America’s Military Health System provides care and services to more than 9.5 million active-duty, Guard, and Reserve service members, veterans, and their families. That ranges from helping new inductees with the level of health required for military service to care of the wounded from point of injury on the battlefield through advanced treatment and rehabilitation, to transition to lifelong care under the Department of Veterans Affairs.
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.
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.