Charting Army Medicine’s Path for the Future

Group Editor Marty Kauchak discusses Army Medicine with Surgeon General Nadja West.

On 13 May, LTG Nadja West the 44th SurgeonGeneral of the United States Army and Commanding General, US Army MedicalCommand, spoke with Halldale Group Editor Marty Kauchak. The entire transcriptfrom their wide-ranging interview follows below.

LTG Nadja Y. West, the 44th Surgeon General of the United States Army and Commanding General, US Army Medical Command. Image credit: US Army Office of the Surgeon General.

Medical TrainingMagazine: LTG West thank you for taking time to speak with us. It’s beenseveral years since we last engaged from an editorial perspective. Much haschanged in the world, this nation and especially the Army – with its continueddisengagement from Iraq and Afghanistan, and increased focus on a near-peerconflict. What are some of the implications during this dynamic era for ArmyMedicine now and in the next several years?

LTG Nadja West (LNW): First, you arewelcome, and I always appreciate the opportunity to talk about our great teamand this great organization. It has been quite a transition. Before becomingthe Army Surgeon General, I served as the Joint Staff Surgeon. The operationalfocus on the Joint Staff is different than the Army Staff, especially formedicine. This was an eye opener for me. When I delivered my “day one” brief asthe Army Surgeon General in December 2016, my vision raised eyebrows. I soundedvery operational by discussing how Army Medicine needed to be expeditionary andglobally integrated. This focus on expeditionary and globally integratedmedicine was based upon my experiences as the Joint Staff Surgeon and how Armymedicine integrates with the Joint Concept for Health Services. My initialfocus was to ensure all of my team understood that Army Medicine must developexpeditionary and globally integrated medical capabilities to effectivelysupport combatant commanders’ requirements and every single member of theorganization must understand where they fit in. I stressed every member becauseArmy medicine also has many wonderful Department of the Army civilians. Wecould not do our job without them. This was the first part, getting the mindsetshift to being a globally integrated expeditionary force.

MTM: To follow on, yourcommand vision statement is quite clear about Army Medicine having attributeswhich include being the ‘premier expeditionary and globally integrated medicalforce’.

LNW: I tell our team that expeditionary doesnot mean everyone deploys. Expeditionary is a mindset. Being expeditionarymeans having the agility, adaptability and comfort with change and uncertaintywhen faced with constraints or a different environment. Global integration meansunderstanding what is around us and having the ability to synchronize medicalcapabilities with our sister services around the world in support of combatantcommand operations. Our sister services have capabilities integrated into ArmyMedicine on a routine basis. Army Medicine also has facilities overseas.Examples include Landstuhl Regional Medical Center, Germany, and Tripler ArmyMedical Center, Hawaii. We have organizations all around the world.

What is really important and exciting isvirtual health. That is global integration. Virtual health provides ArmyMedicine the operational reach to support combatant command operations withspecialty consultation far forward on the battlefield without employingadditional operational units into the area of responsibility.

LTG Nadja Y. West, the 44th Army Surgeon General speaks at a command surgeons conference. Image credit: US Army Office of the Surgeon General

MTM: Another takeawaywith this initial discussion is that Army Medicine is an evolving learningorganization.

LNW: Yes, Army Medicine is uniquely posturedas an evolving and learning organization. When I first took command, we werefaced 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 isnow in its third year of mission support. Our concept became the template usedby the Air Force and Navy, creating more capability to meet growing demands.

The Army is undergoing the biggesttransformation since the 1970s when US Army Forces Command and US Army Trainingand Doctrine Command were established. This Army-wide organizational change istotally revamping our entire Army structure to meet future needs and maintainparity with adversaries. This includes the establishment of Army FuturesCommand. Army Medicine is in lock step with the Army as it undergoesorganizational change through integration into Army Futures Command and anassessment of how Army Medicine must be configured in the future to meet theneeds of our Army and the Joint Force.

MTM: Tell us a bit moreabout Army Medicine’s role in Army Futures Command and that organization’smission.

LNW: Army Medicine is integrated at everylevel of Futures Command. This includes Army Medical Department (AMEDD)officers serving in key leadership billets within the Command, theestablishment of the Futures Command Surgeon Cell and integration within thecross functional teams. The Executive Officer to the Futures Command DeputyCommanding General is an AMEDD officer. This speaks of Army Medicine’s abilityto grow and develop strategic leaders that are not only medical subject matterexperts but also outstanding Soldiers.

Army Medicine also has representation onFutures Command’s six lines of effort and the two cross-cutting lines ofeffort; all integrated by an AMEDD officer. For example, long range precisionfires demonstrate how Army Medicine supports and integrates into FuturesCommand lines of effort. In support of the long-range precision fires line ofeffort, AMEDD leaders are determining implications on ergonomics, impacts onthe Solider at the delivery end of a system and effects to troops in the impactzone.

Lt. Gen. Nadja West, U.S. Army Surgeon General, and U.S. Army Medical Command commanding general, receives an artificial face and hand injury as she visits the moulage facilitate at Fort Hunter Liggett, Calif., during a tour of the center. Image credit: Fort Bliss Bugle.

MTM: And beyondactivities directly at Futures Command?

LNW: Although the Army Medical Research andMateriel Command (MRMC) is now aligned under Army Materiel Command (AMC), itcontinues to lead as a learning organization by staying in touch with deployedSoldiers to identify new and emerging threats. This ultimately leads to MRMCdeveloping counter measures to meet these new threats.

An example of MRMC’s ability to identifyemerging threats and develop solutions can be found with the new malariavaccine. Malaria is still one of the leading causes of death and illness aroundthe world as lack of vaccination results in quite a few deaths where thedisease is endemic. As a part of a multi-center effort, MRMC researchers developeda vaccine that helps the military and civilians globally.

Changes to battlefield medicine anddoctrine serve as the catalyst for updating the training curriculum at theHealth Readiness Center of Excellence to ensure Army Medicine remains relevantin current and future operational environments. Included in curriculum changesat the Health Readiness Center of Excellence are the innovations developed byMRMC.

The end state of newly developed solutionsand training curriculums is prolonged field care on the battlefield.Multi-domain operations highlight the potential that the next adversary may bea near peer competitor. There will be multiple domains – land, sea, air andcyber – the enemy will target simultaneously. Army Medicine must continue to evolveto 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 maynot have air superiority. Combat operations in Iraq and Afghanistan werehighlighted by the Joint Force having air superiority that allowed us toevacuate a casualty from anywhere in the world by air, uncontested. In thefuture environment, the Joint Force may not have this advantage as theadversary may possess robust anti-access and aerial denial capabilities.Consequently, Army Medicine must have Soldiers comfortable with prolongedmedical care.

MTM: The shift tosupporting multi-domain operations must have significant implications for yourtraining programs.

LNW: Yes. Multi-domain operations requiresArmy Medicine to train on prolonged field care in a combat environment. Insupport of this change, Army Medicine is in the process of determining thecritical skill sets required for every medical military occupational specialty(MOS) and area of concentration (AOC) needed to operate successfully in adeployed and garrison environment. Army Medicine has 120 MOSs and AOCs inmedicine and health service support. Although the skills required in garrisonand deployed environments vary, the Health Readiness Center of Excellence isupdating the curriculum to adjust the skill sets for new Soldiers attendingAdvanced Individual Training as well as for the different advanced courses inprofessional military education and health education.

MTM: How are some ofthe learning technologies supporting this wide array of courses?

LNW: The Army Medical Department iscomprised of approximately 140,000 Soldiers and civilians geographicallydispersed on five of the seven continents; that is a lot of people to train atvarious levels and in various areas. Consequently, Army Medicine leveragesmultiple training methods to reach out to all of these Soldiers and civiliansto ensure we maintain trained and ready forces to support the Joint Force. Oneexample of how Army Medicine reaches out to this vast population is through theHealth Readiness Center of Excellence’s Instructional Technology Division. Thisorganization produces distributed learning products and media to support training.Army Medicine relies on distance learning because we simply cannot move thatmany people around.

There are also institutional courseenhancements, standard courses and point-of-need instruction. Point-of-needinstruction refers to training for individuals deploying to a certain area ofoperation that require special skills. These special skills may includecultural awareness or special skill sets on special equipment not used in agarrison environment. In these cases, we send a team of instructors to trainthese individuals.

There are also simulations. Simulations areone of the lines of effort for Army Futures Command and includes technologiessuch as the synthetic training environment, virtual training labs andmannequins.

MTM: How might trainingfor Army medical personnel further evolve in the short-term – 12 to 24 months?

LNW: Increasing partnerships with civilianinstitutions is an exciting training venue Army medicine leverages. AMEDDMilitary-Civilian Trauma Team Training (AMCT3) is a relatively new trainingprogram initiated approximately nine months ago. This military-civilianpartnership establishes skills sustainment partnerships with civilian Level 1trauma centers in the United States and ultimately improves critical wartimetrauma care in support of the Army and Joint Force. Army Medicine has activemedical training agreements with Cooper University Health System in Camden, NewJersey and Oregon Health and Science University in Portland, Oregon. As ofSeptember of 2018, MEDCOM has embedded five Soldier trauma teams at eachlocation. We are in the process of establishing a medical training agreementwith the Medical College of Wisconsin, located in Milwaukee, Wisconsin. Weanticipate beginning this third site this summer.

Civilian-military partnerships willcontinue to increase in the near term. Several weeks ago, I visited EmoryUniversity and met with a team at the hospital. Certain residency programs areexpanding and there is a willingness to work with the military andopportunities to participate in the programs. These opportunities such as EmoryUniversity enable Army Medicine physicians to obtain the diversity of patientsneed to maintain clinical skill sets. It also enables us to tell the Army storyto those who may not have exposure to the military, with many joining the ArmyReserve or National Guard based on these interactions. This is a win-win forall.

Along with our civilian partnerships, theAmerican Board of Surgery recently recognized two of Army Medicine’s surgicalresidency programs as the best in the nation. Madigan Army Medical Center atJoint Base Lewis McCord was ranked number one and Brooke Army Medical Center inJoint Base San Antonio was ranked number three of over 223 programs assessedacross the nation. The clinical program, matched with unique leadership andoperational training, provide exceptional surgeons to our force.

Along with ensuring skills sustainment,civilian partnerships facilitate a ‘cross pollination’ of ideas both ways. Manyof the clinical skills and best practices learned in Afghanistan and Iraq aretaken back to the civilian community. For instance, a lot of the traumatraining in Cleveland and Cincinnati, Ohio is grounded in the Tactical CriticalCare Evacuation Team training the Air Force conducts. As a result, theUniversity of Cincinnati trauma team is ahead of their civilian colleaguesbased on lessons learned in combat – portable oxygen and whole bloodresuscitation versus the use of blood components, for example.

MTM: And are there anyother 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 thedirection and control of the Defense Health Agency. As of 1 October 2018, thefirst DHA pilot program was started at Womack Army Medical Center, Fort Bragg,North Carolina. MHS transformation allows Army Medicine and the service medicaldepartments to focus on operational medical support and medical support to theJoint Force in an expeditionary environment. This includes medical supportprovided by forward surgical teams, combat support hospitals and emergencyresuscitative surgical teams; the various operational medical units.

MHS transformation will rely oncivilian-military partnerships. DHA will look across the entire enterprise tosee how to leverage and scale partnerships throughout the nation. This includesinternational partnerships where it makes sense. International partnershipswould of course include unique requirements for credentialing and reciprocity.Operational medicine is already a multinational effort in many operational areasof responsibility, so spending time with coalition partners in a garrisonenvironment makes sense.

Lt. Gen. Nadja West, U.S. Army Surgeon General, and US Army Medical Command commanding general (far right), and many other distinguished visitors, met at Fort Hunter Liggett, Calif., to tour the 528th Hospital Center. The 528th Hospital Center is based at Fort Bliss. Image credit: Sgt. Justin Geiger/7th MPAD.

MTM: Following up onearlier comments about distance learning and related learning technologies, howcan the simulation and training industry better meet the Army medicalcommunity’s requirements?

LNW: Trauma is not as prevalent as in thepast. Technology and regulations have enabled less traumatic injuries. BeforeOSHA, there were many more construction accidents and crush injuries.Technology in vehicles led to increased survival rates from motor vehicleaccidents and a reduction in trauma. The reduction in trauma patients resultsin a lack of frequency in trauma training. This is a good problem from theperspective of a prospective trauma victim, but not for surgeons required toremain trained and ready for deployment. The current and future battlefieldwill leverage high kinetic weapons with the potential to inflict significanttrauma on the human body. Simulations are important to ensuring surgeons remainproficient in this new environment. Simulations must be as realistic aspossible to enable trauma surgeons to remain current on the latest techniquesand have the repetition needed to save lives on the modern battlefield.

Live tissue training is another gap, asopposed to using animals to train for trauma. As simulations become morerealistic in the virtual domain, they must also enable a surgeon to ‘feel’ thesimulated 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 Commissionas an external quality control for patient safety. All Army Medicine militarytreatment facilities are evaluated and accredited by the Joint Commission. TheJoint Commission has very stringent patient safety requirements for allhealthcare organizations. I am very happy to say 100% of Army Medicine militarytreatment facilities are accredited by the Joint Commission.

Army Medicine also has a vigorous no-noticeinspection program where the same quality and safety metrics that the JointCommission uses are used. For 100% of our facilities that have inpatientsurgery, Army Medicine uses the National Surgical and Quality ImprovementProgram (NSQIP). Less than 20% of civilian facilities participate in NSQIPbecause it is voluntary; 100% of Army Medicine inpatient surgery facilitiesparticipate. NSQIP evaluates highly complex surgical cases; pancreatic cancersurgery, for example. Army Medicine ranks very well against NSQIP benchmarksand against others who volunteer to participate.

MTM: And internal?

LNW: Army Medicine established a programsimilar to the Army Safety Center. When an aviation accident occurs, theAviation Safety Center deploys a team according to the accident level andleverages a process to determine root cause and inform the field. Army Medicinemirrors the Aviation Safety Center methodology by establishing a standardprocess of investigating patient safety incidents in military treatmentfacilities and evaluating the results.

Leading Army Medicine’s internal controlmeasures on quality and patient safety is the Deputy Chief of Staff for Qualityand Safety; a MEDCOM level leader that is on parity with all other DeputyChiefs of Staff. The MEDCOM Inspector General also serves as a part of thequality and patient safety team by ensuring people feel comfortable reportingincidents to include the near misses. It is a constant environment of safetyand quality.

MTM: Why should acurrent or prospective medical professional want a career in Army Medicine?

LNW: When our professionals actually get toexperience what Army Medicine is about, they are drawn in. There is nothingelse that compares to saving lives on the battlefield and caring for Familiesof our Soldiers. Army Medicine clinicians take care of patients similar totheir civilian counterparts but do much more with the variety of skills andexperiences taught and learned in hospitals and operational units. Our healthprofessionals are afforded the opportunity to lead, conduct research,experience high level educational opportunities and undergo tough and realistictraining.

MTM: Thank you fortaking time to speak with Halldale and MTM today. Is there anything else beforewe 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.