    [House Hearing, 114 Congress]
    [From the U.S. Government Publishing Office]

                    STRENGTHENING OUR NATIONAL TRAUMA SYSTEM

    =======================================================================

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JULY 12, 2016

                                   __________

                               Serial No. 114-160

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                      ______

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                        COMMITTEE ON ENERGY AND COMMERCE

                              FRED UPTON, Michigan
                                     Chairman
    JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
      Chairman Emeritus                    Ranking Member
    ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
    JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
    JOSEPH R. PITTS, Pennsylvania        ELIOT L. ENGEL, New York
    GREG WALDEN, Oregon                  GENE GREEN, Texas
    TIM MURPHY, Pennsylvania             DIANA DeGETTE, Colorado
    MICHAEL C. BURGESS, Texas            LOIS CAPPS, California
    MARSHA BLACKBURN, Tennessee          MICHAEL F. DOYLE, Pennsylvania
      Vice Chairman                      JANICE D. SCHAKOWSKY, Illinois
    STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
    ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
    CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
    GREGG HARPER, Mississippi            JOHN P. SARBANES, Maryland
    LEONARD LANCE, New Jersey            JERRY McNERNEY, California
    BRETT GUTHRIE, Kentucky              PETER WELCH, Vermont
    PETE OLSON, Texas                    BEN RAY LUJAN, New Mexico
    DAVID B. McKINLEY, West Virginia     PAUL TONKO, New York
    MIKE POMPEO, Kansas                  JOHN A. YARMUTH, Kentucky
    ADAM KINZINGER, Illinois             YVETTE D. CLARKE, New York
    H. MORGAN GRIFFITH, Virginia         DAVID LOEBSACK, Iowa
    GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
    BILL JOHNSON, Ohio                   JOSEPH P. KENNEDY, III,
    BILLY LONG, Missouri                     Massachusetts
    RENEE L. ELLMERS, North Carolina     TONY CARDENAS, California
    LARRY BUCSHON, Indiana
    BILL FLORES, Texas
    SUSAN W. BROOKS, Indiana
    MARKWAYNE MULLIN, Oklahoma
    RICHARD HUDSON, North Carolina
    CHRIS COLLINS, New York
    KEVIN CRAMER, North Dakota
                             Subcommittee on Health

                         JOSEPH R. PITTS, Pennsylvania
                                     Chairman
    BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
      Vice Chairman                        Ranking Member
    ED WHITFIELD, Kentucky               ELIOT L. ENGEL, New York
    JOHN SHIMKUS, Illinois               LOIS CAPPS, California
    TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
    MICHAEL C. BURGESS, Texas            G.K. BUTTERFIELD, North Carolina
    MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
    CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
    LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
    H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
    GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
    BILLY LONG, Missouri                 JOSEPH P. KENNEDY, III,
    RENEE L. ELLMERS, North Carolina         Massachusetts
    LARRY BUCSHON, Indiana               TONY CARDENAS, California
    SUSAN W. BROOKS, Indiana             FRANK PALLONE, Jr., New Jersey (ex
    CHRIS COLLINS, New York                  officio)
    JOE BARTON, Texas
    FRED UPTON, Michigan (ex officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Joseph R. Pitts, a Representative in Congress from the
      Commonwealth of Pennsylvania, opening statement................     1
        Prepared statement...........................................     2
    Hon. Gene Green, a Representative in Congress from the State of
      Texas, opening statement.......................................     4
    Hon. Fred Upton, a Representative in Congress from the State of
      Michigan, opening statement....................................     6
        Prepared statement...........................................     7
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     8
    Hon. Joseph P. Kennedy, III, a Representative in Congress from
      the Commonwealth of Massachusetts, prepared statement..........    91

                                   Witnesses

    Jorie Klein, BSN, RN, Director, Trauma Program, Rees-Jones Trauma
      Center at Parkland.............................................    10
        Prepared statement...........................................    12
    David Marcozzi, MD, University of Maryland Department of
      Emergency Medicine.............................................    23
        Prepared statement...........................................    26
    C. William Schwab, MD, FACS, Professor of Surgery, Penn
      Presbyterian Medical Center....................................    32
        Prepared statement...........................................    34
    Craig Manifold, DO, FACEP, Committee Chair, American College of
      Emergency Physicians...........................................    46
        Prepared statement...........................................    48
        Answers to submitted questions \1\...........................   103
    J. Brent Myers, MD, MPH, FACEP, President-Elect, National
      Association of EMS Physicians..................................    58
        Prepared statement...........................................    60
        Answers to submitted questions \2\...........................   106

                               Submitted Material

    Statement of the American College of Surgeons, submitted my Mr.
      Pitts..........................................................    92
    Statement of America's Essential Hospitals, submitted my Mr.
      Pitts..........................................................    98
    Statement of the American Hospital Association, submitted my Mr.
      Pitts..........................................................   101

    ----------
    \1\ Mr. Manifold did not respond to questions for the record.
    \2\ Mr. Myers did not respond to questions for the record.

                    STRENGTHENING OUR NATIONAL TRAUMA SYSTEM

                                  ----------

                             TUESDAY, JULY 12, 2016

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:00 a.m., in
    room 2322 Rayburn House Office Building, Hon. Joe Pitts
    (chairman of the subcommittee) presiding.
        Members present: Representatives Pitts, Guthrie, Shimkus,
    Murphy, Burgess, Blackburn, Lance, Griffith, Bilirakis, Long,
    Ellmers, Bucshon, Brooks, Collins, Upton (ex officio), Green,
    Engel, Butterfield, Castor, Sarbanes, Matsui, Schrader,
    Kennedy, Cardenas, and Pallone (ex officio).
        Staff present: Rebecca Card, Assistant Press Secretary;
    Paul Edattel, Chief Counsel, Health; Bob Mabry, Fellow, Health;
    Graham Pittman, Legislative Clerk; Adrianna Simonelli,
    Professional Staff Member; Heidi Stirrup, Health Policy
    Coordinator; Sophie Trainor, Policy Coordinator; Jeff Carroll,
    Minority Staff Director; Waverly Gordon, Minority Professional
    Staff Member; Tiffany Guarascio, Minority Deputy Staff Director
    and Chief Health Advisor; Samantha Satchell, Minority Policy
    Analyst; Kimberlee Trzeciak, Minority Health Policy Advisor;
    Megan Velez, Minority FDA Detailee; and C.J. Young, Minority
    Press Secretary.

    OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
             CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

        Mr. Pitts. The time of 10 o'clock having arrived, the
    subcommittee will come to order. I ask unanimous consent to
    recognize and allow our colleague, Representative Rick Hudson,
    who's on the full committee, to waive onto the Health
    Subcommittee for today's hearing. Without objection, so
    ordered.
        I recognize myself for an opening statement. Today's
    hearing is an important discussion that will examine the areas
    where we can improve our national trauma system and the care
    provided by emergency responders.
        The recent events in Orlando, Paris and San Bernardino
    remind us of the very real threat of mass casualty events that
    can produce large numbers of traumatically injured casualties.
        Terrorism, criminal violence and road traffic accidents all
    produce traumatic injuries which is the leading cause of death
    for those under age 46. Because it disproportionately affects
    young people, trauma is the number-one cause of productive life
    years lost, greater than cancer or heart disease.
        A recent Institute of Medicine report released just last
    week estimates that one in five trauma deaths may be
    preventable or, in other words, about 30,000 people might be
    saved every year if your nation's trauma system is better
    optimized today.
        We'll hear from witnesses on ways to address our trauma and
    emergency medical systems. First we will hear from three
    authors of IOM report entitled ``A National Trauma Care System
    Integrating Military and Civilian Trauma Care to Achieve Zero
    Preventable Deaths After Injury.''
        They will discuss a number of recommendations included in
    the report aimed at improving trauma care. Our other two
    witnesses will discuss legislation introduced by Congressman
    Richard Hudson designed to ensure our first responders have
    access to critical medications needed to treat emergency
    conditions in the field.
        One of our main challenges in addressing emergency and
    trauma care is leadership. Responsibility for planning,
    coordination, communications, and response are divided across
    multiple agencies and jurisdictions.
        The axiom when everyone is responsible no one is
    responsible applies. Leadership at the federal level is
    required to achieve coordination and ultimate accountability.
        While strong national leadership is needed, we must also
    bolster those on the front lines at the local level. Here we
    can look to the military's incredible advances in trauma care
    over more than a decade of war.
        Lessons learned during war time often drive innovation in
    civilian trauma care. This is not surprising, as many
    experienced combat medical personnel often leave the military
    and go into civilian practice during peace time. Outside of war
    our military trauma teams have few opportunities to care for
    severely injured patients at their base hospitals. The IOM
    proposes integrating military trauma teams into busy civilian
    trauma centers in order to improve not only military trauma
    care but civilian trauma care.
        I look forward to the discussion and encourage the
    thoughtful dialogue about these critical issues. I look forward
    to hearing our witnesses today and yield the balance of my time
    to Dr. Burgess.
        [The prepared statement of Mr. Pitts follows:]

                   Prepared statement of Hon. Joseph R. Pitts

        The Subcommittee will come to order.
        The Chairman will recognize himself for an opening
    statement.
        Today's hearing is an important discussion that will
    examine areas where we can improve our national trauma system
    and the care provided by emergency responders.
        The recent events in Orlando, Paris and San Bernardino
    remind us of the very real threat of such mass casualty events
    that can produce large numbers of traumatically injured
    casualties.
        Terrorism, criminal violence, and road traffic accidents
    all produce traumatic injuries, which is the leading cause of
    death for those under age 46. Because it disproportionally
    affects young people, trauma is the number one cause of
    productive life years lost, greater than cancer or heart
    disease.
        A recent Institute of Medicine report released just last
    week estimates that one in five trauma deaths may be
    preventable. Or, in other words, about 30,000 people might be
    saved every year if our Nation's trauma system is better
    optimized.
        Today we will hear from witnesses on ways to address our
    trauma and emergency medical systems. First, we will hear from
    three authors of the IOM report entitled, ``A national trauma
    care system: Integrating military and civilian trauma care to
    achieve zero preventable deaths after injury.'' They will
    discuss a number of recommendations included in the report
    aimed at improving trauma care.
        Our other two witnesses will discuss legislation introduced
    by Congressman Richard Hudson designed to ensure our first
    responders have access to critical medications needed to treat
    emergency conditions in the field.
        One of our main challenges in addressing emergency and
    trauma care is leadership. Responsibility for planning,
    coordination, communication, and response are divided across
    multiple agencies and jurisdictions. The axiom ``when everyone
    is responsible, no one is responsible'' applies. Leadership at
    the federal level is required to achieve coordination and
    ultimate accountability.
        While strong national leadership is needed, we must also
    bolster those on the front lines at the local level. Here we
    can look to the military's incredible advances in trauma care
    over more than a decade of war. Lessons learned during wartime
    often drive innovation in civilian trauma care.
        This is not surprising as many experienced combat medical
    personnel often leave the military and go into civilian
    practice during peacetime. Outside of war, our military trauma
    teams have few opportunities to care for severely injured
    patients at their base hospitals. The IOM proposes integrating
    military trauma teams into busy civilian trauma centers in
    order to improve not only military trauma care but civilian
    trauma care.
        I look forward to the discussion and encourage a thoughtful
    dialogue about these critical issues.
        I yield the balance of my time to ------------.

        Mr. Burgess. Thank you, Mr. Chairman. I appreciate your
    yielding.
        I'm glad we're doing this today. It's timely, given the
    events of last Thursday and Friday. The nation was riveted upon
    the emergency rooms at Parkland, at Baylor Hospital and the
    country stands in awe of the service that was rendered to
    fallen police officers during that sad interval in our nation's
    history.
        I do want to recognize and thank Dr. Robert Mabry, the
    Health Subcommittee's Robert Wood Johnson Fellow, for the work
    he has done in this area and certainly for his service to the
    country.
        As a lieutenant colonel in the Army and an emergency room
    physician Dr. Mabry brought a lot of expertise to bear for this
    subcommittee on this issue particularly.
        Mr. Chairman, as you mentioned, we have recently received
    the National Academy's report and it identifies a unique
    opportunity to improve the state of trauma care for Americans
    at home and in combat. A partnership between our military and
    civilian health systems could bolster the availability of an
    expert work force in two ways, first by integrating military
    providers into civilian systems and second, military providers
    would be able to continue practicing and maintain their skill
    levels between deployments.
        The Military, Civilian, and Mass Casualty Trauma Readiness
    Partnership Act would facilitate this partnership through grant
    program which would allow us to examine how federal support of
    such partnerships could strengthen our trauma capabilities.
        This bill has the potential to save American lives here at
    home as well as abroad. Again, I want to thank all of our
    witnesses for being here today. This is an important topic, one
    that, again, unfortunately, because of recent events in Dallas,
    Texas we've seen just how critical your service is to the
    country.
        Mr. Chairman, I will yield back.
        I yield to Mr. Hudson.
        Mr. Hudson. I thank the gentleman and thank you, Mr.
    Chairman, for holding this very important hearing and allowing
    me to join in today.
        Regarding our first panel, I know firsthand the experience
    and expertise of our military trauma teams. So I want to thank
    my colleagues, Dr. Burgess and Dr. Bob Mabry, Army physician,
    along with the committee for their work and expertise on this
    important legislation.
        I am also excited to hear from our second panel today as
    this is an issue I have personally been invested in for over a
    year. I want to ask everyone to imagine for a moment that a
    loved one has been injured or the excruciating pain with the
    responding EMS personnel trained to treat them are helpless to
    do anything about their pain. Under current law, this could
    become a reality.
        Congressional action is needed immediately and that's why I
    authored the bipartisan Protection Patients' Access to
    Emergency Medications Act with my colleague, Mr. G.K.
    Butterfield, to clarify existing law so EMS personnel can
    continue to administer lifesaving medications to patients.
        This is vital for our patients and EMS personnel in North
    Carolina and across the United States. I want to thank you,
    Chairman Pitts, for your leadership and holding this important
    hearing.
        I want to thank Mr. Butterfield for his partnership and I
    want to underscore the importance of this being a bipartisan
    measure. There's a lot of issues here that become very highly
    partisanized. But this is one that doesn't have to be and it
    hasn't been because of the strong work of Mr. Butterfield and
    others working with me. And I want to thank all of my
    colleagues for this opportunity today and look forward to
    working to move this legislation into law.
        Thank you, Mr. Chairman. I yield back.
        Mr. Pitts. Chair thanks the gentleman. I now recognize the
    ranking member of the subcommittee, Mr. Green, 5 minutes for an
    opening statement.

       OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
                    CONGRESS FROM THE STATE OF TEXAS

        Mr. Green. Thank you, Mr. Chairman. And we're here today to
    examine two distinct but important ideas. The first is H.R.
    4365, the Protecting Patient Access to Emergency Medications
    Act is authored by our colleagues on the committee,
    Representatives Butterfield and Hudson from North Carolina.
        This legislation would clarify the oversight of care
    provided by emergency medical services practitioners through
    standing orders. Standing orders allow physicians and medical
    directors to establish preset protocols for EMS practitioners
    to follow when delivering emergency care on the ground.
        They are especially important in the administration and
    delivery of controlled substances in emergency situations when
    time is of the essence.
        The second proposal is a discussion draft to authorize a
    tiered grant program to civilian trauma centers that are
    engaged in military-civilian partnerships. This proposed bill
    will also require a study on how trauma care is reimbursed.
        Last month, the National Academies of Science, Engineering
    and Medicine--NASEM for short--released a report entitled ``A
    National Trauma Care System Integrated Military and Civilian
    System to achieve Zero Preventable Deaths After Injury.''
        Trauma injury is the leading cause of death of those under
    age 46 and it is the third leading cause of death overall.
    Trauma has definitive causes which establish method of
    treatment and prevention.
        Frequent forms of trauma include motor vehicle accidents,
    gunshot wounds, and falls. Traumas also result with large-scale
    manmade or natural disasters, too many of which we have seen
    recently and will continue to experience regardless of the best
    prevention efforts.
        Survival among severely injured patients requires
    specialist care delivered promptly and in a coordinated manner.
    Care begins at the scene of injury, continues to the emergency
    department and on to the hospital operating room and on to the
    hospital operating room and intensive care unit.
        This is true in both civilian and military context. Also
    true is the optimal response and care depends on advanced
    planning, preparation and coordination to produce smooth
    transitions and the proper sequence of interventions. Trauma
    care systems are the backbone of preparedness.
        Unfortunately, despite clear evidence of its value in war
    zones and here at home, one in seven Americans, 45 million
    people, lack access within one hour, known as the golden hour,
    to a trauma center able to treat their severe injuries.
        The NACEM report states that the military has made
    significant strides over the past decade in improving trauma
    care based on lessons learned during wartime.
        And Mr. Chairman, years ago when we were heavily involved
    in Iraq and Afghanistan our committee, Health Subcommittee,
    went to Baghdad, Balad and in Afghanistan to see the
    coordination between what they do and the success they were
    having.
        And at one time in the Houston area we--at our Level 1
    trauma centers at Memorial Hermann and Ben Taub they trained
    our military physicians because on a Friday or Saturday night
    you would see things in there that you would see in a war time.
        But after Iraq and Afghanistan now we need to work together
    because I was so impressed. I would see a hurt soldier come in
    and have the many disciplines working on that soldier at very
    primitive conditions compared to what we have in our
    communities.
        But I think there's a lot we can learn from the military.
    There are nearly 30,000 preventable fatalities for trauma
    injury every year that could have been avoided if optimal care
    was provided through coordinated trauma care's system.
        The NACEM envisions a national trauma care system and
    allows the continuous and seamless exchange of knowledge across
    military and civilian health care sectors. This would better
    provide optimal delivery of trauma care to save the lives of
    Americans injured in the United States or on the battlefield.
        Improving our national trauma care system is an issue that
    I've championed for years with my colleague and fellow Texan,
    Representative Mike Burgess. We worked to shore up our trauma
    centers, expand access to care and improve the regionalization
    of our nation's trauma systems.
        On a bipartisan basis we worked to enact and sustain
    federal trauma programs that enhance access to trauma care for
    all Americans. We currently have two bills to strengthen the
    future availability of trauma care which the House of
    Representatives passed 9 months ago and are awaiting action in
    the Senate.
        I am encouraged by this subcommittee's attention to such an
    important and overlooked issue and appreciate our witnesses for
    their thoughtful testimony today.
        I look forward to hearing more about the proposed
    legislation and our continued work to improve trauma care both
    for our men and women in combat and civilians and veterans here
    at home.
        We must ensure that the proper systems and sites of care
    are in a place to provide timely lifesaving care to all injured
    Americans. As we grapple with how to best support our men and
    women in uniform and respond to tragedies at home we cannot
    assume that trauma care will miraculously be there.
        It's the responsibility of Congress to make certain that
    the right care is available at the right time and we can make
    the most impact over the difference between life and death.
        And again, Mr. Chairman, I thank you for calling this
    hearing. I yield back.
        Mr. Pitts. Chair thanks the gentleman.
        I'll now recognize the chair of the full committee, Mr.
    Upton, 5 minutes for an opening statement.

       OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN
                  CONGRESS FROM THE STATE OF MICHIGAN

        Mr, Upton. Well, thank you, Mr. Chairman.
        Trauma causes such tremendous economic and human costs in
    Michigan and every state across the country. New National
    Academy of Medicine, NAM report, underscores that we need to do
    more and this report cites nearly 30,000 preventable civilian
    deaths per year due to trauma. Not overseas in distant war-torn
    land but here at home in the U.S.
        NAM points to a number gaps in our national trauma system,
    including the inconsistency in trauma care quality over time
    and in specific geographic areas.
        They also found a diffusion of responsibility across
    agencies of the government. Additionally, they found
    significant gaps in our ability to exchange knowledge and best
    practices, the result of which is significant variation in
    trauma care deliver which in turn, of course, leads to
    unnecessary suffering and lives lost.
        The NAM report puts forth several recommendations on how to
    move forward including improving the leadership of trauma care,
    integrating military and civilian trauma data system best
    practices and research, reducing regulatory barriers and, of
    course, improving trauma care quality processes.
        Today, we're going to hear from two emergency medical
    service physician medical directors. The practice of medicine
    in a pre-hospital environment is very unique and is a key part
    of our health care system.
        Our EMS folks, physicians, paramedics, other first
    responders are the front line of our emergency medical and
    trauma care system. They got to have the tools, training and
    support to rapidly stabilize and treat a variety of emergency
    conditions 24/7 in every community across the country.
        These EMS physicians will discuss the implication of H.R.
    4365, the Protecting Patient Access to Emergency Medications
    Act of 2016 introduced by Mr. Hudson, to ensure first
    responders have critical emergency medications needed to treat
    a variety of emergency and life-threatening conditions.
        [The prepared statement of Mr. Upton follows:]

                     Prepared statement of Hon. Fred Upton

        Trauma causes tremendous economic and human costs to
    Michigan and our nation. A new National Academy of Medicine
    (NAM) report underscores we need to do more. This report cites
    nearly 30,000 preventable civilian deaths per year due to
    trauma--not overseas in a distant war torn land--but here at
    home in the United States.
        The NAM points to a number of gaps in our national trauma
    system, including the inconsistency in trauma care quality over
    time and in specific geographic areas. They also found a
    diffusion of responsibly across agencies of the government.
    Additionally, they found significant gaps in our ability to
    exchange knowledge and best practices, the result of which is
    significant variation in trauma care delivery which in turn
    leads to unnecessary suffering and lives lost.
        The NAM puts forth several recommendations on how to move
    forward, including: improving the leadership of trauma care;
    for integrating military and civilian trauma data systems, best
    practices and research; reducing regulatory barriers; and
    improving trauma care quality processes.
        Today we will also hear from two emergency medical services
    physician medical directors. The practice of medicine in
    prehospital environment is very unique and is key part of our
    healthcare system. Our EMS physicians, paramedics and other
    first responders are the front line of our emergency medical
    and trauma care system. They must have the tools, training and
    support to rapidly stabilize and treat a variety of emergency
    conditions 24 hours per day in every community in the US. These
    EMS physicians will discuss the implications of HR 4365, the
    Protecting Patient Access to Emergency Medications Act of 2016,
    introduced by Mr. Hudson to ensure first responders have
    critical emergency medications needed to treat a variety of
    emergency and life-threatening conditions.
        I would like to thank the witness for coming here today and
    look forward to their testimony.

        Mr, Upton. I yield the balance of my time to Mrs.
    Blackburn.
        Mrs. Blackburn. Thank you, Mr. Chairman. Welcome to our
    witnesses. We are pleased that you are here.
        I represent Fort Campbell and also right outside of my
    district is the Vanderbilt University Medical Center and I want
    to tell you I am so pleased that Mr. Hudson has brought the
    bill forward and that we are having the hearing today and
    talking about the report from the academies.
        I think this is very appropriate for us to do. Taking down
    the barriers between the military and civilian healthcare, the
    exchange of information, looking for how best to make the
    appropriate response is something that is timely.
        I think that it is also needed and looking at the delivery
    model and optimal delivery. Important for us to have this
    discussion.
        So Mr. Chairman, I thank you for the time and with that I
    yield back.
        Mr. Pitts. Chair thanks the gentlelady. I now recognize the
    ranking member of the full committee, Mr. Pallone, 5 minutes
    for an opening statement.

    OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
                IN CONGRESS FROM THE STATE OF NEW JERSEY

        Mr. Pallone. Thank you, Mr. Chairman.
        Whether it's a gruesome sports injury or an injury from an
    accident on the interstate or a gunshot wound, we depend on our
    trauma care system to provide the services necessary to save
    lives and prevent disability.
        In the case of an emergency no one should be forced to
    wonder whether quality services will be available and we're
    fortunate to have access to some of the best trauma care in the
    world, ensuring access to quality trauma care based on the best
    available evidence.
        However, there are gaps in our current system and
    unfortunately sometimes the determination of whether a person
    survives or dies depends on if the injury occurs near a good
    trauma center and I think we'd all agree that this is
    unacceptable.
        All of our trauma services should be world class and that's
    why I'm eager to hear today about recommendations from the
    recent report that aimed to strengthened our trauma systems to
    ensure that patients get the services they need when a health
    emergency arises.
        In particular, one of the recommendations which is the
    subject of draft legislation being examined today encourages
    the development of military and civilian partnership by placing
    military trauma teams and personnel in civilian trauma care
    centers and I look forward to hearing more from our witnesses
    about the legislation's impact on our trauma care system.
        In addition to ensuring the availability of trauma care
    services we must also make certain that providers have the
    flexibility they need under federal law to treat patients in
    emergencies. Another topic of discussion today is H.R. 4365,
    the Protecting Patient Access to Emergency Medications Act.
    This bill would amend the Controlled Substances Act to clarify
    that emergency service personnel can administer controlled
    substances under a standing order from a physician, medical
    director who oversees emergency care.
        I understand this would codify what is current practice and
    ensure that patients have ready access to important and often
    lifesaving drugs in emergency situation.
        This bill would also streamline the emergency medical
    services registration process and would also hold the MS
    agencies responsible for receiving, storing and tracking
    controlled substances.
        While I support the intent of this legislation I understand
    the drug enforcement agency wasn't to ensure the proper
    safeguards are in place under this framework to limit the
    potential for diversion or misuse.
        And so again, I look forward to hearing more from our
    witnesses today about how EMS agencies can and will ensure a
    appropriate regulatory safeguards are in place to prevent
    diversion of controlled substances and I look forward to
    continuing to work with my colleagues and the sponsors, the DEA
    and stakeholders, to address these issues.
        Mr. Chairman, these are critically important issues. I'm
    glad our committee continues its track record of working to
    improve the public health care system to better serve our
    communities and protect patients, and I yield the remainder of
    my time to Mr. Butterfield.
        Mr. Butterfield. Thank you very much, Mr. Pallone, for
    yielding time and thank you, Mr. Chairman, for convening this
    hearing today on strengthening our national trauma system.
        This is a subject that we all care so deeply about and I
    know our five witnesses today feel very strongly about this
    issue and so thank you for the hearing and I thank the five of
    you for your willingness to testify.
        Mr. Chairman, trauma can occur in many forms from
    concussions or burns to injuries on the athletic field or even
    highway accidents. Pediatric trauma is the most frequent killer
    of children in our country.
        Trauma does not need to lead to death or even permanent
    disability. By providing access to trauma care within what is
    known as the golden hour or the time immediately following the
    injury and I'm sure our guests will talk about that today, we
    can dramatically reduce those threats.
        Of approximately 1,200 hospitals in the country, only about
    one out of every five hospitals are designated for trauma. Even
    fewer are equipped to handle the challenges of pediatric trauma
    care.
        And so in May, Congressman Richard Hudson, my dear friend
    and colleague that usually sits on the other side of the aisle
    but today he's on my side of the aisle--I don't know if that's
    an omen, Mr. Upton--Mr. Upton has left. But thank you for
    sitting with us today, Richard.
        But in May, Richard and I launched the Pediatric Trauma
    Caucus to work to ensure that the U.S. trauma care network has
    the appropriately trained workforce, resources and evidence-
    based practices to meet the challenges of pediatric care. And
    so I'm pleased today that we are considering 4365. This
    bipartisan bill clarifies existing law so that EMS personnel
    under the supervision of a physician can administer lifesaving
    medication to patients in their care.
        This legislation ensures EMS personnel have the necessary
    tools to help victims of traumatic events receive medically
    appropriate treatments before arriving at the hospital.
        In rural communities such as mine and congested urban areas
    alike, such as Dr. Myers, hospitals and clinics can be
    difficult to access and in many cases the administration of
    treatments can prevent death or permanent disability.
        So I thank you. I look forward to the hearing. I yield
    back.
        Mr. Pitts. Chair thanks the gentleman. That concludes the
    opening statements verbal. All written opening statements of
    members will be made a part of the record.
        I have a UC request. I'd like to submit the following
    documents for the record: statements from the American College
    of Surgeons; America's Essential Hospitals; and the American
    Hospital Association.
        Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        We have one panel of witnesses today. I'll introduce them
    in the order of their presentation. We'll start with Ms. Jorie
    Klein, director, trauma program, Rees-Jones Trauma Center at
    Parkland.
        Then Dr. David Marcozzi, University of Maryland, Department
    of Emergency Medicine, Dr. Bill Schwab, professor of surgery,
    Penn Presbyterian Medical Center, Dr. Craig Manifold, committee
    chair, American College of Emergency Physicians. Finally, Dr.
    Brent Myers, president elect of the National Association of EMS
    Physicians.
        Thank you for coming today. Your written testimony will be
    placed in the record. You'll each be given 5 minutes to
    summarize your testimony. And so at this time the chair
    recognizes Ms. Klein 5 minutes for her summary.

     STATEMENTS OF JORIE KLEIN, BSN, RN, DIRECTOR, TRAUMA PROGRAM,
       REES-JONES TRAUMA CENTER AT PARKLAND; DAVID MARCOZZI, MD,
      UNIVERSITY OF MARYLAND DEPARTMENT OF EMERGENCY MEDICINE; C.
         WILLIAM SCHWAB, MD, FACS, PROFESSOR OF SURGERY, PENN
        PRESBYTERIAN MEDICAL CENTER; CRAIG MANIFOLD, DO, FACEP,
    COMMITTEE CHAIR, AMERICAN COLLEGE OF EMERGENCY PHYSICIANS; AND
       J. BRENT MYERS, MD, MPH, FACEP, PRESIDENT-ELECT, NATIONAL
                     ASSOCIATION OF EMS PHYSICIANS

                        STATEMENT OF JORIE KLEIN

        Ms. Klein. Mr. Chair, Ranking Members Pallone and Member
    Green, thank you very much for the opportunity to be here with
    you. I am a trauma nurse. I am the director of the trauma
    program at Parkland Hospital and I also am chair of the State
    Trauma Systems Committee.
        It is my privilege to participate in the National Academy
    of Science Committee that has brought forward this report. I
    would like to also recognize Dr. Burgess, who I have trained at
    Parkland Hospital and is very familiar with our environment.
        So when we talk about trauma we often talk about it as the
    neglected disease and that is not a term that's new to us.
    Actually, R.A. Cowley from the shock trauma center introduced
    that term back in 1966. The sad thing is that those terms and
    many of the things that were pointed out in that report 50
    years ago are still true today. You heard about the stats. Many
    of you read them.
        I'll just give you some stats from my state. Our state
    reported 121,000 injuries in our trauma registry last year.
    This year so far from January my trauma center has evaluated
    4,322 trauma patients. When we talk about those patients they
    all need quick response care.
        So what we would like to do is have you consider our
    report, look at the federal investment in trauma care. If you
    look at the number of individuals that are dying from trauma
    care and you look at the number of dollars that are
    appropriated for trauma care, trauma advances, trauma research
    you will find that there is a disparity there.
        So, again, we're asking you to reconsider some of that or
    help us move forward with that. The key concepts of the
    National Academy Report, again our committee called for
    developing a national trauma system and that national system
    includes integration of the civilian as well as the military,
    which includes all aspects from the prehospital to the acute
    care, inside the hospital for stabilization as well as research
    in prevent activities.
        I'm here today also representing the Trauma Center
    Association of America which strongly supports the bill that's
    being produced--the grant programs being developed that will
    actually create an opportunity for military teams to be inside
    the trauma centers. And, again, this could be very, very
    helpful.
        Many of the trauma centers, again, are growing. Our trauma
    center last month had a 35 percent increase in our number of
    trauma patients and, unfortunately, nothing else in the system
    increased 35 percent. I don't have 35 percent more nurses,
    dollars, or resources to manage those patients.
        So some of the points, again, embedding the military teams
    as they would be fully integrated into the team and they would
    learn to work as a team. If you don't know how to work as a
    team in trauma you set the patients up for risk and that is one
    of the most critical things that we see.
        One of the other things that the report called for is a
    study. If you look at the deaths that were produced from the
    reports from the military as well as civilian, there are
    preventable deaths and when we talked about preventable deaths
    we're talking about after the injury occurred. And so we would
    like to see research and funding to address that and to create
    a nation that has zero preventable deaths.
        Again, appropriate funding would help support that and a
    national place to call home for trauma. We need a trauma center
    cost study that includes an opportunity to look at different
    billing systems. The billing system that we currently have and
    things that we can bill for trauma, for example, if the patient
    arrives by ambulance you can bill for it. If the patient is
    transferred you can bill your trauma activation fee. On
    Thursday night, several of those patients arrive to our trauma
    center in the police car, which means we cannot bill for some
    of the most critical patients that we have cared for and that
    means the bill falls back to other resources.
        So we must establish a national research action plan again
    to look at these deaths, to look at our system and to create
    systems that every echelon of care there's appropriate handoff
    and knowledge and the receiving provider knows and is competent
    how to manage a trauma patient.
        So in conclusion, I would like to say thank you for the
    opportunity to be here with you and, again, I would like to
    engage any other further discussion that you might have
    regarding these proposed bills.
        Thank you.
        [The statement of Ms. Klein follows:]

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        Mr. Pitts. Chair thanks the gentlelady and now recognizes
    Dr. Marcozzi 5 minutes for his summary.

                      STATEMENT OF DAVID MARCOZZI

        Dr. Marcozzi. Good morning, Chairman Pitts, Ranking Member
    Green and members of the subcommittee.
        I'm honored to have served on the committee that we're
    discussing here to release the report on trauma care. The
    committee is part of the National Academies of Sciences
    chartered by the Congress in 1863 to advise the government on
    matters of science technology. Thank you for your invitation to
    testify today. It was an honor to serve on this prestigious
    committee under the leadership of Dr. Don Berwick. I want to
    begin my remarks by pausing to remember those who lost their
    lives during the recent tragedies in Dallas, in Orlando, and
    thank those who answered the call to respond to those crises.
    My sympathies go out to those affected by these and all
    tragedies due to trauma. Additionally, I want to recognize a
    legendary trauma surgeon and committee member from New Orleans,
    Dr. Norm McSwain, who passed away during the drafting of our
    report. His death was a great loss. Finally, I want to thank
    the sponsors of this work, the Department of Defense, the
    Department of Homeland Security, importantly, for its
    supporting a comprehensive deliverable aimed at improving our
    nation's approach to trauma care.
        One could say I've worked on both sides of multiple aisles.
    Within the legislative and executive branches of government,
    under Republican and Democratic administrations as a policy
    maker and practising physician and finally working within the
    military and civilian sectors. It is these experiences that
    help shape my remarks today.
        Right now, regardless of time, age of payer, emergency and
    trauma systems across our nation are diagnosing and treating
    those who are ill, injured, or depressed. Those two health
    delivery systems are inextricably linked. That care has an
    impact on their community and the populations they serve.
    Appreciating this, I reflect on a prior hearing by the House
    Oversight and Government Reform Committee on June 22nd, 2007.
    This committee hearing was in response to a 2006 Institute of
    Medicine report that released their reports on the state of our
    nation's emergency care. Dr. Schwab likely remembers that well
    as he was one of the presenters there testifying that day. At
    that time, Ranking Member Tom Davis commented, ``Emergency
    critical care services are in critical condition.'' He went on.
    ``Such a fragile, fragmented system holds virtually no surge
    capacity in the event of a natural disaster or terrorist
    event.''
        Representative Cummings, who chaired that meeting, further
    remarked, ``After providing a thorough overview of the
    challenges facing our nation's emergency care system, the time
    for action is long overdue.''
        Our nation's trauma care systems are a vital component of
    both our nation's health delivery system and our nation's
    resilience. As the leading cause of death under those at the
    age of 46, preventing injury is certainly an optimal strategy.
    But unfortunately, people still fall or are involved in motor
    vehicle accidents, get assaulted, are shot or are stabbed.
        In addition to those unfortunate daily occurrences of
    traumatic injury, recent events and remarks by CA Director
    Brennan and Secretary of Department of Homeland Security
    Johnson, strongly compel us to assure that our nation's
    emergency and trauma systems also stand at the ready for mass
    casualties.
        Coining a phrase from a comprehensive federal guidance on
    how best to respond to terrorist bombings, a robust system
    needs to be ready to respond in a moment's notice to injuries.
    Simply, that system delivers optimal trauma care and lives will
    be saved. Designing that system to achieve optimal outcomes is
    also important economically as care to victims of trauma
    totaled $600 billion in 2013.
        The title of a famous book, ``Good to Great,'' allows me to
    put in context advances in trauma care and highlight findings
    in two recommendations that I'll discuss I hope you'll fine
    germane to our discussion today.
        We are good in many aspects of trauma care but we aren't
    great. As an example identified by the committee on this
    dichotomy was the finding that approximately a thousand service
    members died of potentially survivable injuries from 2001 to
    2011. One thousand. Here at home, nearly 150,000 trauma deaths
    occurred in 2014. As many of 30,000 of those deaths were
    preventable. That's 80 deaths a day that potentially are
    survivable that we don't yet act on.
        First and foremost, we are good at leadership but we aren't
    great. There are federal offices and programs that attempt to
    address this issue. But those civilian entities have small
    staff and little or no funding to influence and improve our
    nation's emergency trauma systems.
        Within the military, the joint trauma system's future
    remains tenuous and it is not currently utilized across all
    combatant commands. This is a glaring omission by the
    Department of Defense.
        In short, there is no single entity within entity within
    HHS or DoD with the authority and accountability to guide the
    delivery of optimal trauma care.
        Prehospital care has achieved success due to tireless
    champions for improving the care the lives that are saved when
    we recall 911 due to paramedics, emergency technicians, and
    physicians. Chief James Robinson, Lieutenant Colonel Bob Mabry,
    Captain Frank Butler, Colonel Russ Kotwal are just four of
    those champions that worked to shape the recommendations of
    this committee in pre-hospital care.
        We are good but we aren't great. EMS remains a patchwork of
    symptoms, fragmented and largely isolated from health delivery
    and health delivery reform efforts. Unfortunately, and as
    dictated by Congress, prehospital care is considered only a
    transport mechanism, not part of the health delivery mechanism
    and apparatus of the nation.
        As a result, we don't have a seamless construct that
    includes medical care provided before you enter the doors of a
    hospital. The report outlines recommendations on how to address
    this.
        In conclusion, traumatic injury is nonpartisan and the
    delivery of optimal trauma care is a shared responsibility by
    Democratic and Republican leadership alike. Both sides of the
    aisle can and should support a system that benefits service
    members sitting in harm's way as well as every American.
        The report on National Trauma Care System Integrating and
    Military Civilian Systems to Achieve Zero Preventable Deaths
    after Injury Presents a vision for national trauma care--for a
    national trauma care system with a bold aim of zero preventable
    deaths after injury and minimal trauma-related disability. The
    committee's work on this report serves as a dedication to the
    lives cut short because of trauma whether on our streets, at a
    dance club, at a marathon, within our towns, our schools, our
    movie theaters, our places of worship or work. We are good, but
    we aren't great and we should be.
        Thank you, and I look forward to your questions.
        [The statement of Dr. Marcozzi follows:]

       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pitts. Chair thanks the gentleman.
        I now recognize Dr. Schwab 5 minutes for his summary.

                     STATEMENT OF C. WILLIAM SCHWAB

        Dr. Schwab. Thank you. My name is Bill Schwab and I'm a
    trauma surgeon. I'm a professor of surgery and I've trained
    military and civilian trauma surgeons for the last 40 years of
    my life.
        I think as we focus on what's going on in the streets of
    America it's appropriate to take a moment and realize that we
    have soldiers, airmen, Marines, and Navy in harm's way.
        Yesterday, a letter arrived from one of my trainees who is
    currently six miles from Fallujah, Iraq, and I read this letter
    from Lieutenant Colonel John Schavonis, a surgeon: ``I write
    this sitting in my tent about five or six miles from Fallujah,
    Iraq. The tent is pretty big and it has great air conditioning.
    We have hot showers, three minutes combat style, no more, and
    fresh fruit.
        ``Outside it's about 104 degrees, a dry heat we mockingly
    like to say. Our spirits are good. Over the past few weeks I've
    done over dozens of major operations--thoracotamies,
    exploratory laporatomies, amputations, craniotomies and all of
    them to save soldiers' lives.
        ``Now an intense battle rages in Fallujah. We are quiet for
    the time being. I am as ready as I can be for whatever comes
    through these doors and the reason is because of what you
    taught me. Your insights, your intellect, your skills, your
    cell phone always being on brings me the strength and the
    courage to go on.''
        I am the product of a military civilian partnership. The
    United States Navy put me through medical school and trained me
    as a trauma surgeon during Vietnam. Every one of my teachers in
    surgery had served in Vietnam. Trauma surgery became my genes.
    I'm going to discuss briefly recommendation 11 of the National
    Academy report which calls for integrating and optimizing the
    civilian network of America's best and busiest trauma centers
    as robust platforms to train, sustain and retain military teams
    in an expanded expert trauma workforce necessary to perform the
    primary mission of the Department of Defense's military health
    system readiness, battlefield medicine, and combat surgery.
        I'm going to share some data with you that we gleaned and
    published after 2 years of extensive research. I won't bore you
    with the methodology but let me just say it was extensive and
    involved. Over 40 face to face interviews with leaders from the
    United States military medical corps, all three services as
    well as civilian leaders. We looked at how well prepared
    surgeons were to go to war, and I want to clarify I'm going to
    use the word surgeons just to abbreviate the time. But this
    also relates to physicians, nurses, allied health professions
    and administrators. Our research showed that the best word to
    describe the preparation prior to deployment to go to battle is
    inconsistent. Inconsistent in training, inconsistency in skills
    and inconsistency in competency.
        And please don't blame the men and women that wore the
    uniform, because the military has very little opportunity to
    train in trauma surgery in their hospitals. The most common
    invasive or surgical procedure done in military hospitals is
    obstetrical delivery. The most common diagnosis and treatments
    rendered by military physicians and surgeons are the care of
    the diseases of aging among beneficiaries.
        There is only one level of trauma center in the entire
    Department of Defense at its 51 hospitals. As important, when
    war ramps up there is very little time to train physicians and
    nurses to go to war. What was necessary and what is necessary
    is to provide a constant training platform, a network of
    national military civilian excellent trauma centers that has
    embedded full trauma teams interdisciplinary that are
    continuously practicing trauma night after night, day after
    day. And when called upon can rapidly deploy to support the
    modern war machine.
        Let me give you some statistics that might be a bit
    shocking. What was the average age of the general surgeon that
    deployed to Iraq and Afghanistan? Thirty-six. How many years of
    practice did they have under their belt? Two. How many times
    were they accompanied by another surgeon who had combat
    experience? Eighteen percent of the time. That implies
    tremendous flaws in preparing to serve those men and women put
    in harm's way to defend our freedoms and our democracy.
        This has been studied before. The Rand Corporation in 2008
    did an an extensive study and documented that the best place to
    prepare military providers for combat and battlefield medicine
    are in the busy trauma centers of the United States. They also
    went on and studied with nine health organizations any problems
    that might arise--financial, business, statutory licensing, and
    interestingly enough, none of the problems, one, were
    identified as insurmountable, number two, the nine healthcare
    organizations were optimistic and said they would even be
    willing to do cost sharing, and last, from 2009 to 2014 when we
    interviewed the leaders of the five current military civilian
    trauma training hospitals, no problem had arisen with any of
    the things that I mentioned.
        Mr. Pitts. Your time has expired. Would you wrap up,
    please?
        Dr. Schwab. I would like to just show you one map because
    it's very important, if I could.
        This map is actually a map that we generated looking at
    American Colleges Surgeon data. These are the busiest and the
    best academic trauma centers in the United States. We asked the
    question whether it was capacity to absorb as many as 20 to 25
    of these teams by looking at this data and the answer is yes,
    there is. I will also point out that in those orange and yellow
    dots are some of the most stressed hospitals in the United
    States, the safety net hospitals in inner city America who
    could greatly benefit from the placement of these military
    teams to health care of those victims of violence that you're
    reading about in the papers.
        Thank you very much, Mr. Chairman.
        [The statement of Dr. Schwab follows:]

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        Mr. Pitts. Chair thanks the gentleman and now recognizes
    Dr. Manifold 5 minutes for your summary.

                      STATEMENT OF CRAIG MANIFOLD

        Dr. Manifold. Thank you, Mr. Chairman.
        My name is Craig Manifold and I'm an EMS medical director
    in San Antonio, Texas and current chairman of the American
    College of Emergency Physicians EMS committee. And on behalf of
    the 35,000 members of the American College of Emergency
    Physicians I'd like to thank you for the opportunity to testify
    today regarding House Resolution 4365, Protecting Patient
    Access to Emergency Medications Act of 2016.
        A critical component of EMS care is the ability of
    paramedics to administer controlled substances to patients when
    they follow the EMS medical director's treatment protocols,
    more commonly referred to as standing orders. However,
    patient's access to these lifesaving medications is in jeopardy
    and Congress must take action quickly, and I emphasize and
    request quickly, to codify the use of standing orders in the
    prehospital setting.
        In my written testimony I provide a brief synopsis on why
    this legislation is needed at this time and briefly the DA does
    not believe the standing orders comply with the 1970 Controlled
    Substance Act, which was the beginning of the Emergency Medical
    Services. And so the issues and procedural processes could not
    have been envisioned at the time of the enactment of the
    Controlled Substance Act. But the DEA was prepared to
    promulgate a role prohibiting the use of these standing orders
    for EMS personnel.
        ASEP, in conjunction with National of EMS Physicians and
    the National Association of EMTs determine the legislation
    would be needed to codify the current practice of medicine and
    ultimately lead to the introduction of this resolution by
    Representatives Hudson and Butterfield. And thanks to the
    efforts of our groups, our coalition partners, the bill has
    received the support of over 120 bipartisan cosponsors and
    stakeholder organizations at this time.
        While codifying the use of standing orders for EMS
    personnel is essential, we also want the legislation to advance
    policies that would provide uniformity, clarity and certainty
    for EMS agencies and their medical directors around the
    country. One of the easiest solutions to reduce confusion and
    duplicity with regard to the primary point of contact between
    the EMS agency and the DEA is to simplify the registration
    process.
        Currently, most EMS medical directors rather than the EMS
    agency itself register with the DEA and then their agency
    obtains and administers the controlled substances associated
    with these processes. This utilizes the medical director's
    individual DEA number and places a tremendous burden on these
    often volunteer positions because of the potential liability of
    the medical director if the ambulance services a drug
    diversion. Many of my colleagues and I believe it makes sense
    for the EMS agency to be registered with the DEA. It should be
    an agency, not an individual, which assumes the responsibility
    for ordering, storing, dispersing and administering these
    controlled substances. EMS agency registration would also allow
    for the entire organization to be united under one enrollment,
    thereby streamlining the process and reducing administrative
    costs while still preserving accountability. Maintaining a
    separate registration for individual locations and vehicles
    under the purview of the EMS agency is extremely time
    consuming, duplicative, and expensive. Preventing the misuse or
    unintended use of the medications and controlled substances is
    a solemn comment on the EMS medical director's job.
        We as the medical directors and the associated management
    staff work diligently to oversee the implementation,
    administration, and monitoring of these controlled substances
    within their agencies. My colleagues and I take this
    responsibility very seriously and we believe that provisions of
    House Resolution 4365 will actually reduce the opportunities
    for drug diversion. Although diversion is not a common
    occurrence, in fact one recent survey of large EMS agencies
    across the U.S. showed less than 20 diversions were
    investigations over the last 5 to 10 years for nearly 70,000
    doses administered annually.
        As I previously mentioned, many EMS agencies rely on their
    medical director's DEA license to order, transport, and
    administer controlled substances. These medications can only be
    delivered to the address associated with the registration. In
    the recent past, that meant these controlled substances were
    delivered to my house. Alternatively, I could have waited for
    address changes and ordering processes to be updated. But this
    would have placed patient care in jeopardy and I was not
    willing to do that. It makes sense for these substances to be
    delivered to a central location operated by the EMS agency
    where there would be direct supervision of these medications at
    all times.
        It's also vital that the EMS agency has the ability to
    transfer controlled substances within its own organization. A
    colleague in Houston, Texas, has over 100 DEA registrations due
    to the requirement of meeting a specific DEA registration for
    every brick and mortar facility or fire station where
    medications are stored. Completing a distributorship
    registration requires a complex procedure, expense, and
    increases potential for diversion. The ability for an EMS
    agency to track and monitory these controlled substances within
    the agency will improve the efficiency and the medical care
    provided.
        In conclusion, if the DEA prohibits the use of standing
    orders in EMS, patients will needlessly suffer and potentially
    die. Thankfully, the DEA has given us time to pursue
    legislative and relief that will codify the use of standing
    orders and make other common sense changes that will improve
    the delivery of care in the prehospital setting.
        However, I do not believe this grace period is unlimited.
    Congress must take action quickly to ensure millions of
    Americans who require emergency medical services each year are
    not prohibited from receiving these live saving medications.
        On behalf of ASEP and myself, I would like to thank the
    members of Congress who have supported this resolution, our
    coalition partners who have helped advance this legislation and
    the National Association of EMTs in particular for their work
    who have added to this critical issue in today's hearing. I
    look forward to answering questions you may have about this
    bill and my testimony.
        Thank you, Mr. Chair.
        [The statement of Dr. Manifold follows:]

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        Mr. Pitts. I know recognize Dr. Myers 5 minutes for his
    summary.

                      STATEMENT OF J. BRENT MYERS

        Dr. Myers. Good morning, Chairman Pitts, Ranking Member
    Green, distinguished members of the subcommittee. My name is
    Brent Myers and I serve as the president elect of the National
    Association of EMS Physicians, 1,500 members strong, the vast
    majority of whom are EMS physicians providing daily oversight
    for the EMS care that's rendered in the streets of the United
    States. I would like to thank you for holding this particular
    hearing as it relates to strengthening our trauma system and
    the National Academy's report recommendation number ten which
    focuses on EMS and this ties directly in to the bill that we're
    talking about this morning, the Patient Access to Emergency
    Medicines Act of 2016. Our membership would like to thank
    Representative Hudson, Representative Butterfield, and their
    more than 100 co-sponsors of this very important legislation.
        Dr. Manifold and I committed that we would not have
    duplicative testimony so he has covered the issue of
    registration and I'm going to move directly into standing
    orders and talk about the direct importance for daily patient
    care of this very important concept.
        The beginning of the Controlled Substances Act referenced
    normal medical care as we think about it in a hospital. So if
    you think about a patient that comes in a hospital and I, as an
    emergency physician encounter that patient I would write an
    order in the chart or put it into the electronic medical record
    and a nurse would enact that single order for a single
    registered patient. That simply does not apply in the EMS
    environment. We encounter patients who are trapped, who are
    burned, who have near amputations, who have overdoses on
    cocaine or other medications, and place our providers at risk
    and we must be able to immediately provide lifesaving and
    safety-preserving medications to those patients. And the way
    that that is accomplished in almost every community in the
    United States is via a standing order or a written protocol.
        For 12-and-a-half years I've had the honor and privilege to
    serve as the medical director for Wake County EMS in Raleigh,
    North Carolina. During those twelve and a half years, over 1
    million EMS responses occurred under my medical direction. The
    ability of those 250 paramedics, 1,500 firefighters and 200
    emergency medical dispatchers to work on a standing order is
    the only way that the important care for those patients was
    provided and, indeed, is true across the country.
        I'm going to use just a little bit of my time to give a
    couple of examples from our community about how these standing
    orders are so important. Before the end of the day today, a
    paramedic in Raleigh, North Carolina, based on a standing order
    will provide a seizure control medication to an actively
    seizing patient, many of whom are pediatric patients and in the
    absence of a standing order those patients would continue to
    seize and potentially suffer brain damage. Before the end of
    the day today, a paramedic in Raleigh, North Carolina will
    administer a medication to a cocaine overdose that will provide
    control to that situation and provide safety for the
    providers--law enforcement, firefighters and EMS--who have
    responded to that situation.
        In the next 3 hours and every 3 hours until the end of the
    day a paramedic in Raleigh, North Carolina, based on standing
    orders will provide pain medication to a severely injured
    patient. These include in the past year a 2-year-old that
    experienced burns over 40 percent of their body who was able to
    receive immediate pain medication. Seventy-seven year old
    active individuals who were in their work shed at their house
    and amputated three digits of their fingers. How wonderful to
    be 77 years old but how horrible to be there if we could not
    have provided immediate pain control for that citizen based on
    the standing orders. Five-year-olds with 20 percent body
    surface area burns, a 34-year-old male who suffered near
    complete amputation in a motor vehicle crash and was
    uncontrollable due to pain and could not be extricated from
    that severe environment were it not for medications on standing
    orders.
        So these are not theoretical concepts. This is day to day
    practice of medicine in the United States and what we are
    asking with this particular bill is not anything new. It is the
    preservation and codification of our current practice.
        And with that, I yield my time. Thank you very much.
        [The statement of Dr. Myers follows:]

      [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pitts. Chair thanks the gentleman. That completes the
    opening statements of the witnesses. We'll begin questioning.
    I'll recognize myself 5 minutes for that purpose. Start with
    you, Ms. Klein.
        The National Academy of Medicine Committee called trauma
    care in the military and civilian sectors ``a portrait of
    lethal contradiction.'' On one hand, we have never had betters
    systems of care but on the other hand so many trauma patients
    don't receive the benefit and needlessly die or sustain
    lifetime disabilities.
        The committee's report essentially called for overhauling
    our national trauma system to integrate military and civilian
    trauma and this is a sea change from where we are today.
        What do you believe are the most critical components to
    changing this paradigm and achieving the committee's goal of
    zero preventable deaths?
        Ms. Klein. I would say it has to start with the national
    leadership. Second to that it needs to start with the
    infrastructure. The great trauma centers that you hear talked
    about are typically in an urban area and that means if you're
    in the rural areas of the United States you're at great risk.
        And so we've got to figure out systems to move these people
    out and have current systems in the rural area and move them
    swiftly into the trauma centers to take care of them and the
    ideal is to have an integrated system with the military and the
    civilian hospitals working hand in hand to accomplish that.
        Mr. Pitts. Thank you.
        Dr. Marcozzi, in the last few years we've seen much
    destruction as a result of manmade and natural disasters and
    responded to significant threats from infectious diseases such
    as Ebola, influenza, now Zika.
        Six months ago, this committee held a hearing focused on
    another IOM report focused on improving the health care
    response to cardiac arrest. Are we building parallel systems
    for these conditions?
        Should we be or should we be taking a more strategic look
    at where the gaps are in emergency care delivery system and
    approaching this with a broader perspective?
        Dr. Marcozzi. Thank you for the question, Chairman.
        I think that, in those conditions that you just described,
    minutes matter, and when minutes matter system design has to be
    precise and accurate to affect the care of those individuals
    whether or not it's a cardiac arrest patient, a gunshot victim,
    or a victim of a mass casualty, be it a bombing.
        So to that end, I think we are slightly building different
    systems and I also think that the way the health delivery
    systems are evolving are to encourage minimization of surge
    capacity, the minimization and just in time staffing, just in
    time supply chains, which is at odds with the concepts of mass
    casualty and surge development, and that's a challenge for us
    as a nation.
        But there's a way to proceed forward, and you mentioned is
    there a strategic path forward and I think there is, and the
    way to do that is to take some concepts that are championed by
    preparedness colleagues across the nation that are championed
    by trauma surgeons and emergency physicians and move them into
    the health delivery reform aspects. So we don't develop two
    different systems of care.
        We develop a uniform system of care that is able to be
    applied to both the cardiac arrest patient, the stroke victim,
    the trauma patient, or the gunshot victim because when minutes
    matter, getting the system right is important. And to do that
    effectively I think both the military and the civilian sectors
    need to learn from each other, develop one system that actually
    is a learning health system and this is what's described in our
    report. The vision is there. The means to accomplishment is
    there.
        I think that strategically both the Congress and the
    executive sides of government, the authorizing language and the
    appropriators need to think about how we can best shape not
    just a grant program because I don't think we can grant our way
    to success on this. I think we need to include what we think
    about as delivery of care, what we're discussing today, and
    move it within the health delivery construct of what we do
    every day. Thank you, sir.
        Mr. Pitts. Thank you.
        Dr. Schwab, we know that historically many surgical and
    medical advances are made during war time. What happens to
    these lessons? How are they integrated in the medical practice?
    How are they passed on? Are these lessons truly learned? If
    not, why not?
        Dr. Schwab. Thank you, Mr. Chairman. It's a good question.
        Medical history shows that actually it takes about a year
    of war time for physicians and nurses to actually perfect their
    skills.
        It takes much less time for those physicians and nurses to
    work back or to move back into civilian communities and not use
    those skills. So the lessons learned from war are not readily
    adapted or inconsistently adapted to the civilian practices.
        What the National Academy and its recommendations are
    trying to do is to formalize a bidirectional platform for
    learning, for teaching, for education, for creating experts
    that can go back and forth between the military and civilian
    sector and as important to focus those people rendering care
    and seeing the problems as the translators to the research
    laboratories.
        And so in that way in the future the vision is is that
    lessons learned will be lessons maintained and shared. From the
    military to the civilian and during peacetime from the civilian
    to the military.
        Thank you, sir.
        Mr. Pitts. The chair thanks the gentleman. My time has
    expired.
        The chair recognizes the ranking member, Mr. Green, 5
    minutes for questions.
        Mr. Green. Thank you.
        Ms. Klein, I understand that Parkland took seven patients
    from the Dallas attack on the police last week. Can you
    elaborate on the kinds and degrees of costs that it takes for a
    major trauma center like Parkland to be prepare to handle
    devastating injuries and mass casualty incidents?
        Ms. Klein. Yes, sir. Well, the first thing I will just have
    to say is that a hospital has to be integrated into the system
    and the system is EMS and for Texas we are very blessed.
        We have a very strong trauma system which includes our
    regional system and part of the regional system means in 19
    counties the hospital's EMS agencies, public health come
    together to look at plans, how to execute and how to manage
    these plans.
        On this particular night, we knew that there was an event
    going on downtown. No one knew that there was significant
    danger in this event. And so all of a sudden how we were
    notified is that we had a police car with an injured officer in
    it on our dock.
        At that time we began to activate and be able to move
    forward. So our activation process we have three levels of
    disaster response. We spoke immediately to downtown to our
    office of emergency management and we also talked to our
    regional trauma advisory council to put them on alert this had
    occurred.
        In a few minutes we had six of our faculty surgeons that
    were downstairs. Three remained downstairs. The others went to
    the operating suite to wait in that particular area. Anesthesia
    was downstairs.
        Those officers--three, four of them were severely injured.
    The others had wounds that obviously needed operative
    intervention and stabilization but they were not in a life
    situation distress.
        And so the message needs to be that the trauma center, as
    far as I'm concerned, is the absolute foundation for disaster
    response. Then you have to expand it out. It has to be a
    system. The system has to be able to respond and, again, it is
    the foundation.
        So, and last year, or 2 years ago when Ebola hit I happened
    to be the director of disaster response at that time as well.
    Our hospital spent $750,000 to mitigate should a patient with
    Ebola hit our system.
        We never got one patient. We have critiqued our response
    and asked ourselves what would we do different and the answer
    is the same. We feel like we were strongly prepared.
        We had people that were trained for medical decontamination
    that stood up and were immediately available. But we bought the
    suits that you needed and so we felt like our response was
    adequate.
        Mr. Green. In the Metroplex in Dallas/Fort Worth is there
    another level one trauma center other than Parkland?
        Ms. Klein. Yes, sir. There is. There is Baylor's, a level
    one trauma center. Methodist is a level one trauma center and
    we are very fortunate to have Children's that sits right beside
    us as a level one pediatric trauma facility.
        Mr. Green. OK. So you have three in the Metroplex?
        Ms. Klein. Yes.
        Mr. Green. OK.
        Ms. Klein. And that particular night one of the other
    hospitals got patients and then all of a sudden we were
    notified that all the other trauma centers had shut down and we
    remained open.
        In the course of 7:00 p.m. to 7:00 a.m. we received 17
    trauma activations, motor vehicle crashes, motorcycle crashes,
    and severe burns and our trauma center remained open the entire
    time caring for all the citizens that hit our doors.
        Mr. Green. My frustration is Houston. Our two level one
    trauma centers are right next to each other, at Memorial
    Hermann and our public hospital, Ben Taub.
        Ms. Klein. Yes.
        Mr. Green. And relatively recently the one in Galveston at
    UTMB has opened up so we have three within a 50-mile radius.
        In your opinion what does the National Academy of Medicine
    Committee focus on creating a national trauma care system? How
    do you picture that to fit in with the state trauma system
    would fit with the national picture?
        Ms. Klein. Well, again, I think there needs to be national
    infrastructure just like R.M. Caley called for in the neglected
    disease. There has to be some type of national voice to say
    this is what we're going to do and set the stage. That should
    trickle down to the state level.
        The state level should be held accountable for that and
    then it's going to trickle down to the regional. Everything, to
    me, is regional. You can't create something in North Carolina
    that's going to specifically work every single time in Texas or
    New Mexico or New York.
        But there has to be structures that say these are the
    pieces that you have to have and you have to be compliant with
    this in some way to hold people accountable to address that,
    plus the funding. Our hospital last year spent $65 million on
    uncompensated trauma care.
        We have a little bill back that we can get money from the
    state. We got $7 million back. So there has to be some way to
    fund that infrastructure because these citizens are usually the
    ones that are at their most productive years of life. So we can
    not only save them but put them back on the street so they can
    return to work. Then we have done a good job.
        Mr. Green. Thank you.
        I'm almost out of time. But I agree with our other
    witnesses about the military and because, like I said, I saw
    the success in Iraq and Afghanistan, the quickness that may not
    happen in even our level one trauma centers back 10 years ago.
    But I appreciate you all being here today because I think
    there's a lot of coordination we can do to help, and again,
    thank you for being here.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the vice chair of the health subcommittee,
    Mr. Guthrie, 5 minutes for questions.
        Mr. Guthrie. Thank you, Mr. Chairman, and I appreciate it.
        And Dr. Marcozzi, I want to ask you a question based on
    your role on the committee on military trauma care learning and
    health systems.
        One of the recommendations from the committee was to ensure
    that EMS be made a seamless component of health delivery system
    rather than merely a transport mechanism. Why the emphasis on
    prehospital care? I just want you to elaborate and give you an
    opportunity to elaborate.
        If we really wanted to eliminate preventable deaths
    shouldn't the focus be on getting the patient to the hospital
    as quickly as possible and can you explain what really can be
    done by paramedics and EMTs and what do you propose needs to be
    done to improve prehospital care?
        Dr. Marcozzi. I think the committee did a good job in its
    due diligence and learned the lessons from what the military
    learned and if you look at the data from those thousand service
    members what should be palpable to everyone, every American,
    that a thousand brothers, sisters, fathers, daughters, could
    have been saved from potentially survivable death, of those the
    majority of those deaths occurred in the prehospital sector.
        So before they hit the doors of a hospital, not coined a
    hospital overseas, their deaths were potentially survivable
    with the right care. Now, why is that? It's not the medics.
    It's not the physicians.
        It's not the PAs necessarily don't or aren't providing as
    optimal care as they could but we're not providing the system
    of care and integrating that delivery of care in the
    prehospital sector with the hospital sector's care. So why is
    that? And you start to pull that string and fundamentally
    that's a congressional--the Social Security Act has not defined
    prehospital are as one of the service types defined by CMS.
        So therefore it is subject to a different set of--it's a
    different look than how we deliver care in the hospital sector
    and the long-term care sector versus what we do in the
    prehospital sector.
        But the truth of the matter is when someone has anaphylaxis
    or someone gets shot that care that's delivered in the back of
    an ambulance should be seamless. From a patient-centered
    standpoint, that care is delivered on scene in the back of a
    rig and to the emergency department to the trauma suite.
        That team of providers has to be all integrated and
    coordinated and right now, unfortunately, prehospital care is
    subject to a fragmented system and championed by good folks
    like Dr. Myers in North Carolina to try and do the right thing.
        But federally I think we can shepherd that system better
    and make it part of a system of care and not necessarily as an
    outsider. That requires leadership and a leader to help do
    that.
        Mr. Guthrie. Thank you for those comments. I appreciate you
    elaborating further.
        And Dr. Schwab, in your testimony you describe the benefit
    to both civilian hospitals and military combat readiness,
    utilize military trauma teams in civilian hospitals as a way
    they can hone their skills and be best prepared for high-level
    traumas on the battlefield. Can you elaborate on why you
    recommend the entire military team be assigned to civilian
    centers and not just military surgeons?
        Dr. Schwab. Well, thank you. By saying the military trauma
    team, military trauma team defines a little bit less of a work
    force than actually the entire medical corps of the Army, Navy,
    and Air Force.
        In discussion with the Department of Defense after the
    report came out, there's actually been discussion about all
    military medical personnel ought to have some knowledge about
    what's going on on the battlefield. But there are core
    specialties--I'm using that word to describe physicians--and
    core practices among nursing and allied health professions that
    are necessary for trauma and combat casualty care.
        Three specialties are necessary for rapid deployment and,
    again, both the Rand study and our study found that very
    quickly in the early war years general surgery--trauma
    surgery--orthopedic surgery and anesthesia providers were the
    three specialists that were absolutely necessary but quickly
    the military ran out of those specialties because they were so
    rapidly deployed and they needed rest periods.
        So we're not saying the whole military medical provider
    core be assigned to them. But those specialties, those nurses
    and allied health professions that are necessary or combat
    designated, need to be placed into these trauma centers in
    order to train and sustain their proficiencies.
        Mr. Guthrie. OK. Thank you very much.
        And that concludes my questions and I yield back.
        Mr. Manifold. Mr. Chair, if I perhaps could add to the
    comments.
        Mr. Guthrie. Yes. As long as I get my 30 seconds back. OK.
        Mr. Manifold. I apologize. I give you the perspective of an
    emergency medicine physician and military physician with the
    United States Air Force and developing the critical care, air
    medical transport teams and mobile field surgical teams.
        That component of a field perspective is critical on a day-
    to-day basis on trauma care, being faced with that. I trained
    at Milford Hall Medical Center in San Antonio and we had trauma
    patients every day and when we went to war when I was deployed
    to Afghanistan with my team we were ready to go from day one.
        That doesn't occur in every environment, particularly in
    the military setting and that's where the advantages of these
    programs recommended by the National Academy of Sciences
    through their program report is integrating those teams into
    the civilian community allows us to prepare and deploy those
    folks at a moment's notice.
        Not only does it enhance your combat readiness but also our
    disaster response and domestic response capabilities by having
    these folks prepared. And as the joint surgeon for the Texas
    National Guard, it allows me to assure that my medical members
    are prepared to walk out the door and also enhances the
    opportunity to have additional military medical personnel
    perhaps serve in the military without a full-time response
    component but being able to serve in a part-time reserve
    component capacity.
        Mr. Guthrie. I think I agree and I'm supportive. I
    appreciate that and I yield back.
        Mr. Pitts. The chair thanks the gentleman.
        I know recognize the gentlelady from Florida, Ms. Castor, 5
    minutes for questions.
        Ms. Castor. Well, thank you, Mr. Chairman and Mr. Green,
    for calling this hearing on how we improve trauma care and
    thank you to all of the witnesses here today.
        Our discussion draft of the Military-Civilian and Mass
    Casualty Trauma Readiness Partnership Act being considered
    today would encourage civilian trauma systems to accept the
    placement of military trauma teams into the civilian care
    delivery system and I wanted to say I strongly support this. I
    am so pleased that the committee is being proactive on this
    because I have seen it work back home in Tampa.
        Tampa is home to MacDill Air Force Base where we have the
    headquarters for Central Command and Special Operations
    Command. We have the Air Mobility Wing and they are all
    supported by the Sixth Medical Group and they have started a
    partnership with our level one trauma center, Tampa General
    Hospital, back in 2011 starting with nurses and it has now
    evolved to surgeons and then the full team approach.
        It has been a benefit to the community because we have
    fantastic specialists and dedicated military members taking
    care of my neighbors. But it has also provided the training
    that the medical group has needed on--where they wouldn't get
    it in other places because the Air Force and military has
    scaled back a lot of their hospitals on bases across the
    country.
        So this is going to be an important part of the future.
    Tampa General Hospital is our safety net hospital. It's the
    only level one trauma center on the west coast of Florida, big
    metropolitan area. It's the home of one of our only burn units
    in the state and it's our teaching hospital.
        So it's a perfect place. So I wanted to drill down into
    some of the criteria as we--this discussion draft says we're
    going to provide grants.
        We don't have all the money in the world to do this
    everywhere. We're going to have to be particular. So Dr.
    Schwab, what criteria should be fundamental to these kind of
    partnerships?
        What kind of invectives and specifics do we need to build
    into this so that we get we're efficient with the tax dollars?
        Dr. Schwab. Thank you very much. It's a great question, and
    one of the things that we've published earlier is the chance of
    survival in this country is based on where you get hurt and we
    know from the data in Tampa that you do pretty well. So
    congratulations on that.
        Let me just say that I don't want to define for the
    Department of Defense what they need. But we know from other
    studies and comparative studies between what combat physicians
    and surgeons see on the battlefield and what is seen in our
    large very, very busy trauma centers that it's a good match.
        First, you need very, very high volume. The medical
    terminology is you need extremely high case severity indexes,
    which means that the cases are life threatening or limb
    threatening and unless receiving some type of operative or
    invasive intervention in a time manner, death is loss.
        Penetrating injury, unfortunately, in this country, all too
    common, but gun wound injury is a great thing. And then the
    ability to have mass casualty. Where does that come exclusive
    of what you're reading about and seeing in newspapers?
        It actually comes with inner city violence and specifically
    gun violence. Again, in report this is cited but our own work
    and publications actually from the trauma center in New Jersey
    shows that many times when there is warring factions in urban
    violence, trauma centers receive two, three, five, six, seven
    wounded people at one time.
        What is interesting about that a terrible liability to our
    country is the asset is training teams how to respond to mass
    casualties.
        The other piece, and you mentioned it is, these happen to
    be in academic centers because another part of recommendation
    11 is that the Department of Defense and specifically the
    secretary of the Department of Defense create career paths for
    military physicians and nurses to become trauma experts and be
    able to run their own trauma centers or their own trauma
    programs.
        So placing these in academic medical centers is extremely
    important. And the last thing I would say, and it was on the
    map, one of the things that's fascinating, if you look at who
    responded to the questionnaire where we got all of our data--
    this is in 2014--86 military physicians responses.
        They were divided pretty equally between active duty
    reservists, recently separated, and retirees. So these are gray
    grizzlies. These are people that had been to war, deployed
    multiple times.
        It's fascinating. Where do they go when they leave the
    military? They go to the urban centers, one of which is Tampa.
    But they go to the urban centers and they're there. So there's
    this symbiosis that we're looking for, this efficiency that we
    have combat experienced teachers already in many of these
    academic medical centers.
        To quote one of the other representatives, we have the
    right model with the right people in the right places. It's
    just waiting to be nationalized, memorialized, and funded.
        Thank you very much.
        Ms. Castor. Thank you very much.
        Mr. Pitts. The chair thanks the gentlelady.
        Now recognizes the gentleman from Pennsylvania, Dr. Murphy,
    5 minutes for questions.
        Mr. Murphy. Thank you. This is a fascinating discussion. I
    particularly want to thank Dr. Marcozzi and Dr. Schwab. I'm
    also a Navy Medical Service Corps. And I currently work at
    Walter Reed Hospital and we also have a unit in Pittsburgh at
    our 911th Air Force where C-130s have an air med evacuation
    unit. So Dr. Manifold, your thoughts are important too, as I
    look at this.
        And I certainly see that as things have ramped down at
    Walter Reed we don't have the same number of trauma cases.
    There has been other things which the hospital has done. I
    think it's an important model whether it's oncology or
    orthopedics, et cetera, to maintain the skill set of
    physicians.
        But I do think this idea of having military physicians
    embedded in civilian trauma units is important.
        But there's another level to this I want to ask about. One,
    who is in charge in the country? Is DOD, VA, HHS, CDC--is there
    a system already in place where people work together? Anybody?
    Is anybody in charge?
        Dr. Schwab. So one of the questions we ask leading up to
    the publication that came out in 2015 using interviews. The
    responsibility for combat readiness--trauma combat casualty
    care is diffuse across many leaders and many programs and
    departments in the Department of----
        Mr. Murphy. But it needs to be united, doesn't it, and if
    some----
        Dr. Schwab. Not only needs to be united but there needs to
    be actually one particular leader and one of the
    recommendations actually we--there's 11 main recommendations
    and 61 subordinate recommendations. It was hard to go through
    those.
        But one of the very strong recommendations amongst
    leadership is that the Department of Defense and specifically
    the secretary recognized that within the military medical
    health system--that there be one commander, one person in
    charge of readiness in trauma and combat casualty care. It's a
    strong recommendation supported by other recommendations to
    support that office so that policy, standardsand assessment of
    medical care for combat is put in place.
        Mr. Murphy. To add to this too is that I remember
    participating in a exercise called Operation Lycoming Reach
    with the 911th and then NOSC, Naval Operations Support Center,
    in Pittsburgh, and as well as other military and civilian
    trauma physicians and nurses participated.
        So, first, the volunteers were made up to look like various
    trauma victims, put on C-130s, flown out to different parts of
    New York and Pennsylvania, where then they did a triage of a
    mass casualty, and then brought back. Then, the hangar was set
    up with lots of cots and other triage and emergency care was
    done there, and then they were put in ambulances at various
    hospitals in Pittsburgh, really followed the whole way through.
        And I want to say, do you think that with regard to these
    grant programs that gives us enough robust training? Because,
    obviously, when you have a mass casualty event--and as we heard
    Nurse Klein who also said--it is going to go to multiple
    hospitals.
        Not only is there a tremendous value in having a military
    physician embedded in the emergency area and trauma areas, but
    also the cross-training that takes place with regard to we have
    got some military reservists who are trauma physicians,
    emergency physicians, and nurses, and we are going to have to
    be ready if we have a mass casualty event that is from a
    terrorist attack or something else, to send teams into areas
    and pull patients out around the country.
        Should we beef this up and add more robust parts to this?
    Bill? Anyone? Colonel, can you comment on that? Or----
        Dr. Marcozzi. So just to harken back to your first
    question, and then I will just jump to your second. So the
    first question Dr. Schwab mentioned around the DOD leadership,
    and DOD leadership needs to be on two sides on the defense. We
    recognize that the Rangers did it right. The Rangers did it
    right because Colonel Kotwal talked to then-Colonel Stanley
    McChrystal and said, ``Sir, you need to shoot, move,
    communicate, and do medical.'' And so the Rangers dropped their
    preventable deaths from 27 percent to 3 percent. Across the
    combat and commands right now, we don't have that, so there
    needs to be two ownerships to this discussion today, both the
    medical and the line.
        Second, on the civilian side of the house, right now there
    is certainly an ownership from the CDC on preventing injury at
    the CDC. But owning potentially survivable deaths at HHS right
    now, to coin a medical phrase, is bradycardic. And I think that
    it requires some energy and motivation, either from the
    Congress or injected as a result of appropriations to help them
    improve this neglected area of delivery of trauma care, to that
    end, on mass casualty development between the civilian and the
    military sector.
        I think that if we realize what the report describes and
    what Dr. Schwab did a great job of kind of coining with regard
    to military coming into the civilian sector, they are standing
    shoulder to shoulder. I would be shoulder to shoulder with a
    civilian who has never been deployed. This trauma surgeon would
    be shoulder to shoulder with someone who has never seen the
    type of injuries we saw in Afghanistan and Iraq.
        So I think that that hybrid model is joint. It is not joint
    just across all services. It is joint because it is a civilian-
    military construct to get right because both sides of that
    house need to reduce their potentially survivable deaths. So,
    and this doesn't require a lot of funding. It just requires two
    different systems and an encouragement and a nudge to have them
    work together to achieve this.
        Mr. Murphy. I know we are out of time. I hope you will give
    us a response, Ms. Klein.
        Mr. Chairman, this might be one of those areas I would
    recommend that perhaps the committee might want to go over to
    someplace like Walter Reed and some other areas and meet with
    the trauma teams there onsite and see what takes place.
        Thank you very much. I yield back.
        Mr. Pitts. The chair thanks the gentleman. I now recognize
    the gentleman, Mr. Cardenas, for 5 minutes for questions.
        Mr. Cardenas. Thank you very much, Mr. Chairman, and thank
    you for having this hearing.
        I am not a doctor, and I have never played one on TV, and I
    don't pretend to play one in Congress. But I have been a 20-
    year veteran of being a legislator now, and I have played the
    role of being a budget chairman when I was the Chairman of the
    Conference Committee in California, where for the first time we
    oversaw a budget of $100 billion. Sounds like a lot of money
    but, unfortunately, it wasn't enough to do all the wonderful
    things that you are talking about here that we would like to do
    there.
        But let's bring it back to our national situation. When it
    comes to our emergency room preparedness, why are you talking
    to Congress? Isn't this a free market issue? What does Congress
    have to do with increasing our capacity here? That is a smart
    aleck question. I just hit the softball right there, ladies and
    gentlemen. It is all yours.
        Dr. Manifold. I think part of the address, without getting
    into the specifics of financing, is we feel that the response
    component----
        Mr. Cardenas. Call it resources, call it whatever you
    want----
        Dr. Manifold [continuing]. The resourcing for response
    capabilities, the disaster, the contingency components are not
    adequately funded in today's environment. We have attempts, we
    have----
        Mr. Cardenas. Is the free market going to pay for it? Come
    on, let's be honest. Is the free market going to pay for what
    you are asking us to have in the United States? The answer is
    no. Now continue.
        Dr. Manifold. No. Yes.
        Mr. Cardenas. OK. I was hoping one of you would say that,
    but go ahead.
        Dr. Manifold. No, I am happy to say that. I was just trying
    to get around to that without getting myself in trouble in the
    Federal Register. I think that that is true. We have this
    piecemeal approach. And particularly from an emergency
    healthcare system, that is one of the things in the federal
    component of this that is very fragmented is that there is not
    a single federal agency responsible for emergency healthcare
    systems.
        The medical care through the Health and Human Services, we
    have a response component primarily through Department of
    Homeland Security, we have a robust EMS component through
    Department of Transportation, and so there is not a coordinated
    federal effort to put those resources together. And so I think
    there is opportunity. It will not be a free market component to
    currently structure our response and disaster component with
    that.
        Mr. Cardenas. Anybody else like to add? Nurse? Go ahead.
        Ms. Klein. I was just going to comment that the free market
    in healthcare usually means that I am going to go and look for
    the patients who have some type of funding. And when you are
    dealing with disasters, not everybody has funding. And so there
    have been facilities who stood up and said, ``Hey, I want to be
    the mecca, I want to be this,'' and the first time there is a
    real event and they have uncompensated patients that they have
    in their hospital, sometimes not three months, five months, or
    six months, but a year, because there is nowhere to place them,
    they very quickly change their tune.
        So it should be for all, not just the patients who have
    funding.
        Dr. Marcozzi. Thank you, sir. Thanks for the question. I
    think a lot bubbles down to the economics of this. I mean, the
    truth is, a bomb affects a Democrat just as much as it affects
    a Republican, affects a payer, an insured patient just as much
    as a non-insured patient.
        But I think that right now the current construct of our
    government is that we either have supplementals for the next
    latest disaster, or we have a $250 million approximately
    hospital preparedness program to try and influence a $3
    trillion health delivery system.
        The economics just aren't there, so I think that we have to
    figure out a more strategic way to blend what we do every day
    and prepare this construct in that, so that we are ready for
    the mass casualty and we deliver the right economically
    optimized, best outcome, delivery system that we are able to
    achieve. And, right now, I think that those two agendas--there
    is a chasm between the two.
        Mr. Cardenas. So right now, when it comes to the federal
    funding component of everything you are describing today, we
    are woefully short on funding the various aspects of what we
    should be considering and hopefully potentially funding, so
    that we could bring to fruition all of the things that you are
    advocating today.
        Dr. Marcozzi. I am speaking on behalf of myself, not the
    committee.
        Mr. Cardenas. Sure.
        Dr. Marcozzi. But I don't think we can grant our way to
    success. The $3 trillion industry is set up to be a head in the
    bed, and to try and shift to an outpatient market delivery
    system versus an inpatient system, and capitated systems. And
    certainly in Maryland that is where we are going.
        So we have to think about the healthcare delivery system
    today, right now, and then figure out a way to weave in
    concepts of preparedness into that healthcare delivery system.
    But setting up isolated, individual systems that are disparate,
    one for preparedness and one for how we do things today right
    now, it just won't get us where we need us to be.
        Mr. Cardenas. Yes.
        Dr. Schwab. I just want to comment from the military point
    of view, and that is, military health is a $50 billion a year--
    --
        Mr. Cardenas. Or so.
        Dr. Schwab [continuing]. Or more. What is interesting is is
    that almost all of that goes to beneficiary care. Beneficiary
    care dominates what military physicians, nurses, must deliver
    every day. There is no direct appropriation for readiness
    trauma combat casualty care.
        Believe me, I am a surgeon, I am not an economist, but
    maybe reappropriating or redirecting appropriations, one of
    which is talked about in the recommendation, saying to the
    military, ``You must recognize that your funds have to go to
    have readiness force.'' And the reason is no one else can
    deliver this on the battlefield but the military health system.
        Mr. Cardenas . Thank you for your perspectives. I
    appreciate it, ladies and gentlemen.
        Mr. Pitts. The chair thanks the gentleman and now
    recognizes the gentleman from Texas, Dr. Burgess, for 5 minutes
    for questions.
        Mr. Burgess. Thank you, Mr. Chairman. And, again, I want to
    acknowledge that Ms. Klein and I did work together a number of
    years ago. I won't identify how many years ago it was.
        And I also want to acknowledge the presence of William
    Garner here in the committee room. William was on the committee
    staff when Chairman Dingell was chairman of the committee. And,
    William, we appreciate now your service at Parkland Hospital
    down in Dallas.
        So we have the report that several of you worked on, and we
    appreciate your service in that regard, and now the
    recommendation of a civilian-military partnership. And I think
    we have heard several different angles on some of the
    difficulties that will be inherent in starting this. At the
    same time, there are going to be difficulties on the scaling
    side.
        But I wonder if, Ms. Klein and Dr. Marcozzi and Dr. Schwab,
    if you would all just try to summarize some of those inherent
    obstacles that will have to be overcome. And, Dr. Schwab, we
    will start with you and then move back down the line.
        Dr. Schwab. Thanks very much. Let me just say that we are
    going to build on something. We have five military-civilian
    trauma training centers since 1998. We have three for the
    military, for the United States Air Force, we have one for the
    Army, we have one for the Navy. They have been the prototypes.
    They have been the pilot studies.
        We know from interviewing both the military and the
    civilian leaders of the programs that many of the things that
    one might perceive have been worked through--licensing, state
    stature, state medical society authorization. They have been
    worked through.
        We do know that each state is slightly different, and so,
    again, depending on what states the center went into, there
    would be certain things that had to be worked through through
    state statures and through licensing.
        As far as the other thing that needs to be worked through--
    and, again, I didn't get a chance to go through this--is the
    capacity. We don't want these military teams to interfere with
    post-graduate training for our doctors and nurses.
        Now, if you think about it, we have 9 trauma centers that
    admit 5,000 patients a year. Some of them are safety net
    hospitals that are paying moonlighting fees for doctors,
    surgeons, and nurses just to staff. What is fascinating is that
    both Rand and our study found that those would be centers where
    those military teams would supplement and possibly be cost
    effective in delivering care as well as training.
        Mr. Burgess. Thank you.
        Dr. Marcozzi?
        Dr. Marcozzi. I don't have anything.
        Mr. Burgess. Ms. Klein?
        Ms. Klein. I would just comment from the nurse's
    perspective is, if you look at putting a trauma team in, let's
    say, Parkland, so there would be some significant advantages to
    Parkland. For example, we have, you know, 10 nurses vacant in
    the ICU, 15 in the ER. The nurses that come from the military,
    obviously, we could plan in there and take that position, so we
    wouldn't fill that position.
        If you look at our physicians, in the academic world, they
    want to do more publications, and they want to do more
    research. And so if there was another person there to take
    call, then that would give everybody a little bit more time to
    do that. So I can see where it would be a significant advantage
    to have these experts join us.
        And somebody asked about disaster preparedness. When we do
    our drills, when we do actual responses, having the military
    there with us, we will all learn command and control and
    incident command and what we call, you know, disaster medicine,
    which means you are going to move them forward and do the
    minimal care to get them to the next echelon of care. We will
    learn it together.
        Mr. Burgess. Ms. Klein, let me just ask you because you
    referenced it in your opening statement. Some of the first
    patients you got Thursday night were in automobiles, whether
    they were police cars or private cars, and then that affects
    your reimbursement down the line. Can you just kind of walk us
    through that and some of the inherent difficulties Parkland now
    is likely to experience from that?
        Ms. Klein. Right. So, in the trauma center, the only fee
    that we can put--and we call it the readiness fee, to be honest
    with you. So that means that everything you have you have to
    have 24 hours a day, you know, to be a trauma center, we bill
    into our trauma activation fee.
        So in our trauma activation fee, for every patient that
    comes in that arrives by transport, meaning from transfer or
    transported by our EMS agency, that trauma activation fee can
    be applied. If the patient arrives by private vehicle, then it
    doesn't.
        So in this case, on that night, there were three patients
    critically wounded that we have to say we cannot bill that
    trauma activation fee for that patient. So we do that. CMS
    spent a couple of years with this, as you are familiar with.
    And one of the things they looked at very carefully was our
    trauma activation billing. And so we are meticulous to make
    sure that we have validated whether that fee is applicable to
    those patients.
        So if we could, we are allowed to do the appropriate
    activation fee for every patient that came through those doors,
    it would be a much more fair process for the trauma centers,
    and it would also make sure that that readiness fee is
    applicable across every patient that hits the door that meets
    the trauma criteria.
        Mr. Burgess. Now, Mr. Chairman, I would just point out,
    that is a very important point because, as Ms. Klein pointed
    out, they are the court of last appeal in North Texas. They
    don't get to say, ``We are full.'' They don't get to say, ``We
    are tired.'' That is where you go when all the chips are down
    and everything is stacked against you.
        Thank you, Mr. Chairman. I will yield back.
        Mr. Pitts. The chair thanks the gentleman, and I now
    recognize the gentlelady from North Carolina, Mrs. Ellmers, for
    5 minutes for questions.
        Mrs. Ellmers. Thank you, Mr. Chairman, and I want to thank
    the panel for being here today for this subcommittee hearing.
    This is so vitally important. As a nurse, I understand that,
    and I just want to thank everyone--Ms. Klein, Dr. Marcozzi, Dr.
    Schwab, Dr. Manifold, and Dr. Myers.
        Dr. Myers, I did not realize until you started your
    testimony that you are in the Raleigh area. So thank you for
    what you are doing, and all of you. Your service is amazing,
    and so needed, and we do need to fix this problem.
        Ms. Ward, I will start with you. I just want to know--in
    particular, as we know, there are always inside politics in all
    hospitals. Do you find that hospitals are embracing the idea of
    a trauma military team coming in?
        Ms. Klein. Well, I certainly haven't discussed it with all
    the trauma centers, but I know in our hospital I think it will
    be a welcome addition. Again, I think the challenges, I mean,
    we all know about credentialing, licensure.
        Mrs. Ellmers. Yes.
        Ms. Klein. All of that would have to be addressed by the
    regulatory system before it was ever implemented. But for our
    system, we are an academic hospital, just like Dr. Schwab, and
    we embrace education and have new people there frequently. I
    think one of the things that we would probably ask for is that
    the people who are sent there at least have 12 months and not a
    rotator of every 3 months, so then you are really doing
    orientation.
        Mrs. Ellmers. So that it is more of a----
        Ms. Klein. A consistent basis.
        Mrs. Ellmers [continuing]. Consistent issue.
        Ms. Klein. Right.
        Mrs. Ellmers. So that there is a consistency there. I
    agree. I agree.
        Dr. Schwab, I just want to tell you, I represent Fort
    Bragg, and a couple of months ago I had the opportunity to
    actually go down and visit their combat training in the field,
    their trauma readiness, and I was amazed by what they were
    doing, and the evolution since being at war for so long, how
    things have changed over time, and the differences that I see
    in that ability.
        So I thank you, and I see the importance of this, and I
    hope that we can move forward with this. I think these are
    incredible ideas to move forward on.
        And, Dr. Manifold, you spoke about the inventory, the
    controlled substances inventory process now, incredible, and
    absolutely--I know we also talked about the fragmentation of
    all of these services. It sounds like an absolute nightmare.
    Can you expand a little more on what you were speaking about?
        Dr. Manifold. The concerns with management of the
    controlled substance are we all have the same goal of
    effectively being able to administer those medications to our
    patients in need, at the same time balancing and minimizing any
    potential for diversion of these type of medications. And so we
    understand that component of wanting to be able to track
    medications through.
        And so what happens currently in an ideal situation is a
    medication is ordered on a special form. It arrives from the
    manufacturer. It may come to an office, what is directed on the
    physician's license, and that is then inventoried, put in a
    safe place. It may be placed in a vial or with a tracking
    number, and then be put in the place it would be administered
    to a patient.
        In a physician's office or a hospital setting, that is the
    model that was placed for the Controlled Substance Act that was
    written in 1970. For emergency medical services, we have
    vehicles and personnel that are on the move continuously. They
    may not be at that brick-and-mortar station. They may be moving
    to the hospital, and they may have to go back to a supervisor
    or a central location, which takes them out of their response
    area to be restocked with those controlled substances.
        And, again, from a medical director standpoint, when I have
    to have a direct--or a separate license for each one of those
    facilities, it can be very problematic in trying to manage and
    control that. If I have a license or a product that is sent to
    that facility, and the individual there doesn't recognize the
    name, doesn't understand the importance of this delivery, who
    knows where that goes to because it has not been entered into
    our system.
        And, hence, we want to with this legislation try and
    enhance that process of tracking and monitoring the control
    system.
        Mrs. Ellmers. And I can see, Dr. Myers, that you very much
    agree with that as well. And I can see how this probably
    contributes to a lot of errors. Not that anyone would make
    those errors knowingly, obviously, but I can see how there is
    just an incredible disconnect between efficiency and the
    ability to be in a controlled environment, because that is
    essentially what we are talking about here is trying to control
    chaos.
        So, Dr. Myers, would you like to also, in just the few
    seconds that I have----
        Dr. Myers. Sure. Just succinctly, 4365 does one thing that
    helps us all, and that is it creates a mechanism that actually
    applies to EMS that officers from the DA can utilize. The
    problem we have today is there is no mechanism, and so every
    person in the enforcement arm is trying to do the best they can
    under a law that just does not fit the practice. And so we end
    up with this disparate way of doing it, through no one's
    intention. This is the solution to that problem.
        Mrs. Ellmers. Well, thank you, again.
        And thank you, Mr. Chairman, for bringing this important
    subcommittee hearing. Thank you.
        Mr. Pitts. The chair thanks the gentlelady.
        I now recognize the gentleman from New York, Mr. Engel, for
    5 minutes for questions.
        Mr. Engel. Thank you, Mr. Chairman. The state of our trauma
    system is I think something that most of us have likely given
    relatively limited thought to until a personal national tragedy
    brings it to the forefront. I would imagine every one of us has
    relied on our trauma system for care either for ourselves or
    for a loved one, so I would like to start out by saying thank
    you to all the healthcare professionals present today who have
    dedicated their lives to caring for those in trauma situations.
    Your work is truly lifesaving.
        Ms. Klein, I found the portions of your testimony
    concerning trauma activation fees very alarming. If my
    understanding of your testimony is correct, a gunshot victim
    might have to wait in a trauma bay for a full half-hour before
    moving to an operating room in order to ensure that the trauma
    center receives the activation fee it needs to pay its bills.
    Is that true? Is that the case?
        Ms. Klein. No. There has to be 30 minutes of critical care.
    It can be applied at any time, and, you monitor that. So if a
    physician is there looking at the X-rays, putting in chest
    tubes, managing the airway, you can clearly see where that 30
    minutes is addressed.
        In our situation, I will be honest with you, if a patient
    is, what you described is in our trauma bays more than 30
    minutes, then we have an issue with that. So most of our
    gunshot wounds to the chest or to the abdomen come into our
    trauma rooms and go straight to the operating suite.
        Mr. Engel. OK. Let me ask you about partnerships between
    civilian trauma centers and the military. You contended that
    such partnerships might, and I am going to quote you, ``enable
    a military team to be mobilized, not just overseas, but also to
    respond to a mass casualty event like the one we have just
    experienced in Orlando.'' Can you elaborate on how these
    partnerships would help facilitate such response?
        Ms. Klein. Sure. So obviously, the expectation is that
    these military teams would be embedded in our trauma center, so
    they would become our colleagues, not people that were visiting
    us. And so when you go through a disaster response, everybody
    should be trained for the hospital response, as well as how
    they are going to work in the region.
        So I will give you a perfect example. When Katrina hit, we
    had 21,000 people visit Dallas. Houston had the same amount.
    And so when you look at that, we activated a health care
    facility in the convention center. So that means that we had to
    take people from the hospitals, from our EMS off their normal
    jobs and put them in this convention center to take care of
    patients.
        If we by chance had a military team embedded in us, that
    would give us additional resources to be able to do that. So we
    would have the opportunity as a civilian hospital to learn, but
    they would also have the opportunity to learn.
        Now, in those situations there weren't a lot of critical
    gunshot-wound type of events like that, but had we had them
    embedded with us during the event that happened Thursday night,
    they might have been the one that took the patient to the OR
    and the civilian trauma surgeon, wait for the next patient to
    come through. And that is the expectation that we see
    happening.
        Mr. Engel. Thank you. Dr. Marcozzi, you cited a startling
    statistic during your testimony. And I quote you again.
    ``Approximately 1,000 service members died of potentially
    survivable injuries from 2001 to 2011 in Iraq and Afghanistan.
    Here at home, nearly 150,000 trauma deaths occurred in 2014.''
    Can you elaborate on that?
        Dr. Marcozzi. Certainly, sir. So there was a study done and
    it was championed by a trauma surgeon who started to ask, well,
    of the lives that we lost in Iraq and Afghanistan, could I have
    saved any of those? So I asked the right questions and actually
    did a very unique way to look at were those lives lost and
    looked at the autopsy reports of those patients and then
    started to quantify how many of those patients could have had
    lives saved. And then he quantified that and found out that by
    his potentially survivable definition that approximately 1,000
    service members from 2001 to 2011 were deemed potentially
    survivable.
        The majority of those cases were in the pre-hospital
    sector, as I mentioned, and of those in the pre-hospital
    sector, the majority of those died of three different reasons.
    The first was hemorrhage, the second was airway, and the third
    was pneumothorax. So addressing those in the pre-hospital
    sector would certainly mitigate or decrease those number of
    potential lives lost, and you saw a significant pivot by the
    Department of Defense to embrace some of that literature,
    although late. And you saw tourniquets being employed much more
    readily in theater to save some of those lives.
        So that and Secretary Gates' 1 hour. Minutes matter in
    trauma care, and when the Secretary came out with the 60-minute
    golden-hour rule, that a patient needed to be transported back
    to a military treatment facility within 60 minutes, that
    changed and decreased our mortality in theater. So those two
    were significant changes to the way the military does things
    and speaks to that, 1,000 service members.
        Mr. Engel. Thank you, Mr. Chairman. I see my time is
    expired. Thank you. Thank you to the witnesses.
        Mr. Pitts. The chair thanks the gentleman. Is the gentleman
    Mr. Collins ready or do you want me to--the chair recognizes
    the gentleman from New York, Mr. Collins, 5 minutes for
    questions.
        Mr. Collins. Yes, thank you, Mr. Chairman.
        As the former county executive of Erie County, Erie County
    Medical Center is a trauma one. We are the go-to trauma center
    for anyone and everyone in western New York. And so I guess, I
    am certainly familiar with how lifesaving a nearby trauma
    center--and you were saying minutes matter. I know what we are
    talking about with the military, making sure we share best
    practices. What we have learned here, we share there.
        And so I guess perhaps part of my question is we had a case
    with the Buffalo Bills several years back, a spinal cord injury
    on the field, and lo and behold, and it was a trauma surgeon
    who was the Bills' doctor went and used what they called
    moderate hypothermia, cold therapy, which frankly had probably
    never been used before on the football field. And the prognosis
    then of this player was night and day, night and day different
    than what a traditional therapy might have been, somebody
    thinking truly out of the box.
        So I guess my real question is if anyone would want to
    weigh in on how we are in fact communicating one trauma center
    to another, whether it is military, civilian, or civilian or
    even with trauma physicians. The best of the best save lives
    every day, and we know too tragically in some cases folks who
    might have been near Erie County Medical Center would have
    lived and those not near did not.
        So, you know, I think that is a general thing of what
    Congress might be able to do to help move that along.
        Dr. Schwab. Well, having been born and brought up in
    upstate New York, moderate hypothermia is present 6 months of
    the year.
        But let me just say that your question is how well does
    communication take place. Communication on the civilian side
    actually in all of the disciplines I think proceeds fairly
    well. There are established academic societies where research,
    observation, data is presented, peer review is accomplished and
    those that are felt worthy are published and people learn
    pretty quickly. And by pretty quickly I mean within a matter of
    years what is going on.
        Where there seemed to be a wall that occurred and was
    really strengthened after Vietnam for whatever reason, probably
    just the adversity to the Vietnam War, where that all broke
    down was between the military and the civilian worlds. There is
    very little formal bidirectional way the military can
    communicate with civilians. It does occur, but it is much more
    informal.
        Interestingly enough, one of the things that we are talking
    about that would be interesting to this committee is reusing
    and asking information technology, data people, software
    developers to make all of our electronic medical records and
    our decision-support tools proactive at the bedside so that we
    can be informed about the latest data at the bedside while we
    are making decisions. That would lead to some standardization
    and therefore decrease actually mistakes that are made and even
    potentially save more lives.
        So I think one of the things and one of the reasons we were
    asked to serve on the committee was to increase and find ways
    to formally promote bidirectional flow across all disciplines
    but between the military and civilian sectors. Thank you, sir.
        Mr. Collins. So another issue, we talk about NIH funding a
    lot, 21st Century Cures in particular, looking at increased
    funding, in my cases, that leads to cancer and other illnesses.
    Is there a way that trauma centers can access NIH funding of
    any significance, or is that not a normal pathway that we see?
        Dr. Schwab. So, again, one of the things that the report
    really focused on is if you look at the burden of injury, both
    death, disability, and you look at long-term disability,
    especially because trauma is the leading cause of death and
    long-term disability in people under 46----
        Mr. Collins. I have only got 30 seconds but----
        Dr. Schwab [continuing]. You basically see that there is
    very little funding.
        One of the things I would invite your attention to on
    chapter 4, 33, is looking at NIH funding measured against the
    burden of disease for Americans and injuries at the bottom of
    the list. So the answer is there is no formal trauma funding in
    the NIH for trauma----
        Mr. Collins. I think that whole issue is one we are going
    to have to look at because in many cases what was happening has
    just continued and maybe it is time to re-jigger that, the
    priorities.
        Dr. Schwab. Yes.
        Mr. Collins. Yes. Thank you.
        Dr. Schwab. Thank you.
        Mr. Collins. Thank you, Mr. Chairman. I yield back.
        Mr. Pitts. The chair thanks the gentleman and now
    recognizes the gentleman from Indiana, Dr. Bucshon, 5 minutes
    for questions.
        Mr. Bucshon. Thank you, Mr. Chairman.
        I was a cardiovascular and thoracic surgeon for 15 years
    prior to coming to Congress, so thank you all for what you do
    on behalf of your patients. It is appreciated. I know. I have
    been there. I was also a Navy Reserve officer from '89 to '99,
    never got called up but I was ready.
        So my question is going to be maybe to Dr. Schwab and Dr.
    Marcozzi about manpower issues. First of all, I support this
    idea, this concept about integrating the systems. It is
    important. I think it makes sense.
        That said, even though I was in a community hospital,
    obviously I had had a lot of background in trauma surgery and
    still did a fair amount on the thoracic side. I would have been
    willing, had I been--I wasn't on IRR or anything but had I been
    called, I would have been willing to go in a heartbeat for a
    month or two to Afghanistan or to Iraq and helped if needed or
    somewhere else to support--to Germany to support people from
    Germany that were going in theater. But that isn't really a
    possibility. And when I became a Member of Congress, I
    discussed that with the head of the Navy Reserve from the
    formal admiral, Admiral Debbink was his name. Any thoughts on
    that in not only helping train people that are active-duty in
    the trauma setting but having the ability to access potential
    people who you may not think would be otherwise available to
    you if needed? Any thoughts?
        Dr. Marcozzi. So, as a reservist, it is palpable to me that
    there is a better way to address these issues. I think that
    from a military standpoint this requires DOD, which is going to
    be kind of a change for them to make dedicated billets at some
    of these major civilian trauma----
        Mr. Bucshon. Yes, I guess I should clarify. I was not a
    reservist. I wasn't in the reserve. Through the reserve, I
    understand there was ways to access that. But for a variety of
    reasons, I wasn't still in the reserve. I had been in and was
    out.
        Dr. Marcozzi. Yes, sir. So I think that there is a way that
    DOD can help shape what these joint military civilian trauma
    centers look like. It requires dedicated billets and dedicated
    staffing. And the center itself has to understand, during a
    deployment, those assets will be removed from there, so
    building in a safety mechanism so that the care is kind of
    continuous when they get deployed, that system can absorb that
    loss because what will likely occur will be they will become
    part of the infrastructure of the center and then the center
    will just adopt them as part of their own. Unfortunately, they
    will get deployed and then the center will have to absorb that.
    So strategically thinking about how to employ them correctly is
    important.
        And the second piece of this is how do you blend an
    approach between the reservist, the IRR, which I think are a
    potential untapped resource to actually achieve what we are
    trying to describe. Right now, I think that the Department of
    Defense doesn't do that entirely right. I think that there was
    a lot of testimony to the committee that says that reservists
    who are deployed went potentially before their training was
    complete on how to manage trauma care. So better training prior
    to deployment contiguous is going to be important.
        Mr. Bucshon. Because for me, just the economics of it and,
    where I was in my practice and with my family it would have
    been difficult to rejoin the reserve, but to be called for 6
    months or a year, it is just not a practical situation. But for
    a month or two, it would be something that I would have done in
    a heartbeat.
        Dr. Marcozzi. One of the things that is not so apparent is
    that this is aimed across the DOD, the military health system,
    reservists, National Guard, and even some other contract people
    that work for the DOD.
        But let's just look at this reserve thing. If you look at
    the map of the United States and you look at where our busiest
    trauma centers are and you just say that you are a reservist
    and I will pick on you and you are in a busy practice in a
    community and you want to do your 2 weeks and you want to re-
    certify or sustain in your trauma aspect, by creating this
    national network with these centers regionally, you could do
    that and go home every night as opposed to now, which is
    reservists being stationed and sent for 2 weeks of training
    actually all over the Department of Defense. And so there is
    some real cost-efficiencies here for reservists that need to
    train or learn new or sustained skills by creating a national
    network of these training centers, especially among the high-
    volume centers. Thank you.
        Mr. Bucshon. Thank you. I yield back.
        Mr. Pitts. The chair thanks the gentleman.
        That concludes the first round. We will have one follow-up
    per side. The chair recognizes Dr. Burgess 5 minutes for
    follow-up.
        Mr. Burgess. Thank you, Mr. Chairman.
        We have been talking about the possibility of setting this
    up, scaling it, building on what has already been there. Let me
    ask a question from a different perspective and primarily I am
    directing this at Ms. Klein, Dr. Marcozzi, and Dr. Schwab. But
    is there a danger in becoming over-providered on the trauma
    side?
        Dr. Schwab. One of the recommendations--let me back up. We
    asked the same question and were asked the same question on the
    committee. Currently, there seems to be a surge among the for-
    profit health corporations to establish level 2 and even level
    3 trauma centers in the more affluent communities, therefore,
    decreasing the volume going to our level 1 trauma centers,
    which are the training centers.
        One of our recommendations, therefore, may be on the
    surface contradictory. One of our recommendations is that,
    where appropriate, a sample, a group of military treatment
    facilities--that is military hospitals--become American College
    of Surgeons verified trauma centers and participate in the
    civilian system.
        We think that is doable and will not take away from the
    other trauma centers that are charged with the education and
    research of the civilian sectors and may be these training
    centers. The DOD would have to be selective, and they would
    probably have to follow a model that was created in San Antonio
    because San Antonio has the only level 1 trauma center in the
    military which is fully integrated into the civilian trauma and
    emergency system.
        Dr. Marcozzi. Dr. Burgess, my comment would be, wouldn't
    that be a nice problem to have, was my first initial reaction.
    I think that when we start to try and strategize----
        Mr. Burgess. It was difficult for me to ask the question. I
    just want you to know that. And I also want you to know that I
    can't believe I used provider as a verb.
        Dr. Marcozzi. So I think that there is a deficit right now
    in our go-to-war mission for the Department of Defense, and it
    primarily revolves around the ability to care for soldiers on
    battlefields. And when I say soldiers, generally all services
    on battlefields. And that is a neglect that we need to address
    as a nation, as a Congress, as a White House because we can't
    do our nation's--we can't ask young service members to go in
    harm's way and not provide them the best ability to save their
    life if they were injured on a battlefield.
        So I think that I would like to have another congressional
    hearing on how do we reduce our trauma capability in 5 years
    for the Department of Defense when we get there from here, but
    right now, I think that there was a recognition from the
    committee that the current strategy that DOD uses to best care
    for soldiers on the battlefield is inadequate, and I think the
    report describes a vision on how to get there from here.
        Mr. Burgess. The genesis of asking the question, a couple
    of years ago we had the Ebola crisis, if you will, in the
    Dallas-Ft. Worth area, and you did have patients showing up at
    one of these ancillary--they were actually not ancillary. They
    are full ERs. And how do you--scarce resource, the moon suits
    that were available, how do you deal with the distributional
    problems that when a patient--you can't control where the
    patient accesses. So that was one of the reasons that made me
    think in terms of is there going to be some problem with our
    designation.
        So I realize it may be a good problem to have and I would
    obviously welcome working through that, but at the same time,
    from a planning standpoint where we are talking about planning
    being one of the primary foci of this, from the planning
    standpoint, I think that is one of the things that we have to
    consider.
        I am sorry, Ms. Klein. You wanted to say something as well.
        Ms. Klein. There are two ways we can look at this. So,
    first, to take a patient to a facility that you know is going
    to have to turn around and transfer that patient to another
    facility in some ways to me doesn't make sense because they
    should go where they are needed to go in the first place. And
    so some of these facilities, especially in Texas we are having
    the standalone ERs; and don't get me wrong, I think there is
    definitely a role for the freestanding emergency departments--
    but to be engaged in some of these critical pieces, they need
    to be prepared, yes. But if you know you are going to take a
    patient there that is going to have to be transferred, there
    are some questions there. It doesn't mean it can't happen, but
    we just need to look at that.
        But one of the things I really want to talk about is data
    management. So to answer your question and some of the other
    questions is that this should be a data-driven system. And the
    performance improvement process in a trauma center is the DNA
    of that trauma center. If it is a strong PI process, then you
    are going to have a strong program. And why? Because you are
    looking every day at what you are doing right, what needs to be
    fixed, what needs to be adjusted.
        And so part of what this model that we are talking about is
    to bring together the civilian trauma center's data and
    performance improvement with the military and asking who is
    doing it right and who is doing it best and how do we learn
    from you? We have a thing called Trauma Quality Improvement
    Program through the American College of Surgeons. We call it
    TQIP. And in TQIP we compare our hospitals. We call it
    benchmarking. And so the ideal is to provide that same
    opportunity in the military world so we can see where are our
    best performers and how do we get there? How do we follow their
    lead to be best performers ourselves?
        Mr. Burgess. Thank you. Thank you, Mr. Chairman. I will
    yield back.
        Mr. Pitts. The chair thanks the gentleman and now
    recognizes Mr. Green, 5 minutes for a follow-up.
        Mr. Green. Thank you, Mr. Chairman. And as I said earlier,
    at University of Texas Health Science Center in Houston where
    Dr. Burgess went, we had an ER doctor who actually was the one
    who told me back before 9/11 that they were training a lot of
    their--they were doing rotations from the military through Ben
    Taub Hospital and Memorial Hermann, which is right next door to
    each other. And when I was in Iraq, I was surprised even at
    Landstuhl in Germany the military would call up neurosurgeons,
    anesthesiologists, and they would serve their 90-day rotation
    so they could still have a practice back home.
        But because of our issues with the lack of level 1 trauma
    centers in our country, I think it is a great idea to see if we
    can partner with the Department of Defense and say these are
    facilities that you can be trained in, and it helps us with the
    funding, too, because, again, we have second and third level
    may be easy in some areas, but level 1 takes a big investment,
    whether it be Parkland or in Houston. So I think that is a
    great idea to do that.
        Dr. Marcozzi, you had the opportunity to participate in
    both the military and civilian trauma from so many vantage
    points, so do you believe this Federal leadership is important
    by improving our ability to serve both our military and our
    civilians in trauma? And to what extent does the military
    medicine for trauma differ for civilian trauma care?
        Dr. Marcozzi. Yes, thank you, sir. I appreciate the
    question. So believe it or not, last night anticipating
    questions I actually did a back-of-the-envelope look on who
    would own this report from at least the congressional side. And
    in a quick look, the Senate Armed Services Committee, the
    Senate Finance Committee, the Senate HELP Committee, the Senate
    Veterans' Affairs Committee, House Armed Services Committee,
    the House Ways and Means Committee, the House Energy and
    Commerce Committee, the House and Senate Appropriations
    Committee, and the House Committee on Veterans' Affairs would
    have and has equities within this report.
        Mr. Green. Yes.
        Dr. Marcozzi. So to that end on the executive side not only
    does the White House and policymakers have ownership of this
    but so does OMB. And both of those, from an administrative
    standpoint, have to embrace what we have described here
    because----
        Mr. Green. Yes.
        Dr. Marcozzi. And the only place to execute a multi-
    departmental effort has to be championed at the White House.
    What the committee realized is to have this be a successful
    effort, both need to be successful. If one arm of that fails,
    then both arms fail. So the White House needs to own this.
    Congress can certainly help the administration, encourage them
    to embrace some of the recommendations here. But if the White
    House does that and calls the Department of Defense and the
    Department of Health and Human Services to task on this and
    says create a nidus for leadership and accountability and data
    collection, then both will actually succeed in their efforts.
        Mr. Green. Well, of course, in Congress the Energy and
    Commerce Committee would like to have all the jurisdiction, but
    you are right, Homeland Security, Armed Services, of course
    appropriators, and so that makes it sometimes difficult to be
    able to put these all together, and that is why there does need
    leadership from the White house, I guess, in doing that.
        But you have given me some ideas and, like I said,
    Congressman Burgess and I for years have authorized funding for
    trauma care, but it is tough to get the money out of the
    appropriators. And so this gives us a way that maybe we can
    bring in other resources because a partnership between the
    private sector and the military has worked on medical research,
    breast cancer research. It has helped us in the private sector
    as well as the military so there may be a way that we could do
    that on trauma. And again, I am more interested in level 1
    trauma because of the need for it in our urban areas.
        So, again, Mr. Chairman, thank you for the hearing. I think
    it has been real educational for members and I look forward to
    working with you on it.
        Mr. Pitts. Thank you. The chair agrees. And we have heard
    some very good recommendations and issues that need to be
    addressed here today and some important information.
        That concludes the questions of the members present. We
    will have some follow-up questions in writing, other members
    may have in writing. We will send those to you. We ask that you
    please respond. I remind members that they have 10 business
    days to submit questions for the record, so they should submit
    their questions by the close of business on Tuesday, July 26.
        With that, this hearing is adjourned.
        [Whereupon, at 12:04 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

               Prepared statement of Hon. Joseph P. Kennedy, III

        Thank you, Mr. Chairman. Recently, I spoke with a
    constituent whose family was forever changed by the Boston
    Marathon bombing and the life-saving work of first responders
    and trauma care providers especially those at Brigham and
    Women's Hospital (BWH). The story the Reny family shared with
    me is inspiring and critically relevant to today's hearing, and
    I would like share some of their words now.
        On April 15, 2013, Gillian Reny, an eighteen year old high
    school student and aspiring dancer, stood near the finish line
    of the Boston Marathon with her parents, Steven and Audrey
    Epstein Reny, waiting for her sister Danielle to finish the
    race. Then two bombs went off and a beautiful day turned to
    heartbreaking tragedy for the Renys and all of Boston.
        When first responders rushed the Renys to Brigham and
    Women's Hospital, doctors and nurses worked heroically to save
    Gillian's life. In the process, they also saved both of her
    legs, a miraculous outcome.
        Inspired by Gillian's resilience and forever grateful to
    the BWH team that saved her life, the Reny family established
    the Gillian Reny Stepping Strong Fund in February 2014.
        The goal is to fund innovative trauma research, training
    world class clinicians, and transforming outcomes for trauma
    survivors. The Stepping Strong Fund fuels innovative research
    and clinical programs in trauma healing and limb
    reconstruction.
        To date, the Stepping Strong Foundation has raised over $7
    million and counting. With this momentum, BWH is moving to the
    next level, with the creation of the Stepping Strong Trauma
    Center. The program will now from a virtual catalyst for change
    into a physical hub, anchoring a sustainable network dedicated
    to the collaborative research endeavors in trauma, limb
    salvage, and tissue regeneration.
        Whether we are talking about caring for victims of mass
    violence such as the Boston Marathon bombing, responding to
    natural disasters, or treating America's injured men and women
    in uniform, a strong trauma system plays an invaluable role in
    our nation's health care system. While the Affordable Care Act
    included funding for several trauma care programs, including
    regional systems for emergency care and trauma care centers, we
    must continue to provide robust funding to ensure that an
    experienced, collaborative trauma system is there when we need
    it most.
        I am grateful to the Reny family for their bravery and for
    allowing me to share their story today.
        Thank you, Mr. Chairman. I yield back.
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