The Army Medical Research and Materiel Command (MRMC) – formerly the Medical Research & Development Command, created in 1958 – was redesignated in the 1990s when the Army’s medical logistics function was added to its portfolio. But MRMC can trace its roots back to the American Revolution, and the effort gained its first real public recognition with Army Maj. Walter Reed’s successful efforts to combat tropical diseases that had made completion of the Panama Canal doubtful at the start of the 20th century.
A subordinate unit of the U.S. Army Medical Command (MEDCOM), MRMC is headquartered at Fort Detrick, Md., with oversight of 14 labs and three subordinate commands. Its primary focus is to develop medical information, products, and procedures to enhance the health and safety of U.S. and allied forces deployed worldwide, especially in combat. But its creation also significantly streamlined the entire life cycle management of medical materiel by placing everything under a single commander.
“Prior to MRMC, there was not one person who had the overall responsibility for technology-based research, advanced development programmatics, logistics, fielding, and sustainment of medical materiel,” Col. Jeffrey W. Davies, MRMC’s chief of staff, explained. “The reorganization gave MRMC’s commander that accountability.
“As a result, if the center and school identify a need requiring R&D funds or there is something off the shelf that will meet warfighter needs, having everything under the command of one general officer enables us to more quickly respond to that need and align our priorities. That is critical because it allows us to procure a product and, with linkages to the logistics command, put the fielding and sustainment plans in place, including, when it is no longer needed, pulling it back. Before MRMC, there were things produced that took far longer to get out into the field.”
About 5,200 military, civilian, and contractor personnel provide the command’s in-house medical, scientific, and technical expertise, as well as standard administrative tasks. They work closely with both corporate and academic medical research organizations and other military service and government labs outside the Department of Defense (DoD).
Six MRMC labs are dedicated to core science and technology biomedical research, with an emphasis on infectious diseases, combat casualty care, operational medicine, and defenses against chemical and biological warfare. The other eight components focus on developing and sustaining a comprehensive concept of medical materiel acquisition through development and logistics, information management/information technology (IM/IT), and congressional special interest (CSI) programs. Those also involve collaboration across a broad spectrum of partners.
“We now take things from very basic research to delivering products almost to the last mile,” according to Dr. John Frazier Glenn, a neurophysiologist who serves as MRMC’s principal assistant for research and technology; he also was the command’s interim director from March through June 2009. “In the past 10 years, we’ve made the greatest impact in combat casualty care in terms of the number who survive after wounding. For many years, 20 percent of those wounded in action died; during the most intense force-on-force part of the operations in Iraq, we were down to only a fraction of that.
“Resources in recent years have gone to combat casualties and the signature injury of this war – mild TBI [traumatic brain injury]. However, we’re trying to convince the leadership that just because we don’t have people in hospitals due to malaria now, that doesn’t mean it won’t be a threat at another time.”
The bulk of MRMC’s research is housed within Research Area Directorates (RADs): the Military Infectious Diseases Research Program (MIDRP), Combat Casualty Care Research Program (CCCRP), Military Operational Medicine Research Program (MOMRP), and Clinical and Rehabilitative Medicine Care (CRMC).
The RADs historically have been numbered – MIDRP, for example, was RAD 1, while MOMRP was RAD 3. However, the numbers were reused as old programs ended and new ones took their place, eventually leading to considerable confusion. Some still refer to them as RAD MIDRP or RAD CCCRP (without numbers), but just using the program name by itself is the currently preferred approach, with the colonel in charge of each being called the RAD (Research Area Director).
“For MIDRP, we have some great efforts going on in malaria and dengue fever that have been critically important to our warfighters going into areas where those diseases will challenge, including Afghanistan,” Davies said. “The partnerships we have with others also have been important, such as supporting the diagnostic effort on H1N1 [swine flu]. One of the newest areas is wound infections and what we have seen coming back from theater.
“Hemorrhage control has been a primary focus for CCCRP, while MOMRP has focused on psychological health and TBI. Our main focus in CRMC has been twofold – first on regenerative medicine, and second on amputees and the development of new prosthetics. Our regenerative medicine program involves two consortia with a total of more than 20 universities. We also partner with DARPA [Defense Advanced Research Projects Agency] on different efforts, such as the Military Amputee Research Program [MARP] and its development of prosthetics.”
The ongoing conflict in Southwest Asia also has affected the direction of medical research, which for years was geared toward deployment medicine: preventive vaccines to make warfighters immune to the diseases they would encounter, insecticides to knock down pests carrying diseases for which there were no vaccines, advances in field sanitation, new guidance for clean water and how much an individual needs to drink when wearing so much gear, etc.
“It was all about the deployed force. During the Cold War, where if we had to stop the Russians coming through the Fulda Gap, the war would have been over pretty quickly or escalated to nuclear, our feeling was if they were in the fight and evacuated from theater, they would become a VA problem. But what we’ve found out in this war is we actually have to reset troops,” Glenn said. “We are having redeployment after redeployment – and up to 70 percent of those wounded severely enough to be evacuated to our major medical centers voluntarily return to duty.
“So we have now shifted our investment more to reset – a term long used for equipment – which has given us a portfolio in clinical and rehabilitative medicine we didn’t have even three years ago. That also has broadened our perspective of what our core mission is – not just keeping troops in the fight, but restoring them to a condition where they can return to the fight or otherwise be productive members of society.”
Post 9/11, military medicine has seen a number of significant advances, most the direct or indirect result of MRMC efforts. Early on in Southwest Asia, that included the re-introduction of the tourniquet – especially the one-handed version a wounded warfighter can apply to himself or a buddy – along with hemostatic dressings that help blood clotting and reduce the danger of bleeding to death, the leading cause of combat deaths. Both are now part of every warfighter’s first aid kit, itself considered an MRMC success.
“Coupled to that was the concept of hypotensive (low pressure) resuscitation. In the past, a medic, if you had lost a lot of blood, was trained to pump the pressure back up with fluids to make sure you got enough blood to the brain, which also got blood pressure back up to a normal range. But hypotensive resuscitation just adds enough fluid to keep the person alert; if they can communicate at all, that’s enough,” Glenn said.
“Clotting is a natural response to bleeding and pumping in a lot of fluids and upping BP was blowing out clots. So with all these ‘new’ devices, such as bandages and tourniquets, we were better able to keep people alive until we could get them back for surgery.”
Elements of the journey from one level of care to the next also have changed significantly. As Glenn pointed out, movies of medevac helicopters taking off with patients often showed a lot of paper blowing about in the rotor’s downwash.
“Those were the bits of paper [that] medics, when they had a chance, would pin to a patient’s shirt to tell the next level what already had been done,” he said. While not yet universal, much of that paper has been replaced by electronic trauma registries. “They collect data on patients from the point of injury, all treatment done through the process and into surgery, then use that information to make adjustments in the care given at each level. We really didn’t have the capability to get that information at the beginning of the current conflict; we were still using paper records. But the likelihood of that piece of paper remaining with the patient through the system was quite low.
“Now we put in data collectors at the combat support hospital level to reconstruct those records and are getting very detailed records of what we did at that level. That information is then passed to a study group in San Antonio [Texas], which made recommendations on changes in the standard of care. Coupled with the introduction of new technology, we’ve gotten better at that, although we still have gaps, especially at the medic level. But we’ve done much better than previous conflicts.”
In addition to greatly improved medical training for all warfighters, including a new breed of “warrior medic” with skills equivalent to a civilian paramedic, MRMC has helped move almost every level of medical expertise as far forward as current technology allows – which often means to the combat medic.
“We have been a leader in telemedicine, to reduce the footprint in austere environments, where we can’t have a lot of specialty care but can use remote telemed to get back to specialists, whether in Europe or the U.S. That has been a revolutionary way of supporting forward forces,” Davies said.
While MRMC is an Army command, it also has changed to reflect the joint nature of the current and, presumably, most, if not all, future conflicts.
“We have really revolutionized the way we prioritize and execute our research since 9/11 as we look at a greater sense of urgency and a true focus on those programmatics we have tried to deliver as expeditiously as possible,” he explained. “That has included a move toward greater efforts to bring other services into leadership positions within MRMC. We have Navy officers in charge of our infectious disease programs and congressionally directed research, an Air Force officer in our blast program [studying the relationship between explosions and TBI], and our incoming deputy commander is a Navy captain.”
Considerable attention has been given to dramatic advances in prosthetics during this war – which, due to the lowest killed in action rate in the history of warfare, has seen more amputees than any since the Civil War. However, MRMC also has taken a DARPA-like “far side” view of how to treat those who have lost hands, arms, feet, or legs. Their goal is not only to create better mechanical replacements, but to literally grow new limbs.
“The Armed Forces Institute of Regenerative Medicine is a major part of that,” Glenn said. “As we became more intrigued about current and future medical advances with the promise to restore function, we began looking at regenerative medicine, primarily adult stem cell-based.
“Through a competitive process, we put out an announcement that resorted in the funding of two consortia – one centered on a team of Wake Forest and the University of Pittsburgh, the other on Rutgers and Cleveland Clinic. Both include multiple other universities and small and large industries, including biotech. Eight of the top 10 published regenerative scientists in the United States are part of these consortia.”
The application of regenerative medicine covers a wide range of possibilities, most of which still may seem the stuff of science fiction rather than serious research for what are hoped to be near-term solutions. And it will be a long-term process, with many incremental applications along the way.
“We’re looking at new ways to do hand transplants, whole face transplants, new ways to grow skin – scar tissue doesn’t have the flexibility or range of motion of real skin and is the biggest problem our burn patients have. If we can give them full flexibility, it is not just cosmetic, but functional. We want to give those who have sacrificed so much a far better chance than their predecessors to return to society,” Glenn said.
“In the long term, we want to actually regrow damaged tissues and organs. One problem with wounds is you lose a lot of tissue – chunks of missing muscle, tendons, etc. We’d like to be able to regrow that, to replace that lost tissue mass and restore function. Everything works better when you have all the parts. The group at Wake Forest has pioneered growing a bladder from a person’s cells, then re-implanting a functional bladder. They’re now working on replacing more complex organs, but for the military, we will be focusing on muscle mass, tendons, bones, and the sorts of injuries soldiers often have. And we have great hopes for that in the future.”
In the meantime, even physical therapy is beginning to benefit from research MRMC conducts or funds for advanced rehabilitative techniques.
“For a long time, physical and occupational therapists have used traditional techniques, but now we have looked at virtual reality and advanced prosthetics and learned from sports medicine to treat with the best available technology. That includes comparing various approaches to make sure we can introduce the best outcomes for everybody, seeing which treatments are the most effective,” Glenn explained.
“DARPA has taken the lead in developing prosthetic arms with direct attachments to the nervous system. The Army is working on a leg with functional ankle and knee joints. People can get around OK on existing artificial arms and legs, but they haven’t been fully functional in all areas, such as going up and down stairs. You can apply some approaches in robotics to extend the range of motion.”
Individual physical therapists, using their own skills, physical strength, and memory, may introduce small, unintentional changes in the treatment a given patient receives to help regain range of motion. A robotic device, however, would remember each previous session precisely and be able to replicate each of its own motions. In addition to consistency, that will enable patients to do their own exercises at home without the expense of a human therapist.
“We didn’t invent all these technologies – we don’t invent everything we introduce into the military health system and don’t claim to have a monopoly on good ideas. Instead, we work extensively to take the best ideas out there, test them for military use, and introduce them into the military health system,” Glenn said.
All of the new and enhanced data-gathering systems that follow a warfighter from enlistment to discharge (and beyond, through the VA) are primarily directed at identifying better ways to treat wounds, infections, disease, or psychological problems in the field and through the recovery process. But they also are now being applied to help combatant commanders develop improved techniques, tactics, and procedures.
“The idea is to work hard to make better use of medical information, linking it with other battlefield data to effect better survivability for our warfighters. In partnership with the Armed Forces Institute of Pathology, National Ground Intelligence Center, Army Material Command labs doing vulnerability analyses, PEOs for personal and vehicle protection, Army medics, and Navy corpsmen, we have created the Joint Trauma Analysis for Prevention of Injury in Combat,” Glenn said.
“Basically, that works like what you see on TV’s CSI – we now get all the operations information, data on those killed in action from the medical examiners, detailed information from survivors through the trauma registry, and marry it up with data collected about where they were, what they were wearing, what they were riding in at the time of the incident. All that is then put together in near real time in such a way as to inform commanders about procedures in dismounting vehicles after the first IED goes off and about changes in personal and vehicle armoring.”
The scope of MRMC operations, R&D, collaborations across the Army, DoD, the government, industry, academia, and civilian health care has led to previously unimaginable levels of medical care – from preventing bleed-out at the time of injury to rehabilitation and return to duty – research into the most advanced future capabilities, and assistance to commanders in enhancing the health and safety of their troops.
“MRMC is a unique organization that has quality funding of quality research by quality people to develop quality products for our armed forces. But there also are secondary benefits for the nation as a whole. So the work that goes on here every single day makes a difference,” Davies concluded. “I don’t know of any other organization – inside or outside DoD – that has the capabilities we do, which is why so much work does come to us.”
This article was first published in The Year in Veterans Affairs and Military Medicine: 2009-2010 Edition.