontheneedsoftheprotg,itisimportantthatyouclarifyyourexpectationstoyourmentor.Forexample,ifyouareonlylookingforsomeonetobearolemodelorasoundingboard,youshouldmakethatclear.Ifyouarelookingforamorein-depthrelationship,youshouldalsospellthisout.Whatyourequirefromthementoringrelationshipwilldeterminethedegreeofyourmentorsinvolvement.Therefore,openandhonestcommunicationiscriticaltoensurethatyouractualneedsarebeingmet.Clarifyingyourexpectationswillmakeiteasierforyoutogaugeyourprogressanddeterminewhetherornotyourmentoringgoalsarebeingfulfilled. PROTGRULE#8RespecttheChainofCommandItisimportanttorememberthatmentoringisnotawaytobypassorinterferewiththechainofcommand.Forexample,youshouldneveruseyourmentortogooveryourbosssheadinordertoreverseadecisionwithwhichyoudisagree.Also,refrainfromaskingyourmentortointerveneinmattersbetweenyouandyourrater.Now,thatisnottosaythatyoucannotaskyourmentorforadviceonhowtotalkwithyourraterorresolveanydisagreements.However,yourmentorshouldnotbeinsertinghimorherselfbetweenyouandyourrater.Anysuchinterferencewouldbehighlyinappropriate.So,alwaysremembertorespectyourchainofcommandanddonotuseyourmentoringrelationshipasashortcutaroundit.MentorsandProtgs:SimpleRulesforSuccess

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JulySeptember200657 PROTGRULE#9BringMoreThanJustYourProblemsOvertheyears,Ihavehadprotgscometomewithproblemsandtheywantedmetosimplytellthemwhattodo(Muchtotheirchagrin,rarelydidIjustgivethemtheanswer!).Sincetheultimategoalofmentoringisthedevelopmentofaself-reliantofficerthatcanindependentlymaketimelyandeffectivedecisions,itisimportantforprotgstodeveloptheirownskillsinproblem-solving.Tohelpachievethisgoal,itisdesirablethat,alongwiththegivenproblemthatneedssolving,youcomearmedwithpotentialsolutions.Whilethismayseemlikemoreworkforyouandyourproposedcoursesofactionmayultimatelyprovetobeinappropriate,thissortofexercisewillhelpyouinthelongrunbyimprovingyourabilitytosolveyourownproblems. PROTGRULE#10CommittoContinuousLearningWhateveryourmilitaryspecialty,youshouldbededicatedtomaintainingyourtechnicalcompetencyandstayingabreastofadvancementsinyourfield.Thisisalsotruefortheleadershipandmentoringskillsrequiredtobeaneffectiveofficer.Awaytodothisistosetasidesomequiettimeforreadingprofessionaljournals,thoserelatingtoyourmilitaryspecialtyandthoserelatedtoofficership.Whileyouareprobablyawareofprofessionalreferencesforyourtechnicaldiscipline,youmaynotbeawareofjournalsforleaderdevelopment.ArmyjournalsthatmaybeofhelpareMilitaryReview,publishedbytheUSArmyCombinedArmsCenteratFortLeavenworth,KS,andParameters,fromtheUSArmyWarCollegeatCarlisleBarracks,PA.Bothinstitutionssupportwebsitesfromwheretheirarticlesmaybedownloaded:MilitaryReviewhttp://usacac.leavenworth.army.mil/CAC/milreview/index.aspParametershttp://carlisle-www.army.mil/usawc/Parameters/Thispublication,theAMEDDJournal,isanothervenueforstayingcurrentindevelopmentswiththeArmyMedicalDepartment.Finally,ifyouareseriousaboutgrowingasaprotg,youshouldavidlyreadallthatyoucanonthesubjectofmentoring.Foralistofsuggestedreadingmaterial,IhaveincludedabibliographyofbooksandarticlesthatIhavefoundhelpfulinmypersonalgrowthasamentor.SUMMARYThekeypointsoftheprotgsrulesincluderememberingthattheprotgmustcherishthementorstimeandmakethemostofit.Mutualtrustisdependentuponmaintainingconfidences.AprotgmustlearnfromhisorhermistakesifheorsheistogrowasanArmyleader.Beingreceptivetofeedback,bothpositiveandnegative,isessentialtomaximizethementoringexperience.Promisesmadebytheprotgmustbekeptiftherelationshipistolast.Whilenotalladvicemustbefollowed,theprotgshouldgenuinelyconsidertheguidancethatisreceivedand,iftheadviceisrejected,explaintothementorwhyitwasnotfollowed.Clarifyingexpectationswillensurethatthetypeofhelpwantedisprovidedandthatthementoringgoalsareachieved.Protgsmustneverusetheirmentorstobypassthechainofcommandoraskthementortointerveneinissuesbetweentheprotgandhisorherratingchain.Whenbringingproblemstotheirmentors,protgsshouldalsohavepossiblesolutionsinmindtofosterthedevelopmentoftheirownproblem-solvingskills.Finally,thosebeingmentoredmustdedicatethemselvestocontinuouslearning,technically,tactically,andasprotgs.Iofferthesekeypointsinthehopethattheywillassistjuniorofficerstobetterpreparefortheirrolesassuccessfulmentoringpartnersinordertoreapallofthelastingrewardsofbeingmentored.

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58ArmyMedicalDepartmentJournalDalcortCJ.Mentoring:establishingalegacy,shapingthefuture.MilRev.November-December2002;82;No.6:35-39.HendricksHG,HendricksWD.AsIronSharpensIron.Chicago,IL:MoodyPress;1995.HunsingerN.Mentorship:growingcompanygradeofficers.MilRev.September-October2004;84;No.5:78-85.JohnsonW,BandRidleyCR.TheElementsofMentoring.NewYork,NY:PalgraveMacMillian;2004.KemJD.Mentoring:buildingalegacy.MilRev.May-June2003;83;No.3:62-64.KosperGJ,Mentoringinthemilitary:noteverybodygetsit.MilRev.November-December2002;82;No.6:40-44.LaceyK.MakingMentoringHappen.Warriewood,NSW,Australia:BusinessandProfessionalPublishing;2001.MaxwellJC.DevelopingtheLeadersAroundYou.Nashville,TN:NelsonBusiness;1995.MelansonMA,WinsteadAD.officerprofessionaldevelopment:acasestudyinofficermentorship.AMEDDJ.January-March2003:7-10.MurrayM.BeyondtheMythsandMagicofMentoring.SanFrancisco,CA:Jossey-Bass;2001.PeddyS.TheArtofMentoring.Houston,TX:BullionBooks;1998.PeggM.TheArtofMentoring.Gloucester,UK:ForgeHouse;1999.PortnerH.BeingMentored:AGuideforProtgs.ThousandOaks,CA:CorwinPress;2002.SheaGF.MakingtheMostofBeingMentored.MenloPark,CA:CrispLearning;1999.StoddardDA.TheHeartofMentoring.ColoradoSprings,CO:Navpress;2003.WicksRJ.SharingWisdom:ThePracticalArtofGivingandReceivingMentoring.NewYork,NY:CrossroadsPublishing;2000.ZacharyLJ.CreatingaMentoringCulture.SanFrancisco,CA:Jossey-Bass;2005.AUTHOR COLMelansonisChiefoftheHealthPhysicsOffice,WalterReedArmyMedicalCenter,Washington,DC.SUGGESTEDREADING MentorsandProtgs:SimpleRulesforSuccess

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JulySeptember200659INTRODUCTIONIndividualbehavioralpatternsaffecteverymilitaryinteractionandrelationship.Thesepatternshavebeenexaminedempiricallytopredictsuccessamongmilitaryleaders.1SomeresearchershaveassertedthatanunderstandingofonesowninteractionalpatternsaswellasthoseofotherscanbeasignificantassettotheUSmilitaryinthetrainingofcommandpersonnel.2Consequently,severalmentalhealthandorganizationalbehaviormeasureshavebeenusedinmilitarytrainingtoassesspersonaltraitsandinteractionalpatterns.3-6OnesuchmeasurethatiscurrentlybeingusedbyeachbranchoftheDepartmentofDefenseisthePersogenicsPersonalityProfile.7Likemanyoftheothermeasuresmentionedabove,thePersogenicsprofilewasaninstrumentoriginallydevelopedforusewithincivilianbusinessadministrationtrainingwhichhassubsequentlybeenincorporatedasatrainingtoolwithinthemilitary.Inexaminingtheuseofpersonalityand/orinteractionalprofilingsystemsintrainingmilitarypersonnel,theresearchersofthisstudyidentifiedseveralinstanceswherethePersogenicsprofileisused.Forinstance,accordingtoJimBatman,SeniorCorporateTrainerforthePersogenicsCorporationwhoconductsworkshopswithintheDepartmentoftheAirForce,thePersogenicsPersonalityProfileisavaluabletoolthathasbeenwellreceivedandutilized.Trainingsessionshavebeenheldinvarioussectionsincludingpersonnel,engineering,services,hospitalsandclinics,basecommandstaff,andacrossallranks.Hebelievestheprogramhelpsimproveteamrelationships,workplaceskills,peopleskillsingeneral,andconflictresolutionthroughanincreasedunderstandingofindividualstrengthsandweaknesses.Inconductingthisresearch,theauthorswereabletoquicklyidentifytworepresentativesamplesofmilitaryclientswhohaveutilizedthePersogenicsintheirtrainingactivities:COLDavidBird,RandolphAirForceBase,andCOLRichardMihalika,WrightPattersonAirForceBase.Wheninterviewed,COLBirdstatedthathehasbeenawareofthePersogenicssystemfor9yearsandthathehasactivelyusedthesystemforthepast5yearsinhiscapacitiesassquadron,group,andnowwingcommander.HereportsthePersonalProfileandthePersogenicssystemhastakenhimandhiscommandteamstoahigherlevelofteamwork.HeacknowledgesthepastuseoftheMyers-BriggsTypeIndicatorasatooltoidentifyhowhispersonnelscreened,processed,andfilteredinformation,buthereportsthePersogenicssystemissuperiorasitteacheshowtocommunicateandgetapictureoftheoutputkindofbehavioreachindividualdemonstrates.Heviewstheidentificationofindividualstrengthsandweaknessesasagodsend,especiallywhendealingwithpressure,stressand AValidationStudyofaCommonlyUsedMilitaryAssessmentofPersonalityInteractionalPatternsSusanJ.Walley,MSWCOL(Ret)KyleL.Pehrson,MS,USARPatrickT.Panos,PhDABSTRACTMilitaryleadersandtrainersoftenuseassessmentsdevelopedwithinthecivilianbusinesssectorinordertodetermineinteractionalpatternsandpersonalitytraitsthatmayaffecttheoperationaleffectivenessoftheirunit.Unfortunately,validityandreliabilitystudieswiththeseinstrumentsarerarelyconductedtodetermineiftheyareappropriateforusebythemilitary.ThisstudyseekstodetermineifthePersogenicsPersonalityProfile,anassessmentwhichiscurrentlybeingusedbymanymilitarycommanders,isaneffectivemethodofenhancingmissionaccomplishment.Recommendationsforfuturestudiesaremade.

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60ArmyMedicalDepartmentJournaltension(PST).PSTisaparticularinsighttaughtinthetrainingsessionsandidentifiedasbehavioralshiftingorbackupbehaviors.7COLMihalikastatedininterviewthatheutilizesthePersonalProfileandtheNutshellSummary,(abriefprintoutthatcomparestheinteractionalpatternsbetweentwoindividuals)ateachentryinterviewwithincomingofficersandcivilianswhoreportdirectlytohim.Hemakestheprofileavailabletotheminordertohaveitfilterthroughoutthecommand.Althoughheviewstheinstrumentasnobetterorworsethanothers,hetooviewsthePersogenicsPersonalityProfileasastepbeyondtheMyers-Briggsinthatitallowsbetterarticulationofinteractionalpatterns.Heviewstheprofileandimplementationsystemasextremelyusefultoolsinestablishingamoreeffectiveworkenvironment,asitpermitsincreasedunderstandingofcommunicationstyles.HereportsthatthePersogenicssystemhasbecomeapartofthedailylexiconofhisstaff,increasingacceptanceamongdifferingpersonalitystylesandenablingcommunicationwithoutthelevelofoffensepreviouslyseenindailyinteractions.ForCOLMihalika,thePersogenicsProfileimpactsmissionaccomplishmentintwospecificareas.First,itestablishesandreinforcescommunicationasapriorityinmanagementplanning.Second,itassistssubordinatestoadapttothedifferingcommunicationstylesoftheircommanders,anespeciallyvaluablebenefitinthehierarchalsystemofleadershipinthemilitarywheremostpersonnelareindirectsupervision.COLMihalikafindsthepersonalityprofiletobehighlyfunctionalintheseareasofcommunicationItisclear,therefore,thatbecauseofthestronganecdotalsupportfortheiruse,civiliannonclinicalpersonalityassessmentsarebeingusedbymilitaryleadersinanefforttoincreasetheiradministrativeeffectiveness.Further,thereisanassumptiononthepartofthesemilitaryleadersthatthetoolsdevelopedforusewithintheciviliansectorprovideequallyvalidresultswhenusedwithinthemilitary.Unfortunately,thisisanassumptionthathasneverbeentestedwithmanyofthesepersonalityprofilingtools,despitetheircommonuse.Sincemilitaryleadersareusingpersonalityassessmentsdevelopedoutsidethemilitarysetting,theauthorsofthisstudysoughttoexaminetheappropriatenessoftheuseoftheseassessments.Inparticular,theauthorssoughttostudythevalidityofthePersogenicsPersonalityProfile,anassessmentthatwasidentifiedascurrentlyinvogueamongmanymilitaryleaders.Specifically,thisstudyexaminedthePersogenicsprofilewithinthecontextof4fundamentalquestionsthatarisewhenusingsuchassessmentsforthispopulation:1.Isthetestappropriateorsuitableforthemilitarypopulation?2.Whatdoestheassessmentmeasureorwhatpurposewillitserve?3.Isitquicklyadministeredandimmediatelyscored?4.Aretheresultseasilyinterpretedandofbenefittoboththeadministratorandthesubject?Inordertoaddresstheappropriatenessoftheprofileforthemilitarypopulation,theprevalenceof4interpersonalbehavioralpatternsamongmilitaryandcivilianpersonnelwascomparedwiththeprofilepatternsamongthegeneralpopulationandthedifferencesnoted.AnoverviewofthePersogenicsPersonalProfileisgiventoassistthereaderunderstandthedimensionsmeasuredbytheassessmentandstatedpurposesoftheProfile.FundamentalquestionsunansweredbythePersogenicsCorporationregardingthePersonalProfilearealsodiscussed.Anoverviewof4nonpathologicalassessmentinstrumentspreviouslyusedinmilitarystudiesarealsobeexaminedforcomparativepurposes.LITERATUREREVIEWInordertoplacetheuseofthePersogenicsPersonalProfilewithinthemilitaryintocontext,abriefreviewofrelevantliteratureaddressingvariousinstrumentsthathavehistoricallybeenusedinmilitaryleadershipdevelopmentispresented.Myers-BriggsTypeIndicatorAccordingtoCPP,Inc.(formerlyConsultingPsychologistsPress),themostwidelyusedpersonalitytypeassessmentmodelinanonclinicalpopulationistheMyers-BriggsTypeIndicator(MBTI).8This93questioninstrumentconsistsof4perceptionscales,eachrepresentedby2oppositepreferences.TheExtraversion/Introversionscalemeasuresapersonspreferenceforwhereattentionispaid,eithertotheinnerworldortheouterworld.TheSensing/IntuitionscaledescribesthewayapersonacquiresorperceivesAValidationStudyofaCommonlyUsedMilitaryAssessmentofPersonalityInteractionalPatterns

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JulySeptember200661information.TheThinking/Feelingscaledefinesthewayapersonusesinformationtomakejudgmentsordecisions.TheJudgment/Perceptionscaleindicatesthekindofmethodthroughwhichapersonprocessesinformationabouthisorherenvironment,withjudgmental(thinkingorfeeling)orperceptive(sensingorintuition).9TheMyers-Briggsinstrumentisprimarilyconcernedwiththevaluabledifferencesinpeoplethatresultfromwheretheyliketofocustheirattention,thewaytheyliketotakeininformation,thewaytheyliketodecide,andthekindoflifestyletheyadopt9(p4)andisbasedontheworkofCarlJungandhistheoryofpsychologicaltypes.10Campbellstudiedpersonalities,vocationalinterests,values,andrawintelligencescoresofseniormilitaryleadersinasearchtodescribetheirunderlyingpersonalitytraits.3HecomparedArmybrigadiergenerals,high-levelcorporateexecutives,andacontrolgroupsampleofmanagersandtechnicalworkersfromgovernment,education,andpublicserviceorganizations.Hisfindings,basedonMyers-Briggsandotherassessments,ledtothepromotionofwhathecalledanotablepersonalitysyndrometheaggressive-adventurer.3(p167)Thischaracterizationofmilitaryleadersdiscountedthemaspotentialwarmongersunlessaninterveningemphasisoneducationanddemocracywereavailabletomediatethetendencies.Twofindingsofinterestfromthisstudyincludethefactthatnoneofthesamplepopulationsweredistributedevenlyacrossthe16preferences,and2types,Introversion/Sensing/Thinking/JudgingandExtraversion/Sensing/Thinking/Judging,representedmorethan56%ofthebrigadiergeneralsample.Additionally,inCampbellsopinion,ThislackofindividualdifferentiationisoneofthefeaturesthatisabsentfromtheMBTI.3(p157)Inotherwords,thecharacterizationoftopmilitaryleadersasserious,orderly,matter-of-fact,logicalandtake-chargerealistswhoaresteadyinthefaceofprotestordistractiontellssomethingaboutthepsychologicalfeelofthemilitaryenvironment.3(p159)BarberutilizedtheMyers-Briggsinhisstudyof270studentsenteringtheUSArmyWarCollegeinordertoprovideadditionalinsightsintothepsychologicalcharacteristicsofseniormilitaryleaders.2ThemilitarypopulationconsistedprimarilyofArmylieutenantcolonelsandcolonels,althoughsomestudentswerefromothermilitaryservicesandforeigncountriesorciviliangovernmentagencies.Thestudyincludedacontrolgroupfromthegeneralpopulation.BasedontheresultsobtainedusingtheMyers-Briggs,53.5%ofseniormilitaryofficersweredistributedinjust2ofthe4psychologicaltypes,JudgingandThinking.Asignificantdifferencebetweenthecivilianandmilitarypopulationswasfound;leadingBarbertointerpretthefindings,asdidCampbell,3toindicatethatseniormilitaryleadersarecomparativelymoreThinkingandJudgingtypesthanthegeneralpopulation.MurrayandJohnson,usingtheMyers-Briggs,studiedfemaleNavalAcademymidshipmeninanattempttodetermineiftheinstrumentwasausefulpredictorofsubsequentstudentsuccess.1AlthoughtheirstudyfoundtheMyers-BriggsnotespeciallyusefulasatoolforpredictingsuccessamongwomenattheNavalAcademy,1(p893)otherfindingsofthestudyhelpedtoidentifywhichMyers-BriggstypesweremorelikelytosubmitvoluntaryresignationsfromtheNavalAcademy.ThestudyalsorevealedthatwomenattheNavalAcademyhaveonlyslightlyhigherratesofextroversionthanwomenatothercolleges.Theuseofadifferentpersonalityinventorywasrecommendedforfutureresearch.FundamentalInterpersonalRelationsOrientation-BehaviorThe54itemFundamentalInterpersonalRelationsOrientation-Behavior(FIRO-B)instrumentassesseshowpersonalneedsaffectapersonsbehaviortowardsothers.BasedontheinterpersonalbehaviortheoryofWilliamSchultz,11thisthree-dimensionalinstrumentmeasures3basicneeds:Inclusion,thedegreetowhichapersonseekscontactfromothers;Control,theextentofpowerordominionthatapersonseeksanddesiresfromothers;andAffection,theamountofclosenesssoughtordesired.The3basicneedsaredefinedin2dimensions,expressedbehaviorandwantedbehavior.12ShortridgeusedtheFIRO-Binhisstudyof134disabledVietnamveteransattendingpostsecondaryeducationprogramsinordertodeterminedifferencesintheneedsforinclusion,control,andaffectionamongcombatandnoncombatdisabledveterans.6Inthisstudy,disablednoncombatveteranswerefoundto

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62ArmyMedicalDepartmentJournalbebetterequippedtodemonstrateinclusivebehaviorsthandisabledcombatveteransandtoexpressandwantaffectionfromothersmorethanthosedisabledincombat.Althoughexpressedorwantedcontrolbehaviorsdidnotdifferbetweenthetwogroups,itbecameclearthatsoldierswhoweredisabledwhileexperiencingthehorrorsofcombatretreatedfrominterpersonalinvolvementinsocietyingreaternumbersthantheirnoncombatcomrades.Thefindingsofthisstudyhelpedtoidentifyinterpersonaladjustmentdifficultiesexperiencedbycombatveterans.MillonIndexofPersonalityStylesTheMillonIndexPersonalityStyles(MIPS)Revisedinstrument,originallydevelopedbyTheodoreMillonin1994andrevisedin2003,isdescribedasabrief,well-roundedpersonalitymeasureforadultspresentingasnormal13whichconsistsof180true/falsequestions.Itaddresses3keydimensionsofnormalpersonalities:MotivatingStyles,whichassessaperson'semotionalstyleindealingwiththeenvironment,ThinkingStyles,whichexaminesaperson'smodeofcognitiveprocessing,andBehavingStyles,whichassesseshowapersoninterrelateswithothers.BeckmanetalusedtheMIPStoevaluatepersonalitycharacteristicsof72USNavydivers,bothenlistedpersonnel(65)andofficers(7).5Thetop5personalitystylesfoundinthediverswereEnhancing,Modifying,Individulating,Thinking,andControlling.Thestudyauthorsfoundthesetraitsveryadaptivetothedemandsofdivingdutywherethefollowingqualitiesareoftenpresent:independentdecisionmaking,easyadaptationtochangingoperationalneeds,theabilitytosurviveindangeroussituations,andthetendencytoputpersonalsafetyfirstinordertofulfillmissionrequirements.Thefindingsappeartosupportarelationshipbetweenpersonalitystyleandoccupationaltypes.Thisfindingledtheauthorstoproposeconsiderationofpsychometricallysoundpsychologicaltestsinscreeningpersonnelforspecifictypesofmilitaryservice.5(p35)EysenckPersonalityQuestionnaire-RevisedTheEysenckPersonalityQuestionnaire-Revised(EPQ-R)measures3dimensionsofpersonalityandisthemostrecentintheseriesofmeasuresoriginallydevelopedbyHansEysenck,whoinitiallydescribed2maindimensionsoftemperament:neuroticism-stabilityandextraversion-introversion.14Eysenckaddedathirddimension,psychoticism/socialization,afterhedeterminedaneedforathirdcategoryoftemperament.TheprimaryadvanceintherevisionistoincludethenamemodificationofTough-Mindednessinthethirdmajordimension.Thisrevisedscaledealswithnormalbehaviorswhichbecomepathologicalonlyinextremecases.ThetraitsmeasuredareP(PsychoticismorTough-Mindedness),E(Extraversion),N(NeuroticismorEmotionality),andL(Lie).Thequestionnairecontains57items.TheEPQ-RwasusedinastudyconductedbyLeachtodetermineifanyspecificpersonalitytraitspredisposemilitarypersonneltobecapturedandimprisonedduringwar.4Thequestionnaireandotherassessmentswereadministeredto75AirForcecrewmenpriortoanescapeandevasionexercise.Thisprocedurewasperformedinordertoassesswhetherpersonalityfactorscorrelatedwithcaptureandconsequentinternmentasaprisonerofwar.Althoughthevariablesofageorlengthinmilitaryserviceshowednocorrelation,significantlyhighlevelsintheEPQLscalewerefoundinthecapturedcrewmen.AswasthecaseintheproposalofanewpersonalitysyndromebyCampbell3above,Leachidentifiedapossiblecorepersonalityprofilethatexistspriortocaptureandnotedthatthispredispositionmaybemaskedbyamodifiedpostexperienceprofile.4(p80)PersogenicsPersonalProfileThePersogenicsPersonalProfilewasoriginallydevelopedthroughcollaborationbyDrGordonAllportandDrFordCheney.Itcontains24questionsandcanbecompletedinashorttimeperiod,usuallylessthan20minutes.Theprofileforeachindividualparticipantisscoredinlessthan5minutesbyacomputerprogrampriortotraining,inordertoprovideresultsforeachparticipanttousethroughoutthetrainingsessions.Allport,anearlypersonalityresearcher,createdtheMost/Leastfacetsofthepersonalityassessmentmodelthroughhisoriginalworkclassifyingawidevarietyofpersonalitytraits.15Allport'stechniquelistedmultipletraitdescriptiveadjectivesandthenhadparticipantsrateeachadjectiveonthedegreetowhichthewordsappliedmostorleasttothem.DrFordCheneyand11colleaguesthenformedKeystoneResearchLabsin1968andbegantostudypersonalityprofiling,buildingonAllport'spioneeringpersonalityAValidationStudyofaCommonlyUsedMilitaryAssessmentofPersonalityInteractionalPatterns

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JulySeptember200663research.ThegroupalsodeterminedthatthevalidityoftheAllporttechniquecouldbeincreasedbyincludingpredictionsofbehavioron2scales.Thefirstofthese,theAssertivenessScale,measuresthedegreetowhichanindividualiswillingtoexpresshisorherneeds,wants,andopinions.Thesecond,theResponsivenessScalemeasuresthedegreetowhichanindividualiswillingtosharefeelingsorpersonalinformation.16ThebasisofthePersogenicssystemis4differentpersonalitystylesasillustratedinthefigure.Thefirststyle,Dominantsexhibithigh-assertiveandlow-responsivebehaviors.Thismeanstheypossessaprimarilyoutspokennature,butseektomaintaincontroloverthepersonalfeelingsandinformationthattheycommunicatetoothers.Expressivesnaturallyexhibithigh-assertiveandhighresponsivebehaviors.Thismeanstheycommunicateassertively,andaremoreopenintheirgesturesandexpressionsthantheotherstyles.Analyticalsarebynaturelessassertiveandlessresponsiveintheirbehaviorsthantheotherstyles.Thismeanstheyarereservedinthewaytheyexpressthemselvesandthattheyarecontrolledintheiroutwardgesturesandactions.Amiablesarenaturallylow-assertiveandhigh-responsiveintheirbehaviors.Thismeansthattheyarenotforcefulintheircommunication,buttheydooutwardlyshowconcernandunderstandingforothers.Amiablesarepeople-orientedandteam-oriented.Theyareconcernedwiththehappinessandsatisfactionofall.17Everypersonisauniquecombinationofthefourstyles.Thesystemmeasuresforeachpersonwhichoneofthestylesisstrongest;thisiscalledtheirprimarystyle.Thesecondstrongestpersonalitystyleiscalledthensecondarystyle.The2lowestscoringstylesarerelevanttothescoring,buttypicallynotreported.Sinceeverypersonhasatleastsomecomponentofeachstyle,thelowestscoringtworemainavaluablepartoftheassessment.The2highestscoringstylesmakeupapersonalityname,suchasDominant-Expressive.ThePersogenicsCorporationalsoclaimsthatthe4stylesareconsistentlydistributedinthegeneralpopulation,regardlessofnationality,education,gender,orage:approximately12%Dominant,19%Expressive,37%Amiable,and32%Analytical.18(p8)Asmentionedpreviously,thePersogenicsProfileiscurrentlybeingusedwithmilitarypopulations.ItisusefultoreexaminetheaforementionedfundamentalquestionsregardingtheutilityofthePersogenicsPersonalProfile.Namely,hasitbeenshowntobeasrelevantforthemilitarypopulationasthePersogenicsCorporationpurports?Toanswerthisquestion,differencesbetweenthecoreusersoftheinstrument,thebusinesscommunity,andmilitarypopulationsshouldbeexplored,asthePersogenicsCorporationpromotesitselfasimpartialandneutralwithrespecttogender,race,culture,religiousorientation,etc.7Willanassessmentthatmeasuresinteractionalpatternsbasedonthedimensionsofassertivenessandresponsivenessserveausefulfunctionformilitaryleaders,mentalhealthprofessionals,andpersonnelcompletingtheinstrument?Further,willthetimeinvestedinadministeringandscoringtheinstrumentprovidebenefitstotheindividualsoldier,administrator,andoverallmissionofthemilitary?Tobeginthesearchforanswerstothese2finalquestions,theself-reportedaccuracyratesofmilitaryandnonmilitarypopulationswerecomparedanddifferencesbetweentheaccuracyratespurportedbythePersogenicsCorporationwereexamined. IncreasingLevelsofResponsiveness I n c r e a s i n g L e v e l s o f A s s e r t i v e n e s s A NALYTICAL D OMINANT EXPRESSIVE A MIABLE ThePersogenicssystemclassifies4personalitystylesaccordingtotheindividualslevelofresponsiveandassertivebehaviors.

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64ArmyMedicalDepartmentJournalMETHODOLOGYThedesignofthisstudywasasecondaryanalysisofadatabasesetthatcontainsdemographicinformationandcompletedPersonalProfilesfor114militaryand277civiliansubjects.Themedianagesofsubjectsrangedfrom36to45andincluded167malesand224females.RacecategoriesincludedCaucasian,AfricanAmerican,HispanicLatino,NativeAmerican,PacificIslander,andOther.Thesubjectpopulationsincluded114militarypersonneland147civiliansfromRandolphAirForceBase,Texas,69schooldistrictemployeesfromMarysville,Washington,and61personnelfromthepolicedepartmentinAlbany,Oregon.DATAANALYSISTheStatisticalPackageforSocialSciences(SPSS13.0)wasusedtoanalyzethedataprovidedinthedatabase.Thepurposeoftheanalysiswastodeterminethevalidityandreliabilityofstandardizedinterpretationsofpersonalitystylesbyexaminingiftherewasasignificantdifferenceintherateofpersonalitystylesthatoccurinbothmilitaryandcivilianparticipantswithinthisstudy,withthereportedbaselinerateswithinnormativedataprovidedbyPersogenicsCorporation.7Additionalcomparisonsweremadetodeterminethestabilityofbaselineratesofreportedpersonalitystylesofparticipantsandthenormativedataaccordingtogender,race,andage.Finally,acomparisonwasmadebetweenthereportedaccuracyofthepersonalitystylefindingsbyparticipantsinthisstudywiththereportedaccuracyofpersonalitystylesgivenwithinthenormativedata.RESULTSThePersogenicsCorporationwebsite7claimsthattheoccurrenceofeachofthe4personalitystylesisequallyproportional(Dominant=12%;Expressive=19%;Amiable=37%;Analytical=32%)acrossthegeneralpopulationregardlessofdemographicfactors.Inordertodetermineifthemilitarypopulationalsoreflectsthisdistribution,acrosstabulationofgeneralstylewasperformedusingthePearsonChi-SquareGoodnessofFittest.19TabulateddatausedinthiscalculationareshowninTable1.Itwasfoundthattherearestatisticallysignificantdifferences(2=AValidationStudyofaCommonlyUsedMilitaryAssessmentofPersonalityInteractionalPatternsTable1.TabulateddatausedinthePearsonChi-SquareGoodnessofFittest18todetermineifthemilitarypopulationreflectsthenormaldistributionofpersonalitystyles7StyleCivilian%TotalCountMilitary%TotalCountTotal%TotalCount Count4411.3174.46115.6 DominantExpectedCount431861Count9825.14010.313835.4ExpressiveExpectedCount97.340.7138 Count7619.53910.011529.5AmiableExpectedCount81.133.9115 Count5714.61922.47619.5AnalyticalExpectedCount53.622.476Count27570.511529.5390100 TotalExpectedCount275115390Chi-square(2)=1.913<0.05

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JulySeptember2006651.913;p<0.05)betweenthebusinesspopulationthatmakeupthePersogenicsnormativedistributionsandthemilitary/civiliansubjectsinourdatabase.Therefore,oursampleappearstohaveauniquedistribution.MilitarySampleResultsPersogenicsCorporationreportednodifferencebetweenthedistributionsofpersonalitystylesbetweenthegendersintheirnormativedistribution.7Acomparisonofthegenderswithinourmilitarysample,usingtheChi-SquareTestofIndependencetest,isshowninTable2.Nostatisticaldifference(X2=3.980,p=.264)wasfoundbetweentheexpectedPersogenicsdistributionandourmilitarysamplebasedupongender.PersogenicsCorporationalsoreportednodifferenceinthenormativedistributionsofstylesduetorace.7Unfortunately,ourmilitarysample(Table3)wastoosmalltomakesuchacomparisonbaseduponspecificracialdifferences.However,itwasofsufficientsizetoallowcomparisonstobemadebetweenCaucasiansandnon-Caucasians,inwhichwefoundasignificantdifferencewithinthemilitarysampleusingtheChi-SquareTestofIndependence.ThefinalcomparisonwithinthemilitarysamplerelatestothePersogenicsreportthattherearenodifferencesbetweenageandpersonalitystyleintheirnormativepopulation.7AcomparisonofproportionofstylesreportedbythePersogenicsCorporationandagewithinourmilitarysampleisshowninTable4.Nostatisticaldifference(X2(12,N=112)=15.341,p=.223)wasfoundbetweentheexpectedPersogenicsdistributionandourmilitarysamplebaseduponage.CivilianSampleResultsAcomparisonofthegenderswithinourciviliansample,usingtheChi-SquareTestofIndependencetest,isshowninTable5.Unlikethefindingsinourmilitarysample,astatisticaldifference(X2=14.793,p<0.05)wasfoundbetweentheexpectedPersogenicsdistributionandourciviliansamplebasedupongender,afindingthatsuggeststhatcivilianpopulationinthestudydiffersfromthenormativePersogenicsbusinesspopulationandourmilitarypopulation.AcomparisonbetweensubjectsbasedonracewasconductedontheciviliansampleusingtheChi-SquareTestofIndependenceandisreportedinTable6.Nostatisticaldifference(X2=12.716,p=.624)wasfoundbetweentheexpectedPersogenicsdistributionandourciviliansamplebaseduponrace.Inaddition,acomparisonbetweenciviliansubjectsandallracecategoriesfoundnosignificantdifferences.Table2.DistributionofpersonalitystylesbygenderwithinthemilitarysampleGeneralStyleFemaleMaleTotal Dominant9716Expressive241640 Amiable152439 Analytical91019 Total5757114 Chi-square(2)(3,N=114)=3.980<0.264 Table3.DistributionofpersonalitystylesbyracewithinthemilitarysampleGeneralStyleCaucasianOtherTotal Dominant033Expressive257 Amiable7411 Analytical404 Total131225 Chi-square(2)(3,N=25)=9.078<0.05 Table4.DistributionofpersonalitystylesbyagegroupwithinthemilitarysampleAgeRange GeneralStyle18-2425-3536-4546-5556-65TotalDominant4442014 Expressive820120040 Amiable515117139Analytical4591019 Total214436101112Chi-square(2)(12,N=112)=15.341078<0.223

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66ArmyMedicalDepartmentJournalAcomparisonbetweensubjectsbasedonagewasconductedontheciviliansampleusingtheChi-SquareTestofIndependencewithinourciviliansampleandisshowninTable7.Nostatisticaldifference(X2=12.353,p=.418)wasfoundbetweentheexpectedPersogenicsdistributionandourciviliansamplebaseduponage.AccuracyResultsClientaccuracyresultsarereportedbythePersogenicsCorporationtofallbetween87%and93%.7ASingleSampletTestcomparedthemeanaccuracyofthesampletothePersogenicsaverage,90%.Asignificantdifferencewasfound(t(375)=-6.342,p<0.05).Thesamplemeanof86.8%wassignificantlysmallerthanthePersogenicsreportedmeanof90%.DISCUSSIONThestudyspositivecorrelatedfindingsregardingthegenderandagesinthemilitarysubjectsandthenormativebusinesspopulationsuggestthatmanysimilaritiesdoexistbetweenthetwopopulationsandthattheprofilewouldberelevantforusewithinmilitarypopulations.Thestatisticaldifference(X2=1.336,p<0.05)notedinthecollapsedracecategoryandthePersogenicsdistributionsuggestthattheinstrumentmaynotbecompletelyneutralregardingrace.However,itshouldbenotedthatinbothciviliancategories(collapsedandwithallracevariables),nosignificantdifferencesbetweentheciviliansampleandtheexpectedPersogenicsdistributionwasfound.Thisfindingthereforesuggeststhattheinstrumentmaynotbevalidwithinthemoreraciallymixedmilitarysetting.Unfortunately,thereiscurrentlyinsufficientdatauponwhichtomakethisdetermination.Therefore,furtherresearchisneededbeforecommandingofficerscanacceptPersogenicsprofilesasaccurate,particularlyamongtheirtroopsbelongingtoaracialminority.ResearchshouldcontinuefocusingAValidationStudyofaCommonlyUsedMilitaryAssessmentofPersonalityInteractionalPatternsTable7.DistributionofpersonalitystylesbyagegroupwithintheciviliansampleAgeRange GeneralStyle18-2425-3536-4546-5556-65TotalDominant4101319046 Expressive9262921287 Amiable5182229478 Analytical4102421160 Total226488907271 Chi-square(2)(12,N=271)=12.353<0.418 Table6.DistributionofpersonalitystylesbyracewithintheciviliansampleRaceClassification GeneralStyleWhiteAfricanAmericanHispanicorLatinoNativeAmericanPacificIslanderOtherTotalDominant351220040 Expressive645731181 Amiable463400356 Analytical321500240 Total1771018516217 Chi-square(2)(15,N=217)=12.716<0.624 Table5.DistributionofpersonalitystylesbygenderwithintheciviliansampleGeneralStyleFemaleMaleTotal Dominant162844 Expressive613596 Amiable542276 Analytical322456 Total163109272 Chi-square(2)(3,N=272)=14.793<0.05

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JulySeptember200667onthevalidityandreliabilityofthisinstrumentandthenonthereplicationandextensionofthefindingsinthisstudywithlargersamplesofmilitaryandcivilianpopulations.Basedontheambiguousresultsofthesmallmilitarysample,furtherstudiesshouldbeconductedwithalargersampletodetermineifthesignificantfindingintheracecategoryissubstantiated.Additionally,thefindingofasignificantdifferencebetweengenderinthecivilianpopulationandthePersogenicsdistributionraisesadditionalconcernsregardingtheneutralityofthetest.Furtherstudiescomparinginteractionalpatternsbetweenofficerandenlistedranksshouldbeconsideredandthepotentialtoconsiderscreeningpersonnelbasedoninteractionalpatternsforcompatibilitywithspecificmilitaryjobsmayalsobeafutureconsideration.StudiestoassessdirectandtangiblebenefitstomilitarypersonnelwillbenecessaryinthefuturetoassesstheimpactofthePersonalProfileandthePersogenicssystemintheareasofinteractionaldynamics,productivity,communication,andmissionaccomplishment.BasedontheviewsofmilitaryleadersalreadyusingthePersogenicssystemandrecommendationsfromcitedstudies,nonclinicalpersonalityassessmentisadesiredtoolthatfulfillsacommandneed.Therefore,carefulresearchmustbeconductedtoensurethatthemilitaryleaderswhousepersonalityprofilingreceiveaccurateandreliableinformationthatisappropriateforuseinthemilitary.REFERENCES 1.MurrayKM,JohnsonWB.PersonalitytypeandsuccessamongfemaleNavalAcademymidshipmen.MilMed.2001;166:889-893.2.BarberHF.Somepersonalitycharacteristicsofseniormilitaryofficers.In:ClarkKE,ClarkMB,eds.MeasuresofLeadership.WestOrange,NJ:LeadershipLibraryofAmerica;1990:441-448.3.CampbellDP.Thepsychologicaltestprofilesofbrigadiergenerals:warmongersordecisivewarriors?In:LubinskiDJ,DawisRV,eds.AssessingIndividualDifferencesinHumanBehavior:NewConcepts,Methods,andFindings.PaloAlto,CA:ConsultingPsychologistsPress;1995:145-175.4.LeachJ.Personalityprofilesofprisonersofwarandevaders.MilPsychol.2002;14;No.1:73-81.5.BeckmanTJ,LallR,JohnsonWB.SalientpersonalitycharacteristicsamongNavydivers.MilMed.1996;161:717-719.6.ShortridgeJL.TheutilizationoftheFIRO-BforthecomparisonofselecteddifferencesamongdisabledVietnamcombatandnon-combatveterans[dissertation].DissertationAbstractsInternational,1981;41(8-A):3,381.7.PersogenicsCorp.Thefoundationsofpersonalityprofiling.Availableat:http://web.archive.org/web/20041028114121/http://www.persogenics.com/mainpage.jsp?page=site/About/Validity.htm.AccessedOctober10,2003.8.Briggs-MyersI,Briggs,KC.Myers-BriggsTypeIndicator(MBTI).Availableat:http://www.cpp.com/products/mbti/index.asp.AccessedAugust3,2004.9.MyersIB.Introductiontotype:ADescriptionoftheTheoryandApplicationsoftheMyers-BriggsTypeIndicator.PaloAlto,CA:ConsultingPsychologistsPress;1990.10.JungCG.Psychologicaltypes.In:HullRFC,trans-ed.TheCollectedWorksofC.G.Jung.Vol6.Princeton,NJ:PrincetonUniversityPress;1976.11.SchultzW.FIRO:AThree-DimensionalTheoryofInterpersonalBehavior.NewYork,NY:Holt,Rinehart&Winston;1958.12.CPP,Inc.FIRO-B:the15minutetoolforimprovingorganizationalrelationshipsandindividualeffectiveness.Availableat:http://www.cpp.com/products/firo-b/index.asp.AccessedJuly6,2004.13.PearsonAssessments.MIPSrevised(MillonTMindexofpersonalitystyles-revised).Availableat:http://www.pearsonassessments.com/tests/millon.htm.AccessedAugust3,2004.14.EysenckHJ.TheStructureofHumanPersonality.NewYork,NY:Willey;1960.15.AllportGW.Personality;APsychologicalInterpretation.NewYork,NY:H.HoltandCompany;1937.16.CheneyMD.LearningPatternsofInteraction.Provo,UT:Persogenics,LLC;2003.17.CheneyMD.DealingWithPeople.Provo,UT:Persogenics,LLC;2000.

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68ArmyMedicalDepartmentJournal18.CheneyMD.PersonalProfile.Provo,UT:Persogenics,LLC;2000.19.BloomM,FischerJ,OrmeJG.EvaluatingPractice.NeedhamHeights,MA:Viacom;1999.AUTHORS SusanWalleyiscurrentlyaclinicalsocialworkerattheUtahStatePsychiatricHospitalinProvo,Utah.Whenthisarticlewaswritten,shewasagraduatestudentintheSchoolofSocialWork,BrighamYoungUniversity,Provo,Utah.COL(Ret)PehrsonisaprofessorattheSchoolofSocialWork,BrighamYoungUniversity,Provo,Utah.Dr.PanosisanassociateprofessorattheSchoolofSocialWork,BrighamYoungUniversity,Provo,Utah.AValidationStudyofaCommonlyUsedMilitaryAssessmentofPersonalityInteractionalPatterns TheUSArmyMedicalDepartmentCenterandSchool,FortSamHouston,Texas

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