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C o n t e n t s

2012 Medical Book

11 Letter from the Publisher

Taking the Plunge

Navy-sponsored medical research tries to minimize the dangers of the deep.

By Dave Smalley

12

Medicine at 35,000 Feet

Air Force aeromedical evacuation mission evolves along with the modern battlefield.

By James Kitfield

24

12

18

30

44

Landstuhl Medical Center

Military hospital in Germany is the first stop for wounded warriors headed home.

By David Perera

30

Intense Therapy

Rehabilitation specialists help wounded warriors rebuild their lives.

By Sara Michael

38

Battlefield Medicine

A decade of war brings game-changing ad-vances in reducing blood loss.

By David Perera

18

Step By Step

Prosthetic technology advances by leaps and bounds as wartime amputee ranks swell.

By Sara Michael

44

Healing Trauma

Growing understanding of modern warfare drives better treatment of PTSD.

By Sara Michael

54


C o n t e n t s

Louder than Words

62

73

80

56

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Final Frame82

Snapshots from Afghanistan

Design by Samantha Gibbons

‘ 1 3 P r o c u r e m e n t p r e v i e w

Air Force: Space FenceBy Rich Tuttle

Army: CERVBy Matthew Cox

Marine Corps: M777A2By Matthew Cox

Navy: DDG-51By John T. Bennett

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71

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2012 Medical Book

on the coverDan O’Shea, a lieutenant commander

in the Naval Reserve, is loaded down with gear in Afghanistan.

Traumatic Brain Injury

The Pentagon and industry join forces to build a helmet to prevent TBI.

By Sara Michael

56

Body, Heal Thyself

Pentagon invests big to harness the healing power of regenerative medicine.

By Julie Bird

62

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2012 SUMMER EDITION

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P u b l i s h e r ’ s N o t e

Since its beginning nearly five years ago, DEFENSE STANDARD has remained committed to covering the medical issues

that most impact our warfighters. Military medicine is never more important than when our troops are engaged in combat, nor is the motivation to drive innovation in partnership with industry ever stronger.

As we looked back at our coverage, we thought it was time to revisit some of those stories. They represent a retrospective, if you will, of some key advances in military medicine, as well as a tribute to the people that make it happen.

It’s been an inspiring journey, to say the least.We start with the Office of Naval Research’s

ground-breaking research into two debilitating conditions affecting combat divers – decompression sickness and oxygen toxicity. Scientists at ONR labs and affiliated private and academic research centers are confident their work will have applications far beyond the combat diving arena.

University research also is playing a major role in the Defense Department’s foray into regenerative medicine. The Pentagon ponied up $120 million over five years to kick-start eye-popping research into technologies that promote better healing of skin, muscle and cartilage – and eventually, maybe even organs and appendages.

We also look at advances in battlefield medicine, with much of the military and industry research centering on reducing blood loss in the field. As the head of the Army combat casualty care research center says, “The simplest of devices sometimes makes the greatest difference.”

Then we take a ride on an Air Force aeromedical evacuation flight from Afghanistan to Germany,

learning along the way how the mission has changed to reflect changes in the modern battlefield. In Germany, we report from Landstuhl Regional Medical Center, where all serious casualties from Afghanistan are treated before heading stateside for longer-term care.

We continue our tour in the rehabilitation wings of Walter Reed Army Medical Center, where doctors and therapists helped wounded warriors transition back to normal life following devastating injuries. The century-old hospital closed almost a year ago, but the mission continues at Fort Belvoir, Va., and the National Naval Medical Center in Bethesda, Md.

The continuum of care continues with the Department of Veterans Affairs. We look at VA-funded research into the advanced prosthetics technology revolutionizing the lives of amputees, and at VA efforts to better treat post-traumatic stress disorder.

Finally, we come full circle with a selection of photos from Afghanistan provided to DEFENSE STANDARD by Dan O’Shea, a Navy Reservist currently deployed there. (That’s O’Shea on our cover.) As we see these images of our troops, still in harm’s way even when things appear calm, it’s a vivid reminder of why military medicine is so important.

We want each and every one of them to come home – safe, sound and whole.

David Peabody PUBLISHER


12 DEFENSE STANDARD Summer 2012

Combat Camera divers like Mass Communica-tions Specialist 3rd Class Scott Raegen aren’t im-mune from the possible ill effects of deep-water dives.

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By Dave Smalley

Navy-sponsored

medical research

tries to minimize the

dangers of the deep

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TAKING THE

omewhere, in dark waters far below the ocean’s surface, a Navy diver cannot see his hand

in front of his face. But that can’t stop him from performing his mission, whether it’s a covert

operation or explosive ordnance disposal, deep-sea salvage or maintaining the hull of a ship.

Amid the crushing depths and utter blackness of the deep, even basic work for a skilled

diver can result in decompression sickness, oxygen toxicity and other potentially debilitating,

even fatal, afflictions.

“There’s no such thing as a pure, 100-percent-safe dive,” says Cmdr. Matthew Swiergosz, a program manager with the Office of Naval Research (ONR) in Arlington, Va. “The things they do are extraordinarily dangerous, and they do them with a poise and professionalism that would inspire every American who could see it. The same can be said for our submarine force.”

A day at the office is anything but routine, but scientists sup-ported by ONR are working to keep divers safe in their duties. Undersea Medicine is an official National Naval Responsibility—meaning the Department of the Navy has deemed it critically im-portant to maintaining naval superiority.

“The Navy,” notes Adm. Jonathan Greenert, chief of naval op-

erations, must “continue to dominate the undersea domain.” And undersea medicine, experts agree, is a key to dominance. Chief Warrant Officer 3 and Navy diver John Theriot pulls no punches on how important the field is. “Without undersea medicine,” he says, “we would still be in the stone age when it comes to under-water operations.”

“The ocean is still unexplored and full of danger and mystery,” says Master Chief Michael Herbert, an

explosive ordnance disposal technician and Navy diver for more than 20 years. “Our divers face a multitude of dangers on each mission that they run.”


Divers searching for underwater mines are at risk for getting the bends or oxygen toxicity, both serious and potentially fatal conditions.

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The technologies emerging in this field could have revolu-tionary implications for not only the Navy and Marine Corps, but the world at large. “Undersea medicine isn’t just about un-dersea,” says Michael Qin, principal investigator at the Naval Submarine Medical Research Lab in Groton, Conn. “It has huge implications to medicine across the board.”

Swiergosz agrees. A number of illnesses, not only diving af-flictions, are caused by gasses in the body—a topic front and center for ONR researchers. “If we can discover and understand all of the means by which gasses travel within the body, and how it affects our health and performance, then I think that there would be a complete paradigm shift in the way we think about developing pharmaceuticals,” he says. “It could affect multiple fields of study.”

Learning about ONR-supported undersea medical research is like taking a crash course in science, verging on science fiction. Scientists are fighting the two most stubborn foes: decompres-sion sickness, aka the bends, a malady that hits divers as they ascend to the surface; and hyperbaric oxygen toxicity, a perilous byproduct of breathing oxygen in the deep.

In the face of these and other challenges, ONR’s work must be cutting-edge. “ONR has sponsored many individuals who have been later recognized as Nobel laureates,” says Swiergosz, “and I think it’s because we often seek out the avant-garde sci-entist—the one who can really push us into the new frontier.”

One of the main missions for undersea medicine is to pre-vent problems associated with decompression as divers

surface from the deep, where bubbles can form in the body.“If they are breathing air, they’re going to dissolve a lot of ni-

trogen in their bodies when they’re at depth,” or deep under wa-ter, says Dr. Jay Buckey, an ONR-supported researcher at Dart-mouth-Hitchcock Medical Center in New Hampshire. “So when they come back up, they’re at risk for having these bubbles.”

When that occurs, it can lead to everything from skin rashes and joint pain, if a bubble forms in a joint, to catastrophic paraly-sis or death. Buckey’s work includes studying the formation of bubbles, hoping to find a way to stave off the significant afflic-tions associated with returning from the ocean’s depths.

The current treatment for decompression sickness is to place the diver in what’s called a hyperbaric chamber. These machines, which resemble an MRI tube, artificially reproduce conditions under the sea, slowly bringing the diver back to the normal pres-sures found at the surface. But hyperbaric chambers are large, bulky and not easily transported aboard ships. Nor can most of them be used on multiple divers simultaneously.


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Navy divers and special operators from SEAL Delivery Vehicle Team 2 and Naval Special Warfare Logistics Support conduct Lock Out Training with the nuclear-powered fast-attack submarine USS Hawaii for material certification.

“It’s hard to get treatment chambers in remote ar-eas,” Swiergosz notes. “The issue is to try to develop

medical technologies that can augment or replace hyper-baric oxygen chambers. I’m not saying we’re throwing away

the chambers, but that should be our goal for the future: to replace something that’s such a logistical burden.”The what-if scenarios are sobering. If a submarine were disabled, with

rescued submariners numbering in the dozens or even hundreds, a lone hyper-baric chamber on a rescue vessel would be dramatically insufficient.One promising development is being studied at the Naval Medical Research Cen-

ter in Silver Spring, Md. It involves accelerating the healing process for decompression using perfluorocarbons, which carry more carbon dioxide and oxygen than blood alone.

“When a submariner would come up to the surface from being trapped in a disabled submarine,” says Capt. Richard Mahon, “we could actually treat decompression sickness without needing all the

machinery,” using per fluorocarbon injections.

While scientists do pioneering work studying the most minute parts of cell membranes—looking at how gas molecules move through gas channels in the blood—researchers are also taking a broader

biomedical approach, looking at immune system reactions and genetic responses. Navy diver Theriot welcomes the efforts. “Undersea medicine is an important function in every aspect of the busi-

ness, from submarine operations to open water air diving,” he says.As if the perils of decompression sickness weren’t enough for divers to worry about, oxygen toxicity is another

unwelcome, but constant, concern. While oxygen is necessary for survival, in one of life’s ironies, too much of it can kill. “It’s a very complex thing,” says Swiergosz. “In a way, our entire physiology is built on thresholds. You could say that about anything—oxygen, medications, what you eat, anything. Yes, fruit is good for you. But if you keep eating too much of it, it can become toxic. There’s a balance.”

Divers face the same issue with oxygen. While it’s necessary to breathe oxygen to sustain life underwater, the ratio increases to hazardous levels as divers go deeper. In other words: The deeper the dive, the greater the danger.

“When you dive, your blood and tissues can become saturated with gasses that you’re breathing, based on ambient pressure,” Swiergosz explains. “So the deeper you dive, unless you’re adjusting your oxygen mixture, you’re getting more oxygen because of the partial pressure. It’s physics.”

While mechanical devices can adjust the oxygen in a diver’s breathing gasses to some degree, it’s not the best so-


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Mass Communication Specialist 1st Class Shane Tuck trains Mass Communication Specialist 3rd

Class Scott Raegen in underwater videography off the coast of Guantanamo Bay, Cuba.

J

lution. Stealth capabilities vital for Special Forces divers, for in-stance, are jeopardized by the use of such devices. But without them, divers face grim risks.

Oxygen toxicity takes two forms: central nervous system, or CNS, toxicity, and pulmonary.

CNS toxicity symptoms include visual disturbance, ringing in the ears, nausea, muscular twitching, irritability, dizziness, con-vulsions, seizures, unconsciousness or coma. It can strike without warning—and because the symptoms don’t happen in any particu-lar order, divers could simply, suddenly, black out, lose a respirator and drown, without ever having known they were in danger.

Pulmonary oxygen toxicity, considered less dangerous, is none-theless serious. Chest pain and general lung dysfunction, cough-ing, increased blood flow to the nasal passages and even ocular damage are among the potential worries facing divers as they per-form their missions.

“The goal for [every diver] is to go deeper, longer and do it safely,” says Lt. Levi Kitchen of the Navy Experimental Diving Unit (NEDU) in Panama City, Fla. But oxygen toxicity remains one of the major obstacles to achieving that goal. So researchers at NEDU are studying, among other things, how cells behave in deep water, to learn how to one day treat or even prevent the symptoms.

ONR-sponsored research at the University of South Flori-da in Tampa is breaking new ground studying brain-cell

response to elevated oxygen levels. Earlier detection of changes in breathing, blood pressure or heart rate could help predict when oxygen toxicity or seizures might occur. “The data showed that

the cells that are important in the control of your breathing, as well as your cardiovascular system in the brain stem, are very sensitive to oxygen,” says the university’s Jay Dean.

Based on that, Dean and fellow researcher Dominic D’Agostino are developing keytone esters—caloric substances that act essentially as a super fuel for the brain—to help the me-tabolism fight off the dangers of hyperbaric oxygen toxicity. “We have found two particular keytone esters that have a very strong neuro-protective and anti-convulsant properties,” says D’Agostino. “And we think that these keytone esters, in addition to preventing CNS oxygen toxicity, have application for not only ONR projects, but other neurodegenerative diseases.”

At ONR headquarters in Virginia, Swiergosz knows that much work remains. “We do have some interesting advances” in the fight against oxygen toxicity, he says, “but there’s still a long way to go.”

While the perils remain for divers, the progress is real for un-dersea medicine.

The fight continues, in labs at Case Western University in Cleveland, where scientists are analyzing gas channels in the body; in Philadelphia, where University of Pennsylvania sci-entists have discovered elevated quantities of “micro-particles” in the blood after decompression; and in Durham, N.C., where researchers at Duke University are studying genetic responses during dives – all under the auspices of the Office of Naval Re-search.

--Dave Smalley reports for the Office of Naval Research.


BattlefieldMedicineBy David Perera

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Air Force pararescueman Jason Cunningham saved at least 10 lives on an Afghan mountaintop in 2002 after their MH-47 Chinook crash-landed under heavy fire

while on an ill-fated rescue mission during Operation Anaconda.He continued treating the wounded even after being shot through

the lower back by a bullet that would drain the life out of him before a medevac helicopter could get to the chaotic scene.

Senior Airman Cunningham posthumously was awarded the Air Force’s highest honor, the Air Force Cross, in recognition of his bravery and sacrifice. But Cunningham’s death also stands as a reminder that blood loss continues to kill soldiers, sailors, airmen and Marines who could have survived if the bleeding had been stopped on the battlefield.

Similar scenes played out in the streets of Mogadishu in 1993 when soldiers were pinned down by Somali gunfighters, in Vietnam before the choppers could land, in wars stretching back millennia.

One problem was medics couldn’t carry sufficient amounts of blood for frontline care because blood spoils quickly when unprotected. They could stuff gauze bandages into wounds and apply pressure, but in many cases they could only watch someone with curable wounds die. Better body armor helps, of course, but it also has concentrated devastating wounds to the arms and legs.

“When somebody gets blown up, they can have sometimes two, three, maybe all four extremities terribly injured or amputated in the

Originally published in the Fall 2008 issue. field, and they will bleed to death before they get to us,” says Air Force Maj. Gary Vercruysse, a theater hospital trauma surgeon deployed in Balad, Iraq.

But new options now available to battlefield medics are beginning to change that.

A second-generation blood-clotting bandage coated with coagulant material can stop the bleeding. Medics can now

carry blood in heat- and cold-resistant boxes that allow them to give transfusions on the battlefield. And a new generation of redesigned tourniquets is saving limbs -- and lives. “The simplest of devices sometimes makes the greatest difference,” says Col. Dallas Hack, director of the Army Medical Research and Materiel Command’s combat casualty care research program.

Medics and battlefield doctors have a slew of technologies improving the odds of survival. Forward-based surgical teams have laptop-sized digital imaging systems. Rugged anesthesia machines much smaller than hospital versions are used to put soldiers under for surgery. Wounds vacuum-sealed rather than sewn shut let surgeons treat battle casualties with a series of operations instead of a single, stamina-testing marathon surgery. New pain-blockers relieve suffering without risk of addiction. Databases track casualties’ treatment from the front line to Landstuhl Regional Medical Center in Germany to hospitals in the United States, giving each physician fingertip access to their patients’ record of treatment.

But the major cause of preventable death remains blood loss. With

Life-saving technology advances minimizE blood loss in the field

Battlefield

Army Staff Sgt. Mark Ramsey, right, looks on as a soldier applies a tourniquet to a mock wounded

soldier who fell victim to a simulated roadside bomb during training.


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If battlefield medics get the tools they need to quickly stop blood loss, field surgeons will have better opportunities to save life and limb.

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casualties continuing to pile up in two ongoing wars, finding ways to stop the bleeding in the battlefield has become a top priority of military medicine and private industry partners.

After the casualties of Operation Anaconda, the Army was newly determined to solve the problem of blood transportation. Walter Reed Army Institute of Research officials tasked industry with finding a way to transport blood under extreme temperatures and keep it fresh for 24 hours. The transport mechanism had to maintain an internal temperature between 33 degrees and 50 degrees Fahrenheit while the ambient temperature cooled to minus 4 degrees or heated up to 104 degrees. It also had to weigh no more than 6 pounds and contain no active machinery.

“They showed us pictures of these soldiers – it’s like they’re carrying a house. Every ounce counts,” says George Flora, co-founder of Minnesota Thermal Science, a startup company formed specifically to develop a blood-transportation solution. The small company decided at first to concentrate on designing a temperature-resistant box. It didn’t quite work, in part because the prototype used water as a cooling agent. “They came back and told us we were half a [Celsius] degree too cold,” Flora recalls.

The company went to work on a new solution, this time developing a proprietary fluid that would keep the internal box temperature stable. The key was to find a fluid resistant to temperature change – it takes 136 units of heat measured in British Thermal Units to convert liquid water to steam – that would freeze at a precise temperature.

Following months of experimentation, the company sent the institute a new prototype. It worked. “Then they said, ‘George, can you make it last 48 hours?’ ” Flora says. Later, they asked for a 72-hour model. The final product can keep blood fresh up to 93 hours in extreme cold and 82 hours in extreme heat, he adds.

“We gave them as much as we could get in a 6-pound box,” Flora says. In 2003, Army Special Forces officially adopted the company’s box for blood transportation. In 2004, the Army named the company’s work one of the preceding year’s 10

greatest inventions.Throughout the process, the company worked closely with

the Walter Reed Institute, Flora says. They did whatever they could to assist, “so that we were informed and that we weren’t just being shoved on some back shelf.”

A similar story of collaboration underpins a second-generation blood-clotting bandage called Combat Gauze,

manufactured by Wallingford, Conn.-based Z-Medica, which the Army subsequently purchased for use in the field.

The story begins with Z-Medica’s first product aimed at staunching blood loss, granules of a volcanic mineral applied directly into wounds. Revolutionary when introduced to the battlefield in 2002, Z-Medica’s product was 100 percent effective at stopping hemorrhage. But it had nasty side effects, including second-degree burns caused by the physical reaction between the mineral and water molecules.

Then, in 2003, University of California-Santa Barbara scientist Galen Stucky got a call from the Office of Naval Research. A chemist dedicated to studying interactions between inorganic molecules and organic matter, Stucky had research experience with the Z-Medica mineral. Navy researchers wanted to know if he could do something about the heat reaction, ideally within six months.

Stucky went to work and came up with a solution relatively quickly. “But we paid a price for that,” he says. The new product was only 80 percent to 90 percent effective, a large enough margin of fallibility to send Stucky on a new round of government-funded research. To come up with a better solution, he would have to understand exactly how to best trigger the cascading effect of blood clotting. Stucky wasn’t the only researcher examining how to induce clotting, but other efforts focused on blood proteins, a more expensive route. Stucky and his team of researchers zeroed in on investigating the properties of metal oxides. “Once we understood what were the key parameters, then we were able to say, ‘OK, I know what kind of material we need.’ ” That turned



Medical personnel carry an “injured” airman on a litter during an exercise to prepare field medics for treating patients on the battlefield.

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out to be a common clay mineral called kaolin.Coming up with a solution wasn’t just a matter of laboratory

experimentation. Promising products found by Stucky’s team were sent to the Naval Medical Research Center for animal testing. “The in vivo tests are very expensive and they’re time-consuming. Consequently, we had to be careful that we gave them good suggestions,” he says.

Meanwhile, Z-Medica was working on the problem as well. “It was also an issue that we were asking caregivers to pour granules into a wound, which was never done,” says Bart Gullong, chairman of the Z-Medica board. The presence of granules in the body made wound healing awkward and there was the danger of pouring in too much, causing severe burns.

The company responded by packaging granules into a “tea bag,” then into a sponge. After Stucky hit on kaolin, however, Z-Medica managed to impregnate the clotting agent directly into gauze. “The gauze was a brilliant way to go,” Stucky says, adding there’s no way he could have devised it himself.

“I can come up with something on the bench stoop, but that isn’t going to do the soldier any good on the field,” he says, referring to a laboratory test environment. “It’s got to get to him, somehow, in a useful form. I’m not set up here to do packaging, do marketing or do manufacturing.”

Ask military doctors for an important battlefield

medicine innovation and one of the first things they’ll mention is the tourniquet, first used in battle in the 1800s but eventually falling out of favor. But 7 percent to 10 percent of battlefield deaths in Vietnam and Somalia were caused by profusely bleeding arm or leg wounds that likely could have been averted by use of a tourniquet, according to the Defense Department.

“They had a Army tourniquet from World War II, used it for 50 years, and the reports from World War II said they didn’t work so well,” says Col. John Kragh, an Army Medical Corps orthopedic surgeon and proponent of the devices. Mounting groundswell support for tourniquets, intensified by soldiers’ tendency to buy them through the Internet because the military’s basic training strap-and-buckle unit clearly fell short, led to a re-evaluation.

In 2004, the Army Institute of Surgical Research decided to test commercially available products. It recommended acquiring the Combat Application Tourniquet, distributed by Greer, S.C.-based North American Rescue Products AT. The CAT, invented by former

serviceman Mark Esposito of Golden, Colo., is designed for single-handed application so a soldier can put it on himself. The Army surgeon general facilitated widespread re-introduction in 2005. Now, the CAT is part of every soldier’s standard field issue.

The device consists of an inner and outer band: The outer band wraps the tourniquet around the wounded limb while

a rod tightens the inner band to cut off circulation. “The bad devices aren’t commonly used any more, and the effective ones are issued,” Kragh says. The Combat Application Tourniquet won an Army Greatest Invention of 2005 award.

When Kragh was deployed to Bagdad’s Ibn Sina Hospital in 2006, he used a reusable, pneumatic tourniquet made by Vancouver, Canada-based Delfi Medical Innovations during surgery. He communicated often with Delfi about ways the company could improve the product – small changes, he says, that nonetheless made a big difference.

For one thing, a cap on the pneumatic bladder fell off easily. “It being the same color as the floor, you couldn’t see it,” he says, and the surgical team wasted time scrambling for it on the floor as patients bled. Kragh recommended that the cap be attached with a leash. He also wanted the tourniquet to open with less force. “They changed the [clamp] arc to be gentler, so there’s less force, more roll, to open up


J

the tourniquet,” he says. “They were fairly minor things, so we were able to get

them out within a few months,” says Delfi President Mike Jameson.

If many of today’s advances sound prosaic – even though they’re anything but – potential advances

sound like the stuff of science fiction. The Defense Advanced Research Projects Agency

contracted with Siemens Healthcare in 2008 to develop a portable device that would

staunch deep limb wound bleeding using ultrasound waves – a kind of high-tech tourniquet. A cuff-like device would first search for bleeding and then send a concentrated dose of high-intensity ultrasound waves prompting quick coagulation.

Focused ultrasound has already proven effective during animal tests. The directed energy raises tissue temperature, causing it to shrink and small blood vessels to collapse. Tests show tissue can be safely heated to between 158 and 194 degrees Fahrenheit within 30 seconds. The device’s acoustic properties also appear to push blood away from the injured area.

Meanwhile, SRI International of Menlo Park, Calif., requested more DARPA funding to move forward with what could be the most futuristic medical addition to the battlefield: a robot doctor. “Ideally the system would be completely automatic, autonomous, making its own therapeutic decisions,” says Thomas Low, SRI director of medical devices and robotics. With $12 million in

DARPA funding, SRI conducted a two-year research and development project ending in March 2007.

The idea of a robot medic – which SRI and DARPA call a “Trauma Pod” – becomes a lot more believable when it’s described as a machine that recognizes patterns and does something simple as a result, such as putting a needle to a target. “This is not blue sky,” Low says. “We can address a number of serious battlefield injuries, temporarily. We’re not trying to do definitive surgery. We’re not trying to install on a machine the intelligence of a surgeon.”

Still, a robot could probably do better with some front-line procedures than a soldier operating under high-stress

conditions, Low says. He cites a cricothyrotomy as an example: puncturing a patient’s neck with a large-bore hollow needle when the airway is obstructed. Frontline medics are somewhat reluctant to perform a cricothyrotomy “and don’t do particularly well under fire,” he says. But a robot given an image of the airway can do so easily. “It’s putting a needle to a target, based on imagery,” he says.

The first two years of the project were just the first phase of a research and development effort that could last up to a decade, Low says, noting robots already exist in the surgery theater. And, he says, automated external defibrillator devices in public places let laymen treat heart attacks with electric shocks by monitoring a victim’s heart rhythm and firing at the right moment.

“Certainly it’s better than the alternative of dying,” he says.

In World War II, 30 percent of the Americans injured in combat died,

according to Defense Department figures. In Vietnam, the proportion

dropped to 24 percent. During the early years of Iraq and Afghanistan,

about 10 percent the injured died, according to a December 2004 New

England Journal of Medicine article. Col. Mark Mavity, commander of

the Balad Air Force Theater, said the in-theater rate survival rate in Iraq

had always been at least 95 percent and edged close to 98 percent by

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MEDICINE

BAGRAM AIR BASE, Afghanistan -- The wounded return home from war much the way they left, largely invisible to a distracted nation. In this instance the long journey begins

on a darkened, wind-swept flightline at Bagram Air Base, a sprawling airfield that sits in a wide valley surrounded by mountains. An old flight control tower dates back to the Soviet occupation of this Afghan air base in the 1980s.

Another aeromedical evacuation flight is collecting the wounded from America’s longest war.

In a familiar choreography rendered silent by the constant backwash of jet engines, a bus bearing a red cross parks next to the open rear door of a C-17 Globemaster III. Those who can walk shuffle their way up the ramp to webbed seats lining the aircraft’s cavernous hold, followed by stretchers carrying the more seriously wounded and ill, which are lashed bunk-bed style to metal stanchions running down the center of the plane’s cargo bay. Finally, two critically wounded troopers tethered to gurneys and nearly invisible beneath an emergency room’s worth of medical equipment are hoisted into the back of the aircraft.

Though they operate out of sight on restricted military air bases, aeromedical evacuation flights are helping to revolutionize combat medical care. Since Sept. 11, 2001, the Air Force’s Air Mobility Com-

mand has flown more than 35,600 medical evacuation sorties, transporting more than 177,000 wounded or ill service members. A U.S. trooper wounded in Operation Endur-ing Freedom in Afghanistan tomorrow likely will reach Landstuhl Regional Medical Center in Germany in about 30 hours, and arrive at a U.S. medical facility in an average of three days. In 1991, troops wounded in Operation Desert Storm reached home in about 10 days. During Vietnam the whole journey took on average of 45 days.

Combined with advances in combat medicine and body armor, the rapid air evacuation system has resulted in a historically low lethality rate compared with other U.S. wars. Service members wounded on a battlefield today have a remarkable 98 percent chance of survival. As a recent trip aboard one such flight underscores, however, behind every fatality lies a long roll call of the wounded and maimed.

The air and medical crews on this 10th Expeditionary Air Force Evacuation Flight were cobbled together from various active-duty, Air Guard and Air Force Reserve units, which is typical. Though they rep-resent the ultimate “pick-up team,” the crews mesh easily after years of conducting this type of mission.

“We blend active-duty and reserve pretty

Originally published in the Winter 2011 issue.

By James Kitfield

Warfare has changed, and so has the Way the military evacuates its Wounded

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MEDICINE

(ABOVE): Capt. Reggie Brown (left) teaches his Iraqi counterparts how to secure a litter to the floor of a C-130 Hercules. Six Iraqi medics learned the basics of aeromedical evacuation over two days with Air Force and Army advisers. (BELOW): Crew members from the 10th Expeditionary Air Force Evacuation Flight take servicemembers wounded in Afghanistan off a C-17 at Ramstein Air Base, Germany, for transport to nearby Landstuhl Regional Medical Center.

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seamlessly on these missions, because all of us are trained to the same standards and procedures, and like me most of the team have been do-ing this quite a while,” says Tech Sgt. Mike Malone, a reservist with the 360th Aeromedical Evacuation Squadron out of Pope Air Force Base, N.C. A former Marine, Malone is an emergency medical technician in his civilian life. “This mission is different from my work as an EMT, which usually involves moving one or two injured patients a short dis-tance. Here we pick up a whole planeful of injured, and move them halfway around the world. I also like that we are the ones who get to bring these wounded troops home.”

That is an oft-repeated sentiment for aeromedical evacuation team members. “This is an especially challenging mission, but we all do it for those guys in the stretchers,” says Capt. Chris Lane, a National Guards-man and flight nurse who runs an emergency room in Fort Worth, Tex-as, in his civilian life. “It’s important that those soldiers and Marines understand that if they get injured, they’ll get outstanding care from the time they are hurt until we can get them home, whether it’s on the ground or at 30,000 feet. We owe it to them.”

The rapid air evacuation of wounded troops and the new model in combat medical care was largely dictated by

the nature of the counter-insurgency conflicts in Afghanistan and Iraq over the past decade. Fighting multiple wars with very dispersed and fluid front lines and no safe rear areas, the U.S. military did not have the luxury of having huge field hospitals near the fighting. That forced the Pentagon to embrace an entirely new approach to com-bat medical care that emphasized quickly stabilizing wounded warriors on the ground and then flying them back to the United States for defini-tive care as rapidly as possible. It also reunites wounded soldiers with their loved ones more quickly.

Rapid aeromedical evacuation that transports the wounded to defini-tive care within a “golden” 72-hour window, coupled with advances in combat medical care and body armor, dramatically diminished the le-thality of the conflicts in Iraq and Afghanistan. According to Dr. Ronald Glasser, a Vietnam-era Army surgeon and author of the recent book, Broken Bodies, Shattered Minds: A Medical Odyssey from Vietnam to Afghanistan, for every battlefield death in the past decade, 16 U.S. ser-vice members have survived their wounds. The ratio in Vietnam, he said, was 2.4 wounded for every death. In the Civil War, the ratio was less than 1-to-1, with few soldiers surviving battlefield wounds.

The result of that revolution in combat medicine, however, has been that the past decade of war has produced a surfeit of service members with serious,and even catastrophic wounds. According to the Penta-gon, 168,000 service members wounded or injured in these wars are at

least 60 percent disabled. Department of Veterans Affairs hospitals and medical centers have already treated 508,000 veterans of today’s wars.

With tactics and geography shifting over the past decade, those transporting and treating the injured noticed that the pathology of the wounds also mutated over time. Early on in Afghanistan, for instance,

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MEDICINE

An Air Force aeromedical evacuation team secures wounded Marines, their gear and medical equipment onto a C-130 Hercules at Camp Bastion, Afghanistan.

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small arms caused many injuries. A few years into the fighting – as insurgent bombs got bigger and the armor on U.S. military vehicles got thicker – troops increasingly absorbed blast waves through their seats, causing a spike in spinal cord injuries, concussions and brain trauma. Over the last 18 months in Afghani-stan, the profile of wounds changed again.

“As Afghanistan has turned primarily into a war of dismounted infantry, our polytrauma wards have seen a huge influx of troops with really massive injuries from absorbing blasts while on foot patrol, including multiple amputations, really severe brain injury, and the emotional wounds that go with all of that,” says Dr. Shane McNamee, the chief of physical medicine and rehabilitation at the VA’s Polytrauma Rehabilita-tion Center in Richmond, Va. “In the past five years, I can’t tell you how many times we have re-geared to tailor our care delivery to subsequent waves of ser-vice members with different kinds of wounds.”

During the flight from Afghanistan to Ger-many one of the two critically wounded sol-

diers nearly flat-lines, and the onboard Critical Care Transport Team consisting of a doctor, a critical-care nurse and a technician works frantically to save him. Eventually, the emergency medical physician, Lt. Col. George Dockendorf, is able to stabilize the patient. The soldier on the gurney next to him has lost both legs, and never moves throughout the emergency.

“Being at this altitude affects everything, because you can’t hear alarms from the equipment, reactions to medicine are different, and even the flow of vital fluids through tubing is impacted,” says Maj. Kathy Miller, a critical-care flight nurse and Reservist out of Luke Air Force Base, Ariz. The austerity of the operating environment also puts a premium on careful preparation, she says, because there is no running down the hall to the supply room for additional equipment or medicine to handle unexpected emergencies. Despite those challenges, however, Miller prefers aeromedical evacuation missions to her civilian work in a hospital emergency room.

“I’d much rather be taking care of these soldiers,” Miller says. “Honestly, this is the most rewarding job I’ve ever had. I would do it full time if I could.”

The severity of the wounds to the two critically injured troops un-derscores another toxic byproduct of these wars. The enemy’s weapon of choice in both Afghanistan and Iraq has been the improvised explo-

sive device (IED), and their signature wounds account for the more than 1,300 amputees among U.S. service members, numerous burn victims and unknown numbers of troopers suffering from traumatic brain injury. According to the advocacy group Veterans for Common Sense, more than 190,000 troops have suffered a concussion or brain injury from operations in Iraq and Afghanistan. There is also growing evidence of links between traumatic brain injury (TBI) and post-trau-matic stress disorder, or PTSD.

In the back of the C-17, Sgt. Edward Pheifer speaks directly to the gray area of war and its toxic impact. A military dog handler who typi-cally spends his days searching for IEDs and mines, Pheifer is flying his German shepherd, Alf, to the Daniel E. Holland Military Work-ing Dog Hospital at Lackland Air Force Base, Texas. He strongly sus-pects that Alf is part of the roughly 5 percent of military dogs deployed with U.S. combat forces that have developed canine PTSD. Making Alf more proof, if anyone needed it, that war is hazardous to all living things.

“I think Alf does have PTSD, because he just doesn’t want to work any more,” says Pheifer. When asked if Alf’s work in Afghan-istan had been that stressful, Pheifer doesn’t hesitate. “It’s stressful on everybody.”


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LANDSTUHLREGIONAL MEDICAL CENTER

By David Perera

LANDSTUHL REGIONAL MEDICAL CENTER, Germany – Two waves of the wounded and sick from Afghanistan and Iraq will be delivered today through the

front gate of this U.S. Army-run hospital in western Germany.Two sets of blue school-bus-sized ambulances will carry

stretcher-bound troops and contractors fresh from the airstrip of nearby Ramstein Air Base and deliver them into the hands of a multiservice and civilian assemblage of orderlies, doctors and nurses. The number of new patients is nowhere near what it once was; the stream of men with their arms or legs blown off, their internal organs punctured, their brains turned to pulp by bomb blasts is thankfully a comparative trickle.

During the worst weeks of the troop surge in Iraq in mid-2007, about 1,200 new cases were admitted per month. Now, in the spring of 2009, triage nurse Navy Cmdr. Richard Gallaway estimates that about 600 new patients come here monthly. Well awake despite having started his shift at 4 a.m., Gallaway pores over paperwork describing incoming patients’ symptoms, mapping out where in the medical center to send them. These days, thankfully, outpatient cases also outnumber inpatient admissions by more than ever.

“That’s what we want,” he says. “The less numbers we see, the

U.S. military hospital in Germany is the first stop

for wounded warriors heading home

Originally published in the Spring 2009 issue. better things are going downrange.” The largest military medical facility outside of the United States,

Landstuhl is just six hours air time north of Iraq. Wounded warriors are sent here after being patched up at field hospitals. It’s a hub, a place to clean out wounds, check for traumatic brain injury, administer physical therapy and most often send patients onward for long-term care in the United States. Inpatients usually stay here just two to four days before they are U.S.-bound.

Overall hospital admissions are at their lowest level since January 2004, but medical personnel warn that the numbers almost certainly will climb again should troop numbers expand in Afghanistan. “When the war kicks up, we’re of course going to get a lot more,” Gallaway says.

Caregivers describe Landstuhl as the middle point of an hourglass funnel. Patients come in from everywhere and they’re sent back out to everywhere, too. During this period of relative calm, Landstuhl is also the eye of a storm.

Gallaway says he remembers only a single day in his two years of duty at Landstuhl when an ambulance didn’t

disgorge new patients. Just a few days earlier, Army 1st Lt. Joshua Darnell was on

one of those buses, his stretcher handed down from the ambulance

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Army Spc. Cocin Laird Pearcy, who is about to be awarded the Purple Heart, recuperates from his wounds at Landstuhl.

onto a gurney by rubber-gloved medics congregated at the hospital’s emergency entrance. Recuperating today from surgery in a second-floor ward, Darnell wonders whether he will lose his lower right arm. “I’m getting pretty good doing things with my left hand,” he says, his face strawberry-red from the flash of a suicide-bomber explosion five days earlier in Hutal, Afghanistan (just northwest of Kandahar), his eyebrows partially singed off.

The explosion threw him to the ground after a blinding burst. Everything turned white, Darnell remembers. “I took a couple of seconds to regain my breath, started trying to push myself up and noticed that my right arm was just dangling in the mud – a complete open fracture on the arm, it was just barely hanging,” he recollects in a quiet tone. Darnell’s right arm is shattered, held together with a metal device that’s all rods and bolts connecting remaining healthy sections of bone. This is Darnell’s third day here; by the next night, he’ll be in a military hospital in Georgia, near his wife and parents. There, surgeons will decide whether they can put in an artificial joint, fuse the existing bone, “or whatever,” Darnell adds without emotion after a miniscule pause.

This is the third year Army 1st Lt. Andrea Ruff has spent as a ward nurse. When she first arrived at the hospital, “We were totally full,” she says. “You worked all the days you were scheduled to work and got called in to work the day you weren’t.”

Ruff asked to be posted to Germany. “I figured what better place to take care of soldiers, just one spot removed from where it happens,” she says. It was a request prompted by her younger brother joining the Army and being tagged to go into combat.

“It could be him in a second in one of these beds,” she says, then exhales deeply. “And here I am.”

Army Sgt. James Bryant still suffers from a wound received in the bad old days of fighting in Ramadi, Iraq, during 2006. A sniper’s bullet hit him and he fled by swimming in a canal with 80 pounds of field gear still on his back, herniating three discs. He had hoped to avoid surgery but that wasn’t to be; he’s in recovery now. Navy Lt. Cdr. Mitchel Ideve wants him to walk as far down the hallway as he can.

Ideve is a physical therapist with a realistic assessment of his job. “The things we do cause pain. It can’t be helped. But we like to come

back and tell patients that PT [physical therapy] means ‘pretty terrific,’ ” he says. Ideve gets Bryant a walker and Bryant swings himself slowly out of bed. Ideve straps an orange belt around Bryant’s abdomen, grabbing the belt firmly in back. Together the two edge out of the room into the hall. Don’t grab tightly onto the walker, Ideve advises, just push it along. They get about 10 yards down the hall and turn around.

“This may be a Percocet moment,” grunts Bryant.

Before combat operations ramped up in earnest, Landstuhl was basically a quiet community hospital focused on outpatient care,

say people who recall life before war here. Even after casualties from Iraq and Afghanistan began appearing in earnest, at first each busload of patients was a mystery until the doors were thrown open. A patient’s medical record from downrange might not have been any more detailed than a list of symptoms written with a Sharpie pen on a patient’s leg.

“Maybe they’d have a piece of paper with them, if they were lucky,” says Navy Cmdr. Dr. Fred Lindsay, head of the Deployed Warrior Medical Management Center, the hospital unit created in January 2004

to rectify that situation. Unit members now access electronic records of each incoming

patient, informing doctors of what’s coming long before the airplane’s wheels are down. It makes it harder for a patient to slip through the cracks. Military physicians call it a “continuum of care,” a steady line of documented medical attention ensuring the next stage can immediately build on predecessors’ work. It’s one reason the odds of surviving a battle injury are better than ever before -- as high as 98 percent, according to some military physicians.

DWMMC removes the elements of spontaneity from patient receiving

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Then-Defense Secretary Robert M. Gates presented the Purple Heart to Army Staff Sgt. Brent A. Homan at Landstuhl Regional Medical Center. Homas was wounded in action in Balad, Iraq, in June 2007.

and makes it more routine, “which is very important when you’re receiving 40 people a day,” Lindsay says, talking quickly with the air of a very busy person. The ear, nose and throat surgeon is dressed in green operating-room scrubs and he wolfs down two Burger King fish filet sandwiches as he speaks, eyes darting back and forth. On his desk is a bowl full of candy and a half-empty bottle of aspirin.

The system isn’t perfect, Lindsay allows – there are in fact a couple different medical databases DWMMC staff might need to access to gain the most comprehensive medical picture of an incoming patient. It would be nice if the applications could talk to one another, but at this point they can’t. And, ideally, inputting new information could be done by barcodes or scanning rather than manual data entry. Anything can be made better – but even as it is, DWMMC underpins “the best medevac system in the world, in the history of time,” Lindsay says matter-of-factly.

Hospital operations themselves have undergone significant change during wartime.

“We have a lot more advanced equipment and clinical skills that are available here, as well as manpower,” says Army Lt. Col. Dawn Garcia, head nurse in the intensive care unit. Patients show up with more critical injuries than in the past, she notes. In mid-2007, the hospital for the first time gained American College of Surgeons certification as a Level

II trauma center, second only to Level I designation.Garcia says the hospital staff has racked up lessons learned.

Nurses are particularly careful to monitor for hospital-acquired pneumonia, particularly with ventilator patients whose lungs are especially vulnerable. Prevention is as simple as propping up a patient’s head and brushing teeth, but skipping those everyday tasks could be a deadly oversight.

Caregivers also screen each patient for signs of traumatic brain injury. Better body armor means many once-fatal bomb blasts are survivable, but the shock waves they send to the brain can have cumulatively bad effects. Landstuhl was among the first medical facilities to recognize TBI.

They’re also careful to note symptoms of combat stress. “Nobody comes back untouched from a war,” says

Army Col. James Griffith, the chief Army chaplain and a Presbyterian minister. Chaplains meet every new inpatient as they’re unloaded from the ambulance. More likely than not, warfighters will have trouble sleeping, Griffith says. They’ll be prone to recurrent, intrusive thoughts and nightmares. “It’s common for people to have night sweats for awhile,” he adds. Griffith tells his chaplains they should encourage warfighters to speak about their time downrange; turning experience into stories normalizes what happened. It helps the patients start to feel like themselves again.

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• Organizational Leadership - Human Resources Leadership - Public Service / Non-Profit Leadership - Strategic Leadership

• Teacher Leadership* - Mathematics Leadership - Literacy Leadership - Program Improvement Leadership

*Must be a certified school teacher prior to being admitted.

Landstuhl by the numbers

As of early 2009:

• Total personnel: 2,837

• Number of intensive care unit beds:

18, with a reserve capacity of 10

more

• Number of inpatient, non-ICU beds:

64, with a reserve capacity of 34

more

• Number of treated battle injury

patients since operations Enduring

Freedom and Iraqi Freedom began:

10,616; 9,434 from OIF and 1,182

from OEF

• Total number of patients treated

since the start of OEF and OIF,

including outpatients: 52,367

• In a recent typical day, 19 new

patients are admitted, 14 patients

are operated on, 6.2 patients are in

the intensive care unit and 1,226

meals are served

• About 18 percent of patients return

straight to duty.

Source: Landstuhl Regional Medical Center


J

Griffith, Garcia and others say they’re also careful to monitor their own staff for signs of burnout. Ruff said after her first year here she found herself coming down with a case of secondary trauma stress disorder, or as most people call it, “compassion fatigue.”

“You hear so much,” she says. Ruff said she didn’t want to turn to her family – they couldn’t understand anyway and she didn’t want to explain in any detail the suffering she saw while her brother was deployed. In the end she turned to coworkers for support.

Seared into her memory is the case of two ambushed soldiers. She had previously met them during a training exercise in which they played war casualties, only this time it wasn’t fake. One soldier had shrapnel wounds down the side of his head and the other lost a leg. “They’re all important patients, but it just made it extremely real. … It’s real anyway, but I knew these people,” Ruff says.

Griffith, the chaplain, says he goes through similar experiences. As the father of a 22-year-old, it’s hard not to identify with many of the young men admitted to the hospital, he says. A rare chance to see someone broken made whole again can make his day.

He recalls a badly disfigured soldier with his jaw blown off who 18 months later came back as a normal-looking military aide.

That was a good day, he says. But not the best. The best days, he says, are when no new patients show up at all.

Army Secretary Pete Geren visits wounded soldiers at Landstuhl in western Germany in September 2008.

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WASHINGTON, D.C. -- Army Master Sgt. John Souza talks tough, with a hint of a Boston accent and a wit that comes across as laid-

back sarcasm. Sitting in a wheelchair with his left leg extended in front of him, surrounded by what looks like a medieval torture device, Souza, 52, pauses to swig from a bottle of red PowerAde. He tells the horror story of how a 3-pound mine laden with ball bearings the size of his pinky tip ripped through the wall of a local council building in Sadr City, Iraq. “I could feel below the knee just flop,” he says with ease, as if the explosion hadn’t happened just three weeks earlier.

At Walter Reed Army Medical Center in Washington, D.C., Souza shows off how he can slowly lift his leg – including the spatial fixator correcting his broken bones – a few inches without

the help of a nylon blue handle. Just a week ago, Souza relied on a nurse to clean him, leaving this 30-year Army mechanic intensely frustrated.

Souza says he wouldn’t have come this far without the support of the Walter Reed staff: their professionalism, respect, personal touch – and perhaps their ability to take a joke. The staff have helped speed his recovery and buoyed him to keep up the witty banter despite intense pain and frustration.

“I’m not just a number,” he says, his eyes filling with tears as he looks away and takes a breath. “These guys here – I love them. I can joke with them. I haven’t ticked anybody off,” he says with a grin, looking at Hector Romero, the occupational therapist sitting next to him.

Each day, therapists, physicians and support staff at Walter Reed care for hundreds of troops wounded in the

Originally published in the Summer 2008 issue.

armyWalter Reed

With intenSe rehabilitation and SUpport, ampUteeS learn their liveS are Still fUll of poSSibilitieS

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By Sara MichaelPhotos by Jay Westcott

Army Master Sgt. John P. Souza has to learn how

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while he recovers from injuries sustained in Iraq

at Walter Reed Army Medical Hospital in

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wars in Iraq and Afghanistan. Some are service members themselves, others are civilians. But all chose to care for the country’s military members, becoming a vital part of their rehabilitation and

support.These doctors and therapists see an endless

stream of critically ill patients, a constant onslaught of what are often the most horrendous and complex injuries. More than 800 amputees from the wars in A f g h a n i s t a n and Iraq have

been treated at military medical

facilities as of mid-2008, including Walter Reed; Brooke Army Medical Center in San Antonio; the National Naval Medical Center in Bethesda, Md., and the Naval Medical Center in San Diego, according to Walter Reed officials.

At Walter Reed, the orthopedics ward and the new Military Advanced Training Center teem with patients working to rebuild their strength and mobility. Romero’s friends think his job as an occupational therapist at Walter Reed must be depressing because he sees military members at their lowest point, physically and mentally. But for Romero, 28, the opportunity to see them rise from that low is unparalleled. And they do rise.

One of his patients who came to him missing part of his leg now wants to kayak, said Romero, who has worked at Walter Reed for about two years. “We watch them fly,” he says.

The quick progress the staff see in the patients is unique to

the population, said Col. Jeff Gambel, medical director of the amputee care program. About 1.7 million Americans have lost a limb, according to the Amputee Coalition of America. Most civilian amputees are older and lost a limb because of poor circulation caused by arterial diseases or diabetes; diabetics account for more than half of all amputees.

At Walter Reed, the patients are strikingly different from the image of a typical amputee, Gambel says. These soldiers were tactical athletes, in peak shape, with all the dreams and plans of any 25-year-old. The expectations of a young, wounded soldier are very different from a civilian amputee, he says. They want to return to the level of functioning they had before they lost a limb in battle.

“One of the early decisions was to co-locate injured service members here together,” he says. “At a local hospital, they would be among people who are older and have lower expectations.”The soldiers feed off each others’ high expectations – and the signature military can-do attitude. “And that pumps up the staff.”

Cpl. Chris Levi, a youthful-looking 25-year-old Long Island native, explains how the military attitude translates from Army training to rehabilitation.“Just because we got blown up doesn’t mean our standards drop,” says Levi, who lost both his legs and the back of his hand in Baghdad from an “EFP,” an explosively formed projectile, that he says could “rip through armor like a hot knife through warm butter.”

“It’s the same mentality we had in the Army. You may not have the proper equipment, but you can do better,” he says, peddling on a stationary bike in the spacious workout room in the Military Advanced Training Center, an outpatient facility opened in September 2007 to accommodate the growing number of active-duty service members who lost limbs in Iraq or Afghanistan.

The at-times miraculous turnarounds the soldiers make motivates Capt. Aeneas Janze, a resident in physical

medicine and rehabilitation in his final year of training. He described his time at Walter Reed as a blessing. A soldier may be


Staff Sgt. Sara Sutton, a physical therapist technician, works with Army Cpl. Christopher Levi as he relearns how to walk.

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After his leg was shattered by a mine in Iraq, Souza has to learn how to navigate common, daily chores like getting in and out of the bathtub.

in intensive care one month and then an outpatient three months later, walking with a prosthetic limb, says Janze. “To have this patient population that does get better is rewarding.”

Working at Walter Reed also gives Janze unparalleled training. He’s in the “eye of the storm,” he says, treating patients with complex and often multiple injuries he wouldn’t see at a local hospital. “The exposure is really startling.”

Other therapists and physicians point to the flexibility they have to treat a spectrum of ailments. The military provides staff with the training and certification to do several tasks. So rather than just being able to order an X-ray, for example, a therapist could order it, read it and send the patient to orthopedics, says Capt. Dora Quilty, an occupational therapist.

The barrier of health insurance known to plague civilian doctors is absent in the military setting. That frees up military doctors and paves the way for them to offer the most state-of-the-art treatments, staff members say.

Amputees were getting the latest version of the C-Leg – a high-tech computerized artificial leg created by Otto Bock – the same day it went on the market, Janze says. “The military takes care of its people.”

For Quilty, the motivation to come to work each day is intensely personal. Her husband, Capt. Scott Quilty, lost an arm and a leg and spent two years at Walter Reed recovering. She wants the patients she sees to live the life her husband now enjoys. “Everyone deserves a chance for the way they want to live. If we come in here and do our jobs, we are giving them all the tools they need to get where they want to be.”

Dora Quilty works with patients at Fort Independence, a miniature apartment set up in the occupational therapy wing. A complete kitchen and a living room with a couch, chairs and table provide the setting for recovering soldiers to relearn skills needed for daily living. Working in a familiar setting also can help soldiers suffering from Post Traumatic Stress Disorder to focus, Quilty says, allowing them to overcome the speech and memory barriers to complete a task.

“It’s the ‘ah-hah’ moment,” she says, sitting in the small living room. “It’s rewarding when it happens.”

But those breakthroughs don’t happen every

day, and working in the mental health field can be particularly draining, Quilty says. It can often seem like a never-ending stream of patients. One is discharged and a new patient arrives, perhaps only able to move his thumbs and blink his eyes. Then there are days when a soldier she has been working with for two months who was showing progress doesn’t show up for his appointment because he’s back in the lockdown unit where he can’t hurt himself. “Those,” she says, “are hard days.”

That’s when Quilty steps away from the mental health part of her job and works with a patient undergoing physical therapy, shifting her efforts to someone else in need. “When you get discouraged you change your focus on something else,” says Quilty, who also notes she and her husband take frequent weekend trips to ease the stress.

Romero does the same. When he gets particularly frustrated with a patient, he’ll visit one who has made significant strides. He tells himself, “This guy got through it. He’ll get through it too.”

But staff members say none of the stress and struggle of working with severely injured service members compares to the challenges the soldiers endure.

“We are pretty honored to be able to do what we can to help,” says Lt. Col. Paul Pasquina, chief of the integrated department of orthopedics and rehabilitation at Walter Reed and Bethesda. “We all feel a sense of importance in what we do, as we certainly don’t want to let people down in an organization where you have pride.” J

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The lightweight materials and high-tech software of today’s prosthetics are a far cry from the wood-crafted limbs used for decades. The technology

continues to advance, with prosthetics becoming more com-fortable and their use more intuitive.

Clinicians and researchers at the Department of Veterans Affairs are developing and testing some of the newest pros-thetic technologies, such as bionic limbs and powered joints, as well as devices such as GPS systems and reading machines to assist veterans who sustained other injuries. Advanced technology is also commercially available in VA medical cen-ters across the country, where some 40,000 amputee veterans receive care.

“It’s very different today,” says Terry Kalter, chief of the prosthetic labs for Veterans Integrated Service Network 3 at New York Harbor Healthcare System, one of 21 health-care networks within the Department of Veterans Affairs. Kalter has watched the industry evolve dramatically over the last 30 years. “Now you are more of a clinician” than a craftsman.

After a warfighter is discharged from a military hos-pital, his or her care falls to the VA. The VA is in a

unique position to provide just about any health-care solution in the marketplace, regardless of cost and availability, says Frederick Downs, chief of prosthetics and clinical logistics at the VA’s Veterans Health Administration. “We do not limit stuff,” he says. “You name it, we provide it.”

In fact, the VA has historically been a leader in prosthet-ics, says Dr. Joel Kupersmith, chief research and development officer for the VHA. More than 20 years ago, for example, the VA developed the Seattle Foot, which included a spring that revolutionized lower-limb motion. Today, that tradition continues as the VA collaborates with industry to develop and test more cutting-edge prosthetic technology.

Take the advanced prosthetic arm being developed by DEKA Integrated Solutions with funding from the Defense Advanced Research Projects Agency, or DARPA. In 2009 the VA launched a three-year optimization study which clinical researchers tested the DEKA arms on veterans.

The DEKA arm provides increased functionality, allowing users who have lost an arm up their shoulder joint to pick up small objects. The arm can be raised, twisted and bent. Con-trolled by foot movements transmitted through sensors in the shoe, the arm can eventually also be adapted to work with other control systems, such as switches wired to muscles and nerves in the upper body and to impulses from the brain, ac-

Originally published in the Summer 2010 issue.

STEP:STEP BYBy Sara Michael

Propelled by the growing ranks of military amputees, prosthetic technology advances by leaps and bounds

Cpl. Garrett Jones, injured in Iraq in 2007 by an insurgent’s bomb, is the first Marine with an above-the-knee amputation

to deploy to Afghanistan.

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cording to the VA. “We now think the arm is a great leap forward in arm prosthetic technology,” says Kupersmith.

Downs, who lost his arm in Vietnam in 1968 and has worn a mechanical arm for 40 years, was among those who gave the arm a test run. “It was extraordinary the amount of control I had on that,” says Downs, who confessed to initial skepti-cism. He was fitted with a shoulder sock-et, and pads were placed in his cowboy boots. “You can teach an old dog new tricks,” he says. The prosthetic “felt like a part of me. ... This arm is going to come closest to being like their regular arm; it’s eons above the body-part arm.”

Some of the technology currently available to VA med-ical centers already markedly increases com-

fort and functionality.Kalter’s facility in New York fabricates prosthet-

ics for all six labs in his network using a computer-aided design and manufacturing (CAD/CAM) system

provided by Mt. Sterling, Ohio-based Ohio Willow Wood. Using the company’s Ome-ga Tracer, clinicians at each of the hospitals can scan a patient’s residual limb, make adjustments on the computer, and elec-tronically send the file to Kalter’s team. The alternative is having a prosthetist take and fill a liquid plaster cast, which is then modified and fit. “It’s time-saving,” Kalter says. “It expedites the delivery of the pros-thesis to the veteran.”

In the last four years, the CAD system has advanced to using a laser-based scan-ner providing more precise measurements

and shape, says Steve Byers, new product development of-ficer for Ohio Willow Wood. Byers notes that a majority of prosthetists are still doing plaster casting, with many feel-ing that’s the only way to attain proper compression. How-


TOP: The Department of Veterans Affairs’ Frederick Downs demonstrates the DEKA arm, which is controlled by foot movements trans-mitted through sensors in the shoe. BOTTOM: Army veteran Henry Diaz walks down stairs on the microprocessor-controlled Rheo Knee. The knee, developed by Ossur, helps prevent buckling and falls.

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ever, he says, “We believe as people get more and more used to the com-puters, [the CAD system] will be common practice.”

Several years ago, a new tech-nology emerged as an alter-

native to mechanically controlled prosthetics: microprocessor-con-trolled lower-limb prostheses. These sensor-equipped knees promised to improve a person’s gait, provide more natural movement and help prevent falls. About 10 years ago, the VA evaluated the technology. Today many veterans are using the prostheses.

“Now evidence shows it does benefit patients at multiple activity levels, whether they are just walk-ing around their house or they are out in the community,” says Kristen Knox, senior marketing manager for Otto Bock, a German company with North American headquarters in Minneapolis. Otto Bock produces the C-Leg, which is powered by sen-sors in the knee and ankle that detect the weight being displaced. Inside the knee joint is a tiny microproces-sor that takes readings at 50 times per second, making adjustments to stability and stance of the knee and helping prevent falls, Knox says.

C-Leg users also have more con-fidence in their walk and tend to watch the ground less, a habit many amputees picked up to avoid trip-ping while wearing less ergonomic prostheses, she says.

When the C-Leg first hit the mar-ket, officials were skeptical, and a mechanical knee was still the first choice. However, prosthetists in-creasingly are fitting users with the C-Leg first, Knox says, particularly Iraq and Afghanistan vets receiving care at Wal-ter Reed Army Medical Center.

Other companies are providing similar devices, including Foothill Ranch, Calif.-based Ossur. The company developed the Rheo Knee, which uses bionic technology to adapts to a person’s working style. The knee, intended for people with good control over their residual limb, includes a mechanism that limits falls by preventing buckling, says Ian Fothergill,

manager of Ossur Academy, the com-pany’s education arm.

Ossur has also developed the newer-technology Power Knee, with the VA and the Defense Department among the largest customers of the first-gen-eration Power Knee. The knee uses sensors and motors to provide positive power to generate lift for the user. The knee helps the amputee by propelling him forward and actively lifting for in-clines and stairs. It replaces muscle ac-tivity to bend and straighten the knee.

This solution is ideal for those whose mobility is restricted or who struggle with movements such as climbing stairs or getting out of a chair, Fothergill says. “They don’t have the power. They don’t have the balance, or some of the necessary parts to get out of the chair to get walking. We are looking at power in the prosthetic de-vice to help with mobility.”

As the power sources have got-ten smaller, the powered knee be-comes smaller, Fothergill says. Just a few years ago, the motors were too big to fit in a knee joint. Now, Ossur is working on a second generation that’s smaller, fits average-sized users better and has significantly longer bat-tery life.

Fothergill notes that much of Os-sur’s focus in research and develop-ment is on wearability, with the aim that prosthetics should be delivered to the market quickly.

Indeed, the major challenges to prosthetic progress, particularly for artificial limbs, are making sure the device is comfortable, which means composite materials and mechanics must be lightweight enough for ease of control. More power and function-

ality can often mean more weight. The prosthesis also must be comfortable on the skin and fit well with the socket in a load-bearing body part.

As research drives the field of prosthetics to integrate more with the user’s nervous system, more advanced systems will continue to emerge, providing even more mobility and dexterity. Still, size and comfort remain critical.

“It’s the little things like that,” Downs said, “that are so important.”J

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As the notion of a front line of combat has changed, so too has the understanding of how battle affects service members. Troops engaged in direct firefight

aren’t the only ones who may experience trauma, and a single event isn’t the only culprit.

Similarly, the understanding of post-traumatic stress disorder (PTSD) has evolved, prompting the Department of Veterans Af-fairs to make regulatory changes to ease the burden of proof for receiving covered mental health treatment.

“Over time, we have come to realize that PTSD can be trig-gered by other kinds of stressful life experiences that can’t be boiled down to a single incident,” says Dr. Antonette Zeiss, the VA’s deputy chief for mental health services. She calls the VA’s rule change regarding the claims process for PTSD treatment coverage “a response to a growing understanding of warfare, and a growing understanding of PTSD.”

The VA’s extensive nationwide network of medical centers provides PTSD treatment for the nation’s veterans through per-sonalized, evidence-based programs. Through early intervention efforts, the VA has sought to connect veterans with effective pro-grams and ensure they receive the proper treatment.

A veteran seeking PTSD treatment from the VA submits

a claim seeking an evaluation, which is con-ducted by a VA clinician who collects information about the event that could have resulted in PTSD. Before the rule change, the VA tried to substantiate the experience and con-firm that it occurred when the veteran was in the military. Health administrators then determined whether the patient suffered a service-connected trauma.

“This is about that step -- looking at the evidence that an event actually occurred while the person was in the military,” Zeiss says. “Previously if someone was claiming a combat-related PTSD, they had to produce very rigorous evidence,” such as an after-action report, a medal or a description of the event. Not only is that information extremely difficult to produce, but the combat experience is not that cut and dried. And soldiers not engaged in active battle may still experience stress.

Some veterans who weren’t eligible for benefits may now be eligible, and those who hesitated to submit claims may decide to do so, Zeiss says.

Tom Tarantino, an Iraq veteran and legislative associate for the nonprofit Iraq and Afghanistan Veterans of America, calls the change “monumental,” reflecting a recognition of how wars are

Originally published in the Fall 2010 issue.

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by the numbers

in fiscal 2009, 365,836

veterans were treated

for ptSd.

of those, 19 percent

were veterans of

the wars in iraq

and afghanistan.

from fiscal 2002-2009,

nearly 130,000 iraq and

afghanistan veterans

received a provisional

diagnosis of ptSd in va

medical centers.

more than 3,700 va mental

health professionals have

been trained in prolonged

exposure and Cognitive

processing therapy

treatments.

Source: VA

Senior Airman Joseph Vargas uses the Vir-tual Iraq program at Malcolm Grow Medi-cal Center’s Virtually Better training site at Andrews Air Force Base, Md. The program uses prolonged exposure therapy, one of the two evidence-based PTSD treatments used by the Department of Veterans Affairs, to help patients confront and over-come the incidents that scarred them.

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fought and who may experience stress or

trauma. People like medics, truck drivers and other support members often have a hard time proving specific traumatic in-cidents occurred, Tarantino says. “More people are going to have access to more care and benefit from this change.”

Although the change opens the doors for more veterans to receive PTSD treatment through the VA system, it

doesn’t impact the treatment programs themselves, officials say.

Each veteran entering the VA system is screened for mental-health conditions, including PTSD. The screenings can lead to further evaluations. For the first five years after separation, a veteran is screened annually, says Stacey Pollack, director of the trauma service program at the VA Medical Center in Wash-ington, D.C. “We all know there is a huge stigma for people coming forth, so by making screening a part of our standard practice, we are able to get people into treatment and find out who needs to be referred,” Pollack says.

PTSD is caused by exposure to a direct or indirect threat of death or serious injury. Symptoms can include recurring thoughts of the traumatic event, or stressor, reduced involve-ment in work or outside interests, emotional numbness, anxiety

and irritability. According to the VA, the disorder can be more severe and last longer when the stress is a human-initiated ac-tion, such as war.

The VA relies on two evidence-based treatment methods for PTSD: Cognitive Processing Therapy and Prolonged Exposure. Both focus on the trauma, Pollack says, with the veteran talking or writing about his or her traumatic experience in a structured environment.

These two treatment options were determined as the most effective based on an extensive Institute of Medicine (IOM) study commissioned by the VA, says Thomas Berger, senior policy analyst for veterans’ benefits and mental health issues at the Vietnam Veterans of America. The institute reviewed more than 2,700 programs, many of which lacked scientific evidence or a connection to veterans.

“Those are the two treatment programs that pass with flying colors by the IOM,” says Berger. “Clearly, unless the evidence is there based on the IOM report, then we don’t know if the other stuff is good or not.”

Although the VA is always considering innovations in PTSD treatment, officials want to make sure the programs are being researched, and are based on strong evidence, Pollack notes. “PTSD is treated much better today than, say 25 years ago,” she says.


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Cognitive Processing Therapy involves learning about the symptoms and becoming aware of thoughts and feelings. The goal is to look closely at how the trauma is affecting the vet-eran, and then help him or her look at it differently. The patient learns the skills to question or challenge the thoughts.

Prolonged Exposure treatment, on the other hand, centers on the exposure to the thoughts and feelings that cause the dis-tress, and practicing in real-world situations the patient may have avoided, such as driving after a roadside bomb experi-ence. The patient also talks extensively with a therapist about the trauma memory. The duration of the treatment depends on the veteran, and whether he or she is suffering from a recent stressor or one that has gone untreated for 40 years, Pollack says. Some veterans fare better than others.

The stigma about receiving mental health services may sur-face in the beginning, she says, but often a vet will quickly start to see a difference. “They can see week to week how their symptoms are going down and they are feeling somewhat bet-ter,” she says.

The decision on which course of treatment is most appro-priate is based on clinician judgment and patient preference. However, the VA is researching whether one is a better fit for certain patients, Pollack says. “It would be great if we had research out there to let us guide particular patients toward particular treatments and know a better algorithm to see what works for who.”

Moving forward, one challenge for the VA is to ensure that clinicians, both within the system and in the pri-

vate sector, are well-trained on the treatment programs, Pol-lack says. More than 3,700 VA mental health professionals are trained to provide the two therapies, according to the VA. The administration also has a mentoring program that works with personnel at treatment sites to improve care. The mentors make

sure the clinicians are up on the latest research and best prac-tices.

Similarly, many veterans seek treatment outside of the VA system, Pollack notes, and it’s important that non-VA programs and clinicians also are current on treatment and research. In-deed, the treatment network for veterans extends far beyond the VA. Dozens of community-based organizations are providing so-called “wrap-around” care for veterans who need additional support, either as VA contractors or as independent groups.

“The VA is more of a medical model, [which] relies on or-ganizations to provide benefits advocacy, housing [assistance], employment and training -- all that wrap-around care they sim-ply can’t handle,” explains Colleen Corliss, communications manager at Swords to Plowshares, which provides transitional housing and other services to veterans in the San Francisco area. The nonprofit is one of about 50 groups that make up the Coalition for Iraq and Afghanistan Veterans, a partnership of organizations that offer care and support.

Veterans will still go to the VA center to access mental-health treatment, and more intensive medical care, Corliss ex-plains, but community groups can fill in some gaps. Ensuring a veteran seeks treatment at all can be a struggle, officials say. The stigma around mental illness among the military is still strong.

Thomas Hall, a Vietnam veteran and national PTSD/Sub-stance Abuse Committee chair at Vietnam Veterans of Amer-ica, says his organization and others are working to shift the notion of what is considered a strong service member. Some-one who is truly mission-ready takes care of every weapon and equipment he will need in battle, Hall says, including his mind.

“It seems incongruous that someone would be punished or ridiculed for pulling maintenance on that equipment,” he says. “You’d do the same with other weapons. Clear head, and clear mind, and be ready.”

A mock M-16 rifle, a package of various odor concentrations, and a manual for the Virtual Reality Exposure Therapy Application for PTSD are part

of a virtual reality-based software designed to recreate a traumatic situation in a safe environment. Prolonged exposure therapy is one of the

evidence-based PTSD treatments used by the Department of Veterans Affairs.

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Defense-Standard_01.ai 1 04-May-12 15:04:56

TRAUMATIC

brainINJURY

military and industry

join forces to build a

better helmetBy Sara Michael

With every explosion from a roadside bomb or blast of enemy fire, vehicle crash or flying piece of shrapnel, troops serving in Iraq and

Afghanistan face the threat of a debilitating head injury. As traumatic brain injuries become increasingly more common, military and industry officials have worked to understand what happens to the brain – and what kind of equipment will best protect warfighters.

Head gear has evolved dramatically since the days when a leather strap suspended the stiff metal helmet away from the soldier’s head. Today, high-tech, energy-absorbent materials mitigate the impacts and withstand multiple beatings.

Military medical leaders also have changed how medics respond to and treat battlefield casualties, with an eye toward better identifying head injuries and preventing further trauma.

“It’s a marriage of physiology and physics and material science,” said Zane Frund, manager of material science and chemical research for Mine Safety Appliances Co., or MSA, describing the complexity of developing combat equipment minimizing the risk of brain injury.

Blasts from improvised explosive devices are a leading

cause of injury – particularly traumatic brain injuries – in the Iraq and Afghanistan wars, according to a Government Accountability Office report on traumatic brain injury screening. About 30 percent of troops evacuated to Walter Reed Army Medical Center between January 2003 and June 2007 sustained some form of traumatic brain injury, according to the report.

The equipment industry has been feverishly developing and meticulously testing new materials to reduce the number of brain injuries.

“Even relatively mild head impacts, while not life-threatening, can cause short-term impairment from dizziness, headaches, memory loss, lack of ability to concentrate and irritation,” says Dr. John Crowley, science program director for the U.S. Army Aeromedical Research Laboratory at Fort Rucker, Ala. “Given the necessity for speed and aggressiveness in combat, these symptoms become militarily significant, no matter how temporary, by seriously jeopardizing soldier survivability and the success of the unit’s mission.”

The laboratory has researched helmet performance for helicopter crews for 40 years. Ten years ago it turned its attention to ground troops, Crowley says.

Originally published in the Winter 2009 issue.


ultimate warrior approved


Most of today’s ground troops don the Advanced Combat Helmet or the Lightweight Helmet, which consist of a

base shell, a suspension system (the pads between the shell and the head) and a retention system (the strap). The federal government mandates a range of requirements based on projectile weight and speed that dictate the strength of the outside shell.

“It’s the objective of that shell to defeat the projectile, to stop it,” says Frund, whose company, Pittsburgh, Pa.-based MSA, manufactures combat helmet shells. But, Frund adds, that means stopping the projectile from penetrating or even deforming the shell. The shell must have an elastic response to absorb the energy of the projectile. Roughly 85 percent to 90 percent of the shell is made up of a Kevlar-like fabric, known as a para-aramid, which is woven and coated in a resin material. The fabric has some flexibility and absorbs energy, and the resin material becomes solid under heat and pressure.

The exact number of layers of the woven fabric and amount of resin to optimize the helmet’s effectiveness is what Frund called the “sweet spot.” There must be enough, but not too much. Engineers can manipulate the materials to find that ideal combination. “Subtleties of material can have a great impact on the performance,” he says. “At the end of the day, you want to stop the projectiles and absorb the energy so that we don’t get traumatic brain injuries.”

Marine Corps Systems Command, which serves as the life cycle manager for infantry combat equipment, has been working to improve helmets, monitoring damaged equipment for clues,

says Lt. Col. A.J. Pasagian, program manager for infantry combat equipment at the Quantico, Va.-based command.

There’s an urgent need for a new helmet shell, he says, prompting the command to put out a request for information for new helmet designs with improved blast, ballistic and blunt-impact protection. The

next-generation helmet, called the Enhanced Combat Helmet, will likely use a light-weight polyethylene material providing more protection than traditional Kevlar fibers.

“We have come up against some promising technology in the area of the base material that is used to make the helmet,” Pasagian says, referring to the polyethylene material. “Polyethylene gives protection on the ballistic and nonballistic side with the same weight. That’s extraordinary.”

Marine Corps Systems Command awarded contracts to four vendors – MSA, Gentex Corp., Ceradyne Inc., and BAE Systems Aerospace and Defense Group Inc. – to test designs for the Enhanced Combat Helmet, focusing primarily on shell development.

The suspension system – the pads lining the shell – is a major component in protecting against closed head injuries associated with concussions and mild traumatic brain injury. After a series of analyses a few years ago, the military selected pads developed by Team Wendy, a company based in Cleveland, Ohio.

“Consistently our foam provides better management of these blunt impacts than anything out there,” says Ron Szalkowski, a senior product development engineer at Team Wendy. Team Wendy’s pads, made from trademarked Zorbium foam, were originally developed for ski helmets. The company expanded into the military market about five years ago. “The pads absorb the impact energy so your head doesn’t have to,” Szalkowski says.

Pfc. Fred M. Linck was shot in the head and walked away from the incident. The enemy round struck his Kevlar helmet, which saved his life by stopping the bullet from penetrating his head. A piece of fragmentation caused a small laceration to the Marine’s forehead too small even for stitches.

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The pads are designed to limit the speed at which the head stops moving after an impact. Slowing it down too quickly can mean the brain keeps moving inside the skull, thus damaging the brain. The pads aim to spread out the impact over 10 or 20 milliseconds, he says. Impacts that would otherwise have been severe or fatal are less so with the pads, as the foam absorbs the energy. And unlike the foam lining bike helmets, the Zorbium foam is designed to handle multiple impacts.

But the company continues researching ways to improve the material, including the development of a new foam pad system that would have adjustable soft comfort pads in addition to the impact-foam liner piece. “We are constantly tweaking it and trying to make it better,” Szalkowski says. “We are looking at trying to improve protection and comfort.”

The proliferation of improvised explosive devices has challenged engineers to understand what is happening to the

soldier’s brain, which is more vexing than the impact on the body, and adapt the systems to provide better protection. “If there is something we can adjust in the pad system, change the design with the pads to mitigate that pressure getting into the head, that’s something we want to do,” Szalkowski says.

In the next couple of years, Pasagian says, military officials need “to do a full and competitive all-things-under-the-sun comprehensive analysis.”

Military and industry officials are also turning their attention to the response on the battlefield in an effort

to better identify and immediately treat a potential brain injury. For example, BAE Systems developed a small sensor that

secures inside the helmet to record impact data. The Headborne Energy Analysis and Diagnostic System (HEADS) is equipped with a series of accelerometers and pressure sensors and activates upon impact, recording the data associated with an explosion. The information can be quickly downloaded using a USB connection, says Joe Coltman, vice president of Personnel Protection Systems in BAE Systems’ security and survivability business.

“Within minutes, medical professionals have the critical data they need to ascertain the extent of a head injury, identify treatment options and determine whether the exposure, if left untreated, could potentially result in a traumatic brain injury,” he says.

With 7,000 HEADS packages used by Army and Marine Corps personnel, warfighters have some piece of mind that an injury can be more accurately diagnosed, Coltman says. The system “has proven that it is a valuable tool in the identification of head injuries in general, and specifically, in the prevention of permanent damage associated with an untreated traumatic brain injury.”

Meanwhile, military officials changed the protocols for responding to potential brain injuries on the battlefield. In 2005, officials at the Defense and Veteran’s Brain Injury Center, a component of the Defense Centers of Excellence

for Psychological Health Traumatic Brain Injury, revised the response protocols. They also changed the guidelines for screening for mild traumatic brain injury and incorporated them into first-responder medic training.

“That has really significantly helped to standardize the approach and care and screening for mild TBI in the deployed setting,” says Col. Michael Jaffee, director of the center.

The guidelines were based on those used by emergency medical technicians in a civilian setting, but were adapted to battlefield conditions, says Kathy Helmick, director of TBI clinical standards of care. For example, she says, instead of using the traditional mannitol medication for brain swelling, responders use a hypertonic saline solution that is easier to carry. Overall, the idea is to ensure adequate oxygenation of the blood and blood pressure, to prevent secondary injury after the initial brain injury, Helmick says.

Military officials are also shifting away from a self-report process to a system where every soldier is screened and evaluated if he or she has been at high risk for a concussion, Jaffee said.“For the more severe injuries,” he says, “the initial response has a direct effect on the outcome.”

"Within minutes, medical professionals have the critical

data they need to ascertain the extent of a head injury, identify treatment options and determine whether the

exposure, if left untreated, could potentially result in a

traumatic brain injury”"Joe ColtmanVice President of Personnel Protection Systems, BAE Systems

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Regenerative medicine holds promise for healing burns, shattered bones and more

BODY,By Julie Bird

heal thyself


Originally published in the Fall 2010 edition.

“Pixie dust” isn’t the kind of term you’d expect to be tossed around among the green-suited medical minds at the U.S. Army Institute of Surgical Research. The

power of the white, powdery substance to help grow muscle, tissue, cartilage and even body parts has captured the imagination of military medical researchers, who long have sought better ways to repair devastating combat injuries.

But the pixie dust nickname for the substance officially known as extra-cellular matrix drives Smita Bonsale a little crazy. “Pixie dust is magic, and this is science,” says Bonsale, who manages a $120 million, five-year Defense Department project to jump-start major advances in the relatively new field of regenerative medicine.

Science or magic, what they’re doing is pretty amazing.

University researchers are studying using polymer-based materials to rebuild damaged bones in their original shape, and extra-cellular matrix to regenerate chunks of missing muscle. They’re examining how to marry a transplant patient’s cells with donor cells, tricking the body into thinking it’s receiving its own tissue. They’re developing a device like a dot-matrix printer to spray varying thicknesses of treated skin cells onto unevenly burned tissue, prompting rapid skin regeneration with little scarring.

Ultimately, they hope to find ways to regenerate not just muscle, skin, bone and nerves, but limbs and appendages.

The Armed Forces Institute for Regenerative Medicine (AFIRM) at Fort Detrick, Md., rounded up the top academic and private-industry researchers in the field, Bonsale says, including nine of the top 10 regenerative medicine research universities and eight of the 10 most-published scientists.

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Engineered tissues and organs are often built using three-dimensional, porous molds or scaffolds that support cells as they develop. This ear scaffold is being coated with cartilage cells.

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Hundreds of university and private-industry researchers are working on 240 projects under two major research consortia. One is led by North Carolina’s Wake Forest University and the University of Pittsburgh in Pennsylvania. The other is led by Rutgers University in New Jersey and Ohio’s Cleveland Clinic. The U.S. Army Institute of Surgical Research, or USAISR, at Brooke Army Medical Center in San Antonio is the third research partner, providing overall guidance and participating in clinical trials.

The last scientific collaboration on that kind of scale was the Manhattan Project, says Army Col. Robert G. Hale, USAISR’s representative to AFIRM. “This isn’t a bomb, it’s healing. And that’s fantastic.”

The project is indeed “a very, very large enterprise,” says Dr. Rocky Tuan, director of the Center for Cellular and Molecular

Engineering at the University of Pittsburgh. “Somebody said, ‘How is that possible that all of these Type-A people that compete with each other are supposed to work together?’ But it is possible to get the top researchers in the regenerative field to work together toward the common goal of regenerative therapies for the wounded warrior.”

The five targeted research areas are limb repair, craniofacial repair, burn repair, scarless wound repair and compartment syndrome repair, compartment syndrome being when an injured limb swells so severely that muscle dies. “We aren’t asking for the moon,” Hale says. “We are asking for improvement. And that’s inspiring researchers.”

It seems to be working. AFIRM’s original goal was to have one active clinical trial treating patients in five years, says Wake Forest’s Dr. Anthony Atala, co-chair of the Wake Forest- Pittsburgh consortium. Just two years in, though, his consortium alone already has three active clinical trials and four in the works.

Collaboration accelerates technological advances by enabling researchers to quickly share both their discoveries and their failures, says the Cleveland Clinic’s Dr. George Muschler, co-director of the Rutgers-Cleveland Clinic consortium. By quickly dropping dead-end research and concentrating on successes, he says, 20 years of advancements could be squeezed into two to four years.

Some of the most promising research has been in the high-priority area of burn treatment. “It sucks to go to the operating room and do a big burn case and it may be no different from what was done in 1980, or 1996,” says Dr. James H. Holmes IV, director of the Wake Forest Baptist Burn Center and head of AFIRM’s burn project. “We can do better. We have our chance here.”

He is especially optimistic about a commercial product called ReCell already in use in other countries. Cells from a thin, 4-square-centimeter skin graft can be easily processed outside of a lab in less than a half-hour, then sprayed onto the patient’s wound to create more than 320 square meters of skin – an 80-to-1 expansion rate. The Australian manufacturer, Avita Medical, says the new skin heals more quickly than traditional grafts, with significantly less scarring.

AFIRM funded a clinical trial to gain FDA approval of ReCell. If the technology is widely adopted in the U.S., it will be the first major advancement for treatment of major burns since the mid-1970s, Holmes says.

It is one of several research projects addressing one of the biggest challenges in military burn treatment: finding enough healthy skin for grafts on a severely burned patient. “We are very aggressively trying to answer the charge given us … to provide treatment for wounded servicemembers as rapidly as possible,” Holmes says. “I really, truly believe we are going to make advances that will make an absolute difference.”

The goal behind this computer-controlled system to grow human skin the lab is to create large amounts of skin for reconstruction.

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Other researchers are developing an engineered skin that can be used to temporarily cover burns as a first stage of treatment, according to the Army’s Hale, director of cranio-maxillofacial research at USAISR. “Our primary goal is to save lives and close wounds,” he says, “but we also want to return soldiers to full function in work and life.”

Dr. Maria Siemionow of the Cleveland Clinic is working on three major projects to reduce the risk of rejection in face and

hand transplants. As director of plastic surgery research and head of microsurgery training, Siemionow was part of the team performing the first U.S. face transplant in December 2008.

Immuno-suppression drugs that transplant patients must take for the rest of their lives have serious potential side effects, including tumors and lymphoma, Siemionow says. One clinical trial examines how a protein antibody can selectively block certain receptors, minimizing the need for lifelong anti-rejection treatment. The therapy is important for all transplant patients, she says, but is especially applicable to young military members who otherwise could have to take anti-rejection drugs for decades.

Her second project fuses transplant donor and recipient cells extracted from bone marrow, then replicates them in the patient’s body. Because the fused cells are partly the patient’s, the theory is that minimal immuno-suppression treatment would be required. The third project represents a new generation of cell therapeutics, she says.

Siemionow says AFIRM funding is critical to the research. The National Institutes of Health, another major governmental provider of regenerative medicine research grants, won’t generally fund what it considers high-risk procedures. AFIRM, she says, considers the risk in relation to the potential for innovation.

Tuan, who co-chairs the Wake Forest-University of Pittsburgh consortium, expands on that idea. “In treating civilian injuries we often are conservative in what we do. As a result, development happens very sequentially,” he says. “Injuries from war-related trauma are usually very extensive. It’s an upside-down pyramid – the most severe injuries are the most frequent. The approach therefore is totally different from that of projects funded by NIH and even by the VA. We have taken very drastic and sometimes even somewhat risky approaches.”

Hand transplants are an example, Tuan says. A soldier who loses a hand can live a productive life with a prosthetic. “But this is exactly

what you want to do – use this opportunity to really push the envelope. We are committed to going for broke and trying out these crazy ideas. I think by doing this we will break new ground.”

Although transplants are not technically regenerative medicine, the science of improving the interface between graft and host tissue is, Tuan says.

“We very constantly keep track in the consortium of the status of so-called enabling technologies,” he adds. Enabling technologies include scaffolds that serve as fundamental building blocks for generating bone, tissue or nerves. Extra-cellular matrix is one such scaffold. So are adult stem cells and cells extracted from fat, or adipose tissue. “So the people who do cells need to be in touch with the people who use cells. The probability of being able to take advantage of any development is greatly enhanced.”

The Cleveland Clinic’s Muschler, vice chair of the Institute for Orthopedics and Rheumatology, says that optimizing the

environment for bone, muscle and nerve regeneration also can lead to fewer amputations. Rocket-propelled grenades and other explosives can easily blow a gap in bone or muscle that “without very, very aggressive treatment doesn’t heal with very good reliability,” he says.

Muschler says researchers are working on processes to use polymer scaffolds to prepare stem cells harvested from the patient and use them to regrow missing chunks of bone. Related research is looking at ways to better prepare the damaged site to accept the stem-cell therapy.

Not every project has been successful. AFIRM’s Bonsale says some of the compartment syndrome projects, in particular, were abandoned after disappointing early results. But the overall progress is staggering, she says, adding, “We might have to reassess our five-year goals.”

Regenerative medicine is a new field for the Department of Defense, Bonsale adds. “We’ve made a tremendous amount of progress, and I wanted to be part of it. Not a single day do I regret it.”

She knows the research will one day help people like retired Master Sgt. Todd Nelson, who sustained extensive burns and other debilitating injuries in a 2007 suicide bomber attack in Kabul, Afghanistan. Nelson serves on a regenerative medicine advisory committee in San Antonio, where he still undergoes treatment.

“If they can start doing some of the things they’re talking about, it will just be heaven-sent to the folks that have this happen in the future,” says Nelson, who was a senior maintenance supervisor in the Army. “Being in their shoes, I can see it will mean the world to them. We should do this.”

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The job of keeping track of thousands of objects in Earth orbit falls to the Air Force’s

Space Surveillance System, a network of six radar antennas stretching from Georgia to California that has been in operation since 1961.

The system works, but it sometimes shows its age. For instance, it signaled last summer that a piece of space junk was approaching the International Space Station. But the warning came too late for the station to take evasive maneuvers. The six astronauts had to climb aboard two Russian Soyuz capsules docked to the station, ready to return to Earth if the station was struck.

The debris whizzed by only 820 feet away -- reportedly the closest any space junk has ever come to the space station.

A new ground radar system, slated to begin operation in 2015, would have given an earlier warning, says Linda Haines, program manager of the new system. It’s called Space Fence because, like its predecessor, its radar beams will shoot straight up like a fence to detect objects passing through.

But with S-band radar instead of the old VHF radar, Space Fence will see smaller objects – important, because even a centimeter-sized object traveling at 20,000 mph could destroy a satellite. It will track more than 100,000 objects

as far away as 3,000 kilometers, well over the 22,000 objects being tracked today.

It won’t be perfect. There may be millions of pieces in low to medium Earth orbit. Still, networked with other systems, Space Fence is expected to revolutionize the art of space situational awareness – knowing what is where in Earth orbit.

Haines declined to address whether the trackable objects include stealthy satellites.

Lockheed Martin Corp. and Raytheon Co. are competing for Space Fence, which is expected to have a lifetime cost of $4 billion to $5 billion. Each got $107 million in 2011 for preliminary design.

The companies have extensive experience with big, ground-based radars. The Air Force’s Electronic Systems Center at Hanscom Air Force Base, Mass., which is handling the program, is the service’s center of excellence for ground-based radar.

But that doesn’t mean Space Fence isn’t being scrutinized on Capitol Hill. The House Appropriations Committee’s defense subcommittee has targeted the program for budget cuts, which Haines calls “very, very frustrating.”

She says her response is to “increase the confidence” of Air Force, Pentagon and congressional leaders “that you have a good plan and you’re executing to that plan and you’re keeping your promises.”

Congress’s Government Accountability Office, meanwhile, has been worried that Space Fence technologies are immature. But Haines says the GAO used old data. “Basically the technologies for this program are mature,” or will be by the time the preliminary design review is conducted next February.

John Morse, Lockheed Martin’s Space Fence program manager, says technology and

manufacturing risks will be reduced “to almost nothing” as the preliminary design phase ends this summer.

One of the technologies is digital beam forming, according to Doug Burgess, senior Space Fence program manager at Raytheon. He describes it as the ability to simultaneously put multiple beams of radar into a large volume of space.

To help reduce risk, both companies are building prototypes.

’13 AIR FORCE Preview

Space FenceNew radar to see 5 times more orbiting objects

By Rich Tuttle

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This still photo from a Lockheed Martin film dramatizes the collision of two satellites and indicates how debris can be added to Earth orbit. Space Fence operators would have earlier warning of potential collisions.

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’13 ARMY Preview

hybrid tacticsDiesel-electric vehicle adds stealth to range

By Matthew Cox

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The Army’s Clandestine Extended Range Vehicle, made by Quantum Technologies Inc., has a 300-mile range with the diesel engine keeping the batteries charged, and about eight miles of “stealth” range running just on electricity.

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The Army is working on a hy-brid electric vehicle for its special operators, but this

battle wagon is no Toyota Prius.The Clandestine Extended Range

Vehicle (CERV), made by Quantum Technologies Inc., is designed to be a highly deployable vehicle capable of sneaking up on the enemy. “The ve-hicle could roll up next to you and you wouldn’t even hear it,” says Dave Mazaika, chief op-erating officer for Quantum Technolo-gies.

Quantum built six test prototypes for the Army’s Tank Automotive Research, Devel-opment and En-gineering Center (TARDEC). The future of the CERV is uncertain, but Quantum officials maintain that the excitement generated by this new vehicle will be hard to ig-nore.

The CERV runs on a 100-kilowatt motor and a 7-kilowatt lithium-ion battery pack. The vehicle has a 1.4-li-ter diesel engine, but it’s there only to keep the batteries charged, says Phat Truong, electrical engineer and CERV program manager for TARDEC.

With all components running, the vehicle has a range of about 300 miles over rough terrain. But when the diesel engine is turned off, it has up to eight

miles of “stealth range.” “You can’t hear any noise,” Truong says. “As soon as they get to a certain range from the objective, they can switch to the stealth mode.”

Program officials would not com-ment on how much money has been

spent on the CERV and remain tight-lipped about its future. Hybrid electric vehicles, however, are nothing new. Toyota has sold more than 2 million of its popular Prius model.

The CERV program demonstrates how the concept continues to hold val-ue in the face of high fuel costs, says Bill Van Amburg, senior vice president for CALSTART Inc., which develops advanced transportation technologies such as hybrid-electric vehicles. “The hybrid truck world is starting to take off,” he says. “The Army gets it be-

cause deployed cost of fuel is really damn high.”

Quantum Technologies began work-ing with TARDEC on the CERV pro-gram in 2008 to build a lightweight hybrid vehicle for Special Operations Command that’s compact enough to

be carried aboard the V-22 Osprey aircraft, Mazaika says. That meant it could be no bigger than 60 inches wide and 60 inches tall, making for a ve-hicle that is slightly longer and lower to the ground than a standard Jeep.

It also had to be able to perform in rough terrain. “This thing can jump off sand dunes, and climb 40 percent grades,” Mazaika says.

The CERV has to weigh less than 5,200 pounds, so there is no exterior

armor, doors or windows.“It’s a different mission,” Mazaika

says. “It wasn’t intended to be a Joint Light Tactical Vehicle.” The vehicle is capable of speeds up to 85 miles per hour, but it would have to creep along when operating in stealth mode, Mazaika says. “Obviously the faster you go and the higher power you use, it’s going to shorten your range.”

It can travel silently for about eight miles over rough terrain, he says, but “if you are just cruising around on as-phalt roads, it would be a lot more.”

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’13 MARINE CORPS Preview

IMPROVEMENTS TO HOWITZER CONTINUEBy Matthew Cox

M777A2

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An artillery round exits the barrel of an M777A2 155mm Howitzer during a live fire exercise.

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The U.S. military’s new, light-weight 155mm howitzer may one day be able to tell gun

crews if it has been fired too long with-out a break.

Officials at BAE Systems, the maker of the M777A2, say they are working on improvements that could equip the gun system with an electronic thermal warning system. “It tells them the gun is getting too hot,” says Geoff Gonza-lez, M777 integrated project team leader at Global Combat Systems and Weap-ons at BAE Systems.

The Marine Corps, like the Army, has been replacing its heavy M198 155mm towed howitzer with the M777A2 for about 16 years. The Corps budgeted $21.6 million for fiscal 2012 and planned to complete fielding the lightweight gun in 2013.

But the work at BAE is nowhere near done. In addition to the electronic ther-mal warning system, Gonzalez’s crew continues to work on improvements to the M777 series such a hydraulic power pack that would help raise and lower the gun, a job now done by hand.

The M777A2 weighs 9,700 pounds, significantly less than the 16,000-pound weight of the M198. The weight savings comes from using titanium and alumi-num alloys in all of the major structures except the steel gun tube. The lighter

weight should mean that Marine and Army combat units can put the M777A2 anywhere they want on the battlefield.

“It’s uniquely suited for Afghani-stan, where it’s been light enough to be

lifted into high-altitude forward operat-ing base locations,” says Christopher Hatch, deputy program manager for the Army and Marine Corps Lightweight 155mm Joint Program Office at Picatin-ny Arsenal, N.J. “We can’t lift an M198 into those places.”

Because of its lower weight, two M777s can fit into a C-130 Hercules tactical airlift aircraft, versus only one M198, says David Branham, who man-ages congressional and public affairs for the Marine Corps Program Execu-tive Office Land Systems. Unlike the M198, the M777 also can be airlifted by helicopters such as the Marine Corps CH-53E, CH- 46E and CH-53Ds as well

as the new MV-22 Osprey tilt-rotor air-craft, Branham says.

When the program began in the mid-1990s, BAE’s gun soon became known for its durability. Marines in particular

were impressed that they couldn’t break it during testing, BAE officials main-tain. The Marines had a requirement for 511 M777A2s, Gonzalez says; the Army planned to buy 418.

BAE officials, who planned to pro-duce the M777A2 for both services into 2013, say the program has gone “fantastically well.”

“It is one of the few programs I have been involved with where we have never missed a delivery,”

Gonzalez says. “The feedback I have received is it is extremely reliable, ex-tremely maintainable and extremely ac-curate.”

The M777A2 is the latest version of the system. Produced in 2009, it fea-tures a digital fire-control system that helps crews calculate wind speed, me-teorological conditions and even the Earth’s rotation for delivering accurate fire.It can fire the precision-guided Ex-calibur munition up to 24 miles with far better accuracy than traditional artillery shells. That makes the gun safer to use in populated areas, Branham says.

Canada and Australia also pur-chased the M777A2.

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DDG-51FULL STEAM AHEAD FOR DESTROYER

By John T. Bennett

’13 NAVY Preview

The Aegis guided missile destroyer USS Gravely (DDG 107), built by Huntington Ingalls Industries, plows through the Gulf of Mexico.

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These have been an eventful few years for the DDG-51 destroyer program. But it

appears all is well with the program that at one time was slated to stop churning out ships.

The Navy decided to build only a few models of an entire new class of ships -- dubbed DDG-1000 -- and restarted production of the Arleigh Burke-class war ship. The Obama administration made the Aegis Weapon S y s t e m - e q u i p p e d ships a central part of its missile defense plan. And one of the two manufacturers of the ships, Northrop Grumman Corp., spun off its shipbuilding business.

But with the smoke clearing from those moves, Navy and industry officials say the DDG-51 program is progressing on schedule.

The sea service made the call to revive Arleigh Burke production in 2008, and talked of building eight new ships. But now, “the Navy’s plan includes at least 10 continuation DDG-51-class ships, and the number of platforms could ... increase,” says Beci Brenton, a spokeswoman for Northrop spin-off Huntington-Ingalls Industries.

“The approach for the [DDG-51] restart leverages the cost savings of existing production lines, [and] reduces the potential for cost overruns and delays through the

incremental approach of developing new technologies,” Navy acquisition executive Sean Stackley and other service officials said in a 2011 joint statement for the House Armed Services seapower and projection

forces subcommittee. The restart plan also “strengthens

and stabilizes the industrial base to more efficiently and cost-effectively produce ships to meet our national needs,” they told the panel.

Each new ship will cost around $3.5 billion, according to Congressional Research Service analyst Ron O’Rourke. That means both Huntington-Ingalls and General Dynamics stand to benefit from the revived production.

The Navy several years ago had every intention of ceasing production of the ships at General Dynamics Bath Iron Works shipyard in Maine and Northrop Grumman’s Ingalls Shipyard

in Mississippi. Bath is working on the final pair of

51s awarded under previous contracts (DDG-111, the USS Spruance, and DDG-112, the USS Michael Murphy). Picking up work started under the

Northrop banner, Hunt ing ton- Inga l l s Industries is under contract to build DDG-113.

The Navy also has awarded Huntington-Ingalls a contract to build DDG-114. Bath is building DDG-115 and Arleigh Burke 116, which will be named the USS Thomas Hudner.

Despite breaking off from Northrop, Brenton said Huntington-Ingalls is focused on becoming the Navy’s

“shipbuilder of choice in the design and build of future Aegis destroyers.” But its top shipbuilding rival reports it has made big strides in ship design tactics. And that could give it an edge when pursuing DDG contracts.

Jim DeMartini, a General Dynamics spokesman, said the shipyard’s work on the first vessel in the DDG-1000 class “is coming along better than any lead ship has before.”

DeMartini credited three-dimensional computer-aided design, a technology he calls a “game-changer” in improving the company’s shipbuilding process. General Dynamics is slated to build three DDG-1000s.

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AFGHANISTANfromSNAPSHOTS

AFGHANISTAN

Ddefense standard presents this diverse look at operations in afghanistan thanks to lt. cmdr. daniel o’shea, a qualified navy seal, navy reservist and recipient of the meritorious citation from the navy league of the united states. these photos were taken by o’shea and his colleagues during their current deploy-ment. at far left, a scene from Bazar-e-sharif, capital of Balkh

Province. clockwise from top left, a dog named sgt. Panzer and his u.s. army dog handler in faryab Province keep watch; a security forces assistance team is on combat patrol on afghani-stan’s highway 1; members of a security forces assistance team and afghan army soldiers break bread with village elders in ghormach, faryab Province.

FINAL FRAMEBetter medical technology dramatically improves a wounded warrior’s chances of survival, but this photo taken during the Battle of Normandy is a reminder that at its heart, battlefield medicine is still about dedicated medics risking their lives to save the fallen.


2012 summer edition

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