m2va 17 6 final

Dedicated to the Military Medical & VA Community

Defibrillators O Theater Medicine Tactical Combat Casualty Care

Health Strengthener

Lt. Gen. Patricia D. HorohoSurgeon GeneralU.S. Army

November 2013Volume 17, Issue 6

www.M2VA-kmi.com

Medical SiMulation/training

Col. Peter J. BensonCommand SurgeonU.S. Army Special Operations Command

Command ProfileExclusive Interview with:

Special Section:

Propaq—Focused on Your Data Needs Your next-generation Propaq® is here. The standard in vital signs monitoring now has advanced data communications for all levels of care.

Experience CountsZOLL, with over 25 years of experience manufacturing resuscitation technologies for the military, understands that to meet today’s demands, you require more than the best monitoring technology available. In addition to providing the trusted and proven vital signs monitoring you have come to expect from Propaq, the ZOLL Propaq M and Propaq MD* now have signifi cantly enhanced data communications, allowing you to capture patient care data from the point of injury through defi nitive care. Our new open data architecture is designed to support the military’s emerging telemedicine solutions, EHR systems, and custom reporting needs (TCCC, AF3899).

© 2013 ZOLL Medical Corporation, Chelmsford, MA, USA. ZOLL is a registered trademark of ZOLL Medical Corporation. Propaq is a trademark of Welch Allyn.

*With integrated defi brillation and pacing

For more information, call 1-800-804-4356 or visit us at www.zoll.com/propaqdata-mmt.

lieutenant General PatriCia d. HoroHo

Surgeon GeneralU.S. Army

17

Departments Industry Interview2 editor’s PersPeCtive3 PeoPle/ProGram notes14 vital siGns27 resourCe Center

lanCe ronCalliVice President of Sales, Americas Smiths Detection

5vital siGns alGoritHmsMany of the most advanced machines used in treating and assessing battlefield trauma rely upon advanced mathematics and statistical techniques to determine the vital signs of combat casualties. By Peter BuxBaum

8 tHeater mediCal teCHnoloGyThe U.S. military strives to provide the same level of hospital care in theater as in its CONUS hospitals. Machines at military theater medical facilities offer some of the best medical treatment available.By Peter BuxBaum

12findinG tHe ProPer defibrillatorSudden cardiac arrest is a leading cause of death in the United States. The disease is also a threat to the military and veteran populations. Defibrillators offer a lifesaving chance for avoiding a death that often occurs in minutes.By Chris mCCoy

November 2013Volume 17, Issue 6Military Medical & Veterans affairs foruM

Cover / Q&AFeatures

21

28

simulatinG tHe PatientFrom virtual systems to more tangible modern manikins, medical simulation is exploding in both the private sector and military sphere. The training benefits to simulating the patient for military personnel are manifold.By Chris mCCoy

“Army Medicine is embarking

on a long-term strategy that includes transitioning the focus of

our efforts from ‘health care to health’ by

providing the necessary initiatives,

incentives and programs to

support healthy behaviors,

especially in the lifespace…”

—Lieutenant General Patricia

D. Horoho

24

Command Profile

Exclusive Interview with Colonel Peter J. Benson, Command Surgeon, U.S. Army Special Operations Command.

Propaq—Focused on Your Data Needs Your next-generation Propaq® is here. The standard in vital signs monitoring now has advanced data communications for all levels of care.

Experience CountsZOLL, with over 25 years of experience manufacturing resuscitation technologies for the military, understands that to meet today’s demands, you require more than the best monitoring technology available. In addition to providing the trusted and proven vital signs monitoring you have come to expect from Propaq, the ZOLL Propaq M and Propaq MD* now have signifi cantly enhanced data communications, allowing you to capture patient care data from the point of injury through defi nitive care. Our new open data architecture is designed to support the military’s emerging telemedicine solutions, EHR systems, and custom reporting needs (TCCC, AF3899).

© 2013 ZOLL Medical Corporation, Chelmsford, MA, USA. ZOLL is a registered trademark of ZOLL Medical Corporation. Propaq is a trademark of Welch Allyn.

*With integrated defi brillation and pacing

For more information, call 1-800-804-4356 or visit us at www.zoll.com/propaqdata-mmt.

Special Section: Medical Simulation training

The Center on Budget and Policy Priorities recently released a report concerning potential cuts to the Supplemental Nutrition Assistance Program, often known as SNAP. This is a topic of particular importance to the veteran community.

According to the most recent census data, 900,000 veterans rely upon SNAP in order to meet their monthly grocery needs. The Center on Budget and Policy Priorities estimates that this is “almost surely” an understatement since that number does not include homeless veterans who receive SNAP benefits.

Seeing that the American economy is still recovering from a prolonged recession and due to the extra troubles and discrimination veterans come across in finding gainful employment, I think that the cuts to SNAP should be re-examined by Congress.

Denying veterans an opportunity for proper nutrition is also a medical issue. Cuts to SNAP add to the plague of other health problems, such as TBI and PTSD, that the veteran population faces.

In other news, the Department of Veterans Affairs is continuing its efforts to eliminate veteran homelessness by 2015. Recently the VA announced that 25 projects in 11 states will share $4.9 million in grant money in order to enhance services for homeless veterans. The VA’s Supportive Services for Veteran Families program has already allocated approximately $300 million toward enhancing services to the veteran population.

“Our local partners have played a vital role in our effort to find, engage and rescue every homeless veteran,” said Secretary of Veterans Affairs Eric K. Shinseki. “Until no veteran has to sleep on our nation’s streets, we still have work to do.”

According to the VA’s statistics, the population of homeless veterans totaled 62,619 on one January night in 2012. This figure marks a 17 percent reduction from the number of homeless veterans in 2009.

In total, the VA has allocated over $1 billion for fiscal year 2014 to strengthen programs that prevent and treat the many issues that can lead to veteran homelessness.

As usual feel free to contact me with questions or comments for Military Medical & Veterans Affairs Forum.

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Major General Richard W. Thomas, commanding general, Western Regional Medical Command, Tacoma, Wash., will be assigned as director, health operations, Defense Health Agency, Falls Church, Va.

Brigadier General John M. Cho, deputy commanding general (Support), U.S. Army Medical Command, Falls Church, will be assigned as commanding general, Western Regional Medical Command, Tacoma, Wash.

Rear Admiral (lower half) Brian S. Pecha will be assigned as Medical Officer to the Marine Corps, Washington, D.C. Pecha is currently

serving as Force Surgeon, U.S. Marine Forces Reserve, New Orleans, La.

Rear Admiral Clinton F. Faison will be assigned as deputy chief, Bureau of Medicine and Surgery, Falls Church. Faison is currently serving as commander, Navy Medicine West/commander, Naval Medical Center, San Diego, Calif.

Compiled by Kmi media Group staffPeoPle

Compiled by Kmi media Group staffProGraM notes

Leading Brimrose Technology Corporation scientists and engineers are focused on providing ways to identify at a moment’s notice dangerous chemicals spread into the atmosphere in wartime and hazardous accident situations.

President and CEO Ronald Rosemeier, Ph.D., himself a physicist, has taken a personal interest in the work and is heading the effort. “The world we live in unfortunately is becoming an increasingly dangerous place,” said Rosemeier. “By instantly identifying poisonous chemical agents in the atmosphere we can potentially save countless lives.”

Brimrose has many years of experience in gas analysis using its proprietary acousto-optic tunable filter near infrared (AOTF-NIR) technology. The company is in the process of doing proof of principle testing using its AOTF multi-gas analyzer spectrometers.

Using the full spectral range, the spectrometers can potentially match samples of any gas with models already developed and deliver the results to waiting officials in a few seconds. Gas can be pumped into the flow cell of the gas analyzer continuously. The absorption spectrum of the sampled gas is then measured in real time in the full spectral range of the spectrometer, which can potentially be matched with models already developed. The results can be obtained and transmitted to a waiting official in a matter of seconds.

The proof of principle concept involves potentially mounting the AOTF-NIR spectrometer onto Brimrose’s autonomous unmanned flight vehicle, known as Heli-Engagement Reconnaissance Observatory (HERO). HERO has the potential to fly in and through dangerous or hazardous areas and identify gases as it does so.

“Our warfighters and first responders are too valuable to be rushing in uninformed to dangerous chemicals in the air,” said Rosemeier. “We are moving rapidly to find a realistic solution to this problem.”

Can sequencing of newborns’ genomes provide useful medical information beyond what current newborn screening already provides? Pilot projects to examine this important question are being funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the National Human Genome Research Institute (NHGRI), both parts of the National Institutes of Health. Awards of $5 million to four grantees have been made in fiscal year 2013 under the Genomic Sequencing and Newborn Screening Disorders research program. The program will be funded at $25 million over five years, as funds are made available.

“Genomic sequencing has potential to diagnose a vast array of disorders and conditions at the very start of life,” said Alan E. Guttmacher, M.D., director of NICHD. “But the ability to decipher an individual’s genetic code rapidly also brings with it a host of clinical and ethical issues, which is why it is important that this program explores the trio of technical, clinical and ethical aspects of genomics research in the newborn period.”

The awards will fund studies on the potential for genome and exome sequencing to expand and improve newborn health care. Genomic sequencing examines the complete DNA blueprint of the cells, and exome sequencing is a strategy to selectively sequence exons, the short stretches of DNA within our genomes that code for proteins.

“We are at a point now where powerful new genome sequencing technologies are making it faster and more affordable than ever to access genomic information about patients,” said Eric D. Green, M.D., Ph.D., director of NHGRI. “This initiative will help us better understand how we can appropriately use this information to improve health and prevent disease in infants and children.”

Programs currently screen almost all of the more than 4 million infants born in the United States each year. Until now, the testing of DNA has not been a first-line newborn screening method, but has been used to confirm the screening results of some disorders, such as cystic fibrosis.

Each of the new awards will consist of three parts: genomic sequencing and analysis; research related to patient care; and the ethical, legal and social implications of using genomic information in the newborn period. Teams of researchers will work to further the understanding of disorders that appear in newborns and to improve treatments for these diseases using genomic information. Participation is voluntary for those research studies that involve returning results of DNA sequencing to families and physicians, and requires that families provide informed consent. Other research focuses on the analysis of de-identified data, which may be useful in developing and improving screening tests.

Rear Adm.Clinton F. Faison

Real-time Chemical Analysis in Flight

NIH Program Explores the Use of Genomic Sequencing

www.M2VA-kmi.com M2VA 17.6 | 3

Compiled by Kmi media Group staffProGraM notes

VA Offers Dental Insurance ProgramVA is partnering with Delta Dental and MetLife

to allow eligible veterans, plus family members receiving care under the Civilian Health and Medical Program (CHAMPVA), to purchase affordable dental insurance beginning November 15, VA officials announced.

“VA continues to explore innovative ways to help veterans get access to the care and services they have earned and deserve,” said Secretary of Veterans Affairs Eric K. Shinseki. “This new dental program is another example of VA creating partnerships with the private sector to deliver a range of high-quality care at an affordable cost to our nation’s veterans.”

More than 8 million veterans who are enrolled in VA health care can choose to purchase one of the offered dental plans. This three-year pilot has been designed for veterans with no dental coverage, or those eligible for VA dental care who would like to purchase additional coverage. Participation will not affect entitlement to VA dental services and treatment.

There are no eligibility limitations based on service-connected disability rating or enrollment priority assignment. People interested in participating may complete an application online through either Delta Dental, www.deltadentalvadip.org, or MetLife, www.metlife.com/vadip beginning November 15. Coverage for this new dental insurance will begin January 1, 2014, and will be available throughout the United States and its territories.

Also eligible for the new benefits are nearly 400,000 spouses and dependent children who are reimbursed for most medical expenses under VA’s CHAMPVA program. Generally, CHAMPVA participants are spouses, survivors or dependent children of veterans officially rated as “permanently and totally” disabled by a service-connected condition.

Dental services under the new program vary by plan and include diagnostic, preventive, surgical, emergency and endodontic/restorative treatment. Enrollment in the VA Dental Insurance Plan (VADIP) is voluntary. Participants are responsible for all premiums, which range from $8.65 to $52.90 per month for individual plans. Copayments and other charges may apply.

Historically VA’s free dental services have gone to veterans with dental problems connected to a medical condition that’s officially certified as “service connected.” Free dental services will

continue for those veterans.

Thirty-two VA Medical Facilities Named “Top Performers”

Thirty-two Department of Veterans Affairs medical facilities from across the nation were recently recognized as “top performers” by the independent panel that accredits and certifies health care organizations.

“We are proud of the medical facilities that have been recognized for demonstrating VA’s commitment to provide the high-quality care our veterans have earned through their service,” said Secretary of Veterans Affairs Eric K. Shinseki. “This achievement highlights the hard work of our VA medical staff to serve veterans.”

The recognition came from The Joint Commission, a not-for-profit organization that ensures the quality of U.S. health care by its intensive evaluation of more than 20,000 health care organizations.

While all 151 VA medical facilities are accredited by The Joint Commission,

the list recognizes facilities that are the top performers based on The Joint Commission’s annual review of evidence-based care that is closely linked to positive patient outcomes. This program recognizes Joint Commission-accredited hospitals for a significant achievement in accountability and performance measures.

The Joint Commission recognized 19 VA medical facilities as top performers in 2011/2012 and 20 VA medical facilities in 2010. Nine VA facilities have been rated as top performers for two consecutive years—a noteworthy distinction.

“VA health care has been a leader in performance measurement, electronic health records, research and clinical quality for more than a decade,” said VA Undersecretary for Health Dr. Robert Petzel. “I am proud of the staff that works hard every day to care for America’s veterans.”

Tinnitus Relief Industry Leader Shifts Headquarters

Neuromonics Inc., manufacturer and distributor of clinically proven devices to treat tinnitus, is moving its headquarters to Westminster, Colo., from Bethlehem, Pa.

“The move to Colorado is significant for customers, employees and the audiology industry,” said Duane Knight, chief operating officer of Neuromonics. He cited the Denver area’s central North American location and key transportation air hub as factors in better customer service and shipping coverage. “In terms of cost of living, cost of doing business, and overall quality of life, Colorado is an excellent choice for Neuromonics.”

Knight also pointed to the benefits of being part of Colorado’s substantial growing medical device and bioscience community. According to the Colorado BioScience Association, Colorado’s medical device sector is the sixth-largest in the nation. More than 600 bioscience companies in the state employ 27,000 people, creating more than 122,000 direct and indirect jobs. “The ability to engage in this energetic, entrepreneurial environment is invaluable,” he said.

Neuromonics’ FDA-cleared devices and treatments help individuals with tinnitus, a condition described as ringing in the ears when no external sounds are present. According to the American Tinnitus Association, more than 50 million people in the United States suffer from the condition. Usually brought on by exposure to loud noise, the problem is especially significant in the military, with more than 34 percent of returning veterans from Iraq and Afghanistan suffering from the condition.

www.M2VA-kmi.com4 | M2VA 17.6

MatheMatics and advanced statistical techniques are saving lives through the Most advanced coMbat Medical equipMent.

Anyone who has ever received medi-cal care knows that providers first check a patient’s vital signs—heart rate, respira-tion, blood pressure and the like—to get an overall picture of the patient’s health and to identify any obvious problems. The same is true of combat casualty care, the pre-hospital phase of dealing with battlefield casualties that is instrumental in keeping casualties alive and getting them to the next echelon.

Research spearheaded by military health organizations has identified several nontra-ditional vital sign measures that are par-ticularly applicable to combat casualties, allowing medics to identify patients early on

who appear to be okay but who, in fact, are about to crash. Formulas for the early detec-tion of a critically ill patient have been incor-porated in algorithms, which in turn can be loaded into the monitoring devices already carried by medics to help them triage casual-ties most in need of attention and provide decision support for interventions that can prevent the patient from going south.

“Over 90 percent of battlefield casualties die in pre-hospital settings,” said Vic Conver-tino, a physiologist and research manager at the U.S. Army Institute of Surgical Research (ISR). “Eighty-five percent of those die of hemorrhage. The primary focus of what we can do help medics identify someone who

is bleeding badly so they can do something about it.”

Medics need all the help they can get. They are typically young people who are trained in a course for 16 weeks. “There is not a lot they can learn in that time period,” said Convertino. “It takes the best clinicians years to learn how to treat patients effectively.”

Electronic vital signs monitors are a step in the right direction because they replace the subjective and poorly measured record-ing of vital signs that prevailed in the past. “For decades, heart rates were captured by putting a finger on the patient’s wrist,” said Anthony Jones, chief marketing officer at Philips Healthcare. “That is not the most

by peter buxbauM

M2va correspondent

A U.S. Air Force biomedical maintenance equipment technician calibrates a heart monitor

at an undisclosed location in Southwest Asia. [Photo courtesy of U.S. Air Force/by Staff

Sergeant Joshua J. Garcia]


objective way of recording vital signs. Moni-tors capture data from electronic sensors and give a much more accurate reading.”

Loading decision support applications into electronic monitors is the next step in assisting providers in managing their patients. The future holds the likelihood that these will be extended to closed loop auto-mation processes in which a computer will decide on an intervention and execute it in the absence of qualified medical personnel.

“We have developed new vital signs that can be used to better assess the status of patients,” said Jose Salinas, who manages intensive care research at the ISR. “In the future, these applications will guide the treat-ment of patients and even perform the treat-ment themselves.”

The ISR partnered with a company called Flashback Technologies, a software devel-oper, to translate data from its experiments simulating hemorrhage in humans into an algorithm called the compensatory reserve index that could be incorporated into medi-cal monitoring devices. “As a surgeon, I have always been interested in trauma and blood loss,” said Steven Moulton, a founder and chief medical officer at Flashback. “Some-times patients come in relatively stable and later become unstable. The question is how to identify these patients earlier.”

“Traditional vital signs don’t necessar-ily give the best information on the status of patients,” said Barnie Howell, director of military business development at Remote Diagnostic Technologies, a provider of moni-toring devices to the military. “The Army research has shown that there are other, better signs to determine whether a patient is getting sicker.”

The weakness in monitoring traditional vital signs is that they often remain stable until a patient’s system totally collapses and the patient goes into shock, at which point he may be beyond help. “We call that crashing, or falling off the cliff,” said Convertino.

The reason for this phenomenon is that humans compensate for blood loss through a process called vasoconstricting, Moulton explained. “This pulls venous blood back to the heart and allows patients to maintain vital signs in a relatively stable fashion until the point when the system can no longer compensate and the blood pressure drops and they decompensate,” he said.

Convertino’s focus has been to critically assess various measurements and algo-rithms for decision support, particularly as it relates to the leading cause of death on the

battlefield—hemorrhage. His unit has con-ducted sophisticated experiments on humans who undergo a controlled simulation of severe hemorrhage.

“Medics now have available a pulse oxim-eter that gives them a heart rate and a mea-sure of oxygen saturation in the blood,” said Convertino. “Our thrust has been to develop an algorithm that would be loaded on a small, lightweight device that would provide medics with more information.”

This effort was accom-plished in a collaboration between the ISR and Flash-back Technologies. The ISR contributed a large database of human waveforms derived from experiments on humans in a lower body negative pres-sure chamber that simulates hemorrhage. Flashback con-tributed its expertise in mathe-matical modeling and machine learning capabilities.

“Separately, we couldn’t have done this,” said Conver-tino. “Together we accom-plished something nobody did before.”

Waveforms are the visual depiction of data derived from monitoring factors such as lower body negative pressure and heart stroke volume. “We built a model that allowed us to estimate where the subject was from on a slope from nor-mal to decompensation,” said Moulton. “Our approach uses mathematics and advanced statistical techniques to make sense of that data. The algo-rithms interpret the data and provides information to the care provider to act in a more accurate and timely fashion.”

The Flashback algorithm is able to analyze feature changes in waveforms from one moment to the next and access a library of waveforms from the ISR experiments to make a prediction of where a specific patient is on the continuum. “We have used the same tech-nology to estimate intracranial pressure based on aortic wave-forms in the case of head inju-ries,” said Moulton. “Currently

we have to drill a hole in a patient’s head to determine intracranial pressure. Using this technology we can develop algorithms that estimate intracranial pressure based on changes in the features of the waveforms.”

Detecting a crisis earlier will allow medics to intervene that much quicker. “The initial emphasis is always in stopping the bleed-ing,” said Convertino. “So if the algorithm shows the patient is deteriorating, the first

step might be for the medic to check if he missed some-thing. The tourniquet on a bleeding limb may need to be tightened. If that doesn’t work, resuscitation fluids may need to be adminis-tered.”

Knowing that a patient is still bleeding—at the very least—helps with triage. “It will help to figure out who goes first to the battalion aid station,” said Convertino. “The bottom line is that this improves decision support.”

The ISR is also work-ing on an algorithm that could automate the evalu-ation of ultrasound evalua-tions. Focused examinations with sonography for trauma, also known as FAST exams, are used in trauma cases to detect a sucking chest wound known as pneu-mothorax. This condition causes pressure to build up in the lung cavity, which, if left untreated, can cause the patient to go into cardiac arrest.

“Now FAST exams can be performed only by trained physicians,” said Salinas. “Our algorithm can do an automated FAST far forward so interventions can be per-formed sooner, leading to better patient outcomes.”

Coming to the market soon is a device known as the Burn Navigator from Arcos Medical, which uses an Army-developed algorithm known as the burn resuscitation fluid indicator to calculate a burn patient’s requirement for fluids. The

Anthony Jones

Jose Salinas

Vic Convertino

Steven Moulton


U.S. Food and Drug Administration recently gave the green light for the device, which monitors the intake of fluids and the output of urine in severely burned victims to assist in the determination of the patient’s need for more or less fluid therapy treatment.

Manufacturers of existing medical moni-toring devices see the potential for incorporat-ing these government-developed algorithms into their products. “We are actively working on incorporating the compensatory reserve index and the burn resuscitation fluid indica-tor onto our Tempest devices,” said Howell. “We have also been approached about incor-porating the ultrasound algorithm, but it is premature to determine whether that is something we will use.” RDT manufactures the Tempus Pro vital signs monitor, which is in widespread use within the U.S. military.

“Flashback is still waiting on FDA clear-ance for the algorithms,” Howell added. “We will make a final decision based on a commer-cial stance as to whether or not our military customer wants that type of function in the monitors it purchases.”

“Because of the ways we designed our systems, with an open data architecture, they lend themselves to be integrated with decision support systems and algorithms,” said Andrew Fleischacker, senior director of marketing for military products at Zoll Medi-cal. “We have also been approached by sev-eral different companies to incorporate their algorithms into our monitor. We are in the process of evaluating thee requests.” Zoll’s Propaq M vital signs monitor and its Propaq MD monitor/defibrillator are also widely used by the U.S. military.

Zoll has been approached by potential partners who wish to integrate closed loop automated patient care with the Propaq prod-uct line. “They are looking to extract vital sign data from our device and use them to control their device,” said Fleischacker.

Other device manufacturers have devel-oped their own algorithms and incorporated them in their products. Patients who have suffered trauma—whether from a car acci-dent stateside or battlefield wound in Afghan-istan—get hooked up to devices that measure standard vital signs such as blood pressure, heart rate and blood oxygenation levels.

“Those vital signs are indicative of a patient’s status,” said Jones. “We developed an algorithm that processes multiple vital signs to provide an index that better indicates how a patient is doing. Combining that with implementation in managing a patient dur-ing the critical care phase of hospitalization.

We run the vital signs through an algo-rithm to detect a deteriorating condition long before a human could do so and run a code for cardiac arrest.”

When such a detection is made, an early warning is issued for medical personnel to intervene. The hospital sets the parameters for the alerts to be issued, who they are issued to, and the manner in which they are made.

Zoll also incorporates its own unique algorithms for heart rate monitoring that alerts users to life-threatening situations. The Zoll devices also run an algorithm that pro-vides feedback to users on the efficacy of the manual CPR they are administering. “This algorithm allows the user to see the underly-ing heart rhythm without the effect of the CPR,” Fleischacker explained. “This reduces the time the care provider has his hands off the patient and reduces the risk of a sudden drop in blood pressure.”

Salinas predicts that algorithms will indeed be incorporated in closed-loop auto-mated devices in the future. “That means that the algorithms can sense how the patient is doing, can determine the appropriate treat-ment and can actually perform the interven-tion,” he said. “A computer will take over what a provider normally does in cases where there is not a provider available.”

Future battlefields may be dispersed and located in austere environments, according to Salinas. “There may not be a physician or a medic available 24 hours a day,” he said. “Closed loop automation with little interven-tion by providers will be more common in the future because we foresee that there will be fewer human resources available.”

That scenario represents the longer-term future. In the shorter term, Flashback and the ISR have developed a prototype of a pulse oximeter device that uses the compensa-tory reserve index and are performing some laboratory and clinical studies on the device before submitting an application for FDA approval.

“We hope to go to the FDA in 2014 and we’ll await their determination,” said Moulton. “This kind of device could be ready for the market within a year, but it may take two or three years depending on what the FDA requires.” O

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The United States military endeavors to provide theater medical facilities with the same kind of diagnostic and treatment equipment that can be found in military hospitals—indeed, in civilian hospi-tals—in the continental U.S. There are a few reasons for this. First and foremost, not surprisingly, is to provide the highest level of care possible to casualties in theaters of operations.

There are other considerations as well. For example, stateside military medical personnel need to be familiar with equipment used in theater in the event that they are deployed. It makes sense for them to be working with the same or similar equip-ment in CONUS Role 5 facilities as they will overseas. That also means that much of the equipment pro-cured for U.S. military medical facilities is ruggedized to the same extent as that found in areas of operation like Afghanistan.

Allowances have to be made in some situations, however. CT scanners shipped to theater, for instance, are not as advanced as those found in CONUS for both clinical and logistical reasons. Other kinds of medical equipment are specially packaged and kitted to make them more usable and convenient in deployed situa-tions.

“Military medical organizations embarked on a standardization program that goes back to 2000,” said Ben Williams, director of Strategic Accounts at Welch Allyn. “That means that equipment used in stateside hospitals is the same as those shipped to theater. The military learned a les-son from the first Gulf War, when many civilian reservists were

activated and had to work on equipment in theater they had never seen before.”

“Role II and Role III facilities in theater as well as Landstuhl, are expected to deliver the same standard of care as at any facility in CONUS,” noted Brenda Butler, vice president for government sales at Zoll Government Division. “They have operating rooms and intensive care units, and the pieces of equipment they acquire for the theater are standard-of-care items that are required regardless of where they are being used. The military’s vision of standardization

calls for the same kinds of operations and interfaces on all kinds of equipment so that personnel are famil-iar with [the equipment] that they have trained on.”

In a nutshell, Role I care involves the first response on the battlefield, which includes first aid that can be administered by any warfighter as well as by highly trained medics. The second level of care, Role II, is performed by forward surgical teams. Role III refers to Army combat support hospitals. Role IV is the medical facility in Landstuhl, Germany, while Role V facilities include the joint Army/Navy medical center in Bethesda, Md., and the burn center at Fort Sam Houston in San Antonio.

“Much of the equipment we sell to the military is used at different levels of care,” said Andrew Fleischacker, director of business and market development at Zoll. “We have a defibrillator that has been integrated into a monitoring device. The advantage is that someone who knows how to use one device can use the other device. It can be used far forward as well as at levels of care located

Andrew Fleischacker

[email protected]

by peter buxbauM

M2va correspondent

how the u.s. Military provides high-quality care at its theater Medical facilities.


further back. We wanted to develop rugged devices which could be used in hospitals as well as in deployed settings.”

“All of our equipment is pretty portable until you get to Role III,” said Kevin Curry, project manager for medical devices at the U.S. Army Medical Command. “You can’t transport heavy equipment around the battlefield. The biggest pieces of equipment we acquire for theater medical facilities would be deployed at Role III facilities, most notably CT scan equipment. Right now we deploy 16-slice CT scan machines in theater with combat support hospitals.”

“Patient movement items are standardized throughout DoD,” said Dan Kennedy, an assistant project manager at the Army Medical Command. “Those pieces can be used throughout the continuum of care to the point where the patient is transported back to Landstuhl. Our combat support hospitals look like community hospitals. In places like Bagram and Balad, they have become fixed facilities. If you were to be transported into one of those fixed facilities, you would think you were in a community hospital back in the states.”

CT scan technology has leapfrogged since the first single-slice technology was deployed in the early 1990s during Operation Desert Storm. “Many stateside hospitals now use 32-slice and 64-slice tech-nology,” said Curry. “The 16-slice machines we use in theater meet the needs of the procedures performed there.”

The number of slices refers to the number of simultaneous thin images that can be obtained of the area to be imaged. The greater number of slices means the better the resolution of the image and the more data available for three-dimensional visualizations.

“The more advanced technology is usually used for cancer stud-ies or in support of surgery placing heart stents and is not necessary to care for casualties suffering combat trauma,” Curry added. “Also, the electronics in the 32- and 64-slice machines are extremely sensi-tive to vibration and heat. If they were to be deployed to the current theater they wouldn’t be any more useful than paperweights.”

Ultrasound technology is becoming more common in theater settings thanks to the equipment’s increased portability and other technology innovations, such as longer battery life and the applica-tion of wireless technologies.

“My philosophy is that the machines with the longest battery life should be deployed to the lower levels of care,” said Peter Brunelli, managing director of Universal Imaging, a marketer of private label ultrasound devices. “A device that can operate for five or six hours on a battery will provide a good solid day of service before it needs recharging.”

Like the CT scanners, ultrasound equipment offers different levels of resolution and should be chosen on the basis of what is necessary for a specific application, according to Brunelli. “Available ultrasounds vary in the resolution, portability and the battery life they provide,” he said. “There are portable higher-end ultrasounds that provide only half an hour of battery life. Field medical care should be set up like an emergency room, where the patient is stabi-lized and then moved to a higher level of care where they can get a CT scan or an MRI and a better diagnosis. You don’t need heavy diag-nostic equipment in the field. The company that makes the smallest

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machine with the longest battery life and the best resolution will get a lot of business.”

Ultrasound is becoming increasingly important in the initial care of patients suffering trauma, according to Kristin Woitovich, global product marketing manager at Siemens Medical, so much so that it is threatening to displace the iconic stethoscope as a key piece of medical equipment.

“Our Acuson P10 can be carried in a backpack and used for triage,” she said. “It is not meant for definitive diagnoses but it provides a good quick look for things like abdominal trauma, fluid in the lungs and organ damage. The machine was designed for simplicity and for making basic assessments. When you have men down in the field, a medic who needs to determine whether a casualty is still alive may not be able to hear with a stethoscope because of the surrounding noise.”

On the other hand, the medic can see an organ function very quickly with an ultrasound. “There have been papers written about how ultrasound is replacing the stethoscope,” said Woitovich. “Instead of having to train their ears to listen for anomalies, medi-cal personnel can now actually visualize them.”

The Acuson P10, launched in 2007, is also able to transmit images wirelessly in a crude fashion to facilities awaiting the arrival of the patient. “Time to treatment is reduced when you can visualize things,” said Woitovich. “It brings a whole different perspective in making decisions. Any time you have more details before the patient arrives, you reduce decision making on the spot and you allow medical personnel to make better decisions.”

A product that recently came on the market is the Siemens Acuson Freestyle ultrasound device, which is equipped with wire-less transducers. The device is able to display ultrasound images without a cable connecting the transducer to the screen.

“The technology was initially designed for clinical care and interventional settings where physicians perform a procedure in a sterile field,” said Michael Cannon, vice president and general manager of Siemens’ point of care solutions group. “Using a cable is an impediment to working in an operative or sterile environ-ment; it makes it harder to set up the machine, and it introduces complexities in terms of protecting the patient from contaminants coming from outside the sterile field.”

The applications for the device include interventional suites, catheter labs and for preparing patients for surgery. “Although it is portable, the system provides exceptional images,” said Cannon. “Users are under a lot of pressure to get things done fast and they need images to be good. We put some extra engineering into the effort to get image quality to where it needed to be.”

Interference from other nearby electronic devices was another concern in developing the Freestyle. “The FDA and other regula-tory bodies made sure we took a lot of precautions to make sure that doesn’t happen,” said Cannon. “We use a radio technique called ultra-wide band that allows you to have a high data rate, which you need because you have to move a lot of data from the transducer to the system, but it is also a low-energy radio tech-nique that has good coexistence properties with other devices. The design effort reached a point where the Freestyle could work happily with other devices.” Ultra-wide band, which may be used at a very low energy level for short-range, high-bandwidth com-munications using a large portion of the radio spectrum, has also been applied to radar systems that detect underground improvised explosive devices.

The Freestyle has also been designed so that the user can change the settings on the transducer without having to reach over to the machine. That way the machine can be placed several feet away without compromising sterility or control of the unit by the clinician. Cannon expects future developments to the Freestyle to include miniaturization of transducer elements and advance-ments in radio technology.

Medical equipment deployable to theater is increasingly being designed as platforms that can be integrated with other kinds of equipment. For example, RDT makes a vital signs monitor, the Tempus Pro, which is equipped with USB ports to which other equipment such as an ultrasound machine can be attached.

“We are working on integrating ultrasound and video into our vital sings monitor,” said Barnie Howell, U.S. military director of business development at RDT. “We are awaiting clearance from the FDA before we can introduce those features. We anticipate getting that clearance before the end of the year. We are also working on being able to plug in a defibrillator into the USB port.”

Plugging in other devices on the monitor allows the moni-tor screen to also capture ultrasound and video images. “A body map can be displayed on screen to see where a tourniquet should be placed or where burns or blast injuries have occurred,” said Howell.

Military medical products sometimes differ from their civilian counterparts only in the way they are packaged and kitted. The ECG machines Welch Allyn supplies the U.S. military are standard issue, with the exception that they are packaged in rugged cases with interior foam cutouts so that the equipment fits snugly inside and won’t be damaged during transport. A similar situation pre-vails for the digital blood pressure device and the laryngoscope kit that the company offers.

“The devices we offer the U.S. military are commercial off-the-shelf products that have been kitted to meet DoD deployment requirements,” said Williams. “The kits we put together usually also contain extra accessories and batteries. Our thermometer kit contains extra probes and probe covers to support missions until the medic can get back to base or somewhere else where he can

The Acuson Freestyle ultrasound device’s wireless transducers allows the display of ultrasound images with increased mobility for the physician and patient. [Photo courtesy of Siemens]


get resupplied. The laryngoscope blades are exactly the same as those used in most hospitals but the kit contains extra replace-ment blades and batteries.

“The practical reality is that we are in a peacetime mode after two wars,” said Williams. “The size of the military and the funding for the military going forward are yet to be determined. We are working through these uncertainties to learn what the anticipated requirements are, given what the military expects its structure to be in the next five, 10 or 20 years. Will they be doing the same kinds of things or will they be doing something different?”

“As the military’s theater of operations change and as they look forward to the Pacific as the next potential major theater, with sig-nificantly longer transport times, we see the need for equipment with more battery time and more capabilities,” said Butler.

“You want to give them as much power as possible,” said Fleischacker. “You want to try to make equipment lightweight so it doesn’t draw down the battery. If the battery draws down, you are in trouble, especially if you don’t have an easily replaced bat-tery. We have learned from experience that when the equipment is plugged into a vehicle or an aircraft, they will not let you draw on their battery when they power down. The battery in the Propaq MD monitor/defibrillator lasts for six-and-a-half hours when the defibrillator is operating on full power and seven-and-a-half hours when the monitor is operating alone.”

“We call it uninterrupted power because we always have power available for the device, whether it is a second battery, an AC charging unit, or whether it is plugged into an aircraft power system,” said Butler. “We can delivery health care regardless of the power situation.”

The Army Medical Command is looking to introduce innova-tions to help its practitioners better serve patients. Some of these will likely be introduced in the near future while others are still years away.

“We are looking at an oxygen generation system,” said Ken-nedy. “We have a new 3-liter oxygen generation system that would eliminate the use of current oxygen bottles. This has huge poten-tial to ease the distribution of oxygen and to reduce its costs.”

The Army Medical Command is also looking at a device called the noise immune stethoscope. “This just made it through a Milestone C decision-making process,” said Kennedy. “This device allows providers to hear in hard-to-hear environments such as helicopters or in combat situations where the surrounding noise exceeds the ability to hear what is going on.”

“Both of these are things that are getting close to being deployed,” said Curry. “On the horizon, we are looking for closed-loop devices such as ventilation machines that can automate some of the process to improve care and that would free up clinicians. We are also working on a handheld device that would detect the biomarkers of traumatic brain injury. A quick blood sample would determine whether a person had minor to medium TBI and whether he needed to be evacuated or not. These are things that are still five to 10 years out, but we are looking at them and are incrementally working towards them.” O




Sudden cardiac arrest kills more people in the U.S. every year than HIV/AIDS, lung cancer and breast cancer combined. Each year, enough people to comprise a city the size of Minneapolis are wiped out by sud-den cardiac death. A defibrillator’s job is to terminate dangerous arrhythmias to save a patient’s life. It is estimated that 92 percent of people who suffer from sudden cardiac arrest will die within minutes without defi-brillation. Both the military and Department of Veterans Affairs maintain regular con-tracts with defibrillator manufacturers in order to mitigate the risk of sudden cardiac arrest within their ranks.

an integrated approach

Zoll Medical Corporation has been work-ing closely with the U.S. military and world-wide militaries for over 25 years. Zoll’s Propaq MD, developed through a collabora-tive effort with the U.S. Army, addresses the desire to take the Propaq 206 Encore vital signs monitor and add an integrated defibril-lator/pacer. Aside from reducing size, weight and cube, the unique requirements identi-fied from the lessons learned in recent con-flicts dictated the need for improved clinical parameters, a third integrated invasive pres-sure, and advanced data communications for electronic health records and future telemedicine solutions.

“All of Zoll’s military products are designed to meet the rigors of front line combat casualty care. Our air-wor-thy certified products, manufactured in

Chelmsford, Mass., go through rigorous testing to meet all necessary military stan-dards,” said Andrew Fleischacker, senior director, Global Product Management. “The Propaq MD is the smallest, lightest and most robust monitor/defibrillator on the market. It provides advanced monitoring parameters, life-threatening arrhythmia alarms and full AED functionality.”

Moreover, CPR support is available with Zoll’s CPR Dashboard that displays CPR quality in real time, and features See-Thru CPR, which minimizes the duration of pauses in CPR to enable rescuers to see the underlying rhythm. A navigation-friendly display helps the Propaq MD meet mission requirements from tactical casevac to criti-cal care transport.

“A key design criterion of the Propaq MD was to maintain backwards compatibility. With today’s fiscal constraints and the need for joint service standardization, the Propaq MD can utilize a number of the Zoll CCT and Propaq 206 Encore accessories currently in theater, thereby reducing costs and improv-ing logistical efficiencies,” said Fleischacker.

The Propaq MD is a platform to build upon. The system provides the capability to easily integrate new parameters, as devel-oped, with a simple software upgrade. The complete Masimo Rainbow Pulse CO-Oxim-etry technology has been integrated into the Propaq MD, providing SpO2, SpCO and SpMet with additional parameters (pending FDA clearance) of SpHb, SpOC, PVI and PI.

“Zoll is also proud to offer the Masimo E1 ear sensor designed for low perfusion

states, [for use] when traditional finger sen-sors cannot be applied,” said Fleischacker.

Zoll recently signed an agreement with Reflectance Medical Inc. to incorporate a ruggedized version of the Mobile CareGuide sensor into both the Propaq M and Propaq MD. The Mobile CareGuide has the ability, non-invasively, to simultaneously and con-tinuously measure muscle oxygen satura-tion and pH.

“The Propaq MD also has a dedicated communications processor,” said Fleis-chacker. “As data communications and elec-tronic patient care records becomes more important, Zoll’s open data architecture allows the patient data to flow from our device into a number of different EHR sys-tems or telemedicine solutions.”

variable escalating energy

Cardiac Science manufactures the Pow-erheart automated external defibrillators (AED). While the Cardiac Science Power-heart AED G3 Pro is used by emergency service personnel, the Powerheart AED G3 Plus Automatic is the premier public-access AED, designed to be used by lay responders. Incorporated into the design of the Power-heart AEDs is a very high level of automated self-testing called Rescue Ready, which veri-fies the function of all critical components of the AED. This technology self-checks all main AED components (battery, hardware, software and pads) daily. The AED completes a partial charge of the high-voltage electron-ics weekly, and a full charge monthly.

coMpanies are leveraging technological advances to create life-saving devices.

by chris Mccoy

M2va editor




“No other AED on the market does as high a level of automated self-testing as the Cardiac Science Powerheart AED. There is a direct correlation between an AED’s level of self-testing and its reliability,” said Ted Rioux, Cardiac Science director of distribu-tion, North America.

In addition to the self-testing features, the Powerheart AED G3 Plus Automatic incorporates key ease-of-use features, all designed to minimize the requirements of the user.

“Studies show when you minimize the number of operations required of the user, you minimize the opportunity for human error,” said Rioux.

The Powerheart AED G3 Plus Auto-matic’s features include: no on/off button; pre-connected and non-polarized electrodes; integrated text display, no shock button to press (in automatic version); user-paced audio and visual prompts; and Rescue Coach Technology, which provides the user with advanced instruction on how to deploy the AED and deliver effective CPR.

“Powerheart AEDs also incorporate the some of the most advanced defibrillation technology available in AEDs today,” said Rioux. “Variable escalating energy delivers customized therapy to the patient based on their individual level of impedance and escalates the level of energy for subsequent shocks.”

Cardiac Science possesses a GSA sched-ule with the federal government adminis-tered by the VA.

“We also work with a number of dis-tributors that possess specialty contracts. We have provided AEDs to every branch of service and military installations in every state,” said Rioux.

with a voice as a guide

Philips HeartStart AEDs have built-in technology that quickly and easily guides a user through a cardiac emergency with a simple, step-by-step process. A calm, clear voice explains exactly what to do, actively adapting instructions to keep the user on track. Intelligent sensors assess and auto-matically deliver the right therapy unique to each patient.

“We believe ease of use is one of the most important qualities in an AED because the potential user may not be well trained in resuscitating a victim of sudden cardiac arrest. This is consistent with the American Heart Association’s criteria for choosing an

AED,” said Bob Peterhans, general man-ager, emergency care and resuscitation at Philips Healthcare. “The effectiveness of Philips therapy is also backed by a wealth of evidence with more than 40 studies dem-onstrating effectiveness across the entire spectrum of patient profiles.”

HeartStart AEDs feature technological advancements that accelerate the process of delivering CPR and a potentially life-saving shock. Clinical studies have shown that the personalized therapy pioneered by Philips helps give victims of sudden cardiac arrest an enhanced chance for long-term success.

“Not only do our AEDs determine whether a shock is needed, they are designed to automatically deliver the right therapy at the right time,” said Peterhans.

Philips HeartStart AEDs are on two fed-eral contracts: VA Federal Supply Schedule V797P-2238D and DLA contract SPM2D1-09-D-8349.

“These contracts are accessible to cus-tomers through the usual methods such as GSA Advantage, ECAT, FedBid and Prime Vendor agreements,” said Peterhans.

iMplantable cardioverter-defibrillators

According to Marshall Stanton, M.D., vice president and general manager of the tachycardia business at Medtronic, the VA is one of the company’s largest customers for implantable cardioverter-defibrillators (ICDs). ICDs are 98 percent effective in stop-ping dangerous heart rhythms that can lead to sudden cardiac death.

Most modern ICDs have two ways to ter-minate arrhythmias: painless pacing (anti-tachycardia pacing or ATP) or ventricular fibrillation (VF). VF is a lethal condition in which the heart quivers chaotically and pumps little or no blood. ICDs collect infor-mation beat by beat about a patient’s heart that can help physicians better manage both the patient’s device and their underlying condition. Most modern ICDs can also be monitored remotely, allowing patients to stay connected to their physicians, catch problems before they become more severe and reduce the need for in-person clinic visits.

“More patients around the world have a Medtronic ICD than all other ICDs com-bined,” said Stanton. “Medtronic first intro-duced its ICDs in 1989 and over the years has developed several newer models of ICDs, which offer various features to assist

physicians in managing the patient’s device and their underlying condition.”

Medtronic ICDs are part of a system that includes leads—small insulated wires—that connect to the heart to provide ATP or shock therapy for treatment of life-threatening ventricular arrhythmias.

“The Medtronic Quattro family of leads are the most prescribed ICD leads in history and have a proven performance of 10 years. Quattro leads also have a lifetime guaran-tee,” said Stanton.

“Seven independent studies have con-firmed that Medtronic ICDs last longer than any other ICD offered from any other com-pany,” said Stanton. “For the past 20 years, Medtronic has also pioneered research in reducing unnecessary shocks. That’s impor-tant because unnecessary shocks can be painful to patients and expensive to the health care system.”

Most recently, Medtronic launched the Evera product family of ICDs, which includes two devices: Evera XT and Evera S. Both devices provide patients with a smooth, contoured shape to enhance patient com-fort, advanced shock reduction algorithms to reduce unnecessary therapies, as well as greater battery longevity.

“The new Evera product line offers a smaller device and a new contoured shape that is more tapered and domed than that of previous devices,” said Stanton. “The new design features rounded corners that reduce potential high-strain, high-pressure areas between the device and the skin by 30 percent compared to non-contoured devices. It also provides a comfortable fit within the chest area and potentially improves cos-metic appearance for the patient.”

From an analysis of the current market for defibrillators, it can be ascertained that a number of trends are taking place. Defi-brillators are becoming more complex and offering more detailed simple instructions directed at the layperson. Moreover, large companies are leveraging other technologies at their disposal to create more integrated devices that can perform more than simple defibrillation. Ultimately, as these trends continue, active-duty servicemembers and the veteran population will have more life-protecting medical devices at their disposal to prevent sudden cardiac arrest. O


MedEvac Tactical Armored Vehicles

Lenco Industries Inc. introduced the BearCat MedEvac LE and BearCat MedEvac MIL armored tactical vehicles. The LE version of the “MedCat” was designed to meet the combined requirements of SWAT and Tactical EMS teams, while the military model was designed specifically for tactical combat casualty care within the defense sector. Both are equipped to provide operators with a safe and effective environment for handling trauma cases.

All BearCat models are built with Mil-Spec steel armor plate certified to defeat multi-hit attacks from 7.62 AP/.50 Cal BMG, while ceilings and floors provide enhanced blast and fragmentation protection. Ballistic glass windows offer the multi-hit defeat, and also provide superior clarity.

In addition to this protection, the lengthened MedCat variant provides space for multiple litters––two for the LE and four in the military model––to be secured while still leaving enough space for other passengers to continue operations. The vehicles are equipped with oxygen tanks, a lighted work station and ample compartments for medical supplies and gear storage. To meet non-medical needs, the MedCats have a roof hatch with a gunner’s stand, gun ports and a radio compartment work station for communications.

UV Light Robots Make Veterans Affairs

Hospitals Safer

An affordable new technology from Xenex Disinfection Services has been clinically proven to destroy deadly pathogens such as C. difficile, MRSA, VRE and Acinetobacter quickly and effectively. Xenex’s pulsed xenon UV room disinfection system has been studied by VA researchers, who report that it provides superior disinfection and quicker cleaning time than traditional cleaning. Treating a single MRSA infection costs approximately $23,000; by contrast, the Xenex UV disinfection system eliminates MRSA and other superbugs from VA patient-care areas for less than $3 per room treatment cycle.

“In collaboration with the VA, Xenex is improving the quality of care at VA hospitals. Our goal is to enable them to be the safest hospitals in the country, and we are working to achieve this important milestone,” said Mark Stibich, M.D., co-founder and chief scientific officer of Xenex. “We are seeing a significant uptick in purchasing activity from the VA hospitals across the U.S. as the 2013 fiscal year closes and hospitals use their remaining funds to purchase the devices.”

Melinda Hart;[email protected]

Handheld Device to Measure Airway Inflammation in AsthmaAerocrine AB announced the launch of NIOX Vero, a new, fully portable

handheld point-of-care device for the measurement of airway inflammation, such as asthma. NIOX Vero is a new and upgraded version of the gold standard for measurement of fractional exhaled nitric oxide, a validated and clinically proven method for assessing allergic airway inflammation such as asthma. NIOX Vero provides accurate, reproducible and rapid measurement results. The NIOX Vero has an onboard rechargeable battery, upgraded software, wireless technology, patient journaling and has a useful life of 15,000 tests or five years compared to its predecessor’s (NIOX Mino) record of 3,000 tests or three years.

The CE-marked device used to measure airway inflammation––an underlying cause of inflammatory airway diseases––helps physicians to improve patient outcomes and reduce health care expenditures. The product is a complement to the Aerocrine product portfolio and will be initially introduced in selected market segments in Q4 2013 (Sweden, United Kingdom and Germany). The objective of this initial introduction is to conduct a real-life handling test of this device in the daily practice of a limited number of demonstration sites. Further introduction in the remaining European countries is expected during spring 2014.

Among the benefits of NIOX Vero, physicians will have more objective insights into treatment efficacy and can better predict a patient’s response to therapy and the risk of an asthma relapse. Moreover, physicians will be able to identify patient non-compliance with medications, and can adjust the dose of medication based on individual patients’ needs. By using NIOX Vero doctors can measure the underlying inflammation that causes asthma within a few minutes

directly in their offices.


Vital siGns

Advanced Intraosseous Vascular Access System

At the 2013 Military Health System Research Symposium in Fort Lauderdale, Fla., Vidacare Corporation launched the TALON (Tactically Advanced Lifesaving Intraosseous Needle) Intraosseous Vascular Access System for military use.

The TALON system is a groundbreaking single- needle solution for vascular access that provides combat lifesavers and medics with rapid and accurate manual IO access to seven FDA cleared IO sites––proximal tibia, distal tibia, proximal humerus and the sternum. The TALON system is the first IO system to meet all Committee on Tactical Casualty Care recommendations for IO devices.

TALON provides rapid vascular access through the intraosseous space and helps deliver vital fluids and drugs through this space, the body’s largest non-collapsible vein, to injured soldiers safely and quickly. TALON is a non-powered vascular access option that complements Vidacare’s powered EZ-IO Intraosseous Vascular Access System that is widely utilized in combat medicine today.

This system is designed to provide battlefield responders a tactical advantage needed in the combat zone via its lightweight and minimal cube design, proven ability to gain vascular access quickly and safely, and its versatility because no additional intraosseous vascular access gear or tools are needed. As with any vascular access site, the IO insertion site should be monitored frequently and the system should be used only when anatomical landmarks can be clearly identified and are in accordance with the TALON system’s instructions for use.

“This system is designed specifically to address the needs and concerns of military personnel treating patients under strenuous conditions. The TALON system will help achieve vascular access and save lives when seconds count,” said Mark Mellin, president and chief executive officer of Vidacare Corporation.

TALON will be sold to the military market through an exclusive relationship with Combat Medical Systems.

“The seven-site access achievable with TALON will give medical responders a distinct life-saving advantage during casualty resuscitation. We are excited to launch this device with Vidacare, and we are certain it will have an immediate positive impact in tactical medicine,” said Corey Russ, president, Combat Medical Systems.

Improved Chemical Identification for Handheld Analyzers

Military and civilian first responders who use handheld instruments to identify unknown chemicals, explosives and toxic materials can enhance their capability with a new software upgrade for Thermo Scientific FirstDefender RM and FirstDefender RMX handheld analyzers.

The Thermo Scientific FirstDefender RM/RMX 4.1 software includes “tagging”––a feature that enables users to prioritize the chemicals of greatest concern, providing focused analysis on select substances while maintaining a broad identification capability of more than 11,600 chemicals. In short, this enables lower detection limits and on-screen notification for tagged items. The FirstDefender RM/RMX 4.1 software update brings the tagging feature to global customers through Arabic, Chinese, French, German, Japanese and Russian language configurations.

Customizable Digit Hemostasis DeviceMar-Med of Grand Rapids, Mich.,

manufactures the Tourni-Cot. The Tourni-Cot has made it safe and

easy to achieve hemostasis on digits for over 20 years. Emergency physicians, podiatrists and hand surgeons around the world continue to use the device for lacerations and wounds, exploration, nail removal and management, and other elective procedures. The device makes it both safe and easy to occlude vessels during surgery. Each ring is simple to apply and exanguinate by exerting pressure as they roll proximally onto the digit. Once in place the ring applies reliable pressure to maintain a bloodless field, thereby improving the

result of a procedure.Supporting use of the device,

orthopedic surgeon Tony Nguyen of Phoenix, Ariz., said, “The Tourni-Cot makes my life easier. Don’t prepare a whole arm or bother with improvised tourniquet methods anymore. It’s safe, fast and effective. It is that simple.”

“The Tourni-Cot pays for itself,” said Jerry Marogil, sales manager of Mar-Med, “so much so that the United Kingdom’s National Health Service has adopted the Tourni-Cot as the standard of care after performing a study on the risk of improvised methods.”

Jerry Marogil;[email protected]


Compiled by Kmi media Group staff

Lieutenant General Patricia D. Horoho assumed command of the U.S. Army Medical Command on December 5, 2011, and was sworn in as the 43rd Army Surgeon General on December 7, 2011. Her previous positions include Deputy Surgeon General, Office of the Surgeon General, Falls Church, Va., from 2010 to 2011; 23rd chief of the U.S. Army Nurse Corps, from 2008-2011; commander, Western Regional Medical Command, Fort Lewis, Wash., from 2008 to 2010; commander, Madigan Army Medical Center, Tacoma, Wash., from 2008 to 2009; commander, Walter Reed Health Care System, Washington, D.C., from 2007 to 2008; and commander, DeWitt Health Care Network, Fort Belvoir, Va., from 2004 to 2006.

As a registered nurse, Horoho earned her Bachelor of Sci-ence degree from the University of North Carolina at Chapel Hill in 1982. She received her Master of Science degree as a clinical trauma nurse specialist from the University of Pittsburgh. She is a resident graduate of the Army’s Command and General Staff College and the Industrial College of the Armed Forces, where she earned a second Master of Science degree in national resource strategy. Other military assignments include staff nurse on a multi-service specialty ward, staff and head nurse of a Level III emergency department, Evans Army Community Hospital, Fort Carson, Colo.; nurse counselor, 1st Recruiting Brigade (Northeast) with duty at Harrisburg and Pittsburgh Recruiting Battalions; head nurse of a 22-bed emergency department, Womack Army Medical Center, Fort Bragg, N.C.; chief nurse and hospital commander of a 500-bed field hospital, 249th General Hospital, Fort Gordon, Ga.; assistant branch chief, Army Nurse Corps Branch, United States Total Army Personnel Command, Alexandria, Va.; assistant deputy for Health-care Management Policy in the Office of the Assistant Secretary of the Army (Manpower and Reserve Affairs), Pentagon, Washington, D.C.; deputy commander for nursing and commander of the DeWitt Health Care Network, Fort Belvoir, Va.; and deputy commander for nursing, Walter Reed Army Medical Center and North Atlantic Regional Medical Command, Washington, D.C. In 2011, Horoho deployed with I Corps as the special assistant to the commander, International Security Assistance Force Joint Command, Kabul, Afghanistan.

Recognitions include being selected in 1993 by “The Great 100” as one of the top 100 nurses in the state of North Carolina. In the same year, she was also selected as Fort Bragg’s Supervisor of the Year. She deployed to Haiti with the Army’s first health facility assessment team. In 1998, she co-authored a chapter on train-ing field hospitals that was published by the U.S. Army Reserve

Command Surgeon. Horoho was honored on December 3, 2001, by Time Life Publications for her actions at the Pentagon on September 11, 2001. On September 14, 2002, she was among 15 nurses selected by the American Red Cross and Nursing Spectrum to receive national recognition as a “Nurse Hero.” In 2007, she was honored as a University of Pittsburgh Legacy Laureate. In April 2009, she was selected as the USO’s “Woman of the Year,” and in May 2009, she became an affiliate faculty with Pacific Lutheran University School of Nursing, Tacoma, Wash. In May 2010, the Uniformed Services University of Health Sciences appointed her as Distinguished Professor in the Graduate School of Nursing. In 2011, University of North Carolina School of Nursing selected her as the Alumna of the Year.

Horoho’s awards and decorations include the Distinguished Service Medal, Legion of Merit (2 OLC), the Bronze Star Medal, Meritorious Service Medal (6 OLC), Army Commendation Medal (3 OLC), Army Achievement Medal (1 OLC), Armed Forces Expedition-ary Medal, Afghanistan Campaign Medal and various service and unit awards. She served as the head nurse of Womack’s emergency department when the hospital was awarded the Superior Unit Cita-tion during the Pope AFB Crash in 1994. She is also authorized to wear the DA Staff Badge and is the recipient of the Order of Military Medical Merit Medallion.

Lieutenant General Patricia D. Horoho

U.S. Army Surgeon General


Health StrengthenerLeading the Charge Towards a System for Health

Q&AQ&A

Q: At the time of our last interview you had recently been sworn in as the 43rd Army Surgeon General. What significant improve-ments have been made within Army Medicine during your time at the helm?

A: Army Medicine is a learning organization and the demands of supporting an Army at war in two theaters of operation simulta-neously have driven evolution. We improved training, modified processes, eliminated non-essential missions and made significant contributions to global health care, medical research and training. While the wounds of war are and will continue to be ours to mend and heal, Army Medicine now looks forward to charting a new course for medicine and health.

We will set an example for the nation in quality health care, well-ness, prevention and collective health for all those entrusted to our care, which does not change but complements the noble mission we execute today—world-class health care at home and abroad for soldiers, families and retirees. To do this, Army Medicine is creating capacity to influence and enable individual, unit and organizational health and stamina—an essential element in our transition from a health care system to a system for health.

Q: How have your experiences in previous assignments influenced your role as the Army Surgeon General?

A: The most influential assignment that has shaped how I look at our vision, our mission and our strategic priorities for not just the Medical Command but for Army Medicine was my deployment to Afghanistan. That deployment allowed me to do several things. It allowed me to understand the importance of training, manning and equipping our personnel so that they can accomplish their mission in a deployed environment. Being in Afghanistan taught me the importance of working with coalitions and ensuring that our Army Medical Department (AMEDD) personnel had the right skills to operate in an environment that was very reliant on joint multinational forces.

This deployment enabled me to identify our strengths and some gaps that we have across our force, which in turn helped shaped my strategic direction and focus areas for Army Medicine. It reinforced for me the value of what Army Medicine brings to the battlefield, and how inspiring our young medics and soldiers are, and it showed me how individuals are willing to put their life on the line for the values that we protect as Americans. I think I always knew that, but when you see it in action, it just inspires you to ensure that what we do from a policy level, resourcing decisions, training priorities and from a delivery of care model, always accounting for the fact that there is someone on point who is going to be impacted by those decisions.

Being deployed allowed me to develop relationships with the combat arms leaders in a way that has proven to be very helpful in my position as the Army Surgeon General. These relationships and the incredible job our personnel are doing downrange enhance credibility across Army Medicine, and credibility with the Army line.

This deployment also reinforced for me the importance of continuity of care, continuity of capability, and the need to move to a scalable, mission-oriented capability that allows the AMEDD to decrease variance on what we do in the garrison and across the-ater. Since I became Surgeon General, we have been stressing the importance of decreasing variance across the AMEDD as part of our

operating company model, efforts to improve patient outcomes and the overall health care experience for our patients.

Though Afghanistan has had the most recent influence on my views regarding AMEDD’s current strategic direction, I really believe that throughout my career I have been very fortunate to have lead-ers placing me in jobs I would not have selected for myself. Feeling uncomfortable in every one of these jobs made me realize that if you feel too comfortable in your job, you probably need to do something different. Every single assignment and experience is a leadership enhancing opportunity that gives you different skill sets for success.

From the very first push to go into trauma nursing to my experi-ences at Fort Bragg with the Pope Air Force base disaster, working at the Pentagon on 9/11, a deployment to Haiti and every leader devel-opment assignment within the Nurse Corps and the Army all came together to provide me the right skill sets to work at the senior leader level. This is how our Army becomes Army strong—by pushing lead-ers to move beyond their comfort levels and providing the opportu-nity to try new things and learn from one’s successes and mistakes.

Q: What new steps are being taken to address the large number of soldiers suffering from TBI and PTSD?

A: The Army continues to make great strides to standardize pro-cedures to educate, train, treat and track, and assure that the best care is available to soldiers who have sustained a concussion or mild traumatic brain injury. In September 2012, the theater policy in place since 2009 was upgraded to a stronger Department of Defense Instruction 6490.11.

This joint policy codifies the system of care in the deployed envi-ronment, mandating a medical evaluation, downtime and reporting following a soldier’s exposure to a potentially concussive event. In addition, the Army established concussion care centers dedicated to concussion care/mild TBI (mTBI) management. These centers con-tinue to be an integral part of the military health care team in the-ater, and have consistently maintained a return to duty rate of over 95 percent, allowing soldiers to receive care for concussive symp-toms in theater in an environment that is conducive to recovery.

In parallel since 2008, 57 clinics across Army Medicine, both inside and outside the continental United States, have established TBI care capabilities. Care is guided by VA/DoD clinical practice guidelines (CPGs) written in 2009 and rated “the best” of eight CPGs evaluated in the July 2011 issue of Brain Injury. The VA/DoD CPGs address care for those who have sustained an injury seven days or more after the event.

In June 2013, the Army published a policy for acute management of soldiers who are involved in potentially concussive events while in the garrison environment. Therefore, the Army has one worldwide standard of care, from garrison to theater, to educate Army person-nel, and to identify, treat and track soldiers as close to the point-of-injury as possible. This increases awareness and decreases the stigma associated with brain injury and also mitigates the possibility of long-term effects associated with concussion/mTBI.

The Army’s Medical Research and Materiel Command manages the world’s largest TBI research portfolio, and has invested over $710 million to advance TBI diagnostics and treatment. These stud-ies involve DoD, the Department of Veterans Affairs and prominent researchers in well-respected academic institutions. Together with our partners, the Army is constantly working to translate research findings to clinical practice as quickly as possible.


In the area of behavioral health (BH), the Army currently has over 5,000 professionals trained to provide BH BH services for sol-diers and other beneficiaries diagnosed with PTSD and related clini-cal conditions. Effective treatments for PTSD include talk therapies and medications, or both, with a recovery rate as high as 80 percent for patients who complete BH treatment. The Army conducts enhanced BH screenings at five recognized touch points throughout the deployment cycle, to include an in-theater touch. We also now screen for PTSD annually as part of every soldier’s periodic health assessment.

According to the July 2013 Medical Surveillance Monthly Report that focused on mental health across the services over a surveillance period that covered 2000 to 2012, mental health is the leading cause of hospital bed days and the second leading cause of medical encoun-ters. Furthermore, annual incidence rates of anxiety disorders have increased 425 percent.

The Army is responding by providing soldiers and families access to extensive training and programs that promote resiliency before, during and after deployments to lessen the impact of deployments and traumatic events that may result in increased anxiety and PTSD or other related clinical conditions. The newest initiative is the perfor-mance triad, which is a major enabler of the Army’s system for health.

The system for health will drive a cultural shift toward health and wellness by partnering with soldiers, families, leaders, health teams and communities to promote readiness, resilience and responsibility. The goal of the performance triad is to improve individual perfor-mance and resilience through improved sleep, activity and nutrition.

Q: Suicides in the military community have been a high-profile subject in the media. What steps are being taken within Army Medi-cine to help prevent or reduce their occurrence?

A: Suicide is a reality that can be changed, and the Army is making every effort to do so. Last year the U.S. Army and U.S. Army Medical Command conducted phase one (awareness and education) of a two-phased suicide prevention stand-down to empower leaders, soldiers, families and civilians to that end. The goals for the stand-down and all the days that follow are (1) increased respect for life and taking personal responsibility and accountability for our own fitness and for the welfare of our Army family; (2) empowering each of us to inter-vene and save lives by understanding suicide risk factors, protective measures and warning signs, and to take appropriate intervention actions when needed; and (3) strong and visible leadership support from the top down.

That means that Army leaders are present, engaged, have knowl-edge of risk reduction tools, intervention services, facilities and points of contact at each installation, and know when to implement various prevention, intervention and post-intervention actions. Dur-ing phase one, Army Medicine leaders conducted discussions with subordinate leaders and soldiers. In those discussions they utilized the U.S. Army Soldier and Leader Risk Reduction Tool designed for this purpose. Phase one continued with community and family oriented events, identification of local programs and organizations that have utility in suicide prevention efforts and resiliency training. Phase two (training and sustainment) began on September 28, 2012, continues today, and will do so indefinitely.

Q: How do you plan to implement the performance triad program, and how do you see it impacting the future of Army Medicine?

A: The performance triad pilot involves three battalion-sized ele-ments of varying capabilities (i.e., maneuver, fires and effects; operations support; and sustainment units) at three high troop concentration installations in order to diversify the pilot project and align outcomes with the multiplicity of Army units. The performance triad pilot incorporates training, education, technology and practical application designed to improve soldier performance focusing on the tenets of improved activity, nutrition and sleep. The primary inter-vention is the training of leaders, organic medical staff and soldiers to help them make healthy activity, nutrition and sleep choices.

An implementation team also trains local military treatment facility providers, ensuring consistent messaging and clinical inter-vention. The education program follows four main themes: imple-mentation training for both leaders and soldiers; weekly messaging; officer and noncommissioned officer professional development training focusing on how leaders can influence the triad; and warrior time training in which soldiers have additional training emphasizing essential aspects of the program.

The performance triad is the foundation of my strategic vision that is in direct support of the Army’s Ready and Resilient Campaign, with the goal of taking Army Medicine from a health care system to a system for health; moving from a disease model to one that impacts the “lifespace,” which I define as all of those hours, days and weeks when an individual is living his/her life. This foundation will impact Army Medicine by improving activity, nutrition and sleep in order to optimize performance, mental and physical health, overall unit readiness and resilience of the total force. These improvements will

A Madigan Army Medical Center practical nurse observes a soldier performing one of the various exercises during the military power, performance and prevention testing, during the second week of the performance triad pilot program at Joint Base Lewis-McChord, Wash. [Photo courtesy of U.S. Army/by Staff Sergeant Lewis Hilburn]


allow Army Medicine to streamline care and increase the ability to care for our wounded and ill, as well as decrease health care costs through prevention and education.

Q: Please explain the difference between the MHS and a system for health.

A: Army Medicine is embarking on a long-term strategy that includes transitioning the focus of our efforts from “health care to health” by providing the necessary initiatives, incentives and programs to support healthy behaviors, especially in the lifespace, which is the physical and psychological environment of an individual not spent in interaction with the health care system.

While recognizing that both injury and illness care will always be critical, especially to a fighting force, the new strategy places greater emphasis on preventing illness and injury in addition to applying new science towards improved resilience, improved performance and improved overall well-being.

The system for health is a partnership among soldiers, families, leaders, professionals and communities to promote readiness, resil-ience and overall well-being. It is an integration of programs, policies and initiatives to advance prevention and improve health. Transition-ing from a system focused on administering health care to a system for health that integrates health care with health promotion will require culture change through persistent effort and commitment from all of us.

Our current health care system reacts and treats diseases and ill-nesses after they develop. However, to maintain, restore and improve health, we must identify preventable factors that contribute to disease and illness, and encourage personal behavioral changes that support a state of healthy well-being. The system for health provides a framework that encourages soldiers, families, retirees, leaders, pro-fessionals and communities to promote individual responsibility for healthy behaviors and sustains readiness and resilience.

Q: The Military Health System (MHS) implemented the Defense Health Agency (DHA) in October as a means of eliminating dupli-cative and redundant military health logistics, services and cutting health care cost. What specific impact will this initiative have on Army Medicine, personnel and health care delivery?

A: Army Medicine embraces the ongoing changes within the overall MHS governance and the changes to the DHA. I have committed my best and brightest to the various business process re-engineering teams, and we are starting to see some results in the different con-cept of operations emanating from these shared service work groups.

The expectations for a product line like logistics, for example, are to standardize business rules and requirements across the MHS for things like medical/surgical consumables and medical equipment. Each service had great programs within their respective services; this transition captures best practices and creates an MHS-wide standard that will drive savings and reduce unwarranted variation.

In the health information technology work group, the services have moved a large number of service personnel, to include our chief information officers, under the umbrella of the DHA. There is tremendous opportunity to increase both efficiency and effective-ness within these support functions, consolidated at the DHA, but still supporting and accountable to Army Medicine. So at the initial implementation of the DHA in October, the focus is on business

support functions that could be delivered as a shared service across the MHS enterprise with a greater overall effectiveness. This process should be transparent to the health care delivery system within Army Medicine.

Q: What progress has Army Medicine made in expediting the reviews of soldiers’ health records to determine their disability under the Integrated Disability Evaluation System (IDES)?

A: Fiscal year 2013 was a breakthrough year for IDES. Throughout the year, MEDCOM continued to collaborate with the Department of Veterans Affairs, Army G1, regional medical commands and military treatment facilities to improve both the timeliness and quality of disability evaluations for our wounded, ill, and injured soldiers. These partnerships led to unprecedented improvements in the medical evaluation board (MEB) phase of the IDES process over the past year.

During the MEB phase, soldiers are referred to the IDES pro-cess, have the opportunity to claim additional medical conditions, undergo VA medical evaluations for each of their conditions and receive a determination from the Army as to whether each of their conditions meet or fail medical retention standards.

To increase the accuracy and efficiency of MEB phase determina-tions, MEDCOM worked with its VA and DoD partners to publish new policy and guidance, create additional capacity and placed a renewed emphasis on training. For example, MEDCOM standardized the

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format of the narrative summary, which consolidates information about a soldier’s medical condition(s), to allow for more efficient case processing.

Increasing case capacity, MEDCOM established remote operating centers in order to eliminate the backlog of reserve component IDES cases. In reference to training, MEDCOM provided customer service training to all physical evaluation board liaison officers, thus increas-ing soldier satisfaction with the IDES process. Finally, MEDCOM conducted quarterly IDES training to keep stakeholders informed of key policy and procedural changes.

These initiatives and many others helped MEDCOM increase the timeliness of IDES processing for our soldiers. In fact, MEDCOM doubled the percentage of MEB phase cases completed within the 100-day standard [35 percent in August 2012 to 70 percent in August 2013].

While we still have work ahead of us, I am confident that the IDES process will continue to improve, helping to ensure a healthy and ready force.

Q: In some of your talks, you discuss wanting to change the Army’s DNA as it relates to health. Please elaborate.

A: I chose the DNA metaphor to explain how the Army will transform its behavior and views on health. From an institutional perspec-tive, the ingrained behavior and perception of an organization is sometimes referred to as its “institutional DNA.” As we change the thoughts and behavior of the Army, family members and retirees, with respect to health, these external initiatives or efforts can effect change; however, if these efforts are not integrated into the basic being and beliefs––“the DNA” of the Army––then these efforts might not gain much traction.

The Army is a critical enabler of health. Health encompasses more than just the provision of care, and together with other senior Army leaders, we are leading a cultural shift in which soldiers, fam-ily members and retirees will make healthy choices without having to think about it—in essence, “encoding” health into our core. The Army’s Ready and Resilient Campaign, coupled with our transforma-tion from a health care system to a system for health will provide our Army family with the tools and knowledge to choose health in all aspects of their lives and jobs.

When I say transforming Army Medicine from health care to a system for health, it means that we advocate a cultural shift in how we think about and provide health care by encouraging and empow-ering every soldier, family member and retiree to develop a mindset that drives them to optimize their own health in order to improve their personal performance and resiliency. This is how we advance the health of our Army, and the health of our nation.

One component of our system for health is the performance triad, consisting of the proper management of activity, nutrition and sleep to guide soldiers towards optimal health and resilience. There is substantial scientific evidence to support activity, nutrition and sleep as a means to better optimize health and performance. These three areas can directly impact our beneficiaries’ lives for the better, regardless of their current health status.

Transforming to a system for health also means that we are pro-active in identifying, assessing and mitigating unhealthy behaviors before they become significant health problems, and by educating soldiers, family members and retirees about individual choices and access to resources and support.

This includes making healthy food choices in the commissary, grocery stores, restaurants and at home. When health is part of our DNA, individuals make sleep a priority, not just in their per-sonal lives, but in mission planning as well––whether soldiers are downrange, participating in a field training exercise, or in garrison. When DoD and the Army instinctively plan and resource com-munities that provide a safe, secure and accessible environment to maximize healthy living, this indicates that DoD and the Army have inculcated health into their respective organizational behavior and beliefs.

Q: Where do you want Army Medicine to be when you leave your post?

A: My vision and time horizon for where I want Army Medicine to be is not tied to my tenure. One of my main initiatives, system for health, and other efforts that we have started, will not have a measurable impact or outcome for years to come. Success for Army Medicine will be that when our soldiers come on active duty and transition into the Army environment for the first time, they are educated in health, the health determinants and other aspects of healthy living.

More importantly, my hope is that this becomes a way of life not only for them but their family members as well. It should be an expectation of their coming in, something they want and that they automatically “get,” because it is so ingrained in our culture. This refers back to my wanting to change the DNA of the Army. When our soldiers and their family members live healthy, then our hope is that whenever they leave the Army, whether it is at the end of their service obligation or after retirement, that this healthy behavior and desire for health will continue for the rest of their lives.

Concerning nutrition, I would like to see us move from a soci-ety that is focused on processed and fast food to a populace that consistently incorporates health and healthy eating into our daily routines. When all Americans are eating more fruits and vegetables and the right protein; when we know how to cook with it; and when our industries and community leaders are starting to change and partner with the medical community to incorporate health into our societal changes and make it easy for family members to live healthy, then we will be on the road to success.

I also want to ensure that our patient-centered focus remains. Programs like patient centered medical home, embedded behavioral health, and many others that put the patient and patient care first must remain viable and sustainable, because it too has become ingrained behavior within Army Medicine. Our soldiers, family mem-bers and retirees deserve continuity of care and a consistent patient experience from post to post. Army Medicine is improving its capa-bilities of tele-health, tele-technology and other portable modalities to ensure that these relationships remain.

Beyond Army Medicine, I want soldiers and especially Army lead-ers at all levels to fundamentally understand what health entails, and that healthy behavior should be sustained in all aspects of our soldiers’ lives. Our movement to health will be successful when our line leaders look at sleep and nutrition as tools––the same way they consider personal protective equipment. When Army leaders recog-nize that sleep and nutrition really optimize performance and they manage these performance tools as part of their day-to-day routine and mission planning, regardless of the environment in which we may find ourselves, then we will be successful. O


Medical simulation is the connection between classroom learning and real-life patient experience. Simulation-based assess-ments provide the opportunity to learn and rehearse clinical techniques and scenarios, either as an individual or as a team, without putting a patient at risk. Simulated clinical scenarios also provide a safe training environ-ment that can be controlled as well as evalu-ated immediately afterward.

Medical simulation affords instructors the means to provide detailed feedback to the student in areas such as a specific step in a clinical procedure, critical thinking and decision making, and communication skills. Participants can maintain clinical skills necessary to perform critical or complex procedures that are seldom performed, and

can gain proficiency with new techniques or equipment.

Currently, medical simulation is used across all levels of the health care continuum. High-fidelity simulation-based instruction offers medical educators a controlled learning environment with the ability to consistently reproduce or tailor clinical scenarios. Partici-pants are granted a forgiving clinical experi-ence, which furthers patient safety. Outcomes are improved by offering educators and par-ticipants the opportunity to analyze each step of the procedure or process being trained.

“The return on investment can be val-ued in many ways, such as higher clinical proficiency and the increased retention of complex medical protocols,” said Army Lieu-tenant Colonel Christopher Todd, the product

manager for medical simulation at Program Executive Office for Simulation, Training and Instrumentation. “However, the great-est benefit is in a reduction of errors, which improves patient safety, reduces cost and improves outcomes.”

Just as pilots spend hundreds of hours in a simulator rehearsing and preparing for numerous in-flight emergencies, members of health care teams gain confidence and proficiency through simulation by rehearsing procedures and protocols in preparation for a multitude of clinical contingencies.

The military incorporates medical simu-lation in the clinical training of its health care professionals in much the same manner as any other institutions. However, members of our military health care team must be

by chris Mccoy, M2va editor


the field of Medical siMulation training is expanding within the Military doMain.


prepared to treat severe injuries in austere locations.

“One of our specific products, the Medical Simulation Training Center (MSTC), trains combat medics on how to prioritize and manage critical battlefield injuries, extract patients from difficult terrain and transfer care to the next level,” said Todd. “MSTCs enable combat medics to rehearse various clinical scenarios in a simulated-combat envi-ronment. In this regard, medical simulation is the catalyst that advances clinical training and improves medical readiness for com-manders.”

Multidisciplinary siMulators

Founded in 1997, Simbionix is a pro-vider of simulation, training and education solutions for medical professionals and the health care industry. The company offers a wide range of simulators and training solu-tions. Recently, Grey’s Anatomy and Private Practice featured Simbionix simulators in episodes of their award-winning television programs.

“The nice thing about our products is they are designed to support health care profession-als and improve their clinical skills. In fact, we have sold over 2,000 simulators in more than 60 countries across multiple regions around the globe, and that shows we are on the right track,” said CEO Gary Zamler. “We see a lot of potential for worldwide demand to continue and we are fully engaged with an aggressive global sales team, a network of distributors and two global call centers operating 24/7/365. We also have a post sales training support team which is larger than several of our competitors, so we have invested heavily in our future and customers support net-work.”

The company’s U/S Mentor is a multidis-ciplinary simulator featuring highly realistic ultrasound simulation within a comprehen-sive educational environment. The simula-tor offers a true-to-life training opportunity, including a tangible manikin with realistic anatomy, physiology and pathologies.

“The ultrasound display reliably portrays the anatomy per U/S probe position, incor-porating sonographic imaging attributes, artifacts and controls, to best prepare the trainee for systematic scanning and informed diagnosing,” said Zamler.

Designed to provide both solo and team training opportunities, the U/S Mentor offers

ultrasound skill tasks and procedural tasks alongside patient cases with varying degrees of abnormalities and pathologies.

Simbionix’ Arthro Mentor is a virtual real-ity training simulator for knee and shoulder arthroscopic procedures. The Arthro Mentor virtual reality training simulator provides practice in the key aspects of arthroscopic surgery. This simulator enhances the acquisi-tion of basic skills, reduces learning time and considerably improves the learning curve of complex arthroscopic surgery techniques.

“The system provides a teaching proto-col comprised of a series of training mod-ules, providing learners interactive hands-on practice of diagnostic arthroscopy and the chance to train on more complex surgical procedures,” said Zamler. “Training modules include basic skills, diagnostic and procedural knee tasks, and diagnostic and procedural shoulder tasks. Our dedicated development team continually adds more content to this line.”

high-fidelity siMulation

CAE Healthcare offers a broad portfolio of patient, ultrasound and surgical simula-tion training solutions as well as validated scenario packages that range from tactical medical care to perioperative management.

“Our simulators are high-fidelity, mean-ing they are engineered to be as realistic as possible and to respond automatically to medical interventions,” said Paul Bernal, director of government and military sales at CAE Healthcare. “We were the first company to develop and produce a high-fidelity wire-less patient simulator in cooperation with the U.S. Army in 2007. Our iStan and METIman wireless simulators can be operated remotely by an instructor and remain very popular in the field and for training interdisciplinary teams.”

CAE Healthcare’s trauma simulator, Cae-sar, was built to withstand extreme tempera-tures, rain, dirt and dust, and body impact. Caesar was developed for the military but is also generating enthusiasm among disaster response centers that simulate man-made or natural disasters on a large scale, such as the Department for Homeland Security’s Center for Domestic Preparedness in Annis-ton, Ala.

“You can place Caesar in training loca-tions that would be safety risks to live actors, such as a high-angle rescue, a confined space

or under a collapsed building,” said Bernal. “He’s also being used for decontamination exercises.”

CAE Healthcare’s fastest-growing product is a simulation center management system called LearningSpace, which allows centers to capture simulation on video for debriefing. LearningSpace is deployed in one or multiple simulation centers for audiovisual recording, learner debrief, and assessment and report-ing. The U.S. Air Force and U.S. Veterans Health Administration are currently using versions of LearningSpace in their simulation centers.

CAE Healthcare’s Vimedix ultrasound simulator uses both a manikin and virtual reality technology to help practitioners gain proficiency in bedside ultrasound, such as the Focused Assessment with Sonography for Trauma exam. The company also has a wide range of other simulators.

“Our EndoVR and LapVR surgical simula-tors are training medical residents to get a feel for bronchial and gastrointestinal assess-ment and laparoscopic surgery,” said Bernal.

innovative health care training

For over 50 years, Laerdal Medical has continuously strived to develop and improve needs-based products and solutions to meet educational and clinical needs. Since 1940, the company has been a pioneer in medical simulation development.

“We always start with the customer’s objectives. In other words, what problems or initiatives are they trying to solve? How are they approaching it, and what is working and not working? Then we try and build a solu-tion that addresses all aspects of a success-ful program—that includes initial training, implementation and measuring outcomes. Our focus is not on the simulator as much as achieving the outcome the customer is looking to achieve,” said Joe Pahlow, vice president of sales, Laerdal Americas.

Laerdal solutions are used extensively in Army, Air Force, Navy and Marine Corps training centers. Today there are hundreds of Laerdal patient simulators throughout the armed forces community in a variety of envi-ronments, including OCONUS and hospital ships. In addition, Laerdal technologies have been beta tested at military installations in the most demanding environments, includ-ing lane training and litter obstacle courses in various climate elements.



“Laerdal Medical has been at the cut-ting edge of innovative health care training for over 50 years. Simulation has gathered increasing acceptance over the years as a core element of health care training. It serves as a fundamental approach to improving patient safety practice. The challenge now is to make simulation more accessible to the wider health care community, including the military and Veterans Health Administra-tion,” said Mark Owens, government service account manager at Laerdal Medical.

Laerdal Medical’s SimMan is the world’s most widely used advanced patient simula-tor. SimMan 3G is a realistic, full body adult, wireless patient simulator with advanced clinical functionality to teach critical skills. With “simplicity of use” being a fun-damental principle of its design, both nov-ice and experienced instructors can now take full advantage of the benefits of simula-tion. Built with the military standards in mind to be rugged, reliable, networkable and mobile, SimMan 3G Mystic makes simula-tion easier and more realistic than previous manikins.

The initial fielding of SimMan 3G Mystic is to the U.S. Army’s medical simulation training centers. These sites represent over 28 facilities around the world. The high-fidel-ity manikins will also be fielded at the NATO Special Forces Headquarters in Belgium.

hollywood Magic

Strategic Operations Inc. provides train-ing services and products for military, law enforcement and other organizations respon-sible for homeland security. The company focuses on creating medical simulators that are very realistic, appropriate for the task at hand, useful for training, user-friendly, cost-effective, easily maintained and easily user-repairable.

The San Diego-based company also has a history in the motion picture industry, which they leverage in their military training solu-tions.

“After decades of experience in the TV/movie business, 12 years ago we introduced ‘Hollywood magic’ to military training,” said Executive Vice President Kit Lavell. “We have supported the training of more than 700,000 military personnel with a mission to apply the techniques of the entertainment industry to make live military training ‘hyper-realistic.’ Our mission is to make the first combat

mission hopefully no worse than the last hyper-realistic simulation.”

According to Lavell, Strategic Operations’ medical simulation services and products grew out of that mission mindset.

“We designed the Human Worn Partial Task Surgical Simulator ‘Cut Suit’ to be hyper-realistic, a term meaning so realistic as to suspend disbelief that it is not the real thing,” said Lavell. “In this context, it is a simulator that is worn by a person on whom surgical procedures can be performed.”

The company’s tactical combat casualty care version of the Cut Suit allows medics, corpsmen and other first responders to per-form on a live human––under combat condi-tions––procedures to realistically treat the three most preventable causes of death on the battlefield: uncontrolled hemorrhage, airway compromise and tension pneumothorax.

“The Surgical Cut Suit has been used in medical schools to train students in surgical and team skills,” said Lavell. “Peer-reviewed scientific journals like the Journal of Special Operations Medicine and American College of Surgeons Bulletin have also featured arti-cles about the Cut Suit.”

critical trauMa skills

Operative Experience Inc. (OEI) has developed simulation-based systems to rap-idly train both combat medics and surgeons in critical trauma skills. These include all procedures of tactical combat casualty care and a variety of major operations such as the surgical exposure of blood vessels, crico-thyroidotomy, craniotomy, fracture fixation, fasciotomy, wound debridement, emergency thoracotomy and leg amputation.

“Our company does not just make simu-lators. For each combat trauma skill, we produce a multimedia training module based on the technical curriculum,” said Robert F. Buckman III, vice president of sales and marketing. “The training modules detail the anatomy, tactics, tools and techniques for each of the critical trauma procedures and demonstrate the correct performance on the simulator. These modules are formatted so that they could be reviewed in a handheld device, such as a smartphone or iPad.”

The first system OEI developed was in response to a need to teach proper two-incision four-compartment fasciotomy of the lower leg. There was a concern the incision and exposure during this procedure in theater

was often of sub-optimal length, possibly failing depressurization in all compartments. This could result in loss of limb or even death.

The OEI training solution includes an operable lower leg simulator, and a train-ing video detailing the anatomical planes and the correct procedure. The operable leg has embedded landmarks to ensure the incision is of appropriate length and that all four compartments have been decompressed. The early implementation results indicate a reduction in fasciotomy errors. Fasciotomy training cannot be performed effectively on live tissue animals.

Buckman explained that OEI training solutions are unique because their combat casualty care manikins have accurate anat-omy at all levels and form the basis for rapid trauma skills training systems.

“Our simulators are designed by trauma surgeons, not engineers, and are the first in the world in which major, ‘hands-in-the-body’ operations can be performed. OEI sys-tems are, accordingly, designed to support the training of surgeons as well as medics,” said Buckman. “We have also begun to embed integrated sensors and programmed logic controllers directly into the simulators that will permit the automatic and objective grad-ing of trainee performance.”

All branches of the military utilize OEI simulators. “We have a set of manikins with wound patterns that simulate an IED explo-sion followed by an ambush, and all or parts of these are used by the Army, USUHS and USASOC,” said Buckman. “Our two-incision four-compartment fasciotomy training sys-tem is used at all pre-deployment medical centers, the Army Trauma training center, Navy Trauma training center and C-STARs––the USAF’s trauma training center. We are also working with C-STARs and the Navy on an advanced surgical leg, which will facilitate training in seven surgical procedures.”

Ultimately, as medical simulation tech-nologies continue to advance and a range of new companies enter the medical simulation industry, the military community will be flooded with a number of new options for training its medical personnel. These new options will, in the words of Todd, improve patient safety, reduce cost and improve out-comes. O



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coMMand Profile

Medical Trainersafeguarding u.s. arMy special operations coMMand forces colonel peter J. benson

coMMand surgeon

u.s. arMy special operations coMMand

Colonel Peter Benson was born and raised in Winchester, Mass. He graduated from the College of Engineering, Northeast-ern University in Boston in 1985. He received his commission upon graduation as a second lieutenant in the infantry in the Army Reserve.

After completion of the Infantry Officer’s Basic Course, Fort Benning, Ga., and the Special Forces Qualification Course, Fort Bragg, N.C., Benson was assigned to A Company, 1st Battalion, 11th Special Forces Group (Airborne) at Fort Devens, Mass. Dur-ing four years of Reserve Service, Benson worked as a quality control engineer and engineering manager for Raytheon Corpo-ration, Waltham, Mass.

In 1989 he matriculated into the Uniformed Services Univer-sity of the Health Sciences, F. Edward Hebert School of Medicine. Benson graduated and received a Regular Army Commission in the Army Medical Corps in 1993. He completed a transitional (rotational) internship at Madigan Army Medical Center in Fort Lewis in 1994. After completion of the Walter Reed Army Institute of Research, Tropical Medicine Course and the U.S. Navy Diving Medical Officer Course, he was assigned as battalion surgeon, 2nd Battalion, 1st Special Forces Group (Airborne) at Fort Lewis, Wash., in 1994. After three years in the 1st Special Forces Group, Benson was accepted into to the Emergency Medicine Residency program at Madigan Army Medical Center, graduating in 2000.

He was assigned as staff emergency physician and later chief of the Emergency Medicine Service at William Beaumont Army Medical Center, at Fort Bliss, Texas. While at Fort Bliss, Benson was also an augmentee to the Joint Special Operation Command Surgeon’s Office from 2000 to 2004. Benson served in multiple deployments to Operation Enduring Freedom and Operation Iraqi Freedom, serving as the task force surgeon for Task Force 121 in Operation Winter Strike in 2004.

In 2004, Benson was assigned to Special Operations Com-mand Europe in Stuttgart, Germany, as the first permanently assigned Theater Special Operations (TSOC) command surgeon. He returned to Fort Bragg in 2007 as the first U.S. Army Special Forces Command (Airborne) command and regimental surgeon. He was assumed his current assignment as deputy chief of staff, surgeon of the U.S. Army Special Operations Command in 2009.

Benson’s awards and decorations include the Bronze Star Medal, the Defense Meritorious Service Medal, the Meritorious Service Medal with oak leaf cluster, the Air Medal, the Joint Ser-vice Commendation Medal, the Joint Service Achievement Medal, the Joint Meritorious Unit Award, the Army Superior Unit Award, and other individual and service awards.

He has earned the Special Forces Tab, the Combat Medical Badge, the Senior Flight Surgeon Badge, the Master Parachutist Badge, and the US Navy Diving Medical Officer Badge, the French Military Parachutist Badge and the French Army Commando Course Badge. He completed the U.S. Army Command & General Staff College (Correspondence) in 2005.

Benson is also a Diplomat of the American Board of Emer-gency Medicine and a Fellow of the American College of Emer-gency Physicians and the American Academy of Emergency Medicine.

Q: How does USASOC employ its operational medical personnel?

A: The unique missions of USASOC’s Special Forces Regiment, the Ranger Regiment, the 160th Special Operations Aviation Regi-ment, the 95th Civil Affairs Brigade and other supporting units dictate that most are employed in far-forward, austere environ-ments, commonly remote from higher level medical support.

For this reason USASOC’s units have a high ratio of enlisted independent providers: special forces medical sergeants, special operations combat medics and civil affairs medical sergeants. These highly trained, exceedingly skilled providers deliver out-standing medical capability at the small unit level. These soldiers are the main effort in providing tactical combat casualty care, civil-military assistance medical and veterinary capability, and partner nation medical training around the world, every day.

Supporting these tactical and operational elements are professional providers: physicians, physician assistants, veteri-narians and dentists at the battalion and group/regiment level. They provide medical oversight and training, as well clinical support. The operational medical capability in USASOC’s forces is a critical enabler to safeguarding USASOC’s most vital asset: its soldiers.


Q: What are some of the key initiatives or programs that USA-SOC is working on or you would like to see?

A: USASOC always has a number of medical development pro-grams that it’s working on. The most important research initiative in USASOC has been to field freeze dried plasma (FDP) through an FDA-approved investigational new drug request. FDP is a shelf-stable, physiologically balanced fluid that allows a tactical provider to restore a portion of the coagulation proteins a casualty would consume or lose in trauma.

This protocol will continue for several more years, but FDP appears to be effectively used by medics as part of tactical combat casualty care (TCCC) algorithms. Another initiative in partnership with the Army Medical Department’s Center and School’s Direc-torate of Combat and Doctrine Development in San Antonio was to develop a program to restructure Army forward surgical teams (FST) to be modular and more medically agile.

This effort realigns the FST structure to reflect the need and known ability to conduct split-team, one operating room-bed operations in a lighter, leaner package. The new unit, re-titled the forward surgical resuscitative team, will be more suitable to sup-port smaller, more disparate operations of both special operations forces and the regionally aligned conventional forces.

Q: Can you give an overview of how you see Army special opera-tions medicine and its effect on our overseas partner nations in the Pacific region?

A: The Pacific basin is a huge operational area that covers vast distances. The geography of the Pacific area creates the “tyranny of distance effect.” This means that the geography in and of itself engenders a higher level of difficulty in employing and supporting any force. This automatically increases the importance of deploying the necessary “right-sized” medical capability on each operation in order to mitigate medical risk. This is done by a thorough assessment of the operation, the environmental threat, and the assets available for higher level medical support, evacuation and medical logistics.

This means being able to function medically in the joint and combined operational environments. Operational medical flex-ibility or agility is one of Army special operations’ enduring areas of proficiency. This translates to being able to deliver the highest standard of point of injury care, damage control resuscitation and stabilization, and en route care during evacuation when required.

USASOC’s forces also bring a robust capability to train with foreign forces, enhancing partner nation capability and learning lessons in return. All of USASOC’s units, and in particular special forces and civil affairs have a long history of medical training and partnership both with partner military and host nation agencies throughout the Pacific.

Q: Could you tell us about USASOC’s work in the research and development for tools or treatment regimens that can deliver to you what’s needed in the field for combat casualty care?

A: FDP has already been mentioned, and it holds great promise as an addition to TCCC at point of injury in the future. While

USASOC does not have a mandate for medical research and devel-opment, it continues to monitor training, scientific and techno-logical developments to advocate for potential improvements in the delivery of combat casualty care.

Some of the best work being done in this area is through the Committee on Tactical Combat Casualty Care (CoTCCC) currently resident under the Army’s Institute for Surgical Research in San Antonio. By harvesting reports from special operations medics providing treatment on the battlefield, ongoing research from academia and expert opinion, the CoTCCC continually refines the TCCC guidelines to ensure best practice.

In effect, USASOC’s representatives on the CoTCCC and med-ics in the field provide an ongoing feedback loop to improve the TCCC guidelines. USASOC also participates in USSOCOM’s Bio-medical Initiatives Steering Committee that proposes and spon-sors medical scientific studies in support of special operations medicine. Several ongoing projects are: the development of a simple, reagent-free, blood-typing card and a small, self-contained, compact, multi-purpose medic lab kit.

Q: Hemorrhage control has been an important feature of trauma care over the past 12 years of war. What technological capabilities would take hemorrhage control to the next level?

A: Exsanguinating hemorrhage was and still is one of the biggest contributors to battlefield death. Common training in TCCC and the use of tourniquets and hemostatic dressings has made a tre-mendous impact in the treatment of battlefield hemorrhage. TCCC and hemorrhage control must be constantly retrained and rein-forced, as it is a perishable skill. Novel technological innovations in the area of treating junctional hemorrhage are being fielded and are being added to the overall schema of TCCC.

Defeating bleeding from severe vascular injuries at or near the large vascular junctions has been a persistent problem. Mechani-cal clamp devices for the inguinal area and pneumatic abdominal aortic compression devices have recently been approved by the

Special forces medical sergeant students participate in a field-training exercise focused on performing medical care in a combat zone. [Photo courtesy of U.S. Army/by Staff Sergeant Russell Klika]




coMMand ProfileFDA for use. Additionally, several novel products are under devel-opment to treat the serious problem of deep, cavitated wounds by means of sealants or expandable matrix materials. USASOC will continue to monitor and evaluate the efficacy and utility of prod-ucts that would enhance the capability of medics to save lives on the battlefield.

Q: Portable AEDs are a commonplace feature of life here in the United States. What does the military look for when choosing the right AED for deployments in combat zones?

A: AEDs have a niche in the deployed environment. AEDs are gen-erally efficacious in the base camp setting, where a larger popula-tion is concentrated or civilian/host nation personnel are present. AEDs are use to treat acute onset unstable dysrythmias that are amenable to defibrillation.

AEDs are not commonly applicable in the treatment combat wounds or trauma. The vast majority of penetrating or blunt trauma induced cardiac injuries or dysrythmias are not amenable to defibrillation. It is highly uncommon for a healthy, military age soldier to suffer a recoverable cardiac event amenable to AED defi-brillation from combat trauma. However, base camps with large populations of unscreened local national or contract personnel should have AEDs available for the same reason they are present at airports, stadiums or malls.

AEDs deployed to such setting must be simple to operate, have illustrated and audible instructions, preferably in the local language, have a long battery life, and should be shock-, dust- and water-resistant.

Q: What new technologies does the USASOC community need for advanced medical simulation training?

A: Medical simulations are an extremely important area of inter-est for USASOC. Multiple simulations are used in the initial and sustainment training of USASOC’s medics. The ultimate goal would be to produce an un-tethered, man-portable, human patient simulator that produces real-time physiologic-based responses to trainee’s interventions. This simulator would simulate the anatomy, tactile sensation and physiologic response of an actual human patient, to the best level of fidelity that technology permits.

It’s acknowledged that this is an incredibly ambitious goal. What’s needed in this area is an expert user-based consortium to develop a validated requirement for special operations medical simulations to set the target for industry to work toward. Cur-rently, the state of simulator technology remains limited and there is no one anatomical simulation that meets all USASOC training requirements.

Q: Could you tell us about USASOC’s recent efforts to protect against TBI, recognize the injury and develop effective post-injury treatment?

A: In concert with DoD’s efforts to protect against, recognize and mitigate the effects of TBI, USASOC follows DoD and Army policies regarding pre- and post-deployment screenings, casualty

screening criteria and treatment protocols. One of the most important innovations that USASOC has made is the use of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) neurocognative screening test developed by experts at the University of Pittsburgh Medical Center.

This widely used and well-validated web-based screening test is easily performed in 25 minutes at the soldiers’ convenience. All USASOC soldiers are required to take a baseline ImPACT test before deployment. If the soldier experiences a TBI event, after immediate care and the standard Military Acute Concussion Eval-uation screening, a pre-deployment or pre-injury baseline ImPACT can easily be compared to a re-test taken 24-48 hours post-injury.

Being Web-based, this provides timely data on neurocogni-tive performance in the deployed setting, in support of clinical decision-making. It has proven very useful and effective in this regard. USASOC currently has a database of over 12,000 baseline ImPACT studies, which will prove valuable for research on TBI exposure and long-term effects.

Q: Is there anything else that you would like to add that I have not asked?

A: USASOC will remain a relevant force and the premiere special operations capability in the execution of the national defense strategy. USASOC’s medics will be at the leading edge of these operations, dedicated to providing the very best in advanced tacti-cal medical care, in far-flung and hostile environments.

The command is devoted insuring that these soldiers have the best medical training, most appropriate equipment and most responsive medical logistical support to enable their mission. Thank you for this opportunity to discuss some of USASOC’s cur-rent actions and initiatives. O

Green Berets practice placing IVs in a field scenario along with other medical procedures like the application of tourniquets. [Photo courtesy of U.S. Army/by Private First Class Steven Young]


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