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.

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Digital Military Collection

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JanuaryMarch2008Perspective1MGRussellJ.CzerwTheMoralImperative:ReflectingBackandLookingForward5BGMichaelS.TuckerTheComprehensiveCarePlan:BuildingtheStrengthtoDoWellTomorrow8LTC(P)MarieA.Dominguez,MC,USAEnsuringExcellence:TheWarriorTransitionUnitStaffTrainingProgram17SherriA.Emerich,MATheRoleofOccupationalTherapyinWarriorTransitionUnits21COLMaryW.Erickson,SP,USAWhatCanSocialWorkersDoforWarriorsinTransition?25RenJ.Robichaux,PhD,LCSW;COLNicoleM.Keesee,MS,USAFacilitiesMaintenance:UncoveringtheBlackHole27MAJRickySmith,USARMedicalCareforArmyReserveandNationalGuardSoldiers32intheGlobalWaronTerrorCOLSusanDurham,AN,USA;COLAnneBauer,AN,USATheBrookeArmyMedicalCenterExperiencewitha35FocusedMedicationReconciliationProgramCPTJesseW.Neeley,MC,USA;SaraJ.Pastoor,MD,MHATheEnhancedReintegrationActionPlan:TheMadiganExperience38LTCKarlBolton,MS,USA;etalOfferingHopeforourWoundedWarriors:45AnOverviewoftheWomackArmyMedicalCenterPainMedicineClinicMAJThomasWeber,MC,USA;MAJAnthonyDragovich,MC,USAALSOINTHISISSUETheSilentKiller:HyperventilationintheBrainInjured50LTC(P)LorneH.Blackbourne,MC,USA;etalJosephLister,NoncompressibleArterialHemorrhage,andthe56NextGenerationofTourniquets?LTC(P)LorneH.Blackbourne,MC,USA;etalMaximizingPatientThermoregulationinUSArmyForwardSurgicalTeams60LTC(P)LorneH.Blackbourne,MC,USA;etalDefiningCombatDamageControlSurgery67LTC(P)LorneH.Blackbourne,MC,USA WarriorsinTransitionhealingwithdignityanddetermination

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LTGEricB.SchoomakerTheSurgeonGeneral Commander,USArmyMedicalCommandMGRussellJ.CzerwCommandingGeneral USArmyMedicalDepartmentCenterandSchool JanuaryMarch2008 TheArmyMedicalDepartmentCenter&School PB8-08-1/2/3 0801501 GEORGEW.CASEY,JR 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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JanuaryMarch20081AmajorshortcominginthemilitarysapproachincaringforourcriticallyillorwoundedWarriors,resultingfromtheGlobalWaronTerror,wasthelackofanestablishedandsupportedorganizationalstructureensuringeachWarriorisaffordedthebestpossibleopportunitytocompletetheirmission:tohealandprosperinhisorherlife.Fortunately,aprovencharacteristicoftheUSmilitaryistheabilitytoquicklyandefficientlyorganize,mobilize,andattackaproblemintimesofcrisis.Thatstrengthbecameamajorfactorinaddressingthisneed.ThefocusofthisissueoftheArmyMedicalDepartmentJournalistheArmysmultidimensionalresponsetoourobligationtothoseleastabletospeakforthemselvesourWarriorswhohavepaidamajorpricefortheirdedicationandselflessserviceindefenseoffreedomandhumandignity.AsBGMichaelTuckerdiscussesinhisexcellentintroductoryarticle,evenasimmediatecorrectionsweremadetothemoreobviousproblems,DoDrapidlyputintomotionamuchlargerandmorecomplexeffort.ThisundertakinghadtoencompasseveryaspectofcareforthoseWarriorswhoseneedsareextensive,complex,andlongterm.FromhisperspectiveasthefirstAssistantSurgeonGeneralforWarriorCareandTransition,BGTuckerdescribesthereorientationoftheArmysunderstandingofthedynamicsofrecoverytotheperspectiveoftheWarriorinTransition.Noconsiderationremainedunaddressed:physicalenvironment,conveniences,Familyparticipation,treatment,rehabilitation,lifeskills,andmuchmore.AnArmywidetemplatewascreated;requirements,doctrine,andproceduresestablished;resourceneedsidentifiedandfulfilled;andtrainingdevelopedanddelivered.Althoughtheresultstodatehavebeenimpressive,asBGTuckerpointsout,thereisstillmuchtobedoneasthereisalwaysroomforimprovement.Hefinisheshisarticlewithdescriptionsoftheongoingproactiveeffortsandinteragencyinitiativesacrossbothmilitarymedicineandexternalresources.TheWarriorTransitionUnit(WTU)isthefoundationoftheArmyseffortstoaddresstheneedsofthoseSoldiers.LTC(P)MarieDominguezpresentsathoroughdescriptionoftheorganization,staffing,philosophy,andworkingrelationshipsoftheWTU.HerarticledetailstheproceduresinvolvedintheevaluationofaWarriorinTransition(WT)uponarrivalattheWTU,thephasesoftherehabilitationprocessasheorsheprogressestowardtheultimategoals,whethertheyinvolvecontinuedmilitaryserviceoranewstartinthecivilianworld.TheroadmapfortheSoldiersjourneythroughtherehabilitationprocessistheComprehensiveCarePlan,theoverall,personalizedschemecreatedbytheWTandtheWTUcadrewhichdefinesallaspectsoftheWarriorsactivitiesintheWTU.LTC(P)DominguezsarticleprovidesanexcellentinsightintothethoroughnessandattentiontodetailinvestedinthedevelopmentandplanningoftheWTUmodelandtheCarePlan,andthecommitmentbyallofthededicatedprofessionalsinvolvedintherehabilitationprocess.SuccessfulrecoveryandrehabilitationofWTsundertheArmyMedicalActionPlanisdirectlydependentontheeffectivenessoftheWTU,which,byextension,meanstheeffectivenessofthestaffinperformingtheirroles.AsplanninganddevelopmentoftheWTUstructureevolved,therequirementforstandardizedtrainingwasformalizedanddelegated.Inherarticle,SherriEmerichdescribestheArmyMedicalDepartmentCenterandSchoolssuperbresponsetothisextremelyimportanttasking.InaremarkablePerspectiveMajorGeneralRussellJ.Czerw

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2www.cs.amedd.army.mil/references_publications.aspxeffortbytheAcademyofHealthSciences(AHS),theimmediateneedwasfilledinaveryshorttimewith3comprehensivedistributedlearningWTUorientationcourses.ThetrainingexpertsthenquicklyturnedtheirattentiontothedevelopmentofaresidentcoursetoensurethattheprincipalcadresoftheWTUsareaswellpreparedfortheirresponsibilitiesaspossible.Also,toaddresstrainingrequirementsbeforethefirstresidentcourseconvenesinOctober2008,theAHSbuiltanddeliveredasuiteofcoursestotheWTUsfortheirlocaltrainingpurposes.TheresponsebytheAHSisyetanotherexampleoftheteamworkandmobilizationofresourcestoaddressacriticalneedthathaslongbeenthehallmarkofArmymedicine.AsdescribedinanarticleinanearlierissueoftheAMEDDJournal,*occupationaltherapyhaslongbeenarecognizedandrespectedpartoftheUSmilitarytreatmentregimenforrecoveringWarriors.Therefore,itisnosurprisethatoccupationaltherapy(OT)isanintegralcomponentoftherehabilitativeresourcesoftheWTU.COLMaryEricksonsarticleisadetaileddescriptionofthegoalsandconsiderationsdrivingtheOTroleintheWTU,andthevariousaspectsoftheprofessionalandlifeskillsandattitudesaddressedbyOTspecialistswhoworkwiththeWTs.COLEricksonmakesitveryclearhowoccupationaltherapyissuchavitalelementoftherehabilitationprocess.Indeed,restorationoftheSoldiersconfidenceandcompetenceiscriticalforhimorhertoregaintheindependencewhichisabsolutelyessentialforaproductiveandfulfillinglifeinanyenvironment.Ourdedicatedoccupationaltherapyprofessionalsworkveryhardtomakethishappen.WhereastheoccupationaltherapistsfocusisontheWTsinnateskills,abilities,andintereststorestoreself-confidenceandapositiveattitudeabouttheirowncapabilities,thesocialworkersroleistoassisttheWTinhisorherreintegrationintotheenvironmentsurroundingthem.Intheirsuccinct,well-presentedarticle,DrRenRobichauxandCOLNicoleKeeseedescribethesocialworkersapproachtotheWTsrecoveryprocess,andthecontributionsmadeintheoverallrehabilitationprogram.Itisextremelyimpor-tantthatthesocialworkersinsightsandperspectivesareincludedindevelopmentoftheWTsCompre-hensiveCarePlan.AlthoughtheimportanceofhealingtheWTsbodyandrestoringhisorherpsycheandsocialskillsisobvious,itisequallyasimportanttoaccomplishthatwithaviewtowardthecommunityoutsideoftheisolation(andcomfort)oftheWTUsfacilities,staff,andfellowWTs.ThisiswhythesocialworkersearlyinvolvementineachWTsevaluationandCarePlandevelopmentisvitaltohisorherfuture,nomatterthepathfollowedafterleavingtheWTU.Manyfactorscontributetoanindividualsoverallattitudeandopinionofself-worth.Thisbecomesespeciallyimportantwhentheindividualisinasituationwhereheorshehasverylittlecontroloverthesurroundingenvironment,asisthecaseofamilitarymemberrecoveringfromseriousinjuryordisease.Therefore,itfollowsthatthephysicalenvironmentwithinwhichourWTsliveandworkisanextremelyimportantfactorintheirrecovery.ThispriorityhasbeencommunicatedacrosstheArmy.CommandersofinstallationsandmedicalfacilitieshavecommittedtremendoustimeandresourcestoensurethatrecoveringSoldiersarehousedandtreatedinthebestenvironmentwecanoffer.MAJRickySmithstimelyarticleaddressesfacilitymaintenancefromthecommandersperspective.Hecallsuponhismanyyearsofexperiencetoprovideinsightsforresponsibleofficerswhomaybeunfamiliarwiththeinnerworkingsofmaintenancemanagementofbuildingsandotherfacilitycomponents.Hisinformationandrecommendationsshouldbeextremelyhelpfulineffortstoensureourmedicalfacilities,nomatterthesizeandcomplexity,remainsafe,clean,functional,andaestheticallyacceptable.ThisisimportantnotonlytoourWTs,buttoourstaffmembersandallotherusersofourfacilities.Asweallknow,theGlobalWaronTerrorinvolveslargenumbersofactivatedArmyReserveandNationalGuardSoldiers.Manyofthemhavereturnedfromcombattheaterswithseriousinjuriesorlingeringeffectsfromdiseaseorpsychologicalstress.Othersmaybeinjuredorbecomesickwhileonactiveduty,butnotmobilizedtoacombattheater.Ineithercase,thereadinessoftheirunitsforfutureactivationsanddeploymentsisdirectlyaffectedbythephysicalreadinessofeverymember.Intheirinformativearticle,COLSusanDurhamandCOLAnneBauerdescribethe2ArmyprogramswhichwereestablishedtosupportthereadinesspostureoftheReserveandNationalGuardunitsbyallowingtheirmembersPerspective *NewtonS.Thegrowthoftheprofessionofoccupationaltherapy.ArmyMedDeptJ.January-March2007:51-58.

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JanuaryMarch20083THEARMYMEDICALDEPARTMENTJOURNALaccesstomilitarymedicalcarewhiledeactivated.TheMedicalRetentionProcessing2andtheActiveDutyMedicalExtensionprogramsarevehiclesbywhichReservistsandNationalGuardSoldiersmayapplyforactivedutystatusinordertoreceivethemedicalcarenecessarytoreturnthemtoretentionstatusandbacktodutywiththeirrespectiveunitsassoonaspossible.TheArmyReserveandNationalGuardareincreasinglyimportantcomponentstothedefenseoftheUnitedStates,andthereforethehealth,welfare,andreadinessoftheirSoldiersatalltimesisamajorconcern.Theseprogramsareimportanttoolsinmaintainingthepersonnelreadinessofthesecriticalresources.AsawoundedorseriouslyillSoldiermovesfromthebattlefieldthroughthemedicalcareandsupportsystem,heorshereceivescarefordifferentconditionsfrommultipleprovidersatdifferentlocations.Therefore,itisnotuncommonforaWarriortoarriveattheWTUwithastockofsurplusmedications,mostofwhicharenolongerrequiredfortheconditions,orwhichhadbeenreplacedintheWarriorsmedicationplanbyotherprescriptions.CPTJesseNeeleyandDrSaraPastoorhavecontributedanimportantarticlewhichgivesusaninsightintothescopeofthisproblem.TheirdescriptionofthemedicationreconciliationprogramimplementedwithintheBrookeArmyMedicalCentersWarriorTransitionBattalionhighlightsasituationwhichexistsforeveryWTUintheArmy.TheimportanceofgainingcontroloverthemedicationsituationandplanfortheindividualWTcannotbeoveremphasized.AsCPTNeeleyandDrPastoorclearlydemonstrate,medicationreconciliationisvitaltothehealthandsafetyofboththeWarriorandtheFamilyastheyprogressalongtheextendedroadtorecovery.BeforetheimplementationoftheArmyMedicalActionPlaninJune2007,theArmysmedicaltreatmentfacilitiesandinstallationsdevelopedvariousprogramsandorganizationalstructuresatthelocalleveltoassistWarriorsinTransitionwiththeirtreatmentandrecovery.Intheirarticle,LTCKarlBoltonandhisteamdescribeoneexcellentexampleofinitiative,creativethinking,andcooperationdevel-opedattheMadiganArmyMedicalCenterandFortLewis.TheReintegrationActionPlan(RAP)wasdevelopedtoassistWarriorsintheidentificationandpursuitoftheirgoals,aswellastomanagetheresourcesavailabletothem.ThisprogramwasinitiatedinJanuary2007andwasofmajorassistanceinorganizingandfocusingtheeffortsofboththeWarriorsundertreatmentandtheattendingstaff.ThetruemeasureofsuccessoftheRAPisthefactthatitwasupgradedandsmoothlyincorporatedintotheArmyMedicalPlanstructureinthesummerof2007astheEnhancedReintegrationActionPlan(ERAP).Indeed,asLTCBoltonetaldescribe,theRAPandERAPprovidedtheMadigan/FortLewisteamasignificantheadstartaprovenstructurewithinwhichcaregiverswereexperienced,comfortable,andover-whelminglysuccessful,therebygreatlyassistingtheimplementationoftheWTUandComprehensiveCarePlanattheirinstallation.TheERAPisjustanotherexampleoftheinitiative,creativity,andteamworkdemonstratedbyArmymedicalprofessionalsintheiruntiringeffortstoassistthoseentrustedintotheircare.Unfortunately,oneconditionoftenattendanttorecoveryfromtraumaticinjuriessuchasthosesufferedincombatischronicpain,whichsometimescontinueslongafterrecoveryfromtheprimaryinjury.Intheirexcellent,informativearticle,MAJThomasWeberandMAJAnthonyDragovichdiscussthecharacterofsuchpainandtheproblemsitposesforpractitionerswhoworktomitigateit.Aswouldbeexpected,WarriorsinTransitionpresentapopulationwithasignificantnumberofcomplexpatientswithchronicpainduetodifficult-to-treatconditions.ThearticledescribesthecloseworkingrelationshipbetweentheWomackArmyMedicalCentersstate-of-the-artinterventionalpainclinicandtheWarriorTransitionBattalion,andthevariousapproachestopainmanagementforourWTs.LedbytheWomackandWalterReedArmyMedicalCenters,ArmymedicineiscollaboratingwiththefinestcivilianmedicalresearchandeducationalinstitutionstoaddressthemanydifficultissuesassociatedwiththetreatmentandmanagementofchronicpainforourwoundedandinjuredWarriors.TheseeffortsareespeciallyimportanttothoseprovidingcareandassistancetotheWTs,aschronicpaincanresultindepressionandasenseofhelplessness.Motivationandapositiveoutlookareessentialforasuccessfulrecoveryandtransition.FormanyWTs,painmanagementisthefirststepintheirpersonalComprehensiveCarePlan.AllofthearticlesdiscussedabovefocusonthevitalcareprovidedtoWarriorsatorneartheendofalong

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4www.cs.amedd.army.mil/references_publications.aspxpathoftreatmentthatusuallybeginsonthebattlefield.ThosemultiskilledmedicalprofessionalswhosavethelivesofourwoundedWarriorsonthebattlefieldareonlythefirstofmanywhowillbeinvolvedintheSoldierstreatmentandrecovery,buttheirskillsandjudgmentsmakepossibleeverythingthatfollows.WecloseoutthisissueoftheAMEDDJournalwithfourveryimportantarticlesthataddresssomeofthemostcurrentconceptsandexperiencesintraumaticwoundcare.LTC(P)LorneBlackbourneoftheArmysInstituteofSurgicalResearchandhiscolleagueshavebeenregularcontributorstotheJournal,andonceagaintheirwellwritten,extensivelyresearchedarticlesdemonstratethelevelofprofessionalexpertise,initiative,anddedicationthatisthesignatureofArmymedicinetoday.ThefirstarticleisparticularlyrelevanttotheWarriorinTransitionfocusofthisissue.Traumaticbraininjuryoftenresultsinextendedlong-termcareandrehabilitation.LTC(P)Blackbourneandhisteamdescribethehazardsofhyperventilationtothosewithseverebraininjury,withdetaileddescriptionsofthephysiologyinvolved.Thearticleproposeschangestoprotocolandtheuseofrelativesimpletechnologytomitigateasmuchaspossibletheseriousaftereffectsofthisseriousinjury.ThisarticleismustreadingforthoseinvolvedinprovidingearlystagecaretoourseriouslyinjuredWarriors.Italsoshouldbecarefullyreadbythoseinvolvedintrainingthosecaregivers.Thetourniquetisoneoftheoldestbattlefieldtreatmenttoolsknowntoman.Militarymedicineisalwayslookingtoimproveitseffectiveness,easeofapplication,portability,etc.However,onelimitationisitsutilitytocontrolhemorrhagefromthoseinjuriestobodyareaswhichdonotallowcircumferentialpressure.Thesecondarticlelooksintohistoryanddevelopsaninnovativeadaptationofanoldconcept,usingacommonworkshoptooltodemonstratethepotentialtoachievecompressionwhereastandardtourniquetcannot.Thisisaninterestingandultimatelypracticalapproachtoanage-oldproblem.Ithaslongbeenunderstoodbythoseinvolvedintraumacontrolsurgerythathypothermiaisaconditionthathasadeleteriousaffectonthepatient.Thethirdarticledelvesintothecomplexitiesofhypothermia,examinesstatisticalevidenceofitsimportancetosurvivability,andexploresvarioustechniquesandtechnologiestostabilizepatientcorebodytemperature.ThearticleemphasizestheimportanceofmanaginghypothermiaattheForwardSurgicalTeamlevel,aswellasduringhelicoptertransport.Thisisanimportantlookatasituationthatourcombatdeployedmedicalpersonnelexperienceeveryday.Thelastarticleisaninformativecomparisonofdamagecontrolsurgeryaspracticedinthemilitaryandcivilianenvironments.Civiliandamagecontrolsurgeryisaclearlydefinedprocessthatiswellunderstoodbyallinvolvedinitsapplication.Ontheotherhand,combatdamagecontrolsurgeryisverydifficulttodefineandquantify,primarilyduetothedynamicconditionsofthebattlefield,themultipletransportsrequired,andthevariouslevelsofstabilization,surgery,andcareinvolvedasthepatientismovedthroughincreasinglysophisticatedfacilities.LTC(P)Blackbournesarticleisaclear,wellorganizeddescriptionofthecomplexitiesandconsiderationofdamagecontrolsurgeryaswemustpracticeit,whereverandwheneverourWarriorsserve.Thecoverpictureemphaticallysummarizesthecontentofthisissue.SSGChrisPettawaycanwalkforhimselfina5kilometerwalk/runwithhisphysicaltherapist,MarkHeniser(CenterfortheIntrepid,BrookeArmyMedicalCenter)becausebattlefieldmedicsandsurgeonssavedhislife,dedicatedmedicalcaregiversworkedtohealhiswounds,andWarriorTransitionprofessionalsteamedwithhimashecontinuestodedicatehimselftoaccomplishhismissionToHeal!ThereisnocompromisewhenthewelfareofUSArmySoldiersisconcerned,whetheronthebattlefield,inthelong-termaftermathofseriousinjuryordisease,oranywhereelse.Theyaretheonlyreasonthatwearehere.Perspective

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JanuaryMarch20085Asweapproachedtheone-yearanniversaryoftheWashingtonPostarticleonWalterReed,Iwasaskednumeroustimestoreflectonallthatwehaveaccom-plishedoverthepastyear.Theseaccomplishmentscameaboutthroughacoordinated,compassionate,synchronizedteameffort.Justasittakesmorethanasinglemedic,physician,ornursetohealawounded,ill,orinjuredWarrior,ithasrequiredcontributionsfromseveralArmystaffagencies,aswellasassistancefromotherfederal,state,andprivateagenciestoachievetheprogresswehaveattained.WehavemadetremendousstridesforwardinthecareandtransitionofSoldierswhohavebecomewounded,ill,orinjuredinthelineofduty,butthereisstillmuchworktobedone.First,weasanArmyveryquicklyunderstoodthatthiswasnotamedicalproblemitwasanArmyproblem.Webuiltandrenovatedbarracks,yetwedidnothingfortheMedicalHoldandMedicalHoldoverbarracks;wefixedthatbytakingSoldiersoutofbarracksthatweretheworstonpostandputtingtheminthebestonpost.WecombinedtheseparateandunequallysupportedMedicalHold(ActiveArmy,commandedandcontrolledbytheMedicalCommand)andMedicalHoldover(ReserveComponent,commandedandcontrolledbytheinstallationmanagementcommand)intoasingleWarriorTransitionUnitundertheMedicalCommandandprovideditwithanapprovedTableofDistributionandAllowances.*Wherewehadlessthan400untrainedcadremembers,wenowhave2463trainedandcertifiedcadreandstaff.Wehavehiredanadditional26doctors,anadditional157nursecasemanagers,72socialworkers,7occupationaltherapists,and13occupationaltherapytechnicians.Weresistedacultureofhavesandhave-notsbyavoidingtheseparationofcareintocategoriesthatwouldimplyoneSoldierwasmoredeservingthananother(SoldierswithcombatwoundsversusSoldierswithdiseaseornonbattleinjury;seriouslyinjuredorillversusnotseriouslyinjuredorill).WerecognizedthattheSoldierwhosustainedanamputationinatacticalvehicleaccidentintrainingwasjustasdeservingastheSoldierwhosustainedanamputationinavehicleaccidentinIraq,whowasjustasdeservingastheSoldierwhosustainedanamputationinacombatattack.WerecognizedthattheSoldierthatdevelopedanillnessincombatwasnolessdeservingthantheSoldierwhosustainedashrapnelinjury.WerecognizedthatitwasnotjusttheSoldierwhohadsufferedaloss,buttheFamilyaswell,andweimprovedthesupportweprovideFamilies.Wegainedauthorizationtotransportwounded,ill,andinjuredSoldiersandtheirFamiliesingovernmentvehicles.WenowmeetFamilymembersarrivingoninvitationaltravelordersattheairport.WeestablishedSoldierandFamilyAssistanceCenterssoSoldiersandFamiliescangetsupportinasinglelocationwithouthavingtoTheMoralImperative:ReflectingBackandLookingForwardBrigadierGeneralMichaelS.TuckerBGTucker,acareerArmorofficer,istheAssistantSurgeonGeneralforWarriorCareandTransition,USArmyMedicalCommand. *Prescribestheorganizationalstructure,personnelandequipmentauthorizations,andrequirementsofamilitaryunittoperformaspecificmissionforwhichthereisnoappropriatetableoforganizationandequipment.

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6www.cs.amedd.army.mil/references_publications.aspxnegotiateastrangeposttofindadozendifferentplaces.Thesecentersofferone-stopaccesstoessentialservicessuchaspay,legal,healthbenefits,andhousing.Weremovedbureaucraticbarrierstoassigningnonfamilymembersasnonmedicalattendants.WeauthorizedsingleSoldierswithnonmedicalattendantstoliveinfamilyhousing.WeproducedavideotoorientFamilymembersofseverelyinjuredServiceMemberstotheirnewnormal,helpingthemtounderstandthechallengingroadofrecoverythattheyface.WeworkedtoimprovethePhysicalDisabilityEvaluationSystem(PDES)withintheconstraintsofcurrentlaw.WegaveSoldierselectronicaccesstomonitorthestatusoftheirMedicalEvaluationBoardandPhysicalEvaluationBoardthroughtheirArmyKnowledgeOnlineaccounts.WereducedthenumberofformsrequiredforaMedicalEvaluationBoard.WeareconductingatriservicePDESpilotintheNationalCapitolAreathatprovidesforasinglephysicalexamandgivestheSoldierbothVAandArmyratingspriortoseparationfromtheService,allowinghimorhertomoreexpeditiouslyapplyforVAbenefitsandhealthcare.WeimprovedtheratioofPhysicalEvaluationBoardliaisons(PEBLOs)andMedicalEvaluationBoardphysicians.WestandardizedthetrainingforthePEBLOsandcertifiedthem.Wehaverecognizedconcussiveinjuryandposttraumaticstressasparticularchallenges,andhavemadeimprovementsinourculturetowardstheacceptanceoftreatmentformentalhealthdisorderswithoutincurringstigma.WehavebegunbaselinecognitivescreeningofServiceMembersbeforetheydeploytoacombatzone,screenforexposuresandsymptomswhiletheyareinthecombatzone,andscreenforsymptomsuponreturn.Weproducedachain-teach*videoontherecognitionofsymptomsthatcouldbeconsistentwithtraumaticbraininjuryorposttraumaticstressdisorder.WeproducedasecondversiontobeviewedbyFamilymembers.WehaverecognizedthatWarriorsinTransitionhaveamissionToHeal!Andeverythingtheydoduringtheirdutydaymustsupportthatmission.Topromotehealing,wehaverestrictedaccesstoalcohol.WehaverecognizedthatmanyofourWarriorsinTransitionneedmentorshipandguidance,andthereforewearetrainingallofoursquadleaderstobelifecoacheswhowillencouragethemintheaccomplishmentoftheirgoalsandobjectivesastheyprogressthroughtheirpersonalComprehensiveCarePlan.ThePlanrequirestheWarriorinTransitiontospendtheir9-hourdutydaydecisivelyengagedinactivitiesthatpromotetheirhealingmedicalappointments,classes,grouptherapy,therapeuticexercisesandactivities,vocationaltraining,oreducationalactivity.InthiseffortwehavepartneredwithseveralinstitutionsofhigherlearningtoenableWarriorsinTransitiontoachievetheirpersonaleducationgoals.WeprovidedcommanderswiththetoolsrequiredtoaddresstheneedsoftheirWarriorsinTransitionwithanombudsmanandaWoundedSoldierandFamilyHot-Linenumber(1-800-984-8523).Inaddition,weprovidedthecommanderswithtoolsthatwouldenablethemtoseethemselveswithaWarriorTransitionUnitStatusReportandQuarterlyTrainingBrief.Whileitispersonallysatisfyingtoconsiderouraccomplishments,wewillnotcontinuetomoveforwardifwelosesightofwhatwestillmustdo.Wehavemadetremendousprogressinthelastyear,butwecannotrestonourlaurels.Thereisstillmuchtoaccomplish.Wemustcontinuetopushforward.TherearethingsyettobeshapedwithintheArmysbattlespace.WemustcontinuetorefineourmanagementofhighriskWarriorsinTransition,particularlywithrespecttomind-andconsciousness-alteringmedications.WemustcontinuetomakeimprovementsinourculturesothatSoldiersunderstandthattheycanaskforhelpwithoutper-ceiveddetrimenttotheircareer.Wemustcontinuetodevelopdigitalsolutions.Inparticularwemustfullyautomateourprofilesystemtoimprovethecommunicationbetweendoctorsandcommanders.Wemustimprovetheconsistencyofdocumentingalldeployedtraumaticevents,militaryacuteconcussionevaluations,anddeployedhealthcareinthetheaterAHLTAapplication,therebyimprovingourhealthdatarecordforpost-deploymenttreatmentand,ifneeded,forthephysicaldisabilityevaluation.TheMoralImperative:ReflectingBackandLookingForward TheUSmilitaryelectronicmedicalrecord *Chain-teachisamethodofunittraininginwhichdesignatedunitmembersfirstreceivethetraining,afterwhichitistheirresponsibilitytotrainanotherlevelofpersonnel,whointurnwillcontinuetrainingothers.Thetrainingcontinuesinapyramidfashionuntilallpersonnelrequiringsuchtraininghavereceivedit.

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JanuaryMarch20087THEARMYMEDICALDEPARTMENTJOURNALWemustcontinuetorefinethediagnosisandtreatmentofconcussiveinjury(alsocalledmildtraumaticbraininjury)andposttraumaticstressdisorder.WemustcontinuetorefineandfullyimplementourComprehensiveCarePlanpolicy,andreassessourstaffingmodelstoensurewehavetheappropriatestafftoperformtherequiredwork.WemustoptimizeourrelationshipwiththeDepartmentofVeteransAffairs(VA)sothateverySoldiertransitioningoutofthemilitaryisenrolledwiththeVeteransHealthAdministration,and,whereappropriate,hasaprearrangedappointmentwiththeirVAprovider.Inaddition,wemustcooperatewiththeVeteransBenefitsAdministrationtoensureallWarriorsinTransitionsubmittheirapplicationforVAbenefitspriortotheirseparation.WemustcontinueeffortswiththeVAtomodernizeandimprovethephysicaldisabilityevaluationsystem.WestillmustdevelopasingleresourceidentifyingnongovernmentalandveteransserviceorganizationsthatprovidebenefitstoSoldiers.WecontinuetostrugglewiththecoordinationofmatchingorganizationswishingtoofferjobstoVeteranswithSoldierswhowishtointerviewforthosejobs.Whileweremainvigilantinourcause,wewillcontinuetofosterrelationshipswiththeVA,sisterservices,veteransserviceorganizations,andotherintragovernmentagencies.OureffortsattransparencyandkeepingCongressinformedhasforgedanewtrustandconfidencewhichmustbepreserved.Finally,themomentummustbemaintainedand,aswehavefromthebeginning,wemustcontinuetomakedecisionsbasedonwhatbestsupportsthehealingofourWarriorsinTransitionandtheirFamilies.

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8www.cs.amedd.army.mil/references_publications.aspxOVERVIEWTheArmyestablishedtheWarriorTransitionUnits(WTUs)forSoldiersrequiringongoing,time-intensive,medical,surgical,orpsychiatrictreatment.TheWTUsetstheconditionsandestablishesaframeworkforhealingtoenabletheSoldiertoregainfunctionandproductivity.SoldiersassignedorattachedtoaWTUarecalledWarriorsinTransition(WTs),becausetheyareatatransitionpoint;theirliveshavebeenchangedbyinjuryorillnessandtheyareworkingtorecoverandreturntodutyorreturntolifeasavocationallyenabledVeteran.TheCompre-hensiveCarePlanutilizesaholisticapproach;theWTisencouragedtosetgoalsforhealingwithin4lifedomains:physical(body),mental(mind),social(heart),andspiritual(spirit).Theholisticapproachisbasedonthefollowingprinciples:BeresponsibleforonesownfutureGainmorecontroloveroneslifePromotehealthandsenseofwell-beingMaintainapositiveselfidentityShapesatisfyingsocialrelationshipsOvercomesocialandculturalbarriersWhenapersonsbodyormindsuffersillnessorinjury,theheartandspiritareoftenaffected.TofullyimplementaComprehensiveCarePlan,attentionmustbegiventoall4lifedomains.Familymembers,caregivers,andsignificantothersplayanintegralroleinWTrehabilitation;therefore,itisimportanttoencouragetheirparticipationinalllevelsofcare.ForWTswhoaregeographicallyseparatedfromtheirFamilymembersorsignificantothers,thismayinvolvetheinclusionofFamilymembersorsignificantothersinmeetings,useofvideoortelephoneconferencing.Toachievetheprinciplesofholistichealing,itisimperativethatWTsspendtheirdutydaysgainfullyengagedinpurposefulactivitiesthatpromotehealinginall4lifedomains.Topromoteasenseofresponsibilityandcontrol,everyWT(withaidandguidancefromanintegratedWTUteam)willdevelopaComprehensiveCarePlanthataddressesall4lifedomains,andisgoaldirectedandmilestonedriven.Goalsandmilestonesmustbemeasurableandhaveatimelineforattainment.TheWTUtriad(primarycaremanager,nursecasemanager,andsquadleader)andtheWTmustsetatargettransitiondate.TofacilitatetheComprehensiveCarePlan,theWT(withguidanceandencouragementfromtheWTUcadre,clinicalstaff,andsupportstaff)mustdevelopalong-term,weekly,anddailyWTtrainingcalendarthataccountsformedicalappointmentsandotheractivitiesrelatedtohealing.Astandarddutydayis9hours.AllWTsmustspendtheirdutydaydecisivelyengagedinactivitiesdesignedtopromotehealingwhichmayinclude:Medicalandrehabilitationappointments,classes,oractivitiesCognitivelyenhancingactivities(ie,militaryeducationdistancelearningcourses,collegecourses,foreignlanguagestudy)Vocationaltrainingorenhancementprogram(ie,dutyinaunitinamilitaryoccupationalspecialtyforwhichtheWTisqualified,orhopestoqualifyfor,on-the-jobtrainingorinternshipprogramdesignedtocomplementtheWTsvocationalinterestsandfurtherenhancevocationalskills)UponcompletionoftheWTstenureintheWTU,theWTwill:Bephysically,mentally,socially,andspirituallystrengthenedBevocationallyenabledtothemaximumextentpossibleand/orhavelife-careplansinplaceBeequippedwiththetoolstomaintainpersonalandprofessionalrelationshipsBeproudoftheirservicetothenationTheComprehensiveCarePlan:BuildingtheStrengthtoDoWellTomorrowLTC(P)MarieA.Dominguez,MC,USA

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JanuaryMarch20089THETEAMCONCEPTTheWarriorinTransitionisatthecenteroftheComprehensiveCarePlanandisthecentralteammember.EarlyinthedevelopmentoftheWarriorTransitionUnit,thetermtriadofsupportwascoined.TheWTUtriadconsistsoftheWTsprimarycaremanager,nursecasemanager,andsquadleader.Withsupportfromotherkeystaff,theWTUtriadprovidescriticallongitudinalandconceptualintegrationoftheComprehensiveCarePlanandsupportstheWarriorinTransition.Togainsynergyfromtheintegrationofmedicalmanagementandcommandandcontrol,keycadreandsupportstaffmustbealignedintohabitualteamrelationshipsasillustratedintheFigure.Asquadleadershouldinteractwithasinglenursecasemanager(duetoincreasednursecasemanagerstaffingatmedicaltreatmentfacilities,onesquadleadermayneedtointeractwith2nursecasemanagers).Thenursecasemanagerinteractswithoneprimarycaremanager,onesocialworker,andoneoccupationaltherapist.Thecompanycommanderguidesanddirectstheleadership,administrative,andsupportprocesses.Theprimarycaremanagerguidesanddirectsthemedicaltreatmentandclinicalsupportplan.Thenursecasemanageroverseestheimplementationandcoordinationofthemedicaltreatmentandclinicalsupport.Theplatoonsergeantandsquadleaderserveasmentorsandlifecoaches.Inaddition,theyareresponsiblefordailyimplementationofleadershipandcoordinationforadministrativesupport.Tobesuccessful,theWTUtriadreliesonahostofotherclinicalandinstallationsupportstafftofullypromotehealing.Twokeymembersoftheteamarethesocialworkerwhoassistswiththeevaluationforandcoordinationofsocialandcommunitysupportservices,andtheoccupationaltherapistwhoassistswiththeevaluationoftheWTforvocationalinterests TeamOrganizationofastandardWarriorTransitionUnitCompanyserving216WarriorsinTransition.GlossaryCOCommandingofficerXOExecutiveofficer1SGFirstsergeantPCMPrimarycaremanagerNCMNursecasemanagerPSGPlatoonsergeantSLSquadleaderWTsWarriorsinTransitionWTUWarriorTransitionUnitOTOccupationaltherapyMTFMedicaltreatmentfacility(military)MEDCENMedicalcenter(military)

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10www.cs.amedd.army.mil/references_publications.aspxandcapabilities,andthecoordinationofpurposefulactivitiesinthevocationaloreducationalrealm.TEAMCOMMUNICATIONANDCOORDINATIONCommunicationandcoordinationareessentialtoeffectiveteamfunction.Therearerecurringcom-municationepisodesthatoccurbetweenvariousteammembers.ThesquadleaderandtheWTinteractonadailybasistocontinuallyassessforobstacles.Formations.WarriorTransitionUnitsmayrequiretheirWarriorsinTransitiontoattendformations.FormationsareanefficientandeffectivemeansofaccountingforSoldiers,communicatingcommandandgeneralinformation,developingteamidentification,maintainingSoldierstandards,andassessingtheinteractionsofWTswithpeersandsupervisors.Whenplanningformations,WTUleadershipmustconsidermobilitylimitationsoftheirWTs.DailySquadLeaderWTinteraction.TheSLwillhaveinteractionwitheachWTinhisorhersquadeverydutydaytoassesspotentialproblems,gaugetheWTswell-being,providementorshipandguidance,andmonitorprogresswiththeComprehensiveCarePlangoalsandmilestones.IfthecommanderortheWTUtriaddeterminesthataWTisathighriskforsuicide,medicationerror,orotherrisktolifeorhealth,thesquadleaderorhisclearlydesignatedrepresent-tative(suchasastaffdutynoncommissionedofficer)isrequiredtomakenondutydaycontactwiththeWTforawell-beingassessment.WeeklyNurseCaseManagerWTinteraction.ThenursecasemanagerwillmeetwiththeWTatleastonceweeklytoassessforproblems,gaugetheWTswell-being,providementorshipandguidance,andmonitorprogresswiththeComprehensiveCarePlangoalsandmilestones.TheWTUTriadMeeting.TheWT,theprimarycaremanager,thenursecasemanager,thesquadleader,Familymembers(orsignificantothers)andotherteammembers(asappropriate)willgatheroccasionallytodevelop,define,andassessgoals.Ataminimum,afullWTUtriadmeetingisheldduringthegoal-settingphaseandatdecisionpoints.WTUtriadmeetingsmaybecalledatothertimesasnecessary.WTUTriadSynchronizationMeeting.Itisimper-ativethattheWTUtriadandsupportinghealthcareandsupportservicesfunctionasateam.Tofacilitatesuchteamwork,itissuggestedthatweeklysynchronizationmeetingsbeheldtoachievesynergybetweenthemedicalmanagementandcommandandcontrolelements.UnfortunatelymanyWTUsareusingthesevaluableopportunitiesprimarilyasmeetingstogaugetheprogressoftheMedicalEvaluationBoard(MEB),and,inmanyplaces,theWTUcommanderortheprimarycaremanagerisnotpresent.WithMEBdurationasthemainyardstickandindicatorofwhethertopresentaWTornot,theteamisnotfocusedonthemostat-riskSoldiers.InsteadofMEBduration,IrecommendthenursecasemanagerandplatoonsergeantpresentupdatesonWTswhoarenew(inthereceptionphase),inthefinaltransitionphase,inrecovery(veryillordebilitated),atadecisionpoint,oranyotherWTaboutwhomtheyhaveconcerns.Thecommandercanthenprovideguidanceonleadership,administrative,andsupportissues,andtheprimarycaremanagercanprovideguidanceonclinicalcareandcoordination,thusachievingsynergyfromcombiningcommandandcontrolwithmedicalmanagement.TheWTsarenotpresentandthesemeetingsarenotmeanttobein-depthreviewsorcoordinationefforts.IftheteamfindsitselfspendingmorethantwoorthreeminutesdiscussingaSoldier,itisanindicationthataseparateWTUtriadmeetingdedicatedtothatWTisrequired.Ideallythemeetingwilllastone,oratmost2hours.Duringtheinitial50minutes(90minutesfora2-hourmeeting),thenursecasemanagersandplatoonsergeantspresentprogressandissuesencounteredbytheirWTs.OtherstaffwithtrainingintheHealthInsurancePortabilityandAccountabilityAct1(HIPAA)alsoattendthesynchronizationmeetingsandprovideinputasnecessary.Thelast10to30minutesarereservedfornon-HIPAAtrainedpersonneltojoinandhaveanopportunitytobringtheirobservationsandconcernstotheWTUtriad.Theseindividualsremainavailableafterthemeetingstofacilitateone-on-onecoordinationefforts.PHASESOFTHEREHABILITATIONPROCESSTherehabilitationprocessisdividedinto6contiguousphaseswithboundariesthatoftenoverlap,eg,medicalassessmentsmaybeginwhiletheSoldierisstillofficiallyinthereceptionphase.AssessmentsforFamilyassistanceandsupportandreferralsfornonmedicalbenefitsandserviceswilloccurthroughoutallphasesoftherehabilitationprocess.TheComprehensiveCarePlan:BuildingtheStrengthtoDoWellTomorrow

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JanuaryMarch200811THEARMYMEDICALDEPARTMENTJOURNALReceptionPhaseDuringthereceptionphase,thecadreandthedesignatedBattleBuddy*welcomeandorientthenewWTtotheWTU.Thecadreintroducethemselves,completeinitialintakeinterviews,andassesstheWTforrisksrelatedtohismedicalcondition,mentalhealth,mobilitylimitations,cognitiveabilities,medicationsandotherdrugs.TheriskassessmentisusedtodeterminetheWTshousingassignmentandurgentmedicalandbehaviorhealthappointments.Duringthisphase,theWTcompletesadministrativeandfinancialinprocessing.ThecadremembersorienttheWTtohisorherrightsandresponsibilitiesandsetexpectations(initialcounseling),orienttheWTtothegoal-settingconcept,andintroducetheconceptoftheWTtrainingcalendar.Withguidancefromthecadre,theWTwilldevelop,update,andmaintainapersonaltrainingcalendarwhichisreviewedatnursecasemanagerandsquadleadermeetings.InitialAssessmentPhaseDuringthisphasetheWT,WTUtriad,andotherhealthcareprofessionalsassessthecurrentcondition,abilities,andcapabilitiesinthedomainsofbody,mind,heart,andspirit.AsshowninTable1,theassessmentphaseincludesanappraisaloftheWTsleveloffunction,needforservices(medical,surgical,behavioralhealth,andcommunity),Familyneeds,vocationalandeducationalgoals,abilities,self-carecapability,andlifestyle.ArmyCommunityServicenowprovidesacareerassessmenttoolthatwillassisttheWTindetermininghisorherinterests.Assessmentsaremadeinthe4lifedomainsandtailoredtotheneedsoftheWT.ItisimportanttonotethatassessmentoftheWTdoesnotstopattheendofthisphase.Thisphaseallowsanin-depthinitialassessment.Continuedreassessmentsoccurthroughouttheremainderoftherehabilitationprocess.Generalassessmentsaremadewitheachsquadleaderandnursecasemanagermeeting.Specificassessmentsaremadealongthetimelineforgoalandmilestoneachievement.Goal-SettingPhaseManyWTswillbegintoformulateideasabouttheirgoalsandobjectivesastheyprogressthroughtheassessmentphaseandmayhavealreadystartedworkingtowardsthosegoals.TheWT,WTUtriad,andFamily(ifavailable)willmeetandtheWTwillformallysethisorhergoals,withintermediateobjectives,atimeline,andadefinedplantoachievethem.Considerationshouldbegivenwhethertofocusonskillsforasuccessfulreturntoduty,orskillsforatransitiontoahealthy,successfulVeteran.ThecadremembersguidetheWTinthedevelopmentofgoalswithafocusonhealingandthedevelopmentofpositivelife-skillsandhabits,forimprovementinbody,mind,heart,andspirit.Dependingonneeds,theWTmayestablishgoalsintheareasoffunctionalindependenceandmobility,communitymobility(transportation),returntoduty,andothervocationalskills,education,socialinteraction,leisure,andrecreation.Injuryorillnessisparticularlystressfultorelationships,therefore,allWTsareencouragedtodevelopgoalswithrelationshipenhancementinmind.DocumentingtheWTsgoals,objectives,timeline,andplanintheelectronicmedicalrecord(AHLTA)facilitatescommunicationamongcaregiversandenablesthemtoreinforcetheplan.ActiveRehabilitationPhaseDuringthisphase,WTsplaceactivitiesonthetrainingcalendarsthatwillassisttheminaccomplishingthegoalsandobjectiveseachhassetforhimorherself.Familymembersandcaregiversareactivelyencouragedtoparticipateasfullpartnersintheprocess,alongwithancillaryhealthcareprofessionalsandsupportstaff.DuringtheirscheduledmeetingswiththeWT,thesquadleaderandnursecasemanagerprovideencouragementandoversightinmonitoringtheachievementofmilestonesonthetrainingcalendar.Thisphaseisdividedinto4tiers:TierA:Recovery.Recoverymayinterruptanyphaseoftherehabilitationprocess,butitdoesnotsendtheWTbackintoanyphase.Ofcourse,areassessmentofthegoalsandobjectivesiswarrantedafterrecovery.WTsareplacedinrecoveryonlyiftheyareunabletoparticipateinanyphysical,mental,relationship,orspiritualstrengtheningprograms.Thisisanunusualsituationforanoutpatientsetting,butsomeWTsmaybeplacedinTierAforshortperiodsintheimmediate *DefinedasthepersontowhomtheWTcanturnintimeofneed,stress,emotionalhighsandlows,thatwillnotturntheWTaway,nomatterwhat.ThispersonknowsexactlywhattheWTisexperiencingbecauseheorsheiscurrentlygoingthroughasimilarexperienceorhasbeenthroughasimilarexperienceand/orsituationbefore.

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12www.cs.amedd.army.mil/references_publications.aspxpostoperativeperiod,orduringprofoundlydebilitatingtherapy,suchaschemotherapy.TierB:BasicReset.TheWTspendstheentiretrainingdayperformingactivitiesrelatedtotherapeuticrehabilitation.Heorsheisactivelyengagedinmedicalandtherapeuticappointments;groupand/orindividualtherapy;andstrengthening,rangeofmotion,orenduranceexercisesatthegymorpool.Inadditiontospecifictherapeuticregimens,allWTscompleteabasicresetcurriculumcontainingthefollowingprogramsofinstruction:TransitionrightsandresponsibilitiesPosttraumaticstressdisorder/traumaticbraininjurychain-teach*programGoalplanningMaintaininghealthyrelationshipsManagingstressandenergyCommunicationskillsMaintainingahealthyweightandnutritionstatus(includingmedicationeffects)whilerecoveringfrominjuryorillnessManaging/reestablishingcardiovascularfitnessConflictresolutionBattleBuddyskillsFinancialbenefitsoverviewandbasicmoneymanagement *Chain-teachisamethodofunittraininginwhichdesignatedunitmembersfirstreceivethetraining,afterwhichitistheirresponsibilitytotrainanotherlevelofpersonnel,whointurnwillcontinuetrainingothers.Thetrainingcontinuesinapyramidfashionuntilallpersonnelrequiringsuchtraininghavereceivedit.Table1.InitialassessmentoftheWarriorinTransitionnormallyincludesthefollowingareasaddressedacrossthe4functionaldomains. Body(physical)MedicalevaluationsSurgicalevaluationsPsychiatricevaluationsPainassessmentPhysicalabilitiesandlimitations,includingprofilelimitationsAerobicconditionBalanceMuscularstrengthFineandgrossmotorskillsRangeofmotionBodyfat&nutritionassessmentFunctionalassessmentActivitiesofDailyLiving(ADLs)InstrumentalADLsMobilityTransportation(commutinganddriving)AddictionsandmisuseofsubstancesQualityofsleep Mind(cognitive/vocational/emotional)VocationaleducationstatusInterests/assessmentsPsychologicaltestingCognitiveassessmentsConcentrationskillsAttitudeandmotivationFinancialsituationandskillsLeisuretimemanagementScreeningfortraumaticbraininjuryandposttraumaticstressdisorderLanguageskillsSpeech,hearing,reading,writing Heart(social)Interpersonal/relationshipskillsSupportsystemsFamilydynamics/statusParentingCommunicationskillsConflictresolutionAngermanagementIntimacySociallyacceptablebehaviorCurrent/futurelivingarrangementsUnitofassignmentMotivation:values,beliefs,goalsWhatprovidesmeaningandpurposetotheWTslifeSupportsystemsReligious/CulturalSupportAvocationalpursuitsRecreation,sports,hobbies,music,art,andleisureactivitiesthataddjoyanddepthtotheWTslifeCommunityservice,volunteeractivitieswaystocontributetothecommunity,bothnowandinthefuture Spirit TheComprehensiveCarePlan:BuildingtheStrengthtoDoWellTomorrow

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JanuaryMarch200813THEARMYMEDICALDEPARTMENTJOURNALEducationalbenefitsoverviewandcareerdevelopmentUnderstandingmedications,safety,andavoidingaddictionsBasicrelaxationtechniquesandsleephygieneskillsTimemanagementskillsLocationswithArmyCenterforEnhancedPerformance*(ACEP)facilitieswillincorporatethefullACEPcurriculumintotheirbasicresetcurriculum.TierC:IntermediateReset.WTsspendpartoftheirdutydayinvocationaloreducationalactivities,butstilldedicateasignificantportionoftheirdutydaytoactivitiesspecificallydesignedtorehabilitatetheirbody,mind,heart,andspirit.TierCwillgenerallyinvolveinterventionstargetedataddressingaspecificgoal.Advancedtrainingandinterventiontoaddressindividualizedneedsmaybeprovidedbyvariousmedicalspecialists,including:OccupationaltherapyPhysicaltherapySocialworkChaplainSoldierandFamilyassistancecenterArmyCenterforEnhancedPerformanceEducationcenterUnitmentors(aSoldierthatispartofaunitonpostthatsupervisestheWTinareturntodutyskillsuchasanewmilitaryoccupationalspecialty)Topicsmayinclude:AngermanagementAssertiveness/communicationskillsSpecificnutritionand/orweightmanagementPhysicaltrainingSpecificlife-skillsTargetedrelationshipcoachingFunctionalactivitiesWarriorbasicskilltrainingandreturntodutyskillsMilitaryoccupationalspecialtytrainingSpecificproblemsolvingandgoalsettingSpecificfinancialmanagementskillstrainingSpecificleisure/timemanagementskillstrainingWorkreadinessskills(workhabits,values,interests,workskills,vocationalexploration)TierD:LifeReset.GenerallytheseWTshavecom-pletedtheirMedicalEvaluationBoardsandareawaitingthefindingsofthePhysicalEvaluationBoards,orarepreparingforreturntoduty.Theyspendthemajorityoftheirdutydayinvocationaloreducationalactivities,butmaystillrequireongoingmedicaltreatmentorrehabilitation.FormanyWTs,theirworkassignmentwillbecompatiblewithestablishedgoalsandwithintheconfinesoftheirphysicalprofile.AnadditionalaspectofthisphaseisanincreasedemphasisonFamilyandcommunityreintegration.FinalTransitionPreparationPhaseThephasebeginswhentheSoldierknowswhetherheorshewillreturntodutyorseparate(orretire)fromtheservice.TheWTandsignificantFamilymember(s)aregivenupto90daystoprepareforreturntodutyortransitiontolifeasaVeteran.WTsfoundfitfordutymustcompletethenecessaryadministrativetaskspriortotransfertotheirnextdutystation.FortheWTreturningtocivilianlife,finalpreparationsmustbemadetoensureasuccessfultransitiontoVeteranstatusandcivilianlife,withtheVeteranfullyintegratedintothecommunity.WTsreturningtodutywillcompletethefollowingtasks:ArmyphysicalfitnesstestUpdatesecurityclearanceUpdateORB/ERB *TheCenterforEnhancedPerformanceisadepartmentoftheUSMilitaryAcademyPreparatorySchool,WestPoint,NewYork.Informationisavailableathttp://www.usma.edu/USMAPS/pages/academics/cep_home.htm.TheORB(OfficerRecordBrief)andERB(EnlistedRecordBrief)areonepageArmyformsdesignedtoprovideasummaryoftheSoldiersqualificationsandcareerhistory.TheORBandERBareproducedfromdatastoredintheSoldiersMasterFileattheArmyPersonnelCenter.2

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14www.cs.amedd.army.mil/references_publications.aspxUpdateofficialphotoDiscussfutureassignmentswithbranchmanagerArrangetoshiphouseholdgoodsand/orvehiclesArrangementsforrequireddurablemedicalequipmentIdentificationofapost-transitioncontactphonenumberWTstransitioningtoVeteranstatuswillmakethefinalpreparations,whichcaninclude,butarenotlimitedto:Applyingforfederalandstateveteransbenefits,includingdisabilityEnrollmentintheVeteransHealthAdministration(VHA)andidentificationofaVHAtreatmentfacilityneartheVeteransdesiredhometoincludeaninitialappointmentandidentificationofaDepartmentofVeteransAffairs(VA)casemanagerApplicationforsocialsecuritybenefitsifindicatedApplicationandacceptancetoeducationalinstitutionsDevelopmentofemploymentopportunitiesfortheVeteranandtheFamilymemberArrangementsforhousingtoincludeadaptivemodificationsHealthcareenrollmentfortheVeteranandtheFamilyTransferServicemembersGroupLifeInsur-ance*toVeteransGroupLifeInsurance*orotherarrangementsforlifeinsuranceArrangingschooltransfersforchildrenArrangementsforrequireddurablemedicalequipmentIdentificationofapost-transitioncontactphonenumberEnsurethatallpaperrecordshavebeenscannedintotheSoldierselectronicmedicalrecordEnsureWTisprovidedwithacopyofhismedicalrecordsTransition/Post-TransitionPhaseDuringthisphasetheWTcompletesadministrativeandfinancialout-processingandconfirmsthearrangementsfortheWTspost-transitionlife.ThirtydaysaftertheSoldierleavestheWTU,thenursecasemanagerconductsapost-transitiontelephonesurveytoassesshowwelltheWTwaspreparedforthetransition.IftheWTidentifiesproblems,thenursecasemanagerwillcoordinatewiththeVAorotherappropriateentitytoresolvetheproblem.DECISIONPOINTSDecisionpointsshouldnotbeconfusedwithprogressassessmentswhichareguidedbythegoalsandmilestonesthattheWTsetduringthegoal-settingphase.DecisionpointsarespecificpointsonthetimelinewheretheWTUtriad,inconsultationwiththeSoldierandthemultidisciplinaryteam,formallyassesstheSoldiersreturntodutypotentialanddocumenttheassessmentinhis/herelectronicmedicalrecord.Thesereturntodutyassessmentsareconductedevery3months,withthefirstdecisionpointat3monthsafterinitialassignmentorattachmenttotheWTU.At3monthsafterassignment(orattachment)totheWTU,theWTUtriadwillholdaformalmeetingwiththeWTandFamilywiththefocusonthequestion,HastheSoldiersconditionandfunctionimprovedsufficientlytomeetretentionstandardsinaccordancewiththeArmysStandardsofMedicalFitness?3Iftheanswerisyes,appropriatestepstoreturntheSoldiertoduty,eitherinthesameoranewmilitaryoccupationalspecialty,shouldbepursued.Iftheanswerisno,theWTUtriadandSoldiermustdecidewhethertocontinuetreatmentandrehabilitationintheWTU,ortoprepareforongoingtreatmentandrehabilitationasaVeteran.At6months,theWTUtriadholdsameetingwiththeWTandFamilywiththefocusonthequestion,HastheSoldiersconditionandfunctionimproved *ServicemembersGroupLifeInsurance(SGLI)isaprogramoflowcostgrouplifeinsuranceforservicemembersonactiveduty,readyreservists,andmembersoftheNationalGuard.VeteransGroupLifeInsurance(VGLI)isaprogramofpost-separationinsurancewhichallowsservicememberstoconverttheirSGLIcoveragetorenewableterminsurance.Memberswithfull-timeSGLIcoverageareeligibleforVGLIuponreleasefromservice.Source:VAwebsite,availableathttp://www.insurance.va.gov/sgisite/SGLI/SGLI.htmTheComprehensiveCarePlan:BuildingtheStrengthtoDoWellTomorrow

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JanuaryMarch200815THEARMYMEDICALDEPARTMENTJOURNALsufficientlytomeetretentionstandardsinaccordancewiththeArmysStandardsofMedicalFitness?3Iftheanswerisyes,appropriatestepstoreturntheSoldiertoduty,eitherinthesameoranewmilitaryoccupationalspecialtyshouldbepursued.Iftheanswerisno,theSoldierandtheWTUtriadmustthenconsider,Withinthenext6months,willtheSoldiersconditionandfunctionimprovesufficientlytomeetretentionstandardsinaccordancewiththeArmysStandardsofMedicalFitness,3orwillhebeacandidatetoeithercontinueonactivedutyorcontinueonactivereserve?IffurthertreatmentandrehabilitationwilldefinitelyorpotentiallyreturntheSoldiertoaconditionthatmeetsmedicalretentionstandards,furtherrehabilitationintheWTUiswarranted.IffurtherrehabilitationortreatmentwillnotbringtheSoldiertoaconditionthatmeetsretentionstandards,orbringtheSoldiertoaleveloffunctionthatwillpermitcontinuationonactiveduty,thenpreparationforentryintothephysicaldisabilityevaluationsystemiswarranted,andcontinuedrehabilitationandtreatmentintheWTUisindicatedonlyinextraordinarycircumstances.4Examplesofextraordinarycircumstancesinclude:Asignificantinjurythatwarrantslongerrehabilitationeffort(indicatedbythereceiptofTraumaticServicemembersGroupLifeInsurance*orentryintotheArmyWoundedWarriorProgram)Asignificantillnessthatmedicalstaffdetermineshasagoodprognosisforfullrecoveryandreturntoduty.Inthiscase,theWTsactivitiesshouldbedirectedtowardsreturntodutyskillsandactivities,withvocationalactivityinanappropriateunit.TofacilitateassistancewithpossibletransitiontolifeasaVeteran,WTsreferredtotheMedicalEvaluationBoardshouldattendtheTransitionAssistanceProgram(TAP)orDisabledTAP,whileWTsreferredtothePhysicalEvaluationBoardwillmeetwithaVeteransbenefitscounseloronsiteorattheinstallationsBenefitsDeliveryatDischargeoffice.UponreferraloftheWTtotheMedicalEvaluationBoard,attentionmustbepaidtotransitionservicestheFamilymembersmayneed,inadditiontothoserequiredbytheWT.Forexample,iftheWThasaFamilymemberwithsignificanthealthconcernsorexceptionalneeds,considerationmustbegiventohowthoseneedswillbemetiftheSoldierisseparatedfromtheArmy.CoordinationforappropriatecareandservicesaftertheSoldiersseparationmustbeinitiatedwhentheSoldierisreferredtotheMedicalEvaluationBoard.SuchcoordinationwillsignificantlyreducetheSoldierandFamilystressrelatedtoeitherthemedicalorPhysicalEvaluationBoardprocess.PROFILESToalleviateconfusionuponassignmentorattachmenttotheWTU,theprimarycasemanagerevaluatestheWTsprofileanddeterminesifitadequatelyaddressesalllimitingconditions.Theprimarycasemanagermaychoosetowriteanewtemporaryprofile.Physicianswriteprofilesfor2reasons:1.TopreventtheSoldierfromcausinganinjurytohimselforothers.TheSoldiermaybemotivated,buttheriskofinjuryistoohighortheconsequencestooseveretonotwritetheprofile.Anexamplemightbeahelicopterpilotwithacurrentseizuredisorder.NomatterhowmotivatedthatSoldiermaybe,theconsequenceswouldbetoosevereandano-flyingdutyprofilewouldberequired.AnotherexampleisaSoldierthathasmobilitylimitationsthatwouldpreventhimfromevacuatingaburningvehicleortakingcoverintheeventofanattack.AnotherexampleistheSoldierwithpost-concussivesyndrome(oftencalledmildtraumaticbraininjury).Toprotectthebrainwhileitishealing,thephysicianmayopttowriteano-alcoholprofile.No-alcoholprofilesmayalsobeconsideredwhenaSoldierhasotherdiagnosesoristakingcertainmedications.2.ToprotecttheSoldierfromundopainandsuffering.OnlytheSoldiercandeterminewhatisunreasonableforhimorherwithrespecttopain.NotallSoldierswithkneepainneedaprofilethatnecessitatesaMedicalEvaluationBoardandseparationfromtheService.TheSoldiermustunderstandthattheyarethebestjudgesofwhattheyarecapableof.Tofacilitateretention,theSoldiershouldstrivetomeetthefollowingminimumstandards5:Beabletotakeanaerobicfitnessevent(run,walk,bike,orswim). *TraumaticServicemembers'GroupLifeInsuranceisatraumaticinjuryprotectionriderunderSGLIthatprovidesforpaymenttoanymemberoftheuniformedservicescoveredbySGLIwhosustainsatraumaticinjurythatresultsincertainseverelosses.Source:VAwebsite,availableathttp://www.insurance.va.gov/sglisite/tsgli/tsglifaq.htm.

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16www.cs.amedd.army.mil/references_publications.aspxBeabletofireapersonalweapon,eithershoulder-firedorhandheld.Beabletowearthepersonalprotectiveequipment(chemicalprotectivegear,helmet,individualbodyarmorvest).PLANNINGFACTORSAWTUinasteadystatethestandardnumberof216WarriorsinTransitionwhostayanaverageof180dayswillgainanaverageof36newSoldierseverymonth.Theprimarycaremanagerandoneofthenursecasemanagerswillperformtheintakeprocessingforthese36Soldiers(36hoursamonth),attend36goal-settingWTUtriadmeetingspermonth(36hoursamonth),andattend36decisionpointmeetings(18hoursamonth).ThesteadystateworkloadfortheprimarycaremanagerissummarizedinTable2.Theoccupationaltherapistandsocialworkerwillalsoneedtoperformnewintakesforthese36Soldiersandmayberequestedtoattendgoal-settinganddecisionpointmeetingsforcertainSoldiers.Themilitarytreatmentfacilityshouldconsidertheworkloadrequirementswhenprovidingtheirclinicalstaffwithadjunctivepersonnelandsupportstaff.WTUsthathaveattainedasteadystatecancalculatetheirrequirementsbyreviewingthenumberofnewWTsreceivedeachmonth.SUMMARYTheWarriorTransitionUnitsprovideSoldiersanopportunitytofocusfullyonhealing,withthegoalofreturningtodutyorreturningtocivilianlifeasasuccessfulVeteran,withsuccessdefinedasem-ployable(oralife-careplanestablished),capableofmaintainingrelationships,andproudoftheirservicetothenation.ThesuccessoftheindividualWarriorTransitionUnitwillbedeterminedbyhowwelltheyassisttheirWarriorsinTransition.TheWarriorTransitionUnitcadremustask:IsourWTUdoingeverythingitcantobuild-upourWarriors?AreweprovidingthemwiththetoolstodeveloptheirStrengthtoDoWellTomorrow?REFERENCES 1.PublicLaw104-191HealthInsurancePortabilityAndAccountabilityActOf1996.August21,1996:Availableat:http://aspe.hhs.gov/admnsimp/pl104191.htm.2.ArmyPamphlet640-1:OfficersGuidetotheOfficerRecordBrief.Washington,DC:USDeptoftheArmy;April1,1987.3.ArmyRegulation40-501:StandardsofMedicalFitness.Washington,DC:USDeptoftheArmy;December14,2007.4.DepartmentofDefenseInstruction1332.38:PhysicalDisabilityEvaluation.Washington,DC:USDeptofDefense;November14,1996.5.ArmyRegulation600-60:PhysicalPerformanceEvaluationSystem.Washington,DC:USDeptoftheArmy;June25,2002.AUTHOR LTC(P)DominguezistheExecutiveOfficertotheAssistantSurgeonGeneralforWarriorCareandTransition,OfficeofTheSurgeonGeneral,Alexandria,Virginia.TheComprehensiveCarePlan:BuildingtheStrengthtoDoWellTomorrowTable2.MonthlyworkloadfortheWarriorTransitionUnitprimarycaremanagerina216memberunitaccessing36newarrivalseachmonth.36newintakes1houreach36hours36WTUtriadgoal-settingmeetings1houreach36hours36decisionpointmeetings0.5hourseach18hours4WTUtriadsynchronizationmeetings2hourseach8hours Totalhoursrequiredfornewarrivalsandstandingmeetings 98hoursAvailablehours:21dutydays@8hours168hours Remainingtotalhoursforallotherappointmentsthroughoutthemonth 70hoursTheprimarycaremanagerwillthereforehave3.3hourseachdayduringthemonthforallotherappointments,includingsickcall(acutecare),medicationreconciliation,profileevaluation,routineappointments,andmeetingswithotherhealthcareproviders.

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JanuaryMarch200817BACKGROUNDTheArmyMedicalActionPlanestablishedthedevelopmentanddeliveryofstandardizedtrainingforthestaffoftheWarriorTransitionUnits(WTU),withspecialfocusontheWTUTriad.Thetriadconsistsofthesquadleader,thenursecasemanager,andtheprimarycaremanager.EveryWarriorinTransition(WT)isassignedtoatriaduponjoiningtheWTU.Whiletrainingisnottheentiresolutiontoprogressandimprovement,itisakeycomponentinthechangeprocess.Indeed,standardizedtrainingforWTUstaffwasoneofthe10quickwinsestablishedbytheArmyAssistantSurgeonGeneralforWarriorCareandTransitionwhentheArmyMedicalActionPlanwasunveiledinJune2007.InAugust2007,theAcademyofHealthSciences(AHS)attheArmyMedicalDepartment(AMEDD)CenterandSchoolwastaskedtoaccomplishthenewtrainingrequirement.Veryquickly,greatthingsbegantohappen.WhenanArmyneedfortrainingiscombinedwithoverwhelmingsupportandsubjectmatterexpertise,theresultisexceptionalqualitytraining.DISTRIBUTEDLEARNINGThetrainingmissionwasinitiatedwitharequestforthedevelopmentanddeliveryofdistributedlearningonavarietyofsubjects.Thefirstsuspensewasshort.Theteamincludedsubjectmatterexperts,distributedlearningdevelopersanddeliverers,instructionalsystemsspecialists,AHSqualityassurancepersonnel,andtrainingsystemsspecialists.Theinitialtrainingproductwastheshort-term,short-suspensesolution.Thisproducthassincebeenimproved.TheAHSiscurrentlyworkingonthethirdrevision.FuturephasesofimprovementincludeproducingaSharableContentObjectReferenceModel*compliantproductwhichwillimprovesequencingandstandardization.TwodistributedlearningtrainingcoursesweredevelopedtoprovideanoverviewoftheWTUandallitsservicesandfunctions.RecentlyitwasdeterminedthatallstaffmembersofaWTUwouldbenefitfromtheinformationandtrainingprovidedbybothcourses.Therefore,thesecourseswerecombinedintoasinglecourse,theWarriorTransitionUnitCadreOrientationcourse.ItislocatedontheArmyLearningManagementSystem.SoldierscanenrollinthiscourseviatheArmyTrainingRequirementsandResourcesSystemasaself-developmentcourse.TheWTUCadreOrientationcourseencompasses28lessonsasshowninTable1.Additionallessontopicshavebeenidentifiedforconsiderationanddevelopment.Inadditiontotheoverviewcourse,nursecasemanagersarealsorequiredtotaketheWarriorTransitionUnitNurseCaseManagementcourse.ThiscoursecoversnursecasemanagementrolesandresponsibilitieswithspecialattentiontotheWTUpatientpopulation.Distributedlearningmodulesoncasemanagement,ambulatorycareguidelines,utilizationmanagement,post-traumaticstressdisorder,andtraumaticbraininjuryareintegrated.BRIDGINGTHEGAPFurtherintotheArmyMedicalActionPlan,itwasdeterminedthattheWTUtriadandplatoonsergeantsshouldattendresidenttraininginadditiontothedistributedlearning.TheresidentcoursewillbelaunchedinOctober2008.However,toprovideresident-typetrainingassoonaspossible,interimtypesoftrainingwereestablishedtobridgethegapbetweendistributedlearningandtheresidentcourse.LOCALLYCONDUCTEDTRAININGAtaJanuary2008conferenceinSanAntonio,7lessonsweredeliveredtodesignatedtrainersorEnsuringExcellence:TheWarriorTransitionUnitStaffTrainingProgramSherriA.Emerich,MA *ADeptofDefensesetofstandardsandspecificationsfordevelopmentanddeliveryofelectroniclearning. ArmyTrainingCourse6I-F8/300-F36ArmyTrainingCourse6E-F2

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18www.cs.amedd.army.mil/references_publications.aspxtrainingcoordinatorsfromeachWTU.Thedesignatedtrainerswilleitherdeliverthetrainingorcoordinatethetrainingemployinglocalsubjectmatterexperts.ThetrainingmustbeprovidedtotheWTUstaffbytheendofSeptember2008.DocumentationiscompletedintheDigitalTrainingManagementSystem(DTMS).The7lessonsaredesignedtoengagethestaffthroughdiscussions,videos,practicalexercises,andscenario-basedtraining.Thetrainingtopicsinclude:PosttraumaticstressdisorderandtraumaticbraininjuryPainmanagementDrugandalcoholawarenessSuicidepreventionArmyphysicaldisabilityevaluationsystemPersonalgoalsettingBasicmedicalterminologyCommandandcontrol/personalaccountabilityThemedicalterminologytrainingisintendedfornonmedicalstaff.ManyofthesquadleadersandplatoonsergeantsintheWTUsandcommunitybasedhealthcareorganizations(CBHCOs)arenotmedicalprofessionals.Whilethelessononcommandandcontrolisbeneficialtoall,itsfocalpointisthesquadleaderandplatoonsergeant.ARMYCENTERFORENHANCEDPERFORMANCETRAININGMODULESTheArmyCenterforEnhancedPerformance*(ACEP)willsendtrainingteamstoeachoftheWTUsandCBHCOsbetweenFebruaryandSeptember2008.TrainingfromtheACEPteamstakesamoreholisticapproachtotraining,usingadvancedperformancepsychologyandacademicstrategiestoenhancepersonalandprofessionalperformanceandstrength.Trainingisprovidedatthementalandemotionallevelofhumanperformance.Physical,technical,andtacticaltrainingarealreadydonewellbytheArmy.Thetrainingmodulesembracethefollowing:LifecoachingawarenessandprovidingstrengthtoothersPsychologyofinjuryandhealingMentalskillsfoundationstobetterusethemindtoenhanceperformance *TheArmyCenterforEnhancedPerformanceisadepartmentoftheUSMilitaryAcademyPreparatorySchool,WestPoint,NewYork.Informationisavailableat:http://www.usma.edu/USMAPS/pages/academics/cep_home.htm. 1Orientation 2 WTUIntegratedManagementTeam3ServiceSupport 4 WTIntegrationandDisposition5ArmyWoundedWarriorProgram 6 CompassionateLeader7Cadre(staff)Resiliency 8 ArmyCareerandAlumniProgram9SoldierFinancialReadinessVisibilitySystem 10 PhysicalProfiles11CommunityBasedHealthcareOrganization 12 AssistingVeteranswithTraumaticBrainInjury13SeamlessTransition 14 TransitionAssistanceAdvisors15VeteransAdministration 16 VeteransBenefitsAdministrationCompensationandPensionServices17VocationalRehabilitationandEmployment 18 WomenVeteransProgram19Combat-relatedInjuryRehabilitationPay 20 Computer-ElectronicAccommodationsProgram21MobilizationProcess 22 TricareOverview23TraumaticServicemenbersGroupLifeInsurance 24 MedicalEvaluationBoards25PhysicalDisabilityEvaluationSystem 26 HumanResourcesCommand27Ombudsman 28 SuicideAwarenessTable1.ThecurrentcompositionoftheWarriorTransitionUnitCadreOrientationCourse.* *ArmyTrainingCourse6IF8-300-F36TRICAREistheDoDhealthcareprogramformembersoftheuniformedservices,theirfamilies,andtheirsurvivors.Informationavailableathttp://www.tricare.mil.EnsuringExcellence:TheWarriorTransitionUnitStaffTrainingProgram

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JanuaryMarch200819THEARMYMEDICALDEPARTMENTJOURNALConfidencebuildingGoalsettingIntegratingimageryAttentioncontrolandactivelisteningEnergymanagementTeambuildingSENSITIVITYTRAININGSensitivitytrainingwillbedeliveredviaunitministryteams.TheywillemphasizetheprovisionofcompassionateandsensitivecareinsupportoftheWTsandtheirFamilies.SquadleadersandplatoonsergeantsfindthemselvesinanatypicalleadershiproleinaWTU.Firm,yetcompassionateleadershipisrequired.RISKCOMMUNICATIONTRAININGProfessionalRiskCommunicationtrainingwillbedeliveredtotheWTUsbytheArmyCenterforHealthPromotionandPreventiveMedicine(CHPPM).Thistraininguseseducationandscenariostohelpthestafftobetterplanandexecutecommunicationsinhighrisk/lowtrustenvironments.Learningtoapplytheprinciplesofriskcommunicationisafundamentalimperativeforthetriad.Asinglebadcommunicator,albeitsomeonewithreallygoodintentions,canaffectthehealingprocess.Thetrainingisexcellentandishighlyrecommendedforanyone,especiallythosewhosejobentailscomplexinteractionsandcommu-nicationinatrustingenvironment.RESIDENTCOURSEThefirstresidentcoursewillbepresentedinOctober2008.Twoweeksareblockedforthiscourse,althoughtheprogramofinstructionisnotfinal.AllmembersoftheWTUtriadandallplatoonsergeantswillattend.TheACEPteamisresponsibleforthefirstweekofthecoursewhichwillbedevotedtocoaching,mentoring,andeducation.Thetrainingisamorethoroughversionofthecurrentinterimtrainingpackage.TheACEPteamatFortSamHoustonispresentlydevelopingcurriculumspecificallyforthiscourse.Thesecondweekwillincludea6-hour,comprehensivelessoninRiskCommunication.ThecoursewillalsoincludesensitivitytrainingandanoverviewoftheDTMS.ThelessonspreviouslydeliveredbyWTUdesignatedtrainerswillbeprovidedbythesubjectmatterexpertsthatdesignedanddevelopedthelessons.Professionalvideoshavebeenscriptedandareunderproductionfortraininginbothsuicidepreventionandsuicideintervention.TheAHSSoldierandFamilySupportBranch,AMEDDtelevisionproductionspecialists,andCHPPMarecollaboratingonthisproject.Thelastpartofthecoursewillinvolvebreakoutgroupssimilartotechnicaltracktraining.Squadleadersandplatoonsergeants,alongwithnursecasemanagersandprimarycaremanagers,willreceiverole-specifictraining.TheAMEDDNoncommissionedOfficersAcademywillplayavitalroleinsquadleaderandplatoonsergeanttraining.TRAININGSUMMARYThecurrenttrainingrequirementsforWTUstaffareshowninTable2.ItshouldbenotedthatafterSeptember30,2008,thereisnolongeranymandatoryrequirementforthelocalclassroomtrainingshowninTable2,asthelearningobjectivescoveredinthattrainingareincludedintheresidentcoursedescribedabove.However,thisdoesnotprecludelocalcommandsfrompresentingsuchrelatedtrainingastheydeemnecessary.THEROADAHEADTheWTUTriadTrainingProgramisevolving.Recently,asdirectedbytheArmyTrainingandDoctrineCommand,aWTUoverviewtrainingsupportpackagewasdevelopedforimplementationintoArmyleadershipcourses.AWTUbreakoutsessionwasjustestablishedfortheAMEDDPre-CommandCourse.TheWTUTriadTrainingProgramwebsitewasestablished.Themissionisexpanding.AdditionaldistributedlearningcontentisunderdevelopmentfortheorientationcoursewhichwillcoverFamilyReadinessSupportAssistants.LessonsinPersonnel(S1)andComprehensiveCarePlanningareintheanalysisphase.Professionalexpertiseandsuggestionsarecommonresourcesduringthisplanninganddevelopmentevolution.Althoughthereisavastamountofexpertisewithintheschoolhouse,involvementextendsaboveandbeyondtheAHS.Professionalexpertiseisnotlimitedtoschoolhouseresources.KnowledgeableandpracticedprofessionalsoutsideoftheAHS,suchasACEPand

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20www.cs.amedd.army.mil/references_publications.aspxCHPPM,areintegralcontributorstothisprogram,.WewillcontinuewithinterviewsofWTUstaffandcommanderstosustainaprogramofinstructionthatiscurrentandrelevant.Astheprogramprogresses,wewillusesurveytools,observations,interviews,andotherformsofevaluationandanalysistopreserveaqualitytrainingprogram.AsthepopulationofexperiencedWTUstaffmembersgrows,wemustcapturetheirtacitandexplicitknowledgeandfindawaytoproliferateit,creatinganeducationalcircleamongtheincomingandoutgoingmembersoftheWTUtriad.Thepowerofknowledgecanonlyachieveitsfullpotentialifweshareitwithasmanypeopleaspossible.Imagine100peopleinaroomwithprobesandwiresinterconnectingtheirbrains.Then,withtheflipofaswitch,alloftheinformationandknowledgeineachbrainissharedwiththeothers.Whileourprogramincludesnoprobesorwires,wedowantourtrainingprogramtoshareknowledgeinaninteractiveandengagingmanner.Wewanttodomorethantrain;wewanttoimprovehumanperformance.AUTHOR MsEmerichistheProgramDirectoroftheWarriorTransitionUnitTrainingProgram,AcademyofHealthSciences,AMEDDCenterandSchool,FortSamHouston,Texas.*EithertheWarriorTransitionUnitCadreSupportcourse(ArmyTrainingCourse6I-F6/300-F34)andtheWarriorTransitionUnitSupportOrientationcourse(6I-F7/300-F35),ortheWarriorTransitionUnitCadreOrientationcourse(6I-F8/300-F36)ArmyTrainingCourse6E-F2(P)CoursemandatoryuntilSeptember30,2008.Afterthatdate,personnelassignedassquadleaders,primarycaremanagers,nursecasemanagers,andplatoonsergeantsmustattendtheresidentWTUtrainingcoursepresentedattheAMEDDCenterandSchool,FortSamHouston,Texas.NotrequiredafterSeptember30,2008Table2.CurrentmandatorytrainingrequirementsforstaffpersonnelassignedtoallUSArmyWarriorTrainingUnits.DistributedLearningCoursesClassroomTrainingatLocalInstallationWarriorTransitionUnitOrientation*NurseCaseManagementACEPMobileTrainingUnitMinistryTeamSensitivityTrainingLocallyConductedTrainingRiskCommunicationMobileTraining Squadleader Primarycaremanager Nursecasemanager Platoonsergeant AllotherWTUstaff EnsuringExcellence:TheWarriorTransitionUnitStaffTrainingProgram

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JanuaryMarch200821TheprimarymissionofaSoldierassignedtoaWarriorTransitionUnit(WTU)istoheal.Thecombinationofafamiliarmilitarylivingenvironment,medicalandrehabilitationservices,andsetdailyroutineswithindividualizedgoalshelpWarriorsintransitionfocusonactivitiesthatpromotehealinginthephysical,mental,social,andspiritualdomainsoflife.Theroleofoccupationaltherapy(OT)withinaWTUistohelpSoldiersattainoptimaloccupationalperformanceandgainasenseofmasteryastheytransitionbacktoindependent,productiveliving.TheWTUOTpromotestheSoldiersreturntotheroleofworker,whethermilitaryorcivilian.Occupationaltherapypractitionerspromote,improve,conserve,andrestoretheskills,abilities,andaptitudesoftheWarriorinTransition.TheyhelpguideSoldierstowardreasonableshortandlong-termgoalsthatreflecttheSoldiersavocational(nonpaidorvolunteer)andvocationalinterests.AsupportivemilitaryenvironmentcombineswithengagementinpurposefulworkactivitiesthatmatchtheSoldiersinterestsandskillstohelpthemovercomephysical,mental,oremotionalbarriersandviewthemselvesascompetentworkers.Thisperspectiveisabsolutelyessentialforthemtogaincontrolovertheirdailylivesandtakepersonalresponsibilityfortheirfuture.Occupationaltherapyisdesignedtoachievefunctionaloutcomesthroughafocusonthetherapeuticuseofoccupationtasksandactivitieswithinonesdailylifewhichprovidemeaningandpurpose.Occupationalperformancemayberelatedtoareasofwork,play,education,leisure,self-care,orsocialparticipation.EngagingtheSoldierintherapeuticoccupationsthatarebasedonhis/hercurrentfunctionalabilityhelpsbuildasenseofcompetenceandself-confidence.Engagementinoccupationincludesboththesubjective(emotionalorpsychological)aspectsofperformanceandtheobjective(physicallyobservable)aspectsofperformance.1Occupationaltherapypractitionersconsidertheinterplaybetweentheenvironment,theperson,andoccupationalperformanceinmatchinginterests,skills,andabilitieswithinterventionoptions.Occupationaltherapypractitionersaddressoccupationalpatternssuchasroles,routines,andhabitswithinabroadcontext:cultural,physical,social,temporal,spiritual,andvirtual.EngagementinSoldiertasksanddutyresponsibilitiesasearlyaspossiblehelpstheWarriorinTransitionmaintaintheingrainedhabitsthatsupporttheroleofbeingaSoldier.Occupationaltherapypractitionersincorporatetherapeuticuseofself,consultation,andeducationalapproachestohelpmeettheneedsofWarriorsinTransition.TheWTUOTstaffincludesalicensed,registeredoccupationaltherapist,whoholdsabachelorsormastersdegreeandcertifiedoccupationaltherapyassistantswhoholdassociatedegrees.Occupationaltherapypractitionersmustcompletesupervisedclinicalinternshipsinavarietyofhealthcaresettings,passanationalcertificationexamination,andcompletelicensurerequirementsinmoststates.Theyaretrainedinhumangrowthanddevelopmentwithspecificemphasisonthesocial,emotional,andphysiologicalimplicationsofillnessandinjury.OccupationaltherapypractitionersfacilitateincreasedSoldierinvolvementinproductiveactivitywhileaddressingsafety,physicaltolerance,andfunctionalabilities.Theyareabletodevelopandguidejob-specificprogramsofgradedactivity,jobtaskanalysis,jobstationmodifications,andcanidentifyandaddressworkbehaviors.2Occupationaltherapypractitionersprovideconsultationandcollaborationsupportinmanyareas.TheypartnerwiththeComputer/ElectronicsAccommodationsProgramtoprovideassistivetechnologyassessmentsforSoldiersdemonstratingfunctionaldeficits.OccupationaltherapypractitionersprovideconsultationsupporttohelptheWTUaddressergonomicissues,meetAmericanswithDisabilitiesAct3requirements,andcreatesafebarrier-freeenvironments.Theyhelpidentifytheneedforspecificlifeskillstraining/classesandinterfacewiththeTheRoleofOccupationalTherapyinWarriorTransitionUnitsCOLMaryW.Erickson,SP,USA

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22www.cs.amedd.army.mil/references_publications.aspxArmysCenterforEnhancedPerformance,*incorporatingapeakperformancemodeltobuildWarriorperformanceskills.Inaddition,OTpractitionersmayprovidecognitiveandbehavioralhealthassessmentandinterventionstrategies;ensurethataninterfacewiththeDepartmentofDefense,theDepartmentofVeteransAffairs(VA),andcivilianprovidersexists;connectwithVAvocationalassessmentresources,workadjustment,andworktransitionresources;andworkcloselywithFamilyandcommunityresources.TheinteractivenatureofoccupationaltherapyrequiresacloseworkingrelationshipwiththeSoldierandtheWTUtriad(primarycaremanager,nursecasemanager,andsquadleader).Regularcontactwiththesocialworker,chaplain,andtheWTUcommandteam,aswellasthemilitarytreatmentfacility(MTF)staffassurescontinuityofcare.AcloseworkingrelationshipismaintainedwiththeVAVocationalReadinessandEmploymentbranchthataddressesreturntowork.AnearlyinterfacewithvocationalrehabilitationcounselorsforthosewhowillbeenteringtheVAsystemassuresasmoothertransition.OccupationaltherapypractitionersworkcloselywiththeWTUtriadtoincorporatespecifictherapeuticactivitiesintotheSoldierstrainingcalendaraspartofhisorherdutyday.Suchactivitiesmayincluderequirementsofdailyliving(maintainingamilitaryappearance),educationalactivities(selectedlifeskillstrainingorSoldiertasktraining),work/productiveactivities(dutyassignmentsthatmatchindividualinterests,skills,andabilities),leisure/recreationalactivities(participationinenjoyable,relaxingactiv-ities,games,andsports),andsocialparticipatoryac-tivities(cooperative/competitivesports,games,ceremonies,orcelebrations).4LifeskillstrainingandeducationhelpprepareSoldiersforsuccessfulreintegrationintomilitaryduty,orforreturntotheirhomeandcommunityliving.AteamapproachisusedtoidentifyandmeettheneedsofWarriorsinTransition.TheOTstaffcollaborateswiththeWTUoperationsstaff,theMTF,andgarrisonresourcestoimplementbasicandadvancedtrainingtomeettheSoldiersbasicskillsneedsinthefollowingareas:GoalplanningManagingstressandenergyCommunicationskillsManagingahealthyweightandnutritionstatuswhilerecoveringfrominjuryorillnessManaging/reestablishingcardiovascularfitnessConflictresolutionManaginghealthyrelationshipsFinancialmanagementskillsBasicrelaxationtechniquesandsleephygieneMaintainingbalance/timemanagementBasicintroductiontoillnessandinjuryincludingavoidanceofaddictionsandmedicationmanagementAdvancedlifeskillstrainingisprovidedaccordingtotheSoldiersneeds,includingangermanagement,assertivenessandcommunicationskills,concentrationskills,Warriorbasicskilltrainingandreturn-to-dutyskills,specificproblemsolving,andgoalsetting.Specificskillstrainingintheareaofworkreadinessincludesworkhabits,values,interests,workskills,andvocationalexploration.THEVALUEOFWORKDutyisaSoldierswork.ItisexpectedofallSoldiers.ToaWarriorinTransition,workordutyassignmentsareviewedastherapeuticandaredesignedtoimprovehealth.Theconceptofworkasatherapeuticmediumhasbeenacoreconceptsincetheinceptionofoccupationaltherapy.WorkprogramsforindividualswithmentalillnessbeganduringtheMoralTreatmentmovementofthelate18thandearly19thcenturies.GeorgeBarton,oneofthefoundersof *TheCenterforEnhancedPerformanceisadepartmentoftheUSMilitaryAcademyPreparatorySchool,WestPoint,NewYork.Informationisavailableathttp://www.usma.edu/USMAPS/pages/academics/cep_home.htm.TheRoleofOccupationalTherapyinWarriorTransitionUnits

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JanuaryMarch200823THEARMYMEDICALDEPARTMENTJOURNALoccupationaltherapy,establishedaprograminNewYorkintheearly19thcenturythatincorporatedtheuseofoccupationstoreturnindividualsrecuperatingfromillnessorinjurytoproductiveliving.Hestated,Thepurposeofworkwastodivertthemind,exercisethebody,andrelievethemonotonyandboredomofillness.5In1918,theArmysDivisionofOrthopedicSurgeryorganizedareconstructionprogramfordisabledsoldiersandtrainedreconstructionaidestouseworkactivitiestoreturntheinjuredsoldierstomilitarydutyorcivilianlifetothehighestdegreepossible.4Reconstructionaidesweretheprecursorsoftodaysoccupationaltherapists.Workoftenprovidesasenseofsecurity,belonging,andself-esteem;itisarolewithwhichallSoldierscanidentify.TheprocessofreturningtoworkbeginsassoonastheSoldierentersthemedicalsystem.ItrequiresacollaborativeteamapproachasSoldierstransitionbetweenacuterehabilitationandworkrehabilitation.WhentheSoldierenterstheWTU,theOTpractitionerperformsaninitialscreeningtoaddresslifeskills,occupationalperformance,andpotentialforworkplacement.Duringintake,acollaborativeassessmentaddressestheSoldiersoccupationalhistory(bothmilitaryandcivilian),trainingandeducation,functionalabilitiesanddeficits,andfutureplansandgoals.ThisassessmenthelpstheSoldieridentifyoccupationalgoals,identifyavenuestoreachthosegoals,andinstillthemindsettoachievethestatedgoals.Occupationaltherapyassessmentsmayinclude,butarenotlimitedtolifeskillsassessments,cognitiveassessments,vocationalinterestsurveys,vocationalaptitudeandcareerassessments,occupationalperformanceassessments,Warriorfunctionalcapacityevaluations,anduseofdrivingorfirearmtrainingsimulators.Occupationaltherapypractitionersassesslimitationsthatpreventordelaythereturntotheworkerroleandproviderecommendationsformodificationsand/orequipmentneeds.Followingtheinitialintake,eligibleSoldiersareassignedtoameaningfuljobthatiswithinthelimitsoftheirphysicalprofileandcommensuratewiththeirgrade.TheSoldiersareplacedindutyassignmentsthatincorporatemilitaryoccupationalspecialtyrelatedtasks,training,and/oreducationtowardanoccupationalgoal.OccupationaltherapypractitionersworkcloselywiththeWTUtriadtocoordinatevocationaltraining,jobskillstraining,andworkplacementforSoldiers,withconsiderationgiventotheskillsandinterestsoftheSoldier.TheWTUwillmaintainafileoneachworkreintegrationsitewhichincludes,butisnotlimitedtothejobdescription(duty/workhours,dresscode,andpointofcontact),amemorandumofagreement,andthephysical,cognitive,andpsycho-socialjobrequirements.Thesquadleader,inconsultationwithOT,willmaintainregularcontactwiththeworksiteandwillrecord/reporttheSoldiersworkperformanceandsatisfaction.CommunityreintegrationactivitieshelppreparetheSoldierforsuccessfuldailylifeasanactiveparticipantwithinthecommunity.DutyassignmentsthatinvolvetheVAworkprogramsand/orothervocationalorworkprogramsmayhelptheSoldieridentifyandaccessresourceswithinthecommunity.Addressingcommunitymobility,includingpublictransportationordrivingskills,andpracticingenrollmentineducationalactivitieswhilestillintheWTUhelptoeasetheSoldierstransitionbacktocommunityliving.ParticipationinrecreationalorsportsactivitiesandcommunityoutingsalsohelpsmaintainalinktothecommunitywhilepreparingtheSoldiertopursueindependentleisureactivities.TheSoldiersFamilyorcareprovidermaybeengagedinthedevelopmentofatransitionalcareplanandorlifecareplanwhenadditionalorongoingservicesarerequired.TheOTpractitionerdevelopscollaborationswithinthecommunitytodetermineresourcesandtopreventduplicationofservices.Insummary,occupationaltherapysroleintheWTUappliesafunctionalapproachtohealingthroughdoing,bymatchingtheindividualsinterests,skills,andabilitieswithactivitiesthathavemeaningandpurpose,alongwiththejustrightchallenge.Afocusonoccupationalperformancehelpsrestoreconfidenceandcompetence.Lifeskillscomponentspromotefunctionalindependencethatwillenhancefuturequalityoflife,whilepreparingtheSoldierforalifetimeofproductiveliving.Participationinworkreintegrationpromotesasenseofmastery,apositiveself-identity,andtheacceptanceofpersonalresponsibilityandcontroloveronesownfuture.

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24www.cs.amedd.army.mil/references_publications.aspxREFERENCES1.AmericanOccupationalTherapyAssociation.Occupationaltherapypracticeframework:domainandprocess.AmJOccupTher.2002;56:609-639.2.AmericanOccupationalTherapyAssociation.OTServicesinWorkRehabilitation.Availableat:http://www.aota.org/practitioners/resources/docs/factsheets/conditions/39826.aspx.Accessed23February,2008.3.AmericanswithDisabilitiesAct,42USC12101-12213(1990).4.FM4-02.51.CombatandOperationalStressControl.Washington,DC:USDeptoftheArmy;July2006:chap12,sec12-6.5.PendletonHM,Schultz-KrohnW,eds.PedrettisOccupationalTherapy:PracticeSkillsforPhysicalDysfunction.6thed.Burlington,Massachusetts;Elsevier:2007:265-266.AUTHOR COLEricksonisIMAChief,OccupationalTherapyProponencyOfficeforRehabilitationandReintegration,OfficeofTheSurgeonGeneralHealthPolicyandServices,Alexandria,Virginia.TheRoleofOccupationalTherapyinWarriorTransitionUnits COLDEBBOUNISTHENEWCHAIRMAN,AMEDDJOURNALEDITORIALREVIEWBOARDCOLPASQUARELLAJOINSTHEBOARDAftersevenyears,COLJamesM.Lamiell,MC,USA,isleavinghispositionasChairmanoftheAMEDDJournalEditorialReviewBoard.COLLamiellisanoriginalmemberoftheBoard,joiningasChairmaninNovember,1999.Throughouthistenure,COLLamiellhasbeenasteadfastadvocatefortheJournal,andwethankhimforhisdedicationtothehighstandardsandprofessionalqualityofthispublication,andhisyearsofleadershipandsupporttoourmission.ThenewChairmanoftheEditorialReviewBoardisCOLMustaphaDebboun,MS,USA.COLDebbounisChief,MedicalZoologyBranch,AcademyofHealthSciences,AMEDDCenter&School,FortSamHouston,Texas,andacurrentmemberoftheBoard.TheAMEDDJournalalsowelcomesCOLMichaelA.Pasquarella,MC,USAasanewmemberoftheEditorialReviewBoard.COLPasquarellaisChief,DepartmentofMedicalScience,AcademyofHealthSciences,AMEDDCenter&School,FortSamHouston,Texas.TheEditors

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JanuaryMarch200825TheWarriorTransitionUnits(WTU)areprovidinganalternativetothetraditionaldiseasemodelwhichsuggeststhatindividualswhoarewounded,ill,orinjuredcanonlyachieverecoveryandoptimalhealthbyaddressingthephysicalconsequencesoftheirillnessorinjury.Inthediseasemodel,thoseSoldierswhosephysicalconditionsleadtoadisabilityareoftentreatedaspeoplewhoareincapableofbecominghealthy.Thealternativesocialmodeldescribesdisabilityasaformofsociallyimposedrestrictionsandbarriersthatcanberemovedtoreturnthepersonwithdisabilitytogoodhealth.Theoutcomeofcombiningthebestaspectsofbothmodelsresultsinaholisticapproachtocaringforpeople.Aholisticmodelofrecoveryandrehabilitationfocusesonthesocialcontextofwounded,ill,andinjuredSoldiers(WarriorsinTransition)inadditiontoaddressingtheirmedicalneeds.Itistheresponsibilityofthemultidisciplinarytreatmentteam,includingthesocialworkerandWTUtriad(primarycaremanager,nursecasemanager,andsquadleader),toensurethedeliveryofoptimalhealthcareandalsotocollectivelyeliminatebarriers,restrictions,andthestigmaassociatedwithinjury,illness,anddisability.Byadheringtothesetworesponsibilities,Soldiersareabletofocusonbothphysicalandpsychologicalhealingandareturntogoodhealth.Socialworkersaretrainedtoviewanindividualasaperson-in-environment.Inregardstotheperson,socialworkersleadthewayinassessingandaddressingthespiritual,intellectual,emotional,physical,andsocialaspectswhichcomprisethewholeperson.Asforenvironment,socialworkersareconcernedaboutlivingconditionsimpactinghealingandrecovery.Inshort,socialworkershave2clientswhenworkingwithanindividualthepersonandtheircommunity.Byaddressingboththepersonandtheirsocialcommunity,socialworkersareinastrongerpositiontohelpWarriorsinTransitionandtheirfamiliesbyshapingtheirenvironmentinorderforthemtoachieveafullrecovery.TheholisticapproachtohealingandrecoveryisbasedontherecognitionthatWarriorsinTransitionarewholepersonswithcomplexpsychosocialneedsandshouldnotbedefinedsolelybytheirmedicalcondition.NotallWarriorsinTransitionwillrequiresocialworkservices,butallwillrequireasocialworkassessment.Thisassessmenthelpsthetreatmentteam,WTUtriad,andSoldieridentifyandcapitalizeontheSoldiersstrengthsthroughouttherecoveryandhealingprocess.NotonlyistheSoldiercapableofreturningtogoodhealth,buthelearnstogainmorecontroloverhislife,maintainapositiveselfimageandidentity,improveandstrengthenprimaryrelationships,developself-careskills,andovercomesocialandculturalobstacles.Socialworkerstakeintoaccountthediversityofthepopulationtheyserve,includingserviceorientation,rank,occupationalspecialty,age,race,ethnicity,familystructure,gender,religion,andsex.MackelprangandSalsgiver1present6guidingsocialworkprinciplesassociatedwithdisabilitywhichIhaveadaptedtotheWarriorinTransitionpopulationforthepurposeofthisarticle:1.WarriorsinTransitionarecapableandhavepotential.2.Devaluationandthelackofresourcesarepri-maryobstaclesfacingWarriorsinTransition.3.SocialandpoliticalinterventionsmustbeemphasizedwithWarriorsinTransition.4.ThereexistsanegativeattitudeaboutinjuryandillnesswithinthemilitaryculturewhichprofessionalsshouldbeawareofinordertofacilitatetheempowermentofWarriorsinTransition.WhatCanSocialWorkersDoforWarriorsinTransition?RenJ.Robichaux,PhD,LCSWCOLNicoleM.Keesee,MS,USA

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26www.cs.amedd.army.mil/references_publications.aspx5.ThereisjoyandvitalitytobefoundinbeingaWarriorinTransition.6.WarriorsinTransitionhavetherighttoself-determinationandtherighttoguideprofes-sionalsinvolvementintheirlives.Formoreinformationaboutthemedical,social,andholisticapproachtopeoplewithdisability,IrecommendthearticlebyKimandCanda.2ThebehavioralhealthsocialworkerassignedtotheWTUprovidesacomprehensivebehavioralhealthandpsychosocialassessmentforallWarriorsinTransition,managesrisksidentifiedduringtheinterview/assessment,anddocumentsintoAHLTA*theactionstaken,ensuresSoldierand/orFamilymembercounseling/treatmentusingtheappropriatemodality(ifindicated),collaborateswiththeWTUtriadandothermembersofthemultidisciplinarytreatmentteam,andprovidesavarietyofsocialworkservicesasindicated.TheprimaryresponsibilityofthebehavioralhealthsocialworkeristoprovidetheSoldierandthehealthcareteamwithacomprehensivepsychosocialassessmentoftheSoldiersbehavioralhealthneedsatthetimeoftheirattachmentorassignmenttotheWTU.Throughself-assessmentquestionsandstructuredinterviews,thebehavioralhealthsocialworkerwillbeabletoidentifySoldierswhoareexperiencingpsychologicaldistresssuchasdepression,anxiety,andpost-traumaticstressdisorder,whomaybestrugglingwithalcoholabuse,sleepdisturbance,moodproblems,excessiveanger,relationshipproblems,andfeelingsofhopelessness.Inaddition,theassessmentwillhelpidentifythoseSoldiersinneedofamorein-depthevaluationand/oridentifySoldierswhomightnothavebeenpreviouslydiagnosedwithmildtraumaticbraininjury.Oncetheassessmentiscompleted,theroleofthesocialworkeristomanagetheidentifiedrisks(problems)andensurethatfurtherspecialtyevaluationsareinitiated.ThesocialworkerwillworkcloselywiththeWTUnursecasemanagertoensurethatacomprehensivebehavioralhealthtreatmentplanisdevelopedandinitiated.WhileWarriorsinTransitionmayseeothermembersofthebehavioralhealthtreatmentteam,suchasapsychiatristformedication,andapsychologistforcognitivebehavioraltherapy,thesocialworkercanhelptheWarriorinTransitionwithrelationshipproblemsthathavebeencreatedbyorexacerbatedbytheirinjuries.InordertobesthelptheWarriorsinTransition,thesocialworkermayneedtoinvolvetheirspouses,familymembers,and/orsignificantothersintheirtreatment.TheremayalsobetimeswhenthesocialworkerwillneedtointervenewithothersystemsontheSoldiersbehalf,toensuretheWarriorinTransitionreceivesthebestcarepossible.Tomaximizetheeffectivenessofthesocialworkerinprovidingcomprehensivebehavioralhealthservices,itisimperativefortheWTUtriadandmultidisciplinaryteamtorefertheSoldierand/orFamilymembersandencouragefullparticipationwiththesocialworkassessmentandfollow-onservices.Insummary,goodhealthisoftendefinedastheabsenceofdisease,injury,orimpairment.TheholisticapproachtotreatmentallowshealthcareprofessionalstoviewWarriorsinTransitionascapableofreturningtoduty.Socialworkersaretrainedtoexcelin4areas:advocacy,resourcing,networking,andtheprovisionofservices.AsocialworkpresencewithintheWTUisessentialtothepromotionofSoldierhealthandwellbeing.REFERENCES 1.MackelprangR,SalsgiverR.Disability:ADiversityModelApproachinHumanServicePractice.PacificGrove,CA:Brooks/ColePublishingCompany;1999.2.KimKM,CandaER.Towardaholisticviewofhealthandhealthpromotioninsocialworkwithpeoplewithdisabilities.JSocWorkDisabilRehabil.2006;(2).49-67.AUTHORS DrRobichauxisSocialWorkProgramsManager,BehavioralHealthDivision,USArmyMedicalCommand,FortSamHouston,Texas.COLKeeseeisCoordinator,ContinuumofCareandTransitionServices,WarriorTransitionOffice,WarriorCareandTransitionDirectorate,OfficeofTheSurgeonGeneral,FallsChurch,Virginia. *TheUSmilitaryelectronicmedicalrecordWhatCanSocialWorkersDoforWarriorsinTransition?

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JanuaryMarch200827YOURDREAMJOBTURNSINTOYOURWORSTNIGHTMAREYouhavejustlandedthatcovetedcommanderordeputycommanderpositionandyouareridinghigh.YouhavegreatplansfortheworldofhealthcareandareplanninghowyouwillimprovethecareyourMTFprovidesitspatients,whenyourworldisturnedupsidedownbyamajorfacilitycatastrophe.Itdoesnthavetobeafrontpagearticleinanationallyreadnewspaper.ItcouldbeafailingmarkonaJointCommission*surveyorotherinspection.Itcouldbeanequipmentmalfunctionthatpreventsyoufromprovidingakeyserviceor,worse,resultsininjuryordeathtoapatientorstaffmember.Imaginethefollowingscenarios:Scenario#1:Yourfacilityisundergoinganinspection.Astheinvestigationgroupentersyourolderfacilityitseemstobewellmaintained.Nooneinthefacilitymanagersofficeseemsnervous.Everyoneseemsprofessionalandatease.Theinspectionteamasksthefacilitymanagertopresentspecificfacilitiesmetricswhichheseemstoknowoffthetopofhishead,butreadilypullsthemfromhiscomputer.Theinspectionteamwalksaroundandfindsafacilitythatiswell-maintained.Theteamleaveswiththeimpressionthatthefacilitymanagerknowshisjobandthefacilityiswellmaintained.Scenario#2:Yourfacilityisundergoinganinspect-tion.Astheinvestigationgroupentersyourolderfacility,thefacilitymanagerseemsevasiveandonedge.Whenaninvestigatorrequeststoseenumerousmetrics,thefacilitymanagerstateshewillneedtocallhiscomputerguy.Thecomputerguycomesinandisstillnotabletoproducethemetrics,butdoesproducealistofreasonswhytheydidnothavethedataandtellsthegroupwhowastoblameforthesystemnotworkingcorrectly.Thefacilitymanagertellsthegrouptheproblemcouldberesolvedwithinoneweek,butareviewoftherecordsindicatesverylittledatahadbeenenteredforatleast7years.Theinspectionteamwalksaroundandfindsafacilitythatispoorlymaintained.Theteamleaveswiththeimpressionthatthefacilitymanagerdoesnotknowhisjobandthefacilityispoorlymaintained.ThoseareactualscenariosfromArmyMedicalCommand(MEDCOM)inspectionsofMEDCOMfacilities.Obviouslyyouwanttobeinvolvedinscenario#1,notscenario#2,butwaitinguntilinspectiondaytofindoutwhatscenarioyourepresentisprobablynotthewisestcourseofaction.Mostfacilitymanagersknowtheirbusinessandwillkeepthefacilityoutoftrouble,buthowdoyouknowyouhavefacilitymanager#1andnotfacilitymanager#2?YoudonotwanttowaitforadeathorinjuryorforyourMTFtobeonthefrontofthelocalnews,oruntilyouareinthemiddleofaninspectiontofindout.Youdonthavetobeanexpertinfacilitymaintenanceyourselftogetanindicationofthequalityofyourmaintenanceprogram.Thisarticlewillgiveyousometoolstoassessyourprogram.FACILITYFACT:Facilitiesfoundingoodconditionalwayshavegoodmaintenancedata.Hereareafewofquestionsyoumaywanttoaskyourfacilitymanagerwhenyoufirstmeetinhis/heroffice:Whatareourcriticalassetsandhowdidyoudeterminethem?Answer:Criticalassetsshouldberankedbasedonriskwhichshouldbedeterminedbythecommanderwithrecommendationsfromthestaff.Thedeputycommandersshouldhelpidentifywhichassetsaredefinedascritical.Thehighestriskassetmaybeonethatwouldcauselossoflifeorlimbifitweretofunctionallyfail.Thenexthighestriskassetswouldbethosethatwouldpreventyoufromperformingyourmissioniftheyweretofunctionallyfail.FunctionalFacilitiesMaintenance:UncoveringtheBlackHoleMAJRickySmith,USAR *JointCommissiononAccreditationofHealthcareOrganizations,OneRenaissanceBlvd,OakbrookTerrace,Illinois60181.

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28www.cs.amedd.army.mil/references_publications.aspxfailuremeanstheassetisnotmeetingtheneedsoftheowner.Anexampleofhighriskmaybeabackupgeneratorforlifesupportorfireprotectionsystem,orasteamsterilizerrequiredforsurgicalprocedures.Mostfacilitymanagerswilltellyouthattheycontractthatmaintenanceout.Thatdoesnotletthemoffthehook.Theyarestillresponsibletoknowthestatusofthemaintenanceandreliabilityofallassets,especiallycriticalassets.Whatisthepreventivemaintenancecompliance percentageofourcriticalassets?Answer:Thepreventivemaintenanceprogramcompliance(reportedasapercentageofpreventivemaintenancecompletedontime)forcriticalassetsshouldbereportedmonthlytotheMTFcommander.TheMTFcommandershouldalwaysbeinformedwhenpreventivemaintenancecomplianceforcriticalassetsislessthan100%usingthe10%Rule.Theriskmaynotbeacceptable.The10%RuleofPreventiveMaintenancesimplystatesthatapreventivemaintenanceactionscheduledforanassetmustbecompletedwithin10%ofthetimefrequency.Anexample:Ifapreventivemaintenanceprocedureistobeperformedevery30days,itmustbecompletedwithin3daysofthatfrequencyoritisoutofcompliance.Irecommendyouapplythisruleonlytocriticalorhighriskassets.Whatmetricsareyouusingtomeasurethe effectivenessofourpreventivemaintenanceprogram?Answer:Youarelookingformetricswhichshowatrendovertimeandarecomparedtoothermetrics(Figure1).ThischartshouldbedevelopedandreportedmonthlytotheMTFcommander.Inaddition,ensureyourfacilitymanagercanshowyou100%ofmaintenancelaboriscoveredbyserviceorworkorders.Whatpercentageofthepriority1serviceorders arenotcompletedwithin24hours?Answer:TheUSArmystandardisthatpriority1serviceordersareallcompletedwithin24hours.Iwouldrequirethismetrictobetrendedandincludeallpriority1serviceordersonallassets.Donotacceptexcuses.WORRISOMECOMMENTSFROMAFACILITYMANAGERThesereportscannotbedevelopedwiththesoftwaretheyarecurrentlyusing.ThecurrentsoftwaretheUSArmyprovidesformaintenanceoffacilitieswillprovidethesereportsthedataisentered.Thecontractdoesnotstatethatwemusttrackthesemetrics.Thismaybecorrect.However,Iwouldimmediatelydirectmycontractingofficertomodifythecontractandensurethemetricsaretrackedandusedtodeterminecontractorbonuses.Sir/Maam,letmedomyjob.Youworryaboutthemedicalstuff,Illworryaboutthemaintenancestuff.Youdowanttoletthemdotheirjob,butiftheyareuncomfortablewithyourquestions,howmuchmoreuncomfortablewilltheybewhenaninspectorisaskingthequestions?MAINTENANCEFALLACIESYOUWILLHEARMaintenancefallaciescanresultinfailure.Haveyouheardtheminyourorganization?These 0204060801001201401601801stQtr2ndQtr3rdQtr4thQtr EM PMFigure1.Chartillustratingthedirectrelationshipbetweenpreventivemaintenance(PM)laborhoursandemergencymaintenance(EM)laborhours.Itisalmostunavoidablethatadecreaseinpreventivemaintenancewillresultinanincreaseinemergencylabor,withattendantdisruptionsinproductivityandincreasedoperatingcostsforthesupportedfacility. FacilitiesMaintenance:UncoveringtheBlackHole

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JanuaryMarch200829THEARMYMEDICALDEPARTMENTJOURNALexcusesareajokeamongproactivemaintenanceorganizationsbecausetheyarenottrue.NotimeforpreventivemaintenanceHighfrequenciesofemergencyrepairseemtotakeyouravailablelabortimeawayfrompreventivemaintenance.Togetoutofthatspiral,youmustfirstidentifyhighpriorityassets,andrestorethemtoamanageablemaintenanceroutine.Next,applypreventivemaintenanceproceduresonadisciplinedschedule.Youwillneverovercomeemergencymaintenanceburdensuntilyougetpreventivemaintenanceundercontrol.Emergencyrepairfrequencieskeep goingupfornoknownreason.Whenyouhavesomanyproblemsyoucannotdealwiththem,youmuststepbackanddevelopagoodplantogetthemundercontrol.Thefirststepistotrackallfailuresbyusingametriccalledmeantimebetweenfailure(MTBF).Thismetricallowsyoutofocusontheassetwhichisfailingthemost.Youderivethemetricbydividingunitsoftimebythenumberofemergencyrepairsequencesoccurringduringthattime.Forexample,performing3emergencyrepairsequencesin24hoursgivesyouaMTBFofeight.Notenoughmoneytohireanexpert Ioncevisitedafacilitywheretheroofhadfailednumeroustimes.Overtheyearsduringwhichtherooffailed,theorganizationrepeatedlyrepairedorreplacedtheceiling,flooring,andwalls.Themaintenancemanagerexplainedthattheroofwasnotrepairedproperlybecausethemaintenancepersonwasnotformallytrainedinroofingbutwasthebestonstaff,andthemanagercouldnotaffordtohirearoofingcompany.Thisstatementseemedtoaskmorequestionsthanitanswered,sincethecostofrepeatedroofrepairandroomdamagemusthavefarexceededthecostofhiringaprofessionaltorepairitcorrectlyinthefirstplace.NotenoughmaintenancestaffYouwillneverhaveenoughmaintenancestaffifyoudonotreduceyouremergencyrepairrequirementsforfailingassets.Youalsoneverwillcontrolthefailuresifyoudonotdevelopandmanageatruepreventivemaintenanceprogramfocusingoncriticalassetsfirst.Skimpingonmaintenanceisacceptable becausethisbuilding/equipmentisscheduledforretirement.Arethedemandsorexpectationsonapieceofequipment,orafacility,beingreduced?Ifnot,theymustbemaintainedtofullcapabilityandfunctionality.USArmyMedicalCommandcriteriaformaintaininganassetistofollowreliability-centeredmaintenancemethodologywhichstatesthatanassetmustmeetthefunctionalcapabilityoftheneedsoftheuser.Iftheassetorfacilitydoesnotmeetuserneeds,ithasfailedfunctionally.Assetsorfacilitiesmustbemaintainedtofullfunctionalityuntiltheyarepermanentlyclosed,retired,ordeactivated.SEEINGISBELIEVING:USETHEEYETESTTOCHECKYOURFACILITIESStartwithyoufacilitymanagersoffice.Isitwellmaintained,clean,neat,andorderly?Canheorshereadilyprovidethedatayourequest?Doanunannouncedwalk-throughofyourmedicaltreatmentfacilityandlookforsubtlehintsofproblemswithyourpreventivemaintenanceprogramwhichcouldcauseseriousproblemsthroughoutyourcommand.Askforsomeonewhoknowstheirwayaroundthefacility(yourfacilitymanagerwillwork)togiveyouatour.Makesureyoudirectthetourandgowhereyouwanttogo,toincludeanyundergroundtunnels,mechanicalrooms,storageareas,andothernonpublicareas.TheseroomscontaintheairhandlersthatmovetheconditionedairintoandoutoftheMTF.Theremaybepumpingsystemsandpipesinthoselocations.VisitnumerousmechanicalroomsthroughouttheMTFandtakenotes,makenocomments,butaskquestions.Lookfortrash,brokeninsulationonpipes,cigarettebutts,leakingwater,leakingair,usedparts,brokenequipment,inappropriatestorage,etc(Figure2).

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30www.cs.amedd.army.mil/references_publications.aspxVisittherooftolookforpatchesontheroof,placeswherepeoplehaveleftparts,trash,etc.Lookforsignsofrustonvents,etc.Askthefacilitymanagerabouttheroofreplacementcycleandifhehasaplantoreplacetheroof,andabudgetfortheproject.Ifhesaysno,askwhatistheexpectedlifeoftheroof.Goinsidethefacilityandlookforleaks,oftenindicatedbydarkspotsintheceilingtile.Lookforanythingthatlooksoutoftheordinaryasifitwereyourownhome.Walkingaroundthefacilityonceaweekwithdifferentleadersandthefacilitymanagerwillbringbigrewardsforeveryone.FACILITYASSISTANCEANDASSESSMENTSUPPORTTEAM:AWELLKEPTSECRETSupplyBulletin8-75-11requiresMEDCOMtoperformaninspectionofeachMTFevery36monthstoensuretheMTFcommandersandfacilitymanagershaveanoutsideorganizationidentifyrisksintheirMTFs(notnonmedicalfacilities).1TheFacilityAssistanceandAssessmentSupportTeam(FAAST)providesassistance,assessment,feedback,andoversightrelativetotheFacilities/LogisticsCommandReviewProcess.1(pp8-31-33)TheFAASTsservicesincludethefollowing:ProvidecomprehensiveexpertisetofacilitymanagersandcommandersofMEDCOMMTFsinsupportofthefacilitymanagementfunction.Supportcommandersagainstliabilitiesfromoutsideagencies,suchastheOccupationalSafetyandHealthAdministration,theEnvironmentalProtectionAgency,etc.AssistandtrainthefacilitymanagementorganizationattheMTFlevelonhowtomeetand/orexceedtherequiredstandards,andtopreparefortheJointCommissionandotheraccreditationsurveys.Provideorganizedmanagementtoolstoidentify,prevent,oreliminateproblemareas.Thosetoolsincludeidentificationofsystemicissuesandproblemstothefacilitydirectors.CONCLUSIONEstablishaproactivemaintenanceprograminyourmedicaltreatmentfacilitywhereeveryoneisaccountableformaintenanceofthefacility.HerearethestepsIwouldfollow:1.Identifycriticalassets.Directyourdeputiestoestablishateamtoidentifycriticalassetsinyourfacility.Theseshouldincludefirechief,safetyofficer,facilitymanager,theelectricianwhohasbeenatthefacilitythelongest,andmaybeFacilitiesMaintenance:UncoveringtheBlackHole Figure2.Examplesofpotentiallyseriousmaintenanceproblemsthatcanbeeasilyidentifiedbysimplywalkingthroughoutafacility,includingallofitsmechanicalroomsandspaces,andlookingforsuchdiscrepancies. Awaterleaknearahighvoltageelectricalpanelhasthepotentialtocauseadeadlyexplosion. Astairtreadinneedofimmediaterepair.Theunrepairedtreadisaserioustriphazardonabusystairwell. Thestainindicatesaleakingpipeintheceiling.Suchleakscancreatetheenvironmentforgrowthofmoldandmildew,someofwhichcanbetoxic.Asteamleakinanelectricalareacouldresultinapoweroutage,alongwithotherfailuresanddamage.

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JanuaryMarch200831THEARMYMEDICALDEPARTMENTJOURNALsomeonefromMEDCOMfacilitiesengineering.Clinicalstaffmustidentifyequipmentthathaltsmissionaccomplishmentifitfails.2.Monitormetrics.Establishafacilitiesmaintenancedashboardwithtrendspostedsomewhereinyouroffice.Requirethatthesamemetricsarepostedinthemaintenanceshopandinthefacilitymanagersoffice.3.Watchforwarningcomments(page28).4.Watchformaintenancefallacies(page29).5.Dounannouncedwalk-arounds.Seeingisbelieving.6.RequestaFacilityAssistanceandAssessmentSupportTeaminspectionofyourfacilitiesfromtheMEDCOMFacilitiesGroup.Ihavecoauthored2bookswhichdealdirectlyandingreaterdetailwiththetopicsdiscussedinthisarticle,RulesofThumbforMaintenanceandReliabilityEngineers2(onechapterofthisbookisfocusedstrictlyonrankingassetsbasedonrisk)andLeanMaintenance.3Bothbookshavelistsofmetricswhichareusedbysomeoftheleadingcompaniesintheworldtomanagetheirmaintenance.REFERENCES 1.DepartmentoftheArmySupplyBulletin8-75-11.Washington,DC:USDeptoftheArmy;20November2007:chap8.2.SmithR,MobleyRK.RulesofThumbforMaintenanceandReliabilityEngineers.Burlington,Massachusetts;Elsevier:2008.3.SmithR,HawkinsB.LeanMaintenance.Burlington,Massachusetts;Elsevier:2004.AUTHOR Atthetimethisarticlewaswritten,MAJSmithwasDirectoroftheProcessImprovementTeam,ArmyMedicalActionPlan,OfficeofTheSurgeonGeneral,Alexandria,Virginia.

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32www.cs.amedd.army.mil/references_publications.aspxINTRODUCTIONForthepast5yearstheArmyhasbeenheavilyengagedinoperationsinsupportoftheGlobalWaronTerror(GWOT)andhasincreasedeffortstomanagethehealth,welfare,andreadinessofReserveandNationalGuardSoldierswhoareinjuredorbecomeillwhileservinginthelineofduty.TheArmyhasenactedprogramstoensurecareisavailableandprovidedforGWOTconnectedillnessandinjury,aswellasinjuries,illness,ordiseaseincurredwhileinanonmobilizedactivedutystatus.Thisarticleprovidesabriefoverviewoftwooftheseprograms,MedicalRetentionProcessing2(MRP2)andActiveDutyMedicalExtension(ADME)respectively.ThemajorityofthisinformationistakendirectlyfromtheWarriorsinTransitionConsolidatedGuidanceissuedbytheDepartmentoftheArmy.1BACKGROUNDTheADMEprogramwasestablishedtoplaceReserveandNationalGuardSoldiersonorderstoundergomedicalcare.ThisprogramisavailabletodrillingReserveComponentSoldierswhohaveincurredanon-GWOTrelatedinjury.Historically,thisprogramwasmanagedbyHeadquarters,DepartmentoftheArmy(HQDA)G-1untilOctober2006.ApplicationsweresubmittedtoamedicalpolicyteaminG-1,whoreviewedthepacketandpublishedtheorders.AfterOctober2006,programmanagementwasmovedtoamobilizationteam.ThepolicyoversightfortheADMEprogramcontinuestobemaintainedatHQDAG-1.TheSoldiersubmitsanapplicationpacketthroughhisorherunittothemobilizationteam,locatedattheArmyHumanResourcesCommandinAlexandria,Virginia.Themobilizationteamreviewsthepackettoassureallinformationiscomplete.Theyforwardthepackettoa3-personmedicalreviewboardforevaluation.TheMRP2programwasestablishedon17April,2006bytheAssistantSecretaryoftheArmy,ManpowerandReserveAffairs,toprovideanopportunityfordemobilizedReserveandNationalGuardSoldierswhohadbeeninjuredinGWOTtobeplacedonactivedutyordersformedicalcareandtreatment.TheSoldiersapplicationprocessincludesreviewbyamedicalreviewboard.OVERVIEWBoththeMRP2andADMEprogramsaredesignedtoexpeditiously,effectively,andcompassionatelyevaluateandtreatArmyReserveandNationalGuardSoldierswhohavealine-of-dutyincurredillness,injury,disease,oraggravatedpreexistingcondition.AmilitarymedicalauthoritymustfindthattheSoldierhasanunresolvedline-of-duty(serviceconnected)medicalcondition,meetsprogrameligibilitycriteria,andvoluntarilyrequestsparticipationineitheroftheMRP2orADMEprograms.Theprogramsaredesignedtoprovideongoing,acute,interventionalcaretoreturntheSoldiertoretentionstatusandbacktodutywithhisorherrespectiveArmyReserveorNationalGuardunitassoonaspossible.Ifreturntodutyisnotpossible,theSoldierwillbeprocessedthroughtheArmyPhysicalDisabilityEvaluationSystem(PDES).Theprogramsapplytobothinpatientandoutpatienttreatment.MEDICALRETENTIONPROCESSING2TheMRP2programprovidesforthetemporaryreturntoactivedutyofArmyReserveandNationalGuardSoldierspreviouslymobilizedinsupportofGWOT.UnderMRP2,Soldiersmayvoluntarilyreturntoactivedutyspecificallyformedicalevaluationandtreatment,and,ifnecessary,processingthroughthePDESforinjuryorillnessincurredoraggravatedduringapreviousperiodofmobilizationinsupportofGWOT.1Tobeeligible,theSoldiermustsubmitanapplicationthroughhisorhercurrentchainofcommand,andhavedocumented,unresolvedline-of-dutymedicalissues.MedicalCareforArmyReserveandNationalGuardSoldiersintheGlobalWaronTerrorCOLSusanDurham,AN,USACOLAnneBauer,AN,USA

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JanuaryMarch200833TheReserveComponentSoldierhas6monthsfromthedateofreleasefromactivedutytosubmittheapplication.TheSoldiermustremainamemberoftheSelectedReservesortheIndividualReadyReserve.Forcertaincircumstances,HQDAG1isauthorizedtograntexceptionstopolicy.1AmedicalreviewboardwilldeterminetheSoldierseligibilityforMRP2.TheSoldiermustbecounseledbyhisorherunitontheMRP2programandincapacitationpaybeforesubmittinganapplicationtotheprogram.TheSoldiermustalsovolunteerforrecalltoactivedutyformedicalassessmentandtreatment.Ordersareissuedfor179daysandmayberenewed,ifmedicallyindicated.ASoldiermaydeclineMRP2uptothetimeofpublicationoftheMRP2order.IftheSoldierwishestowithdrawtheapplication,heorshemustsignadeclinationstatement.HeorshemaydeclineMRP2withoutprejudicepriortothepublicationoforders.ACTIVEDUTYMEDICALEXTENSIONTheADMEprogramisdesignedtoplaceArmyReserveorNationalGuardSoldiersonvoluntarytemporaryactivedutyforevaluationortreatmentofline-of-dutyservice-connectedmedicalconditionsorinjuries,andreturnthemtodutywithintheirrespectiveunitsassoonaspossible.IfreturntodutyisnotpossibleunderADME,theSoldierwillbeprocessedthroughtheArmyPDES.1ThemedicalconditionmusthavebeenincurredoraggravatedwhileinanIndividualDutyforTrainingornonmobilizationactivedutystatus,andtherequirementformedicalcaremustextendbeyond30days.ThemedicalconditionmustpreventtheSoldierfromperforminghisorhermilitaryspecialtydutieswithintheconfinesofaphysicalprofile(DAForm3349)issuedbyamilitarymedicalauthority.AmedicalreviewboardwilldeterminetheSoldierseligibilityforADME.TheSoldiermustbecounseledbyhisorherunitontheADMEprogramandincapacitationpaybeforesubmittinganapplicationtotheprogram.APPLICATIONPROCESSTheapplicationprocessissimilarforbothprograms,andhasbothadministrativeandmedicalchannels.TheSoldiersunitsubmitsapplicationpacketsviaFAXtotheArmyHumanResourcesCommandinAlexandria,Virginia.Thepacketisreviewedforadministrativeeligibilityandcompleteness.Ifadministrativecriteriaaremet,thepacketissenttotheADME/MRP2MedicalReviewBoardformedicalreviewandaneligibilitydecision.TheADME/MRP2MedicalReviewBoardisanelectronicboardof3membersrepresentingtheNationalGuardBureau,ArmyReserve,andtheOfficeofTheSurgeonGeneral/USArmyMedicalCommand,respectively.Allboardmembersmustbelicensedproviders(physician,nursepractitioner,orphysiciansassistant).Onemembermustbeaphysician,andtheremustbeonememberwiththerankofcolonel.EachpacketisreviewedbytheboardtodetermineifsufficientdocumentationisincludedtomakeasoundclinicaldecisiontoreturntheSoldiertoactiveduty.Decisionsaremadeusingprofessionalclinicaljudgmentinaccordancewithpolicyguidelines/criteriasetforthintheWarriorsinTransitionConsolidatedGuidance.1TwooftheboardmembersmustrecommendapprovalbeforeaSoldierisofferedADMEorMRP2orders.IfaSoldierisnotrecommendedbytheboard,heorshemayresubmitorappealthedecision.ResubmissionisarequestbytheSoldiertohavetheoriginalpacketreviewedagainbytheboard,withtheinclusionofadditionalclinicaldocumentationandinformation.AppealisarequestbytheSoldiertohavetheoriginalpacketreviewedbyahigherlevelauthority.Thepacketwillincludealloriginallysubmitteddocumentationonly.Itmaynotincludeanyadditionalclinicalormedicalinformation.Keycomponentsformedicalreviewareadefinitivetreatmentplan,whichincludesdiagnosisandprognosis,andaspecifictreatmentplanwhichmayincludephysicaltherapy,surgery,rehabilitation,medications,etc.ThepacketmustalsoincludeanapprovedStatementofMedicalExaminationandDutyStatus(DAForm2173).ASoldierwhoseapplicationsisalreadyinthemedicalevaluationboardprocessisnotusuallybroughtintotheADMEorMRP2programsuntiltheboardactioniscomplete.CONCLUSIONTheADMEandMRP2programscontinuetoevolveandberefinedastheneedsoftheSoldiersandtheArmyemerge.NeverbeforehasourmilitarybeenfacedwiththenumbersofillorinjuredReserveComponentSoldiers,ortheseverityandlong-term

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34www.cs.amedd.army.mil/references_publications.aspxconsequencesoftheirwounds.Woundsthatcanbeseenareoftenmoreeasilyaddressedandtreated.Nonvisiblewoundsareamuchgreaterchallenge,andaresometimesnotimmediatelyevident.ThisisthegreatestchallengeintreatingtheArmyReserveandNationalGuardSoldiers.Withongoingdedicationandvigilance,theArmywillcontinuetomeettheeverchangingandchallengingneedsoftheseSoldiers.MedicalCareforArmyReserveandNationalGuardSoldiersintheGlobalWaronTerrorREFERENCE 1.WarriorsinTransitionConsolidatedGuidance.Washington,DC:USDeptoftheArmy;December2007.AUTHORS COLDurhamisDeputyDirector,ADME/MRP2,WarriorTransitionOffice,WarriorCareandTransitionDirectorate,OfficeofTheSurgeonGeneral,FallsChurch,Virginia.COLBauerisDeputySurgeon,OfficeoftheChiefoftheArmyReserve(Forward)inWashingtonDC.

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JanuaryMarch200835ThemissionoftheWarriorTransitionBattalionistoprovidethebestpossiblecaretoSoldiersastheymakethetransitiontocivilianlifeorundergorehabilitationtoreturntofit-for-dutystatus.AllWarriorTransitionBattalionpatientshavemedicalconditionsseriousenoughtopotentiallypreventthemfromperformingtheirmilitarydutiesandthereforeinherentlyrequireanddeservethebestmedicalcareandoversighttheArmyMedicalDepartmenthastooffer.Todoso,theCommandingGeneralofBrookeArmyMedicalCenterassembledamedicationreconciliationteamtaskedwithauditingmedicationriskforallBrookeArmyMedicalCenterWarriorsinTransition.Themedicationreconciliationteamconsistedof3physicians,3clinicalpharmacists,andsupportstaff.Theprojecttookplaceoveramonth,duringwhichapharmacistandphysicianperformedfacetofacemedicationreconciliationforeveryWarriorinTransition,eliminatedunnecessarymedicationsandsimplifiedmedicationregimens,updatedthepatientselectronicmedicationrecord,screenedforsubstanceabuse,educatedpatientsabouttheirmedications,andensuredtheprimarycaremanagerreceivedafinal,updatedmedicationlist.TheprocessisillustratedinFigure1.Anumberofmedicationdiscrepanciesandissueswereidentified,anditbecameevidentthattherewasroomforimplementationofnewprocessesandprogramsinordertodecreasemedication-relatedriskandimprovepatientsafety.MEDICATIONRECONCILIATIONPROCESSOver500WarriorsinTransition(WTs)attheBrookeArmyMedicalCenterwereseenformedicationreconciliation.Eachpatientbroughtallprescriptionmedications,herbals,overthecountermedications,andsupplementsinhisorherpossessiontotheappointment.Patientswereaskedaboutthequalityoftheirpaincontrol,existenceofasoleprovider,adversedrugreactions,prescriptionmedicationabuse,alcoholabuse,illegalstreetdruguse,andanyknowledgeorparticipationintraffickingordiversionofprescriptionorstreetdrugs.Excessordiscontinuedmedicationswerecollectedanddisposedoforreturnedwithtrackingreceiptstothepharmacy(Figure2).Patientswereeducatedabouttheirmedicationsandeachpatientwasgivenapocketcardlistofallhisorhercurrentmedicationstocarryandbringtofutureappointments.Modificationstotheexistingtreatmentplanwereavoidedunlessabsolutelynecessary.Resultsgenerated114referrals:4totheArmySubstanceAbuseProgram,17toprimarycaremanagerstoaddresscomplaintsofuncontrolledpain,24toprimarycaremanagersforlackofasoleprovider,and69toprimarycaremanagersformiscellaneousconcerns.RESULTSTheworkofthemedicationreconciliationteamidentifiedseveralissues:Themajorityofpatientshadincorrectmedicationprofilesintheirelectronicmedicalrecords.ManyWTswereinpossessionofmedicationstheydidnotneedorwerenolongertaking,toincludecontrolledsubstances.Theprocessforthereturnordisposalofexcessmedicationwasuncleartoboththepatientsandthehealthcareproviders.SomeWTsreportedwitnessingsimultaneousalcoholandnarcoticuse.Therewerealsoreportsofpillorpharmpartiesandmedicationsbeingusedaspokerchips.AnumberoftheWTsalsoreportedwitnessingtheTheBrookeArmyMedicalCenterExperiencewithaFocusedMedicationReconciliationProgramCPTJesseW.Neeley,MC,USASaraJ.Pastoor,MD,MHA

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36www.cs.amedd.army.mil/references_publications.aspxTheBrookeArmyMedicalCenterExperiencewithaFocusedMedicationReconciliationProgram Figure2.ExcessmedicationsreturnedtotheBrookeArmyMedicalCenterpharmacyasaresultofthemedicationreconciliationteamsactions. Figure1.TheprocessoftheBrookeArmyMedicalCenterMedicationReconciliationProgram. TheWarriorinTransitionbringsallmedicationstotheMedicationReconciliationClinicandreviewsthemedicationhistoryinhis/herelectronicmedicalrecord. PhysicianInterview1.Compliance2.Substanceabuse3.Paincontrol4.Adversedrugreactions5.Diversion6.Paincontract/soleprescriber ManagementOptions1.PatientEducation2.ReferraltoArmySubstanceAbuseprogram3.Referraltoprimarycaremanager4.Returnofexcessmedications5.Notificationofchainofcommand6.OfferinterviewwithCriminalInvestigationDivision7.Changemedications Anyquestionsand/orrecommendationsfromthepharmacist ClinicalPharmacistInterview1.Druginteractions/duplicates2.Updateelectronicmedicalrecordlist3.Generatepocketcard4.Printupdatedlistforprimarycaremanager TheWarriorinTransitionreturnstotheprimarycaremanagerforfollowup,issuemanagement,paincontract,etc.

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JanuaryMarch200837THEARMYMEDICALDEPARTMENTJOURNALtrading,sharing,andsellingofcontrolledprescriptionmedicationaswellasillicitdrugswithintheWarriorTransitionBattalionbarracksandlodgingfacilities.MultipleSoldiersreportedwitnessingtheuseandsaleofcocaine,marijuana,andmushroomswithintheWarriorTransitionBattalionbarracks.OneindividualadmittedtopersonallyusingstreetdrugswhileassignedtotheWarriorTransitionBattalion.ThisindividualdescribedatlengththesubcultureofillicitdrugusersintheWarriorTransitionBattalion.Thesamesetofindividualsusingstreetdrugswasreportedasalsousingprescriptionmedicationsand/oralcoholincombination.WarriorsinTransitionwereofferedtheopportunitytodiscusswhattheyknewwiththeArmyCriminalInvestigationDivision,butalldeclined.TheWarriorTransitionBattalionleadershipwasinformedofthereportsinageneralmanner,butnoidentificationoftheWTsmakingthereportswasprovidedtothechainofcommand.Thisprojecthighlightedaclearmedication-relatedriskforBrookeArmyMedicalCentersWarriorsinTransition,andprovidedanopportunitytoincreasesituationalawarenessforallmembersoftheWTUtriad.Theissuesrangedinseverityfrommereprocessinefficiencytoflagranthealthhazardsandillegalactivity.Recommendationstoimprovecamefrommanysources,includingtheWarriorsthemselves,andinvolvedprocessimprovement,enhancedprograms,andgreaterfocusonthescreeningandmitigationofmedication-relatedrisk.Inresponse,BrookeArmyMedicalCenterhasimplementedanaggressiveandthoroughongoingmedicationreconciliationprogramforallWarriorsinTransition.Thepharmacyhasdevelopedauser-friendlymedicationturn-inprocess.Thesoleproviderprogramisreceivingheightenedattentionandemphasis.TheWarriorTransitionBattalionchainofcommandhastakenstepstoincreaseunitactivitiesintendedtofightboredom.NeweducationalprogramsareincreasingawarenessforbothWarriorTransitionBattalionpatientsandstaffregardingmedicationsafety,selfandbuddy-referralforhelpwithsubstanceabuse,andunitpoliciesandguidelines.AUTHORS CPTNeeleyistheMedicationReconciliationSpecialistintheWarriorsinTransitionClinic,BrookeArmyMedicalCenter,FortSamHouston,Texas.DrPastoorisChief,DepartmentofFamilyandCommunityMedicine,BrookeArmyMedicalCenter,FortSamHouston,Texas.

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38www.cs.amedd.army.mil/references_publications.aspxBACKGROUNDTheArmyMedicalActionPlan,implementedinJuneof2007,directedbroad,sweepingchangestoensurewoundedandinjuredwarriorsreceivetoppriorityforcareservices,housing,andcommandsupport.Asaresultofthesedirectives,WarriorTransitionUnits(WTUs)wereestablishedtoprovidecommandandcontrol,primarycare,casemanagement,andtransitionsupportservices.TheformationofWTUsaddressedavoidinexistingorganizationalstructuresandresourcesforWarriorsinTransition(WTs),thoseWarriorswhohaveuniquerequirementstoeitherpreparethemforreturntothefightingforce,orassistthemintransitioningtoserveintheircommunities.TheFortLewisGarrisonanditssubordinateJointMobilizationBrigadehaddevelopedtheReintegrationActionPlan(RAP)programforFortLewisSoldiersonMedicalHoldstatusinJanuary2007.TheprogrammatchedSoldierinputregardingfuturegoalswithresourcesavailable.InAugustof2007,aspartoftheMadiganArmyMedicalCenter(MAMC)implementationoftheArmyMedicalActionPlan,theWarriorTransitionBattalionbuiltdirectlyuponthesuccessoftheRAPprogramtocreateatimelinefortheprojectedcareplan,useofavailableresources,andmeetingthegoalsofeachWarrior.Italsomadetheprocessvisualandtrulymultidisciplinary.TheEnhancedReintegrationActionPlan(ERAP)becamethefoundationfortheestablishmentoftheWTUstructureandtheComprehensiveCarePlan*processatMadiganandFortLewis.ManyWTscanablyserveinuniformuponreleasefromtheWTU.However,somecannolongerserveasaSoldierduetotheirinjuryorillness.ThisisparticularlytroublingiftheWarriorisaNationalGuardorReserveComponentSoldierwhomustreturntotheircommunityandreentercivilianlife.Asaresult,WTUsmustlookbeyondtheprimarymissionofhealingtowardfacilitatingthetransitionprocessforeachWarrior.TheERAPisdesignedtoaddressthistransitionperiod,engagingtheWarriorindevelopinggoalsandmeasuresofsuccessfortheirtenureintheunitandbeyond.Itconsistsofamultidisciplinarysupportteam:theWarrior,theWarriorsFamily,andtailoredsupportagenciesworkinginconcerttoachievetheestablishedgoals.Warriorcareplansandothergoalsareputonamilestone(eg,Gantt)chartwithinputfromsocialwork,casemanagers,occupationaltherapy,andotherteammembers.Morethan600WarriorsinTransitionhavebenefitedfromthiscomprehensiveapproachatMAMC.ThesuccessfulimplementationofERAPanditsintegrationdirectlyintotheArmysComprehensiveCarePlanconceptcanserveasthemodelforothercommandsinterestedinadoptingERAPwithintheirWTUs.PROGRAMTENETSTheERAPprocessseekstointeractivelyengagetheWarriorinnextstepsplanning.Itisanindividualized,goaldriven,visual,interactive,digitizedprocessthatmapsoutcareplanandlifegoalmilestones.DesignedtoaccommodateWarriorssufferingfrommildtraumaticbraininjuryandposttraumaticstressdisorderalongwithothertypesofinjury,theprocessusescommonresourcessuchaswhiteboardsandcomputerstoestablish,manage,andfacilitategoalssetbytheWarrior.ThekeytenetsoftheERAP:1.EachWThasamultidisciplinaryteam.ThecorestakeholdersoftheERAPprogramareresourcesTheEnhancedReintegrationActionPlan:TheMadiganExperienceLTCKarlBolton,MS,USA1LTSherriZimmerman,USAMsEllenBloom,MSW,LCSWCPTMichaelHunter,USAMAJKennethWest,USALTCAliHunt,AN,USARMAJMichaelLawrence,USA *Seerelatedarticleonpage8

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JanuaryMarch200839InprocessingSquadLeader:IntroductionLicensedClinicalSocialWorker/NurseCaseManager:Administerintakequestionnaire01AssessmentNurseCaseManager,PrimaryCareManager:PlanofCareMultidisciplinaryteamledbyLicensedClinicalSocialWorkerassessWT*responsesonintakequestionnaire.Teamidentifiesgoalswithprojectedachievabledates.SetsdateforERAPgoal-settingScrimmagewithunit.17814ERAPGoal-settingScrimmageVisualizationofgoal-settingprocessusingwhiteboardmediumERAPTeam,WT,andFamilysetadditionalgoalsGoals/milestonesareplacedonatimelineResultsareplacedindigitalformatforarchives/easeofuse30Follow-upSquadLeaderandERAPteam:Follow-upplanexecution.Every30daysorasneededFunctionResponsibility:ActivityDaysAfterReportingtoWTU Figure1.EnhancedReintegrationActionPlanexecutiontimelinefortheWarriorinTransition*afterheorshereportstotheMadiganArmyMedicalCenterWarriorTransitionUnit. Figure2.ExampleofanEnhancedReintegrationActionPlanScrimmagestoryboard.

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40www.cs.amedd.army.mil/references_publications.aspxoftheexistingWTUTableofDistributionandAllowances,*andincludelicensedindependentclinicalsocialworkers,nursecasemanagers,theprimarycaremanager,occupationaltherapistsortechnicians,thesquadleader,theWTsthemselves,andtheirFamilies.OtherstakeholdersontheteamincludetheSoldierandFamilyAssistanceCenterteamdedicatedtoeachWTU,nongovernmentalsupportorganizations,physicaltherapists,andfitnessexperts.2.Asingle,electronic,intakequestionnaireiscom-pletedbytheWTduringarrivalprocessing.ThisquestionnaireisacompilationofquestionsfromeachdisciplinewhichcoverallkeyappraisalindicatorsnecessaryfortheERAPTeamtoestablishinitialcare,mentalhealth,career,andlifeskillsplan/goalsforeachWT.3.Visualizationofthegoal-settingprocesswithtransferencetodigitalmedium.4.Aformalwork,vocationalrehabilitation,anded-ucation/trainingprogramtailoredforeachWTconsistentwiththeircareplan.5.Periodicreviewofmilestoneaccomplishment.ERAPEXECUTIONTheWTsinvolvementwithERAPatMAMCstartswiththearrivalprocessing(inprocessing).Asmentionedabove,eachWTcompletesacomputerizedintakequestionnairewhichpopulatestheERAPdatabasewithbasicinformationontheWarrior,anddevelopsahotsheetofanswersforthesocialworksectionoftheunitasaprimerfortheinitialERAPscrimmage(goal-settingmeeting).Thegoal-settingprocess,roughly30daysafterarrivalintheunit,assiststheWTwithlinkinginternalandexternalresourcesbybringingthefullexpertiseofthemultidisciplinaryteamonboardtohelpguidetheprocess.Eachgoalwithinfunctionaldomainsispublishedonawhiteboardasamilestone.Subsequenttrackingofgoalaccomplishmentismanagedbythewholeteamwiththesquadleaderservingastheprimarymanageroftheprocess.Goal-orientedmanagementofeachWTstenureintheunithasproventomaximizeutilizationofresourcesandprovideatemplateforthatWarriorskeyeventswithintheunit.ThenominalERAPprocesstimelineatMAMCisillustratedinFigure1.InprocessingERAPisembeddedintheMAMCWTUsinprocessingphase.Uponarrivalintheunit,theWTssquadleadereducatestheWarriorontheERAPprogram.TheassignednursecasemanagerortheWTsdedicatedlicensedclinicalsocialworkerestablishesanappointmenttocompletetheintakequestionnaire.Alsoduringinprocessing,thenursecasemanagerassignedtotheWTandtheirprimarycaremanagercompletetheinitialcareplanforthatWarrior.ThecompletedquestionnaireandcareplanarereviewedbytheWarriorsmultidisciplinaryERAPteam.TheteamestablishesadatefortheERAPgoal-settingscrimmage,ameetinginwhichtheteam,theWarrior(andFamilyifavailable),andthesquadleaderreviewgoalssetbytheteamandcoachtheWTtoestablishgoalsoftheirown.Goal-SettingScrimmageDeliversAllElementsTheERAPscrimmageistheheartoftheprogram.Itproducesavisualrecordandtimelineofgoals,synchronizedparalleltocareplankeyeventssothattheWarriorwillunderstandallaspectsofwhattoexpectwhileintheWTU,andhowtoreachthenextphaseoftheirlife.ShortlyaftertheWTjoinstheunit,theWTscareplan,developedbythenursecasemanagerandprimarycaremanager,iscoupledwithrecommendedgoalsfromtherestoftheERAPteambasedontheintakequestionnaire.Thecareplanandthesuggestedgoalsareplacedonalargewall/whiteboard.Thegoalsaregroupedbydomains,suchascareer,behavioral,etc.TheWTiscoachedthroughtheprocesstoidentifytheirpersonalgoals,withtheERAPteamsinput.Thesegoalsarethenputonalarge,digitizedwhiteboardacrossatimeline,inastoryboardfashion(seeFigure2),withparticipationoftheentireERAPteam,theWT,andtheFamily.ThevisualdisplayofgoalsacrossthedomainswithassociatedmilestonesreinforcesthemethodologyandgarnersWTacceptanceoftheirowntransitionplan.Digitizingtheresultsofthegoal-settingmeetingallowsrapidresetofthegoalsandmilestonesforperiodicreview,aswellas *Prescribestheorganizationalstructure,personnelandequipmentauthorizations,andrequirementsofamilitaryunittoperformaspecificmissionforwhichthereisnoappropriatetableoforganizationandequipment.TheEnhancedReintegrationActionPlan:TheMadiganExperience

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JanuaryMarch200841THEARMYMEDICALDEPARTMENTJOURNALfacilitatingtheupdateofchangestotheplanastheyoccur.TheprocesshasproventobesuccessfulatreenergizingeventhoseWarriorswhohaveextendedlengthsofstayintheMAMCWTU.OneWarriorhadspentmorethan14monthsintheFortLewisMedicalHoldOvercompanyandthentheWarriorTransitionBattalionbeforehewasintroducedtotheERAPscrimmageprocess.Attheendofthesessionhestated,ForthefirsttimesincebeingintheunitIcancallmywifeandtellherwhentoexpectmebackhome.TheprocessaccommodatesboththoseWarriorsexpectedtoreturntoduty(RTD)aswellasthosewhowillnotbeabletocontinueserviceinuniform(seeFigure3).ForthosewhowillRTD,ERAPestablishesaplantoensuremilitaryoccupationalspecialtyskillsareretrainedandsustained.TowardstheendoftheWarriorsexpectedstayintheMAMCWTU,ArmyWarriorTasks,weaponsqualifications,andadiagnosticphysicalfitnesstestcanbeadministered.TheWTUsgoalistoreturneachWarriortotheforceinthehighestconditionofdeployablereadinessaspossible.Forthosewhocannotcontinuetoservein Figure3.CareeranalysisflowchartreflectingthefitfordutydeterminationandsubsequentcareerdecisionprocessforeachSoldiersprogressthroughtheWarriorTransitionUnit.GlossaryFFDFitfordutyMOAMemorandumofagreement(workprograms)MOSMilitaryoccupationalspecialtyACESArmyContinuingEducationSystem

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42www.cs.amedd.army.mil/references_publications.aspxTheEnhancedReintegrationActionPlan:TheMadiganExperience E R A P P r o c e s s e s L i n e s o f E f f o r t T i e r 1 D i f f i c u l t y T i e r 2 D i f f i c u l t y T i e r 3 D i f f i c u l t y M a x i m i z e E R A P U t i l i z a t i o n P e r c e n t a g e o f W T s w i t h E R A P S N u m b e r o f E R A P S p e r w e e k N u m b e r o f r e m o t e W T s w i t h E R A P r e s o u r c e s N u m b e r o f r e m o t e s w i t h E R A P p l a n N u m b e r o f E R A P S i n v o l v i n g F a m i l i e s P e r c e n t a g e a p p l i c a t i o n s f o r V B A S t r e a m l i n e E R A P p r o c e s s e s A v e r a g e t i m e / S c r i m m a g e N u m b e r o f t i m e l i n e s d i g i t i z e d E R A P S w i t h i n 3 0 d a y s o f i n p r o c e s s i n g P r o v i d e m e a n i n g f u l w o r k o p p o r t u n i t i e s R e d u c t i o n o f c l i n i c n o s h o w s N u m b e r o f W T s f i l l i n g F L W B M M s l o t s P e r c e n t a g e o f M O S s w h i c h m a t c h t o w o r k N u m b e r o f W T s w i t h M O A o r A C E S W a r r i o r O u t c o m e s P r o m o t e p e r s o n a l a n d p r o f e s s i o n a l g r o w t h N u m b e r o f W T s e n r o l l e d i n A C E S W T G P A i m p r o v e m e n t N u m b e r o f W T s w i t h c e r t i f i c a t i o n s P W s a t i s f a c t i o n s u r v e y s c o r e s P r o v i d e t r a n s i t i o n s a f e t y n e t N u m b e r o f E R A P r e f e r r a l s t o S F A C N u m b e r o f n o n R T D W T s w i t h j o b i n t e r v i e w s N u m b e r o f W T s w i t h j o b o f f e r s N u m b e r w i t h f i r s t V A a p p o i n t m e n t s c h e d u l e d w h i l e i n W T U I m p r o v e W a r r i o r h e a l t h a n d f i t n e s s L e n g t h o f s t a y i n u n i t R e d u c t i o n i n W C C u t i l i z a t i o n r a t e R e d u c e d s u i c i d a l e v e n t s P W s e l f s c o r e o n i m p r o v e d h e a l t h S u p p o r t t h e G l o b a l W a r o n T e r r o r P e r c e n t a g e R T D i n c u r r e n t o r n e w M O S N u m b e r & p e r c e n t a g e o f W T s r e t u r n e d t o p a r e n t u n i t N u m b e r r e t u r n e d t o d u t y w i t h b a s i c A W T s k i l l s N u m b e r R T D i n c u r r e n t M O S S u p p o r t o r i m p r o v e u n i t M E T L C a r e / s u p p o r t / t r a n s i t i o n t a s k s P C a r e / s u p p o r t / t r a n s i t i o n t a s k s T I m p r o v e F a m i l y w e l l b e i n g N u m b e r o f E R A P S w i t h F a m i l y r e f e r r a l s R e d u c e d r a t e o f d o m e s t i c v i o l e n c e F i g u r e 4 A n e x a m p l e o f t h e E n h a n c e d R e i n t e g r a t i o n A c t i o n P l a n L i n e s o f E f f o r t m e t r i c s m o d e l G l o s s a r y A C E S A r m y C o n t i n u i n g E d u c a t i o n S y s t e m M O A m e m o r a n d u m o f a g r e e m e n t ( w o r k p r o g r a m s ) A W T A r m y W a r r i o r t r a i n i n g M O S m i l i t a r y o c c u p a t i o n a l s p e c i a l t y B M M b o r r o w e d m i l i t a r y m a n p o w e r R T D r e t u r n t o d u t y E R A P E n h a n c e d r e i n t e g r a t i o n a c t i o n p l a n S F A C S o l d i e r a n d F a m i l y a s s i s t a n c e c e n t e r E R A P S E R A P g o a l s e t t i n g s c r i m m a g e V A U S D e p a r t m e n t o f V e t e r a n s A f f a i r s F L W F o r t L e w i s W a s h i n g t o n V B A V e t e r a n s B e n e f i t s A d m i n i s t r a t i o n G P A g r a d e p o i n t a v e r a g e W C C W a r r i o r c a r e c l i n i c M E T L m i s s i o n e s s e n t i a l t a s k l i s t W T W a r r i o r i n T r a n s i t i o n

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JanuaryMarch200843THEARMYMEDICALDEPARTMENTJOURNALuniform,ERAPtailorssupportservices,introducesArmyContinuingEducationSystemresources,initiatesDepartmentofVeteransAffairsenrollmentandbenefitsprocessing,andpresentsotherArmyandciviliantransitioningprograms.Themilestonetimeline/storyboardingapproachallowsWarriorstovisualizewheneachmajortaskshouldoccur,andpreparesthemwithaplanofaction.ERAPMETRICS:TRACKINGPROGRAMPERFORMANCEANDEFFECTIVENESSLikeotherinitiatives,itisimportanttogaugetheERAPprogramsperformanceandeffectiveness.Usingaline-of-effort(LOE)model,criticaltasksoftheERAPprogramcanbetracked.EachLOEhasspecificmetrics,segmentedintoMeasuresofPerformanceandMeasuresofEffectiveness.MeasuresofPerformanceassesstheimplementationofERAPprocesses,whileMeasuresofEffectivenessaddressWarrioroutcomes.TheLOEsofMeasuresofPerformanceinclude:MaximizeERAPutilizationStreamlineERAPprocessesProvidemeaningfulworkopportunitiesMetricswithintheseLOEscouldincludetrackingthenumberofscrimmagesexecuted,thepercentageofWarriorswithanERAPplaninplace,andsimilarstatisticalmeasures.TheLOEsofMeasuresofEffectivenessinclude:PromotepersonalandprofessionalgrowthProvidetransitionsafetynetImproveWarriorhealthandfitnessSupporttheGlobalWaronTerrorSustainorimprovetheWTUmissionessentialtasklistImproveFamilywell-beingMetricswithintheseLOEscouldinclude,forexample,theWarriorsself-assessmentofhealthstatussinceenrollmentintheprogram,thenumberofWarriorsenrolledintheArmyContinuingEducationSystemwhohavehadimprovementingradepointaverage, Figure5.AnexampleoftheorganizationandinformationaccessscreensavailableinthedatabasewhichwasdevelopedtocreateafullrecordofeachSoldiersinvolvementandprogressintheEnhancedReintegrationActionPlan.

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44www.cs.amedd.army.mil/references_publications.aspxandthepercentageofWarriorswhoarereturnedtotheiroriginatingunit.Figure4illustratestheERAPLOEapproachtotrackingandevaluatingaprogramseffectiveness.ERAPEVOLUTION:THEWAYAHEADThecomplexityandcomprehensivenessofERAPdictatethattechnologyenablerssustainaneffectiveprogram.Whilemanyprojectmanagementsoftwareprogramscanemulatethetimelineaspectofthegoal-settingscrimmage,thoseprogramsareoftennotuserfriendlyandcanbecumbersometomaintain.Theyalsodonotprovideeffectiveassistanceintrackingmetrics.Asaresult,arelationaldatabasewasdevelopedlocallyattheMadiganArmyMedicalCentertopresentmilestonesinusefultimelines,andcreateafullrecordofeachWarriorsERAPinvolvement.ThedatabaseallowsquickentryofWarriordemographicsandeachestablishedgoalormilestone,andtracksexecutionofeachmilestone.AnexampleofthedatabasepagesisshowninFigure5.DataminingallowsextractionofoverallprogrammeasurementdatawhichcanbesortedbyvariousdemographicstoidentifygapsinexecutionoftheERAP.ManyWarriorsareassignedtoWTUswhicharenotphysicallylocatedattheirrespectiveinstallations.Thispresentsaproblem:howdoWTUsremotelyprovidetransitionservicestoWarriors?Thefuturecouldinvolvetheuseoftelehealthtechnologies,witheachWarriorusingadonatedlaptopandasuiteofsoftwareandperipheralstoallowremoteexecutionofthemultidisciplinaryteamsERAPgoal-settingscrimmage.TheremoteexecutionofERAPensuresthatallassignedWarriorsinTransitionhaveaccesstothesamebenefitsasthoseontheinstallation.Itwillalsofacilitate,inamoremeaningfulway,theinteractionoftheWarrior,theFamily,theassignedcasemanager,squadleader,andprimarycaremanager.CONCLUSIONTheexperienceoftheMadiganArmyMedicalCenterWTUvalidatestheEnhancedReintegrationActionPlanasacomprehensiveapproachtomaximizeeachWTstenureintheWTU.TheprogramformalizesexecutionoftheentireWTUmissionessentialtasklist.MAMCsexperienceisrepeatableacrossWTUsintheArmyMedicalCommandusingtheexistingWTU/WarriorTransitionBattalionandSoldierandFamilyAssistanceCenterstructures,laptops,andregularwhiteboardsorablankwall.ThemultidisciplinaryteamcreationofauniqueERAPplanforeachWTshouldbeembeddedinunitstandardoperatingprocedures.Asaresult,productivitywillbeincreasedfortheentireERAPteambecauseitsroleintheWTUisclearlydefined,andtheuseofasingle,combinedintakequestionnairereducesduplicationofeffortswithintheERAPteam.ERAPprovidesaclearlyunderstoodandsustainableprogramforintegratinginternalandexternalresourcesandagenciestosupportWarriorsandtheirFamilies.ERAPparticipantsattheMAMCWTUhavestronglyrecommendedthatthisprogramberequiredforallWarriorsinTransitionithasempoweredeachWarriortotakechargeofhisorherowntransitionplan,andhasprovidedtheassistancetheyneedtoserveinagreater,morerewardingcapacityupontheirreturntoservice,orreleaseintocivilianlife.AUTHORS LTCBoltonisCommander,WarriorTransitionBattalion,MadiganArmyMedicalCenter,FortLewis,Washington.1LTZimmerman,anAdjutantGeneralCorpsofficer,isCommander,BravoCompany,WarriorTransitionBattalion,MadiganArmyMedicalCenter,FortLewis,Washington.MsBloomisChief,WarriorTransitionBattalionSocialWorkClinic,MadiganArmyMedicalCenter,FortLewis,Washington.CPTHunter,anArmorofficer,isAssistantOperationsOfficer,WarriorTransitionBattalion,MadiganArmyMedicalCenter,FortLewis,Washington.MAJWest,aFinanceofficer,isERAPProgramManager,WarriorTransitionBattalion,MadiganArmyMedicalCenter,FortLewis,Washington.LTCHuntisChief,ClinicalOperations,WarriorTransitionBattalion,MadiganArmyMedicalCenter,FortLewis,Washington,andSeniorCaseManagerfortheWesternRegionalMedicalCommand.MAJLawrence,anIntelligenceofficer,isExecutiveOfficer,WarriorTransitionBattalion,MadiganArmyMedicalCenter,FortLewis,Washington.TheEnhancedReintegrationActionPlan:TheMadiganExperience

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JanuaryMarch200845ChronicPainisadiseasestatethatisjustnowbeingrecognizedasasignificantindependentclinicalentity.Unmitigatedchronicpaincanbeasdestructiveasanychronicmedicalcondition.Painisnotamonolithicentitysuchasafractureordeficiencyofsomeessentialnutrient.Painis,rather,aconceptusedtofocusandlabelagroupofsensations,thoughts,emotions,andbehaviors.Sincetherearemanyfacetstopain,itshouldbeobviousthatnosingletreatmentisavailableinthemajorityofcases.OurexperiencewithSoldiersinvolvedinourcurrentconflictisconsistentwithinjuriesthathavebeenreportedsincethe16thcentury.TheFrenchmilitarysurgeonAmbroseParefirstdescribedphantomlimbpain,phantomsensations,andstumppain,allofwhichweregularlyseetoday.1TheAmericancivilwarsurgeon,S.WeirMitchel,whocoinedthetermcausalgia,stated:Perhapsfewpersonswhoarenotphysicianscanrealizetheinfluencewhichlong-continuedandunendurablepainmayhaveonbothbodyandmind.Undersuchtormentsthetemperchanges,themostamiablegrowirritable,thebravestSoldierbecomesacoward,andthestrongestmanisscarcelylessnervousthanthemosthystericalgirl.Nothingcanbetterillustratetheextenttowhichthesestatementsmaybetruethanthecasesofburningpain,or,asIprefertotermit,Causalgia,themostterribleofalltortureswhichanervewoundmayinflict.2DrMitchelpoignantlyillustratedthephysicalandemotionaltollthatisextractedbychronic,unremittingpain.Surprisinglyhowever,themostcommoncausesofchronicpainduringourrecentandcurrentmilitaryconflictsarestillordinaryconditions,suchasaccidentsandmusculoskeletalcomplaints,withlowbackpainaccountingforover50%ofpresentingpaincomplaintsinSoldiersfromOperationsIraqiFreedomandEnduringFreedom.3-7Consequentlyourpatientpopulationiscomposedofpolytraumapatientsaswellaspatientsthataretypicallyseenincivilianpractice,where17%ofpatientsinanaverageprimarycarepracticepresentwithchronicpaincomplaints.8PaintheoryhasevolvedovertimefromDescartesproposedtheoryin1634,tothegatecontroltheoryofMelzakandWallin1964,toourcurrentunderstandingofpain.Descartestheorystatedthatpainistransmittedthroughasinglechannelfromtheskintothebrain.Thistheoryhasdirectedthestudyandtreatmentofpainfor330yearsandunfortunatelyisstilldescribedinsomephysiologyandneurosciencetextbooksasfactratherthantheory.Itisalsothepredominatepainparadigmofpatients.MelzakandWallsdescriptionofthegatecontroltheory9rejuvenatedpainstudyandhasledtoourcurrentunderstandingofthecomplexneural-humeralpro-cessingthattakeplaceat3distinctlocationsasanimpulsetravelsfromitsorigintothebrain.Ateachleveltheperiphery,thespinalcord,andthesupra-spinallevels(brainstemandcortex)thepainimpulsecanbeaugmentedordiminished.10Therefore,effectivetreatmentmustactatoneormoreoftheselevels.Thesupra-spinallevelisthemostcomplexandleastunderstoodregion.Inspiteofthis,anyprogramortreatmentcoursemusttakeintoaccountthecomplexsubjectivedimensionsofpainthatoriginateinthebrain,describedasthesensory-discriminative(whereandwhatthepainfeelslike),affective-motivational(howthepainmakesyoufeel/whatthatfeelingmakesyoudo),andcognitive-evaluativedimensions(whatdoyoubelieveistheetiologyofyourpain).11OfferingHopeforourWoundedWarriors:AnOverviewoftheWomackArmyMedicalCenterPainMedicineClinicMAJThomasWeber,MC,USAMAJAnthonyDragovich,MC,USA

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46www.cs.amedd.army.mil/references_publications.aspxTheemotional/cognitiveaspectsofpainmustberecognizedandtreatedappropriatelyforallpatientswithchronicpain,butitisevenmoreparamountinourpatientpopulation,manyofwhomalsohaveposttraumaticstressdisorder(PTSD)and/ortraumaticbraininjury(TBI).12ItiswellrecognizedthatpatientswithTBIandPTSDhaveheightenedexperiencesofpain,impairedcopingmechanismscausedbycatastrophicinterpretationsofpain,elevatedanxietylevels,anddiminishedattentionalcontrolwhichimpairstheuseofcognitive-behavioraltherapies.13-16WomackArmyMedicalCenter(WAMC)recognizedtheneedforexcellentpaintreatmentforourSoldiersandnowboastsastateoftheartinterventionalpainclinicthatcloselycollaborateswithworldrenownedpainmedicinephysiciansattheJohnsHopkinsSchoolofMedicineinordertoprovideallofourSoldierswiththebestpossiblemedicalcare.ManySoldierswithacuteorsubacutepainconditionsaretreated.Thevastmajorityofpatientswhoreceivetreatmentremainonactiveduty.ThisisindeedatestamenttothequalityandcharacterofourSoldiers.Theremainderofthisarticle,however,willfocusonthecomplexpatientwithchronicpainduetodifficult-to-treatconditions.Inresponsetothiscomplexity,theWAMCWarriorTransitionBattalion(WTB)hasbeeninstrumentalincoordinatingthecareforthesewoundedwarriors.Giventheenormousbreadthofpainetiologies,rangingfrompolytraumatomoremundanebutstillpotentiallydebilitatingconditionssuchaslowbackpain,itisnotsurprisingthatsimplealgorithmicapproachestotreatmentarenotsuccessful.Someconservativechronicpaintreatmentshavegoodevidenceofefficacy,suchascognitive-behavioraltherapy,aerobicexercise,spinalmanipulation,andinterdisciplinaryrehabilitation.17Oftenthesetreatmentsmustbecombinedinacohesiveprogramwithinterventionaland/ormedicaltreatmentstoachieveoptimalsuccess.18,19TheWTBisthestructuralcenterofourmultidisciplinaryapproach.Thepainmedicineclinicprovidesinterventionalandmedicaltreatmentstopatientswhoarealreadyinvolvedinothermultidisciplinarypaintreatment/rehabilitationprograms,aswellasrecommendationsformultidisciplinarytreatmentregimens.Earlyidentificationandtreatmentofpainareknowntoreducetheincidenceandseverityofchronicpainandthereforeconservehealthcareresources.20Early,effectiveinterventioniskeytosuccessfullong-termoutcomes.Weareworkingtobecomeevenmoreeffectiveasweinitiateourpainsurveillanceprogramwhichisreviewedlaterinthisarticle.Successfulpaintreatment,evenifshortterm,improvesaffectivedimensionsofpainandimprovestheefficacyofallothertreatmentmodalities.ThemoststunningsuccesswasaSoldierwithcomplexregionalpainsyndrome(ie,DrMitchelscausalgia2)whowastreatedwithaspinalcordstimulator(SCS)implan-tation.Thereisgoodevidencefortheefficacyofthistreatmentforcomplexregionalpainsyndrome,21-23aswellasarecenttrialof10consecutiveMarineCorpsandNavypersonnelwhoobtainedgreaterthan80%painreliefwithSCSimplantation.24TheSoldierhadfailedconservativetherapyandcommoninterventionaltechniques.Hispainwasdebilitatingwithmarkedeffectsonmood,sleep,andbasicdailyfunction,however,hegreatlydesiredtocontinueonactivedutyandremaindeployable.Hehadasuccessfultrialandthedevicewasimplanted.Todate,heisnowtheonlySoldierknowntobedeployedwithaSCS.Overall,hereportsveryfewlimitationsandhisactivitiesincludepush-ups,sit-ups,running,weightlifting,scubadiving,hiking,backpacking,ruck-marching,andcombatoperations.HehasalsomademodificationstohisclothingandequipmenttoaccommodatetheSCSprogrammersohecanchangemodesasneeded.ThisSoldierrepresentstheoptimaloutcomeforourwoundedWarriorswithchronicpainfrompolytrauma.Unfortunately,theSoldierdiscussedabovedoesnotrepresentatypicaloutcome.Currently,theWTBhasover400Soldiers,25%ofwhomareseeninthepainmedicineclinic.ThisproportionisconsistentwithreportedVAstatisticsthat47%ofVeteransreportedatleastmildpain,and28%reportedpainsevereenoughtobeassociatedwithfunctionalinterference.7Manyofthesepatientshaveconditionsthatareonlywelltreatedacutelywithopioids.However,sincethereisnoevidencethatlong-termopioidtherapyisaneffectivepaintreatmentstrategy,everyeffortismadetodevelopaplantolimittheuseofopioidsinthepatientsfuturetreatment.Commoninterventionaltechniques,suchasepiduralsteroidinjectionsandradiofrequencynerveablations,aswellastricyclicantidepressantsandanticonvulsantshavebeenusedaspartofacomprehensivetreatmentplaninmanyOfferingHopeforourWoundedWarriors:AnOverviewoftheWomackArmyMedicalCenterPainMedicineClinic

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JanuaryMarch200847THEARMYMEDICALDEPARTMENTJOURNALpatients.Effective,earlynonopioidpaintreatmentisabsolutelycriticaltoavoidthedevelopmentofharmfulaffective-motivationalandcognitive-evaluativedimensionsofpain,eg,depressionandcatastrophizingideations.Thepredominatereasontolimitchronicopioiduseisabasicrisk/benefitanalysis.Opioidshavenotbeenshowntoprovideclinicallysignificantlong-term(morethan3months)painreliefinthepublishedliterature.Anecdotally,oncepatientspassthroughtheacutepainstageoftissuedamage(ie,muscle,bone,tendon/ligament)weaningfromopioidsmaynotresultinanincreaseinpain.Thereisamarkedincreaseinaffectivesymptoms(anxiety,stress,catastrophizing)whenopioidwithdrawaliscontemplated.ManySoldiershaveexperiencedterriblepain.SomehavePTSDand/orTBIassociatedwiththeirpainsymptoms.NoSoldiereverwishestoexperiencethatlevelofpainagain.OpioidsarecommonlythemedicationthatinitiallyalleviatedthepainandtheSoldierbelievesthattheyarethereasonthepainhasnotreturned.AgreatdealoftrustisrequiredforSoldierstoagreetoweanfromthemedicationthattheybelieveisthereasonthattheyarenolongerinexcruciatingpain.Therisksoflong-term(morethan2years)opioidtherapyaremuchclearer.Theriskofphysicaldependenceis100%.Chronicconstipationiscommon,asissedation,nausea,pruritis,andurinaryretention,butthesetendtowanewithtime.The2mostconcerningcomplicationsofopioidtherapyinSoldiersareabuse/addictionandhypogonadotroic-hypogonadism.Theriskofabuse/addictionisreportedfrom10%to18.9%intheliterature.25,26TherateinourSoldiersislikelyneartheupperendoftherangegiventhatmalesandyoungeradultsaremorelikelytodevelopopioidabuse/dependence.27Long-term(morethan2years)opioidtherapyisclearlyassociatedwithhypogonadotropic-hypogonadism.Thisresultsindepressionofanabolichormonestoincludegrowthhormone,testosterone,anddihydoepiandosterone.Inunpublisheddata,12Soldiershadfreeandtotaltestosteronelevelsdrawn.All12Soldierswereonover30mgofmorphineorequivalentperdayandwerefoundtohavelowfreetestosteronelevels.Thisfindingisconsistentwiththereportedliterature.28Hypogonadismresultsindepression,lethargy,irritability,impairedwoundhealing,immunosuppresion,osteoporosis,decreasedlibido,andimpotence.Allofthesesymptomsareconcerning,especiallyinyoungSoldierswithconcomitantPTSDorTBI.Opioidtherapyand,moredirectly,side-effectsofopioidtherapyexacerbatePTSDandTBI.Westronglyrecommendscreeningallpatientswithanyofthesesymptomswhoareonopioidtherapyforevidenceofhypogonadism.Theappropriateuseofopioidsforpatientswithchronicpainisanenormouslydifficult,complexclinicaldecision.Ononehand,youhaveaSoldierwhohasbeenthroughatraumaticexperienceandhasclearreasonstopotentiallystillhavepainresponsivetoopioidsandapsychologicalaffinityforthemedication.Ontheotherhand,youhaveamedicationthatwillclearlybeharmfultomanypatientsoverthelong-term.Ourpolicyistohaveallpatientssignanopioidconsentstatementandopioidconductagreementpriortotheinitiationofopioidtherapy.Theconsentstatementinformsthepatientoftheknownrisksofthemedication.Theconductagreementdefinesthegroundrulesforcontinuedopioidmanagement.Soldiersarerequiredtobringtheirmedicationbottlestoeveryappointmentforrandompillcounts.Theyarealsosubjecttorandomurinetoxicologyscreening.AllSoldiersarecounseledthatperiodicopioidholidaysmayberequiredtodetermineifopioidsarestilleffectivepaintherapy.IftheSoldierdoesnotexperienceanincreaseinpainoffopioids,theyarenotreinitiated.Itisclearlyevidentthatpaintreatmentisacomplex,resource-intensiveendeavorwithoutclearempiricevidencetoserveasaguide.Akeyfirststepintreatmentisidentifyingindividualswhoareexperiencingpainorwhoareatriskofdevelopingapaincondition.AllWTBpatientsreferredtothepainmedicineclinicwillcompletescreeningtoolsconsistentwiththerecommendationsoftheIMMPACTconsensusconference.29Fourchronicpaindomainswillbeevaluated:PainintensityMcGillpainquestionnairePhysicalfunctioningbriefpaininventoryandEpworthsleepinessscales

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48www.cs.amedd.army.mil/references_publications.aspxEmotionalfunctioningBeckdepressioninventoryPatientsratingofoverallimprovementpatientglobalimpressionofchangescaleTheseevaluationswillbecompletedontheinitialencounterandthenevery6monthssubsequently.Thisdatawillbeusedtotailorthepatientstreatmentandensurethattheyreceivethelevelofcarerequired.MultidisciplinarycarewillprovidedatWAMConanoutpatientbasis.Selectpatientswhorequireinpatientcomprehensivepainrehabilitationarereferredasappropriate.AcentralfocusispaincontrolwithselectiveuseofopioidsasmodeledaftertheproceduresusedattheJamesA.HaleyVeteransHospitalinTampa,Florida.Sinceresourcesarelimited,wehaveoutlined3keycomponentsthatwillmosteffectivelyleverageourcurrentcapital.First,wewillimproveprimarycareproviderknowledgethroughourlectureseriesinanefforttopusheffectivepaintechniquestothefrontlines.Second,incooperationwithWalterReedArmyMedicalCenterandJohnsHopkinsUniversitySchoolofMedicine,wehaveinitiatedcuttingedgeresearchprotocolsthathavethepotentialtoredefinehowsomepainconditionsaretreated.Finally,everyeffortismadetoprovideexcellent,nonopioidanalgesiawithperipheralnervecathetersforallSoldierswhoareamenabletothetechnique.Peripheralnervecathetershaveproventobeanexcellentmethodofanalgesiawiththeenormousbenefitofavoidanceofopioidtolerance,dependence,andsideeffects.Theseareresourceintensiveefforts,currentlyintheirinfancyatWAMC,whichhavethepotentialtomitigatelong-termdisabilityduetochronicpain.Theresultswillbedecreasedhealthcareutilization,decreasedhealthcarecost,and,mostimportantly,improvedpatientqualityoflifeandfunction.Overthenextseveralyears,theArmyMedicalDepartmentwillbeexperiencingthedauntingchallengeoftakingcareofourwoundedwarriors.Earlyandeffectivepaintreatmentisofparamountimportance.Earlyinterventionwilldecreasethelong-termriskofdisabilityinthispatientpopulationandwillalsoallowourSoldierstoreturnquicklytothefight.ItisessentialthatamultidisciplinaryapproachisusedthattakesintoaccountthephysicalandmentalaspectsofeachSoldierscare.OurSoldiersaregivingtheirbesttoprotectanddefendthisgreatnationofours.Weowethemourbest.REFERENCES 1.PareA,JohnsonT.TheapologieandtreatiseofAmbroiseParecontainingthevoyagesmadeintodiversplaceswithmanyofhiswritingsuponsurgery.London:CotesandYoung;1634.2.MitchellS.Onthediseasesofnerves,resultingfrominjuries.In:FlintA,ed.ContributionsRelatingtotheCausationandPreventionofDisease,andtoCampDisease.NewYork:USSanitaryCommissionMemoirs;1867.3.WhiteR,CohenS.Diagnosis,treatment,andreturn-to-dutyratesinsoldierstreatedinaforwarddeployedpainmanagementcenter.Anesthesiology.2007;107:1003-1008.4.HoefflerD,MeltonL.ChangesinthedistributionofNavyandMarineCorpCausaltiesfromWorldWarIthroughtheVietnamconflict.MilMed.1981;146:776-779.5.WriterJ,DeFraitesR,KeepL.Non-battleinjurycasualtiesduringthePersianGulfWarandotherdeployments.AmJPrevMed.2000;18:64-70.6.CohenS,GriffithS,VillenaF.Presentation,diagnoses,mechanismsofinjury,andtreatmentinsoldiersinjuredinOperationIraqiFreedom:anepidemiologicalstudyconductedattwomilitarypainmanagementcenters.AnesthAnalg.2005;101:1098-1103.7.GirondaR,ClarkM,MassengaleA,WalkerR.PainamongveteransofOperationEnduringFreedomandIraqiFreedom.PainMed.2006;7:339-343.8.GurejeO.Persistentpainandwell-being:aWorldHealthOrganizationstudyinprimarycare.JAMA.1998;280:147-151.9.MelzackR,WallP.Painmechanisms:anewtheory.Science.1965;150:971-979.10.DeLeoJ.Basicscienceofpain.JBoneJointSurgAm.2006;88(suppl2):58-62.11.MelzackR,KatzJ.Thegatecontroltheory:reachingforthebrain.In:HadjistavropoulosT,CraigKD,eds.Pain:PsychologicalPerspectives.NewYork:LawrenceErlbaum;2004:13-34.12.BryantR,MarosszekyJ,CrooksJ,BaguleyI,GurkaJ.Interactionofposttraumaticstressdisorderandchronicpainfollowingtraumaticbraininjury.JHeadTraumaRehabil.1999;14:588-594.OfferingHopeforourWoundedWarriors:AnOverviewoftheWomackArmyMedicalCenterPainMedicineClinic

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JanuaryMarch200849THEARMYMEDICALDEPARTMENTJOURNAL13.DrottningM,StaffP,LevinL.Acuteemotionalresponsestocommonwhiplashpredictssubsequentpaincomplaints.Aprospectivestudyof107subjectssustainingwhiplashinjury.NordicJPsychiatry.1995;49:293-299.14.SmithT,AbergerE,FollickM.Cognitivedistortionanddisabilityinchroniclowbackpain.JConsultClinPsychol.1986;54:573-575.15.DifedeJ,JaffeA,MusngiG.Determinantsofpainexpressioninhospitalizedburnpatients.Pain.1997;72:245-251.16.BryantR,HarveyA.Processingthreateninginformationinpost-traumaticstressdisorder.JAbnormPsychol.1995;104:537-541.17.ChouR,HuffmanL.Nonpharmacologictherapiesforacuteandchroniclowbackpain:AreviewoftheevidenceforanAmericanpainsociety/AmericanCollegeofPhysiciansclinicalpracticeguideline.AnnInternMed.2007;147:492-504.18.FairbankJ,FrostH,Wilson-MacDonaldJ,YuL,BarkerK,CollinsR.Randomisedcontrolledtrialtocomparesurgicalstabilisationofthelumbarspinewithanintensiverehabilitationprogrammeforpatientswithchroniclowbackpain:theMRCspinestabilisationtrial.BMJ.2005;330(7502):1233-1238.19.BroxJI,SorensenR,FriisA,etal.Randomizedclinicaltrialoflumbarinstrumentedfusionandcognitiveinterventionandexercisesinpatientswithchroniclowbackpainanddiscdegeneration.Spine.2003;28(17):1913-1921.20.TurkD.Clinicaleffectivenessandcost-effectivenessoftreatmentsforpatientswithchronicpain.ClinJPain.2002;18:355-365.21.KemlerMA,deVetH,BarendseGA,vandenWildenbergF,vanKleefM.Spinalcordstimulationforchronicreflexsympatheticdystrophy-five-yearfollow-up.NEnglJMed.2006;354:2394-2396.22.KemlerMA,BarendseGA,vanKleefM,etal.Spinalcordsimulationinpatientswithchronicreflexsympatheticdystropy.NEnglJMed.2000;343:618-624.23.GrabowTS,TellaPK,SrinivasaN.RajaM.Spinalcordstimulationforcomplexregionalpainsyndrome:anevidence-basedmedicinereviewoftheliterature.ClinJPain.2003;19:371-383.24.VerdolinM,Stedje-LarsenE,HickeyA.Tenconsecutivecasesofcomplexregionalpainsyndromeoflessthan12monthsdurationinactivedutyUnitedStatesMilitaryPersonneltreatedwithspinalcordstimulation.AnesthAnalg.2007;104:1557-1560.25.FishbainD,RosomoffH,RosomoffR.Drugabuse,dependence,andaddictioninchronicpainpatients.ClinJPain.1992;8:77-85.26.PortenoyR,FoleyK.Chronicuseofopioidanalgesicsinnon-malignantpain:reportof38cases.Pain.1986;25:171-86.27.EdlundM,SteffickD,HudsonT,HarrisK,SullivanM.Riskfactorsforclinicallyrecognizedopioidabuseanddependenceamongveteransusingopioidsforchronicnon-cancerpain.Pain.2007;129:355-362.28.DaniellH.Hypogonadisminmenconsumingsustained-actionoralopioids.JPain.2002;3:377-384.29.DworkinR,TurkD,WyrwichK,BeatonD.Interpretingtheclinicalimportanceoftreatmentoutcomesinchronicpainclinicaltrials:IMMPACTrecommendations.JPain.Inpress.AUTHORS MAJWeberisChief,AnesthesiologyService,DepartmentofSurgery,WomackArmyMedicalCenter,FortBragg,NorthCarolina.MAJDragovichisMedicalDirectorofthePainMedicineClinic,DepartmentofSurgery,WomackArmyMedicalCenter,FortBragg,NorthCarolina.

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50www.cs.amedd.army.mil/references_publications.aspxINTRODUCTIONTheabilityofmodernmedicinetoeffectacureforseverelybrain-injuredpatientsislimited.Theinitialimpactorinsultrepresentstheprimaryinjuryandinterventionforthisinjuryispurelypreventive.Secondaryinjuryrepresentsthedeleteriouscascadeofeventswhichoccuraftertheinitialinsult,someportionsofwhichcanbemitigatedbyintervention.Themostimportantgoaloftreatingbrain-injuredpatientsisavoidanceofsecondaryinjury.Multiplestrategiestominimizesecondaryinsultincludemaintainingoxygenation,andmaintaininganormalbloodpressureandattendantcerebralperfusionpressure.Maintenanceofbloodflowandassociateddeliveryofoxygenandnutrientshelpskeeptissueviableandisonewaytoavoidsecondaryinjury.1Prehospitalhypotension(systolicbloodpressurelessthan90mmHg)andlowoxyhemaglobinsaturation(below90%)havebeendocumentedasriskfactorsfordeathandpooroutcomeinbrain-injuredpatientstransportedtociviliantraumacenters.2,3Theavoidanceofhypotensioninthebrain-injuredisofparticularsignificancetomilitarymedicsastheuseofhypotensiveresuscitationinpenetratinginjurymustbeabandonedinthebrain-injuredpatient.Theskullistypicallyafixedvolumestructure.Increasedintracranialpressure(ICP)resultsindecreasedcerebralbloodflowandmayresultinbraintissueischemiaandnecrosis.OnemethodtorapidlydecreaseICPcommonlyemployedinthepastwashyperventilation.Hyperventilationhasbeenfoundtobedetrimentaltothebrain-injuredpatientinallbutthemostdiresituations(eg,brainherniation).4Itisnowestablishedthatcerebralvasoconstrictionduetoprofoundhypocarbia(lowcarbondioxidebloodlevels)fromhyperventilationresultsindeleteriousbraintissuehypoxiaandmayincreasemediatorsofsecondarybraininjury.5-7Hyperventilationandextremehypocarbiaareespeciallyworrisomeasmostmedicsandmanytransferpersonneldonothaveameanstomonitorcarbondioxidelevels,makinghyperventilationinthebrain-injuredpotentiallyasilentiatrogenickiller.OXYGENATIONOxygenationisthedeliveryofoxygentothelungsandisnoteffectedbyventilationexceptatverylowratesofgasexchange.Oxygenationisrelatedtotheamountofoxygendeliveredintheinspiredgastothealveoli.Atmosphericairis21%oxygen.Thebrain-injuredpatientoftenrequiresanincreaseintheinspiredoxygencontent(FiO2)tohaveadequatesaturationofthearterialhemoglobin(SaO2).Anincreaseinoxygenconcentrationcanbeobtainedwithbottledoxygen,afirehazardasoxygenisafireaccelerant.TheotheroptionforincreasingtheFiO2isanoxygenconcentratortoconcentratetheoxygenininspiredgas.Adequateoxygenationisimportantinavoidingischemia(lackofadequateoxygen)oftheinjuredbrain.Whilethemajorityofcombatwoundedwillnotbenefitfromsupplementaloxygenation,thesubsetoftheseverelyheadinjuredmaybenefitfromit.5-8HYPERVENTILATIONANDHYPOVENTILATIONVentilationistheprocessbywhichgasesaremovedintoandoutofthelungswhich,amongotherthings,resultsincarbondioxide(CO2)gasexchange.Ventilationisseparatefromoxygenation.TheamountTheSilentKiller:HyperventilationintheBrainInjuredLTC(P)LorneH.Blackbourne,MC,USAMAJJohnCole,MC,USAMAJRobertMabry,MC,USAMAJAndrewMorgan,MC,USALTCPaulBarras,AN,USACOLBrianEastridge,MC,USACOLJohnB.Holcomb,MC,USA

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JanuaryMarch200851ofgaspassedthroughthelungsbybagvalvemaskoraventilatorresultsinalossofCO2directlycorrelatedwiththerateofventilation.TheamountofCO2isthenreflectedintheamountofCO2presentinthearterialblood,knownasPaCO2(normalPaCO2is35to45mmHg).Ifventilationisincreased,thePaCO2willfall.Ifventilationisslowed,thePaCO2willrise.AlowPaCO2istermedhypocarbia,andanelevatedPaCO2istermedhypercarbia.CO2ANDTHEBRAINThecerebralarteriesareverysensitivetolevelsofCO2inthebloodstream.TheresponseofcerebralarteriestoincreasinglevelsofPaCO2inthebloodisvasodilation.Thisresultsinalargercerebralbloodvolumeand(duetothefixedspaceoftheskull)resultsinanincreaseinICP(knownastheMonroe-Kelliehypothesis).TheresponsetolowerlevelsofPaCO2isopposite.AreductioninPaCO2causescerebralarterialvasoconstrictionresultinginlowerbrainbloodvolumeandlowerintracranialpressure.Howeverthisoccursatthetheoreticalexpenseofbloodflow(withoxygenandnutrients)totheareasofinjuredbrain.TheresponseofcerebralarteriestodifferentlevelsofCO2inthebloodstreammayevenbeexaggeratedinischemic,injuredcerebralvessels.9-12Theearlypost-injuryperiodisespeciallysignificantascerebralbloodflowduringthefirstdayafterinjuryismarkedlyreducedandisoftenlessthanhalfthatofnormalindividuals.13,14Thisresultsinapotentiallyincreasedsusceptibilitytosecondaryinsult.METHODSFORMONITORINGBLOODCO2LEVELSTherearenoclinicalsignstohelpdeterminebloodlevelsofCO2.ThegoldstandardforPaCO2isanarterialbloodgasevaluation.15Thenextbestmethodisavenousbloodgas.Althoughthismethodislessaccurate,itwillhelpinrulingouttheextremesofPaCO2levels.16ThebestnoninvasivemethodtodeterminethePaCO2isend-tidalPaCO2,alsoknownascapnometry.End-tidalPaCO2monitorsmeasuretheCO2levelofexhaledgasesandusuallygiveavalueslightlylowervaluethanthearterialPaCO2duetomixingwithdeadspaceair.17End-tidalPaCO2monitoringismostaccurateinintubatedandventilatedpatients.However,theutilityofthismonitoringmodalityislimitedtotheavoidanceofextremelyloworhighPaCO2levels.18,19Specifically,end-tidalCO2determinationshavebeendocumentedtobeofbenefitinavoidinghyperventilationinventilatedheadinjuredpatients.15,20Additionally,patientshavealsobeensuccessfullymonitoredwithend-tidalPaCO2monitorsinthenonintubatedstate.21End-tidalCO2monitorshavetheaddedbenefitofhelpingtodetermineifinadvertentesophagealintubationhasoccurred.22-24BRAINHERNIATIONTheonlyclinicalindicationforiatrogenichyperventilationwiththegoalofhypocarbiaiscerebralherniation.Herniationoccurswhenthebrainisforcedoutoftheskullthroughtheforamenmagnumorassumesanabnormalintracranialpositionsecondarytosevereelevationinintracranialpressure(eg,transtentorialuncalherniation).Thesignsofbrainherniationincludeflexororextensorposturingand/orasymmetricornonreactive(blown)pupil.TheBrainInjuryFoundationguidelinesrecommenddoublingtheprehospitalnormalventilationrate(20breaths/minuteinadults)inpatientswithclinicalsignsofbrainherniationtoachieveiatrogenichyperventilationandattendanthypocarbia.25CIVILIANPARAMEDICANDTRANSPORTOFBRAIN-INJUREDDATAPrehospitalhypotensionandhypoxiainthebrain-injuredpatientsareestablishedriskfactorsforincreasedmortalityandpooroutcomes.Additionally,hyperventilationandhypocarbiaarerecognizedasapreventablecauseofiatrogenicsecondarybraininjury.Theuseoforotrachealintubationwithoutend-tidalPaCO2monitoringprehospitalbyUScivilianparamedicshasbeenassociatedwithanincreaseinmortalityanddeleteriouseffectonsurvivors.26,27Thisincreaseinmortalityandpoorneurologicoutcomesofintubatedandventilatedbrain-injuredpatientsisthoughttobeduetohypocarbiafromhyperventilation.27-29TheoptimalPaCO2duringtransporthasnotbeenclearlydefinedalthoughadmissionPaCO2levelsfrom30to39mmHghavebeenassociatedwithlowermortalityandbettersurvivaloutcomes.30,31Theuseofend-tidalcapnometryhasbeendemonstratedtobeeffectiveinavoidingprehospitalhyperventilationandhypocarbiainintubatedhead-injuredpatients.15,21,32-34ReplacingthebagvalvemaskintheintubatedpatientwithamobileventilatorremovesthehumanerrorandhasbeendemonstratedtoproducemoreuniformPaCO2levelsandbetteroutcomes.35Hyperventilationisoftentheresultoflowsaturationsenroutetothehospitalwheretheparamedictreatshypoxiawiththenaturalresponseofmorevigorousventilation.36

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52www.cs.amedd.army.mil/references_publications.aspxOPTIMALHAND-BAGVENTILATIONOFBRAIN-INJUREDPATIENTSCurrently,hand-baggingventilationisanimpreciseartallowingforawiderangeofminuteventilationsandresultantPaCO2levels.Thenaturalresponseinventilatingseverelyinjuredpatientsisaggressiveover-ventilation.Handstrength,singlehand-bagging,2-handedhand-bagging,andfrequencyofbagcompressionsareallfactorsintheuseofthebagvalvemask.37Inonestudy,squeezingastandardone-literbagwithasinglehandgivesadifferentmeanamountofgasventilation(694cm3percompression)whencomparedtoamean2-handsqueezeofthesameone-literbag(827cm3percompression).38Thestandardminuteventilation(theamountofgasventilatedperminute)foranormalPaCO2ina70kgpatientisapproximately10timesthebodyweightinkilograms.Thusa70kgpatientwillhaveaminuteventilationofapproximately700cm3,andtheBrainInjuryFoundationrecommends10breathsperminuteventilationinbrain-injuredpatientsprehospital.5Withagoalof10cm3/kgasaguide,theoptimalgasexchangewilluseadifferentfrequencyofbagcompressions,dependingonwhetherthepatientissinglehand-bagged(approximately10compressionsperminuteif70kg)orhand-baggedby2hands(approximately8compressionsperminuteif70kg).Thisvariabilitycanprovedetrimentalifitresultsiniatrogenichypocarbia.MAXIMIZINGENROUTECAREOFCOMBATBRAIN-INJUREDPATIENTSTheapplicationofpatientmanagementstrategiesderivedfromcivilianstudiestothebattlefieldislimitedbecauseofsignificantdifferencesbetweenthepatientpopulations.Therearesubstantivedifferencesbetweenthepopulationsintermsofinjurypatternandballistics.However,untilcombatdatacontrarytotheciviliandataareestablished,thepracticeoftransportingcombatinjuredpatientsshouldmirrorthegoalsofcivilianparamedics.Alleffortsshouldbemadetoavoidthetriadofsecondarybraininjury(illustratedbelow).Whilehypotensionandhypoxiaareroutinelyconsidered,hypocarbiaisoftenoverlookedbycombatmedicsandtransportpersonnel.Allcombatbrain-injuredpatientsintubatedandventilatedshouldhaveanend-tidalCO2monitorandeveryeffortshouldbemadetoprovidemobilemechanicalventilatorsforventilation(toremovetheimprecisehand-baggingventilation).Allpersonnelinvolvedwiththebagvalvemaskshouldbetrainedinthecorrecthand-baggingfrequency,tidalvolume,andtechnique.Optimally,thebrain-injuredshouldbeventilatedwithanadditionaloxygensupplyinthesafestway,possiblywithasmalloxygenconcentratortoavoidthehazardsofbottledoxygentoavoidthedeleteriouseffectsofhypoxiaandtheresultantincreaseinthefrequencyof AdaptedfromGabriel5andKnuth25HYPOTENSIONBloodpressuremustbemonitored,andsystolicbloodpressurekeptabove90mmHgwithjudicioususeofIVfluids,hemostaticdressings,andcompression/tourniquets.HYPOXIAOxygensaturationsmustbemonitoredtomaintainhemo-globinsaturationgreaterthan90%byairwaymanagement,reductionofpneumothorax,andsupplementaloxygenasneeded.HYPOCARBIAAvoidhyperventilationwithend-tidalCO2monitoring. BRAININJURYLETHALTRIADTheSilentKiller:HyperventilationintheBrainInjured

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JanuaryMarch200853THEARMYMEDICALDEPARTMENTJOURNALhand-baggingoftentriggeredbythehypoxiathatcausesorexacerbateshyperventilation.Inthismanner,thedetrimentaleffectsofhyperventilationanditsresultanthypocarbiacanbeavoided.FUTURETheoptimalcareofbraininjuredmayincludeventilationandoxygenationbaseduponminute-to-minutecomputerizedfeedbackloopanalysis.39Acomputerizedfeedbacklooponaventilatorwouldimplementchangesindeliveredoxygenlevelsbasedonthehemoglobinsaturations.Additionally,theventilatorrateandtidalvolumesofpositivepressureventilationwouldcontinuouslyadjustinresponsetomeasurementsoftheend-tidalCO2levels.Bagvalvemaskventilationcouldbeimprovedinthenearfuturewithaprecisemechanismformeasuringdeliveredtidalvolumes,andwithanattachedend-tidalCO2monitor.ThedevelopmentofanaccuratenoninvasivemonitorofarterialPaCO2wouldbeoptimalforcombatbraininjuredaswellasahugemedicaladvancement.CONCLUSIONSFirstdonoharm.Preventionofiatrogenicsecondarybraininjuryinthecombatenvironmentislimited.However,relativelysimpleprotocolchangesandacquisitionofsimpleandinexpensivetechnologycanpotentiallyresultinmeaningfuldifferencesinoutcome.Theventilationstatusofcombatbraininjuredshouldberevisitedbyallcareproviderstoavoidinadvertenthyperventilation.End-tidalCO2monitorsshouldbeplacedonallcasualtyevacuationandmedicalevacuationplatforms,andlevelIandlevelIImilitarymedicalfacilities,andusedforallintubatedhead-injuredpatientstoavoidextremePaCO2levelsinthispatientpopulation. REFERENCES1.ElfK,NilssonP,EnbladP.Preventionofsecondaryinsultsinneurointensivecareoftraumaticbraininjury.EurJTrauma.2003;29:74-80.2.ChesnutRM,MarshallLF,KlauberMR,etal.Theroleofsecondarybraininjuryindeterminingoutcomefromsevereheadinjury.JTrauma.1993;34:216-222.3.FearnsideMR,CookRJ,McDougallP,etal.TheWest-meadHeadInjuryProjectoutcomeinsevereheadinjury.Acomparativeanalysisofpre-hospital,clinical,andCTvariables.BrJNeurosurg.1993;7:267-279.4.MuizelaarJP,MarmarouA,WardJD,etal.Adverseeffectsofprolongedhyperventilationinpatientswithsevereheadinjury:arandomizedclinicaltrial.JNeurosurg.1991;75:731-739.5.GabrielE,GhajarG,JogadaA,etal.GuidelinesforPrehospitalManagementofTraumaticBrainInjury.NewYork:BrainInjuryFoundation;2000.Availableat:http://www.braintrauma.org.6.MarionDW,PuccioA,WisniewskiSR,etal.Effectofhyperventilationonextracellularconcentrationsofglutamate,lactate,pyruvate,andlocalcerebralbloodflowinpatientswithseveretraumaticbraininjury.CritCareMed.2002;30(12):2619-2625.7.ColesJP,MinhasPS,FryerTD,etal.Effectofhyperventilationoncerebralbloodflowintraumaticheadinjury:clinicalrelevanceandmonitoringcorrelates.CritCareMed.2002;30(9):1950-1959.8.StockingerZT,McswainNEJr.Prehospitalsupplementaloxygenintraumapatients:itsefficacyandimplicationsformilitarymedicalcare.MilMed.2004;169(8):609-612.9.McLaughlinMR,MarionDW.Cerebralbloodflowandvasoresponsivitywithinandaroundcerebralcontusions.JNeurosurg.1996;85:871-876.10.MarionDW,DarbyJ,YonasH.Acuteregionalcerebralbloodflowchangescausedbysevereheadinjuries.JNeurosurg.1991;74:407-414.11.SalvantJB,Jr.,MuizelaarJP.Changesincerebralbloodflowandmetabolismrelatedtothepresenceofsubduralhematoma.Neurosurgery.1993;33:387-393.12.RaichleME,PlumF.Hyperventilationandcerebralbloodflow.Stroke.1972;3:566-575.13.BoumaGJ,MuizelaarJP,StringerWA,etal.Ultra-earlyevaluationofregionalcerebralbloodflowinseverelyhead-injuredpatientsusingxenon-enhancedcomputerizedtomography.JNeurosurg.1992;77:360-368.14.FieschiC,BattistiniN,BeduschiA,etal.Regionalcerebralbloodflowandintraventricularpressureinacuteheadinjuries.JNeurolNeurosurgPsychiatry.1974;37:1378.15.DavisDP,DunfordJV,OchsM,ParkK,HoytDB.Theuseofquantitativeend-tidalcapnometrytoavoidinadvertentseverehyperventilationinpatientswithheadinjuryafterparamedicrapidsequenceintubation.JTrauma.2004;56(4):808-814.

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54www.cs.amedd.army.mil/references_publications.aspx16.ChuYC,ChenCZ,LeeCH,ChenCW,ChangHY,HsiueTR.Predictionofarterialbloodgasvaluesfromvenousbloodgasvaluesinpatientswithacuterespiratoryfailurereceivingmechanicalventilation.JFormosMedAssoc.2003;102(8):539-543.17.RussellGB,GraybealJM.End-tidalcarbondioxideasanindicatorofarterialcarbondioxideinneurointensivecarepatients.JNeurosurgAnesthesiol.1992;4(4):245-249.18.HoffmanRA,KriegerBP,KramerMR,etal.End-tidalcarbondioxideincriticallyillpatientsduringchangesinmechanicalventilation.AmRevRespirDis.1989;140(5):1265-1268.19.FerberJ,JuniewiczHM,Lechowicz-GogowskaEB,PieniekR,WroskiJ.Arterialtoend-tidalcarbondioxidedifferenceduringcraniotomyinseverelyhead-injuredpatients.FoliaMedCracov.2001;42(4):141-152.20.HelmM,SchusterR,HaukeJ,LamplL.Tightcontolofprehospitalventilationbycapnographyinmajortraumavictims.BrJAnaesth.2003;90:327-332.21.KoberA,SchubertB,BertalanffyP.Capnographyinnontracheallyintubatedemergencypatientsasanadditionaltoolinpulseoximetryforprehospitalmonitoringofrespiration.AnesthAnalg.2004;98(1):206-210.22.GrmecS,MallyS.Prehospitaldeterminationoftrachealtubeplacementinsevereheadinjury.EmergMedJ.2004;21:518-520.23.TakedaT,TanigawaK,TanakaH,HayashiY,GotoE,TanakaK.Theassessmentofthreemethodstoverifytrachealtubeplacementintheemergencysetting.Resuscitation.2003;56(2):153-157.24.TimmermannA,RussoSG,EichC,etal.Theout-of-hospitalesophagealandendobronchialintubationsperformedbyemergencyphysicians.AnesthAnalg.2007;104(3):619-623.25.KnuthT,LetarteP,LingG,etal.GuidelinesforFieldManagementofCombat-RelatedHeadTrauma.NewYork:BrainInjuryFoundation;2005.Availableat:http://www.braintrauma.org.26.DavisDP,HoytDB,OchsM,etal.Theeffectofparamedicrapidsequenceintubationonoutcomeinpatientswithseveretraumaticbraininjury.JTrauma.2003;54(3):444-453.27.DavisDP,PeayJ,SiseMJ,etal.Theimpactofprehospitalendotrachealintubationonoutcomeinmoderatetoseveretraumaticbraininjury.JTrauma.2005;58(5):933-939.28.DavisDP,DunfordJV,PosteJC,etal.Theimpactofhypoxiaandhyperventilationonoutcomeafterparamedicrapidsequenceintubationofseverelyhead-injuredpatients.JTrauma.2004;57(1):1-8.29.LalD,WeilandS,NewtonM,FlatenA,SchurrM.Prehospitalhyperventilationafterbraininjury:aprospectiveanalysisofprehospitalandearlyhospitalhyperventilationofthebrain-injuredpatient.PrehospitalDisasterMed.2003;18(1):20-23.30.DavisDP,SternJ,SiseMJ,HoytDB.Afollow-upanalysisoffactorsassociatedwithhead-injurymortalityafterparamedicrapidsequenceintubation.JTrauma.2005;59(2):486-490.31.WarnerK,CushieriJ,CopassM,JurkovichG,BulgerE.Emergencydepartmentventilationeffectsoutcomeinseverebraininjury.WesternTraumaAssociationAbstract,2007.Contact:http://www.westerntraumaassociation.org/index.html.32.DavisDP,IdrisAH,SiseMJ,etal.Earlyventilationandoutcomeinpatientswithmoderatetoseveretraumaticbraininjury.CritCareMed.2006;34(4):1202-1208.33.PosteJC,DavisDP,OchsM,etal.Airmedicaltransportofseverelyhead-injuredpatientsundergoingparamedicrapidsequenceintubation.AirMedJ.2004;23(4):36-40.34.BernardSA.Paramedicintubationofpatientswithsevereheadinjury:areviewofcurrentAustralianpracticeandrecommendationsforchange.EmergMedAustralas.2006;18(3):221-228.35.DaveyAL,MacnabAJ,GreenG.ChangesinPaCO2duringairmedicaltransportofchildrenwithclosedheadinjuries.AirMedJ.2001;20(4):27-30.36.DavisDP,DouglasDJ,KoenigW,CarrisonD,BuonoC,DunfordJV.Hyperventilationfollowingaero-medicalrapidsequenceintubationmaybeadeliberateresponsetohypoxemia.Resuscitation.2007;73(3):354-361.37.HessD,SpahrC.Anevaluationofvolumesdeliveredbyselectedadultdisposableresuscitators:theeffectsofhandsize,numberofhandsused,anduseofdisposablemedicalgloves.RespirCare.1990;35(8):800-805.38.McCabeSM,SmeltzerSC.Comparisonoftidalvolumesobtainedbyone-handedandtwo-handedventilationtechniques.AmJCritCare.1993;2(6):467-473.39.HoskinsSL,ElgjoGI,LuJ,et.al.Closed-loopresuscitationofburnshock.JBurnCareRes.2006;27(3):377-385.TheSilentKiller:HyperventilationintheBrainInjured

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JanuaryMarch200855THEARMYMEDICALDEPARTMENTJOURNALAUTHORSLTC(P)BlackbourneisChief,TraumaService,InstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.MAJColeisastaffneurosurgeon,BrookeArmyMedicalCenter,FortSamHouston,Texas.MAJMabryistheEmergencyMedicineFellow,USArmyInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.MAJMorganistheBattalionSurgeon,3rdSpecialForcesGroup,WomackArmyMedicalCenter,FortBragg,NorthCarolina.LTCBarrasistheAssistantChiefNurseAnesthetist,WomackArmyMedicalCenter,FortBragg,NorthCarolina.COLEastridgeistheProgramDirector,SurgicalCriticalCare,USArmyInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.COLHolcombisCommander,USArmyInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas,andTraumaConsultanttoTheArmySurgeonGeneral. BrookeArmyMedicalCenter WomackArmyMedicalCenter

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56www.cs.amedd.army.mil/references_publications.aspxHemorrhageremainsthegreatestthreattolifeonthebattlefield,accountingforhalfofalldeaths.1Inrecentmilitaryconflicts,newlydesignedandtestedtourniquetsandmoreaggressivetourniquetuseguidelines,hemostaticdressings,fluidsforresuscitation,andinnovativemethodsofresuscitationarethecurrentoptionsavailabletomilitarymedics.Noneofthesetreatments,however,areabletostopbleedingfromnoncompressibleinjuries.Currenttourniquetscanstoparterialhemorrhagedistaltothegroincreaseandaxillawherethetourniquetcanbeplacedcircumferentially.Duringevacuationandbeforereachingdefinitivecare,manualpressureandhypotensiveresuscitation,inwhichthepatientsbloodpressureiskeptatapproximately90mmHg,isabouttheonlymethodatourdisposalforhandlingnoncom-pressiblearterialhemorrhageinthegroinandaxilla.2AnintriguingdevicecreatedbyJosephListerin1862maybethestartingpointforanadditiontothemedicsarmamentariuminthefieldtoextendtheanatomicgeographyformechanicalhemostasisbycompressingthegroinandaxillaryvessels.JosephListerisbestknownforhisintroductionandvigorouspromotionofantisepticsurgicaltechniqueandwoundcare,buthealsomadeanumberofsignificantcontributionstosurgicaltechnology3:AbdominaltourniquetChromiccatgutsutureCorkaorticcompressorSinusforcepsHerniabistouriesPatellahookUrethralforcepsSuprapubicretractorTrachealretractorWirehammerFracturesteelpegsBoneforcepsOfinteresttoushereisacuriousinventionthathecalledtheabdominaltourniquet,showninFigure1.Becauseextremitytourniquetscouldnotstopproximalarterialbloodflowduringhipsurgery,Listerdesignedamechanicalmeansofstoppingtheinflowofbloodtothehip.HecommissionedW.B.HilliardofGlasgowtoconstructthisabdominaltourniquet,basedonthecommonC-clamp,tohisspecificationsforplacementexternallyabovetheaorta,compressingtheaortatostoptheflowofblooddistally,asshowninhisillustrationdemonstratingitsuse(Figure2).Itisunlikely,however,thatListersabdominaltourniqueteversawmuchaction.Althoughnophysicalevidenceofthetoolsurvived,asimilardevicewasdesignedandmanufacturedbyJosephPancoastofPhiladelphiaataboutthesametimethatListerswasproduced.Pancoastreportedseveralproximalthighandhipsurgerieswithverylimitedbloodlossandnointerruptionofrespirationwhilethepatientreceivedetherbreathingspontaneously.4SeveralothersimilarC-clampextremitytourniquetswerealsoinventedaroundthetimeoftheAmericanCivilWar,mainlytoavoidcircumferentialcompressionandtheresultantgangrene.DupuytrenscompressorandtheSignoritourniquetswereclamp-likedevices,suchasthatshowninFigure3,butweredifficulttoposition Figure1.JosephListersAorticTourniquet(circa1862).Reprintedwithpermission.Copyright:HunterianMuseumatTheRoyalCollegeofSurgeonsofEngland.JosephLister,NoncompressibleArterialHemorrhage,andtheNextGenerationofTourniquets?LTC(P)LorneH.Blackbourne,MC,USAMAJRobertMabry,MC,USALTCJamesSebesta,MC,USACOLJohnB.Holcomb,MC,USA

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JanuaryMarch200857 effectively.ThesedeviceswereeventuallyabandonedinfavorofthePetittourniquet.5,6POTENTIALROLEFORMODIFYINGTHEABDOMINALTOURNIQUETFORTHEBATTLEFIELDInabilitytomaintainhemostasiswithmanualpressureinanexsanguinatinggroininjurywaswidelypublicizedafterthedeathofaUSSoldierinSomaliain1993.7,8Considerabletimeandthoughthavegoneintotreatingthisinjury,includingseveralstudiesexploringhemostaticagentsthatcanbepoured,packed,orsprayeddirectlyintothewound.9-12Todaysengineeringcapabilities,computerimaging,andhightechmaterialscouldpossiblymakeListers19thcenturyideaareality.AversionofListersabdominaltourniquetusingamodifiedadjustablebarclampplacedoverthegroin,axilla,orclavicle(asillustratedinFigures4,5,6,and7)bymedicsonthebattlefieldcouldpossiblyimpedebloodflowthroughtheexternaliliac,proximalfemoraloraxillaryarteries,whichmayallowaSoldierwithacurrentlynoncompressiblewoundtoreachdefinitivecarealive.Currently,mechanicalhemostasisinvolvingthegroinvesselsisactuallybeingsuccessfullyobtainedbyacommerciallyavailabledeviceforuseafterfemoralarterycatheterpuncture(Figure8).Usingspaceagematerialsandengineering,suchadevicecouldbeshapedtoconformtothepelvicoutlet/axillaandeasilyfoldedintoasmallmobileunit.CONCLUSIONJosephListerwasauniqueindividualwhooftentookuniqueapproachestoproblems.Now,morethan100yearsaftertheuseofhisdesignforcessationofarterialbloodflowtothepelvisandgroin,theideamayholdanswerstobattlefieldtreatmentofcurrentlynoncompressiblebleedingwhichisnotamenabletocurrentlyavailabletourniquetdesign.Butfirst,wemustovercometheinitialskepticismhistoricallyassociatedwithJosephListerswork. Figure2.WatercolorpaintingbyJosephListerdemonstratingtheplacementofthetransab-dominalabdominaltourniquet.Reprintedwithpermission.Copyright:HunterianMuseumatTheRoyalCollegeofSurgeonsofEngland. Figure3.C-clampextremitytourniquetfromtheeraoftheAmericanCivilWar Figure4.Modifiedadjustablebarclampappliedtogroinbloodvessels.

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58www.cs.amedd.army.mil/references_publications.aspxFigure5.Modifiedadjustablebarclampappliedtogroinbloodvessels. Figure6.Modifiedadjustablebarclampappliedtocompressinfraclavicularaxillarybloodvessels. Figure7.Adjustablebarclampappliedtoprovidecompressionofaxillarybloodvessels. Figure8.Commerciallyavailablefemoralarterypuncturesitecompressiondeviceappliedtothegroin.JosephLister,NoncompressibleArterialHemorrhage,andtheNextGenerationofTourniquets?

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JanuaryMarch200859THEARMYMEDICALDEPARTMENTJOURNALREFERENCES1.BellamyRF.Thecausesofdeathinconventionallandwarfare:implicationsforcombatcasualtycareresearch.MilMed.1984;149:55-62.2.McSwainNE,etal.PHTLSPrehospitalTraumaLifeSupport:MilitaryEdition.5thed.StLouis,MO:MosbyJems/Elsevier;2003.3.WangensteenOH,WangensteenSD,KlingerCF.Somepre-Listerianandpost-Listerianantisepticwoundpracticesandtheemergenceofasepsis.SurgGynecolObstet.1973;137:677-702.4.AtkinsonWB,PancoastJ.PhysiciansandSurgeonsoftheUnitedStates.Philadelphia.PA:CharlesRobson:1878:710.5.HellingTS,McNabneyK.Theroleofamputationinthemanagementofbattlefieldcasualties:ahistoryoftwomillennia.JTrauma.2000;49:930-939.6.WellingDR,BurrisD,HuttonJ,MinkenS,RichN.Abalancedapproachtotourniquetuse:lessonslearnedandrelearned.JAmColSurg.2006;203:106-115.7.MabryRL,HolcombJB,BakerAM,etal.UnitedStatesArmyRangersinSomalia:ananalysisofcombatcasualtiesonanurbanbattlefield.JTrauma.2000;49:515-528.8.KurzwegFT.Vascularinjuriesassociatedwithpenetratingwoundsofthegroin.JTrauma.1980;20:214-219.9.PusateriAE,HolcombJB,KheirabadiBS,etal.Makingsenseofthepreclinicalliteratureonadvancedhemostaticproducts.JTrauma.2006;60:674-682.10.AhujaN,OstomelTA,RheeP,etal.Testingofmodifiedzeolitehemostaticdressingsinalargeanimalmodeloflethalgroininjury.JTrauma.2006;61(6):1312-1320.11.AlamHB,ChenZ,JaskilleA,etal.Applicationofazeolitehemostaticagentachieves100%survivalinalethalmodelofcomplexgroininjuryinswine.JTrauma.2004;56(5):974-983.12.AlamHB,UyGB,MillerD,etal.Comparativeanalysisofhemostaticagentsinaswinemodeloflethalgroininjury.JTrauma.2003;54(6):1077-1082.AUTHORS LTC(P)BlackbourneisChief,TraumaService,attheInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.MAJMabryistheEmergencyMedicineFellow,USArmyInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.LTCSebestaisaGeneralSurgeonattheMadiganArmyMedicalCenter,FortLewis,Washington.COLHolcombisCommander,USArmyInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas,andTraumaConsultanttoTheArmySurgeonGeneral.

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60www.cs.amedd.army.mil/references_publications.aspxINTRODUCTIONTheforwardsurgicalteam(FST),designedformobility,provideslevelIIforwardlifesavingandresuscitativesurgery.Resuscitativesurgeryincludescontrollinghemorrhagefromtraumaticamputation,aswellasdamagecontrolsurgery,usuallyanabbreviatedlaparotomyorthoracotomy.Thegoalsoftheabbreviatedoperationaretostophemorrhageandgastrointestinalsoilage.1Theoverallgoalofdamagecontrolsurgeryincludesavoidanceofacidosis,coagulopathy,andhypothermia,alsoknownasthelethaltriadorbloodyviscouscycle.2Traumarelatedhypothermiaisdefinedbybodycoretemperaturebelow36C.Hypothermiaintraumaandsurgerypatients(especiallybelow34C)isanindependentriskfactorandmarkerofmortality.3-7Theisolatedbraininjurypatientsaretheonegroupthatyoumustbecarefulrewarming.Theyshouldnotberapidlyrewarmedaboveanormaltemperature.Themajorpathophysiologicmechanismassociatedwithtraumaandhypothermiarelatedmortalityisanexacerbationofcoagulopathyandplateletdysfunction,aswellasotherlifethreateningcomplicationsincludinginfection,electrolytedisturbances,andcardiacdysrhythmias.8-10Studiesofcivilianpatientsrequiringdamagecontrolsurgerywhopresentedwithhypothermiathatwassubsequentlytreatedwithrewarmingdemonstrateddecreasedmortalityaswellasdecreasedbloodandintravenousfluidrequire-ments.11-13InatraumaregistryoftraumapatientsevaluatedataCombatSupportHospital(CSH)duringOperationIraqiFreedom,mortalitywasalsofoundtobeindepen-dentlyassociatedwithadmissionhypo-thermia(temperaturesbelow36C).14ThatcorrelationispresentedintheFigure.PatientswithadmissionhypothermiaattheCSHinthisstudyalsohadasignificantlyhigherbloodproductandfactorVIIarequirements.ThepreventionandcorrectionofhypothermiaindamagecontrolpatientsatFSTsshoulddecreasemortality,aswellasthevolumeoffluidandbloodproductsthesepatientsrequire.Thisisespeciallyimportantinthelogisticallychallenged,austereenvironmentoffar-forwardcombatsurgery.Currently,therapiestopreventandtreathypothermiaarenotstandardizedandvarybetweenUSArmyFSTsandMaximizingPatientThermoregulationinUSArmyForwardSurgicalTeamsLTC(P)LorneH.Blackbourne,MC,USALTCKurtW.Grathwohl,MC,USALTCPaulBarras,AN,USACOLBrianEastridge,MC,USA 0102030405060 % M o r t a l i t y<9090-90.991-91.992-92.993-93.994-94.9TemperatureF95-95.996-96.997-97.998-98.999-99.9100-100.9>101Mortalityrateofpatientsatthe31stCombatSupportHospitalinIraq,correlatedwithbodytemperatureuponarrival,January31throughDecember20,2004.

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JanuaryMarch200861THEARMYMEDICALDEPARTMENTJOURNALbetweentheservices(ie,USNavyandUSAirForcelevelIIsurgicalfacilities).Duringthedevelopmentofajointtheater-widetraumasystem,theUSmilitaryhasbeenchallengedto:1.DefinetheoptimalmeasurestopreventandtreathypothermiaatlevelIIsurgicalfacilities.2.ProvideimplementationanduniversalapplicationofthesemeasuresatalllevelIImilitarysurgicalfacilities.OPTIONSFORPREVENTIONOFHEATLOSSANDTHERAPIESTOINCREASECOREBODYTEMPERATUREHeatlosswithdecreasesincorebodytemperatureisthoughttoresultfromoneoracombinationof4mechanisms:RadiationEvaporationConvectionConductionPrimaryattentionshouldfocusonthepreventionofheatlosssincerewarmingpatientscanbedifficultandmayrequireactivemeasureswhichareinvasiveandlimitedinthecombatenvironment.Furthermore,oncehypothermiahasoccurred,patientsmaybesubjectedtotheself-propagatingvortexofthelethaltriadhypothermiacausescoagulopathy,whichthencausesmorebleeding,whichthenresultsinheatloss,whichthencausesmorecoagulopathy,whichcausesmoreandthecyclecontinues.Optionsforpreventingheatlossandwarmingsurgicalpatientsinvolveseverythingthattouchesorgoesintothepatient.Sinceasignificantcauseforthelossofbodytemperatureisradiationheatloss,theobviousfirstareaofconcernistheambienttemperatureintheoperatingroom.AMBIENTOPERATINGROOMTEMPERATUREThesummermonthsinSouthwestAsiaareverywarm,thenightsandwinterhowever,especiallyinthedesertenvironment,canbesurprisinglycold.Ambienttemperatureslowerthan80Fintheoperatingroomareassociatedwiththemostcommoncauseofheatlossfromradiation.Elevatingambienttemperatureintheoperatingroomtoover80Fisoneofthemostimportantmeasurestopreventheatlossanddecreasesincorebodytemperatureinsurgicalpatients.15-17Limitationstothissimplemaneuverincludetheinabilitytoadequatelyheattheoperatingroom.However,environmentalcontrolunitshavedemonstratedthecapabilitytoeffectivelyheattheoperatingroomandpostoperativeareasandshouldbewidelydeployedwiththeFSTwheneverfeasible.INTRAVENOUSBLOODANDFLUIDWARMERSDamagecontrolproceduresareusuallyassociatedwiththemostcriticallyinjuredpatients.Insomecaseswithdocumentedsurvival,theresuscitativeintravenousfluidrequirementhasexceededseverallitersofcrystalloidandupto40to50unitsofbloodandbloodproducts.Theselargeamountsofrefrigeratedbloodandroomtemperaturefluidcanhaveadramaticeffectondecreasingcorebodytemperature.Infusiondevicesthatwarmbloodandintravenous(IV)fluidbeforeenteringthepatienthavebeendocumentedtopreventheatlossandmaintainbodycoretemperature.18,19Furthermore,useofrapidinfusionsystems,inadditiontofluidwarming,hasbeendocumentedtodecreasefluidandbloodrequirements,preservebodytemperature,anddecreaseacidosisinhypovolemictraumapatients(optimallyaftersurgicalhemostasis).20TheBelmontFMS-2000(BelmontInstrumentCorpo-ration,780BostonRoad,Billerica,MA01821)rapidinfusionwarmingdevicehasdemonstratedthecapabilitytoadequatelywarmandinfuserapidamountsofbloodandIVfluids.21Currently,warmingdevicesarenotuniversallydeployedwiththeFST.SeveralfieldexpedientandothernoveldeviceshavebeenusedtowarmIVfluids.Theserangefromwarmingwaterbathstoimmersingthefluids,utilizingtheheatingelementofameal-ready-to-eat(MRE),handwarmers,coffeemakers,andwrappingIVfluidsinheatblankets.Thetemperatureofthefluidmaybehardtocontrolwiththesefieldexpedientmethodsandcouldresultinoverheating,sothesemethodscannotbeuniversallyendorsed.CONVECTIVEHEATBLANKETSHeatingblanketspreventradiationheatlossandactivelywarmpatientsbyconvection,blowingairwarmedto44Cthroughaircolumnswithintheblankets.Thesesystemsrequireelectricityandaheatingairflowgeneratingunit,aswellasdisposable

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62www.cs.amedd.army.mil/references_publications.aspxblankets.Therequirementscanlimititsuseintheaustereenvironment.Heatingblanketsareplacedstrategicallyoverthepatientsbodyareasthatarenotundergoingthesurgicalprocedure.Unfortunately,patientswhocanbenefitthemost,polytraumapatients,frequentlyremainuncoveredbecauseseveralbodyareasrequiresimultaneousoperativeinterventiontocontrolhemorrhage.TheconvectiveheatsystemmostcommonlyusedinmilitaryfacilitiesandciviliantraumacenterswithintheUnitedStatesistheBairHuggerBlanket(ArizantHealthcareInc,10393West70thStreet,EdenPrairie,MN55344)system.Usedintraoperatively,convectivewarmingdeviceshavebeenshowntomaintainbodytemperatureandavoidhypothermia.22-25Despitethelogisticallimitations,manyFSTsuseBairHuggersintheoperatingroomandpostoperativerecoveryareas.ThedeploymentofBairHuggersorsimilarconvectivewarmingdevicesshouldbeuniversalatalllevelIIbsurgicalfacilities.Modificationstothedevicetolimitsizeandweightcouldbemadewithminimalindustryeffort.Conductiveheatlossisanotherimportantcauseofdecreasedcorebodytemperatureinseverelyinjuredpatientswhenthesepatientsareplacedoncoldstretchers,gurneys,oroperatingroomtables.Simpleactionssuchastheplacementofwoolblankets,sheets,orothermaterialsthatconductlessheatcanhelpminimizeheatloss.Hemorrhagicshockandphysiologicderangementsresultinperipheralvasoconstrictiontoconservecorebodytemperature.Thesehomeostaticsystemsareoftenoverwhelmedinthepostoperativeresuscitativeperiod,resultinginvasodilationandmayallowforfurtherpotentialbodytemperatureloss.Thispotentialforpostoperativeheatlossfurtheremphasizestheimportanceofambientroomtemperature,convectiveheatingdevices,andtheavoidanceofconductiveheatlossintheimmediatepostoperativeperiod.IRRIGATIONFLUIDWhileitisunusualtousecopiousirrigationfluidforperitonealwashoutduringtheinitialabbreviatedlaparotomyofdamagecontrol,manypatientsalsoneedirrigationoflargesoft-tissuewounds.Usingambienttemperatureirrigationfluidcancontributetohypothermia,whileusingirrigationfluidwarmedclosetonormalbodytemperaturecanhelpmaintainnormothermia.26,27Thereareseveralpotentialwaystowarmirrigationfluid,includingtheflamelessMREheaters,microwaveovens,ormodificationofaconvectiveheater.28-30Forexample,in2002aconvectiveBairHuggerheatinghosewasusedtoheataboxofIVandirrigationfluidsduringdeploymenttotheAfghanistantheater.31Severalothercommerciallyavailableheatingdevicesforfluids,suchasthoseproducedbyEnthermicsMedicalSystems(W164N9221WaterStreet,MenomoneeFalls,WI53051),arealsoavailable.Astandardmethodforwarmingirrigationandintravenousfluidshouldbefield-testedforuniversalusebyallFSTs.Evaporativeheatlossesarealsoimportant.Patientswithopenabdomenmayexperiencesignificantheatlosses.Theabdomenshouldbeprotectedwithwaterandairtightbarriers,suchas,Ioban2(3M,St.Paul,MN55144-1000)tominimizeevaporativeheatlosses. BairHuggerconvectionblanketinuseintheemergencydepartmentMaximizingPatientThermoregulationinUSArmyForwardSurgicalTeams

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JanuaryMarch200863THEARMYMEDICALDEPARTMENTJOURNALOPTIMALMEASURESFORHYPOTHERMIAPREVENTIONDURINGHELICOPTEREVACUATIONAllpatientsundergoingsurgeryattheFSTorlevelIIfacilitywillbeevacuatedtotheCSHorlevelIIIforcontinuingcareandmoredefinitiveoperativeprocedures.Intratheaterpatientmovementisusuallyaccomplishedbyhelicopter.Patientmovementisassociatedwithenvironmentalexposures,includingcoolerairataltitudeandwindchill.32Inastudyofheatlossduringtransportinacivilianintensivecareunit,patientstransportedtotheradiologydepartmentforacomputedtomographicscanwerefoundtoloseupto2Cofbodytemperature.33Preventinghypothermiainapostoperativedamagecontrolpatientinahelicopterismuchmorechallengingthantheintrahospitaltriptoradiology.Airflowthroughthehelicoptershouldbeminimizedasmuchaspossiblewithinconstraintsofsecurity(ie,doorgunner).Anecdotalreportsindicatethatplacingthepostoperativepatientinahotpocketconsistingofamodifiedbodybagwith2woolblanketsandareflectiveblankethasbeenusedinbothAfghanistanandIraqforretentionofbodyheat.Alternatively,thepatientcanbeplacedinacommerciallyavailableNARPHypothermiaPreventionandManagementKit(HPMK)(NorthAmericanRescueProducts,Inc,481GarlingtonRoad,SuiteA,GreenvilleSC29615),whichincludesanactiveheatingelement.SomehaveusedtheHPMKinsidethehotpocketaswell.Themajorlimitationofbothofthesebodytemperaturepreservationtechniquesisthattheycompletelycoverthepatient,whichinhibitspatientaccessanddoesnotallowobservationofenroutebleeding.Furtherevidencetosupportthetechniqueofmultiplelayersfortransportisthatlayersofinsulatingmaterialshavebeenshowntohelpdecreaselossofbodyheatinperioperativecivilianpatients.34Whilelayersofinsulatingmaterialsdecreaselossofbodyheat,activewarmingviaaconvectivewarmingdevicehasbeendemonstratedtoofferoptimalpreventionofhypothermiaincivilianpatientsduringtransfer.33Theadditionofanactiveconvectiveheatingdevice(eg,BairHugger,ThermalAngel[EstillMedicalTechnologies,Inc,4144NCentralExpressway,Suite260,Dallas,TX75204])andlayersofinsulatingmaterialsmayoffertheoptimalhypothermiapreventiontopatientsundergoinghelicopterevacuation.Helicoptersafetytestingandsubsequentfieldingofaconvectiveheatingsystemtoeveryhelicopterevacuationplatformshouldbeconsidered.OPTIMALANESTHESIAFORTHERMOREGULATIONGeneralvolatileanesthetics(ie,gasanesthetics)furtherexacerbatehypothermiaintraumapatientsbylossofnormalthermoregulatoryvasoconstrictionwithresultantvasodilationandredistributionofheattotheskinandperipheraltissues.35,36Onetechniquetoavoidanesthetic-relatedhypo-thermiamaybetheuseofTIVA(totalintravenousanesthesia).TIVA,whichutilizesintravenousmedicationssuchaspropofol,ketamine,andfentanyl,withorwithoutaparalytic,maybeassociatedwithlessperipheralvasodilationandsubsequentheatloss.37,38TIVAhasbeenusedinthousandsofcivilianpatientsandhasbeenusedbyprovidersinthe Fieldexpedienthotpocket HypothermiaPrevention&Managementkit

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64www.cs.amedd.army.mil/references_publications.aspxIraqtheater.39Oneoftheauthors,LTCGrathwohl,usedTIVAanesthesiaforcombatpenetratingneurologicalinjuryinover125patients,demonstratingthesafetyandeffectivenessofitsuseintheaustereenvironment.TIVAshouldbeconsideredforuseinthemajorityofpatientsundergoingdamagecontrolsurgeryatFSTs.UNIVERSALLEVELIIbSUGGESTIONSSuggestionsforconsiderationforcreatinguniversalthermoregulatorymeasuresforLevelIIbarelistedintheTable.Webelievethesemeasureswillhelpdecreasethemorbidityandmortalityofdamagecontrolpatients,anddecreasethelogisticrequirementsforeachindividualpatient.FUTUREMEASURESFORFSTTHERMOREGULATIONCurrently,far-forwarddeployedventilatorshavenoabilitytoheatventilatorgases.Warmingofventilatorgaseshasbeendocumentedtohelpconservebodycoretemperature.40Humidifiermoistureexchangershavealsobeendemonstratedtopreventfurtherrespiratoryrelatedheatloss.Futureresearchandacquisitionofthesespecializedventilatorscouldhelpmaintainbodytemperatureinthefuture.Aclearplastichotpocketwithmultipleaccesspointswouldallowpatientobservationandaccessenroute,similartothecommerciallyavailablenuclear,biological,andchemicalcontaminationpatientcovers.Improvementsinconvectivewarmingdevices,includingwater-warmedbody/bedpads,mayrepresentoptimalbodywarmingandreplacewarmairconvectivedevicesinthefuture.41TheArcticSunisanotherproprietarydevicethathasdemonstratedpromiseinimprovingtheabilitytorapidlywarmpatients.Someciviliantraumacentersareusingthefluidrapidinfusiondevicewithadaptationtoanarterial-venousbloodwarmingdeviceinpatientswithseverehypothermia.Thismayhavefutureapplicationinthefar-forwardsurgicalplatformsandlevelIIIsurgicalfacilities.11Lookingatlong-termadvancestoprovidenoninvasive,deeptissuewarmingusingcurrentlyunknowntechnologywillproviderapidtotalbodywarmingtoanydesiredtemperature.While,atfirstglance,onemightconjureimagesofasciencefictionmovie,thistechnologymayincludeadvancesinmicrowaveheatingorotherdeepradiatingheatsources.Thiscouldconceivablyincluderegionaltemperaturegradients,forexample,providingbraincoolingandtruncalheatinginthemultiplesysteminjuredpatient.Whilethistechnologyisprobablyfarinthefuture,theUSmilitaryshouldprovideleadershipinitsdevelopment.CONCLUSIONCreatinguniversalminimalthermoregulationstandardsforallFSTsmaydecreasemorbidityandmortalityofcombatdamagecontrolpatients.ThesestandardswillalsodecreasethebloodandIVfluidrequirementsforeachindividualpatient,decreasingthelogisticalchallengesfortheFSTs.Theimportanceofmaintainingbodycoretemperatureinthesecombatdamagecontrolsurgerypatientscannotbeoveremphasized.REFERENCES 1.RotondoMF,BardMR.Damagecontrolsurgeryforthoracicinjuries.Injury.2004;35(7):649-654.2.DeWaeleJJ,VermassenFE.Coagulopathy,hypothermiaandacidosisintraumapatients:therationalefordamagecontrolsurgery.ActaChirBelg.2002;102(5):313-316.ItemQuantity BairHuggerwarmingunit 4BairHuggerconvectionblanket20 BelmontFMS-2000fluidwarmer 3BelmontFMS-2000tubing20 Bodybags 10Woolblankets20 Reflectiveblankets 10EnvironmentalControlUnit2 EnthermicMedicalSystems fluidwarmer 1TotalIntravenousAnesthesiainfusionpump2RecommendedStandardThermoregulatoryEquipmentforLevelIIbSurgicalFacilities MaximizingPatientThermoregulationinUSArmyForwardSurgicalTeams

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JanuaryMarch200865THEARMYMEDICALDEPARTMENTJOURNAL3.AsensioJA,McDuffieL,PetroneP,etal.Reliablevariablesintheexsanguinatedpatientwhichindicatedamagecontrolandpredictoutcome.AmJSurg.2001;182(6):743-751.4.TyburskiJG,WilsonRF,DenteC,SteffesC,CarlinAM.Factorsaffectingmortalityratesinpatientswithabdominalvascularinjuries.JTrauma.2001;50(6):1020-1026.5.CushmanJG,FelicianoDV,RenzBM,etal.Iliacvesselinjury:operativephysiologyrelatedtooutcome.JTrauma.1997;42(6):1033-1040.6.HoytDB,BulgerEM,KnudsonMM,etal.Deathintheoperatingroom:ananalysisofamulticenterexperience.JTrauma.1994;37(3):426-432.7.JanczykRJ,HowellsGA,BairHA,HuangR,BendickPJ,ZelenockGB.Hypothermiaisanindependentpredictorofmortalityinrupturedabdominalaorticaneurysms.VascEndovascSurg.2004;38(1):37-42.8.MartiniW,PusateriA,UscilwiczJ,DelgadoA,HolcombJ.Independentcontributionsofhypothermiaandacidosistocoagulopathyinswine.JTrauma.2005;58:1002-1010.9.CosgriffN,MooreEE,SauaiaA,Kenny-MoynihanM,BurchJM,GallowayB.Predictinglife-threateningcoagulopathyinthemassivelytransfusedtraumapatient:hypothermiaandacidosisrevisited.JTrauma.1997;42(5):857-861.10.FerraraA,MacArthurJD,WrightHK,ModlinIM,McMillenMA.Hypothermiaandacidosisworsencoagulopathyinthepatientrequiringmassivetransfusion.AmJSurg.1990;160(5):515-518.11.GentilelloLM,JurkovichGJ,StarkMS,HassantashSA,O'KeefeGE.Ishypothermiainthevictimofmajortraumaprotectiveorharmful?Arandomized,prospectivestudy.AnnSurg.1997;226(4):439-447.12.JohnsonJW,GraciasVH,SchwabCW,etal.Evolutionindamagecontrolforexsanguinatingpenetratingabdominalinjury.JTrauma.2001;51(2):261-269.13.BernabeiAF,LevisonMA,BenderJS.Theeffectsofhypothermiaandinjuryseverityonbloodlossduringtraumalaparotomy.JTrauma.1992;33(6):835-839.14.ArthursZ,CuadradoD,BeekleyA,etal.Theimpactofhypothermiaontraumacareatthe31stCombatSupportHospital.AmJSurg.2006;191(5):610-614.15.MacarioA,DexterF.Whatarethemostimportantriskfactorsforapatient'sdevelopingintraoperativehypothermia?AnesthAnalg.2002;94(1):215-220.16.KeanM.Apatienttemperatureauditwithinatheatrerecoveryunit.BrJNurs.2000;9(3):150-156.17.ClossSJ,MacdonaldIA,HawthornPJ.Factorsaffectingperioperativebodytemperature.JAdvNurs.1986;11(6):739-744.18.SmithCE,DesaiR,GloriosoV,CooperA,PinchakAC,HagenKF.Preventinghypothermia:convectiveandintravenousfluidwarmingversusconvectivewarmingalone.JClinAnesth.1998;10(5):380-385.19.SmithCE,GerdesE,SwedaS,etal.Warmingintravenousfluidsreducesperioperativehypothermiainwomenundergoingambulatorygynecologicalsurgery.AnesthAnalg.1998;87(1):37-41.20.DunhamCM,BelzbergH,LylesR.Therapidinfusionsystem:asuperiormethodfortheresuscitationofhypovolemictraumapatients.Resuscitation.1991;21(2-3):207-227.21.DubickMA,BrooksDE,MacaitisJM,BiceTG,MoreauAR,HolcombJB.Evaluationofcommerciallyavailablefluid-warmingdevicesforuseinforwardsurgicalandcombatareas.MilMed.2005;170(1):76-82.22.CasseyJ,StrezovV,ArmstrongP,etal.Influenceofcontrolvariablesonmannequintemperatureinapaediatricoperatingtheatre.PaediatrAnaesth.2004;14(2):130-134.23.KoberA,ScheckT,FulesdiB,etal.Effectivenessofresistiveheatingcomparedwithpassivewarmingintreatinghypothermiaassociatedwithminortrauma:arandomizedtrial.MayoClinProc.2001;76(4):369-375.24.PatelN,SmithCE,KnapkeD,PinchakAC,HagenJF.Heatconservationvsconvectivewarminginadultsundergoingelectivesurgery.CanJAnaesth.1997;44(6):669-673.25.BormsSF,EngelenSL,HimpeDG,SuyMR,TheunissenWJ.BairHuggerforced-airwarmingmaintainsnormothermiamoreeffectivelythanthermoliteinsulation.JClinAnesth.1994;6(4):303-307.26.MooreSS,GreenCR,WangFL,PanditSK,HurdWW.Theroleofirrigationinthedevelopmentofhypothermiaduringlaparoscopicsurgery.AmJObstetGynecol.1997;176(3):598-602.27.PitMJ,TegelaarRJ,VenemaPL.Isothermicirrigationduringtransurethralresectionoftheprostate:effectsonperioperativehypothermia,bloodloss,resectiontimeandpatientsatisfaction.BrJUrol.1996;78(1):99-103.

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66www.cs.amedd.army.mil/references_publications.aspx28.LeamanPL,MartyakGG.Microwavewarmingofresuscitationfluids.AnnEmergMed.1985;14(9):876-879.29.AnshusJS,EndahlGL,MottleyJL.Microwaveheatingofintravenousfluids.AmJEmergMed.1985;3(4):316-319.30.GarciaGD,ModestoVL,LeeKT.Avoidinghypothermiaintrauma:useoftheflamelessheaterpack,mealreadytoeat,asafield-expedientmeansofwarmingcrystalloidfluid.MilMed.2000;165(12):903-904.31.CraigR,PeoplesGE.Anoveldevicedeveloped,tested,andusedforwarmingandmaintainingintravenousfluidsinaforwardsurgicalteamduringOperationEnduringFreedom.MilMed.2006;171(6):500-503.32.BeekleyAC,WattsDM.CombattraumaexperiencewiththeUnitedStatesArmy102ndForwardSurgicalTeaminAfghanistan.AmJSurg.2004;187(5):652-654.33.ScheckT,KoberA,BertalanffyP,etal.Activewarmingofcriticallyilltraumapatientsduringintrahospitaltransfer:aprospective,randomizedtrial.WienKlinWochenschr.2004;116(3):94-97.34.BrauerA,PerlT,UyanikZ,EnglishMJ,WeylandW,BraunU.Perioperativethermalinsulation:minimalclinicallyimportantdifferences?BrJAnaesth.2004;92(6):836-840.35.NebbiaSP,BissonnetteB,SesslerDI.Enfluranedecreasesthethresholdforvasoconstrictionmorethanisofluraneorhalothane.AnesthAnalg.1996;83(3):595-599.36.MatsukawaT,SesslerDI,SesslerAM,etal.Heatflowanddistributionduringinductionofgeneralanesthesia.Anesthesiology.1995;82:662673.37.ShorrabAA,AtallahMM.Totalintravenousanaesthesiawithketamine-midazolamversushalothane-nitrousoxide-oxygenanaesthesiaforprolongedabdominalsurgery.EurJAnaesthesiol.2003;20(11):925-931.38.IkedaT,KazamaT,SesslerDI,etal.Inductionofanesthesiawithketaminereducesthemagnitudeofredistributionhypothermia.AnesthAnalg.2001;93:934-938.39.MatsukiA,IshiharaH,KotaniN,etal.Aclinicalstudyoftotalintravenousanesthesiabyusingmainlypropofol,fentanylandketaminewithspecialreferencetoitssafetybasedon26,079cases.AnesthResus.2002;51(12):1336-1342.40.GinsbergS,SolinaA,PappD,etal.Aprospectivecomparisonofthreeheatpreservationmethodsforpatientsundergoinghypothermiccardiopulmonarybypass.JCardiothoracVascAnesth.2000;14(5):501-505.41.JanickiPK,HigginsMS,JanssenJ,JohnsonRF,BeattieC.Comparisonoftwodifferenttemperaturemaintenancestrategiesduringopenabdominalsurgery:upperbodyforced-airwarmingversuswholebodywatergarment.Anesthesiology.2001;95(4):868-874.AUTHORS LTC(P)BlackbourneisChief,TraumaService,attheInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.LTC(P)GrathwohlistheChiefofAnesthesiaCriticalCare,andconsultanttotheOfficeoftheSurgeonGeneralonCriticalCare,BrookeArmyMedicalCenter,FortSamHouston,Texas.LTCBarrasistheAssistantChiefNurseAnesthetist,WomackArmyMedicalCenter,FortBragg,NorthCarolina.COLEastridgeistheProgramDirector,SurgicalCriticalCare,USArmyInstituteofSurgicalResearch,BrookeArmyMedicalCenter,FortSamHouston,Texas.MaximizingPatientThermoregulationinUSArmyForwardSurgicalTeams

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JanuaryMarch200867WHATISCOMBATDAMAGECONTROLSURGERY?Whileciviliandamagecontrolsurgeryhasbeenwidelydefined,damagecontrolsurgeryonthebattlefield(combatdamagecontrolsurgery)hasnot.Todefinecombatdamagecontrol,itisimperativetofirstdefinethephilosophyofdamagecontrolsurgery,andthendescribethecurrentsystemfordamagecontrolinciviliantraumacenters.Combatdamagecontrolsurgery(asitiscurrentlybeingemployedinOperationsIraqiFreedomandEnduringFreedom)canthenbedefinedincontrast.Needlesstosay,performingdamagecontrolsurgeryinacombatzonehasmanypitfallsandchallenges,andithasevenbeendescribedasanalmostimpossibletask.1-3Nonetheless,aggressivedamagecontrolsurgeryhasbeen,iscurrently,andwillbecarriedoutsuccessfullybycombatsurgicalteams.4-7CombatdamagecontrolconsistsofmanystagesduetothemultipleevacuationsinvolvedinmovingcombatinjuredUSmilitarypersonnelfromthebattlefieldto,ultimately,thecontinentalUnitedStates.Figure1providesanoverviewofsuchevacuationthroughthedifferentlevelsofmilitarymedicalcare.8Withtheuniquerequirementforintratheaterandglobalevacuationarisesthesimilarlyuniquerequirementforamodified,multistageddamagecontrolsurgicalapproach.Ourgoalistodefinecombatdamagecontrolanditsmanystagessoastoprovideaplatformforanalysisofourcurrentcapabilities.Wemustchallengethecurrentsituationtoallowformaximumimprovementateachstageinmilitarycombatdamagecontrol,inbothcurrentandanyfutureconflicts.Ifonelooksatthestatisticsofmilitarypersonnelwhowerewoundedincombatanddiedofthosewoundsafterarrivalatasurgicalfacility,thensubtractsthenumbersforsevereheadinjuries(approximately15%high-mortality)andallextremitywounds(approximately55%ofcombatwounds,low-mortality),onemustconcludethatimprovementofthemortalityofdamagecontrolpatientsistheonlywaytosignificantlydecreasetheoverallmortalityrateofcombatwoundedinthenearfuture.9,10Acidosis,hypothermia,andcoagulopathyfollowingdamagecontrolsurgeryhavebeendocumentedaspredictiveofmortality.11Therefore,itisonlylogicaltoconcludethat,inordertodecreasetherateofmortalityofdamagecontrolpatients(andtheoverallmortalityrateofwoundedreachingsurgicalfacilities),theabilityoffarforwardsurgicalteamstostopbleeding,stopgastrointestinalsoilage,warm,resuscitate,andcorrectcoagulopathymustbeoptimized,andthesegainsmaintainedthroughoutevacuation.DAMAGECONTROLSURGERYDamagecontrolsurgeryisamedicalparalleltotheUSNavydisciplinefocusedonthecapacityofashiptoabsorbdamageandmaintainmissionintegrity.12WhenaNavyshiphastakenhostilefirethatis,hasbeenwoundedthesailors,atallcostsandasfastaspossible,immediatelyputoutallfiresandstopanyflooding.Thesurgicalanalogyistostopallhemorrhagingandgastro-intestinalsoilageasfastaspossible.DefiningCombatDamageControlSurgeryLTC(P)LorneH.Blackbourne,MC,USA USArmyMedicalCenter(Overseas)MilitaryLevelIVForwardSurgicalTeamMilitaryLevelIICombatSupportHospitalMilitaryLevelIIIUSArmyMedicalCenter(US)MilitaryLevelVBattlefieldMilitaryLevelI Figure1.EvacuationrouteforSoldiersinjuredincombat.

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68www.cs.amedd.army.mil/references_publications.aspxTheneedforspeedinobtainingthesegoalsinseverelyinjuredtraumapatientsistheavoidanceofthetraumalethaltriad.Thelethaltriadistheviciouscycleofhypothermia,acidosis,andcoagulopathy.13Theacidosisisfromhypovolemicshockandinadequatetissueperfusion.14Hypothermiaisfromexsan-guinationsandlossofintrinsicthermoregulation.15,16Coagulopathyisfromhypothermia,acidosis,consumptionofclottingfactors/platelets,andbloodloss.17-20Coagulopathy,inturn,causesmorehemorrhage,andthuscausesmoreacidosisandhypothermia;sothebloodyviciouscyclecontinuesasillustratedbyFigure2.Wheninfullfruition,theviciouscycleofthelethaltriadisalmostuniformlyfatal.Inalandmarkpaperin1993,Rotondoetal21reportedthesuccessfuluseofanabbreviatedoperationintraumapatientstoavoidthelethaltriad,andcoinedthephrasedamagecontrolwithamortalityof50%(priortousingthisapproachthesewerenearuniversallyfatalinjuries).Manytraumacentershavereportedsimilarlysuccessfulresultsusingthedamagecontrolapproachtotheseverelyinjuredtraumapatient,anditisnowconsideredthestandardofcare.22-28Whileoriginallyreportedasanapproachtosevereabdominaltrauma,thedamagecontrolprocesshasevolvedtocoverallanatomicregions,includingthoracictrauma,neurologictrauma,urologictrauma,andextremitytrauma.Thedamagecontrolprocessisespeciallyapplicableinthemultiplesysteminjuredtraumapatient.29-36CIVILIANDAMAGECONTROLSURGERYCiviliandamagecontrolsurgeryisnowwellestablishedasthestandardofcareforseverelyinjured IntensiveCareUnitICURESUSCITATIONAdministerpackedredbloodcells,freshfrozenplasma,andplateletsasneededusingthetenetsofdamagecontrolresuscitationlimitingcrystalloidfluids.39,40Thepatientisrewarmedandfulllaboratoryanalysisisundertakenwiththebasicgoalofnormalizingthepatient.41Whenthepatientisdeterminedtobehemodynamicallystablewithlabvalues,ventilatorstatus,andbodytemperatureincloseproximitytonormal,thepatientisthenreturnedtotheoperatingroomforthedefinitiveoperation.DEFINITIVEOPERATIONThissecondoperativeproceduremostoftenoccurs24to36hoursaftertheinitialoperation.Thedefinitiveoperationwouldincludebowelanastomosesorcolostomymaturation,definitivevascularrepairwhereaninterpositionvascularshunthadbeenpreviouslyplaced,removalofhemostaticpackingandclosureofabdominalfasciawherefeasible.Thepatientisthentakenbacktotheintensivecareunit(ICU)andthepostoperativecareprogressestowardstheultimategoalofdischargetohomeorrehabilitationcenter.OperatingRoomABBREVIATEDSURGICALOPERATIONStopallsurgicalhemorrhageand,secondarily,stopallgastrointestinalsuccussoilageintheshortesttimepossible.OperatingRoompatientsintheUnitedStates.Theciviliandamagecontrolparadigmisbasedonthefollowingdamagecontroltrilogy37,38: Figure2.Thetraumalethaltriadofconditionswhichcanoccurinseverelyinjuredtraumapatients. ACIDOSIS COAGULOPATHY HYPOTHERMIA DefiningCombatDamageControlSurgery

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JanuaryMarch200869THEARMYMEDICALDEPARTMENTJOURNALFigure3.Thebasicoutlineofthemultiplenecessarystagesofcombatdamagecontrolsurgery. BattlefieldCare AbbreviatedOperationLevelIIbLevelIIbForwardSurgicalFacilityPostoperativeResuscitation FixedWingEvacuationtoUS,LevelV LevelVDefinitiveOperationorIntensiveCareUnitCare HelicopterAirEvacuationResuscitationFixedWingGlobalEvacuation LevelIVDefinitiveOperation/SecondLookOperationorIntensiveCareUnitCareResuscitation DefinitiveorSecondLookAbbreviatedOperation LevelIIICombatSupportHospitalPreoperativeResuscitationPostoperativeResuscitation

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70www.cs.amedd.army.mil/references_publications.aspxEachpatientundergoingtheseoperativeproceduresandICUcarerequiresignificantpersonnelandlogisticsresources.Thedocumentedmortalityforthedamagecontrolapproachtopatientsrequiringadamagecontrollaparotomyisapproximately50%withadocumentedmorbidityofapproximately40%.42Inreview,thecivilianlevelItraumacenterdamagecontrolmodelinvolvesthedamagecontroltrilogyabbreviatedoperation,ICUresuscitation,anddefinitiveoperationallinthesamesurgicalfacility.Militarycombatdamagecontrolsurgerydoesnothavetheluxuryofperformingallstagesofdamagecontrolsurgeryinasinglefacility,asthepatientundergoesglobalevacuationandstopsatseveralmilitarysurgicalfacilities.USMILITARYDAMAGECONTROLSURGERYInstarkcontrasttotheciviliandamagecontrolsurgerytrilogy,combatdamagecontrolinvolvesupto10stagestoallowforbattlefieldevacuation,surgicaloperations,andresuscitations.Figure3portraysthebasicoutlineforthemultiplenecessarystagesincombatdamagecontrol.Incomparisontociviliandamagecontrol,themostnotabledifferenceistheprocessofresuscitation.Combatdamagecontrolpostoperativeresuscitationandrewarmingoccursinseveralfacilitiesandmultipletimesduringenrouteairevacuationduringthecombatdamagecontrolprocess.CONCLUSIONCombatdamagecontrolisauniqueenterprise.AsillustratedinFigure4,whileciviliandamagecontrolsurgerycanbedescribedasasimpletrilogyinonehospital,combatdamagecontrolsurgeryundertakesmanystagesandinvolvesmultiplefacilitiesasthepatientundergoesglobalevacuation.Toimprovecombatdamagecontrolsurgery,wemustfirstdefinethestages,andthenassessthepersonnel,logistics,techniques,complications,uniquechallenges,andoutcomesofeachstage.Onlythencanareasforimprovementbedefinedbystage,andpatientcareoptimized.Combatdamagecontrolisanamazingandveryuniqueprocess.Thesuccessfulrecovery,care,andtransportofaseverelyinjuredSoldierfromthebattlefieldtomedicalcentersintheUnitedStatesisanextremelychallengingundertaking.Allmilitarypersonnelinvol-vedincombatdamagecontrolsurgeryshouldbejusti-fiablyproudandyetalwaysstrivingtoimprovefurther. AbbreviatedOperationMilitaryLevelII MilitaryLevelIIResuscitation HelicopterEvacuation/Resuscitation LevelIIIPreoperativeResuscitation DefinitiveorSecondLookOperationLevelIII PostoperativeResuscitationLevelIII FixedWingEvacuation/ResuscitationtoLevelIV DefinitiveOperationorICUCareLevelIV FixedWingGlobalEvacuationtoLevelV LevelVDefinitiveCare MILITARYDAMAGECONTROL AbbreviatedOperation IntensiveCareUnitResuscitation DefinitiveOperation CIVILIANDAMAGECONTROLFigure4.Acomparisonofthestagesofcarerequiredinmilitarycombatdamagecontrolsurgerytothatinvolvedinciviliandamagecontrolcare. DefiningCombatDamageControlSurgery

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JanuaryMarch200871THEARMYMEDICALDEPARTMENTJOURNAL REFERENCES1.EisemanB,MooreF,MeldrumD,RaeburnC.Feasibilityofdamagecontrolsurgeryinthemanagementofmilitarycombatcasualties.ArchSurg.2000;135(11):1323-1327.2.LeppaniemiAK.Abdominalwarwounds--experiencesfromRedCrossfieldhospitals.WorldJSurg.2005;29(suppl):S67-S71.3.NeuhausSJ,BessellJR.DamagecontrollaparotomyintheAustralianmilitary.ANZJSurg.2004;74(1-2):18-22.4.ChambersL,RheeP,BakerB,etal.InitialexperienceofUSMarineCorpsforwardresuscitativesurgicalsystemduringOperationIraqiFreedom.ArchSurg.2005;140(1):26-32.5.BeekleyA,WattsD.CombattraumaexperiencewiththeUnitedStatesArmy102ndForwardSurgicalTeaminAfghanistan.AmJSurg.2004;187(5):652-654.6.BurrisD,FitzharrisJ,HolcombJ,etal,eds.EmergencyWarSurgery.3rded.Washington,DC:BordenInstitute,OfficeoftheSurgeonGeneral,USDeptoftheArmy;2004.7.Bellamy,R.Thecausesofdeathinconventionallandwarfare:implicationsforcombatcasualtycareresearch.MilMed.1984;149(2):55-62.8.MabryRL,HolcombJB,BakerAM,etal.UnitedStatesArmyRangersinSomalia:ananalysisofcombatcasualtiesonanurbanbattlefield.JTrauma.2000;49(3):515-529.9.AokiN,WallMJ,DemsarJ,etal.Predictivemodelforsurvivalattheconclusionofadamagecontrollaparotomy.AmJSurg.2000;180(6):540-545.10.Surfaceshipsurvivability.NavalWarfarePublications3-20.31.Washington,DC:USDeptoftheNavy;January2004.11.ParrMJ,AlabdiT.Damagecontrolsurgeryandintensivecare.Injury.2004;35(7):713-722.12.DeWaeleJJ,VermassenFE.Coagulopathy,hypothermiaandacidosisintraumapatients:therationalefordamagecontrolsurgery.ActaChirBelg.2002;102(5):313-316.13.EddyVA,MorrisJAJr,CullinaneDC.Hypothermia,coagulopathy,andacidosis.SurgClinNorthAm.2000;80(3):845-854.14.TsueiBJ,KearneyPA.Hypothermiainthetraumapatient.Injury.2004;35(1):7-15.15.MartiniW,PusateriA,UscilwiczJ,DelgadoA,HolcombJ.Independentcontributionsofhypothermiaandacidosistocoagulopathyinswine.JTrauma.2005;58:1002-1010.

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