Charting Army Medicine’s Path for the Future

On 13 May, LTG Nadja Y. West, the 44th Surgeon General of the United States Army and Commanding General, US Army Medical Command, spoke with Halldale Group Editor Marty Kauchak. The entire transcript from their wide-ranging interview follows below.

MTM (M): LTG West thank you for taking time to speak withus. It’s been several years since we last engaged from an editorialperspective. Much has changed in the world, this nation and especially the Army– with its continued disengagement from Iraq and Afghanistan, and increasedfocus on a near-peer conflict. What are some of the implications during thisdynamic era for Army Medicine now and in the next several years?

LTG Nadja West (LNW): First, you are welcomeand I always appreciate the opportunity to talk about our great team and thisgreat organization. It has been quite a transition. Before becoming the ArmySurgeon General, I served as the Joint Staff Surgeon. The operational focus onthe Joint Staff is different than the Army Staff, especially for medicine. Thiswas an eye opener for me. When I delivered my “day one” brief as the Army SurgeonGeneral in December 2016, my vision raised eyebrows. I sounded very operationalby discussing how Army Medicine needed to be expeditionary and globallyintegrated. This focus on expeditionary and globally integrated medicine wasbased upon my experiences as the Joint Staff Surgeon and how Army medicineintegrates with the Joint Concept for Health Services. My initial focus was toensure all of my team understood that Army Medicine must develop expeditionaryand globally integrated medical capabilities to effectively support combatantcommanders’ requirements and every singlemember of the organization must understand where they fit in. I stressedevery member because Army medicine also has many wonderful Department of theArmy civilians. We could not do our job without them. This was the first part,getting the mindset shift to being a globally integrated expeditionary force.

LTG Nadja Y. West, the 44th Surgeon General of the United States Army and Commanding General, US Army Medical Command. Source/credit: US Army Office of the Surgeon General

M: To follow on, your command vision statement isquite clear about Army Medicine having attributes which include being the‘premier expeditionary and globally integrated medical force’.

LNW: I tell our team that expeditionary does notmean everyone deploys. Expeditionary is a mindset. Being expeditionary meanshaving the agility, adaptability and comfort with change and uncertainty whenfaced with constraints or a different environment. Global integration means understandingwhat is around us and having the ability to synchronize medical capabilitieswith our sister services around the world in support of combatant commandoperations. Our sister services have capabilities integrated into Army Medicineon a routine basis. Army Medicine also has facilities overseas. Examplesinclude Landstuhl Regional Medical Center, Germany, and Tripler Army MedicalCenter, Hawaii. We have organizations all around the world.

What isreally important and exciting is virtual health. That is global integration. Virtual health provides Army Medicinethe operational reach to support combatant command operations with specialtyconsultation far forward on the battlefield without employing additionaloperational units into the area of responsibility.

M: Another takeaway with this initial discussionis that Army Medicine is an evolving learning organization.

LNW: Yes, Army Medicine is uniquely postured as anevolving and learning organization.  WhenI first took command, we were faced with a validated but unresourcedrequirement from a Combatant Commander. Within months, Army Medicine, seeingthe importance of this mission; developed, trained and deployed an EmergencyResuscitative Surgical Team to Africa that is now in its third year of missionsupport. Our concept became the template used by the Air Force and Navy,creating more capability to meet growing demands.

The Army is undergoing the biggest transformation since the 1970s when US Army Forces Command and US Army Training and Doctrine Command were established. This Army-wide organizational change is totally revamping our entire Army structure to meet future needs and maintain parity with adversaries. This includes the establishment of Army Futures Command.  Army Medicine is in lock step with the Army as it undergoes organizational change through integration into Army Futures Command and an assessment of how Army Medicine must be configured in the future to meet the needs of our Army and the Joint Force.

M: Tell us a bit more about Army Medicine’s rolein Army Futures Command and that organization’s mission.

LNW: Army Medicine is integrated at every level of FuturesCommand. This includes Army Medical Department (AMEDD) officers serving in keyleadership billets within the Command, the establishment of the Futures CommandSurgeon Cell and integration within the cross functional teams. The Executive Officerto the Futures Command Deputy Commanding General is an AMEDD officer. Thisspeaks of Army Medicine’s ability to grow and develop strategic leaders thatare not only medical subject matter experts but also outstanding Soldiers.

Army Medicinealso has representation on Futures Command’s six lines of effort and the twocross-cutting lines of effort; all integrated by an AMEDD officer. For example,long range precision fires demonstrate how Army Medicine supports and integratesinto Futures Command lines of effort. In support of the long range precisionfires line of effort, AMEDD leaders are determining implications on ergonomics,impacts on the Solider at the delivery end of a system and effects to troops inthe impact zone.

M: And beyond activities directly at FuturesCommand?

LNW: Although the Army Medical Research and MaterielCommand (MRMC) is now aligned under Army Materiel Command (AMC), it continuesto lead as a learning organization by staying in touch with deployed Soldiersto identify new and emerging threats. This ultimately leads to MRMC developingcounter measures to meet these new threats.

An exampleof MRMC’s ability to identify emerging threats and develop solutions can befound with the new malaria vaccine. Malaria is still one of the leading causesof death and illness around the world as lack of vaccination results in quite afew deaths where the disease is endemic. As a part of a multi-center effort,MRMC researchers developed a vaccine that helps the military and civiliansglobally.

Changes tobattlefield medicine and doctrine serve as the catalyst for updating the trainingcurriculum at the Health Readiness Center of Excellence to ensure Army Medicineremains relevant in current and future operational environments. Included incurriculum changes at the Health Readiness Center of Excellence are the innovationsdeveloped by MRMC.

The endstate of newly developed solutions and training curriculums is prolonged fieldcare on the battlefield. Multi-domain operations highlight the potential that thenext adversary may be a near peer competitor. There will be multiple domains –land, sea, air and cyber – the enemy will target simultaneously. Army Medicinemust continue to evolve to provide prolonged field care in thisenvironment.

M: Which supported, in part, aerial medicalpassenger transport and evacuation, correct?

LNW: Yes. In the future, the Joint Force may nothave air superiority. Combat operations in Iraq and Afghanistan werehighlighted by the Joint Force having air superiority that allowed us toevacuate a casualty from anywhere in the world by air, uncontested. In thefuture environment, the Joint Force may not have this advantage as theadversary may possess robust anti-access and aerial denial capabilities. Consequently,Army Medicine must have Soldiers comfortable with prolonged medical care.

M: The shift to supporting multi-domain operationsmust have significant implications for your training programs.

LNW: Yes. Multi-domain operations requires Army Medicine to train on prolonged field care in a combat environment.  In support of this change, Army Medicine is in the process of determining the critical skill sets required for every medical military occupational specialty (MOS) and area of concentration (AOC) needed to operate successfully in a deployed and garrison environment. Army Medicine has 120 MOSs and AOCs in medicine and health service support. Although the skills required in garrison and deployed environments vary, the Health Readiness Center of Excellence is updating the curriculum to adjust the skill sets for new Soldiers attending Advanced Individual Training as well as for the different advanced courses in professional military education and health education.

LTG Nadja Y. West, the 44th Army Surgeon General speaks at a command surgeons conference. Source/credit: US Army Office of the Surgeon General

M: How are some of the learning technologiessupporting this wide-array of courses?

LNW: The Army Medical Department is comprised of approximately 140,000 Soldiers and civilians geographically dispersed on five of the seven continents; that is a lot of people to train at various levels and in various areas. Consequently, Army Medicine leverages multiple training methods to reach out to all of these Soldiers and civilians to ensure we maintain trained and ready forces to support the Joint Force. One example of how Army Medicine reaches out to this vast population is through the Health Readiness Center of Excellence’s Instructional Technology Division. This organization produces distributed learning products and media to support training. Army Medicine relies on distance learning because we simply cannot move that many people around.

There are also institutional course enhancements, standard courses and point-of-need instruction. Point-of-need instruction refers to training for individuals deploying to a certain area of operation that require special skills. These special skills may include cultural awareness or special skill sets on special equipment not used in a garrison environment. In these cases, we send a team of instructors to train these individuals.

There arealso simulations. Simulations are one of the lines of effort for Army FuturesCommand and includes technologies such as the synthetic training environment,virtual training labs and mannequins.

M: How might training for Army medical personnelfurther evolve in the short-term – 12 to 24 months?

LNW: Increasing partnerships with civilianinstitutions is an exciting training venue Army medicine leverages. AMEDDMilitary-Civilian Trauma Team Training (AMCT3) is a relatively new training programinitiated approximately nine months ago. This military-civilian partnershipestablishes skills sustainment partnerships with civilian Level 1 trauma centersin the United States and ultimately improves critical wartime trauma care insupport of the Army and Joint Force. Army Medicine has active medical trainingagreements with Cooper University Health System in Camden, New Jersey, andOregon Health and Science University in Portland, Oregon.  As of September of 2018, MEDCOM has embeddedfive Soldier trauma teams at each location. We are in the process of establishing a medical training agreement withthe Medical College of Wisconsin, located in Milwaukee, Wisconsin. Weanticipate beginning this third site this summer.

Civilian-militarypartnerships will continue to increase in the near term. Several weeks ago, I visitedEmory University and met with a team at the hospital. Certain residencyprograms are expanding and there is a willingness to work with the military andopportunities to participate in the programs. These opportunities such as EmoryUniversity enable Army Medicine physicians to obtain the diversity of patientsneed to maintain clinical skill sets. It also enables us to tell the Army storyto those who may not have exposure to the military, with many joining the ArmyReserve or National Guard based on these interactions. This is a win-win forall.

Along withour civilian partnerships, the American Board of Surgery recently recognizedtwo of Army Medicine’s surgical residency programs as the best in the nation.Madigan Army Medical Center at Joint Base Lewis McCord was ranked number oneand Brooke Army Medical Center in Joint Base San Antonio was ranked numberthree of over 223 programs assessed across the nation. The clinical program,matched with unique leadership and operational training, provides exceptionalsurgeons to our force.

Along with ensuring skills sustainment, civilian partnerships facilitate a ‘cross pollination’ of ideas both ways. Many of the clinical skills and best practices learned in Afghanistan and Iraq are taken back to the civilian community. For instance, a lot of the trauma training in Cleveland and Cincinnati, Ohio, is grounded in the Tactical Critical Care Evacuation Team training the Air Force conducts. As a result, the University of Cincinnati trauma team is ahead of their civilian colleagues based on lessons learned in combat – portable oxygen and whole blood resuscitation versus the use of blood components, for example.

M: And are there any other high-level trainingefforts which are of significance?

LNW: As part of the military health system (MHS) transformation,all military treatment facilities will be under the direction and control ofthe Defense Health Agency. As of 1 October 2018, the first DHA pilot program wasstarted at Womack Army Medical Center, Fort Bragg, North Carolina. MHStransformation allows Army Medicine and the service medical departments tofocus on operational medical support and medical support to the Joint Force inan expeditionary environment. This includes medical support provided by forwardsurgical teams, combat support hospitals and emergency resuscitative surgicalteams; the various operational medical units.

MHStransformation will rely on civilian-military partnerships. DHA will lookacross the entire enterprise to see how to leverage and scale partnershipsthroughout the nation. This includes international partnerships where it makessense. International partnerships would of course include unique requirementsfor credentialing and reciprocity. Operational medicine is already amultinational effort in many operational areas of responsibility, so spendingtime with coalition partners in a garrison environment makes sense.

M: Following up on earlier comments about distancelearning and related learning technologies, how can the simulation and trainingindustry better meet the Army medical community’s requirements?

LNW: Trauma is not as prevalent as in the past. Technologyand regulations have enabled less traumatic injuries. Before OSHA, there weremany more construction accidents and crush injuries. Technology in vehicles ledto increased survival rates from motor vehicle accidents and a reduction intrauma. The reduction in trauma patients results in a lack of frequency intrauma training. This is a good problem from the perspective of a prospective traumavictim, but not for surgeons required to remain trained and ready fordeployment. The current and future battlefield will leverage high kineticweapons with the potential to inflict significant trauma on the human body. Simulationsare important to ensuring surgeons remain proficient in this newenvironment.  Simulations must be asrealistic as possible to enable trauma surgeons to remain current on the latesttechniques and have the repetition needed to save lives on the modernbattlefield.

Live tissue training is another gap, as opposed to using animals to train for trauma. As simulations become more realistic in the virtual domain, they must also enable a surgeon to ‘feel’ the simulated pressure on the scalpel when conducting a virtual incision.

Lt. Gen. Nadja West, U.S. Army Surgeon General, and U.S. Army Medical Command commanding general, receives an artificial face and hand injury as she visits the moulage facilitate at Fort Hunter Liggett, Calif., during a tour of the center.
Source: Fort Bliss Bugle

M: We at Halldale also have Civil Aviation Training magazine, whichprovides another focus on safety. How are you maintaining a focus on patientsafety in a very diverse environment – from the battlefield to statesidemedical facilities?

LNW: Army Medicine uses the Joint Commission as anexternal quality control for patient safety. All Army Medicine militarytreatment facilities are evaluated and accredited by the Joint Commission. TheJoint Commission has very stringent patient safety requirements for allhealthcare organizations. I am very happy to say 100% of Army Medicine military treatment facilities are accreditedby the Joint Commission.

Army Medicinealso has a vigorous no-notice inspection program where the same quality andsafety metrics that the Joint Commission uses are used. For 100% of ourfacilities that have inpatient surgery, Army Medicine uses the NationalSurgical and Quality Improvement Program (NSQIP). Less than 20% of civilianfacilities participate in NSQIP because it is voluntary; 100% of Army Medicineinpatient surgery facilities participate. NSQIP evaluates highly complex surgicalcases; pancreatic cancer surgery, for example. Army Medicine ranks very wellagainst NSQIP benchmarks and against others who volunteer to participate.

M: And internal?

LNW: Army Medicine established a program similar tothe Army Safety Center. When an aviation accident occurs, the Aviation SafetyCenter deploys a team according to the accident level and leverages a processto determine root cause and inform the field. Army Medicine mirrors the AviationSafety Center methodology by establishing a standard process of investigating patientsafety incidents in military treatment facilities and evaluating theresults.

LeadingArmy Medicine’s internal control measures on quality and patient safety is the DeputyChief of Staff for Quality and Safety; a MEDCOM level leader that is on paritywith all other Deputy Chiefs of Staff. The MEDCOM Inspector General also servesas a part of the quality and patient safety team by ensuring people feelcomfortable reporting incidents to include the near misses. It is a constant environment of safety andquality.

M: Why should a current or prospective medicalprofessional want a career in Army Medicine?

LNW: When our professionals actually get to experience what Army Medicine is about, they are drawn in. There is nothing else that compares to saving lives on the battlefield and caring for Families of our Soldiers. Army Medicine clinicians take care of patients similar to their civilian counterparts, but do much more with the variety of skills and experiences taught and learned in hospitals and operational units. Our health professionals are afforded the opportunity to lead, conduct research, experience high level educational opportunities and undergo tough and realistic training.

Lt. Gen. Nadja West, U.S. Army Surgeon General, and US Army Medical Command commanding general (far right) , and many other distinguished visitors, met at Fort Hunter Liggett, Calif., to tour the 528th Hospital Center. The 528th Hospital Center is based at Fort Bliss. Source/credit: Sgt. Justin Geiger / 7th MPAD

M: Thank you for taking time to speak withHalldale and MTM today. Is there anything else before we close out, please?

LNW: You are quite welcome. I am approaching the endof my career in uniform – I have been fortunate to serve our Army as The SurgeonGeneral. I cannot be more honored and proud to work with the phenomenal team membersat Army Medicine. I am sincere when I say I have never seen a group of peoplethat are so dedicated to what they do, that really understand the importance ofwhat they do. The American public should know what a gem they have in militarymedicine.