The commonly used term “combat fatigue” reflected the prevailing attitude that once a soldier was removed from combat and provided with time for rest and relaxation, his war trauma would disappear. Post Traumatic Stress Disorder (PTSD) was not a clinical diagnosis until 1980, when it was added to the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM III). Prior DSM editions had no specific classification for postwar trauma. Terms like stress response syndrome, gross stress reaction, psychoneurotic disorder, anxiety neurosis, character disorder, and adjustment reaction to adult life were all diagnostic phrases utilized by the Veterans Administration (VA) to describe the World War II combat veterans who applied to the agency for help because they could not leave the war behind.

A U.S. Marine after two days and nights of hell on the beach of Eniwetok in the Marshall Islands, Feb. 1944. His face is grimy with coral dust but the light of battle stays in his eyes. The theory at the time was that combat fatigue could be cured with rest and relaxation. National Archives photo

The prevailing theory to explain war trauma was based on Freudian analysis. This approach posited that the main reason a combat veteran had psychological issues postwar was because feelings of infantile anxiety and hostility were repressed until his underlying neurosis was aroused by war. The horror of combat was not considered to be a major independent cause of psychological problems. The assumption was that the soldier/veteran was already emotionally flawed prior to the war. Since the mental distress was seldom considered service related, the veteran was often not entitled to VA benefits.

World War II veterans who exhibited severe mental and behavioral problems were often institutionalized in Veterans Administration (VA) hospitals. By the 1950s the VA system operated a hundred and nine general hospitals and thirty eight neuropsychiatric hospitals.  There are estimates that psychiatric cases accounted for half of veterans’ hospitalizations in VA facilities in the fifties, according to the Committee on Veterans Compensation for Posttraumatic Stress Disorder in PTSD Compensation and Military Service.

Commonly used therapies in VA hospitals during early postwar years were shock treatments – insulin and electric. Insulin shock was induced when patients received large doses of insulin over a period of weeks, causing daily comas that supposedly would shock the patient’s system out of mental illness.  Electric shock operated on a similar principle of disordering the mind and jolting the veteran out of his emotional distress by electrodes sending electric currents to the brain.

In 1949, the American Journal of Psychiatry published results evaluating the efficacy of these procedures performed during an experimental study on one thousand VA hospitalized veterans. The article noted that social recoveries had been achieved for a large percentage of those diagnosed with psychotic reactions to wartime. Not mentioned in the report were possible side effects of the therapies, including organic brain damage.

The shock treatments were not the most egregious of procedures performed on veterans in the VA system. Lobotomy, or psychosurgery, which consisted of severing the frontal lobes of the brain, was utilized to relieve anxiety and psychological distress. VA research on lobotomized veteran patients was done through a cooperative study process sponsored by the agency. Under this model, VA hospitals applied to be part of a VA Lobotomy Study, consisting of experimental research on psychiatric veteran patients which tested the effectiveness of lobotomy as a treatment. Jack Pressman in his book, Last Resort: Psychosurgery and the Limits of Medicine,estimated that by 1950, prior to the creation of the formal study, 1500 lobotomies had already been performed in VA hospitals. There are no accurate numbers on how many total lobotomies were performed on the hospitalized veteran population.

Various journal articles from the 1950s discussed studies done at VA hospitals in California, Minnesota, New Jersey, New York, Virginia and Tuskegee, Ala., a site where studies were done on African-American veterans. Psychosurgery as a treatment choice began to diminish in the mid to late fifties, after the advent of pharmaceuticals for psychiatric cases. A retrospective study evaluating ten years of lobotomies at VA hospitals was published in 1969 in the Hospital and Community Psychiatry Journal.  Patients who had severe emotional tension, assaultiveness, suicidal behavior and unresponsiveness to shock treatments had been subjected to the procedure. It was determined that assaultiveness had lessened, but a significant number of lobotomized patients had intellectual disabilities and seizures. Only ten percent had ever been discharged from the hospital.

Post Traumatic Stress Disorder may not have been an official diagnosis until 35 years after the end of World War II, but many veterans of that war suffered from war related trauma. While the story of the Greatest Generation’s achievements is well known, the invisible wounds of World War II and the ineffective and sometimes inhumane responses to the veterans’ psychiatric distress is a less familiar tale.

War also leads to new medical technologies and techniques, such as vastly improved prosthetics and a greater attention to and understanding of concussive force injuries. Noting that as he transitioned from the Bush to Obama administrations, then-Secretary of Defense Robert M. Gates issued a memo stating an even greater emphasis was required to ensure the military was doing the research needed to restore severely wounded warfighters to full function.

“We did not have a core program in this area until just a few years ago, so without the current conflict, there would not be a CRMRP [Clinical and Rehabilitative Medicine Research Program], for example,” according to the program director, Army Lt. Col. John M. Scherer. “That doesn’t mean certain aspects would not still be under investigation – burn treatment and rehabilitation, for example. We coordinate closely with our Combat Casualty Care office to look at the continuum of burn injuries – where … the injury stops and rehab begins.

“The previous focus of the U.S. Army Medical Research and Materiel Command [USAMRMC] was on care up to a fixed facility, then the VA [the Department of Veterans Affairs], civilian medical community, NIH [National Institutes of Health], and others would conduct research and find solutions to repairing those traumatic injuries because those people would have been discharged from the military. But it was determined DoD [the Department of Defense] also has a responsibility and we needed a coherent program to research traumatic injuries and restore [wounded warfighters] to full function. But much of that would not have happened within DoD without the current conflict.”

In response to the Gates memo and the requirements of the ongoing war in Southwest Asia, both DoD and the individual services ramped up already existing efforts to improve care by creating additional new programs and agencies focused on those requirements. CRMRP was one such example, created by USAMRMC in 2008 to focus on expanding traditional research to include even more innovative means of rehabilitative care required to “reset” wounded warriors, both in terms of duty performance and quality of life.

Doctor Richard Erff, chief of the Carl R. Darnall Army Medical Center Pain Clinic, administers cervical epidural steroid injections to Spc. Michael Ryan, who suffers from chronic neck and back injuries. Ryan's pain stems from a traumatic brain injury he received while deployed to Iraq. Pain management is another CRMRP focus area. U.S. Army photo by Patricia Deal, CRDAMC Public Affairs

According to its mission statement, CRMRP “provides policy and process oversight for all clinical and rehabilitative medicine congressional programs managed by the USAMRMC’s Telemedicine and Advanced Technology Research Center (TATRC) and Congressionally Directed Medical Research Programs (CDMRP). It is the lead for program development and oversight of the Armed Forces Institute of Regenerative Medicine (AFIRM), which is a multi-institutional, interdisciplinary network working to develop advanced treatment options for severely wounded service members. The CRMRP also more tightly links the USAMRMC research and development community with the clinical investigations community of the U.S. Army Medical Command and the Military Health System.”

Although part of the Army’s medical care structure, Scherer emphasizes the program’s comprehensive approach to multiservice needs, especially at the individual warfighter level.

“We’re trying to take basic research that has been done and translate it into clinical practice so we can return function to the most traumatically injured soldiers, sailors, airmen, and Marines from the current conflict. So that is focused on the most severely injured warfighters, returning them to duty or getting them back to function,” he explained. “Our goal is always to restore them back to the function they had previous to the injury – not to get to the ‘good enough’ answer, but the best answer for that person.

“In addition, the medical community at large was expressing a level of interest in progressing into this area because we had been working these traumatic injuries without the ability to treat effectively. Injuries to the head and neck, for example, have gone up substantially in this conflict and we need programs to address those.”

CRMRP came out of the Army’s Combat Casualty Care Program, which already was leaning toward developing and implementing new ways to restore the function of severely damaged tissue. At the same time, Congress increased funding for new efforts in prosthetics, regenerative medicine, and other cutting-edge technologies to address the growing number of service members surviving despite extreme trauma to arms, legs, and head. That also involves advancements in repairing damaged hearing and overall enhancements in rehabilitative care.

CRMRP-sponsored research currently is focused on four key areas:

1. Rehabilitation and Prosthetics: This includes not only advances in returning damaged limbs to full functionality – or replacing them, if necessary, to achieve the same goal – but also dealing with associated problems, from psychosocial recovery and substance abuse to other injuries that may restrict rehabilitation.

2. Pain Management: Improving ways to reduce chronic and acute pain while also establishing safe levels of medication for each individual, identifying and treating pain generators, and developing new ways to empower patients in the management of their own pain.

3. Vision: Advancing procedures to repair retinal/corneal or optic nerve damage, create artificial eyes that are functional rather than merely cosmetic, improve ocular diagnostics, and treat vision problems associated with TBI.

Induced stem cells, adult skin cells that have been genetically reprogrammed to mimic embryonic stem cells, have been made potentially safer by removing the introduced genes and viral vector used to ferry the genes into the cells. These cells were reprogrammed to an embryonic-like state with the aid of a plasmid, a loop of DNA, which prompts the reprogramming but is not integrated into the genome of the cells. The work was accomplished by geneticist Junying Yu in the laboratory of James Thomson, a UW-Madison School of Medicine and Public Health professor and the director if regenerative biology for the Morgridge Institute for Research. Adult stems cells are being investigated today to aid military regenerative medicine initiatives. University of Wisconsin-Madison University Communications

4. Regenerative Medicine and Transplants: Improving wound healing, reducing scarring, improving function and appearance following craniofacial injuries, eliminating the need for tissue rejection therapy, improving surgical techniques, regenerating missing tissue (muscle, bone, skin), repairing nerve gaps, and developing the architecture to integrate “created” tissue.

While DoD, the individual services, the VA, National Institutes of Health, academia, and industry had been pursuing research and implementing advanced care capabilities in many of those areas, CRMRP was deemed necessary to create a “critical mass” of coordinated research expertise on definitive and rehabilitative care innovations. Success will be measured by reducing permanent disabilities, enabling a more rapid return to duty, decreasing long-term care needs and costs and, by resetting wounded warriors to their full health and capabilities, increasing warfighter morale.

Each of the four key focus areas is important in itself – and even more so in combination – to achieving that goal. But the level of effort by CRMRP and the programs and institutions with which it works is perhaps most clearly seen in efforts to repair injuries to the head and face, a complex task still in the nascent phase of research, despite recent headlines about face transplants and other components.

“If you look at a fractured leg, you basically have a one-dimensional direction, with the bone going up and down the leg. But on the face, you have multiple contours, which make repairs much more complicated than a simple leg fracture,” Scherer explained. “The bone scaffolds, molding, even tissue types are different.

“If you have a leg burn, you are dealing with one tissue type. But a facial burn has different tissues and unique functions – lips, eyelids, etc. – that cannot be repaired with a simple skin graft. You have to be able to replace an eyelid, for example, to save the patient’s sight. So we’re not only trying to repair major deformities resulting from a blast injury to the face, but also regenerate different tissue types so they can function as normal. And that has been a challenge.”

Unfortunately, just as CRMRP came into being, the global economic downturn began having an impact on budgets. While that is expected to slow some work, at least in the near term, Scherer said efforts are under way to ensure critical programs and treatments continue to advance. Whatever the status of U.S. combat or the federal budget, the intent is to provide the best care available to those wounded in Afghanistan and Iraq – including after they leave the military and the VA takes over, from rest-of-life health care to furthering future advances through the Veterans Health Administration (VHA) Rehabilitation Research & Development Service.

“We have a wide variety of interaction with the VA, from sitting on our programmatic committees to making sure projects of interest to both continue on from the research side. A good example of that is the DARPA-developed prosthetic arm; we are providing funds to get the next generation of the arm into clinical trials by the VA, probably in the spring of 2012,” Scherer said.

Sgt. Marco A. Robledo explains his prosthetic arm and hand to Lt. Cmdr. Benjamin Nguyen at the Al Faw Palace, Camp Victory, Baghdad, June 21, 2011. Robledo, along with five other soldiers, returned to Iraq to visit forward operating bases to witness the changes that have taken place due to their sacrifices. Robledo was injured May 26, 2007, by an IED while in a convoy. CRMRP is seeking to advance the state of the art in prosthetics. U.S. Army photo by Master Sgt. Michael R. Daigle

While major advances in prosthetics, especially for lower limbs, have garnered considerable media and public attention, that is only one part of CRMRP’s portfolio.

“We’re looking across the spectrum of severe combat injuries. The face transplants in the news recently were DoD-funded efforts managed by CRMRP. We also have a program in hand transplants,” he said. “We’re also looking at regenerating lost tissue. In a traumatic injury, can we salvage those parts of the limb that are not removed by basically regrowing the muscle, bone, and nerves that have been lost? The program is relatively new, but a lot of promising clinical trials are under way looking at many of these aspects.

“Some other efforts, including burn products, are in clinical trials now and likely will move into standard clinical use in the U.S. in the next several years. Cloning is a bit further down the road, although some investigators are working on those things – just not necessarily with DoD funds. And a doctor at Wake Forest has developed a tissue 3-D printer to make small [body] parts.”

Military medical R&D also has to follow the mandates of Congress, which typically specifies how funding it provides is to be spent – so many dollars on face or hand transplants, another specific amount on cranial injuries, TBI, damage to sight or hearing, etc.

“We prioritize what we do based on the types of injuries and degree of trauma from the current conflict, but also the current state of the art. Are industry, DARPA, the VA already working on this problem? We base our effort not only on the type, number, and severity of injuries, but how our funds fit into existing efforts so we don’t over-fund one area and under-fund another,” he explained.

“So the priorities we set, to get the most benefit from the resources we have to apply, are not easy to articulate. We may bump something up to the top just because it is close to going into clinical trial, for example, even though other efforts may be considered more urgent – but that one can get the most immediate impact from available funding.”

This generation of warfighters also has shown a determination to use advances in military medicine, especially prosthetics, to either remain in uniform – including returning to war – or re-enter civilian life with at least the same capabilities as before they were injured. An unexpected development, however, has been an increase in the number of “elective” amputations – patients whose limbs were saved by surgery, but with some loss of function, believing they would have a better life with a prosthetic.

As a result, military researchers now are looking not only at how to improve prosthetics, but how to achieve full recovery without prosthetics.

“I don’t have the statistics, but we have had a lot of elective amputations, where the surgeon saved the limb but it did not function to the patient’s satisfaction. Looking around at others who are functioning better with prosthetics, they elect to do the same,” Scherer said. “And I find that a tragedy – that a limb the surgeon was able to save is still amputated because the individual believes a prosthetic will be better than keeping an injured real limb.

“Basically, the loss of a limb or multiple limbs is an area in which we are very, very focused. There are lots of approaches to restoring some level of function. If you lose a lower limb, obviously you could do a prosthetic replacement. But is there something else we can do? Did that individual even have to lose that limb? Is it an issue of muscle loss, bone loss, nerves? How can we take what we know and apply new techniques coming into clinical trial so individuals do not elect amputation when the limb can be saved?

U.S. Army Spc. Saul Martinez trains with a medicine ball while standing on a balancing tool and using the hands-free harness walking gait-training device during a therapy session in the new Comprehensive Combat and Complex Casualty Care (C5) facility. C5 is a program of care that manages severely injured or ill patients from medical evacuation through inpatient care, outpatient rehabilitation, and their return to active duty or transition from the military. The new 30,000 square-foot facility incorporates new, state-of-the-art technologies that improve prosthetic and rehabilitation services including a 3,500-square-foot multi-terrain obstacle course, a 30-foot climbing wall, and a technologically advanced training apartment. U.S. Navy photo by MC2 Greg Mitchell

For military personnel, both while still in uniform and in later life as veterans under VA medical care, any advancements in artificial limbs, new ways to restore or improve hearing or vision, reconstructive surgery or other techniques for skull, dental, facial, or other severe injuries are covered by the nation’s contract with those who fight its wars. While those same advances also become available to the civilian population at large, ease of access does not.

“Medicare is looking closely at what should be paid for for civilians, especially prosthetics,” Scherer said, “but we are here to look at what can be developed and made available.”

After only three years of bringing a new level of coordination and focus to some of the most difficult and cutting-edge technologies and procedures in combat medical care, CRMRP is anticipating the development and eventual clinical use of a number of products. Those include:

• engineering skin products, bio-printing artificial skin in the field, and using stem cells to effect repairs to burned skin;
• Compartment syndrome treatments to reduce post-surgical inflammation, a potential cause of impaired blood flow, nerve damage, and muscle death.
• products to heal severe wounds without scarring, leading to both increased function and improved cosmetic appearance;
• improved and more “natural” foot and knee prosthetics and the capability to rebuild lost bone and tissue by capitalizing on advances in neural interfaces, nanotechnology, and prosthetic design; and
• improved eye injury diagnostics, treatments, and technologies to rehabilitate and restore vision.

Even with U.S. forces withdrawing from Iraq and Afghanistan and ever-tighter budgets anticipated through the next few years, Scherer believes the military will continue to push forward in developing new medical technologies and techniques. It is a requirement not only to meet the lifelong needs of those injured during Operation Enduring Freedom-Afghanistan and Operation Iraqi Freedom, but also wounded warriors from previous and future conflicts.

“Combat casualty care, infectious research, and so on were in existence prior to 9/11, so I would say we will continue on in this office because the injuries already sustained will still be there,” he concluded. “Just because the conflict is over, those injuries already have been sustained and our job is to return their function. The future is uncertain with budget cuts, but I have heard no talk of what we are doing here being disbanded.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

One such example is Jeff Miller of Hendersonville, N.C., and the many people in his community who have supported HonorAir – a local chapter of the Honor Flight Network.

In September 2006, Miller had gathered enough donations from local businesses and citizens to charter two round-trip U.S. Airways flights that would take a total of 211 World War II veterans from Asheville, N.C., to Washington D.C. for a day-long tour of the war memorials. Upon their landing in the capital, they were greeted by a band before boarding buses that took them to the National World War II Memorial, Arlington National Cemetery to watch the changing of the guard at the Tomb of the Unknowns, Lincoln National Memorial, Vietnam Veterans Memorial, Iwo Jima memorial, and the Air Force memorial.

The flights were funded entirely by donations from the local community – from individuals to Boy Scout troops that held fundraisers in front of grocery stores. When people found out what Miller’s group was doing for veterans, they literally reached into their pockets and gave whatever they could afford on the spot.

During his first trip with the group, Miller had arranged to meet Earl Morse, a private pilot who already had been taking veterans to the capital on a different scale – leading groups of small personal aircraft from Springfield, Ohio, with veterans as passengers. “He flew over to meet up with us and see what we were doing,” says Miller. That’s when we decided to combine our efforts, and we created the Honor Flight Network.”

Soon, Morse was buying blocks of seats on Southwest Airlines flights for veterans from his area. And with some key national news coverage, it wasn’t long before more similar regional organizations – under the Honor Flight umbrella – started popping up all over the country. Today, there are dozens of Honor Flight groups around the country.

Over the years, Miller has been involved with about 20 flights. He’s found financial and logistic support from individual citizens, the local Rotary club (which has drummed up funding for multiple flights), and corporate sponsors. He estimates that a single flight and tour out of Asheville Regional Airport costs about $60,000.

Not every state has a chapter, however. Under the Lone Eagle program, Honor Flight also makes arrangements for individual veterans who live in areas that have no regional chapter. They are flown to Washington and tour the memorials with groups from other regions. Honor Flight also recently started a program called TLC (Their Last Chance), which flies terminally ill veterans of other wars to Washington.

The Grand Tour

A flight with HonorAir veterans aboard is given a water cannon salute at Ronald Reagan National Airport. Photo courtesy of HonorAir

“It’s evolved so much since we started,” says Miller, whose tours land at Reagan National Airport, noting that the airport rolls out the proverbial red carpet for the arriving veterans. “When the plane arrives, it’s given a water cannon salute, and when the men get off the airplane, they are greeted by anywhere from 100 to 300 people cheering and waving flags. We have part of the National Symphony Orchestra’s brass section set up – they do that all on their own. “Then we take the veterans down to the coach busses, and we get a police escort to the World War II memorial.”

For the day, veterans are assigned support volunteers depending on their physical needs. For independently mobile veterans, Miller says there might be one volunteer assigned to three veterans. But wheelchair-bound veterans get one-on-one support.

“I can’t say enough about the way they treated us, from the reception that we got to the way they took care of us all the way through,” says Horace Flack, a World War II sailor who went on an HonorAir tour in 2006.

Flack still recalls his visit to Arlington National Cemetery very proudly. “We were there for the laying of the wreath ceremony, and two of our guys were able to participate. One had served in Patton’s 3^rd Army, and I believe the other fellow was a Marine who was at Iwo Jima. They laid the wreath,” says Flack. “Some of the men were in wheelchairs, and they were given room up front so that they could see. It was a very moving moment.”

When the veterans return home that same evening, they are often greeted by crowds of family and supporters at their home airports. According to Miller, one flight that was sponsored by a local Borg-Warner factory had a couple thousand of the company’s employees waiting at the gate for the group’s arrival.

“That kind of ‘welcome home’ is the ‘welcome home’ that 99 percent of them never got when they returned from the war,” says Miller.

It’s that welcome home, the camaraderie of being with fellow veterans, and the continued recognition of their service that leave an impression on men like Flack.

“I’ve had veterans tell me that it gave them a reason to live,” says Miller. “I’ve had family members tell me that it added years to their grandfathers’ or fathers’ lives. And I’ve had some tell me that it helped them open up to their families about what happened to them [in the war] – things that they’d had bottled up all their lives.”

Running Out of Veterans

Sadly, Miller says that many local chapters of the Honor Flight Network are slowing down or consolidating their flights with other nearby chapters. It’s not that the local organizers are running out of donations, rather they’re running out of veterans. “Louisiana did more than 20 flights out of that state, but they’ve ceased operations. North Carolina’s last flight will be this Veteran’s Day, and I’ll be on that flight with them,” says Miller.

“We’re more on the tail end than the front end,” he says, “as some of these groups have run their course – and run out of veterans to serve in their area.”

“It’s really sad,” says Miller. “I keep up with these guys, and I’d say 30 percent of the ones I’ve taken to DC are gone now.” He says that he keeps a roster of the first 600 veterans that went to DC with him. “I put a red dot next to their name and write the date when I know that they passed away. There are way too many red dots beside those names.”

The oldest confirmed human – a French woman named Jeanne Louise Calment who died in 1997 at the age of 122 – marked what generally is thought to be the maximum human lifespan. However, recent research indicates there may be no absolute maximum lifespan, only a life expectancy limited by infant mortality, childhood deaths, disease, accidents, and war.

When Social Security was enacted in the United States in 1935, it set a benefits-eligible retirement age of 62, which was beyond the actuarial tables’ American life expectancy at the time. That has increased, for full benefits, to about 67 today, but U.S. life expectancy for those reaching retirement is more than 10 years beyond that age and the number of Americans living into their 80s, 90s, or even past 100 has increased dramatically.

While that – and especially the beginning retirement of the Baby Boom generation (born 1945-65) – is putting Social Security under extreme pressure, an aging population of military veterans – significantly expanded by a decade of war in Southwest Asia – will do the same for the Department of Veterans Affairs (VA). Even the Department of Defense (DoD) is being affected, with service members living longer, healthier lives not as eager to leave the military and the new TRICARE for Life program acting as a Medicare supplement for veterans 65 and older.

The current veteran population dates back to those born as early as the 1920s and grows larger with each succeeding generation. Even with better overall health, those numbers mean the VA will face a constantly increasing demand for health care, at least through most of this century. And in addition to the possibility of an older active duty, Reserve, and Guard population, more veterans also will mean increased TRICARE for Life expenditures for DoD.

War and military medicine – especially in the past decade – have played a significant role in increasing American life expectancy. Treatments for what in the past would have been fatal wounds, improved long-term care and rehabilitation, and advances in bio-technology, regenerative medicine, transplants, etc., for the military have provided equivalent life-saving care to the civilian population. And military medical research, which has become far more expansive and intensive in recent years, also has opened new doors and possibilities for non-military-specific research that could dramatically increase human health and life expectancy even more.

World War II veterans sign autographs after a commemoration ceremony at Angoville au Plain, France, June 4, 2011. The ceremony honored two medics from the 101st Airborne Division who rendered aid to 80 combatants and a local child in 1944 during the war. The U.S. military and government have pledged to provide health care for all veterans, a challenge given increased life expectancy and current economic conditions. U.S. Army photo by Staff Sgt. Tramel S. Garrett

“That’s a good news story – there’s no question people are living longer and we hope both the DoD and VA health care systems will add to that,” said Dr. Jonathan Woodson, assistant secretary of Defense for Health Affairs and director of the TRICARE Management Activity. “And if we build healthier populations, we can care for these individuals longer and at lower cost.

“But for those wounded in war who are likely to survive longer and require services, I would like to state unequivocally we have a commitment and understanding to provide services for as long as they need them. That includes prosthetics, mental health care, etc. One of our strategies is to improve overall population health, making sure we bring the important focus to prevention measures to keep our people healthy as long as possible.”

Not everyone is as sanguine about the prospects of a population of centenarian – much less super-centenarian – veterans later in this century and beyond, as there is general agreement many young warfighters now in combat in Afghanistan almost certainly will still be on the VA health care rolls at and after the turn of the 22nd century.

The Census Bureau reported the number of centenarians in the United States more than tripled from 1980 to 2010. And according to the Department of Health & Human Services (HHS) report, “A Profile of Older Americans: 2010,” the United States will see a 36 percent increase in the over-65 population during this decade alone.

“By 2030, there will be about 72.1 million older persons, almost twice their number in 2008 [and more than 23 times as many as in 1900]. People 65-plus represented 12.9 percent of the population in the year 2009, but are expected to grow to be 19.3 percent of the population by 2030. The 85-plus population is projected to increase from 5.6 million in 2009 to … 6.6 million in 2020,” the report predicted. “In 2009, 41.6 percent of noninstitutionalized older persons assessed their heath as excellent or very good, compared to 64.5 percent for all persons aged 18 to 64 years.

“During the next three to four decades, we can expect a very dramatic increase both in the number of elderly persons and in the proportion of elderly persons in the population. The arrival of the large Baby Boom cohorts at age 65 will trigger the large increases in the number and percentage of elderly in the next half century. These prospective demographic changes have given rise to a general concern about the social, economic and physical ‘health’ of our nation’s population,” according to the report.

As the Baby Boom generation continues to age, it will push each succeeding age category to record highs – such as an estimated 88.5 million people age 65 and older by 2050. That includes a 400 percent increase in the over-85 population, boosting their part of the total population from about 1.4 percent today to 5 percent by midcentury. Aside from the sheer number of Baby Boomers, those changes will be heightened by shifts in birth rates, the volume and age pattern of future immigration, improved medical care – and lower birth rates in the generational groups born after 1965.

“The rapid growth of the elderly, particularly the oldest old, represents in part a triumph of the efforts to extend human life, but these age groups also require a disproportionately large share of special services and public support. There will be large increases by 2030 in the numbers requiring special services in housing, transportation, recreation, and education, as well as in health and nutrition,” the aging report continued.

“There will also be large increases in some very vulnerable groups, such as the oldest old living alone, older women, elderly racial minorities living alone and with no living children, and elderly unmarried persons with no living children and no siblings. These are also groups with high percentages living in poverty or with low incomes. The number of persons requiring formal care (mainly nursing home care) and informal care (mainly care at home) will rise sharply even if the share of persons at each age remains unchanged. Accordingly, there will be a large increase in the numbers participating in various entitlement programs, such as Social Security and Medicare.

Retired U.S. Air Force Master Sgt. Alfredo Alferez, left, undergoes a screening for diabetes, provided by the 61st Medical Group, at the annual Retiree Expo in the Gordon Conference Center, Los Angeles Air Force Base, Calif., June 26, 2010. U.S. Air Force photo by Joe Juarez

And the VA.

Committees in both houses of Congress, as well as independent studies by DoD, VA, HHS, academia, and others, are trying to determine the best projections, not only for the number of increasingly older veterans, but also what it will cost to continue benefits. Those numbers also tend to change rapidly, as with the VA’s August 2010 extension of grant payments to Vietnam veterans for Parkinson’s Disease, certain types of leukemia, and heart disease – the nation’s leading cause of death – in addition to lung cancer, prostate cancer, and other major ailments. The initial cost projection for that change, based on disease rates in the general population, was $42.2 billion across 10 years, but a later recalculation, looking only at Vietnam veterans, raised that projection by 60 percent, to $67 billion.

“The irony [is] that the veterans who saved this country are now, in a way, not helping us to save the country in this fiscal mess,” Sen. Alan Simpson, R-Wyo., an Army veteran, former chairman of the Senate Veterans’ Affairs Committee and co-chair of the president’s deficit commission, said at the time. “It’s not that I’m an uncaring person, but common sense is the most uncommon thing in Washington.”

However, there are those who believe an aging population will cost the government less. In order to reach those high ages, they first must survive the most costly and health-destructive period in American life – the 50s, where obesity, lack of exercise, poor diet, etc., are the leading causes of poor health and death. Those who live beyond 70, especially with the ongoing and increasingly rapid evolution in medicine, thus are likely to be healthier, overall, than those in middle age.

A National Research Council study released in January 2011 confirmed better health care for middle-aged Americans will lead to longer lives. While that also would mean more funds to cover later-life pension and Social Security benefits, the study estimated it also would result in a major decrease in health care costs – nearly $18,000 per person. That converts to a health care savings of more than $1.1 trillion by 2050, more than half in government payments.

The nation’s oldest veteran and last surviving combatant from World War I – having lied about his age (16) to join the Army in 1917 – died in February 2011 at the age of 110. While there are few veterans even close to Frank Buckles in longevity, more and more are moving in that direction. An 18-year-old who went to war in 1942, for example, would now be almost 90, which is no longer a major anomaly.

VA costs also are likely to begin rising as more and more veterans become Internet literate and learn about programs they may not have known existed. One VA analysis reportedly discovered only 27 percent of veterans and 14 percent of surviving spouses with potential eligibility have applied for the Veterans Non-Service Connected Improved Pension Benefit Program. It is open to any veteran (including Coast Guard) with at least 90 days active duty, at least one of which was served during a U.S.-declared war, even if not as a combatant. The benefits help cover specific financial needs for those demonstrating a physical need for health care not already covered.

States, counties, and cities also are beginning to expand services to veterans, programs that also will be affected by a population increased by post-9/11 military expansion and living decades longer than their predecessors. New York State, for example, estimates at least 78 percent of its 1 million resident veterans are older than 55, with both total numbers and ages rapidly increasing.

Then-Chief of Staff of the Army Gen. George W. Casey, left, and then-Chairman of the Joint Chiefs of Staff Navy Adm. Mike Mullen give interviews at the premiere of the HBO documentary "Wartorn 1861-2010" Oct. 28, 2010, at the Pentagon. The film explores the history of post-traumatic stress disorder and its impact on service members, veterans, and their families. New health concerns may develop in the future for veterans of today's wars related to TBI and PTSD, along with recognized age-related illnesses. DoD photo by Mass Communications Specialist 1st Class Chad J. McNeeley, U.S. Navy

Concerns about the impact of aging veterans on the VA health care system are not new, as evidenced by a 1983 National Institutes of Health (NIH) study entitled, “Aging Veterans: Will They Overwhelm the VA Medical Care System?” But it is more than just raw numbers and percentages or even increasing age.

With each increase in human life expectancy has come the appearance of ailments rarely – if ever – seen before, simply because few people lived long enough for those to appear or become life-threatening. Adult onset (Type II) diabetes and Alzheimer’s are two major examples, but others may develop in the future as the result of recently recognized combat-related problems, such as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI), along with problems that may develop with increasing age for amputees or those who survived severe burns.

According to the VA National Center for PTSD, “many older veterans find they have PTSD symptoms even 50 or more years after their wartime experience.” As combat-related problems, both TBI and PTSD are as old as war itself, the latter previously having been known as “shell shock,” “battle fatigue,” “combat stress reaction,” etc. But only now, with the accumulation of clinical data leading to its redesignation as PTSD, are those afflicted living past age 75 in large numbers.

“Many older Veterans have functioned well since their military experience. Then later in life, they begin to think more or become more emotional about their wartime experience. As you age, it is normal to look back over your life and try to make sense of your experiences. For Veterans, this process can trigger Late-Onset Stress Symptomatology (LOSS),” according to the VA.

Similar age-related developments already have begun to emerge or are expected for those who survived a range of battlefield wounds that would have meant death – or significantly shorter post-combat lives – in earlier wars.

Another change in the veteran population – and one with significant questions as they grow older – is the number of women who have served in the military, especially in the current conflict. While comprising only about 1.8 million of the nation’s 23 million living veterans, women are one of the fastest growing segments of that population. The VA estimates female veterans will increase from 7.8 percent today to 10.5 percent by 2020. Given women in the United States continue to outlive men by five to 10 years (although that gap has been growing slowly smaller) and more women are joining the military, by 2050 they are expected to be a significant share of the veteran population – especially those 70 and older.

An aging population is more widespread than U.S. military veterans, of course. It extends to the entire U.S. population and globally, with the number of people age 65 and older worldwide expected to double by 2040 to 1.3 billion – 14 percent of the Earth’s forecast population at that time – according to a National Institute on Aging study. Medical advances developed for the U.S. military – and following on to the care of veterans – also will affect global health care, just as developments elsewhere will have application in the United States.

The big question for the VA – and all federal, state, and local governments – as the 21st century progresses will be cost: With a presumably unshakeable pledge to provide health care for all senior citizens – and a particular emphasis on veterans – but a U.S. and global economy currently facing severe problems, how can that rapidly growing population best be served?

As noted by former Census Bureau Director Louis Kincannon: “The social and economic implications of an aging population – and of the baby boom, in particular – are likely to be profound for both individuals and society.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

Overseeing more than 133,000 military and civilian doctors, nurses, medical educators, researchers, health care providers, allied health professionals, and health administration personnel worldwide is Dr. Jonathan Woodson, assistant secretary of defense for health affairs. He also is director of the TRICARE Management Activity and principal medical advisor to the secretary of defense.

A vascular surgeon and brigadier general in the U.S. Army Reserve, Woodson has had combat deployments to Saudi Arabia (Operation Desert Storm), Kosovo, Operation Enduring Freedom-Afghanistan, and Operation Iraqi Freedom. As a senior medical officer with the National Disaster Management System in 2001, he responded to the Sept. 11, 2001, attack in New York City. Woodson has been awarded the Legion of Merit, the Bronze Star, and the Meritorious Service Medal (with oak leaf cluster).

He recently spoke with senior writer J.R. Wilson about how combat health care has evolved since 9/11 and how the Department of Defense (DoD) is working with the VA and civilian medical community to further advance and maintain cutting-edge technologies and procedures.

The Year in Veterans Affairs and Military Medicine: After a decade of war, how has the DoD health care system changed to meet the medical needs of U.S. warfighters?

Dr. Jonathan Woodson: Throughout periods of war there always are advancements in medical care. Ten years ago we had a legacy system of battlefield care that involved larger, more complex combat support hospitals and infrastructure. The nature of this war and advancements in technology allowed us to meet the mission of superb battlefield care even as we maintain a relatively small footprint far forward.

It begins at the point of injury with a system that allows us to get injured service members to care within that first “golden hour” – a time limit defined by civilian trauma systems and refined by our military medical strategy. So the wounded are taken to medical facilities that can perform resuscitative care in minutes. This has led to unrivaled statistics in the history of warfare, including the lowest killed in action numbers ever.

We also bring advanced technology to the battlefield and medics who have been trained to a level unequaled in the past, certified to EMT [emergency medical technician] national standards and able to recognize and resolve life-threatening injuries at the point of injury. Including significant wounding events, such as those resulting from IEDs, we have specifically addressed ways to stop hemorrhaging and treat TBI [traumatic brain injury].

The care continues on through the continuum, with our overall strategies refined by an unparalleled strategic evacuation system in which a wounded service member can be sent to Landstuhl [Germany], a Level 4 facility, within a day. And the care continues on from there, including transport back to CONUS [the continental United States] for Level 4 and 5 care and reconstruction and rehabilitation.

What have been the most demanding requirements to date?

There are several levels to that. The kinetics of these two wars are a little different from prior combat. There are no battle lines, which makes delivering care more difficult because battle and communications and medical logistics are all intermixed.

One of the things I’m proudest of is, in the early days of the war, some forward-thinking leaders established the Joint Theater Trauma System and Registry. That allows us to examine the care of the wounded warrior and make improvements almost as we deal with them.

Each casualty is entered into the database and care delivered is tracked from the point of injury through the combat support health care system to Langstuhl and back to the U.S. We can then analyze how to improve that care, with weekly conference calls looking at the care given every service member and how to improve that.

Another challenge has been recognizing the extent of invisible injuries such as TBI, mental health support, and building resiliency. We have a strategy now to assess mental health needs and have embedded mental health professionals far forward, which not only is helpful to behavioral health issues but also in treating TBI. And now we have better strategies that begin in basic training to build skills to help service members become resilient and resistant to the stresses of war.

What have been the most important developments in medical technology for DoD?

We can look at individual products, such as the combat action tourniquet, hemostatic agents, resuscitation formulas that look at products to be transfused, fielding of blood supplies, the use of technology in the forward area to support diagnosis and treatment. On the other end, our strategy for training folks in these technologies has included extensive use of medical training simulators, which allow us to produce greater degrees of skill in medics as well as advanced practitioners.

Other advances have been in the way we communicate data, including telemedicine and teleconsultation, which has been a great enhancement in our ability to deliver mental health care to the battlefield when there is not a co-located mental health professional.

And in overall medical capability, with respect to the needs of the warfighter?

You can’t do strategic evacuation without a sophisticated group of health care providers using advanced technology to monitor the wounded en route, especially when the altitude of the aircraft carrying them can alter physiology.

That rapid movement of wounded not only meets their medical needs but also their social and psychological needs, getting them back to their families, who deeply care for them and can contribute to the healing process.

The American public will not accept care [for wounded warriors] that is not at least to the standard of the civilian population – and now, I believe, superior to it. For any injury severity score, which is the metric we use to gauge how sick or injured an individual is, survival rates for the military now surpass those of the civilian sector.

There also has been a growth in health care needs for service families – how is DoD addressing the needs of military spouses and children?

That involves a whole strategy for maintaining care for active-duty family members, who often receive care at military treatment facilities. TRICARE has worked hard, as military members have been deployed, to not interrupt care for dependents left behind. So we have provided more providers and contractors to help support delivery of care.

One specific health care issue I think is important to dependents is the psychological stress on the family, both children and spouses, left behind, as these disruptive and sometimes multiple deployments have become necessary. We have enhanced access to mental health specialists, both face-to-face and via teleconsult, and added a significant number of mental health care providers to our network.

What are the most important medical lessons learned from the war in Southwest Asia?

There are a number of different levels to that. One lesson clearly learned early is if you are going to save lives you must have medics with advanced skills. When injuries happen, our frontline medics, men and women who walk shoulder to shoulder with units going into harm’s way, are well-trained to recognize and address life-threatening wounds by applying these advanced technologies and procedures.

We’ve learned a lot about blood products, especially component blood products in the right proportion – red cells plus platelets – instead of water, which can lead to secondary problems that compromise respiration and cardiovascular function.

We’ve learned a lot about rapid assessment and not trying at the earliest moment to definitively repair all injuries, but instead perform damage control surgery. That means we stop the bleeding and prevent further damage without spending excessive time trying to fix all injuries when the wounded need to be cleared off the battlefield to an area more able to do definitive care.

Dr. Jonathan Woodson, assistant secretary of defense for health affairs and TRICARE Management Activity director, asks Lt. Gen. Eric Schoomaker a question during a briefing at the Fort Belvoir Community Hospital project office, Jan. 14, 2010. Schoomaker is the U.S. Army surgeon general and U.S. Army Medical Command commander. Construction of the $1 billion hospital began in January 2008, and is scheduled for completion this year. When complete, the hospital will be a joint-service facility serving all branches of the U.S. military. U.S. Army photo by Marc Barnes

How does military medicine work with the designers and builders of modern combat equipment – from helmets and vests to vehicles – to help increase and improve protection against injury?

In times past, things were looked at in isolation. Contractors produced trucks and vehicles and helmets in isolation, the safety people looked at safety often based on civilian standards that did not consider the combat environment or preventing [changing types of] battlefield injury. Today that is radically different, so much so we are producing metrics and models to produce equipment to prevent specific medical injuries we have recognized occur.

Unfortunately, there are individuals who do not survive their wounds and armed forces medical examiners use rigorous means to see if their equipment failed to protect those individuals from injury, then feed that to the safety people. So patterns of injury are recognized, as are equipment improvements, to prevent future injury and focus on where to produce improvements.

What role does the DoD play in providing medical assistance to host nation civilians?

If war is viewed as the dark side of humanity, I like to say military health care is what introduces renewed humanity into inhumane situations. We ethically and by mission are responsible for saving lives; once someone is ill or injured, we don’t really distinguish who they are. Obviously that includes host nation civilians caught in the crossfire or injured on the battlefield, and we put as much into saving them as we do our own service members.

That not only is the right thing to do, from an ethical and moral point of view, but I think it has a major role in creating goodwill. I’ve had direct experience in my own deployments, where when host nation civilians see us deliver the same care to them that we do to our own service members, they have a new view of us, no matter what they may think of our politics.

In what ways do you provide field care for and work with host nation and allied medical care, with respect to both military and civilian needs?

Quite extensively, looking at what happened in Iraq and is happening in Afghanistan, where we have multi-national medical facilities.

If you look at what is happening around the world, the United States has the most robust ability to project a military medical system into austere environments, whether for kinetic warfare operations or military operations other than war, such as a humanitarian crisis or natural disaster. But a number of other nations are willing to be partners in delivering care.

After 10 years of war, we have become more skilled at working with international partners and NGOs [non-governmental organizations] and understanding where the military effort starts and stops and should transition to the State Department or USAID or NGO missions or the host nation, which ultimately will have the long-term responsibility for caring for its citizens.

What are the most important ways DoD and VA cooperate on health care?

In the years since 9/11, we clearly understand we need to take a whole-of-government approach to the long-term care and rehabilitation of wounded warriors. One of our most significant partners in that is the VA and the beneficiaries they do or will serve are those we have or are serving. So we have created a number of collaborative programs to allow smooth transition from DoD to the VA care system.

If you take a larger than one partner agency approach to care, you can produce a lot of efficiencies. So we have programs looking at the appropriate use of VA hospitals – the five polytrauma centers – to provide care to active-duty members, especially for TBI. These programs care not only for the physical needs, but the psychological and rehab needs, not only making sure they can walk again, for example, but long-term planning to build new skills and find lifelong jobs.

The VA is helping us a lot in terms of mental health and telemed support, especially for the Guard and Reserve, both service members and their families, along with sharing agreements on training, especially for mental health providers. We have a health executive committee – co-chaired by myself and the deputy under secretary at the VA – to actively look for new projects on which we can coordinate.

How does DoD work with the civilian health care community in developing medical advances, from R&D to testing to training?

We work very closely with our civilian partners. Historically, this is not new, but we have taken it to a new height.

We have a robust ability to do medical research within DoD, but research and innovation have always been a collaboration between the military services, civilian partners, academia, and industry. Academic medical centers, because of their fundamental approach, produce those individuals involved in investment and innovation in the development of new techniques and technologies.

Warfighters and combat support personnel have been called on for repeat tours of duty in Southwest Asia, but what about military medical personnel?

Military medical personnel are tremendous individuals who have committed to this kind of service to troops going into harm’s way. And it is some of the most professionally rewarding work a medical care professional can do.

But there are only a finite number of high-end specialists – surgeons, critical care nurses, etc. – so when you have a war that lasts a decade, clearly some are going to be called upon more than once – and, if asked, they would do it again.

There is an interesting dynamic occurring in the U.S. at this time – the proportion of individuals who have served in combat, in relation to the total population, is the smallest in the nation’s history. So those medical professionals who have served need to tell their stories so others will do the same.

Before 9/11, military doctors and nurses received trauma care experience in urban hospitals; is that still necessary – or are those hospitals now benefitting more from the experiences of returning military doctors and nurses?

That’s an interesting dynamic. In peacetime, the urban centers provide a platform for maintaining skills in trauma management, but in wartime, military health providers have a greater experience and depth in managing complicated injuries.

I do think we need to maintain our connections with civilian trauma centers. The advances we learn about in war eventually should be transmitted to those civilian centers for the benefit of the public at large. And when the kinetic war is over, then it is about maintaining skills and continuing to improve even as we look at non-combat related wounds. Then, if another kinetic war comes along, we have a basis to provide skilled health care providers to care for our warfighters.

Overall, how does current military health care compare to what was in place just before 9/11?

Our effort has always been to stay ahead of the curve and constantly improve what we do. We now have put into place some systems to monitor that.

For families, we do not think access to or quality of care is a problem any more. We continue to have challenges with Guard and Reserve families in remote locations, but we have made great strides, especially in partnership with the VA.

What other changes do you expect in the next 5, 10, 15 years?

Can we do better? Absolutely.

Military health is a complex system that really provides, first of all, a strategy for keeping people healthy, with robust public health and force protection programs on the battlefield. We’re also a learning organization and 10 years of war has resulted in advances in saving lives that would not have been saved in prior conflicts.

This is an area without a lot of existing investigation and science, but we are forging ahead in building and understanding the science, not only for our service members, but also their families.

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

Construction of the Las Vegas VA Medical Center is scheduled to be completed in late 2011, and when it opens its doors in early 2012, on a 150-acre campus at the southwest corner of the I-215 North Beltway and Pecos Road in North Las Vegas, it will offer a long-needed central location for primary care to veterans: a seven-story, 790,000-square-foot medical center housing a 90-bed inpatient care unit, a 20-bed mental health facility, and a 120-bed nursing care unit. The nursing care unit is architecturally tied to the medical center, a multi-tiered structure enclosed in a glass curtain wall and powered, in part, by an advanced photovoltaic system that capitalizes on southern Nevada’s most abundant energy resource.

In Orlando, the new VA Medical Center, a 1.2-million-square-foot, $665 million facility, will be only part of a new “Medical City” under development in East Orlando, a complex that will include the University of Central Florida Medical School, the Sanford-Burnham Institute for Medical Research, the Nemours Children’s Hospital, and the University of Florida Academic and Research Center. Set to open in late 2012, the Orlando VA Medical Center will increase access to medical care for about 400,000 Central Florida veterans. The LEED-certified silver facility, the first VA medical center built on a completely new “greenfield” site since 1995, will include a large multi-specialty outpatient clinic, 134 inpatient beds, a 120-bed community living center, and a 60-bed domiciliary.

The Orlando and Las Vegas medical centers are two of the most recent in a series of ambitious construction projects launched since 2004, when the Department of Veterans Affairs completed the early portion of its Capital Asset Realignment and Enhanced Services (CARES) study of VA Medical Centers nationwide.

“These are long-awaited projects,” said Bob Neary, acting director of the VA’s Office of Construction and Facilities Management. “We have six brand-new hospitals under way; four under construction right now. In Las Vegas and Orlando, two of the biggest and fastest-growing cities in the country, they have never had a VA hospital.”

Fulfilling President Barack Obama's commitment to rebuild New Orleans, Secretary of Veterans Affairs Eric K. Shinseki joined state and local officials for a groundbreaking ceremony for a new 1.5 million-square-foot medical center for the Department of Veterans Affairs. When it opens, the facility will have 120 inpatient beds in addition to 60 transitional-care beds that provide rehabilitation, hospice and palliative care, and mental illness research. The hospital will accommodate a half-million outpatient visits annually. All mission-critical services will be 20 feet above ground level, and the facility will have a heliport and boat dock for evacuations. VA photo by Dennise V. Sauvage

The other new medical centers – in New Orleans, La.; Denver, Colo.; Omaha, Neb.; and Louisville, Ky. – are replacing decades-old facilities that no longer serve their surrounding populations as well as they should. In New Orleans, the need is especially urgent; the VA Medical Center on Perdido Street has been closed ever since Hurricane Katrina incapacitated much of it in August 2005. Since then, care for tens of thousands of veterans has been dispersed among seven clinics and an ambulatory care center, with some VA doctors providing inpatient care at other area hospitals.

Restoring a home base for a completely integrated health system for veterans, including inpatient care, long-term rehabilitation, and research, is an important step for New Orleans. The proposed 200-bed, $800 million medical center, set on 29 acres in the South Market District, will, like the Orlando VA Medical Center, be part of a larger medical district that will include the Louisiana State University Medical Center, the New Orleans BioInnovation Center, and the Louisiana Cancer Research Center. Construction on the VA Medical Center began in late 2010, and delivery of care is expected to begin in late 2014. Several features of the new hospital are noteworthy, including a heliport and boat dock for evacuations, and the location of all mission-critical service areas at least 20 feet above ground.

The New Orleans VA Medical Center represents another first for the VA: It’s the first time the VA has contracted a large project under something resembling the “construction manager at risk” delivery method, which establishes a maximum price early in negotiations. “As the design is going on, there’s a firm price negotiated with the contractor,” explained Neary. “Under federal acquisition regulations, that private-sector model gets a little tricky, so in New Orleans and in Denver, we held a competition with some of the early design drawings available, and firms had to come forward, demonstrate their qualifications, and then also provide us with what we call a ceiling price – they can’t go over that – and then a target price, the price they felt they could bring the project in for. So it’s our hope and expectation – and we believe it’s being borne out – that when they actually had to commit to a price, they knew more about the job, and therefore didn’t have to put in extra contingencies to guard against the unknown.”

The new Denver facility, Neary said, will replace the Denver Medical Center for the Eastern Colorado Health Care System, and is under construction on the system’s campus in the Denver suburb of Aurora. The 184-bed replacement center will include a 30-bed Spinal Cord Injury/Disease Center, a 30-bed community living center, and a research building.

Both the Louisville and Omaha centers are in earlier phases of development, Neary said. “Both those cities have VA Medical Centers, both constructed in the early 1950s, so they’re fairly old. In Omaha we’re in design now and we’ll be building the new hospital on the grounds of an existing hospital. In Louisville, we’re in the site selection process. We’re looking at five sites: the existing site, a site downtown next to the university of Louisville, and then on three greenfield sites – sites that have not been developed in the past. We’re finishing up the environmental compliance review work now.” The final site decision for the Louisville Medical Center is expected sometime in the fall of 2011.

New medical centers are, of course, the VA’s most conspicuous and often-discussed projects, but they don’t represent the totality of the department’s ambitious construction program. Three new projects are under way to provide facilities for the VA’s Polytrauma System of Care, established to accommodate the injuries suffered by many service members in Iraq and Afghanistan. “We’ve had people coming back from the field who, in past wars, wouldn’t have made it home,” said Neary. “They’ve suffered blasts, burns, loss of limbs. These are very sophisticated medical care centers. We’re building new ones to replace the existing ones in Tampa [Fla.] and in Palo Alto [Calif.], and we’re also building a new Level One center in San Antonio, Texas.”

Department of Veterans Affairs Secretary Eric K. Shinseki and Sen. Harry Reid, D-Nev., listen to VA Medical Center Director John Bright explain the construction plans for the new Las Vegas VA Medical Center. VA photo

The San Antonio Polytrauma Center, the nation’s fifth Level One center, is a cutting-edge facility, a three-story, 84,000-square-foot space integrated in the Audie L. Murphy Memorial Veterans Hospital. The center includes a ward, physical medicine and rehabilitation services, prosthetics services, and polytrauma research and support programs.

The department has also recently completed, or is currently building, spinal cord injury centers in New York; Milwaukee; Syracuse; Dallas; Minneapolis; Chicago; and Brockton, Mass. Across the country, many outpatient clinics are under way (the Fort Worth Clinic, opened in November 2010, is the largest outpatient clinic in the nation); as well as various improvements, expansions, renovations, and retrofits. The VA strives for maximum efficiency in every facet of a project, from contracting methods to the choice of building materials to power supply.

Many VA projects, some funded by the American Recovery and Reinvestment Act (ARRA), have replaced or supplemented aging power plants with renewable energy resources; VA has contracted no fewer than 40 photovoltaic projects at medical centers and national cemeteries across the nation. “For every project,” said Neary, “we’re looking for ways to include renewable energy. We’re putting in photovoltaic solar systems, and new and much more efficient heating and power plants. We’re also installing windmills at several facilities around the country to generate electricity.”

Newer VA projects also feature retrofits that ensure earthquake resistance, which has been a top priority for the department since the 1971 San Fernando earthquake, in which 49 people were killed in a partial collapse at the local VA hospital. Of the four new major projects proposed in the department’s FY 2012 budget, three have been prioritized primarily because of the seismic safety risk faced by existing facilities.

The Standard in Patient-centered Care

Anyone can build a new hospital, of course; it’s the VA’s focus on patients that places its medical centers at the leading edge of care in the United States. The VA’s new hospitals aren’t just bigger and newer – they’re better, in many ways.

“By far the most important difference [between old VA hospitals and new],” Neary said, “is the concept of patient-centered care: designing facilities primarily with the patient in mind, and having more home-like environments. In recent years we’ve had a very robust program of physical plant upgrades, with a focus on improving patient areas, improving clinic space, and getting better efficiencies. It used to be one exam room per doctor – when you finished examining a patient, you went for coffee while they cleaned the room and got the new patient in. Now we’re putting two and three exam rooms into a space, so physicians can move from room to room, and the staff has the patient in place.”

Retired Capt. James A. Lovell, left a NASA astronaut, speaks to more than 750 guests at the official opening of the Capt. James A. Lovell Federal Health Care Center in Chicago, Ill. The center is the nation's first fully integrated Department of Veterans Affairs (VA) and Department of Defense (DoD) entity combining DoD and U.S. Navy medical personnel with VA staff members. U.S. Navy photo by Scott A. Thornbloom

In mental health settings, the long-corridor hospital, designed like any other medical ward, with patients in individual rooms, will soon be a thing of the past in VA facilities: “We’re now building facilities that have more of an apartment-like feel to them,” Neary said. “You have something like a living room, and a kitchen area, and you might have four bedrooms or six bedrooms off that living room. So each patient has his or her own bedroom, and more of a common area with a television and other features. That’s a big deal, a big change in the model of mental health care.”

In ambulatory settings, the VA is designing spaces in accordance with its new model of patient-centered care, the Patient-Aligned Care Team, or PACT. “On a PACT team you have a physician, a nurse,” said Neary, “and you might have a clinical medical physician. You might have a mental health physician. Those folks, instead of having their offices located around the building, will be located in the clinic itself, so that they can do a better job of engaging with the patient. We’re also putting family spaces in; in the hospital rooms themselves, there are larger spaces, so a family member can not only be there for old-fashioned visiting hours, but there might be a fold-out sofa they could sleep on during the night, if it’s appropriate and could be a benefit to the patient. In our physical spaces we’re looking at ways to enhance engagement with the patient.”

The VA finds out what veterans need from its facilities in two simple ways: First, it asks. For all large projects, such as the new medical centers, development is driven in part by a council of veterans who meet regularly with planning and design teams. For facilities that have a narrower focus, a more specialized group may advise; the Paralyzed Veterans of America (PVA), Neary said, have offered their collective insight to help the VA design its spinal cord injury facilities. “PVA has their own group of professional architects,” Neary said, “who work on things like accessibility. They’re very, very knowledgeable people, and they make a big contribution to our work.”

The VA and its design partners also – like so many leading designers of patient-centered health care facilities – rely on studies of how and where patients and providers move and spend their time. Many studies involve the placement of radio frequency identification (RFID) tags on staff members, which then track their movements for up to 60 days or so, to document traffic flows and areas of congregation.

Knowing where people spend their time, Neary said, may sound like a simple thing, but such studies are actually a fairly recent development. Too often in the past, without this knowledge, facility design has allowed other factors – aesthetics, compactness, or simply the inertia of age-old practice – to nudge aside the needs of the VA’s patients. That’s not likely to happen in today’s VA medical centers and clinics. “In our new order of things,” Neary said, “we don’t want to just build a brand-new old place.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

Ramona Kausch assists Spc. Jay Mendoza, from the 23rd Ordnance Company, in creating a new user account with GoArmyEd, a computer portal that must be used for tuition assistance, at an open house at the education center on Rhine Ordnance Barracks. File photo by Christine June, USAG Kaiserslautern

The Post-9/11 GI Bill has been a blessing for service members and veterans seeking education and training opportunities. The law’s benefits are far more generous than its previous incarnation, the Montgomery GI Bill, which covered veterans beginning in 1984. Even in the current budget climate, most Americans agree that better benefits are due to the members of our all-volunteer force who have served in Iraq and Afghanistan – and who have served as never before, in multiple tours that have, in many cases, spanned a decade.

When the first iteration of the Post-9/11 GI Bill was passed in the summer of 2008, it was widely believed that there was, at long last, a veterans’ education benefits bill to match the original GI Bill, which lent aid to more than half the nation’s 15 million World War II veterans and is widely considered to have played a key role in launching an era of optimism and prosperity. The Post-9/11 GI Bill authorized the Department of Veterans Affairs to pay for up to 100 percent of a veteran’s tuition and required fees at a state college or university, depending on the veteran’s length of service.

Subject to some restrictions, the 2008 law also included allowances for housing and books. In certain cases, the benefit could be transferred to the veteran’s spouse or other dependent. Private or graduate schools with tuition higher than the in-state maximum were given the option to participate in the Yellow Ribbon Program, designed to help veteran students who want to attend higher-priced private and public universities. Under the program, the school or institution may provide up to half the amount of the total tuition cost, which will then be matched by the VA.

Fault Lines

Beth Juachon, a Veterans Affairs military services coordinator, explains details of the Montgomery GI Bill for active-duty service members to Naval Special Warfare sailors at Naval Amphibious Base, Coronado, Calif. The Post 9/11 GI Bill offers tuition and fees, yearly books and supplies, and a monthly housing allowance to qualified service members. U.S. Navy photo by Mass Communication Specialist Seaman Megan N. Anuci

The early months of implementing the Post-9/11 GI Bill revealed that, generous as it was, it had some problems. It was difficult – unnecessarily difficult, many critics charged – to process claims, which were calculated on a state-by-state basis. The benefit equaled 100 percent of the tuition and fees at the most expensive public school in the given state, which provided a moving target for processors. Combined with some technical problems, VA’s troubles created a backlog of claims in the fall of 2009.

The law also had some unintended consequences that left certain categories of veterans uncovered. It seemed too narrowly focused on academic, degree-granting institutions, neglecting many opportunities for veterans to pursue vocational training, apprenticeships, or on-the-job training. It failed to account for the prevalence of distance-learning opportunities in the contemporary educational system, neglecting to offer housing assistance to full-time distance learners at schools such as the University of Phoenix or the American Military University. It forced disabled veterans to choose between their Vocational Rehabilitation and Employment (VR&E) benefit and their GI Bill benefit, which have different coverages for tuition and housing. And it left out entirely a significant number of National Guard and Reserve service members – those who served full-time stateside for the purpose of organizing, recruiting, training, instructing, or administering Reserve components, or those who served in support of contingency operations or in response to a national emergency.

It’s important to remember that when it was passed in 1944, the original GI Bill wasn’t perfect, either; it was amended in later legislative sessions to expand and refine benefits. “The folks that worked on this first Post-9/11 GI Bill,” said Tim Ebree, legislative associate for the nonprofit Iraq and Afghanistan Veterans of America (IAVA), “had a huge task, trying to figure out so much information – so many things have changed since that first GI Bill passed. Many of these people were learning for the first time, but they got a great bill passed. Some of the consequences were things that people didn’t foresee. So the veterans service organizations, IAVA and other groups, were saying: ‘Hey, guys, great benefits – we just need to tweak a few things and make it phenomenal.”

2.0: The Tweaks

Reserve Cpl. Stephanie Alexis enthusiastically flips the tassel from the right to left side of her graduation cap during the ceremony in which she received an associate degree in management. Alexis has been working on the degree for the past six years and plans to continue her education using her GI Bill benefits. U.S. Marine Corps photo by Lance Cpl. Scott L. Tomaszycki

In the spring of 2010, a second bill – the Post-9/11 Veterans Education AssistanceImprovements Act – was introduced by Hawaii Sen. Daniel K. Akaka. More commonly known as the GI Bill 2.0, the law addressed these and other shortcomings in the original Post-9/11 GI Bill. Passed during the final hours of the last legislative session of 2010, 2.0 was signed into law by President Barack Obama on Jan. 4, 2011.

Most of the provisions of the Post-9/11 GI Bill 2.0 were effective Aug. 1, 2011, including:

• expansion of GI Bill eligibility to National Guard members who serve on active duty stateside in a number of circumstances, including emergency response or training Reserve components.
• expansion of transfer entitlements – the ability to transfer benefits to a dependent – to include qualified members of the commissioned corps of the Public Health Service (PHS) and the National Oceanic and Atmospheric Administration (NOAA).
• elimination of the confusing state-by-state “undergraduate cap” method of calculating benefits, establishing instead a $17,500 annual tuition and fee cap for private institutions. (The Yellow Ribbon Program still serves to cover costs for out-of-state fees and costs above this cap.) Students attending public schools will still have tuition and fees completely covered, at the rate applicable to in-state residents.
• coverage for a greater number of licensure, certification, or placement tests such as the SAT, GRE, LSAT, and CLEP.
• resolution of the apparent conflict between GI Bill and the VA’s Vocational Rehabilitation and Employment (VR&E) program benefits. One of the most confusing difficulties of the Post-9/11 GI Bill involved the difference, for wounded veterans, between the Post-9/11 GI Bill housing stipend and the subsistence allowance of the VR&E program: Under the VA’s disability rating system, wounded warriors are assigned a subsistence rate that’s often lower than the housing stipend for which they’re eligible under the Post-9/11 GI Bill, explained Col. Bob Norton (USA-Ret.), deputy director of Government Relations for the Military Officers Association of America.

“If you are a disabled veteran coming back from Iraq or Afghanistan and you are rated by the VA at 20 percent or greater – in other words you have a disability that came as a result of your military service since 9/11 – you can get counseling services, testing, job placement, and use your GI Bill underneath that Voc-Rehab umbrella,” Norton said. “But your cost of living stipend was way less than the Post-9/11 GI Bill’s. So now those folks who want to go to college and use the VR&E can choose, if they wish, to take the full national average for housing, which in many cases more than doubles what they were getting under VR&E.”

2.0 provisions that went into effect on Oct. 1, 2011, include:

• expansion of the annual book stipend eligibility – up to $1,000 for textbooks – to include active-duty service members and their spouses.
• a living/housing allowance for service members who are full-time online or “distance learners,” of up to half the national average Basic Allowance for Housing (BAH) for 2011, a total of $673.50 per month. Norton thinks this allowance for distance learners – a growing segment of veteran students – is one of the most significant provisions of the Improvements Act. “If you are cranking out online courses in your basement and you don’t go to a physical campus, you can still get $673.50 to help you make ends meet, for whatever you need to do to continue your program,” he said. “This is a great provision for folks who had been excluded before.”
• expansion of coverage to non-degree-granting programs. The VA will pay the same benefit as at degree-granting colleges and universities: the net cost for in-state tuition and fees at public programs; for private and foreign programs, the actual net cost or $17,500, whichever is less. The VA will also provide up to $83 per month for books and supplies.
• expansion of coverage to on-the-job training or apprenticeship programs. VA will pay a monthly benefit based on the amount of time spent in the program, and up to $83 per month for books and supplies.
• expansion to include flight training programs. VA will pay the actual net costs of the program annually or $10,000, whichever is less.
• the online or correspondence training benefit for tuition and fees will be capped at $8,500 annually.

Trade-offs

Though widely supported, the bill was introduced at a time of intense budget pressure. Congress’ ability to pass the law was due, in part, to the fact that it is projected to save $730 million over the next decade. In order to expand coverage to more veterans, some cost-saving trade-offs were necessary, including:

• Prorated housing payments: The monthly housing stipend will now be prorated based on a student’s “rate of pursuit.” This provision, Norton explained, was added to eliminate a deal that was considered a bit too sweet for students who were previously considered “full-time” simply because they took a shade over half of what the VA had designated as a full course load: 12 credits. “It used to be that if you were enrolled for seven credits at a college, you would get the full monthly housing allowance,” Norton said. “So you’d get about $2,400 a month, for example, to take seven credits at San Francisco State – a pretty darn good deal. The government has said: ‘Not really what we intended, not really fair.’” Under the new law, the student in Norton’s example would receive about 58 percent of the basic housing allowance. Prorated payments are probably the biggest money-saver in the Improvements Act – which means a significant number of students will see their housing allowances reduced under the new law, which, while simplifying the formula for tuition payments, makes the calculation of housing/living allowances a bit more complicated for the VA. Three factors – rate of pursuit, locality, and the student’s eligibility tier (the amount of creditable active-duty service) – will now be used to calculate each student’s housing payment.
•  The housing stipend will not apply during mandatory school breaks – when school is not in session, students are assumed capable of earning their rent.
• The $17,500 cap on tuition and fees will, in a handful of states, not cover the entire cost of education at certain institutions – but this doesn’t necessarily mean students will be left out in the cold. The provision is intended not only to save government money, but to urge participation in the VA’s Yellow Ribbon Program, which will pay up to half the total amount of fees and tuition if participating institutions agree to pay the other half.

Still, this provision, more than any other, is claimed to be unfair by some current benefit recipients. In seven U.S. states, Norton pointed out, “if you are already enrolled as a nonpublic school student – in other words you’re in a private college or university – under the change that was passed in January, you had a de facto cut in your benefits because of the new cap.”

Veterans Affairs Secretary Eric K. Shinseki, seated at right, meets with Student Veterans of America on June 11, 2010. Student Veterans of America is a coalition of student veterans groups from college campuses across the United States that works to develop new student groups, coordinate between existing student groups, and advocate on behalf of student veterans at the local, state, and national levels. They provide, peer-to-peer networks for veterans who are attending school, coordinate activities, provide pre-professional networking, and generally provide a touchstone for student veterans in higher education. From left to right (far couch): Rodrigo Garcia, Brian Hawthorne, and Derek Blumke. VA photo by Michael Moore

Overall, Norton considers these trade-offs to be well worth the outcome. Three years ago, he pointed out, few veterans would have contemplated attending private schools at all; most were simply out of reach. “When you consider all the good of expanding the number of veterans eligible now to get all kinds of GI Bill benefits under these fixes,” he said, “it far outweighs the perceived or real cuts, both in terms of the number of people affected and in terms of the quality of the benefit overall.”

A GI Bill 3.0?

Given the budget climate, it’s unlikely that a major expansion of benefits will make its way through Congress anytime soon, though a bill called the Restoring GI Bill Fairness Act of 2011 cleared Congress in July 2011. Essentially, the bill proposes to eliminate the $17,500 cap for students who were enrolled in a private school before the GI Bill 2.0 became law. It’s a minor provision, expressed in an unusually short (four-page) piece of legislation, but restoring those benefits to an estimated 30,000 veteran students will cost about $50 million that has to come from somewhere – in this case, by means of raising home loan origination fees on loans backed by the VA.

“Some folks objected to that on the Hill within committee,” Norton said. “They said: ‘Well, that’s not fair. You’re borrowing from one set of veterans to pay for another.’ … Would we have preferred another source of the funding? Absolutely. Would it happen in this environment? There’s only three ways you can do that: deficit spending, which ain’t going to happen; raising taxes, which ain’t going to happen; or table the bill. When you look across the board at the potential good that this bill does for the current generation of returning veterans – who down the road will be possibly seeking VA home loan assistance – right now they’re focused on job training and college, and that’s what they need moving forward. And this sort of evens out some of the lumps, if you will, that still remained in the 4 Jan. [2011] legislation.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

It all began with a change in attitude and perspective among doctors, both those in the battlespace dealing with wounded warfighters in the “golden hour” after injury and those at advanced treatment and rehabilitation facilities in the United States and at Landstuhl Regional Medical Center in Germany, the first stop between combat and CONUS for most severely wounded warriors.

“Early in the war there were issues related to the salvaging of limbs. When we discovered better ways to do that, we got that information to the field to ensure all limbs that can be saved are saved,” Dr. Jonathan Woodson, the assistant secretary of Defense-Health Affairs, said. “So the system has done a good job of being a learning organization and improving strategies for care.”

Like Woodson (an Army Reserve brigadier general), Air Force Lt. Col. Michael R. Davis, chief of Reconstructive Surgery & Regenerative Medicine at the Army Institute of Surgical Research (ISR) – has served as a combat surgeon. His experiences in theater and at USAF hospitals in the United States led him to focus on finding faster and less painful ways to improve both functionality and aesthetics for warfighters with extremities loss or severe damage.

“As a surgeon stationed in Afghanistan, I witnessed firsthand the impact of that on our troops and, back here, I have seen an increasing capability in being able to care for these injured soldiers,” he said. “We have a great responsibility to develop techniques and technologies for those in need. And with the conflicts drawing to a close, there will be a heavy emphasis within the military medical community to further those advances.

U.S. Marine Corps Sgt. Jordan Pierson climbs a 30-foot rock-climbing wall during a therapy session in the new Comprehensive Combat and Complex Casualty Care (C5) facility. C5 is a program of care that manages severely injured or ill patients from medical evacuation through inpatient care, outpatient rehabilitation, and their return to active duty or transition from the military. Prosthetics today must be designed with active-duty personnel in mind, because many amputees are choosing to remain in the armed forces. U.S. Navy photo by Mass Communications Specialist 2nd Class Greg Mitchell

“In the past, the standard was to reconstruct everyone, salvage every possible limb. But over time, as prosthetics have become more advanced and the benefit of a prosthesis has gone up, we have seen many cases where patients are more debilitated than they would have been with primary amputation. That has caused a paradigm shift in the orthopedic and reconstruction communities about how they feel about reconstruction versus primary amputation and prosthesis.”

The new prosthetics provide more than just better functionality, added Lt. Col. John M. Scherer, director of the Army’s Clinical and Rehabilitative Medicine Research Program (CRMRP), they offer the prospect of a return to duty or a far more “normal” civilian life.

“Most prosthetics before were not designed with a highly active 20-year-old amputee in mind. In addition, we now are looking at them from a combat environment requirement, because we have deployed people back into the combat zone with lower extremity prostheses,” he explained.

“Outside the military, they normally don’t have to be waterproof or sandproof because, if the weather is bad in the U.S. and you have a powered prosthetic limb, you either don’t go out or make sure it is protected from the weather. You can’t do that in combat, so there have been changes to make the batteries last longer and function in harsh environments – sand, heat, water, exposure – as well as giving them additional functions, such as the ability to go backwards.”

CRMRP is working with the Military Amputee Research Program to capitalize on advancements in neural interfaces, nanotechnology, and prosthetic design to improve foot and knee prosthetics, knee prosthetic control, and haptic [touch] feedback. Their coordinated research is designed to improve prosthetic performance through advanced clinical practices and strategies, but also will contribute to the overall advancement beyond prosthetics.

The vast majority of advances during the current conflict have involved replacing amputated feet and legs.

“Microprocessors in the knee have replaced control by the physics of the prosthetic movement. Basically, that makes you fall less and your gait is closer to normal, so you don’t injure the healthy limb. From that perspective, there has been a huge improvement in the ability to walk in a normal way compared to how you would have moved prior to these advancements,” Scherer said.

“There really has not been a lot of effort in changing the current state of the art for upper extremities – which includes the ‘hook’ that has been used for quite a while. There are lots of reasons for that, but DARPA’s [the Defense Advanced Research Projects Agency’s] prosthetics program has brought a lot of robotic improvements to upper extremity devices and we hope to go into clinical trials soon. Most of the biomechanical neural interfaces to prosthetic limbs also are being done by DARPA. And that is the holy grail – making the prosthetic work with a neural interface, with feedback, so you can actually feel in your ‘fingertips’ what you are touching and do direct movement.”

Advancements in lower limb prosthetics that have enabled many amputees to regain a more normal life also have resulted in a new development that concerns many in military medicine: Warfighters whose damaged feet or legs were saved by advances in battlefield and follow-up surgery asking to have the limb amputated anyway because they believe a prosthetic would give them greater functionality than their reduced capability real foot or leg. Those advances also give warfighters other “positive” arguments for amputation.

“Someone who undergoes primary amputation will heal and get through the process of rehab much faster. Someone who undergoes limb salvage could face 10 or more operations over a period of years before they see adequate healing and rehabilitation – if they ever get to a point of full functionality. So it requires very careful patient selection for complex reconstruction and who we recommend for primary amputation and fitting of an advanced prosthesis,” Davis said, but added new options are becoming available. “You can’t compare a prosthesis to a natural limb, but you can compare it to a reconstructed limb using techniques such as free tissue transfers and bone grafting.”

Sgt. 1st Class Leroy Petry salutes former Chief of Staff of the Army Gen. George W. Casey Jr. with his prosthetic hand at the Center for the Intrepid on Fort Sam Houston, Texas, Nov. 17, 2008. Prety received the Medal of Honor on July 12, 2011. U.S. Army photo by D. Myles Cullen

Historically, medical research has been an isolated pursuit, both in terms of competition in academia and industry and in a single-issue or application focus, such as brain injuries, orthopaedics, dentistry, etc. In recent years, however, the U.S. Military Health System has sought to bring multiple university and commercial researchers and disciplines together to pursue specific issues but also to share knowledge and find new applications for what works in one area to the needs of another.

Col. Robert G. Hale, commander of the Army Dental Corps’ Dental and Trauma Research Detachment (DTRD), spends the majority of his time on issues related to regenerating bone, tissue, muscle, and nerves, including face transplants, and ways to block or kill biofilm, which causes plaque and gum disease in the mouth but also keeps open wounds from healing. Tapping into DoD-sponsored multidiscipline research has brought new solutions to his concerns, while DTRD advances are finding applications in amputation and prosthetics – and moving beyond both.

“Advanced bone regeneration biomaterials, better than our most recent capabilities, could improve patient outcomes with fewer and less invasive surgeries, both for craniofacial and limb salvage. Another advance is adipose fat, which regenerates very quickly. If we can tap into the regenerative abilities we know exist in fat and place that into a wound, it can heal with less scarring and improve mobility anywhere on the body there is movement,” he said.

“A follow-on, perhaps starting next year, will be a stem cell-enriched fat. We may not be able to regenerate an arm muscle in the next 10 years, but maybe in 15 or 20 years we can slide a scaffold under the skin, then inject stem cells that will homein on that scaffold and help patients recover better.”

Tissue scaffolds are considered the medical implants of the future. Made of fully degradable biomaterials, they support cells at the site of injury and assist the body in growing new, functional tissue. Once that new tissue has successfully replaced damaged or lost tissue, the body’s natural systems will dissolve and recycle the scaffold.

Currently, the cells used in that process are either produced synthetically or taken from the patient’s body and processed for application to the wound or transplant area. That process is expected to become substantially more successful with the use of stem cells – unspecialized cells with the ability to transform into specialized cells in the body. Adult stem cells, recently found to be both more plentiful and more adaptable than previously thought, are at the center of many medical research programs.

While those efforts cannot regenerate entire limbs – yet – in combination with bioactive factors and biomaterials, stem cells can form new bone, nerves, and soft tissue (skin, tendons, muscles, blood vessels) to replace damaged tissues and speed recovery. Even if salamander-like limb regrowth does become possible, however, growing a new hand, arm, foot, or leg that would be a true part of the patient’s body may have more drawbacks than advantages.

“There are studies under way to figure out how other organisms can regenerate body tissues and hopefully translate that into a human ability to do the same. The answer probably will lie with stem cells, but to regenerate something as complex as a hand is still science fiction,” Davis said.

“In another hundred years, will we be further along in terms of that kind of capability? Yes. The problem is, when someone needs a functionalized limb, growing one can cause substantial delay. So even if that becomes possible in the future, the time involved to complete the process may be prohibitive.”

Continued advances in limb salvage that return the damaged hand or leg to an acceptable level of function and appearance are seen as the best hope to avoid future amputations. For those who already have lost a limb or future wounded warriors whose limbs cannot be saved, if full regeneration is not a viable option, the ultimate answer may lie in improved biomechanical interfaces and – for hands, at least – transplants, from human donors or using hands cloned from the patient’s DNA.

Rear Adm. Elaine Wagner, director of Medical Resources Plans and Policy Division and chief of the Navy Dental Corps, is shown the advanced features of various prosthetics by Dr. Joanne Smith, president and chief executive officer of the Rehabilitation Institute of Chicago, during a Chicago Navy Week 2011 event. U.S. Navy photo by Valerie A. Kremer

Because a cloned limb would take as long to grow into adult size and appearance as the original, that source for a hand transplant would be a long-term solution, requiring some other approach immediately after amputation. While using a donated hand for transplant appears to offer the best choice, as with any surgical procedure, it has drawbacks, including an average 16-hour operation – twice that of a heart transplant. Finding a match also is more difficult than with a heart – in addition to all the usual blood and tissue match requirements, it also has to match the recipient’s age, sex, hand size, and skin color.

“There is a debate over what would make a hand transplant standard care. For a bilateral hand amputee, there is no better way to rehabilitate someone than through a transplant. But what if it is a single hand – either dominant or non-dominant? Those questions are still subject to determination, and whether they are still experimental or part of standard care is still a great debate within the military and civilian medical communities,” Davis explained.

“There needs to be great collaboration among the facilities doing these procedures to answer those questions and advance the field. And we are seeing that, with centers coming together and forming groups to answer these questions. We really need to go forth responsibly, not just doing transplants because we can, but because we should. Ultimately, those are patient decisions, but we need to be in the best position to recommend a course of care.”

One of those facilities is the Atlanta VA Medical Center and its affiliate, Emory University, where Dr.  Linda Cendales performs hand transplants and is conducting a new VA study tracking transplant patients.

“In my experience, patients report the new hand has been better for them than the prostheses they were wearing,” she said. “It’s a human hand, not a device. The hand recovers sensation and patients are able to perform activities such as turning doorknobs, holding the newspaper, tying their shoes. It’s not a life-saving organ – it’s a quality-of-life transplant.

“We have a multidisciplinary team that is patient-centered. Our program aims to provide another option for a selected group of patients and to provide the best options overall for our amputees. If it’s a prosthesis, the best prosthesis; if it’s a hand, the best-matched human hand.”

The other leading option for the future is a greatly improved biomechanical interface – linking the amputee’s living tissue to a prosthesis. Some elements of that already are available, some are in or close to beginning clinical trials, some are still in the lab, and, for a few, science and technology have not yet advanced far enough to move them from science fiction to science fact.

One that recently did make that transition is 3-D bio-printing – similar to industrial fast prototyping, where a solid object is built, layer by layer, from special plastics or other materials. In this case, researchers at Wake Forest University have successfully “printed” human skin. While a revolutionary leap in current technology, it may be years from wide-scale clinical use for other body parts.

“Being able to print biological materials, such as skin, will greatly advance our ability to create functionalized synthetic reconstructive tissues. It holds a lot of promise, but bio tissues are complex and much more difficult to synthesize and print than industrial materials,” Davis noted. “So I think that capability will come, but not in the near term.”

In the meantime, tissue regeneration in vitro, using processed body cells or adult stem cells, may be combined with new titanium bone implants to resolve a number of problems with the interface of prosthetics and human bodies. First on that list is bacteria entering the space where the prosthetic connects to the body; second is the body’s tendency to reject the prosthetic as a “foreign body.”

Both are being addressed by VA-sponsored research led by Thomas Webster, associate professor of engineering and orthopaedics at Brown University. Webster’s team has developed two techniques, which may work together: first, modifying the surface of titanium leg implants to promote cell growth and create a natural skin layer to seal the gap; second, covering the implant connection point with a molecular chain of proteins to hasten skin growth.

“You definitely have a complete layer of skin,” Webster said of the process. “There’s no more gap for the bacteria to go through.”

Improving prosthetics and how they connect to and work with the body, and developing new techniques to replace prosthetics or even avoid the need for amputation are subjects of active and intense research across the DoD, VA, academia, and industry. While spurred by a modern record number of severe combat limb injuries and amputations, it is an effort that will continue long after the last U.S. warfighter leaves Afghanistan.

“The biggest point to all this is we have a responsibility to get the best possible outcome for our wounded service members, who risk their lives every day and many suffer devastating injuries. I’ve seen these injuries firsthand while stationed in Bagram [Air Base, Afghanistan] and, knowing our current capabilities, realized the long-term outcome was not nearly as good as we could achieve. And they deserve the best outcome possible,” Davis concluded.

“Many within the military have the capability to advance these techniques, which in combination with top-level support and funding for this research, creates an environment where we can help them. What this does is create hope for our warfighters, which is one of the most positive outcomes of what we do, that a wounded service member can regain functionality they lost to injury.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

With these encrypted records available to authorized caregivers wherever a service member or veteran may be, getting emergency care, seeing a new doctor, filling a prescription, etc., have become far easier and faster. It also provides a valuable safety factor. When Hurricane Katrina destroyed VA facilities and records in New Orleans, La., for example, veterans only had to go to the nearest unaffected VA center, where their EHRs could be accessed immediately.

“We have made an effort to combine with the VA to create a single EHR, a lifetime virtual record, so from the point of entry into the military through their veteran status, that information can be shared between the military and VA and the private sector,” according to Dr. Jonathan Woodson, assistant secretary of Defense for Health Affairs and director of the TRICARE Management Activity.

The private-sector component is the next major step in the evolution and universal adoption of EHRs.

“We have to put patients first,” U.S. Surgeon General Regina M. Benjamin said. “It is so important that we get our records in electronic format.”

The Obama administration’s 2009 stimulus law included a provision calling for full adoption of EHRs by all health care providers by 2014 – a goal also set by his predecessor. Whether that constitutes a government mandate, however, or even requires sharing all patient records remains somewhat uncertain.

In an October 2010 email response to a query from CBS News, for example, a spokesperson for the Office of the National Coordinator for Health Information Technology, a division of the Department of Health and Human Services (HHS), wrote: “Providers will treat health information the same in the electronic world as they have in the paper world. They will record the information necessary to treat the patient in the electronic medical record [EMR].

“HHS’s rules for doctors to receive payments for meaningfully using health information do not require the recording of any particular test result or procedure. The rule does not require a doctor to include a cancer diagnosis, abortion, or HIV/AIDS diagnosis in an EHR. What is recorded in an electronic medical record remains largely a matter between the physician and the patient.”

Many private practice doctors, while adopting EHRs, have done so reluctantly and with considerable criticism of what most consider to be a government requirement. Converting from paper to digital records can be expensive and time-consuming, as is training staff – and doctors – to use laptops or electronic tablets/pads instead of the paper charts and patient records they traditionally carry into an appointment.

A 2010 study by the University of California-Davis, involving about 100 internal medicine, pediatrics, and family care physicians through a four-year period, found a significant – but anticipated – drop in doctor productivity, down 25 to 33 percent following initial implementation of an EHR system. Within a month, most internists had returned to pre-EHR levels or slightly better, while pediatricians and family doctors continued to show some degree of reduced productivity.

As a result, Hemant Bhargava, associate dean and professor of management and computer science at the UC-Davis Graduate School of Management, concluded: “Our research suggests that a ‘one-size-fits-all’ design does not work – the ideal technology design should vary by physicians’ requirements and workflow demands.”

Indeed, some doctors print out the EHR, put it in a file folder and take it into the examination room, making handwritten notes on the paper record, which is then handed over to a staff “scribe” to be transcribed into the patient’s EHR. Others have been so caught up with hunt-and-peck typing to fill out the digital forms that  patients have complained they are being ignored.

A $27 billion federal earmark was created to help some private practice doctors pay for the conversion to EHRs – but only up to $44,000 each.

At the 2011 annual meeting of the National Association of Medical Directors of Respiratory Care, the group’s president – Dr. Steve G. Peters, a Mayo Clinic pulmonologist – said even his clinic’s substantial resources, including a pre-existing system-wide EHR platform, found compliance with the universal EHR law difficult, at best.

“It sounds easy, but it’s not. It’s very tricky and it differs from measure to measure,” he said, creating a major IT challenge. “We have 85 percent of it there, but the last 15 percent is hard.”

With many doctors predicting the government funds will cover less than a quarter of the actual costs of converting to EHRs, Peters issued a dire forecast to his association: “Many predicted what you’re experiencing, that this incentive will not buy much. No one will admit it, but there is de facto pressure that there won’t be private practice in the future. Everyone will need to report measures on hundreds of patients [and] will need to be part of an organization [to afford it].”

In various medical publications and websites, comments from private practice doctors across the nation tend to echo common concerns and frustrations – along with some with a more positive view:

• “We are not adopting EMR because we think it will enhance our productivity, reduce costs or improve the quality of care we provide … [but] solely to satisfy the desires of our federal and state governments.”
• “We do not adopt EMR with great enthusiasm for the benefits it will provide us or our patients, but with great anxiety, fear and trepidation.”
• “There’s clearly a future [in EHRs], but I don’t believe any of the systems in their current form are where they ought to be and where they need to be.”
• “At the end of the day, the good overtakes the not so good. Change is not always easy. There will be days when things don’t go well. It’s a transition. Educate, educate, educate – and in the case of some physicians, educate again.”
• “I think IT can and will improve quality of health care if used effectively at point-of-care.”
• “The idea that [some providers] would willingly exchange health information and thereby give competitors access to their patients’ longstanding health information and thereby make it easier for competition to woo away their patients strikes a lot of CFOs as totally crazy.”
• “Most providers say after they use [EHRs] for six months, they would never go back.”

Woodson is among those who believe universal EHRs not only are the future of medical record-keeping, but key to the future health of military service members, veterans, and civilians.

“The Military Health System – and more importantly, the TRICARE insurance program – serves more than 1 million beneficiaries. And many of those actually will be served in the private sector. So it is extremely important for us, if we are to monitor access quality and improve care, to communicate with the private sector,” he said.

“Our efforts, combined with the VA, are to look at how we build EHRs that can effectively communicate with the civilian health sector. We look at what kind of common applications and standardization will allow those EHRs to talk to each other going forward into the future.”

As part of that effort, in September 2011 the VA announced an expansion of its pilot Virtual Lifetime Electronic Record (VLER) program for sharing of veterans’ health records.

“The expansion of the VLER pilot program will allow more veterans and facilities to participate in this exciting new technology,” predicted VA Secretary Eric K. Shinseki, a retired general and Army Chief of Staff. “It will keep health care providers informed, improve continuity and timeliness of care, and eliminate gaps in health care information.”

Basically, VLER employs a portfolio of health, benefits, personnel, and administrative information to share VA, DoD, and selected private health care facility data across the secure Nationwide Health Information Network. Starting with a base of 50,000 signed authorizations from veterans, the health information exchange is now available at 11 VA medical centers, along with partnered DoD and private health care entities.

More than 900,000 text-based documents pour into the VA network every day, a number that would increase substantially with implementation of universal EHR sharing.

The next step for the VA may help reduce private physician reluctance – a technology called “natural language processing” (NLP) that scans the complete text in medical records, including doctors’ notes, performing a Google-like search for anything that might indicate an unrecognized problem. The process is considered especially useful in detecting possible post-surgery complications.

A new interactive guide to aid deployed medics, nurses, and commanders in recording medical information is now available on iPhone, iPod Touch, iPad, and Android devices. U.S. Army photo

According to the Journal of the American Medical Association (JAMA), a scan of the 1999-2006 records of 3,000 VA patients would have provided early detection of such post-surgical complications as acute renal failure, deep vein thrombosis, sepsis, and pneumonia.

“The excellent care VA provides to our nation’s veterans relies, in part, on our electronic health records,” Dr. Robert Petzel, VA’s under secretary for health, told JAMA. “This latest study shows how we can continue to improve the usefulness of our electronic medical records.”

In its September 2011 issue, the VA newsletter “Research Currents” reported the NLP software used to scan physician-written progress notes, imaging reports, discharge summaries, etc., not only was more sensitive than other methods – including reviews by experienced surgical nurses – but detected some complications other methods did not. However, it also was considered to be less “specific” than other methods and produced some false alarms, but only slightly more than others.

“Moreover, the researchers suggest that NLP has advantages … because search queries can be easily customized and refined to do an even more accurate job of finding problems,” according to “Research Currents.” “Another plus, say the researchers, is that NLP can potentially be used while a patient is still in the hospital to help doctors catch adverse events – something that would be less practical with the automated method that uses billing data.”

NLP is part of the VA’s Consortium for Healthcare Informatics Research (CHIR), designed to find ways to get the greatest possible value out of VA EHRs for use by researchers, clinicians, managers, and even veterans themselves.

“If you can convert narrative text into structured data, you can improve your measurement of quality, improve surveillance of infectious diseases and adverse drug events, create new decision-support systems, and help clinicians improve documentation of problems in the medical record. There are a huge number of applications,” according to Dr. Matthew Samore, a clinician and epidemiologist at the Salt Lake City VA Medical Center who serves as lead investigator for CHIR.

The VA’s EHRs were designed with large open blocks doctors can use for “free text” documentation of patient care, providing significantly more detail than checkboxes or pull-down menus.

“There’s a real limitation to asking clinicians to input only structured data when they are evaluating patients, recording those evaluations, describing what’s happening with the patient, documenting their decisions,” Samore continued. “There’s a richness to free text, a communication benefit. It allows people to express themselves.”

To protect patient privacy for NLP applications outside immediate care, CHIR also is looking for the best approaches to “de-identify” patient charts, enabling researchers to access clinically relevant data without incorporating patient names or other means of identification.

In the past, the VA’s 1,400-plus care sites across the United States have consolidated information only at the regional level. But EHRs are part of a VA umbrella system called the Veterans Health Information Systems and Technology Architecture. As of the end of 2009, VISTA housed more than 1.3 billion clinical text documents (with nearly 1 million more added each workday), 1.4 billion images (1.7 million new daily) and 1.6 billion vital-sign measurements (again, nearly 1 million new records added each workday).

Another new initiative – Veterans’ Informatics, Information and Computing Infrastructure (VINCI) – will pull EHR data from all those sites into a single secure, centralized repository. CHIR projects then will make that data useful to researchers trying to determine if doctors’ free text notes, for example, could shed new light on the symptomology and progression of post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), heart disease, cancer, and even “super-bugs” that are resistant to current infection-control methods.

That collective database also means veterans who go to medical centers that are not part of a research program can be included in future research, providing a far more representative sampling of veterans nationwide. Eventually, that will include expanded new research covering decades of unbroken EHR patient data.

Efforts also are under way to merge VISTA data with DoD’s Armed Forces Health Longitudinal Technology Application (AHLTA) as part of the creation of a common EHR system to improve health care to 7.8 million VA and more than 9 million DoD patients. A March 31, 2011, report by the Government Accountability Office (GAO) stated incompatibilities between the existing VA and DoD systems were hindering a continuance of care for injured combat personnel and veterans.

In testimony before a Senate Appropriations Committee subcommittee on Veterans Affairs that same month, Shinseki said a joint VA/DoD EHR system would fix reported problems with AHLTA and improve the overall capabilities of both departments: “We [VA] have a terrific electronic health record, but again, it’s about 20 years in being. So we’re going to have to adjust also to ensure the sustainability of that system. It’s a great opportunity for both of us to put our heads together.”

In FY 2012 budget hearings testimony before the House Committee on Veteran’s Affairs, Shinseki reported on the VA’s digital data efforts.

“The effective use of information technology is critical to achieving efficient health care and benefits delivery systems for veterans … IT is not a supplementary function – it is key to the delivery of efficient, modern health care,” he told lawmakers. “Our health informatics initiative is a foundational component for VA’s transition from a medical model to a patient-centered model of care.

“The delivery of health care will be better tailored to the individual veteran, yet utilize treatment regimens validated through population studies. Veterans will receive fewer unnecessary tests and procedures and more standardized care based on best practices and empirical data.”

Another VA effort to improve EHR maintenance and acceptance is the Transformation Twenty-One Total Technology (T4) program. T4, subject of a five-year, $12 billion series of 15 contracts, is intended to modernize VA health care services “through transformational capabilities, systems engineering and other solutions that span the entire range of lifecycle-based IT, including cyber security, LAN/WAN management, and technical facilities support.”

“T4 is a major tool in the transformation of VA into a 21st century organization,” Shinseki said. “These contracts will enable VA to acquire services for information technology programs that will help ensure timely delivery of health care and benefits to our veterans.”

However, the July 2011 T4 contract awards brought an immediate flurry of protests from a wide range of the 75 or so contractors who failed to make the cut, including IBM and General Dynamics. While temporarily suspending contracting activities after the IBM protest was filed in August, the VA soon reversed itself, citing an “urgent and compelling” need to move ahead rather than wait for a ruling from the GAO, which already had denied a number of protests.

Elements of the T4 modernization plan not only will affect the VA side of EHR implementation, but may have subsequent impact on its interface with – and the implementation of – civilian EHRs.

The rapidly growing VA population will mean sharing facilities and physicians with both DoD and civilian hospitals and clinics and private practice doctors. Along with more complete and accurate lifelong tracking of patient health and care, that is a primary driver behind the development of a universal EHR system.

Whether mandatory – with serious penalties for non-compliance – or voluntary, EHRs must overcome not only current opposition from private practice doctors, but also patient concerns about the privacy of their medical records. With computer hackers increasingly gaining access to presumably secure private information, from Social Security and credit card numbers to shopping habits and financial records, many people are reticent about opening their medical records to similar cyber attacks.

That concern was heightened in September 2011 when some 4.9 million military clinic and hospital patient EHR back-up tapes – including Social Security numbers, personal addresses, and phone numbers – spanning 20 years were stolen from a contractor’s car. That followed an independent research report claiming four out of five medical IT specialists admit their facilities had at least one data breach in the previous year.

While many of those involved electronic records, the survey also reported a majority of civilian hospital administrators believe full implementation of EHRs compatible with DoD and VA systems will improve security.

In the end, according to a report by research firm Frost & Sullivan, the transition to a universal system of electronic health records will be achieved and physician concerns about costs, security, impaired efficiencies, etc., will be addressed, even if not fully resolved. But an important element that has not been a priority to date also must be brought to the forefront, noted senior industry analyst Nancy Fabozzi.

“Branding and outreach must extend beyond physicians to include non-physician health care providers, as well as health care consumers. Both should be directly engaged as advocates for the use of health information technology,” she concluded. “Patients need to understand the role EHRs play in driving quality improvements and care coordination among all of their [physician and non-physician] providers.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.

Major advances in both personal and vehicular armor, combined with significantly advanced battlefield care from advanced Warrior Medics and far forward surgical teams, have led to the lowest killed in action numbers of any war since the beginning of human conflict.

At the same time, those surviving warfighters who would have died on any previous battlefield are returning from combat with far more extensive injuries to hands and arms, feet and legs, vision and hearing. Burns, especially to the face, also have been more prevalent, as has damage to the teeth. While advanced helmets have prevented many once-common head wounds, concussive force damage has become a signature injury in Southwest Asia.

It is the job of the Military Health System to treat all of those, from point of injury in combat to often extensive repair, recovery, and rehabilitation back in the United States. Eventually, all surviving wounded warriors will leave active duty, at which point the Department of Veterans Affairs (VA) takes over their health care and, as needed, continued rehabilitation for the rest of their lives.

More so than any other conflict, this war has forged closer and more extensive ties between the Department of Defense (DoD) and VA health care, from research and development to clinical trials to providing the best possible “reset” of even the most severely wounded to the most functionality medically possible. That is a commitment that never ends, so each new advance will be made available to further improve the lives and abilities of the nation’s now greatly expanded veteran population. That population includes, also in record numbers, members of the Reserves and National Guard, as well as all military family members.

Those leading the way in advancing the technologies and procedures at the cutting edge of medical technology include the U.S. Army Medical Research and Materiel Command (MRMC), Army Medical Department (AMEDD), Army Institute of Surgical Research(ISR), Army Dental and Trauma Research Detachment (DTRD), National Alliance for Eye and Vision Research (NAEVR), MRMC’s Clinical & Rehabilitative Medicine Research Program (CRMRP) and Telemedicine and Advanced Technology Research Center (TATRC), DoD/VA Vision Center of Excellence (CoE), Armed Forces Institute of Regenerative Medicine (AFIRM), Center for the Intrepid, Orthopaedic Trauma Research Program (OTRP), Uniformed Services University, Veterans Health Administration (VHA), Defense Advanced Research Projects Agency (DARPA), Office of Naval Research (ONR), Navy Bureau of Medicine & Surgery (BUMED), National Institutes of Health (NIH), and the Army Wounded Warrior Transition Command.

While the Army, with the most warfighters likely to be wounded in direct combat, has the lead in most on that partial list, it pursues them as joint efforts with its sister services. The other services do have medical research and treatment programs of their own, largely reflecting areas of special interest to their personnel, but also worked jointly. The Navy, for example, has oversight for the DoD/VA Vision CoE and is the lead agency on hearing issues.

One of the most prominent words across the spectrum of 21st century military medicine is regeneration, where various areas of research have application to a wide range of wounds and injuries. A leader in that arena is ISR, created in the 1970s with a primary focus on advances in burn care at Brooke Army Medical Center, now the San Antonio Military Medical Center following a September 2011 merger with the Air Force’s Wilford Hall Medical Center.

“ISR does both clinical and research work in support of caring for combat wounded. It has a long and illustrious history with regard to burn care and is the preeminent DoD center for burn care,” according to Lt. Col. Michael R. Davis (USAF), the institute’s chief of Reconstructive Surgery & Regenerative Medicine.

Sandia Researcher Joe Cesarano demonstrates the perfect fit of a Sandia ceramic scaffolding in a model jaw that also re-creates the upper line of an original jawbone. The scaffold's layers, crossed like a child's Lincoln Logs, are approximately 500 microns apart to expedite passage of a new bone and blood vessels. The science of using bone and cartilage scaffolding for reconstructive surgery has accelerated in recent years. Photo by Randy Montoya, Sandia National Laboratories

“In addition, there is a very large research capacity, mostly geared toward reconstruction and regenerative medicine, with very strong support within DoD. For the military, it is basically the mecca for care of combat wounded, research and rehabilitation, working with the adjacent Center for the Intrepid, which is not technically part of ISR but is very closely related and co-located within the Air Force/Army San Antonio Military Medical Center.”

While many people may associate regeneration with the ability of some species to regrow lost limbs (which is, in fact, an area of long-term human research), its primary application now relates to reconstructive techniques, such as composite tissue transplantation, which includes hand and face transplants. Other studies involve skin regeneration, artificial skin, and the use of adult stem cells to facilitate healing and regenerate functional, rather than scarred, tissue.

“A major limiting factor with burn care is getting adequate coverage of the wound, so that has become a major research focus within DoD and ISR. Collaboration with civilian facilities and internal research have really advanced that field, especially as related to upper extremity transplantations – soldiers who have lost their hands,” Davis said.

While that research may lead to improvements in the use of prosthetics, Davis believes it also is the key to enabling wounded warfighters – and others – to retain and regain the use of their own limbs as well as other biological solutions.

“We have a major responsibility here to bring the best outcome to our injured soldiers, so we – and I am personally heading this line of research – are evaluating composite tissue reconstruction for battlefield upper limb injuries,” he said. “There is no question now that the ability to transplant a hand gives better function than the best prosthesis, both with regard to motor capability and sensory feedback, which are difficult to achieve in a prosthetic.

“The drawback is it requires immunosuppression, so transplanting a hand becomes a lifestyle issue as opposed to transplanting a kidney, lung, etc., which are life-saving. When there is a life-threatening liver or heart problem, it is a simple decision to put them on potentially life-changing immunosuppression. Hand transplants are not life-saving decisions and putting patients on immunosuppression makes the patient more susceptible to infection, cancers – which may even, at some point, take the limb anyway.”

The solution being pursued by military researchers involves manipulating the immune system to accept the transplant through immunal modulation and immunal tolerance. The result would be the recipient’s immune system accepting the transplant without the risks that come with drugs used to suppress the immune system.

“This is a very large focus in the composite tissue transplant community,” he added. “If we can unlock immunal tolerance, you can imagine the applicability of composite tissue transplantation for reconstruction.”

Such techniques apply to facial reconstruction – especially burn treatment – and a host of other injuries that are far more common in this conflict than previous wars. At the same time, great strides already have been made in many related areas, such as repairing dental injuries – which also has led to discoveries of how various parts of the body interact, sometimes resulting in problems previously considered unrelated to the primary injury.

Col. Robert G. Hale, a member of the Army Dental Corps, recently took command of DTRD, which has developed major advances in dental care, replacement, and reconstruction. The standard assumption is warfighters in austere locations, especially in combat, are unable to care for their dental health as they would at home, leading to an increase in toothaches, cavities, and other dental emergencies. While a toothache might seem the least of a combat warrior’s problems, it actually has the same benefit to the enemy as a wound from a gunshot or explosive – at least two other soldiers are needed to transport the ill or injured to receive medical care, thus removing three warriors from the fight.

While improved helmets have reduced puncture wounds to the skull, the face remains exposed to blast burns and other damage from exploding IEDs.

“An explosion always results in some insult to the brain – and those shockwaves are cumulative. We have nerve tissue within teeth, as well, and as yet we have not determined if there is a risk of a sub-lethal blast to the dental region,” Hale said. “There have been a lot of advancements in dental care, not always in response to the war but technologies developed over the interwar years. For example, we now have bone regeneration technology, which is basically bone in a bottle – bone proteins we can mix up, apply to a sponge, put in a bottle and bone will grow.

“Titanium technology in recent years has revised tooth replacement. Now we no longer have to save a damaged tooth, but remove it, repair the socket and make a titanium implant that won’t rust, decay, or fall out, with a porcelain crown interface with the bone screw. We also don’t wire teeth anymore; we use titanium bone plates. If you have a fractured jaw, we will take a titanium bone plate, which looks like a small track with holes, bend it to the perfect shape, then rebuild the jaw using plates and screws.”

Sergeant Major of the Army Raymond D. Chandler III and his wife, Jeanne, visit with Pfc. Keenan Almeida, a wounded soldier from Niles, Mich., during a visit to San Antonio Military Medical Center at Fort Sam Houston July 8, 2011. Almeida was being treated for burns after a rocket attack on his quarters in Iraq. Chandler also visited the Center for the Intrepid, a state-of-the-art rehabilitation facility to treat amputees and burn victims, U.S. Army North, and the Military Entrance Processing Station during his visit to Fort Sam Houston. U.S. Army photo by Staff Sgt. Keith Anderson

Another mouth-related discovery Hale wants to see DoD and the VA put into clinical trials involves PTSD and TBI patients with headaches that do not respond to or require undesirable levels of drugs. The question is whether dental mouth guards can reduce those headaches, perhaps ending the need for pain medications.

Although he is a dentist by trade, Hale said issues involving teeth only occupy about 20 to 25 percent of his time. The rest is devoted to research and treatment on facial injuries and reconstruction. Even so, some important efforts there stem from ongoing advances in dentistry, especially in the immediate treatment of blast wounds to reduce infection and scarring by killing bacteria and sealing the wound/burn in transit.

“There’s an area I call biofilm-impaired wound healing. Biofilm is a bacterial slime that occurs in all wounds open for more than a few hours, impairing the body’s ability to heal,” he said. “The last thing you want in a battlefield injury is for it to become infected and not heal. When that happens in the extremities, the worst effect is loss of a limb. When the face doesn’t heal, it causes scarring, which can be intense.

“If we could help at the very start to reduce biofilm formation and seal open wounds, that would be a great improvement. Dentistry has very advanced biofilm researchers because dental plaque is a biofilm that destroys tooth enamel and causes gum diseases. That same type of biology happens on open wounds. So dentistry has some of the government’s premier scientists working on biofilms.”

Another major area of concern is eye injuries, ranked as the second most common military injury and having the worst return-to-duty rate among warfighters – 20 percent compared to 80 percent for other battle trauma.

TATRC and MRMC have joined forces with a multi-disciplinary group comprising military, academic, and civilian medical researchers looking to improve protection, treatment, and recovery. Bolstered by an additional $7 million in DoD funding, they have stepped up research into eye injuries from burns and penetrating wounds, lasers, chemical, biohazard, and environmental exposure, and vision problems associated with TBI.

“We’ve purposefully funded these projects as a group because we believe they will work together most quickly and effectively to develop treatments and products to save the sight of our warfighters,” TATRC Director Col. Karl Friedl said. “In this time of closely examining the federal budget, this is a relatively small investment that could produce immense future savings, not only in health care costs, but through maintaining military personnel as active, productive members of our nation’s fighting force and workforce.”

Among the multiple lines of investigation being pursued is one to develop computational models of all the ways the eye can be injured in a blast, which could be used not only in preventing vision loss but also in evaluating improvements in protective eyewear. That effort is being funded by the Peer Reviewed Vision Research Program line item in the DoD appropriations budget.

“This line includes vision research that is not conducted by the Veterans Administration, elsewhere within DoD, or by the National Eye Institute within NIH,” NAEVR Executive Director James Jorkasky noted. “It addresses immediate battlefield needs.”

Another vision-related project, funded by the VA with support from its Atlanta Vision Loss Center, hopes to design a computer-based system to overcome the limitations of GPS-based guidance devices for the blind. Even when not blocked by tall buildings or other obstructions, GPS location is only accurate to within about 10 feet – a potentially fatal margin of error for someone attempting to navigate sidewalks next to busy streets.

One approach is similar to that used in combat, where live images of a target area are compared to known maps and older photographs to better guide warfighters to their goal. In this instance, a laptop in a backpack (eventually, software on a smartphone) is linked to a stereo headset and a small camera on the wearer’s chest. The system compares the camera image with stored photographs, then uses beeps and vocal instructions – similar to a car navigation system – to lead the user to a specified destination. GPS, Google Maps, inertial navigation units, and other systems also are expected to be employed.

U.S. Army Spc. Joshua A. McDowell adjusts his eye protective gear while waiting to begin the Urban Warfare Orientation Course in the U.S. Army Best Warrior Competition on Fort Lee, Va., Oct. 20, 2010. Researchers are working to develop computational models of the ways the eye can be injured in a blast, which may lead to improvements in protective eyewear. U.S. Army photo by Spc. Venessa Hernandez

Atlanta VA researchers are pursuing a variation, replacing the laptop with a smartphone used to link to a remote server. The phone’s camera streams real-time images to the server, which analyzes them, including comparisons to stored images, then sends navigation details back to the phone for the user to hear. Although requiring less on-body equipment, a current drawback is transmission speed.

Researchers believe a combination of the two systems may be the best solution, perhaps with the addition of other research separate from those. One of those would recognize money (including denomination), while another utilizes “natural speech,” with the user asking questions as he or she would of another person and receiving computer voice-generated answers in complete sentences.

Further down the line of research would be the inclusion of facial recognition, possibly even the ability to “read” facial expressions.

Overall, the VA, MRMC, and TATRC programs are dealing with nine critical gaps in vision research and how war-related eye traumas are treated, from point of injury to vision rehabilitation, mechanical assistance, neurological prostheses, and even regeneration.

“Each partner is working on a very important piece of the puzzle,” according to Robert Read, who manages TATRC’s vision research portfolio. “We chose these 12 recipients from 120 research submissions because they best address these critical areas.”

Ultimately, regeneration is key to future treatment of many of the most severe cranial, dental, ocular, and auditory combat injuries. While many advanced approaches are still years away from becoming standard clinical practice – and research to keep pushing the science will never end – what already is being done often seems the stuff of science fiction rather than real medicine.

“We are working to improve the quality of life. We [already] can regenerate skin, which is one of the easiest tissues for us to work with and regenerate. But for the face, you have to have a higher requirement than just closing the wound – it has to have elasticity, be shaped and the right color for aesthetics, then you have delicate contours and boundaries between facial features,” Hale said. “In our burn patients, if there is a really badly scarred face, there isn’t much that can be done other than a face transplant, which is a consideration. But if in the next few years we can regenerate the face, that would be better.

“In 2005, when I returned from Afghanistan, the world’s first face transplant was done in France and shook the whole professional world. Some said it was horrible, with bad consequences. But I was an active proponent of face transplantation as a technique for us to understand and develop for those very few situations where it would be best. Why best? Because rebuilding the face with other body parts could take up to 30 operations – and still look horrible – where a face transplant is only one operation. But you must find a good donor match, then face the daily burden of taking suppressants [against rejection].”

Face and hand transplants, healing severe burn wounds without scarring, restoring – or at least providing a workable replacement for – vision and hearing, reconstructing teeth and jaws without dentures or wires, finding and dealing with the relationships TBI and PTSD may have with the teeth – those are among the goals of military medical research. Some already are in various stages of implementation, others at the earliest level of research.

There are two other major changes stemming from the war in Southwest Asia and the often startling advances in combat medicine: Both doctors and wounded warfighters have new views on battlefield injuries, treatment, and rehabilitation.

“I like to think of regenerative medicine as a technology that can generate hope – hope for soldiers in the system, out of the system, thinking of becoming soldiers or veterans growing older,” Hale concluded. “The emphasis in 2005 was save lives, close wounds. Now, as we look to the long tail of the war, it is to make those lives worth living. That includes defining the burden of disease – what problems these soldiers face, day in and day out, that they would not face if not injured – then finding ways to help cure or at least solve those problems with minimal invasion.

“Regenerative medicine will take decades of continual work to make people even more functional as they age. Technologies such as face transplants are still experimental; we don’t know the long-term effects of immosuppression or even the correct amount for face transplants – how to monitor and adjust the meds so the transplant will continue to work for as long as possible. And we don’t even know how long that will be. But it is technology we are developing and learning and is available should a soldier need and want it.

“But I have had soldiers who would qualify say they would prefer to wait, to be number 50 rather than number 20. They want us to do more research and they will wait for something better. They know the military and VA are there for them, so they don’t feel they have to take whatever is immediately available that might help them. And that’s the key word – might.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.