[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
                        
                                  ______

                         U.S. GOVERNMENT PUBLISHING OFFICE 

22-308                         WASHINGTON : 2017 
-----------------------------------------------------------------------
  For sale by the Superintendent of Documents, U.S. Government Publishing 
  Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
         DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, 
                          Washington, DC 20402-0001
                              
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                    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:]
    
    
   [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
 
  
    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:]
    
    
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
   
    
    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:]
    
    
   [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
 
      
    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.
                              ----------                              


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                                 [all]