Group Editor Marty Kauchak discusses Army Medicine with Surgeon General Nadja West.
On 13 May, LTG Nadja West the 44th Surgeon General of the United States Army and Commanding General, US Army Medical Command, spoke with Halldale Group Editor Marty Kauchak. The entire transcript from their wide-ranging interview follows below.
Medical Training Magazine: LTG West thank you for taking time to speak with us. It’s been several years since we last engaged from an editorial perspective. Much has changed in the world, this nation and especially the Army – with its continued disengagement from Iraq and Afghanistan, and increased focus on a near-peer conflict. What are some of the implications during this dynamic era for Army Medicine now and in the next several years?
LTG Nadja West (LNW): First, you are welcome, and I always appreciate the opportunity to talk about our great team and this great organization. It has been quite a transition. Before becoming the Army Surgeon General, I served as the Joint Staff Surgeon. The operational focus on the Joint Staff is different than the Army Staff, especially for medicine. This was an eye opener for me. When I delivered my “day one” brief as the Army Surgeon General in December 2016, my vision raised eyebrows. I sounded very operational by discussing how Army Medicine needed to be expeditionary and globally integrated. This focus on expeditionary and globally integrated medicine was based upon my experiences as the Joint Staff Surgeon and how Army medicine integrates with the Joint Concept for Health Services. My initial focus was to ensure all of my team understood that Army Medicine must develop expeditionary and globally integrated medical capabilities to effectively support combatant commanders’ requirements and every single member of the organization must understand where they fit in. I stressed every member because Army medicine also has many wonderful Department of the Army civilians. We could not do our job without them. This was the first part, getting the mindset shift to being a globally integrated expeditionary force.
MTM: To follow on, your command vision statement is quite clear about Army Medicine having attributes which include being the ‘premier expeditionary and globally integrated medical force’.
LNW: I tell our team that expeditionary does not mean everyone deploys. Expeditionary is a mindset. Being expeditionary means having the agility, adaptability and comfort with change and uncertainty when faced with constraints or a different environment. Global integration means understanding what is around us and having the ability to synchronize medical capabilities with our sister services around the world in support of combatant command operations. Our sister services have capabilities integrated into Army Medicine on a routine basis. Army Medicine also has facilities overseas. Examples include Landstuhl Regional Medical Center, Germany, and Tripler Army Medical Center, Hawaii. We have organizations all around the world.
What is really important and exciting is virtual health. That is global integration. Virtual health provides Army Medicine the operational reach to support combatant command operations with specialty consultation far forward on the battlefield without employing additional operational units into the area of responsibility.
MTM: Another takeaway with this initial discussion is that Army Medicine is an evolving learning organization.
LNW: Yes, Army Medicine is uniquely postured as an evolving and learning organization. When I first took command, we were faced with a validated but unresourced requirement from a Combatant Commander. Within months, Army Medicine, seeing the importance of this mission; developed, trained and deployed an Emergency Resuscitative Surgical Team to Africa that is now in its third year of mission support. Our concept became the template used by the Air Force and Navy, creating more capability to meet growing demands.
The Army is undergoing the biggest transformation since the 1970s when US Army Forces Command and US Army Training and Doctrine Command were established. This Army-wide organizational change is totally revamping our entire Army structure to meet future needs and maintain parity with adversaries. This includes the establishment of Army Futures Command. Army Medicine is in lock step with the Army as it undergoes organizational change through integration into Army Futures Command and an assessment of how Army Medicine must be configured in the future to meet the needs of our Army and the Joint Force.
MTM: Tell us a bit more about Army Medicine’s role in Army Futures Command and that organization’s mission.
LNW: Army Medicine is integrated at every level of Futures Command. This includes Army Medical Department (AMEDD) officers serving in key leadership billets within the Command, the establishment of the Futures Command Surgeon Cell and integration within the cross functional teams. The Executive Officer to the Futures Command Deputy Commanding General is an AMEDD officer. This speaks of Army Medicine’s ability to grow and develop strategic leaders that are not only medical subject matter experts but also outstanding Soldiers.
Army Medicine also has representation on Futures Command’s six lines of effort and the two cross-cutting lines of effort; all integrated by an AMEDD officer. For example, long range precision fires demonstrate how Army Medicine supports and integrates into Futures Command lines of effort. In support of the long-range precision fires line of effort, AMEDD leaders are determining implications on ergonomics, impacts on the Solider at the delivery end of a system and effects to troops in the impact zone.
MTM: And beyond activities directly at Futures Command?
LNW: Although the Army Medical Research and Materiel Command (MRMC) is now aligned under Army Materiel Command (AMC), it continues to lead as a learning organization by staying in touch with deployed Soldiers to identify new and emerging threats. This ultimately leads to MRMC developing counter measures to meet these new threats.
An example of MRMC’s ability to identify emerging threats and develop solutions can be found with the new malaria vaccine. Malaria is still one of the leading causes of death and illness around the world as lack of vaccination results in quite a few deaths where the disease is endemic. As a part of a multi-center effort, MRMC researchers developed a vaccine that helps the military and civilians globally.
Changes to battlefield medicine and doctrine serve as the catalyst for updating the training curriculum at the Health Readiness Center of Excellence to ensure Army Medicine remains relevant in current and future operational environments. Included in curriculum changes at the Health Readiness Center of Excellence are the innovations developed by MRMC.
The end state of newly developed solutions and training curriculums is prolonged field care on the battlefield. Multi-domain operations highlight the potential that the next adversary may be a near peer competitor. There will be multiple domains – land, sea, air and cyber – the enemy will target simultaneously. Army Medicine must continue to evolve to provide prolonged field care in this environment.
MTM: Which supported, in part, aerial medical passenger transport and evacuation, correct?
LNW: Yes. In the future, the Joint Force may not have air superiority. Combat operations in Iraq and Afghanistan were highlighted by the Joint Force having air superiority that allowed us to evacuate a casualty from anywhere in the world by air, uncontested. In the future environment, the Joint Force may not have this advantage as the adversary may possess robust anti-access and aerial denial capabilities. Consequently, Army Medicine must have Soldiers comfortable with prolonged medical care.
MTM: The shift to supporting multi-domain operations must have significant implications for your training programs.
LNW: Yes. Multi-domain operations requires Army Medicine to train on prolonged field care in a combat environment. In support of this change, Army Medicine is in the process of determining the critical skill sets required for every medical military occupational specialty (MOS) and area of concentration (AOC) needed to operate successfully in a deployed and garrison environment. Army Medicine has 120 MOSs and AOCs in medicine and health service support. Although the skills required in garrison and deployed environments vary, the Health Readiness Center of Excellence is updating the curriculum to adjust the skill sets for new Soldiers attending Advanced Individual Training as well as for the different advanced courses in professional military education and health education.
MTM: How are some of the learning technologies supporting this wide array of courses?
LNW: The Army Medical Department is comprised of approximately 140,000 Soldiers and civilians geographically dispersed on five of the seven continents; that is a lot of people to train at various levels and in various areas. Consequently, Army Medicine leverages multiple training methods to reach out to all of these Soldiers and civilians to ensure we maintain trained and ready forces to support the Joint Force. One example of how Army Medicine reaches out to this vast population is through the Health Readiness Center of Excellence’s Instructional Technology Division. This organization produces distributed learning products and media to support training. Army Medicine relies on distance learning because we simply cannot move that many people around.
There are also institutional course enhancements, standard courses and point-of-need instruction. Point-of-need instruction refers to training for individuals deploying to a certain area of operation that require special skills. These special skills may include cultural awareness or special skill sets on special equipment not used in a garrison environment. In these cases, we send a team of instructors to train these individuals.
There are also simulations. Simulations are one of the lines of effort for Army Futures Command and includes technologies such as the synthetic training environment, virtual training labs and mannequins.
MTM: How might training for Army medical personnel further evolve in the short-term – 12 to 24 months?
LNW: Increasing partnerships with civilian institutions is an exciting training venue Army medicine leverages. AMEDD Military-Civilian Trauma Team Training (AMCT3) is a relatively new training program initiated approximately nine months ago. This military-civilian partnership establishes skills sustainment partnerships with civilian Level 1 trauma centers in the United States and ultimately improves critical wartime trauma care in support of the Army and Joint Force. Army Medicine has active medical training agreements with Cooper University Health System in Camden, New Jersey and Oregon Health and Science University in Portland, Oregon. As of September of 2018, MEDCOM has embedded five Soldier trauma teams at each location. We are in the process of establishing a medical training agreement with the Medical College of Wisconsin, located in Milwaukee, Wisconsin. We anticipate beginning this third site this summer.
Civilian-military partnerships will continue to increase in the near term. Several weeks ago, I visited Emory University and met with a team at the hospital. Certain residency programs are expanding and there is a willingness to work with the military and opportunities to participate in the programs. These opportunities such as Emory University enable Army Medicine physicians to obtain the diversity of patients need to maintain clinical skill sets. It also enables us to tell the Army story to those who may not have exposure to the military, with many joining the Army Reserve or National Guard based on these interactions. This is a win-win for all.
Along with our civilian partnerships, the American Board of Surgery recently recognized two of Army Medicine’s surgical residency programs as the best in the nation. Madigan Army Medical Center at Joint Base Lewis McCord was ranked number one and Brooke Army Medical Center in Joint Base San Antonio was ranked number three of over 223 programs assessed across the nation. The clinical program, matched with unique leadership and operational training, provide exceptional surgeons to our force.
Along with ensuring skills sustainment, civilian partnerships facilitate a ‘cross pollination’ of ideas both ways. Many of the clinical skills and best practices learned in Afghanistan and Iraq are taken back to the civilian community. For instance, a lot of the trauma training in Cleveland and Cincinnati, Ohio is grounded in the Tactical Critical Care Evacuation Team training the Air Force conducts. As a result, the University of Cincinnati trauma team is ahead of their civilian colleagues based on lessons learned in combat – portable oxygen and whole blood resuscitation versus the use of blood components, for example.
MTM: And are there any other high-level training efforts which are of significance?
LNW: As part of the military health system (MHS) transformation, all military treatment facilities will be under the direction and control of the Defense Health Agency. As of 1 October 2018, the first DHA pilot program was started at Womack Army Medical Center, Fort Bragg, North Carolina. MHS transformation allows Army Medicine and the service medical departments to focus on operational medical support and medical support to the Joint Force in an expeditionary environment. This includes medical support provided by forward surgical teams, combat support hospitals and emergency resuscitative surgical teams; the various operational medical units.
MHS transformation will rely on civilian-military partnerships. DHA will look across the entire enterprise to see how to leverage and scale partnerships throughout the nation. This includes international partnerships where it makes sense. International partnerships would of course include unique requirements for credentialing and reciprocity. Operational medicine is already a multinational effort in many operational areas of responsibility, so spending time with coalition partners in a garrison environment makes sense.
MTM: Following up on earlier comments about distance learning and related learning technologies, how can the simulation and training industry better meet the Army medical community’s requirements?
LNW: Trauma is not as prevalent as in the past. Technology and regulations have enabled less traumatic injuries. Before OSHA, there were many more construction accidents and crush injuries. Technology in vehicles led to increased survival rates from motor vehicle accidents and a reduction in trauma. The reduction in trauma patients results in a lack of frequency in trauma training. This is a good problem from the perspective of a prospective trauma victim, but not for surgeons required to remain trained and ready for deployment. The current and future battlefield will leverage high kinetic weapons with the potential to inflict significant trauma on the human body. Simulations are important to ensuring surgeons remain proficient in this new environment. Simulations must be as realistic as possible to enable trauma surgeons to remain current on the latest techniques and have the repetition needed to save lives on the modern battlefield.
Live tissue training is another gap, as opposed to using animals to train for trauma. As simulations become more realistic in the virtual domain, they must also enable a surgeon to ‘feel’ the simulated pressure on the scalpel when conducting a virtual incision.
MTM: We at Halldale also have Civil Aviation Training magazine which provides another focus on safety. How are you maintaining a focus on patient safety in a very diverse environment – from the battlefield to stateside medical facilities?
LNW: Army Medicine uses the Joint Commission as an external quality control for patient safety. All Army Medicine military treatment facilities are evaluated and accredited by the Joint Commission. The Joint Commission has very stringent patient safety requirements for all healthcare organizations. I am very happy to say 100% of Army Medicine military treatment facilities are accredited by the Joint Commission.
Army Medicine also has a vigorous no-notice inspection program where the same quality and safety metrics that the Joint Commission uses are used. For 100% of our facilities that have inpatient surgery, Army Medicine uses the National Surgical and Quality Improvement Program (NSQIP). Less than 20% of civilian facilities participate in NSQIP because it is voluntary; 100% of Army Medicine inpatient surgery facilities participate. NSQIP evaluates highly complex surgical cases; pancreatic cancer surgery, for example. Army Medicine ranks very well against NSQIP benchmarks and against others who volunteer to participate.
MTM: And internal?
LNW: Army Medicine established a program similar to the Army Safety Center. When an aviation accident occurs, the Aviation Safety Center deploys a team according to the accident level and leverages a process to determine root cause and inform the field. Army Medicine mirrors the Aviation Safety Center methodology by establishing a standard process of investigating patient safety incidents in military treatment facilities and evaluating the results.
Leading Army Medicine’s internal control measures on quality and patient safety is the Deputy Chief of Staff for Quality and Safety; a MEDCOM level leader that is on parity with all other Deputy Chiefs of Staff. The MEDCOM Inspector General also serves as a part of the quality and patient safety team by ensuring people feel comfortable reporting incidents to include the near misses. It is a constant environment of safety and quality.
MTM: Why should a current or prospective medical professional want a career in Army Medicine?
LNW: When our professionals actually get to experience what Army Medicine is about, they are drawn in. There is nothing else that compares to saving lives on the battlefield and caring for Families of our Soldiers. Army Medicine clinicians take care of patients similar to their civilian counterparts but do much more with the variety of skills and experiences taught and learned in hospitals and operational units. Our health professionals are afforded the opportunity to lead, conduct research, experience high level educational opportunities and undergo tough and realistic training.
MTM: Thank you for taking time to speak with Halldale and MTM today. Is there anything else before we close out, please?
LNW: You are quite welcome. I am approaching the end of my career in uniform – I have been fortunate to serve our Army as The Surgeon General. I cannot be more honored and proud to work with the phenomenal team members at Army Medicine. I am sincere when I say I have never seen a group of people that are so dedicated to what they do, that really understand the importance of what they do. The American public should know what a gem they have in military medicine.
Originally published in Issue 3, 2019 of MT Magazine.