Eric B. Schoomaker, MD, PhD Uniformed Services University of the Health Sciences

Bethesda, MD

“Advances in Military Medicine: Reaching the Summit…and Remaining”

State of the Science Symposia Series: Advances in Military and Veteran Health Research from Post-911 Conflicts For Wounded, Injured, and Ill Veterans

"Americans should not expect one battle, but a lengthy campaign, unlike any other we have ever seen.”

President George W. Bush Address to a Joint Session of Congress

September 20, 2001

“…the long war” GEN John Abizaid

Preparations and Ongoing Improvements in

Warrior Protection & Care • Improvements in Warrior protection

• Improvements on the battlefield

– Better trained medics – Improved equipment – Far forward emergency & surgical care

• Improvements in in-theatre (tactical) evacuation

• Improvements in between-theatre (strategic) evacuation

• Improvements in the continuum of resuscitative, surgical, medical & nursing care

• Improvements in rehabilitative care and transition

Protecting the Force

Better trained medics--EMTs

IFAK: Saved Countless Lives & Limbs

NovoSeven Injectable Clotting Agent

HemCon Bandage

One of Army’s “Top Ten Greatest Inventions of 2005”

Combat Application Tourniquet (CAT)

QuikClot

Plasma:RBC Ratio Groups

% M

ortality

Borgman MA, et al, J Trauma. Oct 2007

P < 0.05

Mortality by Plasma:RBC Ratio

One of Army’s “Top Ten Greatest Inventions of 2004”

Combat Gauze

One of Army’s “Top Ten Greatest Inventions of 2008”

Better Field Medical Equipment

Evacuation: Tactical and Strategic

“ROLE 2” (<1 hour)

Current Operations: A Seamless Continuum of Care

Deployed Hospitals

Role 3

Since Sep 2001

CY 2014*

Total Patients Moved 199,000 6,901

Critical Care (CCATT) 10,200 152

CENTCOM 105,700 1,935 *from AMC/SGK as of 30 Sep 2014

“ROLE 3” (<24 hrs)

“ROLE 4” (24-72 hrs)

“ROLE 5” (3+ days)

Transformed Strategic Evac System: One Trauma System… Three Continents… 7,000 miles…

Joint Theatre Trauma System - Comprehensive Trauma Care

• Spans the spectrum from preventive measures, wounding, treatment through to rehabilitation and return to duty

• Systematic and integrated

• Focus not just on writing papers but on

functional products

• Knowledge-based as well as product-based

TRAUMA SYSTEMS TEAM: TRAUMA NURSE COORDINATORS

* May 2008 DoD Data **3 June 2010 DoD Data

% Survivability O

ver Time

[Wounds Not Mortal / (Battle Deaths + Wounds Not Mortal)] * 100

69.7% 75.4%

86.5% 89.9%

Improved Survival Over Time

0.00000

2.00000

4.00000

6.00000

8.00000

10.00000

12.00000

0.000%

5.000%

10.000%

15.000%

20.000%

25.000%

30.000%Cum KIA%

Cum DOW%

Cum CFR%

Cum Avg mISS

Produced by the Joint Theater Trauma Registry Data Source: JTTR v.3 data extract supplemented by data provided by DMDC Statistical Analysis Division & US Pentagon OSD

Month / Year

Died of Wounds Rate Remained Stable Despite Steadily Rising Military Injury Severity Scores

“To stay a Warrior…”

Rest atop the summit…

…and reflect on the route that got you there.

https://www.youtube.com/watch?v=IRCgaUcLA8A

How Did We Get to the Summit?

What are our remaining challenges?

OIF Mental Health Advisory Team: Dwell-Time is Critical

Page 19

PTSD N=232 68.2% 2.9%

16.5%

42.1%

6.8%

5.3%

10.3%

12.6%

TBI N=227 66.8%

Chronic Pain N=277 81.5%

The intersection of mind & body

Prevalence of Chronic Pain, PTSD and TBI in a sample of 340 OEF/OIF veterans with polytrauma

Lew, Otis, Tun et al., (2009). Prevalence of Chronic Pain, Post-traumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD.

Slide 20

Trauma Spectrum Response

Rising Musculoskeletal & Mental Disorders—Ambulatory Visits

Rising Hospitalizations for Mental Disorders

(JAN-SEP ONLY)

Increasing Combat TBI Cases

2000

9000 10000 10,963

20,199 27,507

20000

6,282 (27%)

7,135 (26%)

4,133 (20%)

2007 2008 2009 DoD Baseline DoD OIF/OEF DoD OIF/OEF DoD OIF/OEF

DoD Total

Data Source: AFHSC

Deployed Forces 23,002

OVERALL TBI CASES HAVE MORE THAN DOUBLED

Prescription Opioids

An Epidemic in Opioid Problems in the US

– Provide recommendations for a MEDCOM comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for Soldiers and other patients with acute and chronic pain.

– Relieving Pain in America: A Blueprint for

Transforming Prevention, Care, Education and Research

DoD Pain Management Task Force

Institute of Medicine

Comprehensive Pain Management

Evidence-Based Complementary and Alternative Therapeutic Modes

Acupuncture Biofeedback Yoga Meditation

Standardizes Pain Management Services at echelons of care across our Medical Treatment Facilities: Team-Based

Provides optimal quality of life for Soldiers and patients with acute and chronic pain

2009/2010 2011/2012 2013 2014 2015

Pain Management Task Force Report

NCCIH: Strengthening Collaborations w/ DoD and VA: Effectiveness Research on Mind/Body Interventions

National Pain Strategy

MHS Review IOM “Pain in America” Report

VHA Pain Mgt Directive 2009-053

DoD Pain Mgt Task Force

NIH Interagency Pain Research Coordinating Committee

VHA Pain Program Office

Institutes of Medicine as directed by

Affordable Care Act

NCCIH Council Working Group

Military Health System

Federal Initiatives Supporting Complementary & Integrative Medicine Pain Management

Post-Pain Task Force major lines of effort

Defense and Veterans Pain Rating Scale (DVPRS) – New DoD pain scale

Extension for Community Healthcare Outcomes (ECHO) – Pain knowledge network

Interdisciplinary Pain Management Centers (IPMC) – Integrative Pain Clinics

PASTOR/PROMIS-Patient Assessment Tool and Outcomes Registry

EDUCATION INFRASTRUCTURE SOCIETAL PRIORITIES

Critical to Business Success

HEALTHCARE

Essential to the Creation of Health

Waste $750 Billion

Markets $

Goods / Services

Macro Economic Concept Model

Cathy Baase, M.D. • The Dow Chemical Company • July 30, 2014 32

30%

10%

40% 20%

Health Behaviors

Clinical Care

Social & Economic Factors

Physical Environment

Health Factors

Positive Health Outcomes • Performance and Productivity • Safety • Attract and Retain Talent • Engagement and Satisfaction • Sustainability and Reputation

$

Business (Generates $)

Employee Wages

Common Resource Pool % of Gross Domestic Product

• Leadership • Vision • Culture • Guiding Principles • Alignment • Teamwork

Thank you! Questions?