Veterans Affairs & Military Medicine OUTLOOK, Spring 2021

THE WAR AGAINST COVID-19 The U.S. military’s ongoing fight against the novel coronavirus INTERVIEW

Lt. Gen. Ronald J. Place, MD Director, Defense Health Agency

VA and MHS Nurses Respond to Pandemic Challenges Battlefield Medicine in the Korean War

CONTENTS 4 10 THE WAR AGAINST COVID-19

INTERVIEW: LT. GEN. RONALD J. PLACE, MD Director, Defense Health Agency (DHA) The U.S. military’s ongoing fight against the novel coronavirus

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VA AND MHS NURSES RESPOND TO PANDEMIC CHALLENGES

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TECHNOLOGIES SUPPORT 26 INNOVATIVE PERSONALIZED HEALTH CARE

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SUPPORTS SUPPLY CHAIN 34 DMLSS MODERNIZATION

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PRECISION MEDICINE IN MENTAL HEALTH VA’s PRIME Care study aims to take the guesswork out of prescribing antidepressants.

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INTERVIEW

LT. GEN. RONALD J. PLACE, MD Director, Defense Health Agency (DHA)

Veterans Affairs & Military Medicine Outlook: Let’s start with the obvious.

COVID has hit the military and veteran communities pretty hard. Has the global pandemic changed the way DHA does business?

Lt. Gen. Ronald J. Place: I think that it’s important to start by recognizing the challenges that millions of Americans have had to navigate, along with the specific challenges to those who deliver health care. In that light, I think that the pandemic changed the way everyone does business! The questions for all of us are these: Were these changes ones that we should have made sooner and it took a crisis for us to act? Or are these changes that were borne of the moment, and that were smart steps to take and

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Before coming to DHA, Lt. Gen. Place served as the director of the National Capital Region Medical Directorate – leading the delivery of health services in the greater Washington, D.C. area, to include management and oversight of DOD’s flagship medical center, Walter Reed National Military Medical Center, and the Fort Belvoir Community Hospital. Prior to that he served in a variety of leadership roles, both in deployed and garrison environments. He deployed with the 67th Forward Surgical Team during Operation Iraqi Freedom, Task Force Med Falcon IX to Kosovo, and the 249th General Hospital to Afghanistan for Operation Enduring Freedom. He has commanded military treatment facilities (MTFs) at Fort Knox and Fort Stewart, and served as commanding general of Army Regional Health Command-Atlantic.

Lt. Gen. Place is board-certified in both general surgery and colorectal surgery and is a clinical professor of surgery at the Uniformed Services University of the Health Sciences. A native of South Dakota, Lt. Gen. Place is the author of more than 40 peerreviewed articles and book chapters. Earlier this month, Lt. Gen. Place responded to questions from Veterans Affairs & Military Medicine Outlook regarding key DHA initiatives and where he sees the agency heading as the force continues to transform and evolve in unprecedented times.

deal with the crisis, but don’t fit into longterm plans?

Examples?

Virtual health is the perfect place to start. Prior to the COVID-19 pandemic, the Military Health System [MHS] developed a wide range of capabilities to support use of telemedicine in both operational and garrison environments. We were doing virtual health before virtual health was cool, whether that was moving radiologic images from ships at sea, or building a global electronic health record [EHR] that captured health care delivery from the point of injury to care in the VA [Department of Veterans Affairs]. We had plenty to be proud of – and we helped move the

industry – so I don’t think we were way behind the curve.

Yet when the pandemic hit, we had 60 to 70 percent of our work move to virtual environments – primary care visits, behavioral health, specialty consults (both surgical and medical). You get the idea. The good news was this – our medical infrastructure was ready; we managed this transition in record time; and we got the word out to our patients. Everyone – patients and providers – adapted pretty quickly. We learned that some of this care could have been virtual much sooner.

On the flip side, we can go too far.

Some care is likely better performed in person – and methods to evaluate the effectiveness of the venue often [are] lacking. Some people chose to avoid care

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DHA PHOTO

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he Defense Health Agency (DHA) supports the delivery of integrated, affordable, and highquality health services to almost 10 million beneficiaries of the Military Health System (MHS) – including service members, families, and retirees – and is responsible for driving greater integration of Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force in both peacetime and wartime.

As DHA director, Army Lieutenant General Ronald J. Place, MD, leads the DHA and directs shared services across the department. These services include the TRICARE program; pharmacy operations; medical logistics; health information technology; research, development and acquisition; education and training; public health; facility management; budget resource management; and contracting.

On Oct. 1, 2021, the DHA will also complete the transition of all military hospitals and clinics – more than 700 – across the entire Department of Defense (DOD) from the individual military departments to the DHA.

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U.S. MARINE CORPS PHOTO BY CPL. MICHA PIERCE

rather than getting it virtually or coming in for care. We are in the early stages of encouraging people to come back in for needed care – whether that’s immunizations, preventive screenings, or regular laboratory analysis.

We were forced to innovate quickly, which on balance has been good for sustaining access and is sensitive to patients’ needs. But, we need to keep this in balance.

I agree that telehealth has come very far since the pandemic. But improving and expanding these capabilities doesn’t mean that your beneficiaries are taking advantage of them.

There’s no doubt that individuals need to get comfortable with new technology and new approaches, but it’s not as high a hurdle as you might think. Necessity drove [the] adoption rate of telehealth higher in the pandemic. And both patients and providers realized, “You know, I wish I had done some visits virtually before

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U.S. Army Lt. Gen. Ronald J. Place, right, director of the Defense Health Agency (DHA), speaks with Courtney Hayes, left, a clinical social worker at Naval Health Clinic Cherry Point, North Carolina, about her billet and the care of patients at the outpatient clinic, Aug. 12, 2020.

now.” What might have taken 3 hours for a patient – travel, parking, waiting-room time, the visit, and travel back home again – was now 20 minutes or less. Not to mention other challenges like childcare, or loss of income from work. And, we saw older beneficiaries, who some people assume are less tech savvy, adapt quite quickly.

But, the challenge for us is knowing when virtual health is the right solution, and when an in-person visit makes more sense. In that sense, we are still learning.

And we’re still looking to industry and academia for ideas that we can evaluate and pilot. There is a lot of innovation occurring in this space right now.

I’ve asked our team to keep scanning for emerging technology and emerging

practices that we can adopt and adapt for our mission.

Can you share a few programs that weren’t in place before the pandemic?

This is where our work gets interesting. More than just replacing an in-person visit with a virtual visit, I’m interested in seeing where we can expand our ability to monitor health.

One example is DREAM – or Diabetes Remote Electronic Assisted Monitoring – a program we just started in San Antonio that teaches patients how to independently measure and adjust their insulin. This program augments a patient’s diabetes treatment plans, and allows regular monitoring of an individual, and gives both the patient and the medical team near real-time results, rather than allowing months to go by between appointments. So far, we have 133 referrals, and 118 people have participated in the program, and we plan to expand it soon.

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“Wherever I go, people go out of their way to thank me for the active duty and National Guard personnel who are holding the line, and administering shots. I’m so proud of our team, and I know the American people are grateful.”

Let me give another example – National Emergency Tele-Critical Care Network [NETCCN] – is a telehealth system that lets us consolidate telehealth networks and manage a high patient capacity during an emergency or a national crisis.

Early in the pandemic, both civilian and military hospitals were exploring how to manage in a “surge” event – if we needed to significantly increase beds, and have fewer nurse-to-patient or doctor-topatient ratios. NETCCN offers us the capability to work with the civilian sector to respond to public health emergencies by bringing remote critical care expertise to the point of care, providing e-consult support, remote home monitoring, allowing us to more safely adopt tiered staffing levels, and more.

NETCCN is an example of providing us with more flexibility and agility in a crisis, and how we can link remote expertise to frontline providers by using secure, HIPAA-compliant applications on mobile devices.

DHA really rose to the challenge with telehealth. But the real challenge probably was Operation Warp Speed. Let’s talk about that.

The challenge was the disease, not the response. Operation Warp Speed was designed to get bureaucracies to move faster, and still not cut corners.

On this score, it was a success. And lots of credit to Gen. [Gustave F.] Perna and the team at Operation Warp Speed for thinking through the logistics of the vaccine roll-out. From securing contracts, to ordering vaccine, to moving all of the products necessary to get shots in arms, they got most things right in an extremely unpredictable environment.

While no one imagined a vaccine being available in such a short amount of time, in less than one year we have three vaccines approved under EUA [emergency

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use authorization]. When Secretary [Lloyd J.] Austin stepped into the Pentagon as his first day as Secretary of Defense, his first department-wide meeting was to go over our COVID response, and his top priority for the department was to help the nation defeat this virus.

As of April 15, approximately 2.5 million total doses were administered to people eligible in DOD at 350 military vaccination sites around the world, and the amount of vaccine supply is just starting to grow.

Separate from DOD immunization efforts, we have thousands of military members supporting FEMA [Federal Emergency Management Agency] at mass vaccination sites around the country.

For example, FEMA is rapidly opening vaccination centers across the country with the capacity to vaccinate from 1,000 to 6,000 people per day. I know FEMA is working with state governments to open additional sites to continue our mission to vaccinate Americans. That is our number one priority right now, to get this pandemic under control, and the only way to do it is if all of us do our part and agree to get vaccinated when it’s our turn.

Why did FEMA come to DOD? It’s more than just easy access to staff. They know they are getting a cadre of disciplined, well-trained medical technicians. It’s a testament to our training and development programs. Wherever I go, people go out of their way to thank me for the active duty and National Guard personnel who are holding the line, and administering shots. I’m so proud of our team, and I know the American people are grateful.

Increasing the medical readiness of combat forces and readiness of our military medical forces is at the heart of the effort to transition military hospitals and clinics that fall under DHA purview.

Can you share some examples of how readiness is or will be enhanced?

In the DHA we like to say, “Judge us by our outcomes.” We’re still in the early stages of this transition, but I can share a great example. One of our MHS imperatives is to increase the clinical workload for our providers. Just like pilots looking for more flying time to sustain their skills, we need “reps” to keep our skills honed. One of the core components of a market approach is to look at health care from a “systems” perspective, and not just from the perspective of one service or one MTF [military treatment facility]. In the National Capital Region, we now have specialists working out of more than [one] MTF. One day at Fort Belvoir, one day at Quantico; or one day at Walter Reed, and one day at Fort Meade.

What that does is widen the circle from where our patients come to us – for dermatology, for gastroenterology, for surgical referrals. It helps our medical teams with readiness by increasing the amount of, and complexity of, care our providers deliver.

Speaking of the MTFs, there is a lot of movement in the effort to transform them. Can you explain a little about that?

Military hospitals and clinics exist to keep combat forces ready to go to war, and to sustain the readiness, the currency, and competency of medical personnel to support wartime requirements. In the simplest terms, MTFs are “readiness platforms,” where medical professionals from the Army, Navy, and Air Force not only obtain – but sustain – their cognitive, technical, and team skills, especially because MTFs are our first line of medical deployment in support of military operations.

We need to get this balance right, and ensure we have the right mix of clinical

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staff in the right places to keep those skills up. That’s what we mean when we say the MHS intends to match infrastructure to our readiness and mission requirements. In some cases, that might mean we realign services at some MTFs, and have them delivered in the TRICARE network. We’re in the middle of reassessing our models in a post-COVID world, and will return to Congress with our path forward.

For our beneficiaries, my message is the same: Any actions we take will be “conditions-based.” No changes until we’re sure the local TRICARE network has the capacity to provide easily accessible, high-quality care.

DOD PHOTOS BY SGT. 1ST CLASS CALEB BARRIEAU

So is this a one-size-fits-all effort?

It’s the military departments’ responsibility to identify and define their readiness requirements – how many people they need in support of their mission sets. It’s our job at DHA to provide a working environment that enables and empowers each member of these uniformed medical teams to be ready to do that job.

Can you describe the market construct’s basic structure and organization, and how it affects the delivery of care across the MHS? A market is a group of MTFs working together with TRICARE partners, VA hospitals, academic medical centers, and other federal health care organizations, in one relatively small geographic area. This group operates as an integrated system to support the sharing of patients, staff, budget, and other functions across facilities to improve readiness and the delivery and coordination of health services. Market leaders are responsible for managing all health care within that geographic region.

Presently, the DHA is establishing 19 direct-reporting markets in the United States in regions with significant concentrations of MTFs and patients. We have large, multi-service markets like the National Capital Region; Tidewater in southeast Virginia; Colorado Springs; San Antonio; Puget Sound; Fort Bragg;

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Lt. Gen. Ronald J. Place (left) meets with Col. Dwight Kellicut, chief of vascular surgery at Tripler Army Medical Center, in Hawaii.

and the island of Oahu in Hawaii. These markets serve large populations, and we maintain large military medical teams to support them. We’re bringing them together to function as one organization.

Then, there are markets – still big – but largely serving one military community – in places like San Diego; Jacksonville; Augusta, Georgia; or Biloxi, Mississippi, to name a few. And finally, we also have a significant number of smaller, standalone markets with a smaller military medical footprint and a smaller population. Integration isn’t as challenging in these markets, but there is still great value in having a standardized model for managing health care across the entire system. This latter group – the smaller, stand-alone communities – will have a single office at DHA to serve and support them.

Can you explain market establishment?

Is this something new?

Market establishment is just the formal transfer of responsibility from the military departments to the DHA. It signifies that the entire MHS leadership team has agreed that the conditions are met for the DHA to assume its responsibilities for managing the market. The important message for me is that this establishment makes us even more accountable to the Army, Navy, and Air Force. We’re responsible for establishing an organizational model and platform that delivers ready medical forces to them.

With regard to market transformation, what can we expect?

Let’s start with a status. In January 2020, the DHA established the first four markets, comprised of MTFs in the National Capital Region [D.C., southern Maryland, northern Virginia]; Jacksonville, Florida; Coastal Mississippi [Biloxi-GulfportPascagoula]; and Central North Carolina [Fayetteville-Goldsboro].

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Tidewater, Virginia, became effective on April 19, and we expect markets in the following four locations – San Antonio; Colorado Springs; Puget Sound, Washington; and Hawaii – in the next few weeks. The DHA began transition activities for this second wave of markets in early April, and the market offices should be established in the fourth quarter of FY 2021.

By this summer, the DHA expects to have established a Small Market and Stand Alone Organization, or SSO, to manage stand-alone MTFs and other MTFs grouped together into small markets. By autumn, the DHA will have assumed management and administration of overseas MTFs and will operate those facilities through two health care regions: Defense Health Region IndoPacific and Defense Health Region Europe.

In all, this is turning out to be a very busy year!

Revisiting COVID – has the pandemic caused a reassessment of the MHS transition? What adjustments, if any, have been made to transition goals or the transition process?

In April of last year, then-Deputy Secretary of Defense [David L.] Norquist directed a pause in the transition because of the department’s focus on COVID-19 response efforts. That pause was lifted by the Secretary of Defense last November.

In so many ways, the COVID experience strengthened our preparedness for our expanded responsibilities. We learned by doing. Managing hospital bed surge planning, laboratory testing for the force, and enterprise personal protective equipment, and developing a disease registry, collection of convalescent plasma, and then the COVID vaccine roll-out all contributed to our ability to integrate operations across the enterprise.

While table-top exercises are highly valuable, we were tested in a major realworld scenario. The pause delayed some milestones we had initially set, but we’re better prepared as a result.

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Let’s talk about the warfighters. How does DHA support the Combatant Commands? Let’s start with readiness.

Each COCOM has unique challenges and missions, and it’s important that we understand those needs – deployed forces operating in austere locations everywhere in the geographic commands; the tyranny of geography for a COCOM like AFRICOM; the aeromedical evacuation mission of TRANSCOM. One of the steps we’ve taken is to put DHA liaison officers in every Combatant Command, as well as with the Joint Staff, National Guard, and the CDC. Our staff are truly embedded with these organizations – participating in training, exercises, and everyday meetings. It helps with understanding the COCOM’s needs in a direct way, and improves communications as well. These liaisons also know our DHA organization – where to go for assistance, what the processes are for providing support. They help cut through bureaucratic knots and get to solutions.

They’re invaluable.

As a Combat Support Agency, we also get a report card every two to three years from the Chairman of the Joint Chiefs on how well we’re supporting the COCOMs. The shorthand is called the CSART, or Combat Support Agency Review Team.

The Joint Staff goes out and independently meets with COCOMs and gets their candid feedback on how we are doing, and where we can improve. It’s a great mechanism for continuous improvement and staying close to our customer, and we’re currently performing well.

And training? How does DHA support medical readiness training?

Joint military missions are the rule, not the exception. So it’s important that our training programs are more joint as well. The Medical Education and Training Center [METC] in San Antonio balances service-specific training with joint training that is common to all services.

One of the things I’m proud of is that we are now accredited for a number of our training programs, so that our enlisted are getting college credits for some areas. We’re both training our people for the mission and educating them for life.

We also oversee the Defense Medical Readiness Training Institute – offering courses for Combatant Command medical planners, including the Joint Medical Operations Course, the Federal Coordination Center course, and a course to familiarize medical planners with modeling tools available to support their command. And we offer leadership training for MTF commanders and senior staff to familiarize them with the common clinical and business operations in the DHA. Under the Assistant Director for Combat Support, the DHA provides support to operational planning efforts as well. Our planners leverage the resources and expertise from across the agency and service components to ensure combatant commander medical requirements are addressed. These efforts really are a win-win. We not only support training, but we’re learning from the field to ensure our techniques and tactics are relevant to what is needed to keep our force ready on and off the battlefield to save lives.

Not a regional command, but what about functional commands, like U.S. Transportation Command?

The Commander, U.S. Transportation Command, is the DOD Single Manager for Global Patient Movement, and transports ill and injured warfighters every day. The DHA, through our TRICARE Overseas Program contracts, provides TRANSCOM with commercial patient movement capability — this is particularly useful when it may be more cost-effective or otherwise beneficial for the commander to employ a small commercial aircraft to support the movement of an ill or injured warfighter. We could never do what we do without their support – truly the unsung heroes of how we do business!

Let’s shift gears for a second and discuss MHS GENESIS. Can you provide an update on where things stand in regard to its implementation and how that is going?

Sure, this is a good story that keeps getting better. For those who may not know, MHS GENESIS is our new electronic health records – and the first EHR in which we

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“I’ve been in a military-sponsored education position [ROTC] or serving in the military for 39 years, and it still excites me today – the mission, the people, the culture.

It’s a dynamic place to work – and I’m energized by the opportunity to serve.” purchased a commercial product rather than write customized software just for the DOD. It was a major step for the DOD, and when the VA elected to purchase the same commercial product, we really redefined what we can achieve. We will soon have a single electronic health record that a service member uses from the day they come on active duty and stays with them through the transition to the VA. And, MHS GENESIS is the platform for all medical and dental information across the continuum of care, whether in garrison or forward deployed.

In the last year, we’re really gaining traction. After our initial rollout in the Pacific Northwest and then to Northern California and Idaho, we encountered COVID. Though there was some sentiment to pause the MHS GENESIS deployment, we worked with the sites and the contractor team to keep moving ahead even through COVID. We deployed to the rest of California, Nevada, Alaska, and – as we’re speaking now – deploying in Wave Carson to a large number of MTFs. And we’re seeing the value. Early in our COVID testing stages, we needed to standardize the naming conventions around specific lab tests in order to accurately assess case rates and spread of the disease. It was the only way to get reliable data that could compare one installation to another. With MHS GENESIS sites, we were able to do that work in a couple of hours – while it took many days and many man-hours making this happen at multiple legacy EHR host sites elsewhere in the country. It was one of those “Aha!” moments when the value of MHS GENESIS became so apparent.

The same thing’s happening with our COVID-19 vaccination roll-out. The functionality of performing mass vaccinations in MHS GENESIS has been welcomed by

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every MTF using it. We deployed MHS GENESIS to Naval Medical Center San Diego and surrounding MTFs in February – and they saw improvements in efficient workflow, almost overnight.

It’s not just the provider staff and IT staff seeing improvements, though. Our patients are seeing it too. A much more user-friendly patient portal is increasing the use of GENESIS by patients to check their lab results or message their providers. It’s helping them become more empowered, which can only be a good thing in the long run.

With Electronic Health Records Management, the Department of Veterans Affairs has a similar initiative.

Do these efforts intersect at all?

They do. Both the VA and Coast Guard are on board. But it’s going to take a little time to get to the finish line. The VA deployed the new EHR at their facility at [Mann-Grandstaff VA Medical Center] in Spokane, Washington; and the U.S. Coast Guard is deploying MHS GENESIS at four pilot sites in Northern California.

Just as we did after our first deployment at Fairchild AFB, Washington, the VA is taking a pause to work out some kinks.

It’s time well spent. In the meantime, we expanded Joint Health Information Exchanges with the introduction of Common Well, so that we can share more medical information with private-sector hospitals and doctors’ offices too.

There are so many moving parts and ongoing – and new – initiatives at the DHA and within the MHS. How can you keep up with everything going on?

In military strategy and health care, standing still is deadly. Enemies change tactics and capability, and so does disease.

Look at COVID. I don’t know if you saw the

60 Minutes segment on innovation against infectious diseases, but they shared the fact that the military has been investing in research on pandemics for a long time.

And some of our work is what led industry to produce RNA-based vaccines.

How to keep up? Well, even in the COVID world, we’ve continued to hold regular industry days and let the business and academic community know our priorities. We’re getting a lot better at putting our Requests for Information – RFIs – in advance of RFPs. We want new ideas and new approaches.

We try to share our work on our website, www.health.mil, and through social media channels too. It’s not always easy, and engaging with government can be a little daunting for newcomers. But, we remain hungry for ideas and value the work going on in the private sector.

You’ve had a long and storied career.

Any final thoughts?

As a high school student in rural South Dakota, I never dreamed that one day I would be serving in the capacity I’m privileged to perform. As the director of the DHA, I’m literally surrounded by some of the smartest researchers, nurses, physicians, and management executives in the country, and the world. I don’t know everything, but I know I can reach out to people in military medicine who just might.

I’ve been in a military-sponsored education position [ROTC] or serving in the military for 39 years, and it still excites me today – the mission, the people, the culture. It’s a dynamic place to work – and I’m energized by the opportunity to serve. That includes the men and women in uniform, their families, and the retirees who sacrificed so much for us. I don’t know if it sounds like a cliché, but it’s true – it’s honestly the privilege of a lifetime to serve. It’s not always easy work, but it is rewarding. If there are any younger people out there reading this, I do hope you consider putting some time into public service. You won’t regret it.

Thank you, sir.

I enjoyed it too; thanks for asking me to join you!

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THE WAR AGAINST COVID-19 I

t was more than a year ago when the first cases of COVID-19 were reported in the United States. From the start of the pandemic, the Department of Defense (DOD) took on multiple roles in the battle against SARS-CoV-2, the coronavirus that causes the disease: protecting its own people, maintaining military readiness, supporting the national interagency (and sometimes international) response, and contributing valuable research and technology to the effort to learn about and fight COVID-19.

To help handle patients in multiple states and territories, the U.S. Army

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Corps of Engineers, with support from the Naval Facilities Engineering System Command (NAVFAC), designed and built 38 alternate care facilities. Deployable augmentation teams from the Army, Navy, and Air Force assisted medical providers across the country. At the height of the pandemic, more than 47,000 National Guard members deployed in support of emergency medical care and public health efforts in different states and territories, communications, transport, and logistics.

The nationwide effort that began as Operation Warp Speed (OWS), a

public-private partnership among DOD, the U.S. Department of Health and Human Services (HHS), and vaccine manufacturers, has been a historic success, so far leading to the Food and Drug Administration’s (FDA) emergency use authorization for two of the six OWS vaccine candidates. Five DOD medical treatment facilities have participated in Phase 3 vaccine trials. As the partnership evolved into a nationwide vaccination effort led by the Federal Emergency Management Administration (FEMA), it has led to the distribution of more than 180 million vaccine doses – and

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DOD PHOTO BY CPL. LEILANI CERVANTES

The U.S. military’s ongoing fight against the novel coronavirus

U.S. ARMY PHOTO BY JASON W. EDWARDS

PHOTO BY KIMBERLY HANSON

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Opposite page: Blue Angels receive the COVID-19 vaccine aboard Marine Corps Air Station Miramar on Jan. 29, 2021. Vaccines were being administered in a phased approach prioritizing health care workers and first responders as well as mission-critical and deploying personnel. Above: Operation Warp Speed Chief Operating Officer Army Gen. Gus Perna, right, led a table top exercise on Nov. 6, 2020, to explore COVID-19 vaccine distribution scenarios and contingency plans as pharmaceutical companies came closer to an approved vaccine. Right: Crystal Tyler, pharmacy technician, prepares an injection for an Operation Warp Speed patient volunteer at Brooke Army Medical Center (BAMC), Fort Sam Houston, Texas, Nov. 16, 2020. BAMC and Wilford Hall Ambulatory Surgical Center were participating in the Phase III trial to evaluate the vaccine under development

by AstraZeneca as part of a national initiative to accelerate the development, production, and distribution of COVID-19 vaccines, therapeutics, and diagnostics.

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administration of more than 140 million doses – by the end of March 2021. OWS was folded into broader efforts of the White House COVID-19 Response Team at the end of February 2021.

DOD has also helped more than 143 countries with testing, diagnostics, and medical supplies and equipment since the beginning of the pandemic, through the work of its combatant commands, humanitarian assistance programs, or the Cooperative Threat Reduction Program.

All of these successes have been achieved without sacrificing the readiness and effectiveness of the military’s 2.2 million uniformed service members, or of the 700,000 civilians in the contract workforce.

U.S. AIR NATIONAL GUARD PHOTO BY AUDRA FLANAGAN

FORCE PROTECTION AND MISSION READINESS In the beginning weeks of the pandemic, the Pentagon acted quickly to protect service members at home and abroad, issuing a series of travel restrictions, stay-at-home orders, and quarantines for service members returning from some overseas locations. These social distancing requirements compelled the department to adapt in several ways.

In March 2020, the Pentagon began to implement and expand a “commercial virtual remote” (CVR) environment, based on Microsoft Teams, that enabled DOD employees to work remotely; by the fall, more than a million users were able to perform telework and attend virtual conferences, meetings, and teamwork sessions. The success of CVR has led the Pentagon to extend its use through June 2021, and to examine what functionalities and features, including network architecture and security, will be necessary as it continues to adapt this commercial network to the military’s needs.

Likewise, the Military Health System began to maximize the scope and reach

An aerospace medical technician from the 148th Fighter Wing, Duluth, Minnesota, performs COVID-19 testing at the Duluth National Guard Armory on May 23, 2020. The Minnesota National Guard performed testing on Minnesota residents at six National Guard armories across the state over the Memorial Day weekend.

of its telehealth capabilities to maintain the quality of basic clinical and pharmacy services throughout the department while keeping patients safe. The department is looking to expand these capabilities to reach from deployments abroad to fixed facilities, community clinics, and partners such as the Department of Veteran Affairs.

From the start, DOD has done a good job of protecting service members and their families from the worst effects of

COVID-19; its hospitalization rates and case fatality rates remain far lower than the overall U.S. population’s. As of April 1, 2021, more than 265,825 of the department’s uniformed service members, their dependents, and civilian and contract employees had been infected with the virus. Among them, 325 had died: a case fatality rate of 0.001, or a tenth of 1 percent. This may in part be explained by demographics – service members are generally younger and fitter than most Americans – but even within these age groups, DOD employees and their dependents have fared relatively well.

After the FDA authorized the emergency use of monoclonal antibodies for the treatment of COVID-19 – an intravenous “cocktail” developed through

From the start, DOD has done a good job of protecting service members and their families from the worst effects of COVID-19; its hospitalization rates and case fatality rates remain far lower than the overall U.S. population’s. www.defensemedianetwork.com

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Operation Warp Speed – Brooke Army Medical Center opened an infusion clinic to help high-risk COVID-19 patients with mild to moderate symptoms. The goal of the treatment is to hinder the disease’s progression and avoid inpatient admissions, and so far patients appear to be responding well. As of mid-March 2020, the clinic had treated 59 patients; among them, only five required hospital admission.

The first COVID-19 vaccines were authorized for emergency use by the FDA in mid-December 2020, and DOD promptly launched its aggressive immunization program, administering COVID-19 vaccines at 343 sites around the world. Its vaccine distribution plan had three phases: first, health care and support personnel, emergency services and public safety workers, deploying personnel, and other essential workers; second, high-risk beneficiaries; and the third and final phase moving on to the healthy DOD population.

By March of 2021, more than half of U.S. military installations had lifted travel

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restrictions, some of which had been imposed more than a year earlier.

In a March 26, 2021 press briefing, the Pentagon announced that about a third of active-duty, Reserve, and National Guard service members had received at least one injection, and the department expected to open up vaccination to all eligible DOD beneficiaries by May 1. Army Lt. Gen. Ronald J. Place, director of the Defense Health Agency, said it was possible that every person within DOD could be vaccinated by mid-July.

RESEARCH AND TECHNOLOGY Military research played a crucial role in protecting health care workers as the COVID-19 infections surged in the spring of 2020. In May, the FDA authorized the emergency use of a device developed by the U.S. Army Medical Research and Development Command: the COVID-19 Airway Management Isolation Chamber (CAMIC), which has been used to prevent aerosolization of the virus during the treatment and intubation of patients.

Military medical facilities and personnel continue to play a critical role in the clinical trials of Operation Warp Speed’s vaccine candidates.

In early April 2021, the Army announced that it would begin testing a next-generation protein-based vaccine, developed by investigators at the Walter Reed Army Institute of Research (WRAIR) to be effective against newer, more transmissible variants of the SARS-CoV-2 virus. Initial results of the study, which will involve adult volunteers aged 18 to 55, were expected to be available by midsummer – and if those results are promising, Army researchers will likely try to partner with a pharmaceutical company to further test and develop the vaccine.

In addition to vaccine work, investigators are researching the potential protective effect of monoclonal antibodies: human-made proteins that may assist the body’s natural immune response in fighting off a SARS-CoV-2 infection. STORM CHASER, a study led in the Military Health System by the Infectious Disease Clinical Research Program at the Uniformed Services University of the Health Sciences (USUHS), is currently seeking to discover whether a monoclonal antibody might prevent infection in those recently exposed to the virus. At multiple sites, including five DOD facilities, investigators are administering the antibody therapy, via intramuscular injection to asymptomatic study participants within eight days of a known SARS-CoV-2 exposure. If the antibody proves successful in preventing infection during the virus’s incubation period, it could be a benefit to those in high-risk circumstances: health care workers, for example, or people with COVID-19-positive household members.

In a separate study, USUHS researchers have discovered tiny antibodies, or “nanobodies,” produced by a llama, that may be useful in blocking infection altogether by grabbing hold of the SARS-CoV-2 virus’s spike protein.

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U.S. ARMY ACQUSITION SUPPORT CENTER PHOTO

The Defense Health Program is funding DNA vaccine dose manufacturing for COVID-19 prevention and monoclonal antibody manufacturing for COVID-19 prevention and treatment.

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U.S. NAVY PHOTO BY MASS COMMUNICATION SPECIALIST SEAMAN LUKE CUNNINGHAM

PHOTO COURTESY OF LT. COL. ROBERT LONG

Left: Navy Lt. Caroline Mosher, a nurse anesthesia student at USUHS Graduate School of Nursing, conducts “proof-of-concept” testing using the COVID-19 Airway Management Isolation Chamber, or CAMIC. Below left: Aviation Boatswain’s Mate (Equipment) 2nd Class Bryan Bennett, a sailor assigned to the aircraft carrier USS Theodore Roosevelt (CVN 71), donates COVID-19 convalescent plasma (CCP) at the hospital’s Armed Services Blood Program Blood Donation Center. Those who have tested positive for COVID-19 and since recovered are encouraged to donate CCP as part of a Department of Defense-wide effort to alleviate the symptoms of those currently suffering during the pandemic.

Monoclonal antibodies and convalescent plasma – blood plasma rich in COVID-19 antibodies, donated by those who have recovered from the disease – have shown promise as therapeutics that can reduce the length and severity

of the disease. In January 2021, DOD and HHS purchased more than a million treatment courses of a monoclonal antibody, REGN-COV2, that was developed

by Regeneron Pharmaceuticals with Operation Warp Speed funding.

Investigators at several military research facilities – including WRAIR, the Air Force Research Laboratory (AFRL), and the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) – are investigating COVID-19 diagnostics: devices that can rapidly detect the SARS-CoV-2 virus during the early days of infection, as well as immunoassays that can detect COVID-19 antibodies in people without a confirmed history of exposure to or illness from the disease. A team at the Army’s Edgewood Chemical Biological Center is developing a rapid genetic sequencing tool capable of detecting the virus not only in clinical samples, but also in environmental samples – in air, water, or soil. The U.S. Army Research Institute of Environmental Medicine (USARIEM) is evaluating the potential for using wearable monitors to detect the onset of COVID-19 illness: Using machine learning algorithms, the monitors can analyze changes in heart rate to estimate core body temperature and detect early symptoms.

Meanwhile, DOD researchers continue to publish significant findings about the etiology, epidemiology, and pathology of the disease: Navy investigators, for example, in their study of the spring 2020 outbreak aboard the aircraft carrier USS Theodore Roosevelt, showed that young,

Monoclonal antibodies and convalescent plasma – blood plasma rich in COVID-19 antibodies, donated by those who have recovered from the disease – have shown promise as therapeutics that can reduce the length and severity of the disease. www.defensemedianetwork.com

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healthy, working-age adults can play a role in the spread of SARS-CoV-2. The study was reported in the New England Journal of Medicine in November 2020.

In the same issue, a team of researchers from the Naval Medical Research Center and the Icahn School of Medicine at Mount Sinai in New York City reported on their study of nearly 2,000 Marine recruits, which yielded several surprising results: Few of the infected recruits displayed symptoms before their COVID-19 diagnosis; transmission of the virus occurred despite many of the best-practice public health measures; and diagnoses were made only by scheduled tests, rather than by tests performed in response to symptoms. These insights have had implications for the development of safe approaches for settings where young adults are concentrated, such as schools, camps, and sports teams.

SUPPORTING THE INTERAGENCY RESPONSE DOD’s participation in the whole-ofgovernment response to the COVID-19

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Lt. Cmdr. Raben Talvo, Naval Medical Center San Diego’s (NMCSD) Office of Clinical Quality department head, administers the hospital’s first monoclonal antibody (mAb) treatment to a COVID19-positive patient Jan. 26. Bamlanivimab, the mAb treatment, was administered under emergency use authorization (EUA) guidance from the U.S. Food and Drug Administration (FDA) to treat mild to moderate COVID-19 symptoms in some adult and pediatric patients who are at high risk for progressing to severe COVID-19 symptoms.

pandemic has included a leadership role in Operation Warp Speed, which contributed to the development of effective COVID-19 vaccines in record time – about nine months, from the beginning of development efforts to the FDA’s emergency use authorization of the first vaccines in mid-December 2020. Previously, the mumps vaccine was the quickest to have been developed, over a period of about four years.

DOD experts also played a crucial role in the early stages of vaccine manufacturing: OWS leaders deployed 16 DOD personnel to two manufacturing sites to assist with quality control until

the organization could hire required personnel.

During the pandemic’s most intense surges, DOD health care providers, including Reserve health care professionals, have been deployed to either embed with civilian facilities or to establish supplemental or alternate care facilities.

After the FDA’s authorization of the first COVID-19 vaccines, the DOD began to focus on supporting the federal vaccination program led by FEMA. In early February 2021, Secretary of Defense Lloyd Austin announced that active-duty service members, both medical and support personnel, would be deployed in support of five FEMA vaccination centers. Each team, which would be composed of either 222 people (capable of administering 6,000 vaccinations a day) or 139 (about 3,000 vaccinations daily), would include service members from all four of the service branches.

The first 222-person team arrived in California to support a mass vaccination site in Los Angeles beginning on Feb. 15. By mid-March, about 6,235 activeduty service members had been mobilized to support COVID-19 vaccination centers – in addition to the more than 26,000 National Guard members and 3,000 active-duty personnel who have supported COVID-19 efforts over the last year. By March 11, 2021, DOD vaccination teams had administered 500,000 injections, and had achieved a daily rate of 50,000 vaccinations given.

Key to the success of DOD in these vaccination rollouts, both throughout DOD and in support of the domestic effort, has been the scope and sweep of military logistics. Before the FDA had authorized the first COVID-19 vaccine for emergency use in the United States, medical logistics experts at the U.S. Army Medical Materiel Agency (USAMMA) began receiving vaccine orders from all four service branches.

USAMMA tracked shipments from the vendor to each military site where the vaccine was used to immunize service members and military beneficiaries. Using a new software platform,

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U.S. NAVY PHOTO BY MASS COMMUNICATION SPECIALIST 3RD CLASS HARLEY K. SARMIENTO

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FEMA PHOTO BY K.C. WILSEY

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Tiberius, developed specifically for the OWS partnership, logisticians were able to incorporate information from several sources – including the U.S. Census, Vaccine Tracking System, and commercial logistics organizations – and to provide visibility for every component of the partnership, from the manufacturing of the vaccine to its allocation, down to the planning of administration sites down to the provider level.

As the first vaccinations were being administered to health care workers, the Defense Logistics Agency (DLA) prepared to ship doses for DOD employees outside the continental United States and aboard the deployed U.S. Navy Fleet – using the well-developed cold-chain management practices it’s been using to ship flu vaccines for two decades.

As the federal vaccination campaign has ramped up, DOD assisted HHS by transporting needles and syringes to support the delivery of vaccines.

As it has from the beginning of the pandemic, the military has stepped up

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DOD personnel, along with New Jersey state troopers, support FEMA in providing COVID-19 vaccinations to members of the local community in Somerset, New Jersey. FEMA is working with state, local, tribal, and territorial governments on the critical need to open vaccination centers in underserved communities.

to fill gaps in the nation’s supply chain when necessary. DLA helped to procure a massive stockpile of material for the nation’s COVID-19 fight by mid-summer 2020, including millions of nonmedical and surgical masks, N95 respirators, gloves, gowns, ventilators, and test components. The Army, Navy, and Marine Corps partnered to produce 3 D-printed face shields and test swabs to assist in the response. The surge in demand for N95 respirators led to the creation of an N95 working group within the U.S. Army Medical Materiel Development Activity (USAMMDA), to help the DOD work with commercial partners to produce respirators that comply with military needs.

When President Joe Biden took office in January 2021, he named the fight against COVID-19 as “Job 1” for the entire federal government. DOD has done its part. It has, arguably, played a larger role in the response to the national COVID-19 emergency than in any other homeland event in American history – often with personnel or assets who have been deployed for the first time. While assuring the readiness of the nation’s military troops, the Military Health System has exchanged knowledge and best practices with its civilian counterparts.

In March 2021, looking back on the year-long pandemic response effort, Deputy Defense Secretary Kathleen H. Hicks praised the military’s work in support of HHS, FEMA, and other federal partners – and assured Americans that the Pentagon was ready to continue in a supporting role: “It is such a tremendous, phenomenal effort,” she said. “Now it’s about making sure that we help stand up civilian capacity that can endure over the long term.”

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U.S. ARMY NATIONAL GUARD PHOTO BY CAPT. BRENDAN MACKIE

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U.S. Air Force Capt. Jodie Cantey, a clinical nurse with the Delaware National Guard’s 166th Medical Group, talks with a motorist during a drive-thru coronavirus testing mission at Georgetown, Delaware, June 10, 2020. About 25 National Guard members supported the saliva-based testing of more than 200 people there. Nurses with both the Military Health System and the Department of Veterans Affairs took on new responsibilities – including administering COVID tests – to respond to the coronavirus pandemic.

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VA AND MHS NURSES RESPOND TO PANDEMIC CHALLENGES

By Gail Gourley

VA PHOTO

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t’s difficult to overstate the impact of the COVID-19 pandemic on nurses, from those who work directly with the sickest of the virus’ victims to those who provide needed care in myriad other ways in all patient settings. More than a year into the pandemic that threw everything familiar into uncharted territory, nurses everywhere, including those in the Department of Veterans Affairs (VA) and the Military Health System (MHS), have continued caring for patients with courage, compassion, and expertise under circumstances that require perseverance, creativity, and commitment.

Beth Taylor, DHA, RN, NEA-BC, Veterans Health Administration (VHA) chief nursing officer, quickly used the word “challenging” to describe the pandemic’s impact on VA nurses. “It was an unexpected challenge for us this past year; one that was intense, one that was unrelenting for a period of time,” she said.

“But as I think about the response nurses had to the pandemic, the words I would use are ‘resilient,’ ‘resourceful,’ ‘courageous,’ ‘innovative,’ ‘committed to the mission,’ ‘compassionate for the work to be done.’ Another word that I would add is ‘pride’ – pride in their work and pride of the organization, of the work of all clinicians and all staff as we responded to this pandemic.”

“I would echo that, and say ‘dedicated,’” added Jessica Bonjorni, MBA, PMP, SPHR, VHA chief of human capital management. “Our nurses are always dedicated, but they stuck it out and really stepped up to the plate in their response to COVID-19 to make sure that we could be successful.”

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Michelle Cummins, a registered nurse at the West Texas VA Health Care System and an Army nurse veteran, dons personal protective equipment before heading into a mobile intensive care unit at William Beaumont Army Medical Center in El Paso, Texas. Cummins deployed to El Paso to assist in efforts to handle a high number of COVID-19 cases there. Approximately 3,500 VA nurses have deployed around the country to support the pandemic response.

VA NURSES RESPOND The responses to the pandemic’s demands were multi-faceted. VA nurses worked more shifts, longer hours, crosstrained, and more, according to Taylor.

For example, from March 2020 to date, she said, “Over 3,500 VA nurses have deployed, either internal to VA to support the pandemic response, or external to VA on our ‘Fourth Mission’ assignments [supporting state and local health care systems]. They supported state veterans homes, community nursing homes, and

other federal agencies such as the Indian Health Service, and deployed to remote regions of the country to assist. That 3,500 nurses were willing to [deploy] is phenomenal in my view.”

Many nurses engaged in additional training so they could migrate to either a medical-surgical unit or an intensive care unit as needs evolved. “For example,” Taylor said, “we had several nurses that worked in primary care clinics or specialty clinics that engaged in additional continuing education and said, ‘Yes, I will go to the bedside where the COVID patients are, or where other patients that are non-COVID are.’ Where resources were needed, they went to the bedside to assist those other staff.”

Elaborating on other staffing efforts, Taylor identified utilization of contract nurses, as well as a team effort with Workforce Management and Consulting to augment the existing VA Travel Nurse Corps to further enhance agility in addressing staffing needs nationally.

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Bonjorni emphasized, “As the largest integrated health care system in the U.S., the VA is able to shift its workforce across the country, including both the Travel Nurse Corps and staff who volunteered for deployments in areas of greatest need. It is a great benefit of our health care system that we can shift those resources when needed.”

ADDITIONAL VA STAFFING EFFORTS

VA PHOTO

But clearly, additional hiring to meet increasing needs would be essential.

“That was important for us to really boost our hiring,” Bonjorni said, “and we started with a challenge from our leadership to try to get our hiring timelines down to a very, very quick pace. We had excellent partnerships across the department and also with OPM [Office of Personnel Management] and others to help us get some flexibilities on a temporary basis to speed up our hiring process.”

Efforts ranged from hiring fairs, targeted marketing, and direct outreach to retired employees, for example. “We changed around our internal processes to make it quicker to bring people on board,” Bonjorni said, “so that we can front-load the process and get nurses on board quickly, and then follow up with any of the things that we normally do in the pre-employment process. Some of those are things we’re trying to get extended in the long term. Some will require help from external agencies and entities to get additional policy or regulatory or legislative changes. But we are working through those.”

Additional efforts to recruit and retain new hires included leveraging existing authorities to provide group incentive awards, especially in locations with significant private-sector competition for nurses, Bonjorni said, as well as enhancing existing childcare support by expanding the income range eligible to receive funds for covering childcare costs. “We need

Denise Dulude, a nurse at the VA for 37 years, retired in January 2020, only to return to work at the VA Boston Healthcare System in April to assist with the VA’s COVID response. The VA boosted hiring to meet increased demand during the pandemic, reaching out to retired employees, holding hiring fairs, and adjusting internal processes to bring new hires onboard more quickly.

to do everything we can to support our employees so that they can come to work with as few external stressors as we can help them with,” she said.

From March 2020 through February 2021, Bonjorni said the VHA hired 15,431 registered nurses (RNs), 1,065 nurse practitioners, and 137 certified registered nurse anesthetists.

“It was really inspiring to see the number of people that wanted to step in and help out with our mission in caring for veterans during this time,” Taylor said.

Success metrics of the combined efforts also include a decreased RN loss rate. “In fiscal year ’20, our loss rate was about 7.9 percent, under 8 percent, which is really good compared to industry standards, and our loss rate so far in fiscal year ’21 is 7.2 percent. I think it speaks to some of the words we used in the very beginning, of commitment and resilience, but also I think it speaks to success in some of the authorities that Jessica was describing, successfully addressing some

of the needs of our nursing workforce and retaining them,” Taylor said.

With the very real pandemic-enhanced potential for burnout and fatigue among nurses constantly present, Taylor said they monitor data on a national level from employee surveys and standardized industry tools to assess burnout and gauge nurses’ satisfaction with their work environment. She noted that “the scores for overall satisfaction are up year-over-year from last year in data collected in the fall of 2020.”

As an example of the importance of supporting staff wellness, Taylor highlighted a whole health program designed in a partnership between the Office of Nursing Services and the Office of Patient Centered Care and Cultural Transformation. Nurses can participate in facilitated, virtual sessions that include mindfulness, meditation, relaxation, and breathing exercises “to give people a time to collectively pause together and support each other,” she said.

LASTING EFFECTS Asked about the likelihood of longterm effects that the pandemic might have on VA nursing, Taylor predicted a continued strengthening of working relationships with other clinical disciplines and medical staff.

“It was really inspiring to see the number of people that wanted to step in and help out with our mission in caring for veterans during this time,” Taylor said. www.defensemedianetwork.com

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And while the VA has long been at the forefront of virtual care and telehealth utilizing a variety of modalities, Taylor emphasized that pandemic adaptations resulted in a “huge surge” in the amount of virtual and home care provided. “I think it will forever change us in terms of the care that we provide face to face versus assessing the care that we can provide virtually,” she said.

From her perspective, Bonjorni expressed her belief that the new innovative recruitment processes and procedures will change the way that VHA brings top-quality nurses into the workforce. “I think it’s going to really challenge us to make sure that we are being flexible in our hiring policies and practices, so that we’re being swift and thinking differently about how we do that business,” she said. “From an overall recruitment

U.S. Army Spc. Sarla Dominguez, licensed vocational nurse, teaches electrocardiograph procedures and placement to nurses in Tier 2 Nurse Training at Brooke Army Medical Center, Fort Sam Houston, Texas, April 23, 2020. The Center for Nursing Science and Clinical Inquiry, the Department of Hospital Education and Training, and the 3 West staff were providing the training to sharpen the skills of outpatient nurses who might have to transition to inpatient nurses in the event of a patient surge due to COVID-19. MHS nurses have continually adapted to meet the needs of patients during the pandemic.

and retention perspective, I think that we demonstrate ourselves as a model employer in that even when you see a lot of turbulence in the health care marketplace that happened over the course of the pandemic, where in the private sector, they were in some places laying people off or furloughing them, or cutting their pay

“I think our mission is second to none. But this past year, I couldn’t be more proud of the efforts of our nursing corps in addressing the pandemic, and I’m so inspired by the work that they have led and continue to lead on behalf of our nation’s veterans,” Taylor said.

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because of economic concerns, we did not do that, and we were in fact increasing our on-board strength.”

Bonjorni added, “I am in awe of our nursing workforce. They have really shouldered the bulk of this burden over the course of more than a year now. And really, I am grateful. So my message to them is, ‘Thank you.’”

Taylor reflected on the irony that 2020 was the International Year of the Nurse and Midwife acknowledging the 200th anniversary of Florence Nightingale’s birth, and that “we had this global pandemic in which nurses were really the ones that were most relied upon in terms of staffing our units and responding to COVID,” she said. “I think it’s interesting that nursing had an opportunity in that year to demonstrate its heroic efforts in addressing this pandemic and the key role it plays as the backbone to our American health care industry.

“I’ve always been proud of being a VA nurse, and proud of the mission,” Taylor concluded. “I think our mission is second to none. But this past year, I couldn’t be more proud of the efforts of our nursing corps in addressing the pandemic, and

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U.S. ARMY PHOTO BY JASON W. EDWARDS

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

MHS nurses have been integral to the provision of care related to COVID-19, but they have also ensured that patients continue to receive routine medical care, such as immunizations or prenatal checkups, during the pandemic.

I’m so inspired by the work that they have led and continue to lead on behalf of our nation’s veterans.”

PHOTO BY NMCCL PUBLIC AFFAIRS

A MILITARY HEALTH SYSTEM NURSE’S COVID-19 PERSPECTIVE Nurses within the MHS also confronted pandemic-related challenges in inpatient and outpatient settings, requiring continuous adaptation and innovation.

“Caring and providing services for our patients has always been the priority and mission, but the pandemic added many challenges in managing the health of the force with the health of those we serve,” offered Meredith Myatt, CPT, AN, detachment commander and clinical nurse officer in charge (CNOIC) of the Readiness Section at Andrew Rader U.S. Army Health Clinic. This outpatient clinic at Joint Base Myer-Henderson Hall, part of the National Capital Region (NCR) Market, delivers primary, pediatric, and specialty care services to soldiers and families.

Elaborating on some of the challenges, Myatt continued, “Throughout the pandemic, critical decisions have had to be made regarding essential care for patients. We have had to adopt new practices, get used to unfamiliar ways of delivering care, and find ways to safely deliver necessary face-to-face care.

For example, the immunizations clinic delivers essential vaccines to infants and children at the most vulnerable ages, and we knew that was something we were committed to continuing. The challenge came in determining how to deliver this care while keeping our team safe.”

Myatt explained that the immunizations nursing team responded to that need by grouping critical appointments by like-patients, when “infants and young children were provided care on separate days from that of the adult population.

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We also limited the amount of people within the treatment areas and moved to an appointment-only process in order to control the flow of patients within the clinic and section.”

Providing other examples of nurses’ adaptations, Myatt added, “We all quickly learned to do more with less. Compared with many of our sister medical treatment facilities in the area, our clinic is considerably smaller. Despite our size, our patients continued to rely on us for safe and efficient care throughout the pandemic. We were forced to get creative with how we accommodated these appointments and services with new spacing constraints.

“We also learned shared responsibility.

Nurses stepped up and took on roles as COVID-19 screeners, runners, testers, and coordinators. Some adapted to providing care virtually and others took on new roles altogether, such as contact tracing. We were presented with new

roles and opportunities to excel in caring for our patients. The COVID-19 outdoor screening and testing area was designed and executed in part by the nursing team within Rader Clinic, and has successfully completed numerous tests for patients and beneficiaries in the NCR. The COVID vaccine clinic began the operation with a team of just five personnel. We were able to adapt and successfully administer vaccines to emergency responders, medical personnel, frontline essential workers, and those at highest risk for severe illness from COVID-19. We continue this enduring mission and our team has grown; many stepped up and volunteered to support, knowing the importance of vaccinating our community.

We all feel this is one way to give back and contribute to the resolution of the pandemic.”

With new roles and constant necessary adjustments increasing the potential for stress and fatigue, Myatt indicated that

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she and her team found that shared acknowledgement and understanding of burnout was the most effective way to deal with it.

“Nurses tend to run on fumes and refuse to admit we need a break,” she acknowledged. “No one knew how long this was going to last, and I don’t think any of us could have imagined its impact.

When we realized this was a marathon, our team decided to set aside time to discuss coping strategies, stress relievers, and some of our greatest challenges.

We realized we were all feeling the same stress, and the shared understanding of the weight of our role became a huge help in implementing additional coping mechanisms. The clinic commander coordinated training and implemented town halls to deliver information and keep everyone abreast of the pandemic, our responsibilities, and the resources available to us.”

VA PHOTO

MAKING AN IMPACT Myatt shared that her biggest surprise has been the impact she’s been

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A VA nurse administers a COVID vaccine at the VA Southeast Louisiana Veterans Health Care System in New Orleans. VA and MHS nurses are a vital part of the effort to vaccinate the population.

able to make in her role as an outpatient nurse. “Initially it was difficult to watch some of my peers in inpatient facilities who were in the thick of things working tirelessly on a daily basis on COVID-19 units with extremely sick patients,” she reflected. “As a trained inpatient nurse, it felt like I wasn’t doing enough and my role in the outpatient setting didn’t have an impact. I quickly realized that wasn’t true, and that my patients needed me, too.

“Whether it was screening and testing for COVID-19 to ensure treatment and containment of the virus, or vaccinating vulnerable infants and children against other threats, my role was still important,” she continued. “I also felt like every patient we could keep healthy was one less patient that would have to seek additional care at another medical facility, and

potentially one less patient that would suffer from this tragic virus.”

Asked about her message to her patients, Myatt emphasized, “Education is key! As a nurse, it is my duty and greatest pleasure to be able to educate myself and my patients. We are most afraid of what we don’t understand, and this was new for all of us. My patients look to me for answers and understanding. The virus and all of its uncertainty is what caused the most anxiety and stress for all of us. If you can do nothing else, take the time to understand what the virus is, what you can do to prevent its spread, and how the vaccine is key in getting us back to normal.

Just as I felt comfort in knowing that what I did mattered, I encourage my patients that they too can be part of the solution. We can all contribute one vaccine at a time.

“This time is temporary, and we will get through it,” Myatt concluded. “We face difficult times in life that shape us, but they don’t have to break us. I believe this year has made me a stronger nurse, and for that I am grateful.”

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A 3D-printed replica of a patient’s kidney.

The Department of Veterans Affairs is exploring ways in which 3D printing can solve a wide range of problems, such as pre-surgical planning.

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INNOVATIVE TECHNOLOGIES SUPPORT PERSONALIZED HEALTH CARE

By Scott R. Gourley

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THE DEPARTMENT OF VETERANS AFFAIRS

ne continuing characteristic of Department of Veterans Affairs (VA) medical care is the embrace and application of innovative technologies to support the personalized health care of America’s veterans.

A noteworthy example over the last decade can be seen in the application of video telehealth. Still considered to be “cutting edge” by many in the 2010 time frame, video telehealth appointments have become commonplace across the Veterans Health Administration (VHA).

It prompts the question: When yesterday’s cutting edge becomes today’s commonplace, what new capabilities and technologies are emerging to facilitate health care for veterans today and tomorrow?

According to Thomas Osborne, MD, a physician and chief medical informatics officer at VA Palo Alto Health Care System, the answer to that question is “pretty exciting.”

Osborne, who also serves as the director of the National Center for Collaborative Healthcare Innovation (NCCHI), offered, “There are a lot of new technologies that we are leveraging to enhance care, such as virtual reality [VR], augmented reality [AR], 3D printing, big data, artificial intelligence [AI], sensor technology, and enabling technologies such as 5G. There is just so much going on in health care, and specifically at VA, that it’s a very exciting time.”

In terms of both virtual and augmented reality, for example, Osborne noted, “There are multiple different categories of clinical use,” offering the representative example of treatment for

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COURTESY OF VA PUGET SOUND HEALTH CARE SYSTEM

With a 3D-printed model of a patient’s aortic valve, doctors can test-fit a replacement mechanical valve before the implant procedure.

veterans with post-traumatic stress disorder (PTSD).

“There are two general approaches with virtual reality for PTSD,” he said.

“One is the approach of exposure therapy, where a mental health professional utilizes the system to help patients access and work through difficult memories in a supportive environment. The

other approach is through relaxation modules that can reduce stress and anxiety with imagery as well as positive biofeedback. We’re actually working with both ends of that spectrum.”

He added that the exposure approach involves the application of technology from the University of Southern California’s Institute for Creative

Additive manufacturing, also known as 3D printing, is another area where the VA has established a strong and growing presence over the last few years. www.defensemedianetwork.com

Technologies (a Department of Defense [DOD]-affiliated research organization) as well as extensive collaboration with the charitable organization SoldierStrong and the VA’s National Center for PTSD. “The SoldierStrong system is very immersive and not just visual. It’s also audio, olfactory, and vibratory sensory.

The project is being set up to do a comprehensive evaluation and assessment of the indications and efficacy of that treatment,” Osborne explained. “We were put on hold a bit as a result of COVID, because this immersive treatment involves going into a facility and putting on the equipment. However, as things are starting to open up, we’re going to be in a position to make this complementary treatment available.”

Additive manufacturing, also known as 3D printing, is another area where the VA has established a strong and growing presence over the last few years.

“One of my favorite things to say about VA is that we were really an early adopter of this technology,” enthused Beth Ripley, MD, PhD, director for VHA’s 3D Printing Network, who was interviewed simultaneously with Osborne. “I am a radiologist by training, but I have spent the last seven years working on bringing 3D printing into hospitals and really exploring all of the medical applications behind that.

“In fact, we have had it in a couple of our hospitals for just shy of a decade now. And from 2017 to 2021, we’ve grown from three hospitals to over 60 hospitals with 3D printing technologies in house.”

Ripley said that the most long-standing and important applications focus on “assisted technologies for veterans to help them interact with their environment better.

“Examples include different types of adapters, depending on the veteran’s needs,” she said. “One might be something that could be put on the end of a prosthetic to more easily hold a fishing

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The VA is investigating 3D bioprinting of bone, such as the sample shown above, with promising early results.

Ripley pointed to “promising early results,” adding, “we’re really excited about it and we’re hoping that we’re going to see it ‘in action’ in the next couple of years.”

Other exciting developments are reflective of new enablers like 5G wireless technology.

“Here at the Palo Alto VA, we have become the first VA, and one of the first hospitals in the world, to be 5G enabled,” Osborne said. “That milestone was [reached] on Feb. 4, 2020, and since that time, we have initiated a number of different projects that are using 5G as

an enabling infrastructure. Not every system or every technology needs this infrastructure, but for some of them, it is critical for success. This is particularly true for those systems that utilize a lot of data and cannot afford to have any lag or delay in responsiveness.”

One of the first technologies that is already benefiting from 5G is augmented reality.

“As part of a broad collaborative effort, we are working with Verizon, which brought 5G to VA Palo Alto, Microsoft, which brings the virtual reality HoloLens headset and developmental expertise, and Medivis, a medical software company that brings the advanced augmented reality software and the first FDA-cleared surgical AR system. With these innovative partners, we’re on an

“So we have a ‘biobone’ project where we are working to perfect a recipe technique that will allow us to 3D-print living bone. If you imagine ground bone, and you use that as a paste with some collagen and micro vessels, you can print out bone in the shape of whatever the defect is.” www.defensemedianetwork.com

PHOTO COURTESY OF DR. BETH RIPLEY

rod while another could be something that would facilitate interaction with an iPad. It’s anything you can think of.

Obviously orthotics and prosthetics are huge areas for us, but we are also exploring areas like dental and pre-surgical planning.”

Another 3D research and interest area identified by Ripley involves bioprinting.

“There are hundreds of types of materials that you can use for 3D printing,” she said. “They include things like polymers, ceramics, metals, et cetera. Well, it turns out you can also print with living cells and other things that support cellular growth, such as collagen. So we have a ‘biobone’ project where we are working to perfect a recipe technique that will allow us to 3D-print living bone. If you imagine ground bone, and you use that as a paste with some collagen and micro vessels, you can print out bone in the shape of whatever the defect is.

Not only is it made of bone, it is vascularized, so they can hook it up and receive vessels from the patient.”

Although the program is currently in the research and development stage,

PHOTO COURTESY OF VA PALO ALTO HEALTH CARE SYSTEM

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exciting path to bring augmented reality to the surgical suite, to enable more precise, accurate, and safe surgical guidance. With the combined system, you can take someone’s own CT or MRI scans, turn them into a three-dimensional holographic image, and then superimpose that image on someone’s real body. In doing so, we can provide a detailed virtual three-dimensional overlay that allows clinicians to literally see into someone. This allows you to know exactly where to go, the most appropriate approach, and the best angle to efficiently address a medical issue while avoiding nearby critical structures.”

In addition to the future vision of integrated technologies, Osborne identified a number of related efforts and applications.

“As examples, we have begun using the AR technology for general anatomy and

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The Palo Alto VA is the first VA hospital, and one of the first hospitals in the world, to become 5G-enabled.

physiology education for providers and students. We have also begun working with the system for clinical training of routine medical procedures such as vascular line approaches and spinal taps. It’s in the early stage, but we’re also working on more complex surgical approaches for head and neck surgery, as well as for hand surgery,” he said.

Osborne continued, “Just a couple of days ago, I was in a session with one of our excellent surgeons, Dr. Davud Sirjani, and his trainees, who were absolutely amazed because they were able to interact with an enlarged interactive three-dimensional model to discuss the complexities of anatomy and physiology

in ways that were not possible before.

The difference is transformational.”

While 5G wireless technology is clearly in the spotlight, Osborne acknowledged the enabling infrastructure it provides is not required for every technology or application.

“It’s like a pipeline for information,” he said. “If you think about 4G, for example, which most people use for their phones, it can only move so much data at a time.

For the sake of analogy, let’s call that a dirt road. And 5G is more like a five-lane superhighway. Sometimes when you need to move things from place to place, a dirt road is fine. However, if you want to move a large amount of information efficiently, then you really benefit from that 5G infrastructure.”

Elaborating on the impact of new technologies on medical scanning and imaging, Osborne added, “these types

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U.S. ARMY PHOTO BY SPC. NATHAN GOODALL

U.S. Army Maj. Ryan McCormack, an operations officer with the 17th Fires Brigade, tests the Bravemind interactive system at Joint Base Lewis-McChord, Washington, April 18, 2013.

Bravemind is a virtual training system, designed by developers with the Institute for Creative Technologies, which is used to assess and treat post-traumatic stress disorder.

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of systems represent a new frontier; the ability to transform two-dimensional data into a more intuitive and interactive three-dimensional format makes this information more useful and accessible for those who are working to make important clinical decisions.”

“That makes it easier to make datainformed decisions,” Ripley echoed.

“That’s the really exciting frontier we’re facing.”

A somewhat related aspect of health care being facilitated by these scanning and information technologies involves “portability” and the desire to push health care out to rural veteran populations.

“In some areas [of the Pacific Northwest], we have patients who have to travel by boat and by plane to go to the doctor,” Ripley said. “So, from an imaging perspective, we are looking at new portable innovations that can be hooked into a cell phone and can go just about anywhere.”

Asked about new technologies that veterans might see introduced into their own personal health care over the next five years, Osborne identified several likely candidates.

“Absolutely agree with the important insights that Beth just shared regarding point-of-care imaging,” he began. “That is an important way to democratize care.

Another frontier is the ability for providers to collaborate more efficiently at a distance. For example, in the near future, a clinician at a more remote site will be able to collaborate virtually with an expert in a totally different location.

We may have two or more providers sharing the same complex information, in the same virtual room, but potentially located physically on the other side of the world. In other related areas, we are also working with the Department of Defense innovation unit on the development and testing of a new AR- and AI-enabled pathology microscope, which, among other things, may also enable efficient collaboration at a distance.”

Osborne was also quick to praise the innovative work being performed by others across VHA, including that of

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Caitlin Rollins, RN, who is focused on VR projects for pain distraction and anxiety therapy. “That work has a huge amount of potential and is particularly attractive because it is nonpharmacological care that represents an alternative to opioids,” he said. “In other examples, colleagues in our rehabilitation department such as Esmeralda Madrigal, Jerome Sabangan, and Dr. Maheen Adamson are leading VR-enabled home rehabilitation and exercise therapy at a distance, so people can receive the same type of care in the safety of their own residence, thereby limiting travel and hospital exposure. We have also been working with the DOD innovation unit and great colleagues such as Dr. Catherine Curtin on other projects, such as utilizing smartwatches for physiological monitoring and early detection of infectious diseases such as COVID. Suzanne Shirley [clinical social worker and VHA Innovation Ecosystem director of Partnerships & Community Engagement] is also in our group [NCCHI] with Beth and I, and we’re working with her on some really great projects to end diabetic limb loss using advanced sensors and sensor technology. In collaboration with our excellent ICU nurses at Palo Alto, we are driving a comprehensive fall-prevention smart sensor technology project.

We are also very excited about a ‘smart cane’ for the blind we are collaborating on that is being developed by Brian Higgins from our Western Blind Rehab Center [WBRC], which is going to open a new frontier of helping blind veterans navigate the world.”

Expanding on work in the 3D arena, Ripley highlighted the late February arrival of the first-ever FDA approval for compassionate use of a special 3D-printed device for a particular veteran.

“This patient has a really rare form of progressive hearing loss and there’s no off-the-shelf treatment for him at all. So his team at the Charleston VA worked on a device designed exactly for him that could be 3D printed. VA just recently registered with the FDA as a medical device manufacturer at three of our sites, so

we can deliver that. And that’s just the first of what I expect will be many, many patient devices in our future,” she said.

In terms of her takeaway messages for veterans, Ripley asserted, “There is no better time to be in VA.” She added, “Our mission is to serve, and our innovation mission is to make sure that veterans are the first in line for all of the new innovations coming out in the medical space. We really want to make sure that developers, designers, entrepreneurs are thinking of veterans first and what they need, and we want to be delivering those to our patients as fast as possible.

So stay tuned and keep your eyes peeled. There should be a lot of really amazing things coming through the pipeline to veterans. We want them to have these technologies first so they can show them off to their non-veteran friends.”

Osborne added, “This is an exciting time in health care. Never before have we seen these extremes of challenges, not just with COVID, but in general. Against that, we have never had the depth of the technological tools available to solve these problems. On top of it all is the fact that VA is a really unique and wonderful place in so many ways. We’re missiondriven and passionate to serve those who serve. It’s a really noble cause and I feel fortunate to be part of this dynamic learning health care system.”

He concluded, “VA does so much positive work, but we could do a better job sharing that information. There are so many dedicated professionals throughout the agency who are driven and working long hours to provide outstanding care and services. Beth and I are very excited about our work, but there are so many people throughout VA who are working on other impactful projects. As Beth alluded to, we are focused on positive impact for our veterans. However, it’s also important that the things we do at VA can be inspirational and utilized to help others throughout the country and the world, thereby scaling positive impact further.”

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DMLSS SUPPORTS SUPPLY CHAIN MODERNIZATION

By Scott R. Gourley

O

f the many adages and observations frequently voiced about logistics, one common theme is that logistics tend to receive little thought until something goes wrong.

And, while that blanket statement is certainly an exaggeration, it does seem to be true that challenging times serve to highlight the performance of many logistics systems and capabilities.

Take the COVID-19 pandemic, for example. Some early historical review indicates that the week of March 9, 2020, marked the start of myriad “big changes” in the ways that Americans would have to approach their business and personal lives.

Deborah “Deb” Kramer remembers that week very well. On Friday of that week, she began her new job as the acting assistant under secretary for health for support, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA).

“It was a really exciting week,” she recalled. “I had not even seen my office yet when I was asked a simple question

by Dr. [Richard] Stone, then executive in charge, Office of the Under Secretary for Health, VHA. “He asked me how many N95 respirators VHA had. It was a simple question. And I should have been able to go to an enterprise database [the Joint Medical Asset Repository – an information technology system within the Defense Medical Logistics Enterprise Solution portfolio (DMLES)], done a query, and given him an answer. But I couldn’t do that. It

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was unbelievable, but it took days to answer the question.”

In the future, the solution to this and many other logistics challenges will be found in the Defense Medical Logistics Standard Support (DMLSS). DMLSS is an automated and integrated information technology system in the Department of Defense (DOD), within the DML-ES portfolio, that supports all medical logistics functions, including catalog research and purchase decisions, customer inventory management, medical inventory management, biomedical equipment maintenance, property management, facility management, and assemblage management, plus distribution and transportation functions.

“Defense Medical Logistics Standard Support is a system that is run out of the Defense Health Agency and supported by the Joint Medical Logistics Functional Development Center at Fort Detrick, Maryland,” Kramer explained.

“They are the ones who do all of the development, maintenance, and sustainment of the information system.

And DMLSS is now being adopted by VHA.” In describing the system, Kramer was quick to emphasize that DMLSS provides far more functionality than supply chain and inventory management.

“While it does do supply chain management – end-to-end support and not just inventory management, which is what you have on hand – it also does biomedical equipment maintenance. It does property management, facility management, distribution and transportation

management, and assemblage [sets, kits] management. In addition, the Joint Medical Asset Repository gives us asset visibility with a range of dashboards, as well as business analytics, including enterprise analytics. It also does trading partner integration. Significantly, it is already interoperable with the Cerner electronic health record. DOD has already done that. That means VA can just implement and reuse those same interfaces. DMLSS also has a robust integration with GPOs [group purchasing organizations], with Defense Logistics Agency being the primary one used by the DOD,” she said.

According to Andrew Centineo, executive director of VHA’s Office of Procurement and Logistics, prior to the decision to implement DMLSS, some of the identified functions were being partially addressed by a combination of systems originally developed in the 1960s and subsequently deployed in the 1970s and 1980s.

“If you can picture that time frame, we’re talking about rotary telephones,” he said. “That’s the kind of technology that is out there,” he said, pointing to several systems that currently provide property accountability and other legacy applications.

“I would share with you that each one of those applications is not only a standalone application, but it is standalone in each of our 172 medical centers,” he added. “So, you can imagine the diversity and the complication of these legacy applications. They don’t talk to each other. They are all individual

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PHOTO BY NUTAN CHADA, DLA PUBLIC AFFAIRS

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occurrences. There is no enterprise integration and there is no overarching visibility.”

Centineo continued, “The good news is that the technology from that earlier era is now going to be replaced with a modern application that will give us all of those things that Deb indicated.

Seriously, we are finally replacing the 1970s function key driven system; go to menu after menu after menu and start all over if you did something wrong. It is just unbelievable. And, oh, by the way, you actually have to swivel between multiple

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Under the direction of the White House Coronavirus Task Force, employees at Defense Logistics Agency Distribution Susquehanna, Pennsylvania, wearing red to show support to the warfighters, prepare more than 1.5 million N95 respirator masks for shipment to more than 3,000 nursing homes across the United States Aug. 28, 2020, and throughout the weekend.

systems. For example, we don’t have one system doing property accountability.

There are two. So if you’re in AMES/MERS

[Automated Engineering Management System/Medical Equipment Reporting System] or [IBM] Maximo [asset management] doing property accountability, you have to swivel between them to do full view of the enterprise property portfolio.

Then you have to swivel to do a financial transaction. These things are integrated with DMLSS, with a suite of capabilities that will allow us to look at ourselves from an enterprise level and then drill down to an individual facility level.”

Elaborating on just one of the challenges with current stand-alone system

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The day prior to the signing, in testimony before the U.S. Senate Committee on Veterans’ Affairs, Wilkie summarized the significance of the decision: “As we deploy an integrated health record, we are also collaborating with DOD on an enterprise-wide adoption of the Defense Medical Logistics Standard Support (DMLSS) to replace VA’s existing logistics and supply chain solution. VA’s current system faces numerous challenges and is not equipped to address the complexity of decision-making and integration required across functions, such as acquisition, logistics, and construction.

The DMLSS solution will ensure that the right products are delivered to the right places at the right time, while providing the best value to the government and taxpayers.”

Kramer enthused over the significance of the DMLSS decision. Describing the opening scenario in which she was challenged to identify the number of N95 respirators available within VHA, she observed, “I am a former Army Medical Service Corps medical logistician and Desert Storm veteran. And I have got to tell you that in many ways, I had better technology during Desert Storm 30 years ago than with some of the legacy systems that we have in VHA today.”

In addition to identified advantages like available and accessible

maintenance records in support of equipment transfer, she said that another area of medical materiel support advantage involved security.

“DMLSS is already in DOD,” she said. “It meets all of the DOD security requirements, which are even higher than ours. It’s audit-ready. It’s financially compliant. It meets DOD architecture requirements. It meets all of the criteria in terms of the electronic health record. It ‘checks all the boxes’ that you need to be able to support high-reliability health care.”

She continued, “It is a good thing that DMLSS comes from DOD. We will benefit from the work DOD has done to improve the system and its functionality since DOD first deployed it.

We can learn from the mistakes DOD made in deploying the system. And if you think about the continuum of care for the service member, DOD has a health record that will transition electronically from their time on active duty to their time when they come to VA for care. We want to have a supply chain that supports them in the same manner, through the same whole-ofgovernment approach. Moreover, why

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PHOTO COURTESY OF DLA

designs, he offered the contextual example of a particular piece of medical equipment that might be designated for a lateral transfer between two VA medical centers.

“Sometimes there is a need to actually move equipment around, because we have excess or we want to move it to optimize employment,” he said. “When that piece of equipment moves today, it has no maintenance record going with it, because it’s all back at the local level.

But in a future DMLSS environment, when that piece of equipment moves, the electrons can move with it – the entire maintenance record. And that data can be picked up wherever you are.”

Centineo pointed to the criticality of those sorts of capabilities in high-reliability organizations that place a critical importance on things like continuity of patient care.

“You can see and track the history on an item. You don’t lose visibility on a piece of equipment for things like maintenance history or cost of ownership.

With all of its capabilities, DMLSS will really give us a total view at the enterprise level,” he said.

While the Department of Veterans Affairs has been looking at DMLSS for several years, the formal decision memorandum to adopt the system was signed by VA Secretary Robert L. Wilkie on March 27, 2019.

Left: DMLSS supports all medical logistics functions, including customer inventory management, medical inventory management, equipment maintenance, and distribution and transportation. Above: Maryann Bickel, DLA Troop Support Medical’s lead project officer for Army Medical Materiel Agreement Program locations, checks inventory at Walter Reed Army Medical Center during the hospital’s closing. In a future DMLSS environment, an electronic record will follow equipment even during a transfer between medical centers.

PHOTO BY CHRISTOPHER GOULAIT

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would we develop a duplicate supply chain management solution when we’ve got one in the federal space that has been proven already? As I said, we can leverage their knowledge, experience, and expertise to bring improved business practices to the VA.” Original plans called for the VHA to conduct the DMLSS rollout and implementation over a seven-year period. However, Kramer noted that, during 2020 testimony before the U.S. Senate Committee of Veterans’ Affairs, Sen. Jon Tester, D-Mont., requested that the program be accelerated. As a result, the implementation plan now involves a five-year rollout, with DMLSS deployment to be completed across the entire system in 2025.

Asked about interim milestones that might be achieved over the next 12 months, Kramer began her answer with recognition that “COVID gets a vote right now.” Against that caveat, she expressed a desire to roll out DMLSS starting with facilities in VISN (Veterans Integrated Service Networks) 20 (Washington state, Alaska, and Oregon) over the coming year.

“It’s going to depend on what COVID does,” she repeated. “But hopefully

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Then-Defense Logistics Agency Director Army Lt. Gen. Darrell Williams (seated, right) signs an interagency agreement between DLA and the Department of Veterans Affairs with then-VA Secretary Robert Wilkie (seated, left) at the VA Headquarters in Washington, D.C., Aug. 12, 2019.

we’re going to continue to see some of the positive trends we are seeing in terms of lower disease rates and increased vaccination rates. That would mean that we would be able to go out and do the training and the implementation of DMLSS in each of these sites.”

From the perspective of veterans, the implementation of DMLSS should be transparent.

Offering her own logistics adage, Kramer said, “When everything’s going well, nobody thinks about logistics. You don’t need to, because it works.”

But that doesn’t mean that the veterans won’t see the system benefits in other ways.

“Much of what we’ve talked about to this point gives the management perspective on DMLSS,” Kramer said.

“But when you think about it from the

veteran’s perspective, having true visibility means that we will have a better awareness of what is going on throughout the VHA medical supply chain. You can actually have things like early warning indicators. If something is going on in the supply chain, or if the supply levels were to come down, we would know and be able to implement alternative strategies to ensure our clinical staff have what they need to care for veterans. We will be able to see the volume of what we’re buying enterprisewide, and that will give us the information we need to be more effective and efficient with the dollars taxpayers give to us. With DMLSS, we will have the data and information we need for better decision-making at the facility, VISN, and enterprise levels.”

Centineo echoed many similar thoughts in his own message to veterans about the significance of DMLSS, stating, “We are going to obtain new efficiencies here. And those efficiencies will allow us to achieve some cost avoidance. And those dollars that we did not spend because we eliminated so many inefficient practices can now be poured back into veteran health care.”

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Primary Care-Mental Health Integration (PC-MHI) expands access and supports the treatment of common mental health conditions for patients in primary care settings.

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VA RESEARCH

EFFECTIVE TREATMENTS, WHERE THE VETERANS ARE

VA leads the way in integrating mental health care into primary care settings.

By Craig Collins

M

ore than 20 years ago, Sheila Rauch, PhD, director of Mental Health Research at the Atlanta VA, began her career as an intern at the University of Florida Health Science Center. As an embedded primary care mental health provider, she met many people who’d experienced or witnessed traumatic events but who weren’t able, for a number of reasons, to connect with a mental health care provider and receive a full course of treatment.

Post-traumatic stress disorder (PTSD) can be a debilitating condition, afflicting survivors with unwanted thoughts, nightmares, depression, feelings of hopelessness, and hypervigilance. Fortunately, several interventions have proven effective at treating these symptoms, including cognitive processing therapy (CPT), developed by VA clinical psychologist Patti Resick, and prolonged exposure therapy (PE), pioneered by Edna Foa at the University of Pennsylvania. Each of these is recommended as a gold-standard treatment for PTSD. These treatments are challenging for patients psychologically and emotionally, but also pose logistical hurdles for people trying to live normal lives: The PE therapy developed by Foa, for example, is typically provided in 8 to 15 weekly sessions over a period of about three months, working with a mental health care provider.

Rauch’s experience in Florida, she said, “really solidified in me the need to find

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ways to get effective psychotherapy specifically into primary care settings, and to find brief versions that are still as effective as full versions.”

In the early 2000s, as a faculty member at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, Rauch collaborated with Foa and David Riggs, who now chairs the Department of Medical and Clinical Psychology at the Uniformed Services University of the Health Sciences, to develop manuals for the delivery of bibliotherapy – the use of books as a means of exposure therapy – to patients in primary care who were receiving anxiety medication. She focused more specifically on PTSD in collaboration with Jeff Cigrang, a psychologist and professor at Wright State University who, as a lieutenant colonel in the U.S. Army, had treated activeduty service members with PTSD using PE and other interventions. “He was seeing the same problem I was seeing,” said Rauch, “that people needed access to good PTSD treatment.” With funding from the Department of Defense, they pioneered and tested, in a randomized clinical trial, an adaptation of PE for primary care settings: prolonged exposure for primary care, or PE-Primary Care.

“For pretty much my whole career, in different forms,” said Rauch, who is also a professor in psychiatry at the Emory University School of Medicine and Mark and Barbara Klein Distinguished Chair in

Mind Body Medicine, “I’ve been working on getting exposure interventions into primary care.”

PRIMARY CARE-MENTAL HEALTH INTEGRATION (PC-MHI) Rauch is in the right place. The Veterans Health Administration, the nation’s largest integrated health care system, devotes considerable resources to studying, developing, implementing, and refining mental health care interventions for delivery in primary care settings. Much of the VA’s mental health research is conducted at its 17 Centers of Excellence, which include 10 Mental Illness Research, Education and Clinical Centers (MIRECCs). Each of these centers has a different area of focus and is overseen by the VA’s Office of Mental Health and Suicide Prevention, but the centers also collaborate on projects administered by the Office of Research and Development (ORD).

At the Corporal Michael J. Crescenz VA Medical Center in Philadelphia, David Oslin, MD, directs the MIRECC for VISN (Veterans Integrated Service Network) 4, which focuses on the study of pharmacogenetics and precision mental health care.

He’s also chief of behavioral health at the medical center and a professor of psychiatry at the University of Pennsylvania’s School of Medicine. Over the past few decades, Oslin and his colleagues at the VISN 4 MIRECC have been intimately

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been used not only throughout the VA, but in other health care systems, and has been recognized with an award from the American Psychological Association.

“We published a training program, called Foundations for Integrated Care,” he said, “which provides sort of an overview and content training for clinicians who want to work in this space.”

A critical element of PC-MHI is the ability to measure outcomes; these measurements take the form of patient questionnaires. Oslin’s team developed the software that about three-fourths of VA facilities use to track these self-reported outcomes in mental health care.

The software – the Behavioral Health Laboratory – is about to become easier for veteran patients to use: It will soon be rolled out in a format that will allow patients to fill it out and send it back to providers using their phones or other mobiles devices.

“The texting piece will be a huge upgrade for everybody,” Oslin said. It’s a perfect example of the innovations helping to connect veteran patients with quality mental health care, at the VA health care facility easiest for them to access.

TREATING PTSD IN PRIMARY CARE The mental health needs of service members returning from Afghanistan and Iraq created a surge in demand for VA’s mental health care services, and

PC-MHI placement in the spectrum of care.

VA GRAPHICS

involved with the design, implementation, and evaluation of PC-MHI. This work supports the center’s mission to incorporate patient preference in treatment decisionmaking and develop treatment algorithms and decision aids for clinicians practicing in integrated and specialty care settings.

In the 1990s, when Oslin began his career, it was clear that for whatever reason, patients were seeking mental health care from primary care providers.

“In the mid- to late nineties,” he said, “the evidence really started to emerge that primary care was our front-line mental health program in the U.S., and pretty much worldwide. There was lots of data showing that primary care providers prescribed more antidepressants and more psychotropics than all of mental health combined, and that it would be rare for somebody to come to a specialist, a psychiatrist, without having some level of treatment in a primary care setting.

Despite that, primary care was really not set up or designed to treat chronic illnesses like depression or anxiety disorders or alcoholism … So those early studies in the nineties really started to assess the quality of the mental health care we were providing in primary care.”

Oslin was an investigator for a pair of these early studies comparing the clinical outcomes of traditional methods of mental health care and methods that integrated specialized care into primary care

settings. One study, PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly), compared access, costs, and clinical outcomes between the two models of care and found that remission rates and symptom reduction were similar at the three- and six-month follow-ups.

The VA health system acted on these findings. In 2007, it began nationwide implementation of PC-MHI to both expand access and promote the treatment of common mental health conditions for patients in primary care settings.

“The main principles for PC-MHI are behavioral health staff working alongside primary care staff, so that they’re really part of the PACT [Patient-Aligned Care Team] and that they’re seeing patients together,” Oslin said. “They know each other. The clinician, the mental health provider, is an integral part of the PACT, and not just somebody the primary care provider is referring a patient to.”

PC-MHI is also designed to be timely – delivered by the primary care provider when the patient needs it – and time-limited. “You’re not seeing patients for five years, two years – or even for a year,” said Oslin. “You’re seeing them for three to six months at most, and then you’re seeing the next patient or group of patients. If they really need long-term psychiatric or mental health care, they’ll go to our specialty care program.”

The integrated clinical program Oslin developed on the heels of PRISM-E has

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

U.S. AIR FORCE PHOTO BY SENIOR AIRMAN CHRISTIAN CLAUSEN

Post-traumatic stress disorder is a significant or extreme emotional or psychological response to a shocking, dangerous, or traumatic event. It affects 12-18 percent of combat veterans deployed to Iraq and Afghanistan. The development of PC-MHI has been, in part, a response to the mental health needs of returning service members.

the development of PC-MHI has been, in part, a response to this surge. A few years ago, the VA launched a concerted push to expand its capacity to help veterans, hiring more than 1,000 additional mental health professionals around the country.

The mental health needs of veteran patients continue to challenge the VA’s more than 24,000 mental health professionals. “There aren’t enough doctors trained in what works,” said Rauch.

“Whether you’re talking about medication management or psychotherapy, there just aren’t enough of us out there.”

Getting veteran patients into primary care for Rauch’s specialty, PTSD, is important for another reason: “A lot of patients never land in specialty mental health care,” she said. The process of jumping through preliminary hoops to get from primary care to a specialty mental health clinic – submitting a referral, waiting for an intake appointment, undergoing assessment, and then orientation, and in some cases a few weeks of preparatory classes – is often never completed.

“PTSD is a disorder of avoidance,” Rauch said. “If we don’t grab them the moment they say: ‘Okay, I do want to address this,’ and quickly give them the intervention we think works best, they’ll fall back into old patterns of avoidance.

They’re very likely not to follow through on those referrals and never actually show up in specialty mental health.” If they do, she said, they may not be able to stick with

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a program that requires 8 to 15 sessions of 90-minutes duration each.

Rauch has adapted the PE-Primary Care intervention she developed with Cigrang for use in VA primary care settings. This pilot version is briefer than the traditional PE model for treating PTSD. But although it involves fewer and shorter sessions, it’s a demanding course of therapy that asks veterans to approach their worst memories and fears, in procedures known as imaginal exposure (vividly recalling a traumatic experience), in vivo exposure (directly confronting a feared situation or activity), and emotional processing (unlearning the emotional avoidance of traumatic memories).

“We wanted to develop something that was as effective as the full PTSD treatment that could be distributed to a larger population,” Rauch said. She recently completed a randomized clinical trial comparing outcomes of PE-Primary Care – four to six 30-minute sessions, delivered in primary care clinics – to traditional PTSD treatments. “We had a 40 percent remission rate for people who had PTSD,” she said – about the same rate as traditional PE or CPT. “Most of the patients showed clinically significant reductions in PTSD symptoms.”

Both Oslin and Rauch point out that integrated care is meant to complement, not replace, specialty mental health care. Years ago, a subgroup of subjects in Oslin’s PRISM-E study – those with major depression – responded better to

specialty care. And some conditions, such as psychotic disorders or bipolar disorder, tend to be better served in specialty care practice.

Likewise, when a group of patients has completed Rauch’s PE-Primary Care treatment for PTSD, the care team turns its attention to the patients who still experience some symptoms. “There are two groups I would describe there,” she said.

“One group, when we first start seeing them in PE-Primary Care, we know right away that they require more support to be able to approach their trauma memory than we can provide in a brief primary care setting. So they would get a facilitated quick referral to work with a specialty mental health provider in a standard PE or CPT model.”

Another group may have received some benefit from PE-Primary Care, but may need some follow-up with a specialty care provider. Rauch and her team are currently focusing a study specifically on that group of patients, to see whether, compared to those who are referred right off the bat, they are as likely to follow through on the referral after completing a course of PE-Primary Care. The ultimate point of this intervention, Rauch said, is to get veterans into active, effective PTSD treatment in whatever setting they’re willing to participate, and to make sure they stay connected to that care until they have their best chance of remission.

In this, Rauch’s aims are perfectly in tune with VA’s efforts to integrate effective mental health care into its primary care settings: “I want to find ways to get effective treatments out there to people where they are,” she said. “My goal in my career – and not just in my PE-Primary Care work – is really to help people with PTSD have access to care in whatever setting they want to receive it, and have that care be the highest quality possible.”

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VA RESEARCH

PRECISION MEDICINE IN MENTAL HEALTH VA’s PRIME Care study aims to take the guesswork out of prescribing antidepressants.

By Craig Collins

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of individualized treatments: Genomic sequencing could yield molecular targets for drugs or other interventions.

Many Americans associate precision medicine with cancer treatment, which is understandable. A major focus of the federal Precision Medicine Initiative, launched in 2015, was to expand cancer genomics to develop prevention and treatment methods. Relying heavily

on the VA’s Million Veteran Program, the largest genomic database linked to a health care system, investigators across the country have learned, using genomic sequencing, how to evaluate a patient’s cancer risk; prevent some types of cancer; diagnose certain cancers early and with greater specificity; choose the best treatment option; and evaluate how a treatment is working. For

IMAGE BY JONATHAN BAILEY, NHGRI

t’s not clear when the term “precision medicine” was coined, but medical researchers began to use it much more after April 2003, when the international Human Genome Project gave us the ability to read nature’s complete genetic blueprint for a human being. Understanding every human gene, from both a physical and functional standpoint, created the possibility

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IMAGE BY ERNESTO DEL AGUILA, NHGRI

The PRIME Care study seeks to use genomic information of patients to match the best drugs to treat the particular patient’s mental illness.

many cancers, drugs have been developed based on a specific genotype – the set of genes, either within tumor cells or the patient’s own inherited genes or “germline,” known to be cancer-associated. The study of the role of the genome in drug response is known as pharmacogenetics.

David Oslin, MD, chief of behavioral health and director of the Mental Illness Research, Education, and Clinical Center at the Corporal Michael J. Crescenz (Philadelphia) Veterans Affairs Medical Center and a professor of psychiatry at the University of Pennsylvania’s Perelman School of Medicine, was among the first researchers to recognize the potential of pharmacogenetics in treating mental health disorders. In June 2003 – just weeks after the Human Genome Project had wrapped up its work – Oslin was lead author on a paper exploring whether the genotypes of alcohol-dependent subjects might predict their responsiveness to treatment with naltrexone, a drug commonly used to manage alcohol or opioid dependence.

Naltrexone was first synthesized more than 50 years ago and has proven to be an effective drug – but not for everyone.

Oslin’s 2003 study investigated how effective it would be, and for whom, based on genotype. Many mental health disorders, including substance use disorders; depression; anxiety; post-traumatic stress (PTSD); and others, are by definition heterogeneous: risk factors, causes, symptoms, severity, and recurrence vary from patient to patient. This is a circumstance that doesn’t neatly fit with our most basic understanding of “precision medicine” – but Oslin views precision medicine a little differently than, say, an oncologist.

In mental health, Oslin said, “genes can predict the metabolism of medicine – and metabolism is important for two reasons.” First, he explained, some medicines can have harmful side effects.

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Second, some medicines – an obvious example is the blood-thinner warfarin – have what Oslin calls a “narrow therapeutic index.” If the warfarin dose is just right, it can prevent blood clotting.

Too little, and a patient could suffer an embolism or stroke; too much, and they could bleed to death from a cut or injury.

“Some medications have incredibly narrow therapeutic ranges,” Oslin said.

“And pharmacogenetics can help us understand that variability from patient to patient, and help us dose better.”

THE PRIME CARE STUDY Many antidepressant drugs have notoriously narrow therapeutic ranges.

Two of the drugs most widely used to treat depression, tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), are associated with a variety of side effects; among all medications, TCAs have been named as a leading cause of toxic exposure.

Traditionally, selecting and dosing an antidepressant drug is a painstaking trial-and-error process. It takes a while for a drug to take effect, and in the case of SSRIs, it also takes a long time to transition to another drug; patients can suffer from “discontinuation syndrome,” or physical withdrawal symptoms, unless their dosage is tapered off over a period of several weeks. It’s not unusual

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PHOTO BY FRANK CURRAN, BOSTON VA HEALTHCARE SYSTEM

Above: President Barack Obama announced the launch of the Precision Medicine Initiative in 2015 – a bold new research effort to revolutionize health care and change the way we treat disease. Right: Test tubes used in genetic testing, part of VA’s Million Veteran Program.

for a patient and clinician to struggle for more than a year to find the right medication at the right dose.

Depression is a disorder that disproportionately affects active-duty service members and veterans. A 2008 VA study estimated that about a third of veteran patients who visited primary care facilities displayed at least one symptom of depression; about 20 percent had serious symptoms suggesting the need for further evaluation. For Oslin and other VA clinicians, avoiding this often painful trial-and-error period is a priority.

“We have twenty-some antidepressants out there today,” Oslin said. “For two or three of those, a patient might have a genetic variant that causes them to be metabolized very differently – and therefore makes the dosing of those more complex. The easiest thing for me to do as a clinician is just to pick one that’s just as good, but not influenced by the patient’s genetics. I would have more confidence to know how to prescribe and how to adjust that other treatment.”

Pharmacogenetic (PGx) investigations have so far suggested about a dozen of what Oslin calls “actionable genotypes”: specific gene variations that may affect how a patient

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metabolizes certain antidepressants.

Knowing how well a certain patient is likely to metabolize a medication in the liver, or process it in the brain, can allow a clinician to tailor medications and dosages. The standard dosage of the SSRI sertraline (Zoloft), for example, is 100 milligrams. Some patients may need half that dose; some may need twice as much based on their genetics.

A few years ago, with funding from the VA’s Office of Research and Development, Oslin and his team launched a study known as the PRIME (Precision Medicine in Mental Health) Care initiative, aimed at improving outcomes for veterans who haven’t responded well to previous treatments for depression. The team recruited 1,944 veterans to participate at 22 sites in 18 states, and has so far compared these subjects’ genomes to a panel of 12 potential gene-drug interactions. Subjects’ genomic information is gathered by means of a simple cheek

swab, and analyzed with an algorithm designed by a private company.

In March 2021, the team reported in the Journal of Affective Disorders that this PGx panel had the potential to improve outcomes for about 20 percent of the study’s subjects: Around 1 in 5 subjects, Oslin said, had a genotype that would influence how the patient metabolized the antidepressant they were currently on, or the medication that was about to be prescribed by their clinician.

In other words, PGx testing has the potential to benefit 1 out of every 5 patients who are prescribed antidepressants that have the potential for clinically significant gene-drug interactions. “So about 1 in 5 times,” said Oslin, “drug X for that patient would not have been the greatest choice for them from a genetics perspective. I would have either been giving them too much of a dose or too little, because I didn’t know they actually metabolized that drug poorly.” Given the number of effective antidepressants, it’s likely that there’s a “drug Y” available for these patients that’s just as effective, and won’t be influenced by genetics.

The point of the PRIME Care study, ultimately, is to see whether clinicians, armed with this PGx panel, will achieve better outcomes. PRIME Care is a randomized trial: Half the subjects are treated with the benefit of insights offered by the PGx panel; half are treated in the traditional way, informed by a clinician’s best judgment. Results will be available in the fall of 2021.

“We’re looking at two outcomes,” said Oslin. “One: Were we able to reduce that 20 percent of the time, when they were going to choose a medicine that was genetically influenced, to 5 or 1 percent or even zero? Did they avoid using medicines that would be more complicated for this patient? And second: If they did, did patients and providers actually get better results, in terms of their treatment for depression? That’s ultimately the goal. We want healthier veterans, and we’re looking for better care, plain and simple.”

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HEALING BRAINS AND BODIES VA’s Center for Neurorestoration and Neurotechnology

By Craig Collins

I

t was a historic milestone, reported around the world, when it happened about a decade ago: Using the new investigational brain-computer interface known as BrainGate, two people with tetraplegia – stroke victims suffering paralysis in all four limbs and the torso – were able to move a prosthetic arm and perform basic tasks using only their minds.

The BrainGate demonstration had been years in the making. By 2002, a team of Brown University neuroscientists had developed the system’s basics: Using a tiny electrode array the size of a baby aspirin, implanted in the brain just beneath the skull, they detected the electrical signature of neurons firing in a specific area of the brain and translated these impulses into signals that activated and controlled an external device.

Together with a spinoff company from the Brown lab (Cyberkinetics), investigators from Brown, Massachusetts General Hospital (MGH), and the Providence VA Medical Center (PVAMC) began clinical research with the new technology in 2004, and showed that a person with tetraplegia could control a computer cursor on a screen and perform simple tasks such as opening emails, operating a television, and opening and closing a prosthetic hand.

The BrainGate trials combined the expertise of dozens of people throughout the VA and academic research communities, and other VA clinicians and researchers were using some of the same core technologies – electroencephalography (EEG), magnetic resonance imaging (MRI), and computational neuroscience, for example – to inform and validate their own investigations. It seemed natural that this knowledge and capability should be gathered, under the umbrella of VA’s Rehabilitation Research and Development (RR&D), into a single center that could leverage its impact.

A mock-up of a BrainGate interface on display at the Boston Science Museum in October 2005.

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PHOTO BY PAUL WICKS VIA WIKIMEDIA COMMONS

VA RESEARCH

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

PHOTO COURTESY OF BRAINGATE.ORG

A trial participant uses the BrainGate intracortical brain-computer interface to type a search phrase with a standard Android tablet onscreen keyboard.

The screen of the tablet, mounted at right, is inset to show details.

In June 2012, with RR&D Service funding, the Center for Neurorestoration and Neurotechnology (CfNN) was formed as a collaboration between the Providence VA Medical Center, Brown University, Butler Hospital, Lifespan (Rhode Island Hospital’s health care system), and MGH. The center’s director is Leigh Hochberg, MD, PhD, one of the original BrainGate researchers, a Brown University professor, Harvard lecturer, and clinician who directs MGH’s Center for Neurotechnology and Neurorecovery.

“The mission for CfNN,” Hochberg said, “is to discover, design, develop, and deploy novel neurotechnologies and other device-based therapies that will advance the rehabilitation of veterans and others with impairments in mobility, communication, mental health, and limb function.”

The work of the CfNN’s clinicians and researchers is supported by a core of technological and administrative expertise: Experts in the Neuromodulation and Imaging core make advanced software and hardware available to investigators who need the highest-quality MRI. Within the Recording, Decoding and Computational Neuroscience core, specialists record and analyze brain signals to reveal how the brain works, and how device-based therapies might be

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refined to modulate neural networks.

A third core – Assessment, Outcome Measurement, and Implementation – is dedicated to mastering the protocols and regulatory environment for investigators and project coordinators, while facilitating access and continuity of care for study participants.

“We provide these core competencies and services not only to CfNN researchers,” Hochberg said, “but also make them available to researchers throughout the Providence VA and the national VA community.”

At the CfNN, this expertise supports the work of investigators in three focus areas: Communications and Mobility; Affective and Cognitive Health; and Limb Function.

COMMUNICATION AND MOBILITY Investigators in this focus area aim to restore function and independence to veterans with impairments due to ALS, spinal cord injury, stroke, seizure disorders, or other disorders. With the help of new neurotechnologies and medical approaches, CfNN researchers are working to discover and apply new ways to harness the neural activity that can be recorded in these conditions. Led by John

Simeral, PhD, a bioengineer at the center and an assistant professor (research) at Brown University, these activities include continued study and development of the BrainGate system.

The ongoing BrainGate trial is enabling research participants with tetraplegia to browse the internet, chat online, compose and send emails, and control televisions and other home appliances or assistive devices; in some studies, people continue to explore possibilities in using the neural interface to command robotic and prosthetic limbs. In collaboration with experts at Case Western University and the Center for Functional Electrical Stimulation (FES) at the Cleveland Stokes VA Medical Center, the team reported in the journal Lancet that they could link the BrainGate interface to an implanted FES system that delivers what are essentially artificial motor nerve impulses to muscles in the arm and hand of a person with tetraplegia. This is an exciting discovery: It suggests that people, years after paralysis, may be able to use technology to reach and grasp for objects using their own arms.

The ultimate goal for investigations of neural interfaces, said Hochberg, is to give veterans a solution they can use by themselves. In its current form, the BrainGate system conveys neural signals using cables connected to amplifiers and decoding computers that require an expert attendant. “There are all kinds of advantages to testing devices in a well-controlled laboratory,” he said, “but it’s not where these devices need to work. They need to work at home – or wherever that person wants to be in a given moment.” As a result, since the research began, that’s where the BrainGate team has been developing and testing their system – in each research participant’s home.

CfNN investigators are working to improve the reliability and portability of

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PHOTO BY KIMBERLY DIDONATO-FERRO, PROVIDENCE VA

Linda Resnik, PT, PhD, at right, demonstrates the DEKA arm, an advanced upper-limb prosthesis, with her team.

the BrainGate system – including the development of a wireless system first developed at Brown University, with the first human use of the external wireless system just published by a team led by Simeral. “We’ve been able to replace that big cable with a wireless transmitter … and a wireless lead that beams all of these neural data,” Hochberg said. “That’s an important step toward what will be the next generations of this research with fully implanted systems.”

CfNN researcher and PVAMC staff neurologist David Lin, MD, also a neurologist at MGH and instructor at Harvard Medical School, is exploring additional possibilities for brain-computer interface technologies, beyond assistance in everyday function for people with paralysis – they may also have the potential to rehabilitate native function by leveraging neuroplasticity, or the brain’s ability to change and repair itself.

The first step in understanding how this might work, Lin said, is learning more about how the brain changes after an acute neurologic injury such as stroke. “We are tracking the natural history of motor recovery in people with arm weakness after stroke,” he said. “From the acute stroke period forward, we perform a series of outcome measures paired with neurotechnological assessments such as MRI, EEG, and TMS [transcranial magnetic stimulation] to examine how structures and pathways in the brain that have been affected by stroke change and allow for arm motor recovery.”

Leveraging insights from these investigations, Lin is also leading a collaborative study involving MGH, Harvard, and the Providence VA to engineer new technologies to help people recover arm function lost after a stroke. “Our aim is to leverage neurotechnologies that can be deployed in the clinic, such as EEG-based brain-computer interfaces, to restore arm function,” he said. A patient who has suffered a stroke and can’t move their arm, Lin explained, can still imagine moving it – “And when they do that, there are characteristic EEG signals that are evoked over the brain, primarily in areas of the brain that control movement, like the motor cortex.” These patterns of brain

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activity can be linked to a robotic device that can move the person’s arm for them, restoring the connection between intended and actual movement.

“In contrast to a system like BrainGate, where the braincomputer interface can be used to bypass the injury and reenable functional activities,” said Lin, “here we’re trying to restore neural connections themselves. The idea is that after using the EEG brain-computer interface for a number of sessions, the participant who has had the stroke will actually regain lost function.” Lin’s ultimate goal is to translate these technologies to maximize functional recovery for veterans and others with stroke.

EEG plays a key role in the work of W. Curt LaFrance, Jr., MD, MPH, a staff physician at the Providence VA and a professor of psychiatry and neurology at Brown. As the clinical lead for the Tele-Seizures Clinic at the VA National TeleMental Health Center, LaFrance treats patients with neuropsychiatric disorders including seizure, traumatic brain injury, and disorders of cognition, mood, anxiety, and movement.

LaFrance’s work for the CfNN builds on the expertise of seizure monitoring units at the VA’s 17 Epilepsy Centers of Excellence (ECOE), which can characterize seizures using video synched with an EEG of brain activity. Video EEG is a key tool in making an important distinction, LaFrance said: “In many cases, if there’s abnormal brain cell firing on the EEG with a seizure, we can say: ‘That’s an epileptic seizure.’ If there are no abnormal signals, what we call epileptiform discharges, during the event, then we say, for a number of presentations, ‘Ah, that’s consistent with a non-epileptic seizure.’ And it’s so important to be able to distinguish, because anti-seizure medications don’t treat non-epileptic seizures.”

LaFrance has helped to develop and validate a course of psychotherapy to treat patients with these seizures, including psychogenic non-epileptic seizures (PNES), in 12 weekly onehour sessions that can be delivered in person or online. While he considers video EEG to be the gold standard in making the distinction between epilepsy and PNES, he has the same easeof-use concerns as the CfNN’s other investigators. “Not every veteran can spend a week in the seizure monitoring unit,” he said. “And not every veteran who is in the seizure monitoring unit actually has one of their typical events. So the study may be inconclusive.”

LaFrance’s group is experimenting in the use of a wearable wristband that can record biodata such as skin temperature, heart rate, and electrodermal activity. The hope, he said, is that these data may collectively be used to capture seizures, and to help distinguish between epileptic and non-epileptic seizures.

Using algorithms and machine learning to analyze signals from the wristband, the group has identified a possible signature that

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AFFECTIVE AND COGNITIVE HEALTH The work of investigators in the CfNN’s second focus area, Affective and Cognitive Health, involves devices and technologies that alter the brain’s complex neural circuitry. Noah Philip, MD, the psychiatrist at the Providence VA who directs this area, views its mission simply: “What it boils down to,” he said, “is trying to figure out how we can help people, knowing what we know about the brain, without using pills and needles.”

CfNN researchers in this focus area use imaging technologies to identify therapeutic target areas in the brains of people with neurobehavioral disorders – depression, PTSD, suicidal thinking, chronic pain, or obsessive-compulsive disorder (OCD) – and apply electromagnetic fields to increase or decrease neuronal activity in the brain.

A neuromodulation technology often used by these investigators is transcranial magnetic stimulation (TMS): an electromagnetic coil, placed against the patient’s scalp, painlessly applies a magnetic pulse that stimulates nerve cells in the brain. TMS has been shown to be effective in treating depression – though the biology of why it works, exactly, isn’t

PHOTO COURTESY OF KIM DIDONATO-FERRO

differentiates between epilepsy and PNES – but it needs to be replicated among a larger sample. “Identifying novel diagnostic tools is one of our ongoing areas of focus,” LaFrance said.

completely understood. Ongoing investigations at CfNN have suggested that specific patterns of connectivity in the brain’s neural circuitry can predict a patient’s response to TMS. The center’s experts in computational neuroscience have enabled and supported studies demonstrating that the patients most likely to respond to TMS treatment can be identified with the help of machine learning.

A team of researchers from the center and Brown University including Philip; Jennifer Barredo, PhD; Yosef Berlow, MD, PhD; Hannah Swearingen, BA; and Benjamin Greenberg, MD, PhD, recently published a paper demonstrating the promise of TMS in treating suicidal ideation – but the underlying neural mechanisms of suicide remain poorly understood. Greenberg, the CfNN’s associate director, has worked to better understand the neurocircuitry of suicide and use neuroimaging to identify those at risk for suicide. CfNN investigators recently launched the first study combining brain stimulation and psychotherapy to reduce suicide in high-risk veterans.

Another method of neuromodulation being evaluated at the CfNN is transcranial direct-current stimulation (tDCS), the application of positive or negative electrical impulses by electrodes attached to the scalp. Philip’s group has demonstrated that tDCS, coupled with a variation of exposure therapy delivered via a virtual reality headset, can alleviate PTSD symptoms.

“One of the ways we understand post-traumatic stress now,” Philip said, “is that it’s really an imbalance in different neural networks: regions of the brain that act together to have a certain function.” In PTSD, explained Philip, a cluster of brain regions known as the salience network – because it helps the brain figure out what’s most relevant in a given moment – becomes very active when a person is under threat.

Above: A graphic illustrates the three focus areas at the Center for Neurorestoration and Neurotechnology (CfNN). Right: CfNN investigator Mascha van ’t-Wout Frank, PhD, demonstrates placement of transcranial direct current stimulation (tDCS) on Noah S. Philip, MD (lead, affective and cognitive health, CfNN).

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NATIONAL MUSEUM OF HEALTH AND MEDICINE PHOTO BY MATTHEW BREITBART

Fred Downs, Jr., a Vietnam veteran and former executive with the Department of Veterans Affairs, stands next to a temporary exhibit at the National Museum of Health and Medicine featuring a technologically innovative prosthetic arm, known as the “LUKE” Arm, developed by DEKA Research & Development Corp. Downs was one of the first veterans to receive the LUKE arm.

If this fight-or-flight response is activated frequently, or with unusual intensity, Philip says, “that system can get stuck in the on position – or the gas pedal, if you will, can get stuck down. What we’re doing is helping to get the brake working again.” Finding that braking system – in an area of the brain known as the dorsolateral prefrontal cortex, which is involved in self-control and regulating thoughts and emotions – was an effort supported

by CfNN’s core experts and their EEG and functional MRI scans of active brains.

In a recent study of veterans with PTSD, Philip’s group targeted this area of the brain using a TMS paradigm known as intermittent theta-burst stimulation (iTBS): short bursts of magnetic waves oscillating at fives cycles per second.

“That frequency, we have reason to think, helps a lot with getting the brake to work,” Philip said – it matches the frequency of neural impulses in the hippocampus, where memories of trauma are processed.

“What we have seen,” said Philip, “is that if we do this gently enough, and with enough energy, people get better.”

A group of about 50 veterans participated in the study, which was a doubleblind trial comparing the results of those who received iTBS in 10 sessions over 10 days, and those who received a placebo or “sham” treatment. On a range of outcomes, those who received iTBS did better than those in the control group, both two weeks and one month after the treatments.

Further investigations of this promising new treatment will focus on optimal dose of stimulation. For veteran patients, iTBS has a major advantage over traditional transcranial magnetic stimulation: It can be delivered in three - to 10-minute sessions, compared to the traditional 45-minute TMS sessions. “That means

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we can provide a lot more access to care,” Philip said.

Philip’s group has now compiled data on about 800 patients who have received TMS treatments across the VA – and the data affirm that it works. “We have reason to believe it’s safe and effective both for depression and for post-traumatic stress.”

The study of tDCS in conjunction with virtual reality exposure is a sign of things to come for investigators in Philip’s group: joining proven clinical interventions, such as exposure therapy, with new neuromodulating technologies, some of which may be safe for people to use at home. “My primary goal is helping people get better,” said Philip.

“My other goal is to understand how the brain works, so we can develop new ways to help people get better.”

LIMB FUNCTION Investigators in the CfNN’s third focus area seek to maximize the benefit of existing technologies – with a focus on prostheses – for veterans who have lost all or part of their upper limbs.

Linda Resnik, PT, PhD, a research career scientist at the Providence VA and a professor at Brown, directs this focus area using insights acquired over a nearly 20-year career in physical therapy. When the advanced robotic prosthetic known as the DEKA arm became available for study in the early

2000s, she was principal investigator for a multi-site VA study aimed at optimizing its design and usefulness. Her team subjected the prosthesis to an exhaustive evaluation, reporting on its features and functionality in all available configurations, and the study was used to support FDA approval of the device.

Her team compared two methods of controlling the arm – now known as the LUKE arm – using either a wireless foot control system or pattern recognition software that decoded the electric signals of arm muscles. Resnik also led a study investigating the feasibility and benefits of using the prosthesis at home.

At the time, Resnik began to realize she didn’t know as much about the prostheses people were using outside a VA laboratory. “There hasn’t been enough research on currently available devices and their features compared to each other,” she said. “We don’t understand who might best benefit from which type of device. So our motivation is to get more data, so that when we have these more advanced devices, we have good comparison data to understand the ways they may differ.”

Finding answers to that question may seem simple, but Resnik’s group is careful, when designing investigations, to remember the most important determinant. Differences among people – their lifestyle needs and desires and thresholds for comfort or pain – may matter more than hardware.

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“One of the things I’ve learned over these years,” said Resnik, “is that one prosthesis doesn’t fit everyone, and that some people benefit from different types for different situations.”

The Limb Function group at the CfNN is currently involved in two studies of veterans and active-duty service members recruited from among upper-limb amputees nationwide. The first involves nationwide survey and in-person data collected with the help of several partners: four VA sites, the Department of Defense’s Center for the Intrepid at Brooke Army Medical Center, and the University of Massachusetts Medical School.

Recruitment for this study is complete, the data has been collected, and multiple papers have been published. The team is still analyzing those important data.

Some issues revealed so far, Resnik said, have implications for further research in the design of future prosthetics. Many veteran amputees, for example, report pain in a variety of locations including the stump, residual limb, neck, and back, along with pain from the missing or “phantom” limb. “For many people,” Resnik said, “this pain is chronic. It was always present, and it was present again a year later at our follow-up. It’s a significant problem.”

The survey also gauged subjects’ interest in advanced surgical techniques such as osseointegration – the attachment of a prosthetic directly to the underlying bone, which avoids a socket altogether and makes an artificial limb a relatively seamless extension of the residual limb – or neurosurgeries that may improve their movement control. “We did find a really strong interest among these veterans with amputation, a willingness to consider surgery to have some features that are now mostly experimental but becoming more available.”

A second study, also aimed at discovering more about how people interact with specific devices, involves in-person data at multiple sites – but in-person data collection sessions were paused due to COVID-19 concerns. “We’ll be resuming it soon,” Resnik said. She’s hoping the

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study will collect sufficient data from smaller subgroups to focus on more device-specific questions, such as the benefits of having a powered rotator on an upper-limb prosthesis, or a hand with multiple grip patterns.

Resnik’s group is also investigating the needs of woman veterans with upperlimb amputation, who have expressed a slightly different set of needs and preferences – and who have been revealed by the nationwide studies to be less likely to use prosthetic arms than men. “Even though it looked as if, among the people who did use the prosthesis, male and female veterans were about equally satisfied, there were more women who didn’t use a prosthesis,” Resnik said. “So we know that we need to have some sort of way of assessing their perspective on available devices. We’re working on that kind of measure now, and we hope to have something to contribute in that area.”

In collaboration with a team led by principal investigator Dustin Tyler, PhD, of the Cleveland VA and Case Western Reserve University, the Limb Function group has begun work on a study funded by both the VA and the Defense Advanced Research Projects Agency (DARPA) to investigate the impact of a new neural-connected prosthetic. The iSENs system was designed to simulate a sense of touch through an array of fingertip pressure sensors and an aperture sensor, which gives a sense of the robotic hand’s opening or closing.

Data from these sensors is transmitted via leads implanted in the user’s arm, which can be used to activate upperarm flexors and/or to open and close the hand. The workings are complex, but essentially this system – an implanted somatosensory neurostimulator system – allows a user to “feel” sensory input and respond by gripping and lifting or moving items.

Resnik was among a VA research team who first reported the qualitative descriptions given by users of the iSENs system: what it felt like; how natural it was; how useful it was for certain tasks; and the degree to which it helped them return to normalcy. She is now a co-investigator for the new VA-funded randomized clinical trial comparing an advanced version of the iSens system to other prostheses.

After the post-pandemic resumption of data collection, Resnik hopes it will grow into a multi-site study. “We already have a few people with the initial implanted systems who have demonstrated that it’s possible to create a prosthesis that offers sensation,” she said, “and we have a good sense of the fact that it makes a huge difference to people in terms of feeling like the prosthesis is part of them.” The new system, she said, will offer more sensory abilities as well as improved movement control.

All neural-connected prosthetics are still in the experimental phase, Resnik pointed out; if you’re using one, you’re a research subject. The Limb Function group at the CfNN is working to answer questions about the future: about how interested and willing veterans might be to use these body- or brain-powered devices. But it’s just as important to make sure an upper-limb amputee has the right fit for their lifestyle today.

“One of the things I’ve learned over these years,” said Resnik, “is that one prosthesis doesn’t fit everyone, and that some people benefit from different types for different situations.”

Resnik’s observation – different circumstances require different solutions – is an insight shared by everyone at the VA’s Center for Neurorestoration and Neurotechnology; in fact, it’s one of the center’s founding principles. “Our center brings together researchers from multiple disciplines, including neurology, and neuroscience, and engineering, and physical therapy, and computer science,” said Hochberg. “To bring that group together to inform each other’s research, and to be able to focus that research on improving veterans’ health, is incredibly rewarding for all of us.”

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A wounded U.S. Marine awaiting transportation back to a field hospital after receiving first aid in the battle zone.

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BATTLEFIELD MEDICINE IN THE KOREAN WAR

By Dwight Jon Zimmerman

T

hough the Korean War came to be regarded as a failure by many because of its unsettled conclusion, in one area it was an unreserved success: the care and treatment of wounded soldiers. In World War II, the fatality rate for seriously wounded soldiers was 4.5 percent. In the Korean War, that number was cut almost in half, to 2.5 percent. That success is attributed to the combination of the Mobile Army Surgical Hospital, or MASH unit, and the aeromedical evacuation system – the casualty evacuation (casevac) and medical evacuation (medevac) helicopter. Both had been developed and used to a limited extent prior to 1950, but it was in the Korean War that both – particularly the helicopter – came into their own, and, as Army Maj. William G. Howard wrote, “fundamentally changed the Army’s medicalevacuation doctrine.” Helicopter medevacs transported more than 20,000 casualties during the war. One pilot, 1st Lt. Joseph L. Bowler, set a record of 824 medical evacuations over a 10-month period. Another example tellingly highlights the impact of the helicopter. The Eighth Army command surgeon estimated that of the 750 critically wounded soldiers evacuated on Feb. 20, 1951, half would have died if only ground transportation had been used.

The Korean War also provided an opportunity to study and test new equipment and procedures, many of which would go on to become standards of care in both the military and civilian medical communities. These included vascular reconstruction, the use of artificial kidneys, development of lightweight body

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armor, and research on the effects of extreme cold on the body, which led to development of better cold-weather clothing and improved cold-weather medical advice and treatment. The newest antibiotics were used widely, and other drugs that advanced medical care included the anticoagulant heparin, the sedative Nembutal, and the use of serum albumin and whole blood to treat shock cases. In addition, computerized data collection (in the form of computer punch cards) of the type of battle and non-battle casualties was used for the first time. The extensive detail and accessibility of this data allowed for the most thorough and comprehensive analysis of military medical information yet.

Like the other organizations within the military, when the war started in June 1950, the medical departments were short of everything. The most acute shortage was with doctors, particularly specialists. A doctor draft was instituted in August 1950, and the first medical draftees arrived in Korea in January 1951. By the following year, 90 percent of the doctors stationed in Korea were draftees. Combat medical care doctrine in Korea consisted of a relay system. The first line of care was organized around

In World War II, the fatality rate for seriously wounded soldiers was 4.5 percent.

In the Korean War, that number was cut almost in half, to 2.5 percent.

two groups: a battalion aid station and a separate forward collecting station. The latter contained eight men composed of a doctor, medics, and litter-bearers.

Wounded would be gathered at them and an initial diagnosis, triage, and tagging would be performed. Harold Selly was an Army medic, part of a forward collecting station team. “We were always in danger of being attacked by the enemy, overrun by the enemy, being shelled by artillery, shelled by mortar, and grenades thrown into the station,” he recalled.

The wounded would then be transported to a larger collection station located behind the front line. Once the wounded had been stabilized, they would be transported to a MASH unit or a division clearing station, depending on the type of wounds. From there, the wounded would be transported to an evacuation hospital. If the wounds were serious enough, the wounded would then be airlifted to a hospital in Japan.

Prior to the war, leaders in all the branches believed that the best way to transport wounded was by ground-based vehicle or ship. Rotary-wing evacuation was considered a means of last resort.

The primitive to nonexistent road network in Korea forced commanders on the peninsula to reassess that doctrine and seek a faster alternative solution.

In July 1950, the Air Force deployed the 3rd Air Rescue Squadron (ARS) under Capt. Oscar N. Tibbetts. It was a unit trained to rescue downed aircrews behind enemy lines or in the sea.

In August 1950, however, the 3rd ARS received an Army request that changed the role of the helicopter in Korea and

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A wounded American is lifted onto a helicopter at the 21st Infantry Regiment collecting station at Painmal, Korea, one mile south of the 38th Parallel, for evacuation to a base hospital on April 3, 1951.

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Surgeon General Maj. Gen. Raymond W. Bliss heard of Crosby’s demonstration and, after a fact-finding tour of Korea and a meeting with theater commander Gen. Douglas MacArthur, returned to the Pentagon with MacArthur’s recommendation “that helicopters should be in the Tables of Organization and Equipment and should be part of medical equipment – just as an ambulance is.” By the end of October 1950, eight helicopters assigned to frontline evacuation of wounded were on their way to MacArthur’s Far East Command. In 1951, the Army and the Air Force agreed that Army helicopters would be responsible for frontline rotarywing aeromedical evacuation, and the Air Force would provide fixed-wing aeromedical evacuation outside the combat zone.

In January 1951, four aeromedical evacuation helicopter detachments arrived in Korea. One unit, the 1st

MEDEVAC The medevac helicopters used in the Korean War were the Sikorsky H-5, the Bell H-13, and the Hiller H-23. They were fragile, high-maintenance aircraft with

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marked the beginning of a doctrine change in casualty evacuation. A forward aid station located on the summit of a 3,000-foot mountain had a seriously wounded soldier, but couldn’t do a ground-based evacuation because the enemy had cut off its route to the rear.

The request was to fly the wounded soldier out by helicopter. The mission was a success, and the soldier’s life was saved.

Capt. Leonard A. Crosby of the Army Medical Service Corps immediately recognized the helicopter’s potential impact. In order to expedite its implementation as an aerial ambulance, on Aug. 3, 1950, he arranged for a demonstration in the courtyard of Taegu Teacher’s College. The demonstration was so successful that one week later the commander of the Fifth Air Force authorized the use of its helicopters in frontline evacuation of Army wounded. U.S. Army

Helicopter Detachment, never became operational because its helicopters were all reassigned to other units. As none of the units had organic administrative and support units, the remaining three detachments were attached to MASH units that had all the necessary support elements.

The Mobile Army Surgical Hospital evolved out of the Portable Army Surgical Hospital and the forward surgical teams of World War II. As its name suggests, it was a small, fully equipped and staffed hospital capable of following an army in its campaign. Originally conceived as 60-bed hospitals, they soon expanded to 200 beds as a result of the large numbers of wounded they received. As the war went on, orthopedic surgeons, surgical technicians, and other enlisted, as well as more nurses, were added to the personnel originally planned for the MASH. More vehicles and trailers were also added, as the fluid nature of the Korean conflict had meant the “mobile” in the MASH acronym was employed time and time again. As a result of the draft that alleviated the doctor shortage in the military, almost all the staff doctors in the MASH units were civilian draftees, and though they took their work seriously, they displayed a more relaxed attitude about Army rules, regulations, and discipline. Dr. H. Richard Hornberger was one such medical draftee, assigned to the 8055th MASH. His experience with the unit served as the basis for his 1968 bestselling book M*A*S*H, which later became an Academy Award-winning movie and a successful, long-running television series.

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limited range. The early models had no radio or instrument lights in their cockpits. They couldn’t operate in bad weather, were limited on where they could land, and were fatally vulnerable to enemy ground fire. Even though they were not supposed to fly medevac missions at night, in emergencies many pilots did, holding a flashlight between their knees in order to see their instruments.

Ironically, the lack of a radio in some of the helicopters proved a boon. This forced the implementation of a doctrine using colored smoke grenades, marker panels, and hand signals to identify locations and landing sites.

In addition to the direct lifesaving benefit of swift transport from the battlefield to the MASH unit, the use of helicopters

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A helicopter of the 3rd Air Rescue Squadron settles gently to Korean soil to evacuate an injured soldier being carried in a stretcher by medics. In a matter of minutes, the soldier would be under the professional care of a medical officer at one of the Mobile Army Surgical Hospitals (MASH) at the rear.

had an ancillary benefit: It boosted morale. Troops on the front knew that should they get seriously wounded, even if their unit was cut off, they could still be evacuated. Also, once casualties were

strapped into a litter pod, they tended to develop a “the worst is over” feeling, which contributed to their recovery.

Though the primary focus by the military medical staffs was on the care of the uniformed personnel that composed the United Nations Command (UNC), they became involved in additional missions during the war. As a result of the 50-year Japanese occupation of the country that had killed, imprisoned, or exiled almost all the educated classes, there were almost no Korean doctors for

In addition to the direct lifesaving benefit of swift transport from the battlefield to the MASH unit, the use of helicopters had an ancillary benefit: It boosted morale.

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the civilian population. UNC medical staff at all levels assisted in giving care to civilians throughout the war whenever duties permitted.

One of the most unusual, and certainly the most dangerous event involving military medical personnel, was a deeppenetration special operations mission into North Korea involving the theater’s top military medical officer, Chief of the Public Health and Welfare Section of the Supreme Commander of Allied Powers in East Asia Brig. Gen. Crawford F. Sams.

As United Nations (U.N.) troops crossed the 38th parallel and advanced north in the fall of 1950, they encountered a civilian population decimated by epidemics of typhus, smallpox, and

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Above: Personnel and equipment needed to save lives are assembled at the headquarters of the 8225th Mobile Army Surgical Hospital, Korea, on Oct. 14, 1951. Left: An operation is performed on a wounded soldier at the 8209th Mobile Army Surgical Hospital, twenty miles from the front lines, on Aug. 4, 1952.

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typhoid. In addition, captured North Korean, and later Chinese, troops were ill with these and other contagious diseases. All the U.N. personnel had been vaccinated for the variety of diseases they were expected to encounter. But what troubled Sams, who received POW debriefing transcripts, were mentions of men turning black as they died. This suggested to him that bubonic plague – the Black Death – was in Korea. Unlike other vaccines, the one for bubonic plague renders only a short-term immunity.

Because the plague threatened both the U.N. troops and approximately 23 million civilians in South Korea and it would

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One of the first shipments of whole blood from A.R.C. blood centers in the United States for shipment to Korea.

take time to produce sufficient vaccine to inoculate everyone, confirming the presence of bubonic plague became a top priority.

By February 1951, word of disease epidemics in the Communist armies and civilian population were becoming generally known. The North Koreans and Chinese Communists launched a propaganda campaign accusing Eighth Army Commander Gen. Matthew B.

Ridgway and MacArthur of conducting biological warfare, and demanding they be tried for crimes against humanity.

The charges were false. The truth was that North Korea’s rudimentary health care system had collapsed under the combined weight of tens of thousands of infected troops, a large displaced population, bad hygiene, and other problems. But to conclusively refute the accusation, MacArthur needed proof delivered by an authority on the disease. Since the Communists refused to allow the independent International Red Cross access to the infected areas, MacArthur had to take matters into

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his own hands. That meant a special operations mission into one of the infected regions with an expert on the disease who would examine victims, take samples, and if possible, capture someone with the disease and return to Japan with him. The problem was, there was only one man in the theater who had hands-on experience dealing with the disease: Sams. If the theater’s top medical officer, and a general, were killed or captured during the mission, the Communists would achieve an immense propaganda coup. Nonetheless, MacArthur agreed.

“Operation Sams,” as the mission came to be known, was on.

Operation Sams was led by Navy Lt. Eugene F. Clark, who earlier had

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A seriously wounded soldier of the 116th Engineers is prepared for his operation at the 121st Evacuation Hospital, Aug. 17, 1951.

conducted a harrowing reconnaissance mission of Inchon for the amphibious assault of the harbor. Despite the mission being compromised, in the middle of March 1951 Clark’s team, including Sams, was able to covertly land near the North Korean port of Wonsan, an area where bubonic plague had been reported. They found a makeshift hospital. Though he confirmed other diseases, Sams determined there was no evidence of bubonic plague. As it turned out, the “Black

Death” plague was actually a virulent form of smallpox known as hemorrhagic smallpox, which also causes the body to turn black as the victim nears death. The team was able to safely return to Japan, where Sams made his findings public, effectively destroying the credibility of the accusations.

The successes of the MASH and aeromedical evacuation system in Korea were a watershed for military medical care, and the lessons learned, later applied and refined during the Vietnam War, have proved just as applicable today as they were in the 1950s.

This article was first published in The Forgotten War: 60th Anniversary of the Korean War.

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