[Senate Hearing 108-]
[From the U.S. Government Publishing Office]
DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2005
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WEDNESDAY, APRIL 28, 2004
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:05 a.m., in room SD-192, Dirksen
Senate Office Building, Hon. Ted Stevens (chairman) presiding.
Present: Senators Stevens, Inouye, and Leahy.
DEPARTMENT OF DEFENSE
Medical Programs
STATEMENT OF LIEUTENANT GENERAL JAMES B. PEAKE, SURGEON
GENERAL, UNITED STATES ARMY
OPENING STATEMENT OF SENATOR TED STEVENS
Senator Stevens. Good morning. We are pleased to see you
here this morning.
We are going to have a hearing on the medical programs. Two
panels are scheduled. First, we will hear from the Surgeon
Generals, followed by the Chiefs of the Nursing Corps. We have
joining us today from the Army Surgeon General, Jim Peake; from
the Navy, Admiral Michael Cowan; from the Air Force, General
George Taylor. We welcome you all back again.
I understand this is your last appearance before the
committee, General Peake.
General Peake. Yes, sir.
Senator Stevens. And Admiral Cowan.
Admiral Cowan. Yes, sir.
Senator Stevens. We do thank you for your service and
assistance to this committee and value your views.
This is a very difficult period for defense health
programs, as we all know. The President's fiscal year 2005
request for the defense health program is $17.6 billion, a 15
percent increase over the fiscal year 2004 request. The request
provides for the health care of 8.8 million beneficiaries and
for the operation of 75 military hospitals, 461 military
clinics.
Despite the increase that is requested this year, this
committee remains concerned that the funding may not be
sufficient to meet all our requirements. We recognize that the
continuing conflict in Iraq and the global war on terrorism,
along with rising costs for prescription drugs and related
medical services, will continue to strain the financial
resources that are requested in this budget and place increased
demands on our medical service programs and providers.
Now, Senator Inouye and I are both personally familiar with
the value of military medicine and have worked with your
organizations for many years. We committed to work with you and
to address the many challenges that you face.
Let me take a moment to commend the Department's medical
service personnel for their work in the global war on
terrorism. Their performance has been nothing short of
extraordinary. From the moment our soldiers, sailors, airmen,
and marines go into harm's way military medics are deployed as
part of the fight. We applaud their efforts and your efforts in
serving jointly to meet the medical needs of our warfighters
and their families, and we commend all of our witnesses here
today for your leadership and compassion for those who serve.
We have taken visits, as you know, to Walter Reed and to
Bethesda and have been really honored to meet some of the young
men and women that are there. I have got to tell you that
almost every person said, ``Senator, can you help us go back to
our unit.'' The morale of these people is just overwhelming and
we are proud of them all.
I want to yield to my co-chairman for his comments.
STATEMENT OF SENATOR DANIEL K. INOUYE
Senator Inouye. I thank you very much, Mr. Chairman.
I want to join you in welcoming our witnesses this morning
as we review our Department of Defense (DOD) medical programs.
Since this will be General Peake's and Admiral Cowan's last
appearance before this committee, I would like to take this
opportunity to thank them for their dedicated service to the
military.
Lieutenant General James Peake assumed command of the
United States (U.S.) Army Medical Command in September 2000. In
the years following, he oversaw 24,000 medical personnel
deployed for overseas operations and an increased demand on
military treatment facilities back home. He is the son of a
medical service corps officer and a nurse, and your entire life
has been in service to this Nation. Your time as an infantry
officer gave you a unique warrior's perspective on how our
wounded should be cared for, and it has helped to shape your
vision for the Army medical department.
Vice Admiral Cowan has served in the U.S. Navy for 32 years
and as Surgeon General of the Navy and Chief, Bureau of
Medicine and Surgery since August 2001. One could not have
expected that just 1 month after taking that new
responsibility, the military would be deployed at unprecedented
levels and you would oversee the deployment of over 4,300 naval
medical personnel. In addition to the extensive overseas
operation, the Navy was also on the forefront of domestic
events such as the lead laboratory for the recent ricin
incident in the Senate.
Admiral Cowan and General Peake, I commend and thank you
for the service you have rendered to this country, and I am
certain my colleagues all join me in this.
Since the beginning of Operation Iraqi Freedom, I have
heard numerous personal accounts and read dozens of articles
indicating lifesaving changes made in medical deployments,
technology, equipment, body armor, and unit configuration. From
positioning surgeons closer to the front line than ever before
and using new hemorrhage control dressings and embedding
physical therapists in deployed units, decreasing the size of
equipment, and aeromedical evacuation teams, they have
drastically altered the fate of hundreds of lives. We will
continue to support the personnel and programs that improve
your capability to save lives.
We will also look forward to an open discussion today with
our panels. In particular, we will want to look into the status
of the next generation contracts for TRICARE, our force health
protection system, deployments of medical personnel, recruiting
and retention, among others.
Once again, I would like to thank the chairman for
continuing to hold hearings on these issues which are so
important to our military and their families.
Mr. Chairman, you should forgive me. I think I need some
help here. I have got a cold. Any cold medicine here?
Senator Stevens. Is there a doctor in the house?
Senator, do you have an opening statement?
STATEMENT OF SENATOR PATRICK J. LEAHY
Senator Leahy. Just very briefly, Mr. Chairman. I thank you
for having the hearing. I would suggest to Senator Inouye what
he needs is time in the sun and maybe a few days in--oh, I do
not know--Hawaii?
Senator Inouye. It is a good place.
Senator Leahy. I wanted to come to this hearing because I
am concerned about the adequate health care for our armed
services, whether it is active duty or Reserves. I know
everybody here is concerned.
I have gone out and visited some of our wounded soldiers
out at Walter Reed. It is one of the most moving and impressive
things. My wife is a registered nurse and she probably
understood better than I did some of the injuries of some of
the people that she has talked with at greater length.
One of the most impressive things, Senator Stevens and
Senator Inouye, I remember one young man who was trying on a
new prosthetic leg. He had lost his leg. He was trying on a
prosthetic, high-tech leg, microchips. General, I see you
shaking your head. You know exactly what I am talking about.
Microchips check to see how best to design it. The two of us
asked him, what are you going to do now? And he looked at us
like, well, I just want to get the training with the leg done
so I can go back to the service. And I thought what a
wonderful, wonderful answer.
Yesterday's Washington Post had a front page article, and
if you have not read it, please do. It is a heartbreaking story
about the devastating wounds our soldiers are suffering, and
they are devastating. The good news is we can save more lives
that I guess in other past combats we might not have been able
to save them. The bad news, of course, is that they are
horribly wounded, maimed, blinded, and things like this. I
think what we have is a real responsibility because of that to
do our best.
That is all I have to say, Mr. Chairman. I do appreciate
your having this hearing. I think it is an extremely important
one.
Senator Stevens. Well, we all know General Shinseki who was
entitled to a full military discharge based upon his injuries
and he continued in the service to become the Chief of Staff of
the Army. So they have great examples from our past and we are
pleased to be part of the process to help encourage them.
Our first panel is General Peake. We call on you first.
General Peake. Mr. Chairman, Senator Inouye, distinguished
members, it really is an honor to represent Army medicine
before you.
Senator Stevens. We will put all your statements in full in
the record.
General Peake. Thank you, sir.
It really is a unique time in our history. I reviewed the
first testimony I gave before this committee in April 2001 I
think it was, and we talked then about the new set of benefits
that came out of NDA01, TRICARE for life, pharmacy benefit for
over 65 retirees, reduction of catastrophic caps, school-age
physicals, many other things, and we spoke about the need to
adequately fund that benefit.
But I also made mention then of the fundamental importance
from a readiness base of medical support to soldiers that comes
from our direct care system then, and I commented on the U.S.S.
Cole response of wounded sailors passing through our joint
system on their way back to Portsmouth back then. I also said
that it was an exciting time to have this job. I had no idea.
That hearing seems like a long time ago. Since then, your
military medical system has responded to 9/11, was a key part
of the response to the anthrax letters, played a major role of
the cleanup right here on Capitol Hill. Our medics supported
the take-down of the Taliban in Afghanistan. Forward surgical
teams, linked with the special operations forces, combat
support hospitals providing the only sophisticated level of
care in that war-ravaged country, medics fighting uphill on
treacherous terrain to save lives. Even the march to Baghdad
now seems like a long time ago, a march where medical assets
leap-frogged forward with the combat troops. One of our forward
surgical teams set up nine different times in that march to
Baghdad, integral to the fighting formations and operating on
our own soldiers and Iraqi civilians and enemy prisoner of war
(EPW's) as well.
Army medical evacuation helicopter crews have sustained
their legacy as heroes, serving Army and cross-attached to the
marines. Our combat support hospitals operated in split-based
modes, covering each sequential setup of the log bases as we
moved forward. The front ends of that system linked back
through Europe where our jointly staffed facility at Landstuhl
in Germany has continued to be the primary hub for patients
who, under our construct of essential care in theater, could
find themselves there within 24 to 48 hours of wounding, linked
back to centers of excellence like the amputee center that you
mentioned here at Walter Reed or our burn center at Brook in
San Antonio. All of these efforts supported by a base of an
integrated health care system that trains to the highest
standards, that inculturates our physicians and our nurses to
the men and women that they support by a base of research that
focuses on things relevant to the soldier so that we could
field things like new skin protectants, hemostatic dressings,
one-handed tourniquets. It is a base that can provide teams of
world-class experts that go into country to look at things like
Leishmaniasis or investigate pneumonia deaths or to study the
mental health aspects of combat in an active combat zone.
We are about to complete the largest troop movement since
World War II. Across this country, each of our power projection
platforms and power support platforms, our soldiers have had
medical screening, have been medically protected with
immunizations, received care when required as they martialed
for deployment, have received post-deployment screening and
reintegration training and care and counseling, a tremendous
medical effort focused on our balance scorecard objective, a
healthy and medically protected force.
As a health system, our business has increased during this
time not only with the soldiers I have described, but with
family members of the deployed reservists and with the
remarkable increase in our retirees who appreciate the quality
of the benefit that has been legislated. I do believe the next
generation of TRICARE contracts creates the correct incentives
to maximize the use of our direct care system and ensure our
contract partners meet the same high standards for those not
around our military treatment facilities.
But it is not a magic bullet to contain the cost growth of
medicine, of which we are really a microcosm, especially with
the increase in those using our system. It is a cost growth
that is faster than the overall DOD budget growth, as you have
recognized in the past with a history of supplementals.
All of this at the same time that General Shinseki's legacy
of transformation is being carried forward aggressively to make
us more modular, agile, ready, and relevant to the challenges
militarily of today and tomorrow.
We are fortunate to have really great leaders in our Army
from our Secretary, Mr. Brownlee, who is a soldier himself, to
our Chief, General Schoomaker, whose focus on the soldier is
extraordinary.
But equally extraordinary are those soldiers. They inspire
me and they inspire all of us who lead them at all levels. I am
going to close with a couple of quotes from this last week in
Iraq. I got this e-mail.
Since Sunday evening, a little more than 72 hours ago, we
have done almost 60 cases with essentially nonstop surgery. I
am awed at the excellence and dedication of the soldiers in my
command. They have truly done an incredible job, and I am proud
to be associated with them. That is from Steve Hetz, who is the
commander of the 31st Combat Support Hospital in Ballad, a
soldier, a surgeon who ran our teaching program at William
Beaumont Army Medical Center for many years.
From Michael Oddie, a cardiac surgeon from Akron, Ohio, a
reservist, a commander of the 848 Forward Surgical Team who is
commanding the medical facility at the prison near Baghdad. He
sent me a note after an attack that gave them 78 casualties, of
which they air evacked 13, admitted 26, operated on 10 that
night and the next day. He says, it was awesome and inspiring
to see this group of soldiers perform so well and so cohesively
in a dire situation. We really do have a great group of
soldiers. This hospital commander stuff is as headache, but it
is rewarding to see such an effort. It would have made you
proud.
PREPARED STATEMENT
Well, sir, I am proud and I am proud of them and I am proud
to have been a part of this team at this table. On behalf of
all of our soldiers and their families and the medics, I deeply
appreciate the unwavering support that you and this committee
have given us all. Thank you very much.
Senator Stevens. Part of our group visited Ballad. It is a
very interesting operation, an enormous base. Those facilities
are well operated and obviously very modern.
[The statement follows:]
Prepared Statement of Lieutenant General James B. Peake
Mr. Chairman and Members of the Subcommittee, thank you for this
opportunity to appear before you today. This will likely be the last
time I appear before your committee as the Army Surgeon General, and I
wish to express my gratitude for your unwavering support for our
military and especially for our medical personnel.
core competencies
Our Nation is at War, and there is nothing that brings the missions
of military medicine into focus like war. Healthy and medically
protected Soldiers; a trained and equipped Medical Force that deploys
with the Soldiers, providing state-of-the-art medical care; and
managing the health of all Soldiers and their families back home while
keeping the covenant with our retirees--this is the mission of the
United States Army Medical Department (AMEDD). We are keeping our
promise to all of our beneficiaries by providing quality and timely
healthcare.
healthy and medically protected soldiers
This is a part of ongoing health maintenance informed by research
in military relevant areas and about which few outside the military
have much interest. From the development of vaccines for diseases
seldom seen in the United States to formulating an insect repellent
that can serve as a sunscreen and camouflage paint all at the same
time, to working with the Food and Drug Administration to establish
workable protocols for new drugs in remote locations, we meet our
obligations to medically protect soldiers. It requires an integrated
approach to educate soldiers about their health and about the things
they can do to protect themselves day to day and in whatever region of
the world they may find themselves deployed.
current deployments
There have been many improvements in military medicine since I last
appeared before this committee. These improvements are making a
difference in how well we are taking care of our Soldiers on the
battlefield.
To spearhead the Army Medical Department Transformation initiative,
we have implemented the Medical Reengineering Initiative or MRI. MRI
was approved by the Vice Chief of Staff of the Army in 1996 as an Army
medical force design update (FDU), which reorganizes Echelon Above
Division and Echelon Above Corps deployable medical units. These are
the medical units that provide levels of battlefield medical care above
the Battalion Aid Station and Division level medical companies. MRI
will provide the Army with the modular organizational structure that
supports the Current Force and will provide a bridge to the Future
Force. MRI is versatile as exemplified by unit designs that are
modular, scalable and possess standardized medical capabilities that
can be deployed around the globe. The Army Plan (TAP) and the Army
Strategic Planning Guidance (ASPG) 2006-2023, recognizes MRI as an
example of modularity. MRI promotes scalability through easily
tailored, capabilities-based packages that result in improved tactical
mobility, reduced footprint, and increased modularity for flexible task
organization. This design enables the Joint Forces Commander to choose
among augmentation packages, thus enabling rapid synchronization of
desired medical capabilities. MRI is enabling us to provide better care
further forward on the battlefield and faster than ever before.
With your help we are also saving lives through the deployment of
the hemostatic dressings and the chitosen bandage. These are two new
lifesaving wound dressings that are being used in Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF). Approximately 1,200
hemostatic dressings were deployed under an Investigational New Drug
battlefield clinical protocol. A team medic successfully applied a
hemostatic dressing to a left thigh wound after he was unable to
completely control femoral arterial bleeding with a pressure dressing
and tourniquet. Similar success was achieved in two documented reports
of Special Forces Medics using these bandages to treat severe bleeding
caused by gunshot wounds to the extremities. Approximately 5,800 of
these bandages have been deployed to the theater of operations. Our
researchers continue to look for solutions for non-compressible
hemorrhage wounds to the chest or abdomen. A hemostatic foam that can
be injected into the body cavity is currently under research as well as
a hand held high intensity focused ultrasound (HIFU) device. Our
researchers at Medical Research and Materiel Command (MRMC) are working
on a number of projects which will improve health care on the
battlefield and in our treatment facilities. Some examples include the
Hemoglobin-Based Oxygen Carrier (HBOC) a temperature stable, oxygen
carrying solution that can be readily available to treat combat
casualties with life threatening hemorrhage. MRMC is working with
several companies to design Phase 2 and Phase 3 clinical trials with
the goal of attaining FDA approval and licensure. MRMC is also
sponsoring research on developing a better insect repellent, especially
to protect our Soldiers from sand flies. In OIF over 400 of our
Soldiers have been diagnosed with Leishmaniasis, which is a disease
caused by parasites transmitted by sand flies. Leishmaniasis includes a
wide spectrum of diseases ranging from the cutaneous form to the
potentially fatal visceral disease. No prophylactic drugs or vaccines
exist to combat this disease, hence personal protective measures are
currently being used in theater. Each infected Soldier must be
evacuated to Walter Reed Army Medical Center or Brook Army Medical
Center of a 10-28 day therapy. Our researchers are looking for ways to
identify and treat this disease in theater to avoid evacuation and
reduce long-term scarring.
We are progressing in transforming the combat medic to the new 91W
Military Occupational Specialty (MOS). These medics train for 16 weeks
versus the previous 10 week course and gain National Registered EMT-
Basic certification. The 91W combat medic training is conducted at the
Army Medical Department Center and School. Active duty medical
specialists and clinical specialists who have not converted to the 91W
MOS are required to complete the training in their units that include
not only EMT certification, but pre-hospital trauma training and
advanced airway and IV management.
Not only are we improving our training for personnel, but we are
also improving our capability to transport patients on the battlefield.
In order to treat Soldiers on the battlefield we have to be where they
are. The 507th Medical Company (Air Ambulance) and the 126th Company
(Air Ambulance) took our most advanced casualty evacuation helicopter,
the HH-60L Black Hawk, to support operations in Southwest Asia and
Afghanistan. These aircraft include a digital cockpit, on-board oxygen
generation system, external electric hoist, advanced communications,
improved litter support system, medical suction and electrical power
for medical equipment. We currently have nine HH-60Ls and are working
on upgrading the entire medical evacuation fleet. On the ground, we
have the medical evacuation vehicle variant (MEV) of the Stryker. This
vehicle is integrated into the fighting formation of the 3rd Brigade,
2nd Infantry Division that deployed to Iraq last November. The new
ground ambulance can carry four litter patients or six ambulatory
patients while its crew of three medics provides basic medical care. It
can be delivered to the battlefield in a C-130 aircraft, has the speed
and mobility to keep up with fighting forces and can communicate with
the most advanced combat formations.
reserve component and national guard integration
This war has reinforced a lesson we learned long ago: the AMEDD
could not do its wartime mission without the Army National Guard and
Army Reserve. Guard and Reserve medical units play key roles in Iraq,
Afghanistan, and also in replacing active-duty personnel deployed from
our stateside and European hospitals. We rely on Reserve Medical
Support Units to process deploying Soldiers. Without them, active duty
medical forces at mobilization sites would not be able to continue
normal care for Soldiers and families.
Professional Filler System
The Army Medical Department has been very successful in supporting
contingency operations and the Global War on Terrorism (GWOT) by using
a Professional Filler System or PROFIS to man early deploying units.
Our PROFIS system takes AMEDD personnel from our fixed facilities and
assigns them to deploying units who do not have their full complement
of medical personnel. Medical Command (MEDCOM) is currently prepare to
5,787 PROFIS personnel to deploying units. Of the 5,787: 1,177 are
Active Component personnel slated against spaces in Reserve units and
the remaining 4,610 personnel are PROFIS to active component units or
multi-component units. We currently have 839 PROFIS deployed to support
OIF and OEF and all the while, our Regional Medical Commands are still
maintaining their baseline medical care workload despite personnel
being deployed.
Medical Holdover
A small percentage of Reserve Component Soldiers who mobilized in
support of Operation Iraqi Freedom were not medically fit to deploy.
Personnel guidance prior to October 25, 2003 stated Soldiers who were
not medically fit to deploy would remain on active duty until maximum
therapeutic benefit had been accomplished. If the Soldier's condition
was still not at the point where he or she could deploy, then a Medical
Evaluation Board would ensue and the Soldier would be released from
active duty. By the end of October 2003 there were 4,452 Soldiers in
the Medical Holdover (MHO) population and the numbers were growing.
Personnel guidance changed on October 25, 2003 and the Army now returns
Soldiers to their units and their homes if they are found medically
unfit during the first 25 days of mobilization. The number of Soldiers
who enter MHO during mobilization is now less than 1 percent. In
October 2003 the Army also instituted enhanced access standards for MHO
Soldiers, realizing these Soldiers were not near their homes and
family, were living in quarters that were intended for short-term
housing, and that the process of providing maximum therapeutic benefit
was taking too long. The enhanced standards include 72 hours for
specialty referrals, one week for magnetic resonance imaging and other
diagnostic studies, two weeks for surgery, 30 days for the medical
portions of the medical evaluation board processing, and one case
manager for every 50 MHO Soldiers. Currently the AMEDD is meeting or
exceeding those standards more than 90 percent of the time. Of the
Soldiers in MHO on November 1, 2003, 871 remain on active duty. The
total number of MHO Soldiers is 4,393 which is what our modeling
predicted given the number of Soldiers mobilizing for OIF2 and the
number of Soldiers demobilizing from OIF1. It is important to note the
military is in the middle of the one of the largest troop movement
operations since World War II.
Soldier Readiness Processing
As indicated above, a very small percent of Reserve Component
Soldiers are mobilized, but are not medically ready to deploy. Soldier
Readiness Processing (SRP) evaluates Soldiers to ensure they are
medically and dentally ready to deploy. This means the Soldier has the
required immunizations, is medically healthy, has a dental readiness
classification of 1 or 2, and has his personal medical equipment such
as ear plugs, eye glasses and protective mask inserts. Active Component
units participate in the SRP process on a routine basis and are
constantly maintained in a deployable status. RC Soldiers have a
limited amount of time to participate in SRP's hence their medical
status sometimes is not up to par to deploy with the rest of their
unit. An integral part to the successful mobilization of our Army
Reserve (USAR) and National Guard (ARNG) troops is providing medical
and dental services by using the Federal Strategic Health Alliance
(FEDS-HEAL) Program. The FEDS-HEAL program brings together resources of
the DOD, Department of Health and Human Services and Veterans Health
Administration to create a robust provider network. FEDS-HEAL delivers
readiness services to USAR, ARNG, and United States Air Force Reserve
service members in all 50 states and territories. The FEDS-HEAL
provider network performs medical examinations, dental examinations and
treatment, immunizations, and other medical readiness services through
Veterans Administration medical centers, Federal Occupational Health
clinics, and a network of over 1,100 physicians and nearly 2,250
dentists. In addition to exams and treatment, FEDS-HEAL provides a data
management service and inputs patient care data into the Army's Medical
Protection System (MEDPROS). The FEDS-HEAL Program Office provides 100
percent Quality Assurance Reviews prior to MEDPROS reporting. In
Calendar Year 2003, Reserve and Guard forces received 42,624 dental
exams, 44,730 dental treatments, 29,971 physical exams, 54,108
immunizations, and 2,427 vision exams.
90 Day Rotation Policy
From late 1995 to early 1998, one-third of RC physicians who
deployed to the Balkans left the USAR due to the 270 day length of
rotations. Recruitment and replacement of these physicians was
difficult. The loss resulted in personnel shortfalls of physicians,
dentists, and nurse anesthetists. A 1996 survey of 835 RC physicians
found that 81 percent could be mobilized up to 90 days without serious
impact to their civilian practice, however, extended deployments beyond
90 days had a severe negative impact. In late 1999 the Army conducted a
pilot program deploying RC physicians, dentists, and nurse anesthetists
for 90 day rotations. In 2001 a follow-on survey was conducted which
validated the finding that RC physicians, dentists, and nurse
anesthetists could deploy for that period of time without adversely
affecting their private practice. The Army rotation policy was modified
in early 2003 to provide for 90 day ``Boots on the Ground'' or BOG
rotations either in the continental United States or outside of the
continental United States for these specialties. Many medical
professionals want the opportunity to serve their country. This policy
enables them to stay with us in the Reserves and contribute to the
mission.
pre and post health assessments
We place a high priority on maintaining the health of Soldiers
before, during, and after deployment. Before Soldiers deploy we closely
monitor their Individual Medical Readiness (IMR). That means up-to-date
immunizations, periodic health assessments, screening tests and medical
equipment (ear plugs, eyeglasses, etc.). We are working on uniform
metrics to inform commanders on the state of medical readiness of their
troops.
For the first time in military history, we are implementing a
systematic process of capturing this information. All of this data is
part of the pre-deployment health assessment, which provides baseline
information on the Soldier's health status before deploying. Upon
redeployment all Soldiers are required to fill out a post-deployment
health assessment form. We are working on ways to improve the
collection of this data, to include using hand-held devices that can
electronically download the information into the central record-keeping
repository. Once the information is captured electronically, the
TRICARE online web portal can be used by the Soldier's medical provider
to access the record. Department of Veterans Affairs can also access
the information from the individual's medical record, which is
available to the VA upon the Soldier's separation from the military.
Despite these advances in management and use of our databases, we
in the Army recognized the need for improvement. First and foremost, we
realized the limitations of paper forms for pre- and post-deployment
health assessment. Completing, copying and shipping paper forms from a
worldwide deployed and busy Army was a process that was difficult to
comply with, and almost impossible to oversee. In September 2002, we
launched an initiative to improve our assessment process by automating
the collection, distribution, and archiving of the data. The first
automated assessment form on the internet was activated on April 1,
2003. A hand-held computer variant of the enhanced (four-page) post-
deployment program was deployed to the Central Command Area of
Operations (CENTCOM AOR) and to Europe beginning in August 2003. From
June 1, 2003 through February 27, 2004, we have received 127,696
automated health assessment forms, which comprise about one-third of
all forms received during that period. Automated pre-deployment health
screening was accomplished for the entire Stryker Brigade Task Force
before it deployed in November 2003, and is approaching 100 percent for
the 39th and 81st enhanced Separate Brigades. In Kuwait, all post-
deployment health assessments are automated; in Iraq, about half of all
screening is performed using the automated form.
In November 2003, the Army initiated a formal deployment health
quality assurance program. This program includes audits of the
deployment health assessment program on Army installations. Audits have
been conducted at six Army installations (Forts McCoy, Drum, Lewis,
Hood, Stewart, and Bragg). These audits reveal that compliance with the
Army pre- and post-deployment health assessment program is generally
higher than indicated by comparison with Army personnel databases, and
is likely to rise further with automation support and standardization
and centralization of Soldier readiness processing on installations and
across the Army.
lowest kia/wia ratios
Our died of wounds rate after receiving some level of care in OIF
is 1.5 percent, the lowest in recorded warfare. A variety of factors
have contributed to this, to include body armor and Forward Surgical
Teams (FST). FSTs bring resuscitative surgical skills far forward on
the battlefield and apply life-saving techniques that preserve the A-B-
Cs of life: airway, breathing, and circulation. They target the 15-20
percent of wounded who, without care within the first hour after
wounding, would die while being evacuated to the combat support
hospital. Uncontrollable hemorrhage has been the major cause of death
in this group in previous wars. The FST is well equipped to identify
and stop bleeding by using a hand held ultrasound machine which can
identify internal bleeding.
transition to the department of veterans affairs
Our goal for injured and ill Soldiers is to effect a seamless
transition of care from DOD to the VA health care system. In September
2003, Secretary Brownlee put together a Disabled Soldier Liaison Team
(DSLT) specifically to look at the transition process for our most
severely disabled Soldiers and make recommendations to improve that
process. The mission of the DSLT was to assist Soldiers in their
transition from the Army to the Department of Veterans Affairs Health
Care system. The team was chartered to help Soldiers understand the VA
system and their benefits. Our efforts in the medical department
focused on identifying and appointing case managers/discharge planners
who served as the primary point of contact with the VA. The VA also
designated OIF/OEF coordinators in each of their regional offices and
provided staff at our busiest medical centers to facilitate a Soldier's
transition into their system. We currently have five VA coordinators
physically located at Walter Reed Army Medical Center who provide
personal liaison support between Soldiers and the VA.
readiness
One of the key successes in fighting the war on terrorism has been
our use of special medical augmentation teams (SMART). The Army Medical
Department has used this reach back capability to our sustaining base
to provide world-class expertise on the ground to support the
Warfighter. We have rapidly deployed subject matter experts in
leishmaniasis, pneumonia, mental health and environmental surveillance,
to name a few, into Iraq or Afghanistan to provide assessments and
recommendations to the command. A prime example of this capability is
the environmental surveillance team from the U.S. Army Center of Health
Promotion and Preventive Medicine (CHPPM) that was deployed to Iraq to
assess an evolving concern near a nuclear research facility. An
infantry regiment was operating within a few kilometers of the Tuwaitha
Nuclear Research Facility. Concerns were raised about possible
radiation and chemical exposures to U.S. service members and local
civilians due to looting. A SMART Preventive Medicine Team from CHPPM
deployed into the area to assess the Tuwaitha facility, which included
a site inspection and environmental sampling. All of the field data,
reports, and potential health risks were communicated to field
commanders and Soldiers. Due to weather conditions, short exposure
time, conditions of exposure, and location of troops relative to the
site, the resultant health risk was low based on U.S. peacetime
standards.
In July 2003 the Army Medical Department chartered a team of mental
health experts from CONUS treatment facilities around the nation to
assess mental health issues in Iraq. Specifically, the mental health
team was organized to assess the July increase in suicides in OIF,
evaluate the patient flow of mental health patients from Theater, and
assess the stress-related issues Soldiers were experiencing in a combat
operation. This was the first time a mental health assessment team has
ever come together and conducted a mental health survey with Soldiers
in an active combat environment. The team remained in Iraq for six
weeks and with the support of the combatant commanders, traveled to
several base camps conducting their assessment.
The AMEDD also has nationally recognized experts in the chemical,
biological, radiological, and nuclear (CBRN) field, which can be formed
into SMART teams to rapidly respond to a CBRN threat either CONUS or
OCONUS. These experts come from our medical centers, the U.S. Army
Medical Research and Materiel Command, CHPPM, and the Army Medical
Department Center and School. Their expertise ranges from medical
surveillance and epidemiology to casualty management. The AMEDD Center
and School also has developed a number of short and long courses
addressing CBRN topics which can be taught in house or exported to our
treatment facilities. CBRN training has been incorporated into the
Soldiers' common skills training, advanced individual training,
leadership courses, primary care courses, and a number of other
avenues.
Our partnerships and collaboration with civilian counterparts is
crucial in training our medical force. The U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) at Fort Detrick, MD, is a
great national resource of expertise on testing methods to eradicate
dangerous diseases. USAMRIID is partnering with the National Institutes
of Allergy and Infectious Diseases (NIAID) and the U.S. Department of
Agriculture (USDA) towards building a synergistic biodefense campus.
The goal is to leverage the knowledge and capabilities of these
research institutions by co-locating them on a single campus to fight
the Global War on Terrorism.
garrison care
The AMEDD is a $9 billion per year enterprise whose business is to
take care of the Soldier, the family member and the retiree. Managing
this complex organization with its many missions requires a structured
system that directs the members towards a common goal. The system in
place today is the balanced scorecard, which uses a building block
approach to guide the organization in making the right decisions at the
right time. The AMEDD is continually measuring itself and using
assessment tools to ensure best business practices are in place and
being used. The Decision Support Center sends out patient satisfaction
surveys to measure a patient's satisfaction with a provider at a
particular treatment facility. This type of feedback is invaluable in
identifying where the organization is doing well or where the
organization needs to improve.
The AMEDD has used funds to establish venture capital projects and
advanced medical practices initiatives to help military treatment
facilities improve delivery of health care. Such projects include
hiring certain specialties in a particular field to bring in more
patients, renovating clinic space or purchasing new equipment to
capture a particular market niche. Each project is required to have a
business case analysis that must demonstrate the project will pay for
itself within three years. This type of program helps commanders make
better business decisions and saves money for the AMEDD in the future.
Our health care delivery system is poised to move into the next
generation of TRICARE contracts. The new contracts are performance
based and have been designed to control costs through incentives for
the direct care system and for the contractors. Its goals are to
increase beneficiary satisfaction and improve portability. Transition
activities at every level of the military health care system and within
contractor organizations demonstrates a full commitment to a successful
transition. For the AMEDD specifically, there is a TNEX Transition Task
Force that has developed a transition task list that identifies
critical, time sensitive tasks that must be accomplished in sequence
for the transition to be successful at the MTF level. Transition
activities include training and educating staff on market management
and revised financing. The Transition Task Force trains and develops
personnel in key positions such as future commanders, data analysts,
and health care administrators in executive level positions. We look
forward to this exciting era of change, which will begin in June of
this year.
Complimenting our delivery of health care is the availability of
housing for visiting family members. Through the philanthropic efforts
of the Fisher Foundation, there are 14 Fisher Houses operating at 9
locations. In fiscal year 2003 the Army Fisher Houses served 2,560
families, providing 39,680 family-nights of lodging. We estimate that
staying in a Fisher House saved these families over $1.5 million in out
of pocket lodging costs. The average length of stay per family was 15.5
days. The contributions that the Army Fisher Houses have made in
supporting the families of our combat casualties from Afghanistan and
Iraq have been uniquely valuable. Since March 2003, Army Fisher Houses
have accommodated 851 families attending to service members who were
injured in combat operations or in support of combat operations. The
occupancy rate for the Fisher Houses at Landstuhl Regional Medical
Command in Germany, Walter Reed Army Medical Center in the National
Capitol Region and at Fort Sam Houston, San Antonio has averaged over
97 percent. Its obvious that the Army Fisher Houses provide a valuable
benefit for military families.
In an effort to protect direct care funds, the Congress passed
legislation restricting the flow of funds from the direct care system
to the private sector care system and vice versa. With the new health
care contracts using the best business practices, there are incentives
built into the system to use the direct care side as much as possible.
Restricting movement of Defense Health Program funds will not allow the
military treatment facilities the flexibility to manage their resources
efficiently. In the new management environment, military treatment
facilities are incentivized to increase productivity by pulling more
beneficiaries into their facilities. The Army appreciates the
congressional intent to protect direct care funding, but we recommend
that the fiscal year 2005 Defense Appropriations Act language remove
this restriction and allow flexibility to move funds to wherever care
is delivered without a prior approval reprogramming.
summary
Health care is a key quality of life issue for our military. I am
committed to providing that quality care throughout the spectrum of
operations, from the foxhole to the regional medical center. The Army
Medical Department recognizes its responsibility to the men and women
who defend our nation, to their families who support them, and to the
retirees who have contributed so much to our country. We are committed
to providing all of them exceptional healthcare. Army medicine is more
than an HMO. Our system of integrated care includes teaching centers,
research and development organizations, health clinics, field
hospitals, and much more. The direct care system is truly the medical
force projection platform for our Army; the Army we support across the
world and across the spectrum of conflict. We do this quietly and on a
daily basis all the while integrating active, guard and reserve units
in support of the Chief of Staff's vision of THE Army.
I would like to thank my fellow Surgeons General. Their support,
teamwork, and camaraderie are much appreciated. I would also like to
thank the Committee for its continued commitment to our men and women
in uniform, the civilian workforce, and our beneficiaries.
Senator Stevens. Admiral Cowan.
STATEMENT OF VICE ADMIRAL MICHAEL L. COWAN, SURGEON
GENERAL, UNITED STATES NAVY
Admiral Cowan. Thank you, Chairman Stevens, Senator Inouye,
and distinguished members of the subcommittee for inviting me
here today.
We frequently hear it said that post-9/11 everything
changed, but for us in Navy medicine much remains the same. In
fact, the events that have occurred since September 2001 have
continually reemphasized the importance of our total mission of
force health protection.
The four pillars of force health protection are: first, to
prepare a healthy and fit force that can go anywhere and
accomplish any mission that the defense of this Nation requires
of them; second, for our medical personnel to go with them to
protect them from the hazards of the battlefield and
deployment; third, to restore their health wherever protection
fails while also providing outstanding and seamless health care
for their families back home; and finally, to help a grateful
Nation thank our retired warriors by providing them health care
for life through TRICARE for Life.
We strive to create a healthy and fit force by supporting
healthy lifestyles not just for our sailors and marines but for
their families as well. Our long-term goal is to form
partnerships with families to adopt healthy lifestyles that
have positive effects through their lifetimes. Healthier
behaviors result in a fit and healthy force and also reduce the
need for restorative medicine later in life. We work closely
with our people so they are less likely to become our patients.
Nearly one in six of naval medicine's deployable personnel
are deployed today in support of operations on the global war
on terrorism and in Iraq, and we will continue to operate at
that rate for the foreseeable future. Forward medical personnel
provide first responder, stabilization and forward
resuscitative care at modular theater facilities, both ashore
and afloat. Our theater hospitals are deployed independently or
combined with other modules in a Lego-like fashion, a building
block fashion, to provide essential care in theater. Definitive
care is through a medevac process in fixed overseas and
continental United States (CONUS) medical treatment facilities
(MTF).
Naval medicine's most vital asset is our people. Attracting
skilled professionals and, equally importantly, retaining them
to take advantage of their experience and enhanced skills
represents one of our more significant challenges.
We continue to support ongoing efforts implementing the
Presidential task force recommendation to pursue sharing
collaboration with the Department of Veterans Affairs,
specifically to optimize the use of Federal health care
resources. I believe that our progress in these collaborations
is one of our great success stories.
We worked hard to get the best value from every dollar that
Congress has provided, and your assistance is needed to help
restore the flexibility to manage funds across activity groups.
Fenced private sector funds prevent transfer from the MTFs to
private sector and prevent transfer from private sector to the
MTF's. This does not allow us to increase productivity in the
MTF's without the burden of prior approval reprogramming. This
is very important in the upcoming year because the new T-NEX
contracts with their incentives to move care into the MTF's
make restoration of the flexibility all the more vital.
We continue to work on the forefront of technology, and I
would specifically highlight information technologies to
include the development of naval medicine online. This
communication tool will be the key to knowledge sharing
throughout naval medicine as an enterprise, allowing the right
information to flow to the right people at the right time
whenever and wherever it is needed. Naval medicine is also
committed to transforming the naval/Marine Corps infrastructure
and services.
We are further committed to the Chief of Naval Operations
(CNO) transformational vision for projecting decisive joint
capabilities from the sea, SeaPower 21. Examples of that
transformation abound throughout naval medicine where hard work
in identifying deficiencies and cutting costs have resulted in
multiple opportunities to support the recapitalization of the
Navy. This transformation is not limited to shore facilities.
It includes remaking our fleet assets to include the
reconfiguration of forward medical assets from cold war era
platforms to the smaller and more agile task-oriented units
that we deploy today.
Finally, we are right-sizing our active forces to the best
mix of active, civilian, and contract personnel to bring the
right capability to bear and in alignment with the CNO's
vision. We have reconfigured and integrated naval reserve
components in very different ways to shape missions, along with
the active component, creating a single unified force and
assuring the very best use of the skills and talent of all of
our medical personnel.
We are effecting positive change throughout naval medicine,
embracing the CNO's vision, and I am confident that we are on
the right course for the challenges ahead.
PREPARED STATEMENT
I share General Peake's gratitude and sense of having been
honored by the work and the interest of this committee, and I
thank you for everything that you have done with us and for us
during my time as the Navy Surgeon General. It has been a
privilege to serve.
[The statement follows:]
Prepared Statement of Vice Admiral Michael L. Cowan
Chairman Stevens, Senator Inouye, distinguished members of the
subcommittee, thank you for inviting me here today. Each year, the Navy
Surgeon General has the privilege of appearing before the Senate
Appropriations Committee Subcommittee on Defense to provide an update
on the state of Naval Medicine. It has been a year of challenges met
and rewards reaped, and of maturing of programs that we undertook in
the wake of September 11, the anthrax attacks by terrorists unknown,
and the prosecution of the Global War on Terrorism.
Force Health Protection is the primary focus of Naval Medicine.
Force Health Protection is comprised of four mission objectives: (1)
Preparing a healthy and fit force that can go anywhere and accomplish
any mission that the defense of the nation requires of them; (2) go
with our men and women in uniform to protect them from the hazards of
the battlefield; (3) restore health, whenever protection fails, while
also providing outstanding, seamless health care for their families
back home; and (4) help a grateful nation thank our retired warriors
with TRICARE for Life.
Naval Medicine balances all these actions to make force health
protection work and see that all our beneficiaries get the outstanding
healthcare they deserve. Wherever our Marines and Sailors at the tip of
the spear deploy, we are along side them as we provide operational
support in the Global War on Terrorism, achieving very low disease and
combat casualty rates on the battlefield. The lessons we've learned
from previous wars have led us to innovations toward a new level of
agility and capability. Today, Expeditionary Medical Units are being
built and fielded. These are complete lightweight tent hospitals that
can be airlifted on site within days, and smaller units, Forward
Resuscitative Surgery Systems, can be deployed to the action and made
ready for patient care within hours. They, staffed with their ``Devil
Docs,'' have proven to be lifesavers for wounded Marines.
In defense of bio-terror attacks against our Nation, including the
recent ricin attack at the Dirksen Senate Office Building, the Naval
Medical Research Center, has made great advances in developing
enhanced, rapid analysis and confirmation processes. These innovations
have directly supported the nation's security and are a vital component
in protecting our military fighting a war both abroad and here in the
homeland.
Naval Medicine provides the most visually recognizable healthcare
facility in the world--the military treatment facilities aboard the
distinctive white with red-crossed hospital ships USNS COMFORT and USNS
MERCY. These ships are symbols of life saving and caring that also send
a clear message to our enemies: We are committed to our mission, and
are prepared to take care of the casualties we may suffer to accomplish
it.
Naval Medicine is an effective defensive weapon system for the Navy
and Marine Corps Team. Naval Medicine treated every combat casualty
within the critical ``Golden Hour'' through the use of new and
innovative surgical units, such as the Forward Resuscitative Surgery
System (FRSS). We reconfigured our Cold War era Fleet Hospitals to
become more agile, mobile 116 bed Expeditionary Medical Facilities that
are being used to support operations around the world. Sailors and
Marines can be confident that they will have world class health care
professionals at their side at all times--at sea or ashore.
Force Health Protection remains our primary mission. We strive to
create a healthy and fit force through encouraging and supporting
healthy lifestyles not only for our Sailors and Marines, but for their
families as well. Our goal is to form a partnership with our families
to help them adopt healthier lifestyles that will have a positive
effect throughout their lifetimes. These healthier behaviors will not
only result in a fit and healthy force, but will reduce the need for
restorative medicine later in life. We work with our people so that
they will be less likely to become our patients.
We recognize that health care is a major retention and recruitment
issue as well as a readiness issue, and strive to provide world-class
care not only to the families of our Sailors and Marines, but to
retired service members and their families as well. Naval Medicine is
implementing Family Centered Care initiatives to increase patient
satisfaction and continuously improve on our delivery of patient care.
If we can retain our families within the direct health care system,
Naval Medicine can continue to assist them with the tools to form
healthy habits throughout their lives.
force health protection
Force Health Protection is a continuum of services designed to
create and maintain a healthy and fit force. This continuum begins with
medical and dental screening during induction into the service,
followed by annual preventive health assessments, regularly scheduled
physical examinations, pre and post deployment assessments and ending
with separation or retirement physicals. Health care professionals
participate and review every assessment along the continuum. The same
schedule of physical assessments is followed for both active duty and
reserve service members.
Over 100,000 Navy and Marine Corps personnel completed post
deployment health assessment forms since April 2003. Primary care
providers then interview service members if there are any indications
of deployment related illnesses or injuries, or changes in their health
concerns. Service members may be referred for additional specialty care
if indicated. As of March 2004, 7 percent of active-duty and 15 percent
of reservists required post deployment medical referrals.
deployment medicine
In support of Operation Iraqi Freedom (OIF), over 7,300 active and
reserve Naval medical personnel were deployed or mobilized, at sea or
shore. From the battlefield Hospital Corpsmen to the Forward
Resuscitative Surgery System (FRSS), the Fleet Hospitals (FH) and the
hospital ship USNS COMFORT, and to the National Naval Medical Center
(NNMC), Bethesda, wounded, injured, and sick Coalition Force warriors,
Iraqi prisoners of war, Iraqi civilians (displaced persons) received
the highest quality medical care possible.
Our readiness platforms include two 1,000 bed hospital ships, 6
active duty and 2 Reserve Fleet Hospitals as well as special medical
units supporting Casualty Receiving and Treatment Ships (CRTS) and
smaller, organic units assigned to augment the Marine Corps and
overseas hospitals.
Nearly one in six of Naval Medicine's deployable personnel are
deployed today in support of operations fighting the Global War on
Terrorism and will continue to operate at that rate for the foreseeable
future. Forward medical personnel provide first responder,
stabilization and forward resuscitative care at modular theater
hospitals, both ashore and afloat in theater. Our modular theater
hospitals can be employed independently or combined with other modules
to provide essential care in theater. Definitive care is provided in
fixed overseas and CONUS military medical treatment facilities.
During Operation Iraqi Freedom, Naval Medicine employed a new type
of unit to provide far forward surgery. The Forward Resuscitative
Surgery System (FRSS) was developed to provide forward surgical
capability to support the Marine Corps' Regimental Combat Teams. The
FRSS is staffed with a team of two general surgeons, one
anesthesiologist, one critical care nurse and four Hospital Corpsmen.
The FRSS can accommodate 18 casualties in 48 hours without re-supply.
During OIF, six FRSS teams treated 96 casualties and performed 153
surgical procedures during combat operations.
This year has also seen the introduction of the Forward Deployable
Preventive Medical Unit (FDPMU) designed to assess, prevent, and reduce
health threats in support of deployed operating forces. Other missions
for the FDPMU include humanitarian assistance, consequence management,
and disaster relief operations. Capabilities can include chemical,
biological, and radiological agent detection and identification, as
well as toxic environmental chemical detection and identification.
The Forward Deployable Preventive Medical Units are capable of
deploying within 96 hours, can serve as a joint force asset to provide
specialized preventive medicine, and CBRN response services in support
of force health protection to combatant commanders and Joint Task Force
Commanders. Naval Medicine has elements of two FDPMUs currently
deployed to Iraq and elements of another FDPMU currently deployed to
Haiti.
Our mobile platforms continue to be refined, making them more agile
and adaptable to specific missions. Transformation efforts continue by
the Fleet Hospital Program with the continued development and
refinement of the Expeditionary Medical Unit (EMU). The EMU provides
both forward stationed and CONUS-based forces the ability to rapidly
deploy, employ, sustain and redeploy scalable medical capabilities to
austere regions of the globe. The transformation process from Fleet
Hospitals to EMUs is planned to continue over the next several years as
we reshape our forward presence to a lighter, smaller and more agile
force.
EMU Alpha was deployed to Djibouti in September 2003 and is still
receiving patients. NH Jacksonville is providing the staff for EMU
Alpha.
As part of the post Operation Desert Storm lessons learned
analysis, Naval Medicine embarked on an extensive effort to better
organize and train our wartime-required active and reserve medical
force, while at the same time optimizing our peacetime healthcare
benefit mission. Naval Medicine developed and implemented a CONUS
readiness infrastructure strategy that aligned specific operational
platforms to a single Military Treatment Facility (MTF), along with the
active duty and reserve manpower required to perform both wartime and
peacetime missions. This readiness alignment strategy provides the MTF
commander with the authority and the resources to balance wartime
readiness and peacetime benefit missions.
As a result of this new structure, Naval Medicine can employ
``Tiered Readiness.'' This strategy allows platform rotation to support
ready surge requirements. Each platform and their parent Medical
Treatment Facility (MTF) will be on a scheduled rotation: for six
months, two MTFs and their supporting Fleet Hospital personnel will
have to be ready to deploy within 10 days. Three additional Fleet
Hospitals and their parent MTFs have sixty days to prepare for a
possible deployment. Finally, there is a sixth Fleet Hospital, in
reserve, which must be ready to deploy within 120 days. Tiered
Readiness enables Naval Medicine to plan, prepare and meet our
operational commitments and is in synch with the Chief of Naval
Operations' transformational vision for the United States Navy.
naval medicine office of homeland security
Winning the Global War on Terrorism is job #1 and Naval Medicine
brings many assets to bear in this fight. As its Surgeon General, I
think of Naval Medicine as a ``Defensive Weapon System'', which, in
addition to providing the highest quality medical care to our
warfighters, also can take action to deter threats through such
mechanisms as delivering vaccines that eliminate specific disease
threats. We have sophisticated technologies designed to detect
biological, chemical and radiological threats before they cause harm,
and we have highly trained medical personnel who can identify early
signs of an intentional or natural disease outbreak that could degrade
our military effectiveness if unrecognized. Naval Hospitals and clinics
are vital national security assets that are a cornerstone of both force
health protection and the National Disaster Medical System.
The Naval Medicine Office of Homeland Security, only in its second
year, continues to make great contributions to our Force Protection,
disaster preparedness, and homeland security missions, both here and
abroad. Naval Medicine continues to execute cutting edge initiatives to
ensure our hospitals and clinics around the world can continue to
provide care for all who depend upon us--even in the event of an attack
or disaster. Presently, we are executing an enterprise-wide program to
strengthen our effectiveness in responding to disaster. The Disaster
Preparedness, Vulnerability Analysis, Training and Exercise (DVATEX)
Program has been conducted at 24 of our 30 military treatment
facilities. It employs a comprehensive vulnerability analysis of all
hospital operations in a disaster or terrorist attack. DVATEX provides
emergency preparedness education thus far to over 5,000 Naval Medicine
personnel, and it has exercised hundreds of our people, alongside their
loyal civilian counterparts, to improve integration during an
emergency.
DOD is about to deploy a web-based training program that will be
used to educate physicians, nurses and other health care providers on
response to chemical and biological emergencies. Originally developed
for Navy use, the program has been adopted by the MHS and the Defense
Medical Readiness Training Institute is preparing it now for educating
personnel in all three Services.
naval medicine's people: a manpower status
Naval Medicine's most vital asset is its people. Attracting skilled
professionals and, perhaps more important, retaining them to take
advantage of their experience and enhanced skills, is one of Naval
Medicine's greatest challenges.
Naval Medicine strategies to recruit and retain the best people
include a multi-faceted and highly coordinated approach: The
professional and educational needs of our health care professionals
must be met to ensure they, at a minimum, are equal to their civilian
counterparts. Their work environment must be supportive of their
contributions and accommodating to their special needs, missions and
requirements, while continuously challenging them professionally.
Finally, their financial compensation must be sufficiently competitive
with their civilian counterparts for us to attract and retain the right
people.
We require our Naval Medicine professionals to have the same skills
and qualifications as their civilian counterparts, and also require of
them additional unique personal and professional challenges. A status
of Naval Medicine's people is below:
Medical Corps
At the beginning of fiscal year 2004, the Navy's Medical Corps was
manned at approximately 101.8 percent. Navy Medicine is working on
community management initiatives to ensure more of a balance between
specialties. The attrition rate for fiscal year 2003 was 9.2 percent,
with the three-year average rate at 8.9 percent. Attrition is expected
to be higher in fiscal year 2004, due to the number of requests for
resignation and retirement that have already been received. High
operational tempo and longer deployment durations have been cited as
major reasons for this increase.
Despite success at manning and retaining skilled professionals at
the Medical Corps' top line, several critical specialty areas remain
undermanned. These specialties are: Anesthesia (85 percent), Cardiology
(57 percent), Pulmonary/Critical Care (76 percent), Gastroenterology
(79 percent), General Surgery (88 percent), Infectious Disease (89
percent); Pathology (85 percent), Urology (85 percent), and Radiology
(75 percent). Not surprisingly, surgical specialists,
anesthesiologists, cardiologists, gastroenterologists, and radiologists
continue to be the most difficult to recruit and retain because of the
high salaries offered in civilian practices.
Medical Special Pays
To be competitive in a marketplace with a limited number of
qualified applicants and retain them once they have chosen Naval
Medicine, adequate compensation is critical. The civilian-military pay
gap has increased steadily, which makes it difficult to recruit and
retain physicians in high demand specialties.
Dental Corps
At the close of fiscal year 2003, the Navy Dental Corps was manned
at 91 percent. Despite aggressive efforts to improve Dental Corps
recruitment and retention, the annual loss rate between fiscal year
1997 and fiscal year 2003 increased from 8.3 percent to 11.7 percent.
In addition, declining junior officer retention rates has negatively
impacted applications for residency training programs, which have
dropped 18 percent over the last five years. The civilian-military pay
gap and the high debt load of our junior officers are the primary
reasons given by Dental Corps officers leaving the Navy.
Nurse Corps
At the close of fiscal year 2003, the Navy Nurse Corps was manned
at just under 98 percent. The nursing shortage nation-wide has made the
Navy's competition for recruiting and retaining skilled nurses a
challenge. It has been further challenged by the Nurse Reinvestment
Act, which offered loan repayment and sign-on bonuses to nurses in the
civilian sector. Naval Medicine continues to meet military and civilian
recruiting goals and nursing requirements by using a broad range of
accession sources, pay incentives, graduate education and training
programs, and retention initiatives that include such quality of life
and practice opportunities as leadership challenges, operational
experiences, promotion opportunities, and diversity in assignments with
job security. The Nurse Accession Bonus, Certified Nurse Anesthetist
(CNRA) Incentive Pay, Board Certification Pay, and Special Hire
Authority are all initiatives that are critical in supporting Naval
Medicine's success in meeting its nursing wartime and peacetime
missions.
Medical Service Corps
Medical Service Corps manning at the beginning of fiscal year 2004
was 95.6 percent. The loss rate increased from 6.8 percent in fiscal
year 2002 to 7.2 percent in fiscal year 2003. Loss rates vary
significantly between specialties and certain specialties continue to
have either shortages or experience gaps caused by low continuation
rates at the junior officer pay grades. The potential effects of
successive military deployments and the military to civilian billet
conversions on retention and recruiting are being monitored closely.
The majority of Medical Service Corps officers enter military
service directly from the private sector and have funded their own
professional education. Many Medical Service Corps officers incur
significant educational debt prior to commissioning and active Naval
service. Additionally, there is an increasing number of doctoral and
masters level educational requirements for certain healthcare
professions with the increase in qualifying degree requirements,
further exacerbating the educational debt load of our newest officers.
Biochemists, microbiologists, entomologists, environmental health
officers, radiation health officers and industrial hygiene officers are
integral members of Chemical, Biological, Radiation, Nuclear &
Environmental (CBRN&E), homeland security, and operational readiness
requirements and initiatives. With their strong educational background,
significant work experience and security clearances, these officers are
prime recruiting targets for civilian enterprises working in parallel
with Department of Defense and Department of Homeland Security
missions.
Hospital Corps/Dental Technicians
The Hospital Corps manning at the end of fiscal year 2003 was 94
percent. Like the Medical and Dental Corps, some specialty areas,
identified by their Navy Enlisted Classifications (NEC) struggle to
remain manned above 75 percent. In the operational forces, the Marine
Corps reconnaissance Hospital Corpsman specialty is currently manned at
44 percent. In Naval Military Treatment Facilities, cardio-pulmonary
technicians are manned at 72 percent, bio-medical repair technicians at
72 percent, morticians at 56 percent, respiratory technicians at 73
percent, and basic SEAL hospital corpsman at 70 percent of authorized
levels. Manning for the Dental Technician rate is at 95 percent of
authorized levels.
Initiatives to ensure consistent manning levels, as well as to
bolster undermanned NECs, include the Navy's Perform to Serve program,
which allows sailors in other rates to transfer or ``cross-rate'' into
the Navy Hospital Corps and acquire NECs in critically undermanned
areas. A current initiative to merge the Hospital Corpsman and Dental
Technician rates into a single rate may help bolster NECs with poor
manning levels.
Rightsizing the Force
Navy Medicine is converting 1,772 non-readiness military manpower
positions (billets) to civilian/contract positions in fiscal year 2005.
All of these positions are at CONUS MTFs or DTFs. OCONUS and
operational commands are unaffected.
The final determination of which billets will be converted has not
occurred yet. The draft list of the 1,772 billets under consideration
was identified from a larger list of approximately 5,400 over Total
Health Care Support Readiness Requirement (THCSRR) billets that Naval
Medicine has been studying. Our manpower and resource management
experts are working closely with representatives from the Medical,
Dental, Medical Service, Nurse and Hospital Corps Chiefs/Director's
Offices, and the Center for Naval Analyses (CNA). Factors to determine
the final 1,772 positions include readiness impact based on emerging
threats, community manning levels, the cost of conversion, and skill
availability in the market place.
This initiative is very much in line with Navy's fiscal year 2004
human resource philosophy, which includes maximizing civilian and
contract personnel for non-military essential (non-readiness)
positions. The conversion of these positions will help alleviate the
stress on the operating forces and ensure that military personnel are
used to perform tasks that are military essential.
naval medical education and training command
I am pleased to report to the Committee that the Naval Medicine
Education and Training Command, or NMETC, has successfully progressed
as the central source of learning for all Naval Medical personnel. The
five learning centers comprising NMETC are co-located with the Fleet on
the east, west and southern coasts along with basic recruit training in
Great Lakes, Illinois and Naval Headquarters here in Washington.
NMETC has established itself as the Learning Center for Force
Health Protection and is in precise alignment with Navy's Sea Warrior
program. It has demonstrated being on par with the line Navy in
implementing the Chief of Naval Operations' Revolution in Training by
way of the 5 Vector model which when fully operational, will show
sailors what they need to learn, how to access that learning and
provide a career road map, which tracks their learning and promotion
potential. The Naval Medical Department has increasing numbers of
subscribers to the new web-based Navy Knowledge Online or NKO, and is
utilizing the growing number of NMETC developed courses to enhance
their learning. They are also rapidly beginning to share and manage
their knowledge in an environment of community practice--all in one
place, in real-time, in NKO. By increasing our partnership with
civilian academe, we've exploited its skills and knowledge to enhance
the learning of our Sailors by exposing them to newer ways of thinking
and state of the art technologies.
NMETC has established a Naval Reserve medical liaison that provides
input concerning the rapidly evolving requirements of the Naval Reserve
and thus utilizes our Reserve partners in ONE Naval Medical education
and training service.
Our ``A'' School, the Naval Hospital Corps School, is in the lead
to see that our young Sailors, both in Active and Reserve components,
are economically and efficiently trained. This is demonstrated by an
improved technology-based program to train Hospital Corpsmen in a
blended learning environment available both in the classroom, and non-
traditional settings. Our instructors are highly trained and many come
directly from the operational arena.
The Naval Schools of Health Sciences in Portsmouth and San Diego
integrate the precepts of Force Health Protection into every aspect of
the training and educational curricula and programs. The Commanding
Officers personally lead this effort through military training,
leadership and physical fitness. Their mission, to support readiness
through leadership in advanced medical training, is designed to meet
the needs of military medicine in conflict and in peace. It is the
cornerstone for all facets of each training program. All courses
include learning modules directed towards the protection and self-
treatment of that sailor and other casualties resulting from weapons of
mass destruction. Many of our instructors are fresh from the Fleet and
the Fleet Marine Force, and bring enormous operational experience to
new students in the classroom. We have incorporated experiences from
Operation Enduring Freedom and Operation Iraqi Freedom into various
training programs such as the Joint Special Operations Medical Training
Center at Fort Bragg, which teaches trauma and emergency care skills to
corpsmen attached to SEAL Teams and reconnaissance units.
Projected training requirements for fiscal year 2005 through fiscal
year 2010 show an increase in the total numbers of personnel to be
trained as Independent Duty Corpsmen, Laboratory Technicians, Search
and Rescue and Preventive Medicine Technicians to support operational
readiness. We are committed to support and to participate with the
medical activities of our sister services by continuing our
relationships with other DOD training organizations that prepare
medical personnel for delivering care to the Fleet as well as in
integrated operational environments.
As a primary deliverer of skills sets for Sea Warrior, our schools
provide benchmark model training programs where students in
cardiovascular technician, nurse anesthesia, physician assistants,
preventive medicine technician, surgical technician, medical laboratory
and nuclear medicine technician exceed professional national
certification rates by as much as 30 percent thus, augmenting the Chief
of Naval Operations' ``Revolution in Training.''
The Naval Operational Medical Institute, or NOMI, with its
specialty detachments, is our dedicated operational training arm. It is
fully engaged in preparing line and medical personnel to learn and
implement survival and medical skills in hostile environments on land,
in the air and on the sea. Recently, NOMI developed a training program
and standards for Enroute Medical Care to personnel assigned to Marine
Corps units with field medical evacuation requirements.
Naval Medicine at NOMI now has a Center for Medical Lessons Learned
that provides feedback related to the operational environment. This
helps to refine and improve requirements for training both at NOMI, as
well as in our other training programs. The Medical Operational Lessons
Learned Center is a web-enabled system that has captured 31 lessons
learned to date from medical personnel who were forward deployed in
support of operations. The Center is a single point for data collection
and analysis of all Naval Medical observations and provides expeditious
feedback related to the operational environment in areas such as
readiness training, health services support delivery, logistics and
field medicine.
As our duty, and part of the continuum of care, the Mitchell Center
for Repatriated Prisoners of War performs approximately 450 extensive
evaluations per year on former POWs, their spouses and comparison
groups. The results of these studies have facilitated the minimization
of the development or worsening of post-traumatic stress disorder and
other physical and mental conditions among former prisoners of war.
NOMI is also is our service's lead on the Trauma Combat Casualty
Care Committee. Civilian trauma experts participate in this Triservice
Committee, which produces guidelines integrated into special operations
curriculum. These guidelines have also been published as a chapter on
military medicine in the most recent Pre-Hospital Trauma Life Support
Manual. This manual is also being utilized by the civilian EMT-
paramedic community to enhance first responder training and
capabilities within police, fire, and rescue services.
In fiscal year 2003, our schoolhouses prepared 8,732 medical
department enlisted and officers to join the Fleet and Marine Corps
medical components and to staff our Military Treatment Facilities,
research commands and other support communities. Naval Medical
personnel are ready to deploy wherever and whenever the Naval Services
deploy, and much of the time are the only direct care providers in the
field and especially at sea.
In addition to preparing for the operational arena, our educational
programs include learning opportunities in healthcare management,
fiscal responsibility and efficient direct healthcare delivery. We are
ensuring Force Health Protection by producing highly qualified,
technically competent personnel to directly support the Navy and Marine
Corps in any mission the Commander in Chief calls upon them to carry
out.
uniformed services university of the health sciences
As the Executive Agent for the Uniformed Services University of the
Health Sciences (USUHS) and a member of the Board of Regents, I am
pleased to announce that the University recently received a ten-year
accreditation with commendation from the Middle States Commission on
Higher Education. This is a noteworthy accomplishment and it reflects
well on the successful, on-going commitment of the University to
provide the highest levels of professional health care education for
our Nation's Military Health System (MHS).
The quality of the USUHS alumni ensures that the intent of the
establishing legislation, The Uniformed Services Health Professions
Revitalization Act of 1972, is being realized. The military unique
curricula and programs of USUHS, successfully grounded in a multi-
Service environment, draw upon lessons learned during past and present
day combat and casualty care. USUHS alumni, 3,421 physicians, 200-
advanced practice nurses and 798 scientists, have become an invaluable
and cost-effective source of career-oriented, dedicated uniformed
officers. Our University graduates volunteer in large numbers for
deployment or humanitarian missions; they serve proficiently in desert
tents, aboard The Hospital Ship COMFORT, and during air evacuations.
USUHS graduates embody the University's mission-driven goal of Learning
to Care for Those in Harm's Way; they are equal to their sacred mission
of providing care to our Nation's most precious resource--the men and
women who serve in the Armed Forces.
I would also like to take a moment to recognize the USUHS
President, James A. Zimble, M.D., VADM, USN (retired), and 30th Surgeon
General of the Navy, who has successfully guided our University for the
past thirteen years. Dr. Zimble served our Nation for over 40 years,
will retire in August of 2004. Under his leadership, the University has
become the Academic Center for the Military Health System; during his
tenure, the University has achieved peer recognition, on-going
accreditation with commendation from 14 accrediting entities, and the
Joint Meritorious Unit Award from the Secretary of Defense. He is a
public servant who has unselfishly dedicated the better part of his
life to Caring for Those Who Serve in Harm's Way. I wish him the very
best in his well-deserved retirement. He will be greatly missed.
health care delivery
Naval Medicine continually examines our methods of delivering
services to ensure that they are the best value for Naval Medicine, the
MHS and our beneficiaries. We focus on increasing our efficiencies, but
will never compromise clinical quality, access to care, customer
satisfaction or staff quality of life to achieve that goal.
This year the Bureau of Medicine and Surgery (BUMED) developed a
business planning model that combined standard business planning
methodology with an automated business planning tool. This new process
requires all activities in Naval Medicine to develop, submit, and
monitor a comprehensive annual business plan that is integrated with
their existing financial plan. This methodology takes into account the
changes in our financing due to the TRICARE for Life program, the
prospective payment system and the TRICARE Next Generation contracts.
The automated tool takes information from seven different data sources
to help local commands and headquarters personnel identify variations
in cost and productivity for the same services between MTFs. It also
helps identify high cost, low productivity services provided at local
MTFs. We are providing specialized training to the senior leaders in
our MTFs, to ensure that their business plans optimally represent the
size and diversity of services provided at their facilities. Our goal
is to reduce the variation in cost and productivity between our MTFs,
driving out inefficiencies that will result in increased cost savings,
patient satisfaction and quality of medical care rendered.
``Family-Centered Care'' is one of the initiatives we have
undertaken to provide best value for our beneficiaries. Family-Centered
Care initiatives are intended not only to increase patient satisfaction
and improve the delivery of care; they are intended to create
partnerships between providers, patients, and their families by
empowering patient's families to become active in the care plan. In the
military, the definition of family must be expanded to include both
immediate and extended family members as well as friends and the social
support network of both single service members and spouses of deployed
service members. Single service members create virtual families'
through a social network within and outside their units. Family-
centered care must incorporate this non-traditional type of family
support in the delivery of care. By partnering with patients and their
families, we can retain them in the direct health care system. This
will enable Naval Medicine to provide families with the tools to
develop and maintain healthy habits throughout their lives.
Our first Family-Centered Care initiative includes significant
improvements to perinatal services in order to integrate our young
Sailors and Marines into our health care system during the time in
which they are starting their families. Our MTFs have implemented
numerous initiatives to provide increased quality of service for
expectant women and their families. These initiatives include:
increased continuity with providers through prenatal visits with small
care teams or individual providers; encouraging our providers to work
with patients to create a birth plan for their deliveries; providing
private post-partum rooms where possible; providing 24/7 breastfeeding
support; DEERS enrollment by the bedside; and establishing a system to
provide seamless transfer of care between MTFs during permanent change
of station moves for expectant women. These initiatives have been
successful in encouraging our patients to choose to deliver their
babies in our MTFs despite the fact that they now have the choice to
seek perinatal care in the civilian community.
In fiscal year 2003, Naval Medicine embarked on a global Case
Management Program (CMP) in Navy MTFs. This program provided contract
registered nurses and social workers to assist in the coordination of
care for patients with complex illnesses or serious injuries. These
professionals work with all disciplines within a medical treatment
facility and within the TRICARE network to ensure that patients have a
seamless transition in healthcare services, receive the proper referral
to needed services and reduce the incidence of duplicate or unnecessary
services. This program reduced health care costs, increased patient
satisfaction and ensured high quality care for our beneficiaries.
Naval Medicine initiated a third Radiology Residency Program at the
Naval Medical Center in Portsmouth, VA. This proactively addressed
staffing issues in the most critically understaffed and expensive
medical specialty in the Navy, immediately improving access to imaging
services in the short-term while providing long-term specialty
availability.
We have also invested in Pharmacy Automation Equipment at selected
treatment facilities. This program leverages technology by using bar
code scanners and computers to continuously track and monitor
medication administered to our inpatients. This equipment greatly
improves the safety of our patients by reducing the probability of
unintended medication errors.
We continue to fund new pilot projects designed to increase our
effectiveness in providing healthcare services. With our new business
planning tool, we will be able to quickly identify those projects that
successfully increase productivity and share those improvements in all
of the MTFs throughout Naval Medicine. It is our intent to continuously
improve our patient care delivery systems to ensure the best health
care for our beneficiaries.
Patient safety is a top priority for Naval Medicine. Every MTF has
a minimum of one full time staff member dedicated to coordinating
command-wide patient safety initiatives. All of our MTFs participate in
the MEDMARX system for medication error reporting that groups
medication error events and near misses into five process nodes,
allowing MTF staff to evaluate process changes that will increase the
safety of medication administration. Naval Medicine also uses a
standardized root cause analysis methodology that is used by both local
MTF and headquarters staff to track and analyze trends in patient care
systems that affect patient safety. All of our MTFs are required to
submit monthly patient safety scores and receive a monthly Safety
Assessment Score. These scores are used to assess overall MTF
performance and are monitored closely.
We maintain our high standards through rigorous reviews. Our
medical treatment facilities are reviewed by leading accreditation
agencies including the Joint Commission of the Accreditation of
Healthcare Organizations (JCAHO), Accreditation Council for Graduate
Medical Education; the College of American Pathologists and the
American Association of Blood Banks.
Naval Medicine has implemented through the JCAHO a major paradigm
shift in the accreditation process of our MTFs: ``Shared Vision-New
Pathways''. Shared Visions-New Pathways shifts the focus from survey
preparation to continuous improvement of operational systems that
directly impact the quality and safety of patient care. It is intended
to force standards based process integration across all functional
lines by using actual patient experience as a lever.
DOD/VA Resource Sharing and Coordination: Status on Implementation of
Presidential Task Force Recommendation
Naval Medicine continues to support ongoing efforts implementing
the Presidential Task Force recommendations to pursue sharing
collaboration with the Department of Veterans Affairs specifically to
optimize the use of federal health care resources. I believe our
progress is one of our success stories. Site-specific sharing
initiatives, including in the key geographical areas as directed by the
fiscal year 2002 and fiscal year 2003 Defense Authorization Acts, are
occurring and continue to be developed.
Naval Medicine currently has 54 medical agreements, 34 Reserve
agreements, 24 Military Medical Support Office agreements, and 13 non-
medical agreements with the Department of Veterans Affairs. Naval
Medicine has also partnered with the Department of Veterans Affairs on
five medical facilities construction projects. These are:
--1. Naval Hospital Pensacola FL.--This joint venture outpatient
facility will be built on Navy property, and the VA will fund
the project, and provide Naval Medicine with 32,000 square
feet. This will be a replacement facility for Naval Medicine's
aging Corry Station Clinic. Navy and VA have agreed on a site
and negotiations continue on the amount of land to be allocated
for construction and how services will be integrated to best
serve both DOD beneficiaries and Veterans.
--2. Naval Hospital Great Lakes, IL.--A fiscal year 2007 construction
start has been proposed to build a separate Navy/VA Ambulatory
Care Clinic on the grounds of the North Chicago Veterans
Affairs Medical Center. Full integration planning has begun,
with facility and site analysis to follow. The North Chicago
VAMC is now providing emergency and inpatient services to Navy
beneficiaries. Additionally, the North Chicago Veterans Affairs
Medical Center will be available to the Navy for specified
services with the Department of Veterans Affairs funding
modifications of its surgical suites and urgent care
facilities.
--3. Naval Hospital Beaufort, SC.--A tentative fiscal year 2011
construction start has been planned for a replacement hospital.
The Department of Veterans Affairs currently operates a small
clinic within the existing hospital, and is expected to be a
partner in developing the replacement facility.
--4. Naval Ambulatory Care Clinic Charleston, SC.--A fiscal year 2005
construction start has been planned for a replacement clinic
aboard Naval Weapons Station (NWS) Charleston. Navy has offered
the Department of Veterans Affairs the options of an adjacent
site onboard NWS or the take-over of the existing NWS clinic.
The Department of Veterans Affairs is studying these options
with a final decision to be made in the future.
--5. U.S. Naval Hospital Guam.--A fiscal year 2008 construction start
is planned for replacement of the current hospital. The Navy
has offered the Department of Veterans Affairs a site for
nearby freestanding community-based outpatient clinic. It's
proposed that the Department of Veterans Affairs will fund the
clinic, roads and parking, and will continue to utilize Navy
ancillary/specialty care.
Other examples of partnerships that show the depth and variety of
our collaboration include the development of uniform clinical practice
guidelines for tobacco use and diabetes last year, and development of
hypertension and low back pain guidelines scheduled for 2004. Asthma
guidelines are projected for revision in 2005.
In the works is a VA/DOD agreement that would permit the use of
North Chicago VA Medical Center spaces to establish a center to
manufacture blood products in exchange for the use of these blood
products. This agreement would alleviate the necessity for Naval
Medicine construction costs for a new center at Naval Hospital Great
Lakes. An agreement between the Bureau of Medicine and Surgery and the
Department of Veterans Affairs headquarters to share each other's
``lessons learned'' databases is presently being developed.
Aggressive investigation of other mutually advantageous resource
sharing possibilities is on-going at all Naval Medicine facilities with
the focus of providing of our beneficiary populations--military and
veterans, the outstanding healthcare they deserve.
defense health budget for fiscal year 2004
One of Naval Medicine's greatest accomplishments is meeting the
healthcare needs of all its beneficiaries--active duty, retiree, family
members and eligible survivors. Nation-wide, healthcare costs are now
increasing at the fastest rate in the last decade. Healthcare inflation
continues to exceed inflation in other sectors of the economy.
Utilization of healthcare services continues to increase as technology
advances results in effective new--albeit sometimes costly--treatments
and longer life spans.
In addition, as the news of TRICARE's quality and effectiveness
spreads, and as the costs of other insurance programs rises, more
retirees under 65 are dropping other health insurance and relying on
TRICARE. From the trends of the past few fiscal years, it's estimated
that in fiscal year 2004 there will be a 5.2 percent increase in this
population.
DOD has ongoing programs that help control health care cost
increases, such as building cost control incentives to managed care
support contracts and competitively awarding these contracts for best
value, and ensuring the pharmaceuticals delivered in our Military
Treatment Facilities and through the TRICARE Mail Order Pharmacy
Program are procured through using discounted federal government
pricing. DOD and Naval Medicine management programs have also been
utilized to ensure that healthcare provided to beneficiaries is
reviewed for clinical necessity and appropriateness.
Naval Medicine has worked hard to get the best value from every
dollar Congress has provided, but your assistance is needed to restore
the flexibility to manage funds across activity groups. Fencing sector
funds prevents transfer of funds from MTFs to the private sector, but
also prevents transfer of private sector funds to the MTFs. This
fencing prevents funding MTFs to increase their productivity without
the burden of prior approval reprogramming, which can take anywhere
from three to six months. The T-NEX contract, with its incentive to
move care into MTFs, makes having this flexibility all the more vital.
Two-way flexibility between the private sector care and direct care
accounts is necessary for revised financing to function successfully.
The Navy appreciates the congressional intent to protect direct care
funding, but we recommend that the fiscal year 2005 Defense
Appropriations Act language remove the separate appropriation for
Private Sector Care to allow the flexibility to move funds to wherever
care is delivered without a Prior Approval reprogramming.
transition to the next generation of tricare contracts
TRICARE Next Generation has provided sweeping improvements in its
provision of TRICARE Benefits under contracting initiated this fiscal
year. While there will be no significant benefit changes, it simplifies
the old contracts, and provides performance incentives and guarantees.
It also distinguishes health plan management, which includes such
activities as financing, claims, payment rates, marketing, and benefit
design, from healthcare delivery. Some major elements of the old
TRICARE contracts have been sifted out into separate contracts to allow
companies with particular competencies in these contract areas provide
even better service and quality healthcare.
The most obvious change is the transition from 12 regions to three,
and enhancing leadership in each region by putting a Flag, General
Officer or SES as director. This is a significant step in transforming
TRICARE. These Regional directors have a key role in enhancing
participation of providers in TRICARE and in implementing the plan to
improve TRICARE Standard for those who choose to use it, and will also
be responsible for integration of military treatment facilities with
civilian networks, ensuring support to local commanders and overseeing
performance in the region. Rear Admiral James A. Johnson, Medical
Corps, is on board in the TRICARE West Region.
Medical commanders within these regions will also have an enlarged
role and additional responsibilities under the new contracts, with the
focus on accountability. Commanders will take on responsibilities
formerly managed by the TRICARE contractor, including patient
appointing, utilization management, use of civilian providers in
military hospitals, and other local services.
The transition to the new TRICARE contracts in TRICARE West is
going well, and all the services are working closely with TMA to make
the transition phase as seamless as possible for our patients.
closure of u.s. naval hospital roosevelt roads, puerto rico
On February 12, 2004, U.S. Naval Hospital Roosevelt Roads, Puerto
Rico officially closed its doors to patient care, ending more than 47
years of healthcare service to Department of Defense beneficiaries. The
last time a Naval Hospital closed was almost nine years ago when Naval
Hospital Long Beach closed as a result of the Base Realignment and
Closure.
e-health
Naval Medicine continues to be on the forefront of technology with
the development of Naval Medicine Online (NMO). This website allows one
tool for all of Naval Medicine to obtain and access information from
anywhere around the world. This technology will be the key to knowledge
sharing throughout Naval Medicine as an enterprise, allowing the right
information to be obtained by the right people at the right time--
whenever and wherever it is needed.
NMO contains knowledge tools including File Cabinet that allows
individuals to share documents and other electronic files; protected
chat rooms that will allow users to have secure communications with
patients or other Naval Medicine personnel and news services that
provide information of relevance to the Naval Medical community.
A key new function of NMO is the developer whiteboard. This tool
allows Naval Medicine to leverage the brainpower of our workforce by
placing software code in a secure area and allowing members of Naval
Medicine to modify the code, making improvements useful to Naval
Medicine. NMO also has online video teleconference capabilities and
allows Naval Medicine personnel access to the Department of Veterans
Affairs lessons learned database.
The Navy Marine Corps Intranet (NMCI) is a long-term initiative
between the Department of the Navy (DON) and the private sector to
deliver a single integrated and coherent department-wide network for
Navy and Marine Corps shore commands. Under NMCI, EDS and their
partners will provide comprehensive, end-to-end information services
for data, video and voice communications for DON military and civilian
personnel and deliver global connectivity to make our workforce more
efficient, more productive, and better able to support the critical war
fighting missions of the Navy and Marine Corps.
Naval Medicine is committed to transitioning to NMCI infrastructure
and services where feasible. The Naval Medicine--NMCI shared vision is
to create a single Navy and Marine Corps Enterprise-wide Network that
provides seamless access to and exchange of comprehensive healthcare
information throughout Naval Medicine and the Military Health System
Community of Interest.
The Naval Medicine--NMCI transition strategy incorporates four
parallel endeavors. They are:
--1. Transition of BUMED Headquarters into NMCI (800 Seats)
--2. Transition of non-clinical Naval Medical Department Commands
into NMCI (5,900 Seats)
--3. Completion of a Composite Health Care System Computer-based
Patient Record (CHCS II) NMCI Interoperability Beta Test at
Naval Medical Center, Portsmouth, VA (72 Seats). The Military
Health System's (MHS) largest, and most critical, network-
centric information system, CHCS II forms the core of DOD's
computer-based patient record initiative, and as such, is and
will be broadly integrated across the enterprise at the center
of the MHS healthcare delivery mission. The Beta Test will
document infrastructure and network performance characteristics
to include: Interoperability, Accessibility, Continuity of
Business Operations, Quality of Service, Information Assurance,
and Clinical Provider Productivity.
--4. Transition of all clinical Navy Medical Department Commands into
NMCI (38,300 seats).
Naval Medicine is partnering with Electronic Data Systems (EDS),
Science Applications International Corporation (SAIC), and Booz-Allen &
Hamilton (BAH) to complete the financial analysis of our transition
endeavors. We expect positive economies in transitioning to NMCI, which
include robust information security, email server consolidation,
network operations center consolidation, and uniform seat management
services across the Naval Medicine Enterprise.
medical research
Naval Medicine also has a proud history of medical research
successes from our laboratories both here in the United States as well
as those located overseas. Our research achievements have been
published in professional journals, received patents and have been
sought by industry as partnering opportunities.
The quality and dedication of the Naval Medicine's biomedical
research and development community was exemplified this year as Navy
researchers were selected to receive prestigious awards for their work.
CAPT Daniel Carucci, MC, USN, received the American Medical
Association's Award for Excellence in Medical Research for his work on
cutting edge DNA vaccines. His work could lead to the development of
other DNA-based vaccines to battle a host of infectious diseases such
as dengue, tuberculosis, and biological warfare threats. Considering
the treat of biological terrorism, DNA vaccine-based technologies have
been at the forefront of ``agile'' and non-traditional vaccine
development efforts and have been termed ``revolutionary''. Instead of
delivering the foreign material, DNA vaccines deliver the genetic code
for that material directly to host cells. The host cells then take up
the DNA and using host cellular machinery produce the foreign material.
The host immune system then produces an immune response directed
against that foreign material.
In the last year, Navy human clinical trials involving well over
300 volunteers have demonstrated that DNA vaccines are safe, well
tolerated and are capable of generating humoral and cellular immune
responses. DNA vaccines have been shown to protect rodents, rabbits,
chickens, cattle and monkeys against a variety of pathogens including
viruses, bacteria, parasites and toxins (tetanus toxin). Moreover,
recent studies have demonstrated that the potential of DNA vaccines can
be further enhanced by improved vaccine formulations and delivery
strategies such as non-DNA boosts (recombinant viruses, replicons, or
exposure to the targeted pathogen itself). A multi-agency Agile Vaccine
Task Force (AVTF) comprised of government (DOD, FDA, NIH), academic and
industry representatives is being established to expedite research of
the Navy Agile Vaccine.
Naval Medicine is developing new strategies for the treatment
radiation illness. Adult Stem Cell Research is making great strides in
addressing the medical needs of patients with radiation illness. The
Anthrax attack on the Congress and others reminded us of the threat of
weapons of mass destruction, to include ionizing radiation. Radiation
exposure results in immune system suppression and bone marrow loss.
Currently, a bone marrow transplant is the only life saving procedure
available. Unfortunately, harvesting bone marrow is an expensive and
limited process, requiring an available pool of donors. In the past
year, Naval Medicine researchers have developed and published a
reproducible method to generate bone marrow stem cells in vitro after
exposure to high dose radiation, such that these stem cells could be
transplanted back into the individual, thereby providing life-saving
bone marrow and immune system recovery.
In this same line of research, Naval Medicine is developing new
strategies for the treatment of combat injuries. We are developing new
therapies to ``educate'' the immune system to accept a transplanted
organ--even mismatched organs. This field of research has demonstrated
that new immune therapies can be applied to ``programming stem cells''
and growing bone marrow stem cells in the laboratory. Therapies under
development have obvious multiple use potential for combat casualties
and for cancer and genetic disease.
Other achievements during this last year include further
development of hand-held assays to identify biological warfare agents.
During the 2001 anthrax attacks, Navy scientists analyzed over 15,000
samples for the presence of biological warfare (BW) agents. These hand-
held detection devices were used in late 2001 to clear Senate, House
and Supreme Court Office Buildings and contributed significantly to
maintaining the functions of our government. The hand-held assays that
are used by the DOD were developed at Naval Medical Research Center
(NMRC). Currently NMRC produces hand-held assays for the detection of
20 different biological warfare agents. These assays are supplied to
the U.S. Secret Service, FBI, Navy Environmental Preventive Medicine
Units, U.S. Marine Corp, as well as various other clients.
Naval Medicine's overseas research laboratories are studying
diseases at the very forefront of where our troops could be deployed
during future contingencies. These laboratories are staffed with
researchers who are developing new diagnostic tests, evaluating
prevention and treatment strategies, and monitoring disease threats.
One of the many successes from our three overseas labs is the use of
new technology, which includes a Medical Data Surveillance System
(MDSS). The goal of the MDSS is to provide enhanced medical threat
detection through advanced analysis of routinely collected outpatient
data in deployed situations. MDSS is part of the Joint Medical
Operations-Telemedicine Advanced Concept Technology Demonstration
(JMOT-ACTD) program. Interfacing with the shipboard SAMS database
system, MDSS employs signal detection and reconstruction methods to
provide early detection of changes, trends, shifts, outliers, and
bursts in syndrome and disease groups (via ICD-9 parsing) thereby
signaling an event and allowing for early medical/tactical
intervention. MDSS also interfaces with CHCS and is operational at the
Army's 121st Evacuation Hospital in South Korea, and is being deployed
at the hospital and clinics at Camp Pendleton. Currently, MDSS may have
an opportunity to collaborate with other industry and service-related
efforts for the purpose of developing homeland defense-capable systems.
Homeland defense initiatives are currently being coordinated through
the Defense Threat Reduction Agency.
Noise-Induced Hearing Loss (NIHL) is one of the most common
military disabilities with over 353,116 new cases reported in 2003
despite aggressive hearing conservation programs in the military.
Military related NIHL is very costly. When disability costs for
tinnitus and aircraft accidents related to communication problems are
included, costs for military related hearing loss may exceed $1 billion
annually. Additionally, NIHL may degrade warfighter performance,
mission accomplishment, and survivability. Today's hearing conservation
programs are based on fit and frequency dependent personal hearing
protection devices (HPDs), engineering solutions, and noise avoidance;
which are helpful but do not provide adequate protection around today's
noisier weapons systems. Accordingly the Navy has taken the lead in
research to elucidate the mechanisms underlying NIHL. The results have
lead to the development of a safe oral nutritional supplement that has
proven in laboratory settings to enhance resistance and healing to
inner ear damage from noise. The efficacy of these nutritional
supplements to prevent and treat NIHL is being studied in two joint
military-civilian clinical trials lead by the Naval Medical Center, San
Diego. If these trials succeed, we believe that a proven and effective
treatment and prevention strategy, when combined with hearing
conservation measures, could be dramatically reduced. A conservative
estimate based on the robustness of the biological response in
preclinical data suggests that a 50 percent reduction in hearing
related injury is possible.
naval medicine and sea power 21
Naval Medicine is totally committed to the Chief of Naval
Operations' transformational vision for projecting decisive joint
capabilities from the sea--Sea Power 21. Examples of transformation
abound throughout Naval Medicine where hard work identifying
efficiencies and cutting costs have resulted in opportunities to
support recapitalization. These include the ongoing efforts to reduce
variation in costs across our MTFs as well as among clinics within
MTFs. Optimization efforts focusing on maximizing the fixed
capabilities of our facilities to the greatest extent possible are
active, ongoing, and will continue into the future. Transformation is
not limited to shore facilities and includes remaking our fleet assets
such as the reconfiguration of forward medical assets from cold war era
fleet hospitals to the smaller, more agile and more flexible platforms
and units described earlier in my statement.
We are right sizing our active military force to the best mix of
active, and civilian or contract personnel to bring the right
capability to bear at the right time, and in alignment with the CNO's
vision. We have reconfigured and integrated our Naval Reserve
components to shape missions along with the active component, creating
one force, assuring the very best use of the skills and talent our
Reserve medical personnel bring to the mission. Further, Naval Medicine
is committed to the growth and development of our people through
investments in leadership that are directly in support of Sea Warrior
by ensuring the right skills are in the right place at the right time.
Naval Medicine will continue to seek aggressively opportunities to
pursue efficiencies that improve our primary mission of Force Health
Protection and do our part to return resources for recapitalization of
the Navy. We are affecting positive change throughout Naval Medicine,
embracing and implementing the CNO's vision for the Navy, and I am
confident that we are on the correct course for the challenges ahead.
conclusion
Naval Medicine has been successful in accomplishing its mission
over the years, and with your support, the military benefit has become
one of the most respected healthcare programs in the world. We know
from Navy's quality of life surveys that among all enlisted personnel
and female officers, the number one reason these service members stay
Navy is the exceptional healthcare benefit.
You have allowed us to provide our service members, retirees and
family members a benefit that is worthy of their service, and clearly
articulates the thanks of a grateful nation for their selfless service.
With your support, we have opportunities for continued success, both in
the business of providing healthcare, and the mission to supporting
deployed forces and protecting our citizens throughout the United
States.
In just a few short months, I will leave this office, and will
retire after serving more than 32 years in the United States Navy. I
wish to thank this committee for its support to Naval Medicine, and to
me during my time as the Navy's Surgeon General. It has been a
privilege to serve.
Senator Stevens. General Taylor, it is nice to welcome you
back.
STATEMENT OF LIEUTENANT GENERAL GEORGE PEACH TAYLOR,
JR., SURGEON GENERAL, UNITED STATES AIR
FORCE
General Taylor. Thank you, Mr. Chairman. Mr. Chairman and
members of the committee, it is a privilege and a pleasure to
be here today.
OPERATION IRAQI FREEDOM
Much has happened since we met here 1 year ago when we had
just embarked on Operation Iraqi Freedom. A year later we have
found that most of our concepts were validated. Some require
more work, but most importantly the men and women of the Air
Force Medical Service have again served their country with
phenomenal talent, capability, and dedication. The lessons we
have learned in Afghanistan, Iraq, indeed, wherever we are
deployed, and even at home have helped us to hone our force
central capabilities, ensuring a fit and healthy force,
preventing illness and injuries, providing care to casualties,
and sustaining and enhancing human performance.
MEDICAL READINESS
We are doing many things to ensure our force is fit and
healthy before they deploy. Our preventive health assessments
and individual medical readiness program ensures that health
requirements and screenings have been met before deployment.
This program has been adopted DOD-wide and is clearly
responsible, in great part, for the 4 percent non-battle
disease injury rate in DOD that you have been hearing about,
the lowest in history.
POST-DEPLOYMENT HEALTH ASSESSMENTS
I would add that our post-deployment health assessments,
equally important, are going extremely well. Our Active and
Reserve component personnel have returned for deployments and
nearly 99 percent have completed these assessments with a
provider. Our people are coming back in better health because
of individual disease prevention efforts but also because of
the incredible deployment health surveillance program that all
three of us have fielded. From our preventive aerospace
medicine teams to our biological augmentation teams, we are
helping to protect the area of responsibility from biological
and environmental threats. We are using amazing technology such
as our rapid pathogen identification systems (RAPIDS) which can
determine the identity of pathogens in only a few hours. In the
future, we hope to reduce this time even further through new,
more advanced, indeed breakthrough genome-based technologies.
We have shared with you over the past few years our success
in our light, lean, and mobile expeditionary medical system,
known as EMEDS, but before we left for Iraq a year ago, we
realized EMEDS did not have the protection we needed for
chemical weapons. Within 30 days, Air Force medics developed a
mature nuclear, biological and chemical (NBC) treatment module
that could care for 100 radiologic, biologic, or chemical
casualties. This is the level of ingenuity we have in our armed
forces in all the services.
Your staff had the opportunity to view other technical
marvels that are saving lives in the battlefield like the
laptop size ultrasound machine, the ventilator that is the size
of a football, a complete surgical package that fits in a
backpack.
AEROMEDICAL EVACUATION
Aeromedical evacuation continues to be the lynch pin in our
deployed medical operations. In addition to the critical care
air transport teams you have heard about, we continue to field
patient support pallets that allow us to use all available
airlift and have added an aeromedical evacuation center to our
air operations center to allow smooth integration with all DOD
and, indeed, allied air operations in the theater.
From our perspective, the story of Private Jessica Lynch's
rescue is an excellent example of the near seamless integration
of the Air Force and our sister services. Following her rescue
from an Iraqi hospital, Army medics, Air Force aeromedical
evacuation troops, and special operations members transported
her thousands of miles using three different aircraft and
provided care in the air during her entire journey until she
reached the safety of an Army hospital in Landstuhl, Germany,
all accomplished in less than 15 hours. And this same scenario
has repeatedly saved the lives of many other, less famous, but
equally courageous young heroes.
Together the three of us partner closely to see that health
care from the foxhole to home station is seamless. Indeed, I
would tell you that this is a case study in the application of
the joint capabilities, the best of the Army, Navy, and Air
Force, to meet our Nation's needs.
COMBAT MEDICINE
Combat medicine is an ever-evolving art, and we cannot
afford to coast for one minute on these successes. We recognize
the critical value of developing new and better technology and
enhancing human performance. Our human performance initiatives
cross the spectrum from battling combat fatigue, to enhancing
vision through corneal refractive surgery, to creating systems
that will protect our pilots and our aircraft sensors from
laser damage. While all these exciting high-tech programs are
taking place, we are also quietly caring for our members and
their families back home.
TRICARE
We anticipate the promising next generation TRICARE
contracts to be a smarter way of doing business as revised
financing methodology is fielded throughout all U.S. based
military health treatment facilities. We are working hard with
health affairs and the Congress to ensure that our incentives
and our accountability are properly aligned for this increased
and more flexible local responsibility for patient care funds.
While we prepare for next generation TRICARE and for the
enhancement of relationships with the civilian community and
our partners in the Department of Veterans Affairs, we are
always aware of the direct connection between this peacetime
health care and the readiness of our troops.
The Air Force Medical Service has answered the call and
will continue to do so. We will work to resolve tough issues
from the fiscal hurdles to challenges of recruiting and
retention. And wherever we go to perform our mission, you can
see the results of your support to the troops, and we thank you
for this dedication.
PREPARED STATEMENT
Finally, as the last witness and anecdotally, scarily I am
going to be moving to the right-hand side of the table here
this next year, I would like to take a moment to focus on my
two comrades in arms. Jim Peake and Mike Cowan are two of the
finest Americans I have had the pleasure to meet. There are
really no finer examples of the American medic than these two
gentlemen to my right. They dedicated the heart of their adult
lives to the men and women in harm's way. We will miss them,
and our Air Force wishes them godspeed and fair tail winds.
Thank you, Mr. Chairman.
[The statement follows:]
Prepared Statement of Lieutenant General (Dr.) George Peach Taylor, Jr.
Mister Chairman and members of the Committee, it is a pleasure to
be here. When we last met, I described how our transformation efforts
were saving lives during combat operations in support of the war
against terrorism. The week before my testimony, we had just begun
combat operations in Iraq. Now, a year later, major combat in Iraq has
ended, but the mission and danger continue. Although many of my
comments here today address the Air Force Medical Service's
contribution to combat operations, I assure you that the care we
provide to families and retirees is still of great importance. It
continues to improve even as we are engaged in operations around the
globe.
And, of course, we truly are engaged around the globe. Like our
sister services, every step in our transformation is to advance our
ability to operate worldwide with lightning speed. This is reflected in
the Air Force's six Concepts of Operation, or CONOPS. CONOPS are a
statement of our desired end result, or effect, that the Air Force
brings to the battle. The first three are Global Mobility, Global
Strike, and Global Response. The others are Nuclear Response, Homeland
Security and finally Space and Command, Control, Communications,
Computers, Intelligence, Surveillance and Reconnaissance. That's a
mouthful, so we refer to it as Space-C\4\ISR. The medics provide
fundamental support to all six.
Global Mobility, Strike, and Response CONOPS require the AFMS to
provide medical care anywhere at any time to support humanitarian and
warfighting operations. This demands that our medics travel fast and
far, so they pack light, very light. Some of our Expeditionary Medical
System medics travel with just a 70-pound pack. One small 5-person team
carries enough to perform 10 life-saving surgeries in the field under
battle conditions. And our aeromedical evacuation capabilities permit
us to quickly fly into hostile environments, pluck injured members from
the field, and fly out, often providing critical care in flight.
The Air Force's Nuclear Response CONOPS provides a deterrent
umbrella under which our conventional forces operate. Medics support
this CONOP by ensuring that commanders can rely on the medical and
psychological health of the human element of the nuclear force. We also
develop plans for the care of casualties and refugees in a radiological
event of a terrorist or national origin. We assess health hazards and
provide recommendations to protect responding personnel or our
combatants within any hazardous zone.
The Homeland Security CONOPS recognizes that if someone attacks our
homeland again, Air Force medical personal will be an invaluable asset
bringing a wealth of manpower and expertise to the crisis. In such a
contingency, our base clinics and hospitals become part of the local
health care disaster network. They offer their ability to help local
authorities detect and identify chemical, biological, and nuclear
weapons, and we aid in the treatment of those exposed to them.
The final CONOPS, Space-C\4\ISR, serves to integrate the other
five. Simply put, it is the network of intelligence, sensors,
satellites, and communications that allow us to orchestrate our forces
worldwide. Every unit and every function of the Air Force is tied into
this capability. Each contributes information to it and uses
information from it. Air Force medics use this capability to monitor
health threats worldwide, to coordinate care from combat to CONUS, and
to maintain visibility of our patients no matter where they are within
the joint medical system.
We have now been in Iraq over a year. The AFMS has used this time
to review its performance there through a Capabilities Review and Risk
Assessment--a process that drives a hard look at our performance--from
this process we learn what we did right; and what we can do better.
These lessons learned help to hone our four central AFMS capabilities
of: Ensuring a fit and healthy force; preventing illness and injuries;
providing care to casualties; and enhancing human performance.
Ensuring a Fit and Healthy Force
The first capability we provide the Air Force is that of ensuring a
fit and healthy force. Unhealthy troops cannot deploy. A commander who
is short of troops cannot fight; cannot win. We keep troops healthy so
commanders can do both.
While providing a fit and healthy force is ultimately every
commander's responsibility, the AFMS plays a critical role in defining
what is fit, what is healthy . . . how do we get them that way, how do
we keep them that way.
Once recent step is the implementation of the Air Force Chief of
Staff's revised fitness program--a significant change in fitness
standards and how we monitor them. The program is now based upon push-
ups, sit-ups, and a mile-and-a-half run. To this we add body
composition measurements and a strong focus on unit exercise programs.
This model includes the Guard and Reserve who must meet the same
standards as their active duty counterparts.
The program is only a couple months old, but we know airmen accept
and appreciate it. They must like it--I find it much harder lately to
find an open weight bench at the gym, so I know first-hand that our
troops are enthused about the program.
Fitness results will be available on the Air Force's secure web to
commanders and leadership, allowing them to know in near real-time what
percentage of our troops are fit to fight.
Of course, our dedication to health goes far beyond a yearly
fitness test. We employ a life-cycle approach to care. We surround
troops with continual health monitoring and evaluations from the day
recruits first put on an Air Force uniform, during every visit to the
in-garrison or expeditionary clinic or hospital throughout their
career, and especially during their transition to veteran status. We
honor our commitment to our retirees; we are there.
An important tool of ensuring a fit and healthy force has been our
Preventive Health Assessment program. It ensures that at least once a
year, every Airman has an assessment for changes in his or her health
and for needed health screening or immunizations, and has the
opportunity for a medical exam, if needed.
Additionally, preventive health assessments are provided before
members deploy and immediately upon their return. Such screenings were
an interest item for both the DOD and Congress last year. We are
pleased to report our success. For the 61,000 Air Force personnel
deployed from March 1 through December 31, 2003, 99 percent completed
their post-deployment health assessment--which included a face-to-face
appointment with a medic and 97 percent had serum samples collected for
submission to DOD repository.
The medical information from all screenings and appointments is
captured in an innovative information system called the Preventive
Health Assessment and Individual Medical Readiness program, or PIMR.
PIMR data, like that of our new fitness program, are available on the
web to Air Force leadership worldwide.
The next version of the Composite Health Care System--CHCS II--is
another computer information system that will provide significant
benefit to the AFMS as well as the entire DOD health care. Even in its
current decade-old form CHCS is an amazing system. It captures every
visit, prescription, lab result, and procedure provided to every
patient.
We first deployed CHCS in the late 1980s when computer screens were
black and white and a mouse on your desk was cause for alarm. The
upgraded CHCS II will have the look and feel of a web site. It will
also be faster and easier to learn. More importantly, CHCS II will
interface with the numerous other programs that have come on line since
it was first introduced. CHCS II marches us down the path toward an
electronic medical record that will solve many problems for us,
including that of lost or fragmented medical records. Additionally,
CHCS II will be deployable, so it will be the same program used in the
field and at home.
CHCS II, like its predecessor, will be deployed worldwide, accessed
by thousands of users simultaneously, and contain the patient records
of up to 8.8 million eligible beneficiaries. It is the largest health
information system in the world--and an invaluable tool in keeping our
troops--and their families--healthy.
Once we have assured that only fit healthy troops are sent to the
area of operations, we take great effort to ensure they stay that way.
This falls to our next capability, that of preventing casualties.
Preventing Casualties
We are experiencing unparalleled success in the prevention of
illness and injury during Operation Iraqi Freedom. A telling example of
this success is our low Disease Non-Battle Injury Rate--we call it the
``D-N-B-I rate'' for short. The DNBI rate describes the percentage of
troops who become sick or hurt from things other than enemy activity;
things like dental problems, car accidents, the flu, broken bones,
etcetera.
Historically, more troops are removed from battle because of
accidents or illnesses than from enemy fire. In Operation Desert Storm,
the DNBI rate was about 6 percent. During the current Iraqi conflict,
only 4 percent (DOD rate) of illnesses and injuries were non-combat
related. This is the lowest DNBI rate in history. We seek ways to make
it lower yet. One of our doctors in Iraq jokingly suggested that if we
were to cancel intramural basketball games in theater we could
eliminate many sprained ankles and drop that DNBI rate another percent.
The important point is that we continue to address all the challenges--
including sports injuries--that reduce our combatant capabilities.
Much credit for the low DNBI goes to the preventive health
assessments and pre-deployment screenings I mentioned. These allow us
to identify personnel with pre-existing or uncontrolled medical
problems; conditions that would worsen under the stress of deployment.
These folks--if allowed to deploy--are a huge source of DNBI. By
pulling them out of the deployment line and caring for them back home
in-garrison, we not only decrease the DNBI rate, we also ensure these
members get the health care they need to make them worldwide-qualified
in the future.
The Deployment Health Surveillance program is another critical
piece of preventing casualties. Before airmen arrive in large numbers
to establish a base in foreign territory, a special team of medics--
called the Preventive Aerospace Medicine, or PAM team--has already been
there. They have surveyed the environment for biological and
environmental threats, and have stood up surveillance equipment to
detect and identify such threats.
When it comes to total ``battlespace awareness,'' PAMs and another
EMEDS team called the Biological Augmentation Team, or BAT team, are
invaluable. These teams take on the same importance as the radar,
intelligence, and security specialists whose mission it is to detect,
identify, and deter enemy attacks. In the same manner that a radar
operator surveys the skies for threats, our medics survey the
environment with equipment to detect chemical, biological, radiological
or nuclear--CBRN--threats. In combat, speed counts. That radar operator
must detect the presence of an airborne object and then quickly
identify it--friend or foe. The sooner that operator can do both, the
faster we can react--the safer our people are. In the same way, our
teams and their equipment act quickly to detect, identify, and counter
CBRN threats.
For example, it used to take up to a week to detect and confirm the
presence of dangerous biological and chemical weapons--too long.
Imagine a biological agent loose in one of our bases in Iraq for a week
before we were able to identify and contain it. Even the most
conservative estimates predict that 30 percent of our troops would
become seriously ill or worse.
With RAPIDS technology, we eliminate the deadly delay between the
time a pathogen is released and when we become aware of its presence.
The aptly named RAPIDS stands for the Rapid Pathogen Identification
Systems; a fielded and proven system that can determine the identity of
pathogens within a few hours; much better than 4 to 7 days it used to
take. Using new genome-based technologies, we hope to reduce the time
even further.
Another tool in the Air Force Medical Service toolbox is the Global
Expeditionary Medical System, or GEMS. This rugged, laptop-based system
serves as a deployable, electronic medical record for every patient
encounter in the combat zone. To date, it has logged nearly 107,000
patient encounters in Afghanistan and Iraq. But it does more than that.
It also tracks chemical, physical, and radiological hazards and even
tracks the results of food inspections and living conditions in the
field. GEMS provides commanders a theater-wide overview of the health
of their forces. Its sophisticated epidemiology tracking features allow
it to identify potential disease outbreaks very early in the courts of
outbreaks or a chemical or biological attack.
I have described systems and processes we have in place that ensure
oversight of our airmen's health before they deploy, while they are in
the field and even after they return. But we must remember that combat
is inherently dangerous. In spite of our best efforts to prevent it,
some of our troops will fall ill, and some will be wounded. Thus the
critical need for our third capability; that of restoring the health of
the sick or injured--casualty care.
Casualty Care
We have completed the conversion of our large-footprint field
medical facilities into small, rapidly deployable Expeditionary Medical
System--or EMEDS--units. Our performance in Iraq validates that the
EMEDS concept works. It saves lives.
These units can be found throughout the area of operations. They
often provide care from the point of injury, at tented facilities
removed from the front, and during aeromedical evacuations as they
transport the patient from the theater entirely. When the U.N. Building
in Baghdad was car bombed last August, killing 20, EMEDS surgeons and
their staff were only minutes away, and cared for numerous injuries on
the spot.
Shortly before the start of combat operations in Iraq we added a
new capability to EMEDS; hoping against--but preparing for--Iraq's
potential use of chemical weapons, we created EMEDS Supplemental NBC
Treatment Modules--or NBC pallets, as our troops call them. Each module
contains 25 ventilators and medical supplies to care for 100
radiological, biological, or chemical casualties. I find it
extraordinary that it took only 30 days for these packages to mature
from the concept stage until the first pallet was loaded onto an
aircraft for delivery.
While NBC pallets provide the tools to treat NBC casualties, the
EMEDS' hardened tents and infrastructure offer a protective shelter in
which our medics can render that care. Each can be equipped with
special liners and air handling equipment that over-pressurizes the
tents' interiors. Clean, filtered air is pushed in; contaminated air is
kept out. Protected water distribution systems work the same way,
ensuring a safe, potable water supply even in contaminated
environments.
I continue to be impressed with the enabling technologies that
permit the development of things like Push Pallets or advanced air and
water-handling systems. During operations in Iraq we have relied on
these and other technical marvels, like a lap-top sized ultrasound
machine, a ventilator unit the size of a football, and a chemistry
analyzer that--during Desert Storm--required its own tent; now it fits
in the palm of your hand. Our people are saving lives with these
technologies around the globe as we speak. There are EMEDS operating in
Iraq and 11 other countries in support of Air Force operations.
Operation Iraqi Freedom also validated our new aeromedical
evacuation concept of operations. A significant advancement in this
mission is our ability to take advantage of back-haul aircraft, which
has tremendously accelerated the aeromedical evacuation process. This
has eliminated the need for patients to wait days for a designated C-9
or C-141 aeromedical evacuation mission to pass through their area.
Patient Support Pallets--or PSPs--make it far easier to turn any Air
Force mobility aircraft into an aeromedical evacuation platform. PSPs
are a collection of specially packed medical equipment that can be
installed into cargo and transport aircraft within minutes. The plane
that just landed to deliver weapons is quickly converted to carry
wounded patients.
Let me share with you an example of PSPs work. In Baghdad, a 5-
year-old, deathly ill Iraqi girl was brought to one of our allied
locations. She was scheduled to fly to Greece for medical treatment.
Her condition was so poor that upon arrival at the clinic she was
placed on a ventilator. Doctors determined she was too ill to survive
and she was removed from the flight. One of our nearby medics heard of
the situation. He determined that leaving that little girl behind to
die was simply not an option. He, and other members of his Aeromedical
Evacuation team, grabbed one of our PSPs--we have 41 of them
strategically placed around the globe--and within an hour had converted
a section of the Greek aircraft into a small critical care bay. Their
precious cargo was loaded--with her ventilator--and she was flown to
Greece to receive care. We are the only country in the world that can
do this on a regular and sustained basis for our military personnel.
This demonstrates that PSPs allow us the flexibility to convert not
only our own aircraft into AE platforms, we can also take advantage of
our allies' aircraft. This dramatically increases the availability of
aeromedical evacuation opportunities to our troops. It's like one of
our medics told me: ``If it flies, and we have elbow room, we can do
our thing. Our thing is saving lives.''
The medic I spoke of is a member of one of our Critical Care Air
Transport Teams. We call them CCATS. These CCAT teams are comprised of
a physician, a nurse, and a cardiopulmonary technician. They are
specially trained to work side-by-side in the air with our aeromedical
evacuation crews to provide critical care under the extremely difficult
environment of flight.
Recently, one of our aeromedical evacuation crews augmented by a
CCAT team flew into Baghdad on a C-130, under black-out conditions and
while taking fire to retrieve three severely wounded soldiers. These
troops, too, needed ventilators to help them breathe. They were quickly
loaded and even before the aircraft could take off again, our CCAT
teams were providing life-saving care to their patients. While in the
air, the aircraft was diverted to Talil where U.S. forces had come
under attack. Two more men were critically wounded there and needed
immediate aeromedical evacuation. Both of these troops also required
ventilators.
All five soldiers were flown that night to an Army medical facility
in Kuwait. The Air Force medics on that mission are proud of their
accomplishment--never before, or since, has there been a combat AE
mission in which a team cared for five patients on ventilators in one
aircraft. I'm proud of them, too. Without the AE concept and the skills
our medics brought to the theater, each of those five soldiers would
have succumbed to their injuries.
Another enhancement to our aeromedical evacuation capabilities is
the placement of an AE cell in the Air Operations Center. This permits
the smooth integration of our actions with all other DOD or allied air
operations in the theater. The story of Private Jessica Lynch's rescue
provides a famous example of how all these assets--the AE cell,
aeromedical evacuation crews and CCATS, patient support pallets, and
the use of backhaul aircraft--all come together in a successful
operation. Following her retrieval from the Iraqi hospital, Army
medics, Air Force Aeromedical Evacuation troops, and Special Operations
members transported her thousands of miles, used three different
aircraft, and provided care in the air during her entire journey until
she reached the safety of an Army hospital in Landstuhl, Germany. All
this was accomplished in less than 15 hours.
Like so many of our missions, Jessica Lynch's AE mission could not
have been accomplished without the near-seamless integration of our
sister services. Medical and AE operations serve as the perfect example
of the joint application military capabilities.
I also must give praise to the backbone of our AE capability, our
Guard and Reserve. Fully 87 percent of our AE structure is Air Reserve
Component members. They have assisted their active duty counterparts in
transporting over 13,700 patients from OEF and OIF, of which about
2,300 were urgent or priority missions.
As I hope I have made clear, EMEDS capabilities span the geography
of operations from the farthest forward immediate surgical capability,
throughout the area of operations, to include aeromedical evacuation to
facilities around the globe. EMEDS has vastly improved how we care for
casualties, but we still face challenges. Perhaps one of the most
significant of which is caring for victims of weapons of mass
destruction.
Although this country has recently seen two bio-chem attacks--the
anthrax attack two years ago, and the fortunately unsuccessful ricin
scare of January--we have yet to experience a large scale Weapons of
Mass Destruction attack. Therefore, we can never know just how
successful our response to such an attack will be. I guarantee our
response would be superior to any other nation's on earth--but we
always strive to expand the envelope of our nation's capability.
To enhance our response even more, AFMS personnel are implementing
Code Silver. Code Silver is a program that offers tabletop exercises
emphasizing biological and chemical warfare responses by our medical
facilities. We will focus on how our facilities interact and relate to
the rest of the base and with the local civilian community. Forty Air
Force medical facilities and the communities surrounding them will
participate in Code Silver exercises in 2004.
The fourth and critical capability we bring to the warfighter is
the enhancement of human performance.
Enhance Human Performance
As the size of our military decreases and the capability of each
individual platform increases, the relative importance of every
individual also increases. Today's airman receives superior training so
that they can maintain and operate the most sophisticated equipment and
weapons systems in the world. But the stress and exhaustion of combat
operations leads to fatigue. Fatigue dramatically erodes the Airman's
ability to react quickly and think clearly. It eliminates the
intellectual and technological advantages we bring to the battle.
Commonly used methods of combating fatigue involve careful studying
of our airmen's mission schedules, their diets, sleep patterns, even
their biorhythms, to mitigate the impact of drowsiness upon their
missions. These are all important to maintaining wakefulness, because
at the very least, fatigue degrades mission performance. At the very
worst, it kills. In battle, fatigue is a deadly enemy.
We also find we can enhance human performance by enhancing vision.
We do so through corneal refractive surgeries--commonly known as PRK
and LASIK. These procedures are provided to non-flying and non-special
duty airmen. We began offering them after an exhaustive literature
review and extensive expert conference conclusions revealed that the
operations are, indeed, safe, effective, and potentially cost-saving.
In the near future these procedures will be offered to some aviators
and special duty members. We continue to study corneal refractive
surgeries to see what the effects of time or the stresses of the
cockpit--like pressure changes and jarring--have on our flyer's eyes.
The results thus far are highly encouraging. One thing is for sure,
they are very highly desired by our troops.
Good eyesight is, of course, critical to our forces. An enemy who
can temporarily or permanently blind one of our troops will have
succeeded in removing that Airman from combat. One method for
inflicting such an injury is through directed energy, or lasers. In the
little-more-than 40 years since the laser's invention, it has grown
from something found only in a few science labs and an occasional James
Bond movie, to a technology so common that one can find lasers in every
supermarket scanner, in DVD players; and I have even seen them sold as
cat toys. Lasers are also weapons--and are capable of injuring or
destroying eyesight. The proliferation of lasers poses a growing threat
to our pilots and troops.
In response to this challenge, we have created protective eyewear
and faceplates that absorb and deflect laser light. The devices save
our pilots from damaging and potentially permanent eye damage from
these weapons. We continue to study ways to detect the presence of
lasers in battlespace and methods for protecting our men and women
against them.
Another challenge we encounter in enhancing human performance is
our need for ever-increasing amounts of information and communication;
especially that which flows between our EMEDS troops on the ground, our
aeromedical evacuation crews in the air, and our medics in permanent
facilities who receive patients from the area of operations. Our
success at converting any transiting mobility aircraft into an
aeromedical platform outpaced our ability to create the information
systems to track the patients using them. It is difficult to keep
oversight of the location and condition of thousands of patients on a
worldwide scale.
Fortunately, the U.S. Transportation Command Regulating and Command
& Control Evacuation System or TRAC\2\ES [Tray-suhs] is helping us
overcome that challenge. TRAC\2\ES is a DOD information system that
allows us to track the location and status of patients from the moment
they enter the aeromedical evacuation system in the theater of
operations, as they fly to a higher level of care, until they are
safely back in a garrison medical facility.
I have described some of what we learned during current operations
in Iraq, but before closing, I would like to mention a few our
successes here on the home front.
the home front
We are always developing avenues to provide great and cost-
effective care. One way to do so is to seek out partners who share our
dedication to the care of patients and can join us in a better way of
doing business. We continue to strengthen just such a relationship with
our partners at the Department of Veterans Affairs. Of the seven
current Joint Ventures between the DOD and VA, four of them are at Air
Force medical facilities: Elmendorf in Alaska, Travis in California,
Kirtland in New Mexico, and Nellis in Nevada.
These are not the only locations in which the VA and DOD work
together to provide care. We are pursuing several additional Joint
Venture locations and already have nearly 140 sharing agreements
between the Air Force and VA throughout the United States. These are
great examples of partnering with the VA.
We are also developing the exciting possibility of expanding the
traditional concept of Joint Ventures to other major healthcare
institutions. For example, we believe that a unique three-way joint
venture between the DOD, VA and the University of Colorado Hospital
will be a cost-efficient way of caring for all our beneficiaries. This
concept is receiving not only strong support from DOD leadership and
local VA officials, but also all of the Colorado Veterans organizations
and the Colorado state congressional leadership.
next generation tricare contracts
We are passionate about our mission and confident of continued
success, yet there are some uncertainties in the future that warrant
mention. As you know, the DOD is in the process of fielding new
contracts to replace our original TRICARE contracts. This transition is
the focus of a great deal of management attention. Our ability to
smoothly change contractors and governance will be closely watched by
our stakeholders. Not only will there be just three TRICARE regions,
revised financing will be expanded nationwide.
This is a methodology to place the entire costs of a TRICARE
enrollee's care in the hands of the local Medical Group Commander. She
pays the private sector care bills as well being responsible for the
direct care system--that care we provide to our enrollees in our Air
Force clinics and hospitals. Revised financing has proven to be an
effective tool in those regions where it is currently being used. This
is an important advance, leveraging what we've learned in allowing the
Commander to select the most effective and most efficient location for
health care. So, the dollars allocated to the direct care system are
critical, but just as critical are the dollars allocated for revised
financing. With this in mind, two-way flexibility between the private
sector care and direct care accounts is necessary for revised financing
to function successfully. The Air Force appreciates the congressional
intent to protect direct care funding, but we recommend that the Fiscal
Year 2005 Defense Appropriations Act language remove the separate
appropriation for Private Sector Care to allow the flexibility to move
funds to wherever care is delivered without a Prior Approval
reprogramming.
budget
For fiscal year 2004, the Congress's budget adequately funds our
direct care system. However, we do have challenges with the private
sector care budget--the health benefits purchased from civilian
providers for our TRICARE beneficiaries. The TRICARE Management
Activity (TMA), not the Services, manages all of these funds to include
those for Revised Financing.
Two issues will pose significant fiscal challenges as we try to
estimate what our private sector care costs will be.
The first issue is the increased use of TRICARE. TRICARE offers a
very comprehensive benefit. With civilian healthcare plans raising co-
pays and cutting back on benefits, more retirees are dropping their
civilian healthcare and are relying exclusively on TRICARE. As more
people opt for our heath care program, costs for the entire TRICARE
benefit rise. Correctly forecasting this cost is crucially important
and placed pressure on the Department to handle these increases.
In addition to the enhanced TRICARE benefits the Department of
Defense offered to activated Reserve Component members and their
families during fiscal year 2003, the National Defense Authorization
Act of Fiscal Year 2004 included even more new benefits. Because the
new reserve health program is temporary, it offers us the ability to
assess the impact of these benefits after the trial period. We will
review the effects of these programs on reservists and their families
as they transition to and from active duty and look at the overall
effect on retention and readiness. We have concerns that health care
benefits will be enhanced permanently before a full assessment of the
impact can be completed, as well as concerns over the potential cost of
new entitlements for reservists who have not been activated.
Consideration must also be given to the impact on the active duty
force if similar health care benefits are offered to reservists who are
not activated. OMB, DOD and CBO are working together to develop a model
and a resulting five-year cost estimate to price the proposal to expand
TRICARE health benefits for all reservists without regard to
employment, medical coverage, or mobilization status as proposed in the
Reserve and Guard Recruitment and Retention legislation. Preliminary
results indicate that this could range from $6 billion to $14 billion
over five years. Final scoring of this proposal should be completed by
the end of March.
The influx of retirees and their families and of increased Guard
and Reserve beneficiaries have greatly increased private sector care
costs, which DOD will meet with internal reprogramming actions.
These bills are a must-pay, and they affect far more than our
ability to provide the right care at the right place in the most
efficient manner. Care for our military families is not just a medical
issue--readiness is inseparable from family health. It is unmeasurable,
but undeniable, that an Airman's physical and mental fitness to deploy
is tied to the well-being of his or her family. We must provide our
troops piece-of-mind that in their absence their loved ones will have
their social, mental, and health care needs met.
A final challenge we encounter in providing care is that of the
recruitment and retention of our active duty and reserve component
medical professionals, especially physicians, dentists and, nurses. The
civilian health care environment offers significantly more attractive
financial incentives than the Air Force, and we appreciate your support
of recruitment and retention bonuses, special pay programs, and
critical tools such as the Health Professions Scholarship Program and
the Health Professions Loan Repayment Program. These are vital to our
ability to attract qualified professionals and keep them in the Air
Force.
summary
No other military in the world has the expertise, willingness to
devote the resources, or the capabilities of the United States when it
comes to caring for troops and their families, in times of war or in
peace.
One of our medics--a surgeon--just returned from four months in
Baghdad. He was asked, ``What one word sums up your experiences
there?'' He said, ``Satisfied . . . I was caring for people who put
their lives on the line for this country. I know that I made a
difference. That is satisfying.''
It truly is satisfying to make a difference. We do. And we are
proud to bring the special skill of Air Force medics to the service of
our warriors--both present and past--and to their families. I thank you
for your continued support of our medical service and our Air Force. We
are proud to make a difference, and we are anxious to answer the call
again.
Senator Stevens. That was very generous, General, and
deserved. Of course, Senator Inouye and I hate to see such
young men retire.
I do not expect it right now. There is no rush, but when
this pace slows down, I would like the committee to have sort
of a flow chart on how you decided to disperse the wounded from
Afghanistan and Iraq. We have medical facilities in Europe. We
have them in Tripler. We have them in Alaska. We have them
here. And I wonder if we developed a plan to utilize the full
scope of our facilities, given the air transport that is
available today and its worldwide capabilities. But no rush,
just sort of a long-range study to see what we did and see if
there is some way we might help you to do it better for the
interest of the people involved.
I have the impression that the worst cases have come to
Washington. General, is that right? Have the worst cases come
to Bethesda and Walter Reed?
General Peake. Sir, initially that was absolutely the case.
Now as our units are back and the soldiers are flown through,
we regulate them to wherever they need. If it is burn
treatment, they will go to Brook. If the care is available and
they live near or at Fort Hood, they will go to Fort Hood. It
just depends on the level of the severity of their injuries.
Any of our medical centers really can take care of fairly
sophisticated injuries.
What we did was concentrate our amputee care at Walter Reed
because we wanted to have the absolute best. It really started
with Afghanistan, which was the most heavily mined area in the
world, and we therefore anticipated the potential for having
amputees. So we married up with the Veterans Administration
(VA) and all the smart people that we could find and focused
that as an area of a center of excellence.
Senator Stevens. Well, it is my impression that because of
body armor and better helmets, we are having more real serious
injury to the limbs of our service men and women. Is that
observation correct?
General Peake. Sir, I think that is correct. Really as the
article talked about yesterday that Senator Leahy mentioned,
what we are seeing are folks with bad extremity injuries and
head and neck injuries who otherwise would not have made it to
us because their thorax would have been injured as well. Now
they are making it through to the definitive care for their
amputees.
Senator Stevens. Has the surge to Bethesda and Walter Reed
been such that it has required reallocation of funds?
General Peake. Sir, we have put a lot of money into the
amputee center specifically to get that ginned up. This c-leg
that was referred to can cost anywhere from $80,000 to $100,000
for a single limb, but that is what we are doing. It is the
right thing to do and we will continue to do that. Truly we
have been augmented with GWOT funds, global war on terrorism
funds, out of the supplemental last year because these are
operational issues not programmed issues. In fact, I am
anticipating getting another $244 million this year from
somewhere in DOD to be able to--because that is what we are
spending--prosecute the medical aspects of the global war on
terrorism.
Senator Stevens. Are the facilities that we were able to
put into Ballad modern enough and capable enough to take a
substantial part of this surge?
General Peake. Sir, we have modular combat support
hospitals in Ballad, in Baghdad. In Ballad, they are in
basically deployable medical system (DEPMEDS) facilities. In
Baghdad, we have moved them into one of Saddam Hussein's old
hospitals. We have them in DEPMEDS facilities at Mosul and
Tikrit, as well as what we have down in Kuwait. So we have
created a system----
Senator Stevens. I do not want to belabor this. Sometime I
would like to pursue it and see what the schedule is and how
that flow was from those facilities into more permanent
treatment facilities and how quickly these people got back near
their homes.
We had understood that the facilities in the Washington
area have started to limit new beneficiaries. Are new enrollees
now being turned away? I am not talking about people coming
back from the war zone, just new enrollees of people who are
eligible for treatment.
General Peake. Sir, we have limited enrollment in the
military treatment facilities with capacity. What you want to
be able to do is appropriately treat the people that you have
enrolled and give them that care. They can still enroll in
TRICARE within the civilian part, the contractor part of the
managed care system under TRICARE Prime.
Senator Stevens. These are primarily retirees.
General Peake. Yes, sir.
Senator Stevens. Is that part of the problem of taking care
of the increased surge from the war zones?
General Peake. No, sir. It is not part of that.
Senator Stevens. It is a limitation of the facilities
themselves to take on the new retirees?
General Peake. It is the facilities and the staffing and so
forth.
Senator Stevens. And TRICARE for Life.
General Peake. Right, sir.
We have an increase in unique users across our system. If
you look at our retirees, just the retirees over and under 65,
from 2000 to now, it is about a 60 percent increase in retirees
of unique users.
Senator Stevens. I will move on to my co-chairman, but this
committee was critical of the number of hospitals that were
closed in the last base closure round and urged that some of
them be maintained as satellites for other military health
facilities. Are you considering reopening any?
General Peake. Sir, our manpower came down 34.5 percent in
the Army from 1989. So you have to be able to staff a hospital
to run it. It is really the people not just the facilities.
Senator Stevens. I will get into that later.
Senator Inouye.
Senator Inouye. Thank you.
NON-COMBAT INJURIES
General Taylor just reminded me of an article I read a few
weeks ago that more men in the Revolutionary and Civil Wars
died as a result of dysentery, more than bullets. What
percentage of the personnel who are now being hospitalized are
hospitalized for non-combatant injuries?
General Taylor. Do you know the percentage? The only number
I can give you is the idea of the people that we moved through
the aeromedical evacuation system. Of the 15,000 or so people
we moved from the air evacuation system this last year, between
3,000 and 4,000 were for battle injuries. The rest were for
disease non-battle injuries. That gives you some estimate. It
is probably somewhere on the order of one-quarter to one-third
are actually due to battle injuries. The rest are disease non-
battle injury (DNBI) rates.
The interesting part, as General Peake said, is the chance
of dying in theater is much less than historically we have ever
had, and Jim probably has the statistics on that to tell you,
if you are injured in battle, if you make it to a medic, what
your chances of surviving are. Jim, do you want to add to that?
General Peake. Sir, our killed in action (KIA) rate is
about 13 percent. If you look at the theater of operation in
Iraq, it is what the KIA rate is, compared to about 20 percent
as what we have run historically from a KIA rate.
But you are right, sir, about the importance of DNBI and
our preventive medicine measures. We actively review that and
pursue it. I will give you an example of having to do with eye
injuries. Our chief in his rapid fielding initiative for our
soldiers insisted that every soldier get the Wiley X protective
glasses. I have had two e-mails from the field now talking
about how our eye injury rates have dropped down. We had
studied our injuries coming back and had 99 serious eye
injuries just because of lack of ballistic protection for the
eyes. That has changed dramatically and part of it is because
we have got leaders like Pete Chiarelli as the 1st Cavalry
(Cav) commander who said we will wear the eye protection. That
is one of your checkpoints as you go out on patrol. So those
kinds of things are important.
But if you think about the population we have got over
there, it is 150,000 people, and so people get sick. People
have routine injuries. There are motor vehicle accidents. When
you burn the latrines, you have people that get burned in
fires. Those kinds of things are part of what we are seeing and
we wind up taking care of all of that as it comes back through
our system.
Admiral Cowan. Sir, if I could add to that. We used to
accept DNBI as sort of, well, that is just the way it is, and
we do not anymore. So our efforts are very aggressively aimed
at making it no more dangerous and no more likely to become
sick or injured when deployed than if you were at home.
It does not just start when we deploy. Our attention to the
health and the fitness to include the flexibility, endurance,
social stability, family stability of each of our individuals
to help them go be those sticky soldiers and sailors and airmen
that will stay in the field and have the capability to do so.
So that is very much the thrust of force health protection, to
drive those DNBI's down. Part of it is putting healthy people
out there that are likely to survive.
Senator Inouye. Do we have enough research money to look
into this matter?
Admiral Cowan. I would say that there are always more
projects that could be done. I think the money that we have now
has allowed us to focus on near to midterm research development
and ultimately acquisition that gets to the issues that we know
to be the most important. There are others out there that more
resources would allow us to get to and probably concentric
circles of greater research risk. So no absolute money would be
enough or too much.
PROTECTIVE BODY ARMOR RESEARCH
Senator Inouye. I would like to follow up on the chairman's
questioning. We have been advised that additional research is
now being done to develop protective body armor for extremities
and for the head. Can you give us any status report on that?
General Peake. Sir, I have had the program manager for the
helmet project over in the office and married him up with our
head and neck consultant so that we could evaluate the kinds of
injuries that we are actually seeing with what he is projecting
for the next generation of combat helmets. Already we have
improved the helmet from what we had even in Desert Shield/
Desert Storm with better protection inside and better ballistic
protection from rounds. So we are marrying them up.
One of the discussion points is what kind of face
protection that we could have because we have folks standing
outside the hatches when they are on patrol as an example. So
the medics are not the primary developers of the body armor,
but we are actively collaborating.
The Armed Forces Institute of Pathology is analyzing the
body armor that comes back to understand where the
vulnerabilities are. We know already that the axilla is an area
where it can be penetrated. It saves you from a front-on hit,
but it can come through the side as an example. So they are
looking at ways to modify and increase the protection for
soldiers in that regard.
Admiral Cowan. Sir, we have a combat registry that was
initiated by the Army--and all services use it now--that allows
us to track, in a statistical way, patterns of wounding. For
example, we are finding with improvised explosive devices that
the Iraqis are using at the roadside, that our soldiers get
blasts from above. A helmet does not help. They get eye
injuries. So General Peake alluded to the glasses.
We are also finding now that the trunk and the thorax is
protected. We are seeing lots of people with shoulder injuries.
So now the researchers are looking into putting a protective
pad on the shoulder. So the nature of the combat and the nature
of the vehicles people are in matter, but now we can track that
and be responsive like we could not in the past.
Senator Inouye. I realize that it is part of the policy of
our Defense Department to make certain that every person in
uniform carries his or her load. In the medical personnel,
there are some who are extremely specialized and trained. For
example, we have sent surgeons to Iraq who are some of the
finest in the land when it comes to knee, shoulder, or hip
replacement. I do not suppose they have any hip replacement or
knee replacement in Iraq. Why do we have to keep them there for
6 months?
General Peake. Sir, right now they are potentially there
for 1 year for the Army, and what we are trying to do is have
them there for 6 months. We have been rotating our reservists
at 90 days and we think that that is going to allow them to
stay in the Reserves. We are actively--as a matter of fact, I
have got the program on my desk now to carry forward, and I
have talked to some of the leadership in theater about being
able to rotate our folks out. I could run down the list. Jack
Chiles, who is the Deputy Commander at Baghdad, is one of our
premier anesthesiologists. We have subspecialists over there
because really that is why we have them in the Army is so that
we can have the kind of quality forward deployed. But what we
want to do is get them back so that they can maintain their
skills and be used effectively and efficiently in the long run.
But it is an issue of being very, very busy as an Army and
everybody counts for being able to go forward and take care of
those soldiers. So I absolutely appreciate what you are saying.
I know many of the folks that you are talking about personally
and we intend to carry this forward for the active guys to
rotate those specialties at 6 months. As I say, with the
reservists we are sticking to the 90 days because we think that
is what it is going to take to keep them in the Reserves.
Senator Inouye. My time has expired. I will wait until my
turn comes up again.
Senator Stevens. Senator Leahy, you are recognized for 5
minutes.
Senator Leahy. Thank you, Mr. Chairman. I have watched
these 5-minute clocks here for the last 20 minutes, but I will
try to stay somewhat close to it.
General Peake, in one of your answers to the question about
the increase in injuries based on the different type of
fighting, are we seeing an increase in blindness, blinding
injuries?
General Peake. Sir, we saw some very serious eye injuries
and that is why we have put this focus on the eye protection.
So we are seeing a drop-off now. We will analyze it to see if
it has really made that huge a difference.
Senator Leahy. Please do because I get episodic stories on
that. We can replace an arm. We can replace a leg. And I do not
say that in a cavalier fashion by any means. It is still a
difficulty, but it is not as devastating by any means to a
person continuing with their life as blindness is.
I heard your discussion of the--I have kind of watched
that. We actually put together one of the newer, lighter
helmets in Newport, Vermont. They are working around the clock.
I have tried on the old helmet and the new one and there is a
remarkable difference in the weight. They are both pretty
heavy.
General Peake. Yes, sir.
Senator Leahy. But it is a big difference.
I read that New York Times article on the incidence of
post-traumatic stress disorder, this Coming Home article. It
was troubling in the sense not that there is post-traumatic
stress disorder. All three of you have had far more experience
in this than I. You know this happens in our soldiers, our
sailors, our airmen, marines. Hundreds, if not thousands, of
these people are seeing horrific things that they have never
really been prepared for prior to going there, including men
and women who see their own fellow Americans killed before
their eyes.
But the article goes into the question, do we really have
the things set in place to take care of them when they come
back here? It said that a number of them are not identifying
it, even though they feel they have these symptoms of post-
traumatic stress disorder, because they are afraid it will look
bad on their service records so they are not getting whatever
counseling they might get. If they stay in the service, they
have problems of having this untreated. If they go into
civilian life, again the same thing. They have the problem of
being untreated.
Do we have provisions to really treat this? Do we have
provisions to give the counseling, to do the identifying of it,
number one; treat it, number two, and with useful numbers of
our armed services at work trying to retain them and their
skills in our services?
General Peake. Well, sir, there are a lot of pieces to
this.
Senator Leahy. I understand.
General Peake. I think we have and are addressing it
aggressively. I will speak for the Army particularly because we
have had the biggest bulk of folks on the ground facing those
things recently.
This post-deployment screening is more than just checking
off a piece of paper or a computer chip and sending it in. It
entails a face-to-face discussion with a provider who has a
sensitivity to those kinds of things. You are right, sir, that
some people may or may not report at that point.
We have concern about the stigma that goes with an approach
to mental health providers, and so the Army has invested in
having what we call the Army One Source which offers up to six
visits without any link to the military at all, like a civilian
commercial establishment or industry might do. They can pick up
a telephone and get an immediate contact and get into those six
visits.
We have really tried to push to get our combat stress units
integrated out into the units so that they get to know people.
So they are less threatening and they are a part of the team
using sort of the chaplain's model, if you will, because we
want to make that kind of thing accessible.
Senator Leahy. You mentioned the pre- and post-deployment
questionnaires they fill out and I have seen those. I had
raised the same concern about 10 years ago. Do we have a
tracking system? Do we know how to follow this? Do we have
things that, as we go through the periodic health baselines--
they report to a physician when they are in Iraq or
Afghanistan, wherever for something. I do not know what we have
that can show this baseline from beginning to end to, among
other things, have it so readily available even without the
individual names, but quantitatively and qualitatively
throughout the military so that you get an indication of we are
having far more of these, far less of these. It would certainly
be helpful to other parts of the Government, the VA, for
example. It would be very helpful to them, far easier to assess
disability claims that often come up, reliable data for
epidemiological studies later on. But we do not have something
that can really do that, do we, General?
General Peake. Sir, we are heading in that direction. We do
not have.
Senator Leahy. What can we do to help you head a little
faster?
General Peake. Well, we are in the process of trying to
field what we call CHSCII which is basically a computerized
patient record across all three services over the next 30
months. This post-deployment screening is actually going into a
centralized database so that we can query those fields, and
that would be available to the VA as well.
Senator Leahy. But suppose you have, say, a Sergeant Peake
out there who has 2 or 3 years in there, been deployed
different places, to have some way that wherever they are, they
could immediately go back and see Sergeant Peake--I do not mean
to pick on you by any means, but it would be, okay, they were
at Fort Benning and this is what was done. They were in
Afghanistan. This was done. We moved him to Iraq and this was
done. Now we have him at Fort Hood and this was done, but be
able to pull up immediately and know now that you are at Fort
Hood, you are being treated, for them to be able to tell
immediately without having to go through all kinds of
paperwork, to be able to say, okay, this is what happened to
the sergeant in each of these other places. But we do not have
that, do we?
General Peake. Sir, that is what I am saying. In Mobile,
Alabama, we will have a central database that really has a
virtual record, electronic record, for each soldier, sailor,
airmen, and marine. And that is what we will have by the end of
30 months.
Senator Leahy. The reason I mention this, General, you
would get strong support as far as the money is concerned from
both Republicans and Democrats on this committee because we
have to continuously make decisions on where is the money going
to the VA, where is the money going to go whether it is what
Admiral Cowan or General Taylor or anybody else asks us for,
where is the money coming from if we have to make choices. The
only way you can make choices is with the best information, and
if the disease is not malaria or whatever else, but they are
post-traumatic stress syndrome, if it is eye injuries, if it is
stress fractures, or whatever it might be, we can put the money
in there. We could also put the designing of equipment. We can
do everything else.
So I would urge you to keep that as a real priority so that
we not only can track the individual person but that we could
have collectively, whether it is for the VA or for anything
else, we can do that. And also when somebody comes in with a
disability claim years later, we can actually track and know
exactly what happened.
I know I went over, Mr. Chairman, but I know this is
something you are interested in too. I just really want to
stress to them that it is a matter that we are all concerned
with.
Senator Stevens. Thank you very much, Senator.
We do want to move on to the next panel, but I want to give
us each about 3 or 4 minutes for a second round.
MEDICAL RESEARCH
Let me just make a statement to all of you. In the past
bills, we have had a continual increase in medical research
funding. We have had money for neurofibrosis, diabetes,
juvenile diabetes, ovarian cancer, breast cancer, prostate
cancer, leukemia and other blood related cancers, tuberous
sclerosis, and manganese health research, head and brain
injuries, molecular medicine, muscle research. We had about
three-quarters of a billion dollars earmarked last year.
I want you to take a look at that and tell us what of that
is related to your current problems related to the war. I think
we must emphasize war research in this. These people deserve
the best and we have got to do everything we can to improve the
type of treatment we can give them. I am not saying I am going
to recommend we cut them out entirely, but I am going to
recommend we reduce the research for non-war-related injuries
and concentrate for this year that money in fiscal year 2005 on
the real problem of trying to deal with this massive increase
in these injuries.
I do not know if the committee is going to agree with me or
not because there are enormous groups behind all those other
concepts, but I do believe that we should emphasize the
research for the basic people that need the treatment now.
Those other research concepts are going on year after year
after year. These people need help now. So we are going to try
to concentrate on that if we can.
MEDICAL AND DENTAL SCREENING
Other than that, let me ask you this. We enacted
legislation to make medical and dental screening, as well as
access to TRICARE available to service members once they are
alerted for active duty. How is that working out? Is it
possible to do anything more? The former service reservists
have told us that post-deployment medical screening has been
improved, but it falls short of identifying the care that
returning soldiers need. Those two things, upon being called up
and released. What needs to be done? General?
General Peake. Well, sir, I think the opportunity to get
them screened and to provide the care to bring them up to
deployable standards before they are activated is important. It
keeps us from wasting time at mob stations and that kind of
thing. What we need to discipline ourselves better on--and I
think we are really pushing in that direction--is to be able to
have that data available to commanders so they know who needs
what and insist that they maintain the appropriate standard.
In regards to the soldiers coming back, this post-
deployment screening that I referred to makes sure that we
identify at least what they will declare to us, but then they
have the opportunity for VA care for 2 years for service-
connected issues, as well as the opportunity to be in TRICARE
for, right now, up to 180 days after their separation. So we
are very interested in trying to make sure that they do get the
kind of care that they need and the process is in place to do
that.
Senator Stevens. Admiral.
Admiral Cowan. I would echo, sir, what General Peake said.
There are lots of pushups that have to be done to get some of
the reservists ready when they come in, but we have not had
major difficulties doing that to get them up to a level of
deployment health that they need to be able to go.
We believe that the policies for the screening, the post-
and pre-deployment, the annual health assessment that we do are
about right, and any failures on individual cases would be
failures of execution that we work through on a daily basis to
be as seamless as we can.
Senator Stevens. Thank you.
General Taylor.
General Taylor. The Air Force relies heavily on our Reserve
component, and over the last 5 years, from the air war over
Serbia to today, we have constantly had to activate Guard and
Reserves to help us. So our system is built on a fairly strong
program during peacetime to ensure folks are ready to deploy.
So we have had less of a problem on activation.
I think it is an extremely generous benefit from the
Congress to ensure that we can have access to health care upon
notification of orders, and then the 180 days afterwards
becomes very important to us.
Also in the Air Force, we have run a system that requires
the Assistant Secretary of the Air Force to sign off on any
medical mobilization extensions, which puts a driving force on
us medics to make sure we are taking care of our people as
quickly as possible.
So the combination of those two have made our numbers of
folks that have had issues smaller. Very clearly, we have not
had the kind of catastrophic injuries that the marines and the
soldiers have had over the last year.
Senator Stevens. Thank you.
I am going to put in the record Karl Vick's Washington Post
report of the lasting wounds of this war that was in the
Washington Post on April 27. I will put it in the record at
this point.
[The article follows:]
[From The Washington Post, April 27, 2004]
The Lasting Wounds of War; Roadside Bombs Have Devastated Troops and
Doctors Who Treat Them
(Karl Vick, Washington Post Foreign Service)
The soldiers were lifted into the helicopters under a moonless sky,
their bandaged heads grossly swollen by trauma, their forms silhouetted
by the glow from the row of medical monitors laid out across their
bodies, from ankle to neck.
An orange screen atop the feet registered blood pressure and heart
rate. The blue screen at the knees announced the level of postoperative
pressure on the brain. On the stomach, a small gray readout recorded
the level of medicine pumping into the body. And the slender plastic
box atop the chest signaled that a respirator still breathed for the
lungs under it.
At the door to the busiest hospital in Iraq, a wiry doctor bent
over the worst-looking case, an Army gunner with coarse stitches
holding his scalp together and a bolt protruding from the top of his
head. Lt. Col. Jeff Poffenbarger checked a number on the blue screen,
announced it dangerously high and quickly pushed a clear liquid through
a syringe into the gunner's bloodstream. The number fell like a rock.
``We're just preparing for something a brain-injured person should
not do two days out, which is travel to Germany,'' the neurologist
said. He smiled grimly and started toward the UH-60 Black Hawk thwump-
thwumping out on the helipad, waiting to spirit out of Iraq one more of
the hundreds of Americans wounded here this month.
While attention remains riveted on the rising count of Americans
killed in action--more than 100 so far in April--doctors at the main
combat support hospital in Iraq are reeling from a stream of young
soldiers with wounds so devastating that they probably would have been
fatal in any previous war.
More and more in Iraq, combat surgeons say, the wounds involve
severe damage to the head and eyes--injuries that leave soldiers brain
damaged or blind, or both, and the doctors who see them first
struggling against despair.
For months the gravest wounds have been caused by roadside bombs--
improvised explosives that negate the protection of Kevlar helmets by
blowing shrapnel and dirt upward into the face. In addition, firefights
with guerrillas have surged recently, causing a sharp rise in gunshot
wounds to the only vital area not protected by body armor.
The neurosurgeons at the 31st Combat Support Hospital measure the
damage in the number of skulls they remove to get to the injured brain
inside, a procedure known as a craniotomy. ``We've done more in eight
weeks than the previous neurosurgery team did in eight months,''
Poffenbarger said. ``So there's been a change in the intensity level of
the war.''
Numbers tell part of the story. So far in April, more than 900
soldiers and Marines have been wounded in Iraq, more than twice the
number wounded in October, the previous high. With the tally still
climbing, this month's injuries account for about a quarter of the
3,864 U.S. servicemen and women listed as wounded in action since the
March 2003 invasion.
About half the wounded troops have suffered injuries light enough
that they were able to return to duty after treatment, according to the
Pentagon.
The others arrive on stretchers at the hospitals operated by the
31st CSH. ``These injuries,'' said Lt. Col. Stephen M. Smith, executive
officer of the Baghdad facility, ``are horrific.''
By design, the Baghdad hospital sees the worst. Unlike its sister
hospital on a sprawling air base located in Balad, north of the
capital, the staff of 300 in Baghdad includes the only ophthalmology
and neurology surgical teams in Iraq, so if a victim has damage to the
head, the medevac sets out for the facility here, located in the
heavily fortified coalition headquarters known as the Green Zone.
Once there, doctors scramble. A patient might remain in the combat
hospital for only six hours. The goal is lightning-swift, expert
treatment, followed as quickly as possible by transfer to the military
hospital in Landstuhl, Germany.
While waiting for what one senior officer wearily calls ``the
flippin' helicopters,'' the Baghdad medical staff studies photos of
wounds they used to see once or twice in a military campaign but now
treat every day. And they struggle with the implications of a system
that can move a wounded soldier from a booby-trapped roadside to an
operating room in less than an hour.
``We're saving more people than should be saved, probably,'' Lt.
Col. Robert Carroll said. ``We're saving severely injured people. Legs.
Eyes. Part of the brain.''
Carroll, an eye surgeon from Waynesville, Mo., sat at his desk
during a rare slow night last Wednesday and called up a digital photo
on his laptop computer. The image was of a brain opened for surgery
earlier that day, the skull neatly lifted away, most of the organ
healthy and pink. But a thumb-sized section behind the ear was gray.
``See all that dark stuff? That's dead brain,'' he said. ``That
ain't gonna regenerate. And that's not uncommon. That's really not
uncommon. We do craniotomies on average, lately, of one a day.''
``We can save you,'' the surgeon said. ``You might not be what you
were.''
Accurate statistics are not yet available on recovery from this new
round of battlefield brain injuries, an obstacle that frustrates combat
surgeons. But judging by medical literature and surgeons' experience
with their own patients, ``three or four months from now 50 to 60
percent will be functional and doing things,'' said Maj. Richard
Gullick.
``Functional,'' he said, means ``up and around, but with pretty
significant disabilities,'' including paralysis.
The remaining 40 percent to 50 percent of patients include those
whom the surgeons send to Europe, and on to the United States, with no
prospect of regaining consciousness. The practice, subject to review
after gathering feedback from families, assumes that loved ones will
find value in holding the soldier's hand before confronting the
decision to remove life support.
``I'm actually glad I'm here and not at home, tending to all the
social issues with all these broken soldiers,'' Carroll said.
But the toll on the combat medical staff is itself acute, and
unrelenting.
In a comprehensive Army survey of troop morale across Iraq, taken
in September, the unit with the lowest spirits was the one that ran the
combat hospitals until the 31st arrived in late January. The three
months since then have been substantially more intense.
``We've all reached our saturation for drama trauma,'' said Maj.
Greg Kidwell, head nurse in the emergency room.
On April 4, the hospital received 36 wounded in four hours. A U.S.
patrol in Baghdad's Sadr City slum was ambushed at dusk, and the battle
for the Shiite Muslim neighborhood lasted most of the night. The event
qualified as a ``mass casualty,'' defined as more casualties than can
be accommodated by the 10 trauma beds in the emergency room.
``I'd never really seen a `mass cal' before April 4,'' said Lt.
Col. John Xenos, an orthopedic surgeon from Fairfax. ``And it just kept
coming and coming. I think that week we had three or four mass cals.''
The ambush heralded a wave of attacks by a Shiite militia across
southern Iraq. The next morning, another front erupted when Marines
cordoned off Fallujah, a restive, largely Sunni city west of Baghdad.
The engagements there led to record casualties.
``Intellectually, you tell yourself you're prepared,'' said
Gullick, from San Antonio. ``You do the reading. You study the slides.
But being here . . ..'' His voice trailed off.
``It's just the sheer volume.''
In part, the surge in casualties reflects more frequent firefights
after a year in which roadside bombings made up the bulk of attacks on
U.S. forces. At the same time, insurgents began planting improvised
explosive devices (IEDs) in what one officer called ``ridiculous
numbers.''
The improvised bombs are extraordinarily destructive. Typically
fashioned from artillery shells, they may be packed with such debris as
broken glass, nails, sometimes even gravel. They're detonated by remote
control as a Humvee or truck passes by, and they explode upward.
To protect against the blasts, the U.S. military has wrapped many
of its vehicles in armor. When Xenos, the orthopedist, treats limbs
shredded by an IED blast, it is usually ``an elbow stuck out of a
window, or an arm.''
Troops wear armor as well, providing protection that Gullick called
``orders of magnitude from what we've had before. But it just shifts
the injury pattern from a lot of abdominal injuries to extremity and
head and face wounds.''
The Army gunner whom Poffenbarger was preparing for the flight to
Germany had his skull pierced by four 155 mm shells, rigged to detonate
one after another in what soldiers call a ``daisy chain.'' The shrapnel
took a fortunate route through his brain, however, and ``when all is
said and done, he should be independent. . . . He'll have speech,
cognition, vision.''
On a nearby stretcher, Staff Sgt. Rene Fernandez struggled to see
from eyes bruised nearly shut.
``We were clearing the area and an IED went off,'' he said,
describing an incident outside the western city of Ramadi where his
unit was patrolling on foot.
The Houston native counted himself lucky, escaping with a
concussion and the temporary damage to his open, friendly face. Waiting
for his own hop to the hospital plane headed north, he said what most
soldiers tell surgeons: What he most wanted was to return to his unit.
Senator Stevens. Senator Inouye.
Senator Inouye. Thank you very much.
MEDICAL PERSONNEL SHORTAGES
According to information we have received, the Army Reserve
had 3,000 physicians in 1991 and today they are 1,550. The
Naval Reserve went from 2,191 in 1900 to 1,000 today. The Air
Force currently has 761 physicians.
We have been advised that the Air Force is short on
dentists, nurses, occupational therapists, and is relying on
incentive pay and ongoing initiatives for school loan repayment
options for recruiting and retention. The Army is short on
nurse anesthetists, general surgeons, anesthesiologists,
neurosurgeons. The Navy is short on nurses and dental corps
personnel.
I realize that we will not have the time today, but can you
advise this committee as to what you are doing about this or
what can be done and what can be done by this committee? If you
could, please provide us a brief response.
Admiral Cowan. Sir, we will respond to that in more detail
in the immediate future.
Part of the reduction of reservists for the Navy is an
intentional part of the transformation of the Navy because we
use our reservists in different ways. Part of the cuts in
Reserves were actually cuts of billets not people. They were
billets that we could not match the skill next to. We now use
our Reserves as more of an integrated force than in the past.
So the degree of risk that we may be running with our Reserve
assets is only perhaps marginally larger or the same as it was
before.
That being said, we do have ongoing difficulties with
shortages in specific areas, and I will provide you information
on the programs that we are working to improve those.
[The information follows:]
The Medical Corps currently has shortages in anesthesiology,
surgery, urology, neurosurgery and radiology. The Medical Corps
primarily uses the Health Professions Scholarship Program and the
Uniformed Services University of the Health Sciences, as it's primary
accession pipeline. Students are recruited for these programs and then
get into specialties based on the Navy's need and the availability of
training positions. Another method to increase the number of critical
shortage specialists is the use of fellowship training to entice
specialists in critical areas to remain on active duty. In addition, a
new training program in radiology at Naval Medical Center Portsmouth,
Virginia was opened in 2003, which will increase the number of
graduating radiologists per year from in service training programs.
The Nurse Corps continues to focus on a blend of initiatives to
enhance our recruitment and retention efforts, such as:
--Diversified accession sources, which also include pipeline
scholarship programs (Nurse Candidate Program, Naval Reserve
Officer Training Corps, Medical Enlisted Commissioning Program,
and Seaman to Admiral Program).
--Pay incentives (Nurse Accession Bonus, Certified Registered Nurse
Anesthetist Incentive Special Pay, and Board Certification
Pay).
--Graduate education and training programs, which focus on Master's
Programs, Doctoral Degrees, and fellowships. Between 72-80
officers/year receive full-time scholarships based on
operational and nursing specialty requirements.
--Successful recruiting incentives for reservists in critical wartime
specialties include: the accession bonus and stipend program
for graduate education.
The Medical Service Corps is comprised of 32 different health care
specialties in administrative, clinical and scientific fields. The
educational requirements are unique for each field; most require
graduate level degrees, many at the doctoral level. End of fiscal year
2003 manning was at 98.2 percent, however, difficulties remain in
retaining highly skilled officers in a variety of clinical and
scientific professions. Entomology and Physiology are currently
undermanned by more than 10 percent. Entomology has not met direct
accession goals since fiscal year 1999 and Physiology has not met
direct accession goals since fiscal year 1998. Use of the Health
Services Collegiate Program (HSCP), a Navy student pipeline program,
was instituted for the Entomology community in fiscal year 2002 and for
the Physiology community in fiscal year 2003. The use of HSCP for these
communities seems to be an effective means to achieve the accession
goals for these communities.
The Dental Corps currently have their greatest shortages in general
military dentists; endodontists (root canal specialists); Oral and
Maxillo-Facial Surgeons and prosthodontists. The Dental Corps uses the
Health Professions Scholarship Program (HPSP) as it's primary accession
pipeline. Dental students are recruited for these programs and then get
into specialties based on the Navy's need and the availability of
training positions. At the present time, recent graduates are being
deferred for residency training in these shortage areas on a case-by-
case review.
General Peake. Sir, I mentioned the 90-day rotations to be
able to enable dentists, nurse anesthetists, and physicians to
be able to be away from their practice a reasonable period and
still be able to be incorporated back into that practice when
they get there. Even with that 90 days, it is stressful. I have
had one say, well, I can do 90 days, but I cannot do 90 days
every year, that kind of notion. So the OPTEMPO is part of it.
I think we are about to restructure our Reserves so that we
have a United States Army Reserve medical command that will
allow us to focus the management of all of those critical
assets in a more homogeneous way. So there is a restructuring
initiative that is going on.
The other aspects of it are on the active side, and so we
have to keep a close eye on that, given the OPTEMPO and
PERSTEMPO as well. So I think the issue of restructuring our
bonuses is important and we need to be able to look forward to
getting that updated because we have not really updated it in a
while.
General Taylor. We will respond in more detail to you,
Senator.
I also think for the reservists in particular it is
difficult in today's medical practice. Many of the providers
operate very close to the margin. So taking them out for long
periods of time oftentimes can destroy a practice.
So all of us--and you heard from General Peake--are trying
to work ways where we can bring them on active duty for short
periods of times, particularly through a volunteer system, so
they could support perhaps 30 days every couple of years. So we
are all actively trying to work ways of doing that. We have
been aggressively trying to do that so that it counts as 2
years' worth of points and 1 year, one 30-day activation. So we
are working real hard to do that.
Certainly pay and environment of care is an important
aspect, as well as trying to make continued service in the
Guard and Reserve for our folks who elect to leave active duty
an important piece of a smooth transition from being on active
duty status. We are hoping to be able to gather more folks up
to serve in these critical positions in the Guard and Reserve.
We have not seen a radical drop in physicians in particular
within the Guard and Reserves, but it is very troublesome
seeing how much we used them in the last couple of years.
RECRUITING AND RETENTION
Senator Inouye. There are certain statistics we watch very
carefully. One, obviously, is recruiting and retention of
active duty medical personnel. Are we in good shape?
General Peake. Sir, we are in the Army on the Health
Professions Scholarship Program (HPSP), of course, with the
Uniformed Services University of the Health Sciences (USUHS),
but really in the larger extent it is our health professional
scholarship programs. Those costs have increased significantly
to the point where I had to look into other sources of funds
other than what we had programmed just because the tuition
costs have gone up so much as we put people out into civilian
training, which is tremendously important for us. That is
really our best recruiting tool.
I know Debbie Gustke will talk more about nursing in the
next panel, the kinds of things that we are doing to try to
encourage nurses to join our Army as well.
I think what General Taylor talked about in terms of
environment of care is terribly important. We have to have a
quality system and the kind of quality places for them to come
in and practice. Otherwise, they really will not want to be a
part of a second-rate organization. So we have got to keep that
first-rate.
Senator Inouye. Thank you, Mr. Chairman.
Senator Stevens. Well, we would like to pursue that
conversation with you and your successors. I know some medical
people up my way who would welcome a chance to have a quarter
of 1 year away from their practice and to have some different
surroundings. If they had a commitment that they would not be
yanked out for 1 year later, they might make that commitment.
We need to devise some innovative programs to give particularly
these young doctors who get stuck in some place and they do not
get a chance to travel. It will give them a chance to get
involved and be active duty for 2 months a year or something
like that and give them a commitment they will not be called up
for longer in a certain period, whatever it is, and have some
bonuses involved in that training. It might be easier to do
that than to get more scholarships and whatnot, to get more
people who really end up by not being available anyway after
they have left the service.
We want to thank you again. General Peake and Admiral
Cowan, we have enjoyed your participation in our process here
and we respect your commitment to your military service and
your medical profession. So we wish you well.
General Taylor, you will be over at the left-hand side of
the table next year. So we will look forward to that. I
remember when I was sitting down at the end of this table once
when an old friend of mine, who was the chairman--I had known
him years before--he called me over and he said, do you know
how much seat time you are going to have to log to get to sit
where I am sitting?
So cheer up. You moved very quickly.
We will proceed to the nursing now and hear from the Chiefs
of the service nursing corps. We thank you very much, Admiral
and Generals.
Your nursing corps is vital to the success of our military
medical system as any part of it. We thank you for your
leadership and we look forward to hearing from you. We welcome
you again. We are going to hear from Colonel Deborah Gustke,
the Assistant Chief of Army Nurse Corps. We welcome Admiral
Nancy Lescavage, Director of the Navy Nurse Corps, and from the
Air Force, we have General Barbara Brannon, Assistant Surgeon
General for Nursing. We welcome you all back warmly. None of
you are leaving us this year, are you?
Colonel Gustke. Yes, sir.
Senator Stevens. I yield to my good friend and co-chairman.
Senator Inouye. I would like to join you in congratulating
and thanking all of the nurses here.
Major General Brannon, I believe you are the first to be a
major general.
General Brannon. I am, sir, in the Air Force.
Senator Inouye. Congratulations.
General Brannon. Thank you for the great honor. It is very
humbling.
Senator Inouye. Let us hope that you are the first of many.
I am especially proud to see Admiral Lescavage here. I have
special pride in that she served on my staff for a while as a
fellow.
We will hear from Colonel Gustke. Some day, if you stick
around, you will have a star as well.
I understand that the Army has been operating without a
Nurse Corps chief since General Bester retired. I understand
that you will also be retiring.
Colonel Gustke. Yes, sir.
Senator Inouye. Don't you want to wait until you receive
your star?
Seriously, I would like to thank you for your many years of
service to our Nation. Thank you so much.
Colonel Gustke. Thank you, sir.
Senator Stevens. Thank you all. Your statements will appear
in the record in full. We will look forward to your comments.
Colonel, we call on you first.
STATEMENT OF COLONEL DEBORAH A. GUSTKE, ASSISTANT
CHIEF, ARMY NURSE CORPS
Colonel Gustke. Mr. Chairman and distinguished members of
the committee, thank you for the opportunity to update you on
the Army Nurse Corps.
As of April 2004, we have deployed over 814 Army nurses to
places such as Afghanistan and Iraq, serving as members of
forward surgical teams in support of our deployed divisions,
and as staff within our 31st Combat Support Hospital, 67th
Combat Support Hospital, and 325th U.S. Army Reserve Field
Hospital.
We have numerous Reserve nurses who are serving in back-
fill roles in our medical treatment facilities. Furthermore,
158 Reserve and National Guard nurses are serving as case
managers at the regional medical commands, mobilization sites,
and at the community-based health care initiatives which were
established to provide medical holdover management for soldiers
impacted deployment.
We have a very strong focus on reintegration of our
personnel once they return home and are continuing to assess
whether the rapid deployment tempo is impacting retention. I am
pleased to tell you that last year in fiscal year 2003 we
experienced the lowest attrition rate in the past 5 years. We
continue to collect data from Army nurses and the reasons for
attrition have remained constant over the last few years
without any new emerging trends.
At home we continue to leverage all available incentives
and professional opportunities in recruiting and retaining both
our civilian and military nursing personnel. Simply put, the
direct hire authority for registered nurses authorized by
Congress has substantially benefitted our hiring efforts. In
fiscal year 2003 we achieved an unprecedented 94 percent fill
rate of documented civilian registered nurse positions, an
overall turnover rate of less than 14 percent. Our hiring
reflects improvement over the past 3 years for registered
nurses.
We continue, however, to have barriers in hiring our
licensed practical nurses and strongly affirm that direct hire
authority needs to be extended to include this extremely
valuable nursing population.
We believe that we have strong recruitment and retention
tools to address the long-term impact of the decreased nursing
pool on our military nursing recruiting efforts. Although the
Army Nurse Corps was below our fiscal year 2003 budgeted end
strength, the decrement is less than in the past 2 years. We
are confident that the recruiting and retention strategies in
place, such as the increased accession bonus and the health
loan repayment program, will continue to help reduce the
decrement in future years.
We also increased the number of soldiers who are sponsored
to obtain their baccalaureate nursing degree through the Army
enlisted commissioning program. We continue to take aggressive
measures to strengthen nurse accessions through the Army
Reserve Officer Training Corps and the United States Army
Recruiting Command. We offer Reserve Officer Training Corps
(ROTC) nurses scholarships at nearly 200 nursing schools and
have increased the collaborative relationship between our
health care recruiting resources in ROTC and the United States
Army Recruiting Command (USAREC).
Army nurses continue to be at the forefront of relevant
nursing research that is focused on our research priorities of
readiness and nursing practice. We have nearly 90 research
studies currently in progress and continue to foster
involvement in the research process at all levels of our
organization. Our research accomplishments include the
development of 23 evidence-based standardized treatment
guidelines for musculoskeletal injuries most common to
soldiers.
Our Military Nursing Outcomes Database study, known as
MilNOD is now in the fourth year of study and has resulted in
the development of staffing and patient safety reports for the
Army hospitals. This study also affirms our strong belief in
collaborative nursing research as we have influenced the
development of the Veterans Affairs Nursing Outcomes Database
with a similar design. This project truly demonstrates what is
best about nursing research and Federal nursing collaboration.
Along with our Federal nursing colleagues, our commitment
to the tri-service research program and the graduate school of
nursing at the Uniformed Services University of the Health
Sciences remains very strong. Both these programs are distinct
cornerstones of our Federal nursing education and research
efforts and clearly demonstrate nursing excellence.
Thank you, sir, for your continued support of both these
exemplary programs as it enables us to continue to produce
advances in nursing education, research, and practice for the
benefit of our soldiers and their family members and our
deserving retiree population.
Finally, Senators, we are firmly determined to meeting and
overcoming any challenge that we face this year and are
committed to meet the uncertain challenges of the future. We
are further motivated by the impressive, steadfast courage and
sacrifice demonstrated by all the fine men and women in uniform
who are serving our great Nation. We will continue our mission
with a sustained focus on readiness, expert clinical practice,
sound educational preparation, professionalism, leadership, and
the unfailing commitment to our Nation that have been
distinguishing characteristics of our Army nurses and
organization for over 103 years.
As I conclude my 32 years of service in the Army Nurse
Corps, I am most proud of all the tremendous civilian and
military nursing personnel that represent this great Army Nurse
Corps.
PREPARED STATEMENT
Thank you again for your support and for providing the
opportunity for us to present the extraordinary efforts,
sacrifices, and contributions made by all Army nurses who
always stand ready, caring, and proud. Thank you, sir.
Senator Stevens. Thank you very much.
[The statement follows:]
Prepared Statement of Colonel Deborah A. Gustke
Mr. Chairman and distinguished members of the committee, I am
Colonel Deborah A. Gustke, Assistant Chief, Army Nurse Corps. Thank you
for providing the opportunity this year to update you on the state of
the Army Nurse Corps. I am pleased to represent Brigadier General
William T. Bester, Chief of the Army Nurse Corps, who is currently
transitioning to retirement after a very distinguished thirty-five year
military career. The past year has been challenging for our great
Nation as well as for the Army Nurse Corps. We have sustained a
deployment rate in recent months not seen since the Vietnam era and I
am extremely proud to report that the Army Nurse Corps has again
demonstrated our flexibility and determination to remain ready to serve
during these challenging and difficult times.
We remain very engaged in our Army's efforts in support of
operations around the world. As of March 2004, we have deployed over
814 Army nurses to places such as Afghanistan and Iraq. Our nurses are
providing expert care in every health care setting. There are Army
nurses on Forward Surgical Teams performing immediate life-saving care
to our soldiers. We have Army nurses assigned to the combat divisions
who are responsible for educating and sustaining our enlisted combat
medics--our linchpin to soldier care. Army nurses perform both clinical
and leadership roles in the two deployed Combat Support Hospitals (CSH)
and one Field Hospital. At present, the 31st Combat Support Hospital
from Fort Bliss, TX and the 67th CSH from Wuerzberg, Germany are on the
ground in Iraq and the 325th Field Hospital, United States Army
Reserve, headquartered from Independence, MO, is currently on the
ground in Afghanistan. These units in Iraq recently conducted a
seamless transition with the 28th CSH from Fort Bragg, NC and the 21st
CSH from Fort Hood, TX, who have now safely returned home. We are
firmly supporting organized reintegration programs for the members of
these units at their home stations to ensure that the transition to
home is as supportive and successful as possible. We are truly proud of
the Army nurses and all the medical personnel who served and are
currently serving with these and all the medical units.
Our Reserve Nurse Corps officers are demonstrating the necessary
leadership and clinical expertise in support of current operations in
many settings around the world. In addition to the nurses in theater,
numerous other Reserve nurses are serving in backfill roles in our
Medical Treatment Facilities (MTFs). Furthermore, 158 Reserve and
National Guard nurses are serving as case managers at the Regional
Medical Commands, mobilizations sites and at the community based health
care initiative sites, established to provide medical holdover
management for soldiers impacted by deployment. With the addition of
Army nurse case managers in June 2003, the flow and disposition rate of
medical holdovers has increased dramatically. Army nurses possess the
necessary mix of leadership and clinical skills to perform nursing care
in any setting and in any role. I strongly believe that we have fully
demonstrated this throughout our one hundred and three year history,
and especially since September 11, 2001.
The current world environment is not without challenges for the
Army Nurse Corps in several arenas. The National nursing shortage
continues to impact the ability of the Army Nurse Corps to attract and
retain nurses. Although we are encouraged by recent increases in
nursing school application numbers, concerns continue over the lack of
nursing school capacity due to the availability of adequate faculty. We
wholeheartedly support initiatives that attract and retain nursing
school faculty and believe that it will be critical to continue
developing programs necessary to meet current and future faculty
shortfalls.
We have worked diligently in the past year to minimize the impact
of a decreased nursing personnel pool on our civilian nurse strength.
Civilian nurses continue to comprise the majority of our total nurse
workforce and have performed exceptionally during the recent staffing
transitions at our MTFs as our active and reserve nurses mobilize in
support of operations around the world. Our civilian nurses have
demonstrated true resiliency and the willingness to absorb the
necessary roles to ensure that we don't miss a beat as we provide
expert nursing care to our beneficiaries.
We continue to have success with the Direct Hire Authority. In
fiscal year 2003, we achieved a 94 percent percent fill rate of
documented civilian Registered Nurse positions and an overall turnover
rate of 14 percent. These numbers reflect continued improvements over
the past three years and the high fill rate percentage demonstrates
that Direct Hire Authority is successful. We will continue to monitor
strategies to address retention efforts such as supporting
opportunities for continuing education and professional development
programs for our civilian Registered Nurses. Although in fiscal year
2003, for the first time in three years, we experienced a decline in
the fill rate for civilian Licensed Practical nurse positions, but we
experienced a decreased turnover rate. In fiscal year 2003, it took an
average of 84 days to fill a Licensed Practical Nurse position, nearly
30 more days than the Army standard of 55 days. We're reviewing the
options we have to ease the recruitment and hiring lag that we
currently experience in this valuable nursing personnel population.
The Army Nurse Corps remains actively engaged in a DOD effort to
simplify and streamline civilian personnel requirements and prepare our
processes to compliment the evolving National Security Personnel System
(NSPS). We support having the flexibility necessary to respond to the
rapidly changing civilian market and are encouraged by the projected
use of pay banding to facilitate regional hiring and retention
differences. We are now able to implement the needed flexible special
pay strategies within the pay system and are pursuing financing
strategies to execute this authority this fiscal year. In addition, we
are ready to implement the clinical education template currently
required in the legislation in order to ensure consistency of hiring
practices.
We believe that we have assertively leveraged strong recruitment
and retention tools to address the long-term impact of the decreased
nursing pool on our military nurse recruiting efforts. Although the
Army Nurse Corps was below our fiscal year 2003 end-strength of 3,381
by 154, this decrement has closed since fiscal year 2002 and we are
confident that the recruitment and retention strategies in place will
continue to help reduce future shortfalls. We continue to take
aggressive measures to strengthen our position in both the Army Reserve
Officers' Training Corps (AROTC) and United States Army Recruiting
Command (USAREC) recruiting markets. We now offer AROTC nursing
scholarships to students at approximately 200 nursing schools across
the country. One of the greatest recruiting tools for AROTC and nursing
is the Nurse Educators Tour to the AROTC Leader Development and
Assessment Course at Fort Lewis, WA. This course is the capstone
evaluation program for AROTC cadets in the summer between their junior
and senior years and impressively demonstrates the finest qualities of
our future officers. In the past, we were limited to hosting 30 nurse
educators, but now have secured resources to host up to 150 educators.
Last summer, 104 nurse educators came to Fort Lewis and left with a new
found appreciation for the benefit of AROTC training as well as for the
Army Nurse Corps as a tremendous environment for their students to
practice the art and science of nursing. Upon returning to school last
fall, one nurse educator personally escorted five nursing students to
the AROTC cadre to discuss scholarship options. It is clearly evident
that the influence of nurse educators on prospective Army Nurses is
integral to our efforts in AROTC and we will continue to foster those
strong relationships.
We have also taken strides to increase the collaborative
relationship between our health care recruiting resources in AROTC and
USAREC. This collaborative non-competitive partnering was initiated to
maximize the Army Nursing presence on campus and to present a unified
Army Nurse Corps team to the nursing students and faculty. As of
February 2004, this collaborative effort has resulted in 60 referrals
to USAREC by AROTC Nurse Counselors. We will continue to support this
professional partnering in nurse recruiting.
Regarding compensation incentives, we have been successful in
increasing the accession bonus and are working towards incremental
increases up to our authorized level in future years. We are
particularly proud to report that the Health Professions Loan Repayment
Program (HPLRP), implemented at the end of fiscal year 2003 and
continuing into fiscal year 2006, has been very successful. We have
been able to optimize the use of this program for both new accessions
as well as for retention of our fine company grade Army Nurse Corps
officers. We believe that these incentive programs, coupled with
established professional leadership and clinical education programs,
are instrumental in our efforts to retain Army nurses during the early
phase of their careers. Finally, we continue to be extremely successful
in providing a solid progression program for our enlisted personnel to
obtain their baccalaureate nursing degree through the Army Enlisted
Commissioning Program. Our intent is to consistently sponsor 85
enlisted soldiers each year to complete their nursing education to
become Registered Nurses and subsequently, Army Nurse Corps officers.
We have married the support framework of these soldiers to our AROTC
resources at the various colleges and universities in order to ensure
that our enlisted soldiers have the support and mentoring they so
richly deserve while they are pursuing their nursing studies. Graduates
from this program continue to provide the Army Nurse Corps with nurses
who are strong soldiers and leaders.
Our focus on retention of our junior nurses will always be
important and in fact, in fiscal year 2003, we experienced the lowest
attrition rate in the past five years. We believe that the robust
compensation strategies such as their base pay, allowances, the Health
Professions Loan Repayment Program (HPLRP) and the Incentive Specialty
Pays for our Certified Registered Nurse Anesthetists (CRNA) have been
paramount in our effort to recognize individuals for their tremendous
efforts and sacrifices, especially during the continued high
operational tempo. We continue to collect data from Army nurses who
choose to leave the Army and are analyzing the recent data to assess
any impact that the swift deployment tempo may have on our retention
efforts. The results to date do not reflect that the losses are related
to deployment, but we will continue to track and assess this very
closely.
Each year, the Army Nurse Corps continues to sponsor the largest
number of nurses, compared to any Service, to pursue advanced nursing
education in a variety of specialty courses as well as in masters and
doctoral programs. We know that this education program, coupled with
the military leadership development, positively impacts improved
clinical practice environment, mentoring relationships, and role
satisfaction.
It is a pleasure to be able to highlight good news stories about
nurses affiliated with the Army Medical Department (AMEDD) Center and
School and at the many MTFs around the world who are working tirelessly
to improve the clinical, education, research, and leadership
environments. At the AMEDD Center and School, we have increased our
training capacity for CRNAs in order to address a critical shortfall in
this specialty. This involved opening a clinical training site at
Brooke Army Medical Center, in San Antonio, TX, that allows us to
produce an additional four CRNA nurses each year. As a result, we will
increase our ability to fill the operational requirements for these
nurses as well as decrease the current costs of contracting civilian
CRNA personnel in our facilities.
Army Nurses are integral to the Army Medical Reengineering
Initiative at all levels of our organization. To support the conversion
of our enlisted/officer Licensed Practical Nurse (LPN) to an expanded
level of patient care capability, Army Nurses designed and implemented
a new educational program of instruction for the LPN training program.
This improvement refocused training to include a greater emphasis on
critical care and trauma skills in support of the revised wartime
mission of these soldiers. Our first class, under the improved program
of instruction, began in late 2003 and we are confident that this
training will produce the highly trained Practical Nurse sought by the
Army. Army Nurses are also very proud to be an integral part of the
transformation of the new enlisted Healthcare Specialist Military
Occupational Specialty (91Ws). We are imbedded in the training units as
leaders and educators. In fact, there are 32 Army Nurse Corps officers
directly assigned to the combat divisions who are working to ensure
that our 91W soldiers sustain their training and preparation needed to
provide the most far forward care. Over the past year, as they have
throughout history, our medics have performed admirably and we are very
proud to serve side by side with these exceptional soldiers. We will
continue to steadfastly support all aspects of this transformation
until it is completed and sustainment training practices are well
established.
The Army Nurses at Tripler Army Medical Center, Hawaii have
implemented a professional practice model for all its nurses. The model
is a standards and role-based model that clearly delineates the role of
the nurse and provides more consistent tools for use in the performance
evaluation process. This process has significantly assisted our new
nurses in understanding role expectations as well as assisted our nurse
leaders in clearly articulating expectations to the nursing staff. This
process is ongoing and we are exploring the potential of expanding this
concept to other MTFs. The Army Nurses from Hawaii are also in demand
around the Pacific Rim and have established professional dialogue with
the Royal Thai Nurses, The Australian Nurse Corps, and the New Zealand
Defence Corps. In addition, Army Nurses have presented on clinical and
professional nursing issues in Bangkok, Thailand and Hanoi, Vietnam. We
will continue to sponsor this professional collaboration in the spirit
of international cooperation and mutual benefit.
Last year, we presented information on the Combat Trauma Registry
initiative that was employed at Landstuhl, Germany and contained
retrospective data entered on soldiers injured in Afghanistan in
support of Operation Enduring Freedom. I am pleased to report that this
database is now termed the Army Medical Department Theater Trauma
Registry (AMEDD TTR) and is a web-based system, with DOD interface, now
capable of concurrent data collection and casualty reporting. The AMEDD
TTR collects data on all casualties, all U.S. military personnel and
any NATO and allied military personnel and local nationals, treated at
U.S. facilities in Operation Iraqi Freedom. Army Nurses in partnership
with experts from the Institute of Surgical Research, Walter Reed Army
Medical Center, Landstuhl Army Medical Center, the Armed Forces
Institute of Pathology and the Navy Health Research Center have worked
tirelessly on this project. It is expected that the results of this
data collection and analysis will provide information pertinent in the
development of improved medical training, equipment, and practice
modalities for future operations.
Army nurses continue to be at the forefront of nursing research
focused on the five Army Nurse Corps research priorities of
identification of specialized clinical skill competency training and
sustainment requirements, issues related to pre-, intra-, and post-
deployment, issues related to the nursing care of our beneficiaries in
garrison, nurse staffing requirements and their relationship to patient
outcomes, and finally, issues related to civilian and military nurse
retention. Today I will share with you our progress and accomplishments
in these five priority areas.
The Military Nursing Outcomes Database (MilNOD) project is now in
the fourth year of study and incorporates research efforts across the
military nursing services. The participating sites include Walter Reed
Army Medical Center, Madigan Army Medical Center, Womack Army Medical
Center, Dewitt Army Community Hospital, Malcolm Grow Air Force Medical
Center, Naval Hospital Bremerton and Naval Hospital Whidbey Island.
This project is collecting data to support evidence-based clinical and
administrative decision-making and create a reliable and valid database
consisting of standardized nurse staffing and patient safety data. In
addition, the investigation team is working with the California Nursing
Outcome Coalition (CalNOC), a repository of staffing and patient safety
data from 120 California hospitals, to benchmark data from like
facilities. Although still in progress, this project has resulted in
very promising findings to include the development of staffing and
patient safety reports for the Army hospitals. The content of these
reports meets the JCAHO compliance measures for staffing effectiveness
measures and is being used by the nursing leadership in staffing
pattern decisions. In addition, the MilNOD data on patient safety
related to pressure ulcers revealed that nurses at Walter Reed were
noticing that some of the ill or injured patients returning from
deployment were experiencing pressure ulcers. This finding led to a
discussion of pressure ulcer prevention in the field setting and
resulted in the sharing of pressure ulcer prevention protocols from the
Medical Center with the Combat Support Hospital in theater. In
addition, nurses determined that the field litters currently used to
support and transport patients did not provide the necessary padding
protection against the development of pressure ulcers. This finding
opens up a whole new area for potential inquiry and intervention. The
MilNOD project is a tremendous long-term effort by nurses in all three
services and has now influenced the development of the Veteran's
Affairs Nursing Outcomes Database (VANOD). This project truly
demonstrates what is best about nursing research and Federal Nursing
collaboration.
Army nurse researchers at Madigan Army Medical Center have also
developed 23 evidence-based standardized treatment guidelines for
musculoskeletal injuries most common to soldiers. These guidelines
provide information on patient education, exercise regimes with
photographic aids, diagnostic information, and medical profile
information. There have been hundreds of requests for these guidelines
from deploying units as well as from providers at MTFs at home and each
of these guidelines may be found on-line at the Madigan Army Medical
Center website.
Our Nursing Anesthesia students continue to add to our growing body
of knowledge in nursing anesthesia care for our beneficiaries at home
or our soldiers in a deployment setting. This past year, several
studies were done on monitoring techniques, warming techniques, gender
differences in medication dosage levels and the impact of medication
use on pain perception. We are extremely proud of the research that all
our students accomplish while they are completing very vigorous
programs of study.
Our civilian nurses are also very involved in nursing research.
Nurse researchers at Fort Carson, CO received a National Institutes of
Health grant to study self-diagnosis of genitourinary infection of
deployed women. The study plan is to develop a safe and accurate field
expedient self-diagnosis and treatment kit for genitourinary infections
to be used by military women deployed to austere environments. In a
preliminary study involving over 800 military women, the investigators
learned that 87 percent of these women experienced symptoms of
infection at some point during the deployment. Nearly half of the women
reported that the symptoms resulted in decreased work performance and
24 percent reported lost hours of work time. It is evident that the
outcomes of this research could have a positive impact on readiness and
women's health in the deployed environment. This study has far reaching
implications for other humanitarian organizations that send women to
areas in which the needed health care may not be readily accessible or
available.
The Army Nurse Corps research priorities are extremely timely and
relevant to the research being conducted by our civilian nursing
colleagues. A study recently completed in December 2003 by Lieutenant
Colonel Patricia Patrician, an Army Nurse Corps researcher from Walter
Reed Army Medical Center, focused on assessing the Army hospital work
environment in order to describe the work environment attributes, nurse
burnout, job dissatisfaction and intent to leave the Army workforce
from the perspectives of military and civilian staff nurses. The second
purpose was to compare these results to published reports from civilian
hospitals. As we know, recruitment and retention has been tied to
positive work environments, such as those that exist in magnet
hospitals. The final sample from the Army study consisted of 957
Registered Nurses who worked in inpatient settings within the Army's 23
hospitals in the United States. The sample represented 64 percent
civilian and 36 percent military nurses. The study results concluded
that nurses working in Army hospitals rated Army hospitals more
favorably as compared to the ratings of a group of civilian hospitals
in terms of work environment. Nurses who work in Army hospitals
experience less burnout and less job dissatisfaction than those in
civilian hospitals. Finally, when taking into consideration normal
military rotations and rotations within a hospital, Army nursing
personnel are less likely than civilian nurses to leave their current
positions within one year. Research of this nature helps us maintain
our healthy work environment as well as remain competitive with our
civilian counterparts in recruitment and retention.
Our support and appreciation for the Uniformed Services University
of the Health Sciences (USUHS) is also very strong. USUHS continues to
provide us with professional nursing graduates who continue to excel in
their programs of study and subsequent professional military careers.
We are pleased that both the Clinical Nurse Specialist Program in
Perioperative Nursing as well as the Doctoral Program in Nursing are
successfully progressing in their inaugural year. These programs were
established as a result of an identified need in the military services
and the Graduate School of Nursing leadership and staff worked
tremendously hard to develop and execute both of these programs. USUHS
will continue to be our cornerstone educational institution and remains
flexible and responsive to our Federal Nursing needs. We look forward
to a continued strong partnership to maintain the necessary numbers of
professional practitioners to support our complex mission.
The Army Nurse Corps experienced the loss of two tremendous Army
Nurse Corps officers this past year, one whose legacy of leadership and
influence will forever have an impact on the Corps and one whose young
career ended much too soon. Brigadier General (Retired) Lillian Dunlap,
our 14th Chief, Army Nurse Corps, passed away in April 2003. She had a
long and illustrious life, both personally and professionally. BG
Dunlap served in the 59th Station Hospital in the southwest Pacific
area of New Guinea, Admiralty Islands and the Philippines during World
War II and during her 33 year career, held almost every position
available in the Army Nurse Corps from staff duty nurse to nurse
counselor, chief nurse, 1st U.S. Army during Vietnam, director of
nursing services, instructor and director of nursing science at our
Academy of Health Sciences. Without a doubt, one of BG Dunlap's most
powerful and lasting achievements was the elevation of the educational
level of nurses in the Army Nurse Corps. Her support and guidance
assured the success of the baccalaureate degree in Nursing as the
standard for entry into practice for Army Nurses--a standard that the
Army Nurse Corps once again reaffirms today as the minimum educational
requirement and basic entry level for professional nursing practice. We
appreciate your continued support of this endeavor and your commitment
to the educational advancement of all military nurses. BG (R) Dunlap's
legacy will endure and she will be known as an Army nurse who opened
many doors for the future of Army nursing and ``gave that handful
more'' to everything that she did. We salute her self-less service.
Captain Gussie Mae Jones was born in Arkansas and was one of eight
children. She began her Army career by enlisting in 1988 as a personnel
clerk and climbed to the rank of sergeant. In 1986, Captain Jones
earned a bachelor's degree in business administration from Arkansas
University Central. She was selected above her peers to attend the Army
Enlisted Commissioning Program and earned her second bachelor's degree
from Syracuse University in 1998. It was in nursing that she found her
passion. Her career as a registered nurse and a commissioned officer
began in September 1998 at Brooke Army Medical Center in San Antonio.
After completing our specialty course in critical-care nursing in 2002,
she was assigned to William Beaumont Army Medical Center, where she
excelled in nursing in the intensive care setting. Assigned as a
Professional Officer Filler (PROFIS) to the 31st Combat Support
Hospital, Captain Jones deployed with her unit to Iraq in February of
this year. An emerging leader and dedicated nurse, Captain Jones was
admired by her fellow soldiers. On March 7, 2004, Captain Jones died of
natural causes in Baghdad, Iraq surrounded by the soldiers with whom
she served. Captain Jones devoted 15 years of her life to the service
of her Country and the United States Army. She was a soldier and
consummate professional nurse whom we are extremely proud to have had
in the Army Nurse Corps. CPT Jones represents the best in Army nursing.
We will never forget her sacrifice and willingness to serve. She will
be sorely missed.
Finally Senators, we are firmly determined to meeting and
overcoming any challenge that we face this year and are committed to
meet the uncertain challenges of the future. We will continue with a
sustained focus on readiness, expert clinical practice, sound
educational preparation, professionalism, leadership and the unfailing
commitment to our Nation that have been distinguishing characteristics
of our Army nurses and our organization for over 103 years. As I
conclude my 32 years of service in the Army Nurse Corps, I am most
proud of all the tremendous civilian and military nursing personnel
that represent this great Army Nurse Corps. Thank you again for your
support and for providing the opportunity to present the extraordinary
efforts, sacrifices and contributions made by Army nurses who are all
ready, caring and proud.
Senator Stevens. Admiral Lescavage.
STATEMENT OF REAR ADMIRAL NANCY J. LESCAVAGE, DIRECTOR,
NAVY NURSE CORPS
Admiral Lescavage. Good morning, Chairman Stevens, Senator
Inouye. I am Rear Admiral Nancy Lescavage, the 20th Director of
the Navy Nurse Corps and the Commander of the Naval Medical
Education Training Command. It indeed is an honor and a
privilege to speak before you during my third year in this
position and to highlight the achievements and issues of our
5,000 Navy nurses, both Active and Reserve.
The Navy Nurse Corps' exceptional performance during the
past year clearly demonstrates operational readiness as we
continue to meet our primary mission. In support of Operation
Iraqi Freedom, we had 500 nurses deployed and there were over
400 filled reserve mobilization requests to maintain the
continuum of care in our military treatment facilities. In
addition, there were over 400 active and Reserve Navy nurses
involved in additional training exercises.
Through a variety of activities, ranging from direct care
to the conduct of research in support of our operational
forces, Navy nurse fleet support has been well received by our
line community. For example, nurse practitioners assigned to
the Norfolk Naval Base see fleet sailors on board ship or while
underway. Through the newly established force nurse initiative
with the U.S. Atlantic fleet and Pacific fleet, Navy nurses are
now integral to fleet level oversight and lend guidance and
assistance to aircraft carrier medical departments and our
aviation squadrons.
At our naval health research centers, Navy nurse
researchers are leading the way in research projects focused on
things like women's health initiatives and casualty care.
Numerous training opportunities across the Federal and the
civilian sectors have been essential to maintaining critical
Navy nursing specialty skills that are required in the
operational environment. As one example, over 50 Navy nurses
have successfully rotated through the Navy trauma training
program with Los Angeles (L.A.) County and the University of
Southern California Medical Center to enhance their combat
trauma skills. Also, through established agreements between six
military treatment facilities and local trauma centers, an
additional 50 Navy nurses have also benefitted from this
specialized training.
Across naval medicine, military and civilian nurses are
leaders, clinical experts, and researchers in a variety of
programs from population health to specific disease management.
The Joint Population Health Office at Naval Medical Clinic
Pearl Harbor has been labeled as a benchmark for population
health in the Navy with their comprehensive screening and
assessment program to individualize patient care.
Through the vast worldwide case management program across
Navy medicine, the collaborative efforts of 93 civilian nurse
case managers have resulted in an estimated cost avoidance of
$6.4 million through recaptured workload, decreased lost
training days, and better managed care. In addition, innovative
nurse managed clinics include a 24-hour/7-day-a-week nurse call
center which supports increased accessibility, post-deployment
stress briefings and disease management, to name a few.
In the area of research, we value its contribution to
quality patient care and the practice of our nursing
professionals anywhere from utilizing evidence-based medicine
to establishing innovative health care programs. Through a
comprehensive research-based practice initiative, focused on
patient falls, for example, National Naval Medical Center
Bethesda has become a model in promoting patient safety for
civilian, as well as our military facilities.
As an outcome of one of our TriService nursing research
program funded grants, we now assign more seasoned Navy nurses
with specific critical care expertise to our aircraft carriers
to better meet our operational mission. Many of our research
grant findings are collaboratively shared across the services
and presented worldwide at numerous professional conferences
and in professional publications.
Your continued support of TriService nursing research is
greatly appreciated.
With the Nation's focus on the overall nursing shortage, it
is important to address our recruitment and retention efforts.
Our goal is to shape the force with the right number of Navy
nurses in the right specialties, more importantly at the right
time in the right positions. That is done to meet our mission
in all care environments and to become the premier employer of
choice for our Navy nurses and civilian nurses.
Naval medicine has historically been able to meet military
and civilian recruiting goals and specialty nursing
requirements to this point. We had a slow start this year,
specifically in active duty recruiting, with our most recent
report of attaining only 26 percent of our goal although we are
only midway through the recruiting year. We have recently been
successful in increasing the accession bonus, and that occurred
late January of this year. We are also in the process of
seeking funding for the health professional loan repayment
program.
Fortunately, the good news is we have other pipeline
scholarship programs, for instance, our ROTC programs and
seaman to admiral, to help meet our recruiting needs. Based on
our projected gains and losses for this year, we predict a
deficit of 98 for a desired end strength of 3,176 active duty
nurses.
As for our Reserve component, we are right on track with
recruiting and we predict 100 percent fill of our billets. Our
Reserve nurses are at 105 percent end strength.
To meet nursing specialty mission requirements and promote
retention, I do have to say our graduate education scholarship
programs and specialized training for those on active duty have
been extremely successful in retaining our active duty nurses.
Our retention numbers are very high. Our Navy nurses love
education. We continue to focus on our operationally related
nursing specialties, for example, operating room, critical
care, anesthesia, and emergency room nurses, as well as
academic programs that will propel our nurses into the
forefront of health care planning and policy in obtaining
Ph.D.'s and MBA's and public health graduate degrees.
In addition to civilian universities, we also send our
students to the Uniformed Services University of Health
Sciences. Your continued interest in the USUHS Graduate School
of Nursing and their doctoral, perioperative, family nurse
practitioner, and anesthesia nursing programs is greatly
appreciated.
In closing, I again do appreciate your tremendous support
with legislative initiatives and the opportunity to share the
accomplishments and issues that face our great Navy Nurse
Corps. I consistently see our nurses as dynamic leaders and
innovative change agents in all settings, both in our MTF's and
in combat. I remain truly proud of the corps and our civilian
nurses as they stand ready to promote, protect, and restore the
health of all entrusted to our care.
PREPARED STATEMENT
I look forward to continuing to work with you during my
tenure as the Director of the Navy Nurse Corps. Thank you,
sirs, for this great honor and privilege.
Senator Stevens. Thank you very much.
[The statement follows:]
Prepared Statement of Rear Admiral Nancy J. Lescavage
Good morning Chairman Stevens, Senator Inouye and distinguished
members of the Committee. I am Rear Admiral Nancy Lescavage, the 20th
Director of the Navy Nurse Corps and Commander of the Naval Medical
Education and Training Command. It is an honor and a privilege to speak
before you during my third year in this position and to highlight the
achievements and issues of our 5,000 Navy nurses.
Our performance during Operations Enduring Freedom and Iraqi
Freedom clearly demonstrated operational readiness as we continue to
meet our primary mission. I would now like to address Navy Nurse Corps
impact in the areas of readiness and homeland security; nursing
initiatives; education and training; jointness and research.
readiness and homeland security
In support of Operation Iraqi Freedom, we had 500 nurses deployed
from over eighteen facilities to the Hospital Ship COMFORT, Fleet
Hospitals, Casualty Receiving Treatment Ships, Shock Trauma Platoons,
and with the Marines. To maintain the continuum of care back at our
Military Treatment Facilities, there were over 400 filled Reserve
mobilization requests, the second largest recall since Desert Storm. In
addition, there were over 400 Active and Reserve Navy Nurses involved
in training exercises, such as Fleet Hospital Field Training,
Operational Readiness Evaluations, Hospital Ship MERCY Exercises, Cobra
Gold, West African Outreach Program, Operation Arctic Circle and
Combined Armed Exercises. Throughout all operations and exercises, our
military and civilian nurses readily adapted; remarkably delivered
outstanding care; and achieved mission accomplishment at our facilities
and while deployed.
In addition to meeting the medical needs of our Navy and Marine
Corps team ``in theater,'' readiness also includes preparing health
care personnel at Navy hospitals and clinics around the world to
respond to a natural disaster or terrorist attack. Nurses are at the
forefront of emergency preparedness across Naval Medicine in a variety
of roles. Within Naval Medicine's Homeland Security Office at the
Bureau of Medicine and Surgery, there are two Navy nurses executing a
comprehensive ``Disaster Preparedness, Vulnerability, Analysis,
Training and Exercise Program'' to identify vulnerabilities in training
and to test each military treatment facility's emergency response plan.
Their effectiveness was recently put to an immediate test during the
third training day at Naval Hospital Charleston, when a real disaster
occurred. Forty-four participants, two local hospitals and the
Charleston County Emergency Medical System provided topnotch care for
the casualties involved in a bus accident. In addition, we have several
Navy nurses collaborating with local community disaster planning
programs, promoting well-coordinated response plans, such as at Naval
Hospital Pensacola and Naval Hospital Charleston.
Training
Optimizing available training opportunities across the Federal and
civilian sectors is essential in maintaining critical nursing specialty
skills that are required in all operational environments. Great success
is attributed to the Navy Trauma Training Program in conjunction with
the Los Angeles County/University of Southern California Medical
Center, one of the nation's finest Level I Trauma Centers. Since its
inception in the fall of 2002, over fifty Navy nurses have successfully
rotated through this program to enhance their combat trauma skills and
to further increase medical readiness with their respective platform
teams. Due to intense follow-up with health care team graduates in the
field, many operational lessons have been incorporated into their
curriculum. The program has received positive national press coverage
through television, nursing magazines and newspapers, praising the Navy
faculty as experts in the most current trauma standards.
Trauma training is further enhanced through established agreements
between six military treatment facilities with local trauma centers and
critical care settings for over 50 nurses at San Diego, Bethesda,
Jacksonville, Camp Pendleton, Bremerton, and Charleston. Other training
opportunities include web-based critical care courses, such as the
``American Association of Critical Care Nurses Essentials of Critical
Care Orientation'' and other instructor presentations, which provide
continuing education credit. To support dual critical specialty skills
in the operational environment, the Association of Perioperative
Registered Nurses nursing curriculum for Perioperative Nurses Training
has been adapted for critical care nurses. As an adjunct to traditional
platform training, the nursing staff at Naval Medical Center San Diego
conducted ``Operational Skills Days'' to enhance their clinical skills
and didactic foundation. When operational needs required immediate
training, Navy nurses were sent to Naval Hospital Okinawa to assist
with Forward Resuscitative Surgical System training.
In short, our Senior Nurse Executives are very resourceful in
seeking educational resources and skills enhancement training to meet
platform and specialty requirements, particularly when located in
smaller, remote facilities or overseas. These clinical training
opportunities have also expanded to other required nursing specialties,
such as labor and delivery, nursery and mother infant nursing for our
Naval Hospitals at Guam and Keflavik through clinical programs in
facilities stateside and overseas. In addition, we continue to place
strong emphasis in developing a solid clinical foundation for our
graduate nurses through Nurse Intern Programs at several of our
facilities, providing a good mix of clinical rotations tailored to
varied patient acuity and specialties resulting in better prepared
nurses.
Related to operational training while supporting community needs, I
would like to highlight three unique military training exercises. The
Civil-Military Innovative Readiness Training Program with our reserve
nurses helps to rebuild America in underserved areas through Operation
Arctic Care in Alaska. Partnership efforts include regional, state and
local communities with Guard and Reserve units in providing exceptional
medical care. Through our nurses' sound leadership and detailed
coordination in the deployment and movement of these units, operational
and combat readiness skills of the military units are enhanced. While
on the exercise, the health care team on the Hospital Ship MERCY
provided medical care to eighty-three Seattle veteran-eligible patients
last summer, lauded by the Seattle Post for their community support.
While in the Pacific Northwest, our health care professionals met with
Canadian health care counterparts to discuss response plans for a major
earthquake scenario. In addition, during the recent Southern California
fire, our hospital ship provided housing and hot meals for over 100
military families.
At the Deckplate
The expanding direct Fleet support by our Navy nurses has been well
received by the Navy and Marine Corps communities. Our two nurse
practitioners assigned to the Norfolk Naval Base see 300 Fleet sailors
a month onboard ship or while underway for wellness and readiness
efforts alone. They also function as trainers and consultants and have
developed a CD-ROM for Fleet implementation of the Preventive Health
Assessment Program. Women's Health Nurse Practitioners have provided
clinical exams for females onboard the U.S.S. Kennedy and also serve as
instructors for the gynecological portion of the Independent Duty
Hospital Corpsman curriculum. Through the newly-established Force Nurse
Initiative with Commander, Naval Air Force U.S. Atlantic Fleet and
Commander, Naval Air Force U.S. Pacific Fleet, two Navy nurses are now
integral to Fleet level oversight, guidance and assistance to aircraft
carrier medical departments and aviation squadrons. Professional
nursing and technical recommendations are also provided on Force Health
Protection, Shipboard Medical Training, Medical Department Quality
Assurance, Infection Control, the acquisition of new medical equipment
and other programs.
Preventive Health Assessment Nurse-Run Clinics, such as in our
Naval Hospitals at Pensacola and Corpus Christi, have been praised by
the Navy Line Community for promoting healthy, physically fit Naval
Forces as program compliance dramatically increased. With the addition
of a mental health clinical nurse specialist, the Outreach Program at
Corpus Christi has further expanded suicide awareness briefs and other
services.
Within the operational nursing division at our Naval Health
Research Centers, our nurse researchers are leading funded research
projects focused on women's health issues and casualty care. In
addition, they collaboratively developed research-based methods for
providing surgical support during special operations at sea and in
caring for the Medical and Security forces at Camp Delta in Guantanamo
Bay, Cuba. These are just a few examples of how Navy nurses at the
deckplate are involved in diverse activities ranging from direct care
to the conduct of research in support of our operational forces.
nursing initiatives
Across Naval Medicine, Navy nurses are involved in the planning and
implementation of a variety of programs as leaders, clinical experts
and researchers from population health to specific disease management.
Military and civilian nurses are valued catalysts across our facilities
directing patient safety initiatives and leading collaborative teams to
evaluate patient outcomes that reduce error, variability, and cost.
Several nursing initiatives include implementation of the JCAHO
National Patient Safety goals, skin care studies, staffing
effectiveness project, the management of diabetic patients, inpatient
bed utilization, and medication/non-medication related near misses and
actual events.
Navy nurses at our three Healthcare Support Offices have been
primary movers in linking the clinical aspects of Naval Medicine with
strategic and annual business planning efforts to create more efficient
practices and improve outcomes. Their most significant impact is in
relating the clinical processes to business rules and interpreting the
data relative to true clinical practices. In addition, nurse leaders
and researchers are very involved with Navy Advisory Boards, Joint
Readiness Clinical Advisory Boards and nationwide studies to
collaborate on clinical advances and identify specific metrics to
demonstrate efficient business practices.
Joint Population Health Programs
Through the Joint Population Health Program across three
California-based Naval Hospitals at San Diego, Camp Pendleton, and
Twenty-Nine Palms, masters and doctorally-prepared nurses demonstrate
savvy in program implementation, policy, practice and research to shape
the health status of Naval forces and all eligible beneficiaries, while
focusing on quality, cost and access. The Joint Population Health
Office at Naval Medical Clinic Pearl Harbor, Hawaii has been labeled as
a benchmark for population health in the Navy. Based on a comprehensive
screening and assessment process, the program addresses Preventive
Health Assessments (Active Duty); adult and children immunization and
health maintenance status; and health education literature and classes
based on individual needs. Statistically proven results support the
benefits of both of these programs.
Case Management
In today's rapidly changing health care environment, nurse case
managers play a crucial role in helping patients and providers select
the most appropriate level of care in the most cost-effective setting.
Optimal outcome is best exemplified through the Case Management Program
across Navy Medicine based on the collaborative efforts of 93 civilian
nurse case managers. Their focus on Active Duty, Exceptional Family
Member Program families, patients with multi-system medical problems,
targeted disease management entities and frequent emergency room users
resulted in recaptured workload, decreased lost training days, enhanced
patient/provider satisfaction and better managed care. The Active Duty
Trauma Nursing Case Management Program at Naval Medical Center, San
Diego coordinated the health care needs of 87 Operation Iraqi Freedom
wounded and 233 non-operational trauma patients. Among other programs,
such as at Naval Hospital Guam, nurse case managers have been
responsible for reducing emergency room visits and inpatient admissions
for chronically ill patients by responding to hundreds of consults and
processing catastrophic, complex, high risk, high-cost health care
requests.
Nurse-managed Clinics
The rise in nurse-managed or nurse-run clinics has demonstrated the
art and science of nursing in facilitating wellness, prevention and
health maintenance towards self-management for patients. The nature of
registered nurse practice in collaboration with physician champions
meets the standards of the American Academy of Ambulatory Nurses
through the use of research-based clinical practice guidelines,
spanning across the spectrum from neonates to geriatric patients.
Using the latest technological advances in wound care, nurses at
Naval Hospitals Pensacola and Portsmouth enhance the care of complex
battlefield injuries. Within Family-Centered Care, nurses plan,
coordinate, and provide direct care and case management through a
variety of programs, such as Postpartum Care Clinics. Home Action Plans
for Pediatric Pulmonary patients at three of our facilities reduced
admission rates by 50 percent. Other innovative nursing initiatives
include: a nurse call center supporting 24/7 accessibility; post-
deployment stress briefings; and disease management (diabetes,
hyperlipidemia, and hypertension), to name a few.
Successful open access initiatives as a result of the innovative
leadership of nurses at Naval Hospitals Pensacola and San Diego have
increased patient satisfaction; decreased emergency room visits and
unscheduled walk-in appointments; and improved patient/provider
matching. With the assistance of the Institute for Healthcare
Improvement at Naval Hospital Great Lakes, demand and patient flow
processes were reviewed; inefficiencies were identified; new business
plans were developed; and appointments were adjusted to maximize
access. Success has migrated these processes to other clinics and
clinical support areas as well.
research
We value research as an essential component to quality nursing
care, from utilizing evidence-based practice to conducting research.
For example, at Naval Medical Center Portsmouth, adult patients with
bladder problems are now scanned for urinary retention resulting in an
87 percent reduction in catheterizations. Upper respiratory infection,
urinary tract infection, diabetes and asthma clinical practice
guidelines have improved clinical parameters and therefore decreased
the number of appointments. In support of patient safety, an evidenced-
based practice initiative for a more comprehensive risk assessment and
protocol for ``falls'' was implemented at National Naval Medical Center
Bethesda and has become a model for civilian and military facilities.
The Sports Medicine and Reconditioning Team at Naval Medical Center San
Diego includes a nurse researcher to evaluate ``return to duty'' time
and re-injury rates of our Sailors and Marines to identify areas for
improvement. Through a multidisciplinary research study, MedTeams
strive to eliminate errors in the obstetrical area, increase patient
satisfaction, and enhance collegiality and collaboration among health
care professionals.
We continue to focus on advancing the practice of military specific
nursing and its response to requirements of military readiness and
deployment. The TriService Nursing Research Program has conducted Grant
Management Workshops, which provided invaluable mentorship and
training, resulting in an increased number of higher quality grant
submissions. Research results are collaboratively shared across the
services and are further disseminated to other facilities. Many of our
research grant findings have been presented worldwide in numerous
nursing conferences and in at least ten professional publications.
joint initiatives
There are several examples of joint programs across our Federal
agencies, which combine the talent of our health care teams to provide
quality care. Nurses at Naval Hospital Great Lakes are involved in
coordinating a partnership program for active duty treatment and
inpatient care with the North Chicago Veterans Affairs Medical Center.
Nurses at Naval Hospital Corpus Christi are involved in the business
planning and management of specialty care with their local Department
of Veterans Affairs Hospital.
Combined training initiatives and the mutual sharing of clinical
expertise are beneficial, particularly for our overseas duty stations.
Noteworthy coordinated efforts include a mental health nursing program
with Walter Reed Army Medical Center in Washington, DC; an Obstetrics
Course at Langley Air Force Hospital; Labor and Delivery training at
Landstuhl Army Medical Center; assisting Madigan Army Medical Center
with their medic (Licensed Practice Nurse) clinical training; and
providing Advanced Cardiac Life Support and Pediatric Advanced Life
Support classes for the Air Force at our Naval Medical Clinic in
London.
professional nursing in naval medicine
Our goals are to shape the force with the right number of people in
the right specialties, to meet the mission in all care environments,
and to become the premiere employer of choice. Accomplishing this
requires close attention to the national nursing issues; the pursuit of
available recruitment and retention initiatives; and the alignment of
our military and civilian nurses to meet Naval Medicine needs.
The Department of Health and Human Services and other independent
studies project that the current national nursing shortage of several
hundred thousand registered nurses may add up to 750,000 by 2020.
Despite recent increases in the number of nursing school entrants, the
nation could have a long way to go in making a dent in the overall
shortfall. We carefully monitor civilian compensation packages to
maintain the strength of our military and civilian nursing work force
by offering a variety of incentives.
Recruitment and Retention
Through our diversified accession sources, pipeline scholarship
programs, pay incentives, graduate education programs, specialized
training opportunities and varied retention initiatives, Naval Medicine
has historically been able to meet military and civilian recruiting
goals and specialty nursing requirements to this point. We presently
have 96.4 percent of our authorized active duty billets filled and 100
percent fill for our Reserve component. We continue to focus on our
operationally-related nursing specialties, such as medical-surgical,
critical care, perioperative and anesthesia, as well as women's health
nurse practitioner and certified midwives. Although we had a slow start
in recruiting this year when compared to the past 10 years, we expect
to meet our active and reserve recruiting goals this fiscal year.
Our civil service workforce challenges have been identified in
remote locations stateside and overseas, as well in certain
specialties, such as labor and delivery. Recruiting and retention
incentives are utilized and career ladders initiated where possible.
Graduate Education
Graduate education program and specialized training have been
extremely successful in meeting our nursing specialty mission
requirements and promoting retention. This year, we are sending two
nurses to the recently established Doctoral Program at the Uniformed
Services University of Health Sciences (USUHS). In addition, we
continue to send several of our students to the USUHS anesthesia,
family nurse practitioner and perioperative nursing programs.
Nurse Leadership
Navy nurses continue to function in pivotal executive roles to
impact legislation, health care policy and medical delivery systems.
Executive nurse leaders in the Active and Reserve component are in key
command positions as Commanding Officers and Executive Officers; at the
Bureau of Medicine and Surgery Headquarters as Deputy Surgeon General
and Deputy Directors; and other staff positions at Tricare Management
Activity, Health Affairs.
As leaders, we value mentorship, which is accomplished via many
innovative formal programs and informal forums with our enlisted
personnel, Naval Reserve Officer Training Corps students, Medical
Enlisted Commissioning Program students, junior nurses, and novice
researchers.
Recognition
Our nurses are recognized for their exceptional talent, outstanding
leadership and professional nursing community involvement and have
received clinical practice awards through the American Association of
Critical Care Nurses, the Sigma Theta Tau Nursing Honor Society; the
Association of Women's Health, Obstetric and Neonatal Nurses; and the
American Academy of Ambulatory Care Nurses. Our integral presence has
also been documented through an extensive list of journal publications.
For example, the June 2003 Critical Care Nursing Clinics of North
America was specifically dedicated to military and disaster nursing. In
addition, our professional achievements have been highlighted in many
forums at the Academy of Medical-Surgical Nurses Conference, the
Association of Perioperative Nurses Workshop, the California Nurse
Leader Workshop, and at the Institute for Health Care Improvement
Conference.
conclusion
In closing, I appreciate the opportunity to share the
accomplishments and issues that face the Navy Nurse Corps. I see our
nurses as dynamic leaders and innovative change agents in all settings.
I remain truly proud of our Navy military and civilian nurses as
they stand ready to promote, protect, and restore the health of all
entrusted to our care anytime and anywhere.
I look forward to continuing to work with you during my tenure as
the Director of the Navy Nurse Corps. Thank you for this honor and
privilege.
Senator Stevens. General Brannon, my daughter is taking
Chinese and she has learned to read from right to left. I have
not, so although you do have the star, I start from the left.
Please proceed.
STATEMENT OF MAJOR GENERAL BARBARA C. BRANNON,
ASSISTANT AIR FORCE SURGEON GENERAL,
NURSING SERVICES
General Brannon. Thank you, Chairman Stevens, Senator
Inouye. It is a great honor and pleasure to again represent
your Air Force nursing team. What a dynamic time in the history
of our Nation. Our soldiers, sailors, airmen, and marines
continue to valiantly support the global war on terrorism in
dangerous and unpredictable environments. They can count on the
support of Air Force nursing, active duty, Guard, and Reserve,
officer and enlisted. We are one team ready anytime to go
anywhere at our Nation's call to provide robust medical support
to combat units, to victims of natural disasters, and to those
in need of humanitarian or civic assistance.
IRAQ
To support Operations Enduring Freedom and Iraqi Freedom,
2,328 nurses and medical technicians deployed as members of 24
EMEDS units, treating more than 200,000 patients, combat
casualties and those suffering non-combat injury and disease.
Six nurses provided outstanding leadership as EMEDS commanders
in diverse locations around the globe.
AEROMEDICAL EVACUATION
Aeromedical evacuation is a vital link in combat casualty
care and a key Air Force capability. Since last spring, we have
flown over 3,200 missions and supported more than 40,000
patient transports. Our ability to provide critical care in the
air, using specialized transport teams, has bridged the gap
between point of trauma and definitive medical treatment.
RECRUITING
Air Force independent duty medical technicians provide
vital care in remote and deployed locations. They are jacks of
all trades, from providing medical and dental services, to
protecting troops from bioenvironmental hazards.
On the home front, we continue to aggressively organize,
train, and equip the nursing forces we need. A robust
recruiting program is essential to keep our nurse corps strong.
Fiscal year 2003 was our most successful recruiting year since
1998, yet we were still 100 nurses below our requirement.
Thanks to your tremendous support, this year we are offering an
increased accession bonus or loan repayment to new accessions.
We are optimistic that this will result in a more successful
recruiting year.
RETENTION
Retention is the other dimension of force sustainment. Air
Force retention remains strong at 93 percent. So despite
missing our requirement for 5 years, we were only 118 nurses
below our authorized end strength last year.
Education and training and research ensure we deliver top
quality nursing care. Air Force nurse researchers stay on the
cutting edge of military nursing science, and I am proud to
report that 21 are actively engaged in Tri-Service nursing
research program studies with a very strong emphasis on
operational research.
EDUCATION AND TRAINING
The Uniformed Services University Graduate School of
Nursing is aggressively developing programs to meet the needs
of Federal nurses. Their new perioperative clinical nurse
specialist program is the only one in the Nation and includes
preparation for practice in deployed environments. Three Air
Force nurses are in the inaugural class.
RESEARCH
Their new Ph.D. program will promote nursing research
relevant to Federal health care and to military operations.
Although the program is in its first year, the response has
been overwhelming with 12 nurses currently enrolled.
We continue to look for opportunities to capitalize on the
strength of our enlisted force and to provide avenues for
progression to a bachelor's degree in nursing. There is great
interest in the programs and growing our own nurses will
provide a strong nurse corps and ease our recruiting
requirements.
This has truly been an extraordinary year for our nurse
corps and we have reached two major milestones. Colonel Melissa
Rank's nomination to Brigadier General marks the first nurse
corps selection at an all-corps promotion board, and as you
mentioned, I was also promoted to Major General in August and I
am truly honored by the trust that has been placed in me.
PREPARED STATEMENT
Mr. Chairman, Senator Inouye, I am very proud to lead the
19,000 men and women of Air Force nursing, active duty, Guard,
and Reserve. Thank you for your tremendous support and for
again allowing me to share Air Force nursing accomplishments
and just a few of our plans for the future.
[The statement follows:]
Prepared Statement of Major General Barbara C. Brannon
Mister Chairman and distinguished members of the committee, it is
an honor and great pleasure to again represent your Air Force Nursing
team. What a dynamic time in the history of our nation! Last year, at
this time, our allied forces had toppled the regime of Saddam Hussein
and focus had shifted to peacekeeping and humanitarian relief for the
Iraqi people. Today, the fighting continues and our soldiers, sailors,
marines and airmen continue to make the ultimate sacrifice for their
nation. Terrorist organizations continue their campaign of carnage
throughout the world, and horror is commonplace on front-page news.
This war is far from over.
Our nation has expressed pride and grateful appreciation for the
selfless sacrifice of our soldiers, sailors, airmen and marines. The
American Soldier is Time magazine's Person of the Year. And the
American public holds the nursing profession in very high esteem. In a
recent Gallup poll, Nursing was rated the most honest and ethical
profession.
As our military men and women fight far from home, they count on
great medical support in theater and for their loved ones at home.
Nursing plays a pivotal role in Air Force healthcare in both arenas.
Lieutenant General Taylor has highlighted the importance of Preventive
Health Assessments, Individual Medical Readiness, and post-deployment
health assessments. All these programs, in which nursing personnel have
key administrative roles, have been integral to the success of
deployment health. The disease non-battle injury rate of 4 percent for
this conflict is the lowest ever achieved. That translates to more
healthy people ready to execute the mission.
Active duty, guard and reserve Nurse Corps officers and aerospace
medical service technicians also serve around the world to provide
robust medical support to our combat units, victims of natural
disasters, and those who need humanitarian or civic assistance. It is
my honor to share some of our activities in support of deployment and
training and some of the stories of our everyday heroes.
Our first priority, and our greatest success, is our ability to
maintain constant mission readiness for any contingency. We deploy
anytime, anywhere at our nation's call. To support Operations ENDURING
FREEDOM and IRAQI FREEDOM, 725 nurses and 1,603 medical technicians
deployed as members of 24 Expeditionary Medical Support units, or
EMEDS. Five of these deployed units have been equipped with chemical
and biological protection to counter potential threats. Our EMEDS teams
have treated more than 171,000 casualties, those injured in combat and
those with non-combat injuries and disease. I am very proud to report
that six nurses were deployed as EMEDS commanders during the past year.
These nurse leaders, in charge of deployed wing medical facilities,
were absolutely outstanding in meeting healthcare needs of combined and
coalition forces in such diverse locations as Saudi Arabia, Romania,
the United Arab Emirates, Bahrain, and Diego Garcia.
Aeromedical Evacuation has had a starring role in Operation IRAQI
FREEDOM and continues to be a critical core competency for the Air
Force. It is battle tested and it works, providing state-of-the-art in-
flight medical care for transport of U.S. and coalition forces. The
system has exceeded all expectations in providing life-saving care
during transport of the sick and injured from battlefields to their
home units. Since last spring, we have flown over 3,200 missions and
supported more than 40,000 patient transports without a single in-
flight combat-related death. We have transformed the aeromedical
evacuation system from one relying on specific aircraft and dedicated
missions, to an integrated multiplatform capability, which uses
available aircraft and prepositioned aeromedical evacuation crews.
Through the vision and ingenuity of our leadership, we have overcome
numerous challenges and have continued to move forward, demonstrating
flexible, timely support to combat operations.
Our Flight Nurses and Aeromedical Evacuation Technicians are
seamlessly integrated with Medical Service Corps Officers, front-end
aircrews, maintenance crews, and ground medical units in areas of
operations. Combining the capability of the Critical Care Air Transport
Teams (CCATT) with Aeromedical Evacuation crews has brought definitive
care closer to the point of injury, faster than ever before. The
additional capabilities of the CCATT makes it possible to safely
transport stabilized patients by air, reduces the requirement for in-
theater beds, and gets injured troops to definitive care in hours
rather than days.
Major Dan Berg was a member of the Critical Care Air Transport Team
that cared for a 19-year old soldier whose convoy had been hit by
rocket-propelled grenades. Major Berg provided care to the critically
injured patient throughout the 10\1/2\ hour flight. Only able to
communicate by writing on a notepad, the young soldier wrote that he
never expected such care so far from home. Major Berg showed the young
man his flight suit patch, which bore the promise, ``Committed to the
Wounded Warrior.''
Nurses play a vital role in tailoring the aeromedical evacuation
system to meet needs of our forces. The Andrews AFB team converted the
base gymnasium into a 100-bed contingency aeromedical staging facility
(CASF). Eighty-five medical professionals activated from the 459th
Aeromedical Staging Squadron staffed the facility, working with a
smaller active duty team from the 89th Medical Group. During peak
operations, personnel at the CASF managed up to 6 inbound overseas
missions per week with 50-70 patients per mission. Many of the patients
were transported directly from the flight line to Walter Reed Army
Medical Center and the National Naval Medical Center, but up to 92
patients remained overnight in the CASF for further air transport.
Within the past 12 months, the CASF team supported over 850 aeromedical
evacuation flights and coordinated over 15,700 patient movements. Great
teamwork between our Air Force components and sister services made this
mission a resounding success.
Seamless integration with the medical teams of our sister services
has been critical in many locations during Operation ENDURING FREEDOM
and IRAQI FREEDOM. Major Kathryn Weiss, a nurse anesthetist from
Hurlbert Field, deployed with the Army's 10th Special Forces Group to
Northern Iraq to provide frontline emergency medical capabilities in an
imminent danger area within the range of enemy artillery. The team
treated casualties suffering from bullet and shrapnel wounds as well as
those injured in motor vehicle crashes. The team was recognized by the
award of the Bronze Star for their meritorious achievements.
Major Weiss is just one example of the tremendous capability of our
Certified Registered Nurse Anesthetists. They are frequently part of
our Mobile Field Surgical Teams, substituting for anesthesiologists.
Seventeen of the twenty-seven certified registered nurse anesthetists
who deployed in 2003 were filling anesthesiologist taskings and
provided top-notch surgical support.
Our Air Force Independent Duty Medical Technicians are linchpins in
health care delivery in remote and deployed locations. They are ``jacks
of all trades'' and masters of health care modalities from routine and
emergency medical and dental care, to biomedical environmental
management. IDMTs are invaluable in the full spectrum of military
missions to include Special Operations, EMEDS, Forward Air Controllers,
Combat Communications and coalition team activities.
Recently one of our IDMTs, MSgt James Koss from Tyndall Air Force
Base, accompanied a coalition force in Iraq and provided support in
medical intelligence, personnel and field sanitation, force protection,
medical pre-screening and coordination of medical care. His preventive
health initiatives were key to a low rate of heat related injuries and
disease outbreaks.
In Iraq, Nurse Corps Colonel David Adams, Director of Force Health
Operations for the Office of the Assistant Secretary of Defense for
Health Affairs, served as Chief of Strategic Planning for the Coalition
Provisional Authority in Baghdad. Colonel Adams assisted the Minister
of Health in identifying healthcare system needs and then coordinating
support from other nations. Colonel Linda McHale, an Air Force Reserve
Individual Mobilization Augmentee is mobilized to work with the Iraqi
Minister of Health in establishing training programs for nurses and
medical technicians.
In French Village, Iraq, a three-member team from the 122nd Indiana
Air National Guard Fighter Wing set up a medical clinic to restore
health care for the villagers after their civilian clinic had been
looted and destroyed by insurgents earlier in the year. Captain (Dr.)
Jeff Skinner, Senior Master Sergeant Tommie Tracey and Senior Airman
Matt Read collected donations of essential items for the clinic,
including children's vitamins and a play set for the waiting room. When
all was ready, they assisted with the grand opening of the new
facility.
In addition to providing service in Operation ENDURING FREEDOM and
IRAQI FREEDOM, Air Force Nursing actively supports Homeland Security
and humanitarian relief. Air Force Lieutenant Colonel Linda Cashion,
Chief of Air Force Homeland Security Medical Operations, was the first
nurse to complete a fellowship with the National Disaster Medical
System, part of the Federal Emergency Management Agency. She provided
valuable assistance in planning and implementing the Disaster Relief
Program and expertly developed the nursing role for Disaster Medical
Assistance Teams. Colonel Cashion was also instrumental in coordinating
care for 26 critically burned victims in the Rhode Island nightclub
fire.
Air Force nursing support of humanitarian missions reaches around
the globe. Chief Master Sergeant Virginia Thompson, an Air Force
aeromedical technician at Randolph Air Force Base, participated in a
two-week mission to El Salvador last year where the team of eleven
medical personnel treated 3,000 patients. This humanitarian mission not
only advanced host-nation health, but also afforded our military
medical personnel valuable experience applicable to future humanitarian
missions.
During another humanitarian effort, First Lieutenant Lynn
Zuckerman, Master Sergeant Baron Stewart and Staff Sergeant Patricia
Fernandez from the 375th Medical Group, Scott Air Force Base were part
of an eight person team that participated in a U.S. Southern Command
sponsored mission to Guatemala. The team provided medical care to the
under-served Guatemalan population in the isolated villages of San
Sebastian, San Jose Caben, Rincon and Chim. During this mission, 5,600
patients received treatment for a wide range of conditions including
gastrointestinal illnesses from parasitic infection and chronic
debilitating disease from arthritis and heart disease.
Air Force nursing vigorously supports international partnerships.
Personnel from the 435th Medical Group, Ramstein Air Base, participated
in EUCOM-directed multinational mass casualty exercise. Nurses and
medical technicians trained over 100 medical students in Georgia, the
independent state of the former USSR, on a variety of skills to include
moulage, self-aid buddy care, and advanced trauma management. The team
also improved medical support in the community by training 30 local
civil defense authorities in mass casualty and disaster management. The
U.S. Ambassador to Georgia praised the team's tremendous support in
providing much-needed training.
skills sustainment
Air Force medics could not succeed in our expeditionary deployments
without targeted training to ensure clinical currency. The Readiness
Skills Verification Program (RSVP) continues to ensure that our
personnel are trained in the wartime skills they need and that they
stay current in those skills. The training is accomplished at home
station and at multiple off site locations. As I mentioned last year,
at our Centers for Sustainment of Trauma and Readiness Skills (C-STARS)
programs, we partner with civilian academic centers to immerse our
nurses, medical technicians, and physicians in all phases of trauma
management to sharpen combat casualty care skills.
We now offer this terrific program at three locations: The Shock
Trauma Center in Baltimore, The University of Cincinnati Medical
Center, and Saint Louis University Hospital. By expanding the program,
we have been able to train more medics each year. Over the last 2\1/2\
years, 334 nurses and medical technicians have completed the training;
almost half of these were trained in 2003.
First Lieutenant John Cleckner, a critical care nurse preparing to
deploy on an EMEDS validated the program's importance by saying, ``This
experience allowed me to significantly update and hone my trauma
skills. Now I'm confident that I am ready.''
As part of the C-STARS program, nurses complete an Advanced Trauma
Life Support Course, and medical technicians complete the Pre-Hospital
Trauma Life Support course. Both courses teach aggressive trauma care
techniques and how to adjust standard treatment when projectiles and
velocity impact the victim. These competencies are essential to care of
wartime casualties.
recruiting and retention
We have a robust recruiting program, which is essential to keeping
the Nurse Corps healthy and ready to meet the complex challenges in
healthcare and national security. Numerous incentive programs have been
instituted to prevent a nursing shortage in the Air Force, but
shortfalls continue to be an enormous challenge both nationally and
internationally. Last year, the Bureau of Labor Statistics reported
that registered nurses are at the top of ten occupations with the
largest projected job growth through the year 2012. One positive sign
is that the number of enrollments in entry-level baccalaureate programs
increased by 16.6 percent last year, although there were an additional
11,000 qualified students turned away due to limitations in faculty,
clinical sites, and classrooms. Employer competition for nurses will
continue to be fierce and nurses have many options to consider.
Quality of life and career opportunities, coupled with other
incentives, are critical recruiting tools for Air Force Nursing. Fiscal
year 2003 was our most successful recruiting year since 1998. Although
we have recruited approximately 70 percent of our goal each year since
fiscal year 1999, we have seen an increase in the number of new
accessions each year. Last year, we recruited 16 percent more nurses
than in fiscal year 2002, and I attribute the increase largely to our
educational loan repayment program. In order to compensate for our
current shortfall and projected separations, our fiscal year 2004
recruiting goal is 394 nurses. Funding is available to offer new
accessions either a $10,000 accession bonus or up to $28,000 for
educational loan repayment. We have $5.2 million available to fund
these initiatives in fiscal year 2004 and are hopeful that our
accession numbers will exceed last year. As of March 31, 2004, we have
brought 108 new nurses onto Active Duty--on par with last year and
about 27 percent of goal. We attract some of the best nurses in the job
market today, although most are very junior with respect to experience
level.
This year we continue to recruit nurses up to the age of 47 to
boost our ranks. We commissioned 25 nurses over age 40 last year, and
although they are not retirement eligible, they provide tremendous
support during their time on active duty. They have the critical skills
and clinical leadership we need to meet our peacetime and wartime
readiness mission, as well as years of clinical experience to share
with our novice nurses.
Our slogan, ``we are all recruiters,'' continues to rally support
as we tackle the challenge of recruiting. I have fostered more
effective partnering with recruiting teams to maximize recruiting
strategies and success. Among other activities, we have increased
nursing Air Force ROTC quotas from 29 in fiscal year 2003 to 35 in
fiscal year 2004, and 100 percent of our quotas have been filled.
I take advantage of every occasion to highlight the tremendous
personal and professional opportunities in Air Force Nursing. I
encourage nurses to visit their alma mater and nursing schools near
their base to market quality of life and professional opportunities as
an Air Force Nurse. This has proven to be a powerful recruiting tool.
We have also expanded media exposure of the outstanding
accomplishments of our people and their support of troops in Operation
IRAQI FREEDOM. This past fall, Secretary of Defense Rumsfeld's visit
with our aeromedical evacuation teams in Baghdad was highlighted in
print media, and Major Keith Fletcher, an Air National Guard Nurse from
the 379th AES Mobile Aeromedical Staging Facility, was featured in a
photo with the Secretary. Air Force Reserve nurse Major Tami Rougeau
was selected as one of the ``Heroes Among Us'' by the National Military
Family Association, and she rode in the Rose Bowl Parade with other
honorees. Another Air Force Nurse Corps star, Captain Cynthia Jones
Weidman of Scott Air Force Base, Illinois, was awarded the American Red
Cross Florence Nightingale Medal, one of the highest honors in the
nursing profession. She was the first Air Force Nurse to receive the
medal, and the first military nurse since 1955. Air Force nurses
present very positive images in the news.
Retention is the other key dimension of force sustainment. Our
retention remains strong at 93 percent and, despite not meeting our
recruiting goal for five successive years, we were only 143 nurses
under our authorized end strength of 3,862 at the end of fiscal year
2003.
Lieutenant Colonel John Murray, one of our doctorally-prepared
Nurse Corps officers, developed a standardized, web-based officer
assessment tool to identify what influences officers to remain on
active duty or separate from the Air Force. The pilot study began in
January 2004 with a sample of Nurse Corps officers. The assessment tool
will help identify targets of opportunity to enhance quality of life
and professional practice. We continue to recommend Reserve, National
Guard, and Public Health Service transfers for those who desire more
stability in their home base but wish to continue military service and
can meet deployment requirements.
research
Air Force nurse researchers stay on the cutting-edge of advancing
the science and practice of nursing. I am proud to say that twenty-one
Air Force nurses are actively engaged in TriService Nursing Research
Program (TSNRP) funded initiatives.
Air Force researchers are leaders in the Department of Defense and
the Nation in operational nursing research. In fiscal year 2003,
nursing research at Wilford Hall Medical Center continued to focus on
care of the war fighter in military unique and austere environments. A
study on the thermal stresses onboard military aircraft led to
evaluation of products designed to maintain body temperature in
critically injured patients during aeromedical evacuation. This will
identify devices that are effective in maintaining temperature control
to improve support and survivability of casualties.
The TSNRP-funded Air Force Combat Casualty Aeromedical Nursing
research study describe the experiences of AE crewmembers in providing
combat casualty care to gather information that can be used to improve
AE nursing practice. The study also aims to pilot a research instrument
to measure characteristics of casualties in different locations and the
nursing care required. This study will influence AE combat casualty
care and future training.
Another study, ``Recruitment Decision Making for Military Nursing
Careers'' is being conducted collaboratively by military nurse
researchers at Keesler AFB and nursing researchers at the University of
South Alabama. The goal of this study is to describe factors that
influence nursing students in considering military nursing careers.
This study will help identify the characteristics of individuals
interested in military service and guide recruiting services in
deploying recruiting initiatives.
education
The Graduate School of Nursing at the Uniformed Services University
has demonstrated tremendous flexibility and capability in meeting the
needs of uniformed nurses. They began a clinical nurse specialist
master's program at the request of the Federal Nursing Chiefs and also
inaugurated a Ph.D. nursing program. The Perioperative Clinical Nurse
Specialist program is the only one in the nation and includes special
preparation for operating in a field environment so graduates are ready
for deployment challenges. Three Air Force nurses are in the inaugural
class.
The Ph.D. program was established to meet the evolving need for
nursing research relevant to federal health care and military
operations. It affords federal nurses the opportunity to study in a
unique environment and gain exceptional qualifications to lead in
research, education, and clinical practice. Although the program is in
its first year, the response has been overwhelming, and twelve nurses
are enrolled either full or part time.
nursing force development
Nursing has vigorously embraced the Force Development initiative
launched last summer by Air Force Secretary James G. Roche and our
Chief of Staff, General John P. Jumper. General Jumper describes the
construct as making sure ``we place the right technical and leadership
skills in the right places with the right people who are educated and
trained for success''.
Each officer career field has a dedicated Development Team (DT) to
guide the assignments and educational opportunities for each officer.
Our Nurse Corps DT has already played a substantial role in selecting
chief nurses for our facilities, best assignments for our Colonels on
the move and educational programs and candidates we will sponsor.
We continue to work on opportunities to capitalize on the knowledge
and experience of our enlisted force, and provide them more avenues to
acquire advanced training and credentials. Eight medical technicians
will graduate from the Army's Licensed Practical Nurse training course
in April 2004 and we are looking at ways to increase LPN numbers. The
Air Force Reserve is piloting an initiative to send new enlisted
nursing personnel to a civilian LPN program. We have reviewed Navy
enlisted baccalaureate scholarship programs and are reviewing similar
opportunities for our enlisted personnel to earn a bachelor's degree
and a commission in the Nurse Corps. This has great potential to reduce
our recruiting deficit by ``growing our own'' nurse corps officers from
our enlisted ranks.
The global war on terrorism and a resource constrained environment
has driven us to look even harder at efficiencies in nursing force
utilization. Recent research has shown that a more educated nurse
force, implementation of higher nurse-to-patient ratios, and better
nursing work environments contribute to improved patient safety and
lower patient morbidity and mortality. The Air Force Medical Service
chartered Product Line Analysis and Transformation Teams to study
civilian healthcare industry staffing models and best practice
benchmarks. The new models they identified for nursing are being used
to adjust staffing requirements.
The Nurse Corps Top Down Grade Review mentioned in my testimony
last year is progressing, and we have identified the need to rebalance
Nurse Corps grade authorizations to better meet readiness and in-
garrison healthcare requirements, and provide healthy career
progression and promotion opportunities more in keeping with those of
line officers and other medical service corps. Another aspect of our
grade review was to determine the number of active duty nurses required
for deployment and other military unique requirements. With this
process, we have identified opportunities to civilianize many nurse
positions. The methodology employed in the Nurse Corps study is being
applied to all other career fields in the Air Force Medical Service to
determine force structures and appropriate civilian/military mix.
This has been an extraordinary year by all measures, and our Nurse
Corps also reached two big milestones in our history. The nomination of
Colonel Melissa Rank to Brigadier General marks the first selection of
a nurse corps officer by an ``all corps'' promotion board. It is a
testament not only to her outstanding performance but also reflects the
magnitude of leadership and talent we have in our Air Force Nurse
Corps. I was also promoted on the first of August to Major General,
another Air Force first. It is a great honor and very humbling. I am
grateful to have the opportunity to continue to serve. For the first
time in history, we will have two active duty nurses concurrently
serving the Air Force as general officers.
Mister Chairman and distinguished members of the Committee, it has
been a joy and great honor to lead the 19,000 men and women of our
active, guard and reserve total Air Force Nursing team. Thank you for
your tremendous advocacy and stalwart support to our great profession
of nursing and for inviting me to share the accomplishments of Air
Force Nursing once again.
Senator Stevens. Thank you all very much.
I am going to yield to the patron saint of military nurses,
my co-chairman.
Senator Inouye. I thank you very much.
RECRUITING AND RETENTION
Nurses are all angels to me. They are very important.
As all of you have indicated, our major concern is
recruiting and retaining. I just want to make certain that
these programs continue.
For example, the Tri-Service nursing research program is
not funded. I was told it is number nine on the USUHS priority
list. Do you believe this committee should override that and
fund it?
General Brannon. Well, sir, if I may speak, I think the
Tri-Service nursing research program initiatives have
tremendous impact on the progress in military science for
operationally nursing. I think it is a unique funding stream
and allows us to do many great studies. I would hate to lose
that avenue.
Senator Inouye. If it is not funded, would it have any
impact or implication on patient care?
General Brannon. Yes, potentially. At aeromedical
evacuation, we have a Tri-Service nursing research funded
program that is looking at the environment of the various
aircrafts and how we can mitigate some of the heat and cold
concerns to provide a more stable transport environment for
patients. That very clearly would adversely impact patients if
we cannot complete that research. That is just one of many
examples.
Admiral Lescavage. Sir, I echo what General Brannon just
said. I believe research is key to our future. As you queried
the previous panel of our Surgeons General, you did also
mention the subject of research. Research is quite competitive.
There are never enough dollars for any type of research, as you
well know.
Should the funding go away, I see our nursing projects
certainly as very important, but I know all of the good work,
some 75 ongoing projects right now--some of them would not get
the attention they need, and we would suffer from not being
able to do it all. But I am certain we also would keep the
highly relevant ones going, for instance, in the combat arena.
We very much appreciate the funding that we get every year
and frankly do not want to live without it.
Senator Inouye. We have a graduate school of nursing,
Colonel, and also a doctoral program. Should they be continued?
Colonel Gustke. Yes, sir, most definitely. We have had the
opportunity from the Army's perspective for the last 3 or 4
years to use the Uniformed Services University (USU) program
strictly for education of our family nurse practitioners, and
without that program, we would not have the necessary funding
to do that.
Additionally, this past year we had our first inaugural
year of the perioperative nursing program which, of course, is
an extremely, go-to-war skill. This year we have educated four
to six perioperative nurses from the Army and we will continue
to do so every year. We have been extremely fortunate in
educating additional certified registered nurse anesthetists
(CRNAs), which again is another go-to-war mission that is
important for us. Without this program, it would have a severe
impact upon our ability to do so.
Senator Inouye. Do these programs have any impact on
recruiting and retention?
Colonel Gustke. Well, sir, I would say the ability for our
nurses to attend long-term health education is a very big
retention carrot. Many of our nurses say that once they hit
that 6th, 7th, 8th year--it is between the 4th and 6th years
when we lose a number of our nurses. So we probably have our
biggest retention problems, if we have any, at any particular
given year. And many of our nurses say the ability to go back
to graduate school and for the military to pay that bill for
them to get their advanced education is extremely important to
them. It is one of the reasons they come in. It certainly is
not pay. It certainly is not incentive pay of any kind, but it
is the ability to advance their education. I think to lose that
capability would have a severe impact upon our retention.
LOAN REPAYMENT PROGRAMS AND BONUSES
Senator Inouye. We have been impressed upon, that in about
10 or 15 years, we will have a nursing shortage of about
400,000 nurses in this country. Obviously, that will have an
impact upon the military nurse corps. Do these loan repayment
programs and bonuses make a difference?
Colonel Gustke. Yes, sir. I will tell you from our
perspective, this is our inaugural year in using the health
loan repayment plan. We have got three programs in effect
currently for recruitment. First, if individuals used health
professions loan repayment program (HPLRP), they come in for 3
years. Second tier, they can use HPLRP with an accession bonus
of $5,000 and come in for 6 years, and the third tier is for
them to just accept a $10,000 bonus and come in for 4 years.
Under those plans, this past year we have seen anywhere from 12
to 15 applicants come in the Army Nurse Corps each month. With
these continued programs, we firmly believe that we will be
able to meet our mission this year for the first time in 3
years, our USAREC recruitment mission. So having spoken to the
folks out in the field and the recruiters, they want to keep
these initiatives going, and we would also certainly like to
see an increase in our accession bonus as the years progress to
see where we are competitively with the civilian market. But it
has been extremely good to us this past year.
Senator Inouye. I suppose you all agree.
General Brannon. Yes. Of the almost 100 nurses that have
been recruited so far this year, 60 percent have taken a loan
repayment and 40 percent the increased accession bonus. I just
came from a recruiting conference yesterday and they applauded
the efforts, that they are making a tremendous difference
because we are more competitive with the civilian facilities.
So thank you.
Admiral Lescavage. It is my belief nurses anywhere want
three things: to be appreciated, which we do very well I
believe in the military; to be compensated, our pay is very
good; and to be educated. The pipeline programs I mentioned in
my testimony, the ROTC programs, really help us out with
bringing nurses into the Navy and then the issue is to retain
them. We offer about 80 scholarships a year. As I visit our
facilities, I always ask the question, who has been to duty
under instruction. A fair amount of hands will go up. And who
wants to duty under instruction, the scholarships we give while
on active duty. Many, many hands go up. It is sort of a fever
that has been created, and it is our best retention tool. I
myself have had two scholarships from the Navy. It is highly
valued.
Senator Inouye. Well, I am certain I speak for the
committee, and I speak for all of my colleagues in thanking all
of you for your service to this Nation.
On a personal note, I spent just about 20 months in
military hospitals, and if it were not for nurses, I do not
suppose I would be sitting here. So to you, thank you very
much.
Senator Stevens. Well, I did not spend that long, but I
spent my time in military hospitals too. I think that the
Senator is right. You have the calling of the angels.
SURGE CAPABILITY FROM GUARD AND RESERVE
My only question would be, is there enough emphasis on a
surge capability in time of war, as I have talked to my
previous panel, for doctors and surgeons in particular? Do we
have a surge capability from the Guard, Reserve? You mentioned
total force. You mentioned it somewhat too, Colonel. But I
don't want to be offensive, but I do not sense the commitment
to the ongoing capability of former members of the service to
have plans to bring them back in if needed. Can you comment? Do
we have sufficient plans really to call up additional people
from Guard and Reserve if they are needed?
Colonel Gustke. Well, sir, I will tell you from the Army's
perspective, we have three things in place currently. We have
not skipped a beat in providing patient care to date, no matter
what facility you will go to. We have the GWOT dollars to
supplement with our contract civilian nurses, which has been
very successful. We have integrated Reserve units as back-fills
in our medical treatment facilities, both in CONUS and
overseas, and then we have also used our 91 percent fill rate
for our civilians which has been very successful, the direct
hire authority.
We also have had a number of military nurses call up and
want to come back on active duty. So there is a program in
place at our branch right now to look at that plan, should we
ever need that to come to fruition. But for right now, sir, I
think what we have in place is working very well, and should
the need arise, we will look at that and get back in more
detail on it, sir.
Senator Stevens. Admiral.
Admiral Lescavage. Sir, I feel fully confident that we are
ready. During my tenure, what we have done, actually before we
ever went into Iraq, was to look at our critical specialties,
make sure not only do we have the numbers, but that we have
provided the training that they need. And that is in areas of
nurse anesthesia, operating room, emergency room, and critical
care. What happened, once we did go into Iraq, I, as Colonel
Gustke just described, received many calls from previous active
duty to come back, our reservists. We are manned at 105
percent. The key to the Reserves is to get more in the middle
grades. We have many in the senior grades. So we are now
tweaking that to try to recruit more middle grade officers into
the Reserves. But, sir, I feel we are ready.
Senator Stevens. General.
General Brannon. Well, we are a total nursing team, and we
have relied heavily on our Reserve and Guard brethren to
support the nursing missions, particularly aeromedical
evacuation. I will say some has been mobilization. Most of the
positions are really being filled with willing volunteers at
this point. So I remain always impressed and astonished at the
commitment from our Reserves and our Guard.
Senator Stevens. Thank you very much.
My mind goes back to the time that I introduced an
amendment to change the draft laws to draft women. It was
defeated, as we expected, but we also then defeated the draft.
We have relied on volunteer entrants to all of our services,
and retention of some of those people who retire or leave
before retirement for the purpose of surge capability in the
cases of war and emergencies. So I think we sometimes forget
the numbers that we were part of, 6 million and 7 million men.
All-out war requires an enormous capability.
I am not sure we have that capability today under the
volunteer service, but I think we have to find some way, as I
mentioned to the doctors, to try and see if we can provide the
incentive for some people to be trained and just be literally
reserved for crisis or all-out war, not for just the temporary
surges in numbers. We are still in a fairly small war in
comparison to the time when the two of us were in the service.
God forbid we will ever have to do it. But I am not sure we
have plans to do it. That is what bothers me. I would like to
talk to you about it sometime in the future.
ADDITIONAL COMMITTEE QUESTIONS
But meanwhile, I do appreciate what you have done, and I
echo what my friend says about the admiration we have for all
of the people that are in your service. They are not all women,
as a matter of fact. You are all women, but I have met many
male nurses in the service, and I commend them and we commend
all of you. Thank you for your service.
[The following questions were not asked at the hearing, but
were submitted to the Department for response subsequent to the
hearing:]
Questions Submitted to Lieutenant General James B. Peake
Questions Submitted by Senator Patrick J. Leahy
Question. General Peake, I am pleased to hear of the progress that
the Army is making in its efforts to develop modern alternatives to the
deployable medical field systems, or ``DEPMEDs,'' that we've had in
service for so many years. Is it true that the Army would like to begin
fielding an alternative to DEPMEDs as early as calendar year 2005 once
a final design is decided?
Answer. The Army's Transformation Objective requires a Force that
is strategically responsive and dominant at every point on the spectrum
of operations. Heavy forces must be more strategically deployable and
more agile with a smaller logistical footprint, and light forces must
be lethal, survivable, and tactical.
For more than 20 years the Department of Defense has employed
Deployable Medical System (DEPMEDS) hospitals for any significant
deployment of combat forces. Whether configured as the Navy's Fleet
Hospital, the Air Force's Air Transportable Hospital, or the Army's
Combat Support Hospital, each service uses essentially the same concept
of moving special purpose medical shelters, both tents and ISO
shelters, with a very low level of pre-integrated equipment, which
required a significant number of transport containers. As a result of
transformation throughout DOD, the need to rapidly deploy a range of
scaleable, modular medical capabilities, which have the flexibility to
be tailored and packaged to support a full range of combat operations,
has become paramount. Accordingly, the concept for the Future Medical
Shelter System (FMSS) shall respond to the joint requirements of the
U.S. Army and the U.S. Navy.
The FMSS shelter concept integrates the majority of medical
supplies and equipment directly into the ISO containers thus
eliminating separate packaging for these items and reducing the need
for additional transport shelters and reducing weight and cube of the
DEPMEDS hospital by approximately 30 percent. Consequently, the
strategic deployability (air, ship, and truck transport volume)
requirements are correspondingly reduced. Additional benefits of
integration are enhanced tactical mobility as a result of the decreased
time required to set up and prepare a DEPMEDS hospital for operation,
conservation of the fighting strength by providing CONUS standards of
medical care for soldiers deployed in world wide operations, and the
ability to operate in all climates due to the environmentally
controlled and chemical-biological overpressure protected environment.
The fully modular system with integrated plug-and-play capability will
have the required flexibility to be tailored and packaged to support
the full range of combat operations.
The Army is currently managing three separate Congressionally
funded FMSS initiatives, Oak Ridge National Laboratories (ORNL), Mobile
Medical International Corporation (MMIC), and EADS-Dornier. Each is
developing a design for an Operating Room ISO container. ORNL and MMIC
will deliver prototypes to the Army in May 2004 and July 2004
respectively. EADS-Dornier is funded to provide engineering drawings of
the OR ISO by December 2004.
The FMSS program is in the Concept & Technical Development/Systems
Development & Demonstration phases of development. Much work remains to
ensure that these units are suitable for military use. It is unlikely
that this could be accomplished by 2005 due to the fact that there is
no funding available for further development or testing. There was no
fiscal year 2004 Congressional Appropriation for the FMSS and the Army
has no funding to support development or procurement of these
initiatives, however, it is desired to begin replacing our aging
DEPMEDs containers with these new enhanced capabilities as soon as
possible. With your assistance and additional RDT&E funds, we should be
able to achieve a procurement decision by the end of fiscal year 2006.
As a reminder, the original DEPMEDs procurement was funded through
direct Congressional Appropriation. Due to the projected cost of
replacing DEPMEDS and current DOD funding priorities, this approach is
the most likely scenario for a successful procurement of a DEPMEDs
replacement.
Question. General Peake, in that the hard-shell mobile hospital
alternatives you are developing deploy very quickly and feature
nuclear-biological-chemical protective capability, do you see these
units having a possible role in disaster or terrorist incident response
either at overseas U.S. bases or in this country?
Answer. I believe the hard-shell mobile hospital alternative you
refer to is the Chemical Biological Protective Shelter (CBPS). The CBPS
is not exactly a mobile hospital alternative, however, it provides a
highly mobile, self-contained, contamination free, environmentally
controlled medical treatment area for forward deployed medical
treatment units. (Battalion Aid Stations, Division & Corps Med
Companies and Forward Surgical Teams). The CBPSs are complexed to
provide these capabilities.
The CBPS is a 300 square foot, air beam, soft wall shelter rolled
up and transported on the rear of a Highly Mobile Multipurpose Wheeled
Vehicle with Light weight Multipurpose Shelter and a trailer mounted
Tactical Quiet Generator. The system can process 10 Litter/ambulatory
patients per hour. It is Type Classified Standard with full materiel
release and is currently in procurement through the Joint NBC Defense
Program.
The CBPS could have a role in disaster or terrorist incident
response as it provides a contamination free environmentally controlled
environment for treatment and surgery. Its capacity, however, is
limited.
Question. Do you and Dr. Winkenwerder anticipate use of this type
of mobile diagnosis/treatment center in medical diplomacy missions
where the Pentagon is trying to win the ``hearts and minds'' of
ambivalent local populations in places like the Philippines, Middle
East, and the Western Horn of Africa?
Answer. The Chemical Biological Protective Shelter (CBPS) provides
a contamination free environmentally controlled environment for the
provision of sick call, advanced trauma life support and surgery on the
contaminated battlefield. The CBPS currently is in the initial stages
of procurement and is in short supply.
I believe the CBPS can provide a small mobile medical treatment
facility (clinic like capability) for diagnosis/treatment in medical
diplomacy missions. This use must be coordinated between the Department
of Defense and Department of State.
______
Questions Submitted by Senator Richard J. Durbin
blood substitutes
Question. I have heard of advances the Army and the Navy are making
in developing blood substitutes for treating combat wounded. I know the
Army has successfully completed Phases I and II with Northfield
Laboratories in Illinois and are working with the FDA for approval, as
well as the lab, to complete Phase III which would provide for clinical
trials. I believe it is critical that we continue to support these
efforts as they have significant battlefield applications, as well as
first responders in a natural disaster or terrorist attack.
Would you explain what these blood substitutes are, and why they
are important to the future of combat casualty care and your assessment
of their prospects for success for all services?
Answer.
What are blood substitutes
The most common approach that has been taken to develop blood
substitutes is to harvest hemoglobin, the natural molecule that carries
oxygen to vital tissues, from either human or bovine (cattle) sources.
The hemoglobin is then subjected to proprietary processes to remove
unwanted materials and to remove or inactivate potential infectious
agents. Other proprietary processes are used to build the individual
hemoglobin molecules into chains of hemoglobin. This process is
believed to reduce or eliminate toxic effects caused by individual
molecules of hemoglobin. Once processing is completed the hemoglobin is
ready for use as a means to provide oxygen-carrying capability to
subjects who have lost significant amounts of blood. These preparations
are referred to as hemoglobin-based oxygen carriers (HBOC). Other
approaches are being pursued but they are much earlier in their
development and will not be ready, if ever, for many years.
Potential utility for the military services
Combat injury on the battlefield typically occurs in the absence of
ready availability of packed red blood cells (PRBC), the derivative of
whole blood that is normally required to manage patients who have
severe bleeding. Most deaths that result from severe bleeding on the
battlefield occur within the first hour of injury. It has been
difficult to solve this problem because medics on the battlefield
cannot carry PRBC. PRBC must essentially remain refrigerated until
used. HBOC have the advantage that they are much more stable when
removed from refrigeration and can therefore be carried on the
battlefield for at least limited periods (days to weeks) and remain
safe for human use. Thus, more ready availability of HBOC on the
battlefield may provide a bridge for the casualty with life-threatening
hemorrhage that will permit survival until evacuation from the
battlefield can be accomplished.
Prospects for success of HBOC
An early HBOC developed by the Baxter Corporation was developed and
tested in the 90's and subsequently abandoned during advanced clinical
testing when an excessive (unexpected) number of deaths occurred among
patients treated with the product in their Phase 3 study.
Currently, two smaller companies, Northfield Laboratories, Inc.,
Evanston, IL and Biopure Corporation, Cambridge, MA have developed new
products incorporating new processes that it is hoped will mitigate the
toxicity problems seen with the Baxter product. Both Northfield and
Biopure have conducted animal and human studies of their products that
have both so far shown promise. However, large, phase 3 clinical
studies that demonstrate both safety and effectiveness remain to be
completed. Northfield Laboratories began a Phase 3 study in trauma
patients outside of the hospital in December 2003 and plans to complete
this study in 2005. If this study is successful (shows both safety and
effectiveness), the company anticipates licensure sometime in 2006.
Biopure Corporation, in collaboration with the Naval Medical Research
Center, plans to begin a Phase 3 study of their HBOC in trauma patients
outside the hospital later in 2004. If successful, licensure might be
anticipated in 2006 or 2007.
The Army and the Navy have continued to collaborate and remain
connected with both companies to help shape and ensure that their
products will have maximal relevance for military as well as civilian
application. In that regard, the Navy has recently assumed sponsorship
of the Phase 3 study that will be conducted with the Biopure
Corporation HBOC. The Army is collaborating with Northfield
Laboratories to make their HBOC available to Special Operations Forces
casualties on the battlefield in a controlled, pre-licensure treatment
protocol.
dental research
Question. As I am sure you are all aware, a DOD review panel in
2000 confirmed the need for the military dental research but found that
it is hampered by discontinuous funding streams. Last year, the
Committee included language in its report that ``directed'' the
Department to sufficiently fund the military dental research program at
the Great Lakes naval base. Last year Congress added $2 million for
dental research, which was actually only about half of what was
requested.
Could you tell this Committee how much the Army and Navy are each
putting into this program for fiscal year 2005?
Answer. The U.S. Army, through U.S. Army Medical Research and
Materiel Command, Combat Casualty Care and Walter Reed Army Institute
of Research fund the U.S. Army Dental and Trauma Research Detachment at
$1.687 million of which some support is provided for infrastructure and
$1.08 million is available for U.S. Army Dental Research.
Question. It is my understanding that one of the biggest problems
for deployed Soldiers is avoiding gum disease--like trench mouth. What
are the Army dental researchers at Great Lakes doing to address this
problem to prevent dental emergencies for deployed Soldiers?
Answer. The U.S. Army Dental Trauma and Research Detachment
(USADTRD) is approaching reduction of the historically constant 15.6
percent emergency rate in deployed Soldiers from several different
avenues. Firstly, (USADTRD) is developing a rapid PCR that will, if
successful, identify those Soldiers who are most susceptible to
accelerated deterioration of oral health during deployments. Once
identified, special measures, including diet and special oral hygiene
aides, can be prescribed specifically for that Soldier to prevent
becoming an emergency/evacuation. The single largest focus of USADTRD's
science program is the development of a safe, efficacious anti-
microbial peptide that can be added to military rations and control
dental plaque caused disease. It is anticipated this peptide will be
delivered via chewing gum, and will be effective in reducing/preventing
oral diseases even in the face of heightened stress levels and
decreased oral hygiene due to the optempo experienced during
deployments. Currently of the 15.6 percent emergency rate, 75 percent
of those emergencies are related to dental plaque. USADTRD is
projecting at least a 50 percent decrease in plaque related
emergencies. This will be a significant force multiplier for the
warfighter.
Question. The Navy dental researchers at Great Lakes have developed
several new products and pieces of equipment that allow corpsmen to
treat warfighters in the field saving time and money. Can you tell us
about some of that equipment?
Answer. In keeping in line with current U.S. Army doctrine, the
U.S. Army Dental and Trauma Research Detachment (USADTRD) has developed
and fielded a miniaturized dental field unit and operating system
(DeFTOS). This dental field unit significantly reduces the weight and
cube of dental equipment used in deployed environments. This reduction
allows dental equipment to be closer to the warfighter, permitting much
more rapid return to duty following evacuation for dental emergencies
as well as saving very valuable transportation assets for other
requirements. Currently USADTRD is also working to greatly reduce the
weight, size and electrical requirements for field sterilizers. By
accomplishing this, the U.S. Army will not only benefit with a smaller,
lighter sterilizer, but due to a lessened electrical requirement, a
great deal more weight and cubes will be saved by a far smaller
electric generator.
______
Questions Submitted by Senator Dianne Feinstein
Question. The antimalarial drug mefloquine has been identified as
causing severe side effects such as psychosis, aggression, paranoia,
depression and thoughts of suicide, even after use of the drug has
stopped. Could you please tell me why another quinolone, ciprofloxacin,
is being given to soldiers to self administer when consuming suspicious
foods in Iraq when the side effects from one quinolone have the
potential to be compounded by the second?
Answer. Mefloquine is a 4-quinolinemethanol derivative.
Ciprofloxacin is a fluoroquinolone that is an antimicrobial agent, used
to kill bacteria. The two drugs are not related. There are no known
drug interactions between mefloquine and ciprofloxacin. Furthermore, it
is not Army policy to give ciprofloxacin for self-administration when
consuming suspicious foods. In fact, Soldiers are cautioned against
consuming foods on the local economy. Soldiers have a variety of foods
provided for them, including Meals-Ready-To-Eat, T-rations, which
consist of containers of pre-packaged foods and fresh rations, which
are thoroughly inspected for quality.
Question. DOD has begun an investigation into psychiatric adverse
events in soldiers and plans a study of mefloquine. DOD has stated that
it has not included in its assessments several incidents in soldiers
who have taken mefloquine or soldiers who do not demonstrate blood
levels of the drug. FDA's News Release of July 9, 2003 states that
``Sometimes these psychiatric adverse events may persist even after
stopping the medication.'' What is being done by DOD to investigate the
incidents of suicides in soldiers while on or returning from
deployment? Any investigations should include soldiers who consumed
mefloquine and committed suicide or committed other acts of violence
whether there were residues identified in their blood or not. What is
DOD's timeframe for conducting a review of these cases and conducting
other studies of the effects of mefloquine?
Answer. The DOD uses all of the currently recommended antimalarial
medications, basing their choice on medical and operational
considerations for each mission. All of these medications have
potential side effects, and, the risks and benefits of each are
considered by our operational surgeons, when recommending a medication
for malaria prophylaxis. Recently, the antimalarial drug mefloquine has
been highlighted in news reports, alleging severe adverse side effects
potentially related to this medication. DOD is committed to finding
answers to the questions raised by these reports.
Dr. Winkenwerder, Assistant Secretary of Defense for Health
Affairs, has asked an expert panel of independent physicians,
scientists, epidemiologists, and ethicists from highly respected
civilian institutions and academia to recommend study designs that are
best suited to answering questions surrounding antimalarial
medications. Based on these recommendations, Health Affairs has
commissioned two studies. The first, to be led by the Deployment Health
Research Center at the Naval Health Research Center (NHRC) in San
Diego, will look at the (comparative rates of adverse events (including
neuropsychiatric)) associated with antimalarial use. A preliminary
descriptive study is underway and preliminary results should be
completed within one to two months. Based on the recommendations of the
expert panel, the NHRC will then partner with a civilian academic
institution to perform a retrospective cohort analysis of the data to
determine the comparative rates of adverse outcomes associated with
each of the antimalarial medicines. The details of this thorough
analysis are being developed now. We anticipate that this study will
take 12-18 months to complete.
A second study will address the questions raised about suicides in
our deployed and recently deployed service members. The Armed Forces
Institute of Pathology is leading this study. The first step will be a
comprehensive review to characterize all suicides in DOD. They will
then partner with a civilian academic institution to perform a case
control analysis in order to better understand the myriad of potential
attributable risk factors with these deaths. Use of the antimalarial
medication mefloquine will be one factor assessed in this study.
Planning for this study is underway, and we anticipate this extremely
thorough analysis to take 18 to 24 months to complete.
The creditability of this work will hinge on the fact that it will
be comprehensive and validated by the medical community. A non-federal
oversight board will oversee both of these study efforts--DOD will be
working with the American Institute of biological Sciences.
Question. What are you doing to specifically recognize and report
adverse events that are potentially associated with mefloquine
consumption in deployment situations? What kind of reporting systems
are available to deployed physicians, medics and or soldiers for
reporting adverse events?
Answer. Once a health care provider has determined that an adverse
event is likely due to mefloquine or any drug, they first document it
in the patient's health record. Then, they would ensure that the
information is reported. If they were in a deployed medical treatment
facility that has Internet connectivity, they would access the web site
for the Joint Medical Workstation (JMeWS) system, and code the patient
encounter as an adverse drug event. In more remote combat areas, mobile
Army medical personnel use laptops to input patient encounter
information through Composite Health Care System II--Theater (CHCS-II-
T).
Question. What support is provided for soldiers reporting adverse
events who are taking mefloquine? What is the Standard Operating
Procedure for a managing a soldier with side effects from mefloquine
consumption, knowing that stopping the drug is insufficient as the
effects can persist after stopping the product, while on deployment or
here is the United States?
Answer. If a Soldier experiences severe side effects with
mefloquine, then the medication will be stopped and the medical needs
of the Soldier will be taken care of. It is important to understand
that treatment is individualized according to the type of reaction and
what treatment is indicated for that particular adverse event. When
Soldiers have any health concerns that may be related to deployment, no
matter which deployment nor how long ago the deployment occurred, we
use an evidenced-based clinical practice guideline called the post-
deployment evaluation and management guideline. Service subject matter
experts from the Department of Defense and Veterans Health Affairs
developed this guideline. It is used in the primary care setting in
screening, evaluating and managing the post-deployment health concerns
of service members. It provides an algorithm to systematically and
comprehensively address health concerns by reinforcing a partnership
with the Soldier patient. A detailed medical history is taken; followed
by a medical exam, appropriate laboratory tests and consultative
services, if indicated. It also serves to enhance the continuity of
care and foster the establishment of therapeutic relationships.
______
Questions Submitted to Vice Admiral Michael L. Cowan
Questions Submitted by Senator Richard J. Durbin
dental research
Question. As I am sure you are all aware, a DOD review panel in
2000 confirmed the need for the military dental research but found that
it is hampered by discontinuous funding streams. Last year, the
Committee included language in its report that ``directed'' the
Department to sufficiently fund the military dental research program at
the Great Lakes naval base. Last year Congress added $2 million for
dental research, which was actually only about half of what was
requested. Could you tell this Committee how much the Army and Navy are
each putting into this program for fiscal year 2005?
Answer. The Navy's Military Dental Research Program is primarily
conducted by the Naval Institute for Dental and Biomedical Research
(NIDBR) located at the Great Lakes Naval Station. NIDBR's total funding
for fiscal year 2004 and the requested budget for fiscal year 2005 is
summarized in the following table.
NIDBR
[Dollars in thousands]
----------------------------------------------------------------------------------------------------------------
Fiscal Year
Funding Source Research Area 2004
----------------------------------------------------------------------------------------------------------------
DHP, Navy.................................... Mercury Abatement................................ $910
RDT&E, Navy.................................. Science and Technology Projects.................. $1,130
RDT&E, Navy.................................. Transition/Advanced Development.................. $761
RDT&E, Navy.................................. Congressional Add................................ $1,154
RDT&E, Navy.................................. General Purpose Test Equipment and Maintenance... $236
DHP, Navy.................................... Longitudinal Risk Assessment..................... $162
US-EPA....................................... Mercury Hygiene Training......................... $30
Commercial Research and Development Agreement Creighton University............................. $85
---------------
Total Program.......................... ................................................. $4,468
===============
Various...................................... NIDBRI Fiscal Year 2005 Request.................. $4,863
----------------------------------------------------------------------------------------------------------------
The NIDBR request in fiscal year 2005 assumes that research funding
is available in fiscal year 2005 in the same amounts as in fiscal year
2004. In fiscal year 2005 NIDBR has additional requirements for
supplies and equipment and maintenance. Science and Technology projects
have not been awarded for fiscal year 2005.
Question. It is my understanding that one of the biggest problems
for deployed Soldiers is avoiding gum disease--like trench mouth. What
are the Army dental researchers at Great Lakes doing to address this
problem to prevent dental emergencies for deployed Soldiers?
Answer. We would respectfully defer comment on Army dental research
to the Army Surgeon General.
Question. The Navy dental researchers at Great Lakes have developed
several new products and pieces of equipment that allow corpsmen to
treat warfighters in the field saving time and money. Can you tell us
about some of that equipment?
Answer. Recent achievements/products/equipment developed by the
Naval Institute for Dental and Biomedical Research (NIDBR) in support
of the Warfighter in all deployed venues include:
Treatment of Dental Emergencies CD-ROM.--NIDBR has developed and
deployed a dental treatment CD-ROM that aids Independent Duty Corpsmen
in the diagnosis and treatment of common dental emergencies. This tool
assists corpsmen in providing necessary emergency treatment to deployed
personnel in venues where there is no immediate access to dental
officer.
Rapid Salivary Diagnostics.--NIDBR continues the development of
rapid, simple, non-invasive salivary diagnostic tests to assess
militarily relevant diseases such as tuberculosis and Dengue Fever, and
anthrax immunization status of military personnel at risk or preparing
for deployment. Currently, assays for clinic and battlefield-use using
two methods: lateral flow and fluorescence polarization are being
developed to provide corpsman and non-medical personnel a means for
early diagnosis of personnel in the field who have contracted these
diseases. This rapid diagnostic capability will allow for appropriate
treatment and quicker return to duty or necessary evacuation to a
higher echelon of medical care.
Far-forward Interim Dental Restorative Material/Dressing.--NIDBR
continues to develop and test a new novel dental material and delivery
system that can be used to treat dental emergencies in the deployed
environment, thereby reducing MEDEVACs and keeping Warfighters on
station. The far-forward dental dressing has been designed for use by
first responders as a method to treat a wide variety of urgent dental
problems encountered by the deployed Warfighter.
Authorized Dental Allowance List (ADAL) Field Dental Operatory Test
and Evaluation.--NIDBR continues to test, evaluate, and validate new
and existing components of the Marine Corps ADAL to ensure the deployed
dental delivery systems will withstand the rigors of field use during
an operational deployment.
______
Questions Submitted by Senator Dianne Feinstein
Question. The antimalarial drug mefloquine has been identified as
causing severe side effects such as psychosis, aggression, paranoia,
depression and thoughts of suicide, even after use of the drug has
stopped. Could you please tell me why another quinolone, ciprofloxacin,
is being given to soldiers to self administer when consuming suspicious
foods in Iraq when the side effects from one quinolone have the
potential to be compounded by the second?
Answer. A three-day supply of ciprofloxacin is commonly supplied to
travelers (both civilian and military) for the emergency treatment of
diarrhea, in the event that they are incapacitated and not able to
receive immediate medical attention. Ciprofloxacin is usually
prescribed for this type of treatment because it should either
significantly improve or cure about 70 percent of bacterial
gastroenteritis episodes. While it is theoretically possible for one
quinolone to potentiate the side effects of another, this has not been
shown to be a problem with mefloquine and ciprofloxacin. The possible
association between mefloquine and ciprofloxacin with adverse events
has been speculated upon, however, there have been no well-documented
cases of problems due to this drug combination. Whenever mefloquine and
ciprofloxacin are prescribed together, the theoretical risk of
interaction must be weighed against their proven life saving benefits.
Question. DOD has begun an investigation into psychiatric adverse
events in soldiers and plans a study of mefloquine. DOD has stated that
it has not included in its assessments several incidents in soldiers
who have taken mefloquine or soldiers who do not demonstrate blood
levels of the drug. FDA's News Release of July 9, 2003 states that
``Sometimes these psychiatric adverse events may persist even after
stopping the medication.'' What is being done by DOD to investigate the
incidents of suicides in soldiers while on or returning from
deployment? Any investigations should include soldiers who consumed
mefloquine and committed suicide or committed other acts of violence
whether there were residues identified in their blood or not. What is
DOD's timeframe for conducting a review of these cases and conducting
other studies of the effects of mefloquine?
Answer. The Office of the Assistant Secretary of Defense for Health
Affairs (ASD (HA)) is coordinating a DOD study of adverse events
associated with mefloquine, including any possible connection with
suicide. Recommendations for the proposed study have been developed by
a select sub-committee of the Armed Forces Epidemiological Board (AFEB)
and will be presented to ASD (HA) and the AFEB. Questions regarding
whether the anticipated study will include soldiers involved in
specific incidents or how blood levels of mefloquine will be approached
should be referred to ASD (HA).
Question. What are you doing to specifically recognize and report
adverse events that are potentially associated with mefloquine
consumption in deployment situations? What kind of reporting systems
are available to deployed physicians, medics and/or soldiers for
reporting adverse events?
Answer. Reporting of adverse events associated with mefloquine, or
any other medication, is addressed by Naval Medicine's Risk Management,
Patient Safety and Operational Health Care Quality Assurance programs.
Operational units are required by the Chief of Naval Operations to
track adverse drug reactions as a part of the Operational Health Care
Quality Assurance program. These units use U.S. Food and Drug
Administration guidelines for the reporting of adverse drug reactions.
Any provider, civilian or military, may submit adverse drug
reactions to the U.S. Food and Drug Administration (FDA). The FDA
accepts adverse drug reaction reports via website, telephone or mail.
In addition, these drug reactions must be monitored at the local level
through the Operational Health Care Quality Assurance Program.
Question. What support is provided for soldiers reporting adverse
events who are taking mefloquine? What is the Standard Operating
Procedure for a managing a soldier with side effects from mefloquine
consumption, knowing that stopping the drug is insufficient as the
effects can persist after stopping the product, while on deployment or
here is the United States?
Answer. Individuals experiencing possible side effects from
mefloquine are provided support through their local primary care
provider. Management of adverse side effects from medication involves
prevention through proper screening, choice of medication, appropriate
monitoring, and above all, stopping the suspected medication. U.S. Food
and Drug Administration guidelines advise discontinuing mefloquine if
side effects occur. Due to the long half-life of mefloquine, adverse
reactions to mefloquine may occur or persist up to several weeks after
the last dose.
Standard of care for managing a patient with an adverse reaction to
Mefloquine is to change the patient's medication, monitor the patient
for resolution of side effects and refer the patient to appropriate
clinical specialists for persistence of any psychiatric or neurological
side effects.
______
Questions Submitted to Lieutenant General George Peach Taylor, Jr.
Questions Submitted by Senator Dianne Feinstein
mefloquine
Question. The antimalarial drug mefloquine has been identified as
causing severe side effects such as psychosis, aggression, paranoia,
depression and thoughts of suicide, even after use of the drug has
stopped. Could you please tell me why another quinolone, ciprofloxacin,
is being given to soldiers to self administer when consuming suspicious
foods in Iraq when the side effects from one quinolone have the
potential to be compounded by the second?
Answer. Ciprofloxacin (an antibiotic) is used for the prevention or
treatment of certain type of traveler's diarrhea, often caused by
consuming poorly prepared or inappropriately stored food. During
deployments, our public health officials work very hard to ensure that
the food that our airmen consume is safe.
Our healthcare providers prescribe prophylactic medications in
accordance with the Centers for Disease Control and Prevention (CDC)
recommendations, Food and Drug Administration license, and the
manufacturers' prescribing information. While the concomitant
administration of mefloquine and quinine or chloroquine (another
antimalarial) may produce electrocardiographic (heart conduction)
abnormalities, there is no scientific evidence to suggest that the use
of ciprofloxacin would compound the adverse reactions that may be
associated with mefloquine use. It is within the standard of care to
prescribe both mefloquine and ciprofloxacin. Both are excellent
pharmaceutical agents for force health protection.
Question. DOD has begun an investigation into psychiatric adverse
events in soldiers and plans a study of mefloquine. DOD has stated that
it has not included in its assessments several incidents in soldiers
who have taken mefloquine or soldiers who do not demonstrate blood
levels of the drug. FDA's News Release of July 9, 2003 states that
``Sometimes these psychiatric adverse events may persist even after
stopping the medication.'' What is being done by DOD to investigate the
incidents of suicides in soldiers while on or returning from
deployment? Any investigations should include soldiers who consumed
mefloquine and committed suicide or committed other acts of violence
whether there were residues identified in their blood or not. What is
DOD's timeframe for conducting a review of these cases and conducting
other studies of the effects of mefloquine?
Answer. A loss of any airmen to suicide is tragic. For many years,
Air Force leaders have been very committed to preventing suicides. Our
nationally recognized suicide prevention program educates leaders as
well as individual airmen on how to identify at-risk individuals and
intervene when necessary to prevent suicides. Since the program's
inception, our suicide rates have continued to decline.
We, along with our Sister Services and the Assistant Secretary of
Defense for Health Affairs, are very concerned about the number of
suicides among deployed troops and potential adverse outcomes of
mefloquine. At the May 12, 2004 meeting of the Armed Forces
Epidemiological Board (AFEB), the ASD/HA accepted the Board's
recommendations to formally study the factors associated with suicide
and to study outcomes potentially related to mefloquine. His staff is
currently determining the exact details, such as time frame.
Question. What are you doing to specifically recognize and report
adverse events that are potentially associated with mefloquine
consumption in deployment situations? What kind of reporting systems
are available to deployed physicians, medics and/or soldiers for
reporting adverse events?
Answer. All our deployed military treatment facilities have
capabilities to report reportable medical events. Reportable medical
events include adverse events associated with vaccinations and certain
medical conditions. If an airman sees a healthcare provider for an
adverse event associated with medication use, it is documented in the
airman's medical record and the DD Form 2766 (Adult Prevention and
Chronic Care Flowsheet). The DD Form 2766 accompanies deployed
personnel to the field and is returned to the individual's medical
record upon re-deployment. While providers are not required to report
adverse events that are not out of the ordinary (i.e., adverse events
that have been reported in the package inserts for the individual
pharmaceutical agent), they are required to report unusual adverse
events associated with a medication directly to the Food and Drug
Administration. In the 10 years that the Air Force has used mefloquine,
it has not had a significant reportable event associated with
mefloquine administration.
Question. What support is provided for soldiers reporting adverse
events who are taking mefloquine? What is the Standard Operating
Procedure for a managing a soldier with side effects from mefloquine
consumption, knowing that stopping the drug is insufficient as the
effects can persist after stopping the product, while on deployment or
here is the United States?
Answer. If an Airman experiences symptoms while on mefloquine, a
healthcare provider evaluates him or her. If necessary, the medication
is discontinued and an alternative medication is substituted. Airmen
are instructed to seek care for any medical concerns, including those
associated with any medication use. All Airmen receive a post-
deployment briefing and a face-to-face medical visit with a healthcare
provider prior to returning home. Airmen are also provided with
information on how to seek medical care, either through our medical
treatment facilities or the VA system.
SUBCOMMITTEE RECESS
Senator Stevens. We are going to conclude the testimony
here today. We will reconvene on May 5 at 9:30 a.m., when we
hear from nondepartmental witnesses on the total budget for
defense. Thank you very much.
[Whereupon, at 11:50 a.m., Wednesday, April 28, the
subcommittee was recessed, to reconvene at 9:30 a.m.,
Wednesday, May 5.]