Reading Rotunda
Supporting soldiers into the 21st century ; Major General Kevin C. Kiley, MC USA speech
By
Oct 6, 2003, 00:40

Courtesy the EMS House of DeFrance http://www.defrance.org

Good afternoon. It is a real pleasure and honor to be here to speak about the AMEDD [Army Medical Department] Center and School and to review a few Army training initiatives.

Fort Sam Houston is the home of Army medicine and at any one time we are training 3,000 to 4,000 soldiers to be medics of all kinds. They are a unique group of great young Americans.

I would like to run through a couple of things here for you and then open it up for questions. I'm very proud of what we have [been] doing at Fort Sam [Houston] and the [AMEDD] Center and School. It is probably the largest health training organization in the world, if you consider all of our different programs. And I think you'll see the importance of that when we talk a little bit about the combat medic, important at least to the Army.

The AMEDD is supporting not only our homeland defense and what's going on over in Afghanistan, among other places, but [is] still very heavily involved in beneficiary care. I think an interesting and fast-moving subject right now is our homeland defense CBRNE [chemical, biological, radiological, nuclear, and explosive devices] operations and consequence management. The Center School is doing some aggressive training, as well, not only at Fort Sam but across the rest of the Army medical department in our Table of Operations and Expenditures (TOE) and Table of Distribution and Allowances (TDA) units, ensuring that people are trained to manage CBRNE incidents on or off their posts. I think some of the traditional posse commitatus [limitations] which [prohibit] military [involvement] except when invited in under specific circumstances are blurring a little bit based after what happened on September 11, 2001.

You may not know a lot about the AMEDD. [We have nearly 3 million beneficiaries, and spend more than $18 million daily on health care.] Our TOE [generally referring to Army operational field units] units and TDA [referring to nontactical fixed facilities] facilities are fewer in number than [they] were 5 or 7 years ago. TRICARE certainly picked up the slack, and we now have TRICARE For Life [provides effective coverage for our older retirees.] There is a lot happening in the AMEDD in any one day, including, on average, 5,000 immunizations and 63 births. It is a busy organization. [In addition], the AMEDD is [the] executive agent for the anthrax vaccine program. We have all of the veterinarians in the Department of Defense. We have oversight for and assist the Board of Directors in the AFIP [Armed Forces Institute of Pathology] and the Armed Services Blood Program. There are 22 more activities for [which] we are Executive Agent. Our bottom line business is providing good medicine in bad places.

What I would like to [emphasize regarding] Army medicine is that it is not just a concept of logistics. It is a lot more. It starts with our combat soldier and from our perspective that is what we are all about. Combat soldiers will not go into combat without medics and medical support. Once someone is injured, be it disease, nonbattle injury or battle injury, it begins a fairly complex process.

[I will give you an example of] how complex this process is. A couple of years ago, at a conference here, I was asked to sit on a panel with General McDuffy, who was the J-4 at the time, along with several other service representatives. He talked about the Kosovo operations, [in which] one of the helicopters had lost a hydraulic pump, and they had had enough velocity logistics and asset visibility to get a replacement pump down from Europe. Once they had done all that and repaired the helicopter, they realized they could have gone right off the coast to a Marine Amphibious Unit [who] had extra pumps. [They] knew they would have to get better at that.

Well, I took his example and [related it from] a medical [perspective]. My view of combat medicine is that the helicopter has got a pump that's failing. It's sitting on a landing zone. It's still at idle, the crew is still on board, and you have 12 hours to get the pump there. [You must] replace the pump while the engine is still running and if you fail anywhere in that mission, all four crew members will die. It's a whole order of complexity more than the rest of the Combat Service Support Community is really accustomed to having to deal with, but it's hard to articulate that.

It has been interesting to see what has transpired in Afghanistan. We just brought a couple [an] FST [Forward Surgical Team] commanders and surgeons in, who had just come back from Afghanistan or Kuwait and performed an after-action review (AAR) with them. [This AAR] included the Joint Trauma Training Center at Ben Taub [General Hospital, Houston, TX], which is training FSTs and surgeons in the high-trauma, combat-like environment of the inner city. [The] Army is also training in Miami, while the Air Force uses Baltimore, and I think the Navy is going to be [in] Los Angeles.

Did the Joint Trauma Training Center have relevance as a training capability to what we were doing in Afghanistan? Frankly, I was a little surprised. I thought this would have fit nicely. You spend 4 to 6 weeks at Ben Taub, and [have the opportunity] to resuscitate seriously injured patients. [However,] the injuries the FST was seeing in Afghanistan were mostly explosive peripheral injuries with a lot of shrapnel and high-velocity weapon trauma because of the body armor and the types of munitions need. What we're seeing in Miami is lower-velocity thoracic and abdominal injuries [from] bullets, knives, and motor vehicle accidents. As a result, where I thought there would have been a very nice correlation, there still seems to be a potential disconnect. However, the ability to learn and take care of patients that are severely injured is still there as a benefit JTTC.

[The issue is] very complex and I am not sure we have it quite right yet in Afghanistan. We've had a couple of cases of soldiers I think that have survived for 2 or 3 hours after injury, but then succumbed because we weren't able to MEDEVAC [medically evacuate] them [promptly]. That puts us back into pre-Vietnam era medical care in terms of scooping people up off the battlefield and getting them to a hospital. So, we're still working our way through that. One of the other things we've looked at in terms of tactics, techniques, and procedures is "essential care in theater." This is an interesting concept because it [depends upon] the coordination and synchronization of the Army and the Air Force. As we worked our way through how the Army Medical Department and our tactical units are going to provide health care in the battlefields of Bosnia or Afghanistan, part of what we talked about trying to avoid was putting a big footprint on the ground. Instead, we want to MEDEVAC injured soldiers out quickly. Well, has anybody talked to the Air Force about their concept of operations in support of MEDEVACing all those casualties out? We have had some interesting discussions that have opened our eyes up about [the capabilities of] both the Army and the Air Force and set some new standards, guidelines, and policies to define the term stability [prior to medical evacuation]. If you have 15 or 20 severely injured soldiers, how much capability do you have? And how stable do they have to be before they can get on board?

What we are really talking about is changing our capability and elimination, in some respects, of some of our more mature theater medical capability. Another big issue we talked about, in the area of doctrine, is that one of the ways to lower the footprint in theater is to "skip" facilities in the MEDEVAC chain, so that you take people out of the battlefield in Afghanistan, and [send them directly to] Landstuhl, rather than a combat support hospital in Afghanistan or a larger facility in a place like Turkey. The casualties then proceed from Landstuhl to Walter Reed. That makes the footprint smaller, but "skipping" requires the Air Force to be there with a lot of lift [capability] all the time. Consequently, we are still working our way through some of these things.

The DMRTI [Defense Medical Readiness Training Initiative, Fort Sam Houston, Texas] has studied issues like this. Their clinical review claims that we can skip up to 80% and the Air Force is still going to need to work on this. What this would do is to reduce our hospital requirement significantly as we look at how the Army is going [to] look in the next few years.

Now one of the other things you may be aware of is that we're modernizing our Army. It's called the Army transformation, [which in part will] modernize [the] Army Medical Department and Army Medical Department facilities. What we have done is to work from a research and development effort into a material development, building doctrine, training, and leadership-concepts leading to objective force capabilities. Overall, the AMEDD Center and Schools aim to [determine] what the force [is] going to look like in 2008? Why should that be important? This December, the Army's interim combat team, now called the Striker Brigade, will reach its initial operational capability. In theory, in December of this year, the Army will be able to deploy its first interim Brigade with this new combat vehicle called the Striker. By 2008, the Army will be producing future combat systems, which is a system of sy\stem. It's not a tank. It's not a Bradley. It's not a Striker. We're not sure what it is yet. By 2010, which is only 7 years away, we're going to have objective force initial operational capability. What is the medical force going to do to support that? What is it going to do in 2008 or 2010?

Well, as good as we are, I don't think we're going to alter human physiology that much. So we are relying on technology and innovation. We are also relying on industry to help us in terms of developing new technologies and new capabilities [such as] robotic surgery; new anesthetics that will make injured soldiers pain-free, fully alert, and oriented to continue the battle; new monitoring capability; [and] more aggressive telemedicine in terms of transmitting data and information. We [are engaged in] a process that looks at all this, and then returns us to training and readiness. The Army is about training soldiers and building leaders.

At the DMRTI at Fort Sam, where I'm the executive agent on behalf of the Department of Defense and the Secretary, we have a whole host of joint training opportunities. Probably the one that is best known is C4 (the Combat Casualty Care Course), which is aggressively run almost year round. The Army Trauma Training Center, which I've already mentioned, has been working active duty teams through first Ben Taub and now Miami. This summer [this program will include] a series of reservist forward surgical teams-a forward surgical team is a group of three general surgeons and an orthopedist, a nurse anesthetist, operating room and recovery room nurses, and medics- far forward for life-saving surgical resuscitation. Many at Uniformed Services University of Health Services know [more] about Bushmaster than I do, but that is another joint effort.

We are carrying out Assistant Secretary of Defense for Health Affairs Winkenwerder's directive that all personnel in the military health care system have training on CBRNE. In addition, all soldiers, regardless of rank, are going to have some training on self-aid and buddy aid. As we look at leadership, there will be more information provided in courses such as the Officer Advanced Course, BNOC and ANOC (advanced courses for non-commissioned officers). The military unique curriculum efforts here in a professional medical education arena and in Graduate Medical Education training programs, [are already having an impact). All of our courses and our conferences will have a CBRNE piece to them, whether it is an hour or a couple hours.

How do we manage homeland defense and consequence management? This plan is almost complete in terms of its publication and the milestones for the Army Medical Department. We are in the process of doing a gap analysis with the Navy and the Air Force to see what they have that we don't have, and vice versa, in an effort to make sure that everybody in the MHS [military healthcare system] has some familiarity.

We at the Center and School are also working on developing a curriculum and a body of knowledge, with our civilian counterparts, to cover a variety of special issues. [For example], what do pediatricians know about managing a 9-month old that has been exposed to sarin? What do obstetricians know about managing [pregnant] patients that have been exposed to smallpox? What do anesthesiologists need to know about otherwise routine abdominal, thoracic, or orthopedic surgery [in the event that the patients] have been exposed to phosgene or sarin and/or have been treated with Mark-II injectors [comprised of 2-pralidoxime oxide, atropine, and valium]. What is it that we need to know specifically, which we really haven't thought about before? We are working on this in conjunction with the other services.

What does the future hold? From the Army's perspective, General Shinseki [Chief of Staff of the Army] has a vision for the Army of the future that must stay relevant. For example, look at the M-1 tank; it is the biggest, most powerful, [and] most effective main battle tank in the history of the world. Frankly, there is not much right now that can defeat it. However, for it to [remain] dominant on the battlefield of the future, it will have to get thicker armor, heavier, and bigger. If you can get it there, it continues to be an effective weapon. [On the other hand] the 82nd Airborne Division, which is probably the most effective, most highly trained and lethal land warrior force in the world [has the] ability to deploy within 18 hours, "wheels up," to anywhere in the world. But they are not very sustainable or lethal against armor. The vision of an Army of the future simultaneously combines sustainability and lethality, [while] reducing the logistical footprint. [We anticipate the "Objective Force" concept will be fully operational in 2025, but] current research and development efforts should enable initial brigades to have interim operational capability by 2008. We have to have medical capabilities [and] training to support that. [We need] multifunctional soldiers, [and] small unit leaders operating independently over large distances. The new Army combat medic, [bearing the designation] 91W, with EMT [emergency medical technician] certification, [is an important piece]. It is now the second largest MOS [Medical Occupational Specialty] in the Army after Infantry. We have raised the enlistment scores, so that these young men and women are at the top of [their recruiting class], and their first-time pass rates are 80-95% on the EMT examination compared to the national average of about 60%. The Directorate of Combat Medicine has been working since the first pilot groups to improve the quality of the instructors [for the combat medic course]. Much of the instruction now is done with simulations; in fact, we think we have the largest simulated training facility now in the world. It is producing a very high-quality medic, with a lot more capability, and they will have to demonstrate their skills semiannually, with recertification every 2 years.

Key technological advances [that will facilitate our mission] include blood substitutes, static dressings, and the HH60 Lima, which is the new higher capability [aircraft] for MEDEVAC. One innovation that [has not advanced as quickly as desired] is the PIC, the Personal Information Carrier. We would like to have a 32- megabyte dog tag [that could carry all of your medical records]. We want to be able to record what happens to a soldier from the second he is hurt, all the way through the system, so that at any point you can take the dog tag and put the chip into a computer to find out what medications were given, what the diagnosis was, etc. Another is the medial variant of the Striker vehicle, the new combat vehicle for us. We learned coming out of the desert that we need to get smaller, lighter, more uniform, and more modular so that we can respond to the full spectrum of operations. I think we've done a pretty good job of that, but it's like everything else. You have a doctrine [which dictates] how to deploy medical forces and then you proceed to do it just a little bit different every time. [In this fashion,] we are re-engineering the AMEDD.

When you look at what the AMEDD is going to [do] for the objective force, it will be revolutionary by 2025. It will be evolutionary by 2008 or 2010 and, in many respects, more so than the rest of the Army. We are linked to the civilian sector, to the medical community specifically to bring us capabilities like laparoscopy and a newer generations of drugs. A less dramatic example is LASIK surgery, which we are now offering to our soldiers as an operational imperative. We recognize that [after] LASIK, you take your glasses off, walk through the jungle or be out in the desert and [more easily avoid limitations due to fogging or sand in your eye). You also don't need inserts for your protective masks. It is this kind of technology evolution that we look to the private medical sector for support. An example [in the diagnostic area] is computerized tomography scanners, which we now have on the battlefield. [Therapeutically,] anthrax vaccines and other advances that our Research and Development people are working on are going to make our soldiers more resilient. Then when they do get hurt, with the forward-looking infrared radar and the climate-controlled passenger treatment area in our new HH60, the old Q model, I think we're going [to] be better served for taking care of patients.

Question and Answer Period

Colonel Cloonan: Sir, you commented that you debriefed the FST command, and I was curious whether or not the comments that they made reflected what was reported in the Army Times, which is that they were taking care of a lot of primary care problems. [Do you know] whether [this might] lead to a change in the composition of the FSTs to include at least one primary care provider?

Major General Kiley: That is a great question and it strikes to the heart of the whole issue that brought the FSTs to us, because that is exactly what they found. For example, the 250th out of Washington reported that when they first started capturing the Al Qaeda, they had them in holding areas and were literally doing sick call through concertina wire. One of the first missions they had was a debusing operation-for a couple of general surgeons and an orthopedist. FSTs are not designed to operate by themselves-they are intended to operate colocated with forward medical support companies [which would be more appropriate to handle something like this]. [But, in trying to limit the size of] the footprint, sometimes the thinking is that "a doctor is a doctor." The senior tactical commander [really did not understand their capabilities]. Unfortunately, they had no sick call equipment and it was a challenge for them to get medically resupplied. When the medical company finally showed up and linked up with them, they did a lot better.

Questioner: What do you \think needs to be done beginning in medical school and then in residency to be sure that physicians understand medics' capabilities and limitations and, perhaps, as importantly, physician assistants' capabilities and limitations? Do we need them on the faculty here?

Major General Kiley: That's a great question. I think there are a couple of areas, some of which I've talked about as the Chief of the Medical Corps. The understanding [of] young physicians as they're coming through USUHS or the Health Professions Scholarship Program is important, [but] first I think they need to be good physicians. Frankly, I think that needs to be said, because sometimes we run into people that [have] all of the badges, they walk the walk and talk the talk, but they're really not good physicians. Given that, I think that the brigade surgeons' jobs, and courses such as Bushmaster and C-4, [represent engagement], not just with medicine, but also with the military. There are also PROFIS [Professional Filler Service] opportunities, and there are opportunities in the military unique curriculum in internship and residency. For example, [at William Beaumont Army Medical Center] in El Paso 10 or 12 years ago, we had an Honorary Unit Surgeon Program. The Air Defense Artillery Battalions there did not have TOE physicians out there, but we linked residents up with them and let them participate a little bit by getting TA-50 and going out to the field. At every level of training, I think there are opportunities to become engaged in military operations. [This includes] reading, hands-on experience, and mentorship from more senior physicians and others (medical service officers or nurses) that have been in field units. I think PROFIS training helps and the officer's basic course, which we've revamped. The Uniformed Services University and the Health Professions Scholarship Program students come in the summer and then the rest of the doctors we pick up to include the direct accessions and ones we used to slip through. Then [they may or may not go through] the officers' advanced course-we are really starting to see a rise in the number of physicians that are attending that. I think that is another opportunity to rub shoulders with the other corps, talk to mentors and teachers, and work through exercises. I think we have a relatively robust educational system, and [I emphasize] the threes-experience, training, and personal development. I think that's the third thing we need to instill in the young physicians, but really in all corps is that some of this is self-driven and self- based. As a physician, you are still reading your journals and you are still staying up with the Continuing Medical Education, [but it is equally important] to maintain "CME" in military operations so that we don't get caught flatfooted.

MILITARY MEDICINE, 168, 9:33, 2003

Commander, North Atlantic Regional Medical Command, Washington, DC.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as representing the opinion of the Department of the Army or the Department of Defense.

Major General Kevin C. Kiley, MC USA

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