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Dedicated to the Military Medical & VA Community combat casualty care Dedicated to the Military Medical & VA Community

Defense Health Agency

Global Facilitator Dr. Jonathan Woodson Assistant Secretary of Defense for Health Affairs

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August 2014

Volume 18, Issue 3

Medical Organizer Exclusive Interview with:

Craig Robinson Associate Deputy Assist.

Secretary, National Acquisition Center

Degrees in Health O Burn Care O Defibrillators VA Acquisition O Disease in Africa

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Military medical & Veterans Affairs Forum

August 2014 Volume 18, Issue 3

Cover / Q&A

Features

13

Who’s Who: Defense Health Agency

25

19

M2VA presents a pictorial review of the leaders of the Defense Health Agency.

Facing Disease Captain David K. Weiss, command surgeon, AFRICOM, discusses disease prevention and elimination in subSaharan Africa.

Medical Organizer Associate Deputy Assistant Secretary for National Healthcare Acquisitions Craig Robinson discusses the work of the Office of Acquisition and Logistic/ National Acquisition Center.

16 Dr. Jonathan Woodson

Assistant Secretary of Defense for Health Affairs

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8

There are a number of degree programs in the health sciences available to veterans of the services or active duty military members. Many of the classes offered are online, which works for students seeking a more flexible schedule or who are stationed onboard a ship or deployed in a far off location.

By Chris McCoy

The symptoms presented by burn patients seen by the U.S. Army burn center in San Antonio, Texas, changed over the years as the focus of U.S. military actions shifted from Iraq to Afghanistan.

By Peter Buxbaum

Programs in the Health Sciences

Treating the Burn

Departments 2 Editor’s Perspective 3 Program Notes 4 People 14 Vital Signs 27 Resource Center

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21

The most common abnormal heart rhythm for spontaneous cardiac arrest is ventricular fibrillation.

This is essentially when the heart is beating totally ineffectively and erratically at a rapid rate and produces no output of blood. It is almost always fatal if it proceeds for too long.

By Chris McCoy

The decade-plus that the United States has been at war has produced dramatic advancements in tactical combat casualty care. The military itself has developed new structures and strategies through which to provide the quickest and best possible care to wounded warriors.

By Peter Buxbaum

Automated External Defibrillators

Special Section: Combat Casualty Care

Industry Interview Greg Borecki

Vice President of Strategic National Accounts Stanley Healthcare

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“Cooperation missions provide excellent opportunities for the U.S. military abroad, as they revolve around building upon or creating new relationships with other nations’ militaries, agencies and NGOs.” –Dr. Jonathan Woodson

EDITOR’S PERSPECTIVE

Military Medical & Veterans Affairs Forum Volume 18, Issue 3 • August 2014

Dedicated to the Military Medical & VA Community Editorial Editor

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The new Secretary of Veterans Affairs Robert A. McDonald is continuing the VA’s largely successful program of ending veteran homelessness.

A new VA award of approximately $300 million in grants will help approximately 115,000 homeless and at-risk veterans and their families.

The grant money will go out to 301 community agencies in every state and the District of Columbia, the Virgin Islands and Puerto Rico.

VA grant money is flowing through under the Supportive Services for Veteran Families (SSVF) program. These grants are going to private nonprofit organizations and consumer cooperatives that provide services Christopher McCoy Editor to very low-income veteran families living in—or transitioning to— permanent housing.

“By working with community non-profit organizations, we have enlisted valuable partners in our fight to end homelessness,” said McDonald. “The work of SSVF grantees has already helped thousands of homeless veterans and their families find homes and thousands more have been able to stay in their own homes.

We want to make sure our veterans receive the care and support that they have earned and deserve,” McDonald added. “This is a program that, indeed, makes a difference.”

Another major item in military medical is the development of a promising malaria vaccine that is the first vaccine of its kind. Malaria remains a major issue to military servicemembers and to military health missions abroad in Africa.

The quest for a malaria vaccine has gone on for quite some time with little result. The disease is a major killer of children in sub-Saharan Africa.

Until now, combating malaria has focused on prevention and treatment. The focus has been on destroying the mosquitos and their environments that carry disease, employing mosquito nets, developing preventative drugs—the most famous of which has been quinine—and developing other drugs used once the illness has been contracted.

Of 1,000 children administered the newly developed vaccine, 800 did not contract the illness.

As usual feel free to contact me with questions or comments for Military Medical & Veterans Affairs Forum.

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PROGRAM NOTES New Regulations Automate Burial Payments for Veterans’ Survivors New burial regulations now allow the Department of Veterans Affairs to automatically pay the maximum amount allowable under law to most eligible surviving spouses more quickly and efficiently, without the need for a written application.

Under former regulations, VA paid burial benefits on a reimbursement basis, which required survivors to submit receipts for relatively small one-time payments that VA generally paid at the maximum amount permitted by law.

“VA is committed to improving the speed and ease of delivery of monetary burial benefits to veterans’ survivors during their time of need,” said Acting VA Secretary Sloan Gibson. “The recent changes allow VA to help these survivors bear the cost of funerals by changing regulations to get them the benefits more quickly.”

This automation enables VA to pay a non-service-connected or service-connected burial allowance to an estimated 62,000 eligible surviving spouses out of a projected 140,000 claimants for burial benefits in 2014. Surviving spouses will be paid upon notice of the veteran’s death using information already in VA systems. The burial allowance for a non-service-connected death is $300, and $2,000 for a death connected to military service.

This revised regulation will further expedite the delivery of these benefits to surviving spouses, reduce the volume of claims requiring manual processing, and potentially make available resources for other activities that benefit veterans and their survivors.

Compiled by KMI Media Group staff

Acting Secretary Gibson Continues to Provide Transparency on Wait Times The Department of Veterans Affairs released its bi-monthly data update showing progress on VA efforts to accelerate access to quality health care for veterans who have been waiting for appointments.

Acting Secretary of Veterans Affairs Sloan D. Gibson announced that VA outreach has now extended to nearly 140,000 veterans across the country to get them off of wait lists and into clinics for medical appointments.

VA also released the latest updated, facility-level patient access data.

“In many communities across the country, veterans wait too long for the high quality care they’ve earned and deserve,” said Gibson. “As

of today [July 3, 2014], we’ve reached out to nearly 140,000 veterans to get them off wait lists and into clinics, and there is more work to be done. As we continue to address systemic challenges in accessing care, these regular data updates enhance transparency and provide the most immediate information to veterans and the public on improvements to veterans’ access to quality health care. We are fully committed to fixing the problems we face in order to better serve veterans. We must restore the public’s trust in VA, but more importantly, we must restore the trust of our veterans who depend on us for care.”

The latest patient access data is available at www.va. gov/health/access-audit.asp.

VA to Restructure Office of Medical Inspector In response to the Office of Special Counsel’s recent recommendations for the Department of Veterans Affairs, Acting Secretary of Veterans Affairs Sloan Gibson announced VA will restructure the Department’s Office of Medical Inspector (OMI) to better serve veterans.

“At VA, we depend on VA employees and leaders to put the needs of veterans first and honor VA’s core values of integrity, commitment, advocacy, respect and excellence,” said Gibson. “Given recent revelations by the Office of Special Counsel, it is clear that we need to restructure the Office of Medical Inspector to create a strong internal audit function, which will ensure issues of care quality and patient safety remain at the forefront.”

On June 23, 2014, the Office of Special Counsel sent a letter to President Obama

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regarding VA whistleblowers. Following the letter, Gibson directed an immediate review and subsequent briefing of OMI’s operation, process and structure. As a result of the briefing, the acting secretary determined a clear need to revise the policies, procedures and personnel structure by which OMI operates, and has directed a restructuring of the organization.

As long-term restructuring moves forward, the acting secretary has directed that, effective immediately, VA will appoint an interim director of OMI from outside the current office to assist with transition, and VA will suspend OMI’s hotline and refer all hotline calls to Office of Inspector General.

With the June 30 retirement of the individual who has served as the Medical Inspector

of the Veterans Health Administration for more than a decade, this restructuring will occur with the input of the team of individuals that the secretary has brought to VA to assist in addressing systemic issues and rebuilding veteran trust.

On June 13, 2014, Gibson sent a message to all VA employees regarding the importance of whistleblower protection and has met with employees at VA Medical Centers across the country to re-emphasize that message.

“As I told our workforce, intimidation or retaliation—not just against whistleblowers, but against any employee who raises a hand to identify a problem, make a suggestion, or report what may be a violation in law, policy or our core values—is absolutely unacceptable. I will not tolerate it in our organization.”

M2VA 18.3 | 3

PROGRAM NOTES

Compiled by KMI Media Group staff

Statement from Acting Secretary of Veterans Affairs Sloan D. Gibson Acting Secretary of Veterans Affairs Sloan D. Gibson released the following statement after President Obama’s announcement that he intends to nominate former Proctor & Gamble chief executive Robert A. McDonald to be the next secretary of Veterans Affairs.

“Today [June 30, 2014], after a careful search, President Obama announced his intention to nominate former Proctor & Gamble chief executive Robert A. McDonald to be the next secretary of Veterans Affairs.

“I have been close friends with Bob McDonald for over 40 years; I welcome his nomination with the utmost enthusiasm. He is an exceptional person—a great leader, a skilled manager, an extraordinarily talented executive of great experience and a man with the strongest moral compass.

“All of those attributes contributed to his rise through the ranks to the top spot at P&G, a Fortune 50 company with more than 120,000 employees. Under his stewardship, P&G consistently ranked among the best companies in the world for leadership development, being twice named best company for leaders by Chief Executive magazine.

“Bob graduated from West Point in the top 2 percent of his class and served five years in the U.S. Army. He was a captain in the 82nd Airborne Division before leaving the Army to join P&G. He is a life member

of the U.S. Army Ranger Association and the 75th Ranger Regiment Association.

“His commitment to veterans is deeply personal. His father served in the Army Air Corps just after World War II. His wife’s father was shot down over Europe during World War II and ended the war as a POW. Her uncle was exposed to Agent Orange in Vietnam and still receives treatment from VA. “With his years of executive success and principled leadership philosophy, stressing caring for others and personal ethics— choosing ‘the harder right instead of the easier wrong,’ in words he often quotes from the West Point Cadet Prayer—he is an inspired and inspiring choice to lead VA through this period of restructuring and reform.

“The planned nomination of Bob McDonald to be the next secretary of Veterans Affairs is a very positive step. I will do everything I can to help him be successful, and I expect the same to be true for our dedicated VA workforce.

“Personally, professionally, and on behalf of veterans and all of our VA employees, I look forward to Bob’s speedy confirmation—and to working closely with him and the rest of our VA leadership team toward restoring the public trust in VA by providing veterans and their families the very best in timely care and benefits.”

PEOPLE

Capt. David A. Lane

4 | M2VA 18.3

Compiled by KMI Media Group staff

Navy Captain David A. Lane has been selected for the rank of rear admiral (lower half), and will be assigned as medical officer of the Marine Corps and as director, Health Services, Headquarters Marine Corps, Arlington, Va. Lane is currently serving as commanding officer, Naval Hospital Camp Lejeune, N.C.

Brigadier General James H. Mason, U.S. Army Reserve, deputy commander of troop program unit, 807th Medical Command (deployment support), Camp Parks, Calif., has been assigned as deputy commander (troop program unit), 807th Mission Support Element, Camp Parks.

Acting Secretary Gibson Meets with Special Counsel on Whistleblower Protections Acting Secretary of Veterans Affairs Sloan Gibson met with Carolyn Lerner, special counsel of the United States Office of Special Counsel, following the office’s letter to the president regarding VA whistleblowers.

Following through on recent recommendations for the Department of Veterans Affairs, the acting secretary committed to VA working to achieve compliance with the OSC 2302 (c) Certification Program, and also reaffirmed his focus on ensuring protection from retaliation for employees who identify or report problems.

Gibson updated the special counsel on the ongoing review of all aspects of the Office of Medical Inspector’s operation, which he ordered upon release of the letter. He re-emphasized his commitment to earn the trust of veterans who VA is privileged to serve.

Special Counsel Lerner and Acting Secretary Gibson identified in their July 1, 2014 meeting ways to streamline the organizations’ work together to ensure whistleblower protection during the course of an OSC investigation.

Leigh Bradley accompanied the acting secretary to the meeting. She has temporarily joined VA effective Monday, July 7, on a detail from DoD to serve as special counsel to the acting VA secretary. Bradley is a former VA general counsel, former principal deputy general counsel of the Navy, and current director of the Department of Defense Standards of Conduct Office where she is responsible for DoD’s ethics program and policies. She is a veteran of the U.S. Air Force.

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A number of schools offer perks to servicemembers and veterans seeking a career in the health sciences.

By Chris McCoy, M2VA Editor University,” said Sayler. “Many of our graduates go on to achieve their bachelor’s degree, which often can also have additional earned credits applied to the degree within upper electives.”

Tuition at Kaplan is reduced within the amount afforded by the GI Bill in most cases. Tuition is reduced by 38 percent for veterans and 55 percent for active duty for undergraduate programs at Kaplan University. The school also waives technology fees. In addition, books are provided at no additional cost.

“We also waive fees for our veteran students.

Kaplan University Veterans also have the benefit of military experience as well as the challenges of adult learners, often holdKaplan University views the completion of higher ing down jobs and raising families,” said Sayler. “We academic credentials as collaboration between the provide service to our veterans through our military skills earned in the military and those needed to student support center to make the most of the milifulfill the requirements of a college credential. tary training, and help them navigate through the “We place great value on the training that is issues facing adult learners. Our online format allows received. Our culture is not to provide a generalized for flexibility and is often critical to their success.” amount of credit without really understanding how The majority of Kaplan’s military students attend that training stacks up against the skills needed for online, and the school has broad diversity within the degree,” said Brian Sayler, the executive director Brian Sayler this population in gender, race, and the civilian and for Military Affairs at Kaplan University. military mix.

For the Associate of Science in health science “In fact, almost 24 percent of our student body has military (ASHS), Kaplan mapped specific military occupations and created experience or is the spouse of a military member,” said Sayler. “This specialties within the degree corresponding to those occupations. diversity improves the interaction within our virtual classrooms and This provided a higher education credential that mirrored serviceprovides the military perspective to students not often exposed to members’ and veterans’ military work, collectively demonstrating this point of view at many traditional schools.” a comprehensive mastery and application of the curriculum. It in Key areas where veterans can receive service credit for credensome cases significantly shortens the time to gain the credential, tials include medical, combat arms, legal studies and business. sometimes requiring as few as five courses.

“We also do a transcript analysis of all veteran students, “The ASHS program was launched in November 2012 with regardless of occupation, to identify possible credits. A course is great success and is one of the more popular programs at Kaplan There are a number of degree programs in the health sciences available to veterans of the services or active-duty military members. Many of the classes offered by schools are online, which works for students seeking a more flexible schedule or who are stationed onboard a ship or deployed in a far off location. Some of the degree programs available to servicemembers and veterans are examined here, alongside the schools that offer them.

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M2VA 18.3 | 5

also is a subway stop a few blocks from the school’s main buildings.

Johns Hopkins MPH students come from diverse backgrounds such as physicians, nurses, lawyers, health educators, social scientists and more. They have included a number of current and past military personnel.

Some of the military students go through the two-year Occupational and Environmental Medicine Training Program at Johns Hopkins, which includes the MPH as the first year. Others complete the MPH as part of the NASA-funded Aerospace Medicine training program. In addition, approximately two to three students per year complete the MPH as part of their military surgical residency programs.

“Our MPH program is flexible,” said Marie Diener-West, Ph.D., A.T. Still University chair, Master of Public Health Program and Abbey-Merrell Professor of Biostatistics. “Our full-time MPH program is 11 months The vision of A.T. Still University’s College of Graduate Health long. Since the 1990s, we have offered a part-time MPH program Studies (ATSU-CGHS) is to be the preeminent online school for that can be completed over two to three years and includes selecleaders in the health professions, focused on academic excellence tions from more than 100 online courses, as well and innovation. as intensive format courses held over one to three “We provide a contemporary and flexible curweeks.” riculum that empowers our students to translate The Johns Hopkins MPH program has been knowledge to meet the growing needs of domestic noted as one of the best in the world. Consistently and global health and wellness,” said Mike Jackson, ranked the number one school of public health by Ph.D., MPH, chair and professor of public health at U.S. News and World Report, Johns Hopkins BloomATSU-CGHS. “Building off that vision, our program berg School of Public Health was founded in 1916 works with graduate students who are focused on and is the largest and oldest program of its kind in expanding their knowledge and leadership abilities the world. for responsible public health practice, policy and Approximately 35 percent of the MPH student access to care.”

Mike Jackson body is international, coming from 80 different ATSU-CGHS’s Master of Public Health (MPH) countries. All students take courses in the core degree is earned entirely through online study and areas of epidemiology, biostatistics, public health biology, mancourse completion. agement sciences, environmental health and social behavioral “As a part of the larger A.T. Still University of Health Sciences, sciences. However, they can specialize in concentration areas that our aim and focus is to educate current and future leaders in include health in crisis: humanitarian assistance, health leaderthe health professions. As such, we prepare students to work in ship and management, among others. the public health profession through the MPH general emphasis “Although there is no academic credit for military experience, degree,” said Jackson. “For those students who have an interest the background and experiences of the former or current military and education in the dental profession, we offer an innovative MPH students contribute so much to the collective student environdegree with a dental emphasis. For those students who are currently ment, both in and outside of the classroom,” said Diener-West. enrolled in either of the university’s medical or dental schools, it is possible to earn the MPH degree concurrently with their Doctor of Osteopathic Medicine or Doctor of Dental Medicine.

The University of Maryland University College “The MPH program began in 1999 and is earned online, therefore the MPH/public health campus is virtual,” said Jackson. “A.T. The University of Maryland University College’s (UMUC) MasStill University offers medical, dental and health sciences graduate ter of Science in health care administration is an applied degree degrees on campuses in Kirksville, Mo., and Mesa, Ariz. These are designed for mid-career professionals in health care who are seeking the physical locations of the administrative offices for ATSU’s Colto focus their studies in health care administration in areas such as lege of Graduate Health Studies, which is the home of the MPH financial management, information technology, legal and policy, program.” and population health. The degree program dates back to 2002.

One of the benefits for veterans attending the school is reduced “The Master of Science in health care administration [MSHCA] tuition rates. can prepare students for a leadership role in one of today’s fastestgrowing fields,” said Diane Bartoo, associate chair and program director for the MSHCA. Johns Hopkins University Students learn how to produce effective health care outcomes and impact ethical decision making in health care settings while Johns Hopkins Bloomberg School of Public Health is based solving complex health care challenges. in east Baltimore on the historic Johns Hopkins Medical Campus, “While our program is offered fully online, we also offer some which also includes the hospital and the schools of medicine and courses on-site at various military facilities in Europe and Asia, as nursing as well as research libraries. The campus is only one mile well as hybrid (half online and half face-to-face) and on-site courses from the waterfront and Baltimore’s Inner Harbor and provides a in the Maryland /D.C./Virginia area,” said Bartoo. “All of our faculty, shuttle service that also stops at Baltimore’s Penn Station; there also offered that allows them to identify additional skills that can be awarded credit [that are] not present on their military transcript. In total, up to 75 percent of credit can be earned through a combination of all these sources,” said Sayler. “Kaplan University also accepts transfer credit from other accredited schools and Servicemembers Opportunity Colleges Consortium members.”

Since the Kaplan virtual campus is online, the school reaches all corners of the word.

“While our physical campuses reside in states such as Iowa, Maine, Maryland, and Nebraska, the majority of military students study online so can they reside virtually anywhere,” said Sayler.

6 | M2VA 18.3

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including several current and former military servicemembers, are experienced health care professionals who work or have worked within many different health systems. They bring their extensive and practical knowledge and skills into our classes.”

UMUC offers graduate students the opportunity to earn dual health care and MBA degrees. In addition to a Master of Science in health care administration, UMUC also offers a Master of Science in management (MSM) with a specialization in health care administration, a master’s degree in health informatics administration, and a number of certificates and joint degrees, such as a dual MBA joined with either the MSHCA or the MSM with a health care specialization.

While students in both the MSHCA and MSM take some similar coursework, the MSHCA requires the educational and/or experiential background in health care or health care administration for students to be successful.

UMUC also has specially trained advisors that can help veterans plan their academic journey and work directly with them to understand their benefits and how they can best be used to accomplish their academic goals. UMUC also has a Veterans Certification Office which helps veteran students in applying for their veterans benefits. For students, UMUC offers a Veterans Success Club.

“More than half of our approximately 90,000 students are active duty military, their dependents and veterans,” said Bartoo.

“The typical MSHCA student is in his/her mid-30s. Seventy-five percent are female. Approximately 50 percent of students are

African American, 24 percent are Caucasian, 6 percent Hispanic and 5 percent Asian.”

For undergraduate studies, students may receive credit for prior learning in the military. UMUC has advisors specially trained to help plan an academic program for students who have military backgrounds. Advisors work with the student, assess prior learning, and evaluate the student’s record to determine what credits might be awarded.

For graduate students, UMUC also has specially trained advisors who will assist military students. Up to six graduate transfer credits from an accredited institution can be considered.

All veterans living in Maryland are entitled to the resident rate for tuition. For those veterans entitled to the full benefits of the Post 9/11 GI Bill benefits, UMUC fully subscribes to the Yellow Ribbon program that splits the cost between the Veterans Administration and UMUC for the cost above the in-state rate, so there is no cost to the veteran.

Altogether, veterans and active duty servicemembers have a lot of options when picking a program in the health sciences.

Reduced tuition and the GI Bill are two perks to help jumpstart a career in the health sciences. O

For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

Medical personnel: you may be as few as 5 courses from a degree in health sciences.* • 42 military occupations have been evaluated for credit • Associate’s, bachelor’s, and master’s degree programs available • Tuition reduced 55 percent for servicemembers†

Find out more and enroll at militarymedical.kaplan.edu or call 877.809.8445.

For comprehensive consumer information, visit www.kaplanuniversity.edu/student-consumer-information.aspx.

Kaplan University is accredited by The Higher Learning Commission (HLC) and a member of the North Central Association of Colleges and Schools (NCA). For more information, visit their website at hlcommission.org. Use the links under “Contact Us” to reach the Commission. * Based on a full-time active-duty student who transfers in 65 quarter credit hours (the maximum amount of credit).

Credits transferred may vary according to your previously completed MOS/NEC, current military status, or affiliation (active, veteran, member of the National Guard, or reservist). † Military tuition reductions cannot be combined with any Kaplan University scholarships or tuition discounts/vouchers.

Online | Accredited | Servicemembers Opportunity Colleges (SOC) Member

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M2VA 18.3 | 7

The military continues to advance its burn care technologies.

By Peter Buxbaum M2VA Correspondent The symptoms presented by burn patients seen by the U.S. Army burn center in San Antonio, Texas, changed over the years as the focus of U.S. military actions shifted from Iraq to Afghanistan.

“In 2003, most of those patients were from Iraq,” said Colonel Dr. Booker T. King, director of the U.S. Army Institute of Surgical Research Burn Center at Joint Base San Antonio-Fort Sam Houston.

“The vast majority of them were traveling in a vehicle that hit an improvised explosive device when the IED exploded and the vehicle caught fire.”

As the war in Iraq wound down and the conflict in Afghanistan surged, a different kind of patient showed up at the burn center.

“By 2009 or 2010, most of our patients were coming from Afghanistan. Most of these were dismounted soldiers on foot patrol.

When they hit an IED they would have not only significant burns, but also soft tissue trauma,” said King. As a result, the burn center had to broaden its capabilities to treat all of the symptoms and injuries exhibited by these newer patients.

The burn center doesn’t treat only military patients injured in theaters of operations. For that matter, the center doesn’t treat only military patients. “We receive military patients who have suffered burns anywhere in the country or the world,” said 8 | M2VA 18.3

the civilian scenario,” said Patrick Bourke, King. “In the last year or so, we haven’t clinical educator at Water-Jel Technologies received any patients from Iraq or AfghaniInternational. “With civilian patients, the stan. We treat civilians because we are the primary concern would be for the burn. An regional burn center for southern Texas. We injured patient from the military is likely also treat civilians who are military retirees to have suffered burns as a result of an IED and veterans as well as their beneficiaries.” blast or some other explosive. In these cases, Treating burn patients, whether in the the burns are usually secondary to injuries immediate aftermath of an incident or up such as traumatic amputathe line in the course of lontion. In cases where the burn ger-term care, requires adheris of greater concern, one of ence to established protocols. the big problems is the killThe immediate concern after ing of the flesh in the area of a burn injury has been the burn. That is the reason inflicted is the cooling down for having an effective burn of the area to minimize the management protocol.” de-vitalization of tissue and to Debridement of the burn provide comfort to the patient is one key to its effective before moving them on to treatment. “Debridement is the next line of care. It is also Col. Dr. Booker T. King the process of removing dead important that healing be tissue from a wound until facilitated through a process the surrounding healthy tiscalled debridement, which sue is exposed, allowing it to involves the removal of dead advance the wound through tissue and the facilitation of the healing process,” said healthy tissue growth. At all Beth Joy-Dougherty, directimes, the burn site must be tor of corporate marketkept clean. Companies in the ing at Derma Sciences Inc. private sector have introduced “Debridement is indicated products that help clinicians for any wound when necrotic accomplish these aims. tissue, foreign bodies or “The military scenario Patrick Bourke infected tissue is present. The is completely different than www.M2VA-kmi.com

presence of necrotic tissue or foreign bodies within a wound can lead to more serious consequences involving infections and even limb amputation. It is imperative that an effective wound management strategy be structured.”

Because of the complexity of the cases presented by military patients, the Army burn center has acquired advanced technologies to deal with the other injuries warfighters often show in addition to their burns. “These patients usually have multiple injuries,” said King. “Kidney failure and respiratory problems are two of the most common conditions they exhibit. We have different kinds of technologies for kidney failure and advanced ventilators for respiratory problems. The new bypass ventilators can oxygenate the blood while the lungs are healing. We have used this capability for patients with severe inhalation injuries as well as medical patients with advanced respiratory illnesses that couldn’t be treated by conventional means.”

The first step in a burn control protocol is to stop the burning process by cooling the injury. “It is important to remove the heat source in the first place and to keep the area clean as the patient is prepared for transport,” said Bourke. “The heat produces pain. Once the heat is taken away it will stop attacking the nerve endings and provide some comfort to the patient.”

Water-Jel products have been on the market for over 30 years and were originally designed with the military in mind, noted Bourke. “The primary requirement was for something that could absorb the very high

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temperatures that the human flesh was exposed to,” he explained. “Water-Jel can absorb over 2,000 degrees Fahrenheit of heat irrespective of the offending medium.

It is also certified clinically to clean the burn injury and to kill microorganisms that attack the burn within the first [few] hours.”

Water-Jel is a mixture constituting 96 percent deionized water, 0.4 percent tea tree oil and 2 percent food-grade gelling. This mixture is impregnated into dressings that can be applied to a wide variety of wounds.

The dressing itself is made of medical grade woven polyester that can carry up to 13 times its own weight.

“The gelling agent is there to keep it all together,” said Bourke. “If the burn is cooled with water alone, it is not as effective because the water will evaporate quickly.

Water-Jel cools by a convective process that takes excess heat into itself. The gel warms up and then radiates heat off its top. The cooling mechanism is critical.”

The Water-Jel products can be left on the patient for four to six hours and are nonadherent, so that a medic can lift the dressing to observe the wound. “It works well in harsh environments and is effective in a broad spectrum of uses,” said Bourke. “Water-Jel is the only burns product tested and approved as effective for treating white phosphorus burn injury patients in the emergency setting. It works whether the burn is concave—that is, there is a hole in the tissue—or convex—in which the tissue is blistering. The gel fills the aperture and in the case of a blister bursting it provides constant and continual cooling.

The key is that the cooling agent must be in contact with all aspects of the burn. If not, the cooling will not be constant and certain areas will continue to burn.”

The company produces a universal dressing specifically designed to treat burns on the hands and face. “Military surgeons say that 70 percent of burns occur on the hands and face,” said Bourke. “The armor that warfighters wear protects much of the rest of their bodies.”

Water-Jel also produces a line of fire blankets that double as a quick method of administering emergency first aid burn care. “The U.S. military has been using these in transport vehicles because they are facing armor-piercing weapons that can create a heat source and start a fire within a vehicle,” said Bourke. “Since the blankets are gel soaked, they can function as a burn dressing, easing the pain, cooling the burn, and helping to protect against airborne contamination, as well as a fire blanket that can be used to extinguish flames on a victim and put out small fires.”

Derma Sciences produces two lines of products used in the treatment of burn injuries. The company’s Medihoney line is a natural product that aids in the process of autolytic debridement of burns, in which the body’s own enzymes are used to soften and liquefy necrotic tissue so that it can be easily removed. The company’s Bioguard line incorporates an active agent in the substrate level of a dressing that kills pathogens within the dressings, keeping the burn site safer.

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“Medihoney has been on the market since 2007 and has had positive clinical outcomes for first- and second-degree burns,” said Dougherty. “It naturally helps promote autolytic debridement and a clean burn environment. During autolytic debridement enzymes present in the wound have the effect of liquefying non-viable tissue. By maintaining a moist wound environment, the body is able to use its own processes to eliminate devitalized tissue.”

Honey has been documented to have healing properties for thousands of years.

During the 1970s, scientific investigations discovered the specific factors in honey that promote healing. “When it comes to burn care, we are talking about a specific type of honey,” said Dougherty. “We produce medical grade honey from manuka plants that have been pollinated by bees in New Zealand. Ordinary honey can be used to clean burns and to promote debridement but it is not as high in the active ingredients and the properties that make medical grade honey more effective.”

Medical grade honey has a high sugar content, which facilitates the movement of fluid from an area of higher concentration to an area of lower concentration.

Additional fluid is drawn from the deeper tissue to the wound surface, which helps the body’s natural processes to cleanse the wound, removing debris and necrotic tissue.

Medihoney also has lower, or acidic, pH levels. “The failure of a chronic wound to heal has been correlated with alkaline pH levels,” said Dougherty. “The honey helps to reduce the pH of the wound environment and contributes to the acidic environment that promotes healing. Lowering the pH also aids the body’s natural processes for removal of necrotic tissue.” Studies have down that each 0.1 decrease in pH was associated with an 8.1 percent reduction in wound size.

In addition, honey has an off-label use as an antimicrobial. “Medihoney is sold and promoted as an antimicrobial everywhere outside the United States,” said Dougherty.

“We don’t have FDA clearance to promote it as such here, but the literature supports that assertion.”

Medihoney comes in a full line of products, including a tube form that contains 100 percent Medihoney. There is also a gel that contains 20 percent Medihoney mixed with natural emollients and goes on like a cream. It has also been impregnated into a variety of dressings.

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A burn victim undergoes surgery to remove skin from his legs that will be grafted over his burn in the emergency room at Brooke Army Medical Center. [Photo courtesy of Brooke Army Medical Center/by Petty Officer 2nd Class Jhi Scott]

The U.S. military was among the first to study Medihoney. “One of the first articles published on Medihoney was by a U.S. military surgeon in Iraq,” said Dougherty. “We also work with VA and military hospitals.”

Derma Science’s Bioguard line of dressings includes a strong cationic biocide known as poly diallyl dimethyl ammonium chloride, or pDADMAC. “PDADMAC is applied to the dressing substrate during the manufacturing process,” said Dougherty. “It prevents bacteria from proliferating within the wound and also reduces the risk of cross contamination that could come about from the release of bacteria into the air.”

Use of this biocide in wound dressings, along with the bonding techniques utilized to intrinsically bind pDADMAC to wound dressing substrates, is covered by nine U.S. patents and patents pending. The Bioguard product was launched in 2010. “This product received de novo clearance from the FDA, which means that there is no other dressing like it on the market,” said Dougherty.

King expects further advancements in burn care to come from the area of rejuvenative medicine. “We are in involved in FDA studies that are looking at substitutes for skin,” he said.

In one FDA study, some patient skin is removed and dissolved in a solution that can be sprayed on the patient. “The advantage

is that you can take a small piece of the patient’s skin and use it to cover a much larger surface area,” King explained. “This is still in the study phase. The results of testing are looking pretty good and we hope it will be approved by the FDA and made available for general use.”

King expects other advancements in the area of organ support, an often necessary accompaniment to caring for burn patients.

“What often happens with burn patients is that, because of the severity of the injury, they tend to develop organ failure,” he said.

“One common condition is kidney failure.

One of our doctors is heading a study on a support system for kidneys called continual renal replacement therapy. We are looking into that for burn patients.”

Developments that grew out of the conflicts in Iraq and Afghanistan have provided the Army burn center greater capabilities in the treatment of critically ill patients, King noted. “Many of the advancements that have come about and the research that is now being conducted will benefit not only our military population but also burn patients as a whole,” he said. O

For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

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By stopping ventricular fibrillation, a heart can be restarted.

By Chris McCoy, M2VA Editor The most common abnormal heart rhythm for spontaneous cardiac arrest is ventricular fibrillation. This is essentially when the heart is beating totally ineffectively and erratically at a rapid rate and produces no output of blood. It is almost always fatal if it proceeds for too long. CPR alone will not stop the process and early defibrillation is required. The most effective and easy way to deliver defibrillation is through an automated external defibrillator (AED). These devices vary, but they all analyze the rhythm of the heart and if appropriate (i.e., if the patient is in ventricular fibrillation) provide a shock automatically with the push of a button. The operator does not need to do any analysis—they simply follow the directions.

“Contrary to popular belief, defibrillation does not restart the heart. Defibrillation is the process of using electricity to stop the heart completely. If the heart has enough metabolic substrate (energy) left, it will restart,” said Dr. Jeffrey Leggit of the Uniformed Services University of the Health Sciences. “The longer a cardiac arrest proceeds, the less energy is left to restart the heart.

Thus the sooner an AED can be applied, the better the chance of survival. This is why it is important to have AEDs available in public places as well as within medical facilities.”

A History of Resuscitation Zoll Medical Corporation has provided resuscitation products for militaries worldwide for over 25 years.

“As the only defibrillator company to be awarded the Corporate Exigency Defibrillator Contract from DLA-Troop Support twice, we take our responsibility to meet surge military operational and humanitarian requirements seriously,” said Brenda M. Butler, vice president of government sales.

All of Zoll’s military products are designed to meet the rigors of front line combat casualty care.

“Our air-worthy certified products, manufactured in Chelmsford, Mass., go through rigorous testing to meet all necessary military standards. Lessons learned from recent conflicts point to a growing desire for merging patient monitoring and cardiac defibrillation into smaller/single devices,” said Butler. “Unique requirements dictate the need for improved clinical parameters, a third integrated invasive pressure and advanced data communications for electronic health records and future telemedicine www.M2VA-kmi.com

solutions. The result of Zoll’s efforts to close those capability gaps is the Propaq MD.” The Propaq MD is the smallest, lightest and most robust fullfeatured defibrillator/monitor on the market. The Propaq MD offers advanced monitoring parameters, life threatening arrhythmia alarms and full AED functionality. Moreover, CPR support is available with the company’s CPR Dashboard that displays CPR quality in real time. The Propaq MD also features See-Thru CPR, which minimizes the duration of pauses in CPR by enabling rescuers to see the underlying rhythm without stopping chest compressions.

“Weighing just over 11 pounds, it has quickly gained favor with all manners of medical providers, including aeromedical evacuation, special operations, in-garrison care and those across the continuum of en route care,” said Butler.

Battlefield medics assigned to medevac and ground components units are seeking AEDs in smaller form factors that are capable of providing lifesaving medical care at the point of injury.

The Propaq MD provides the patient monitoring and cardiac defibrillation capabilities necessary for health care support operations from role 1 through role 4.

Designed to be used with patients of all ages, its monitoring capabilities include 3-, 5- or 12-lead ECG monitoring, non-invasive blood pressure (NIBP), EtCO2, SpO2, SpCO and SpMet, as well as three invasive blood pressures and two temperatures.

“The navigation-friendly display, six-hour battery run-time and unparalleled ingress rating of IP55 best meet the military’s unique needs. Zoll also offers the Propaq M, an identical vital signs monitor without the integrated defibrillator/pacemaker,” said Butler.

The Propaq MD also has a dedicated communications processor that offers both wired and wireless data connectivity, including integrated WiFi, bluetooth, Ethernet and USB options. USB-based cellular modems designed for the Propaq platform are also available.

“As data communications and electronic patient care records become more important, Zoll’s open data architecture allows patient data to flow from our device into a number of different EHR systems or telemedicine solutions,” said Butler. “Should a cardiac event take place during transport, code data is available for documentation, debriefing and quality improvement initiatives using Zoll’s RescueNet Code Review.”

The Propaq MD also provides the capability to easily integrate new parameters. As an example, the company recently signed an M2VA 18.3 | 11

agreement with Reflectance Medical Inc. to incorporate a ruggedized version of the Mobile CareGuide sensor into the Propaq MD and Propaq M via USB port. The Mobile CareGuide has the ability to simultaneously and continuously measure muscle oxygen saturation and pH noninvasively.

“A key design criterion of the Propaq MD was to maintain backwards compatibility,” said Butler. “With today’s fiscal constraints and the need for joint service standardization, the Propaq MD can utilize the majority of both Zoll M Series CCT and Propaq 206 Encore accessories currently in theater, thereby reducing costs and improving logistical efficiencies.”

Two Types of Defibrillators

The Propaq MD offers advanced monitoring parameters, life threatening arrhythmia alarms and full AED functionality. [Photo courtesy of Zoll Medical Corporation]

Philips Healthcare defibrillators are also ruggedized. The HeartStart MRx monitor/defibrillator and HeartStart FR3 AED have received aeromedical certification from the U.S. Army and Safe to Fly Certification from the U.S. Air Force.

“Our HeartStart defibrillators are on two federal contracts: VA Federal Supply Schedule V797P-2238D and DLA contract SPM2D109-D-8349,” said Peterhans. “These contracts are accessible to customers through the usual methods such as GSA Advantage, ECAT, FedBid and prime vendor agreements.”

So far, Philips Healthcare has sold over 1 million units.

Specific Applications

Philips Healthcare provides both AEDs and advanced life supCardiac Science offers AEDs in three models designed for speport (ALS) monitor/defibrillators. cific applications. The company’s Powerheart AED G3 Plus Auto“The original Philips AED helped trigger the public access matic is designed for public-access use. The Powerheart AED G3 defibrillation movement more than 18 years ago. Philips not only Plus Semi-automatic is used by first responders but is also used in recognizes developments in defibrillation therapy, we engineer some public-access applications. And the Powerheart AED G3 Pro their evolution,” said Bob Peterhans, general manager, emeris designed to be used by professional rescuers with ALS training, gency care and resuscitation at Philips Healthcare. as it incorporates an ECG display, manual override “Our ALS devices unite Philips’ industry-leading and monitoring capabilities. monitoring technologies with superior diagnostic “Each Powerheart G3 AED model incorporates measurements and our patented Smart Biphathe highest levels of automated self-testing available sic resuscitation waveform in single, thoughtfully in the industry, maximizing their levels of reliabildesigned, lightweight devices.” ity,” said Ted Rioux, Cardiac Science’s director of According to Peterhans, Philips’ products comdistribution. “The lithium ion battery technology, bine advanced defibrillation and monitoring techdeveloped for use in the Powerheart G3 lineup, is nology. This technology includes pulse oximetry, highly advanced and supports this high level of NIBP, invasive blood pressure, capnography, conautomated self-testing.” tinuous temperature monitoring, DXL 12-lead ECG Cardiac Science also utilizes the Self-Tracking Bob Peterhans algorithm and ST/ arrhythmia analysis, ST-segment Active Response biphasic truncated exponential elevation myocardial infarction clinical decision waveform technology in its Powerheart AEDs, which support tools and Q-CPR technology. enables the delivery of variable escalating energy based on impedThe company’s Q-CPR technology offers medical professionals ance levels of the patient. corrective feedback on the rate and depth of chest compressions, “Key ease-of-use features minimize the number of operations as well as the frequency and quality of ventilations, encouraging required of users, thereby minimizing the opportunity for human them to adjust their technique as needed to comply with American error. In addition, advanced audio prompts incorporated into CarHeart Association guidelines. diac Science’s RescueCoach technology provide advanced instruction on how to deploy the AED and also instruct the user on how to deliver effective CPR,” said Rioux.

Powerheart AEDs are also ruggedized so they can be used in the most strenuous of environments by clients such as the U.S. military and Canadian Coast Guard. The G3 Pro has also earned air-worthiness certification from the U.S. Army.

The company’s total worldwide installed number of AEDs exceeds 600,000 units and the Powerheart G3 Plus Automatic for public access use is the most popular model.

Although the number of manufacturers of AEDs is small, it’s readily apparent that those manufacturers offer a number of customized machines to serve the purpose of ending ventricular fibrillation. O

The HeartStart MRx monitor/defibrillator has received aeromedical certification from the U.S. Army and Safe to Fly Certification from the U.S. Air Force. [Photo courtesy of Philips Healthcare]

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For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

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Disease prevention and elimination in sub-Saharan Africa.

In an exclusive interview, AFRICOM Command Surgeon Captain David K. Weiss discusses AFRICOM’s medical mission in sub-Saharan Africa.

Q: What is AFRICOM’s medical mission in Africa?

A: The U.S. Africa Command Office of the Command Surgeon medical team works to synchronize with global partners to preserve the health and well-being of our forces, support ongoing operations and activities, and build partner military medical capacity and capability. The Capt. David K. Weiss goal is to foster a stable and secure environment in Africa. The AFRICOM Office of the Command Surgeon is comprised of a joint team of civilian and military medical specialists, which includes medical planners, international health specialists, environmental and public health officers, and an infectious disease specialist.

Q: Could you tell us about the development of a malaria vaccine and its importance?

A: There is no vaccine currently available for the prevention of malaria in travelers, although we are aware of research in this area. The Centers for Disease Control and Prevention (CDC) has made available extensive information about the prevention of malaria in travelers: http://www.cdc.gov/malaria/travelers/index. html.

Q: With the outbreak of Ebola in West Africa recently, what has been AFRICOM’s response? Have you been partnering with national and regional health care providers? Can AFRICOM have a role in treatment options with pharmaceutical companies and national and regional health care providers?

A: The AFRICOM Office of the Command Surgeon is monitoring the situation, and our primary effort is to protect U.S. forces. The Department of Health and Human Services is the lead agency at this point. Much of the partnering with national and regional health entities in Africa is also being done via the CDC and U.N. AFRICOM is prepared to assist the interagency in a coordinated, www.M2VA-kmi.com

Marines take doxycycline once per day in accordance with a weekly dosage of mefloquine to prevent the spread of Malaria. Symptoms of malaria include nausea, headaches, chills and uncontrollable fevers. [Photo courtesy of the U.S. Marine Corps/by Lance Corporal Timothy L. Solano]

whole of U.S government response to the Ebola outbreak in Western Africa.

Q: What are the benefits and challenges of conducting joint medical exercises with friendly African nations?

A: A significant benefit of these medical capacity and capability building engagements is that they do not only benefit host nation militaries, but also the medical care of the general population, as many receive health care at military medical facilities on the African continent. All our lines of effort are in direct support of the theater strategic objectives established by the AFRICOM commander. Opportunities are created whenever we interact with partners. By working with our African partners, we create relationships to help build and support medical capacity and capability. O

For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

M2VA 18.3 | 13

VITAL SIGNS Prosthetic Arm Translates Signals from Muscles to Perform Complex Tasks The U.S. Food and Drug Administration allowed marketing of the Deka Arm System, the first prosthetic arm that can perform multiple, simultaneous powered movements controlled by electrical signals from electromyogram (EMG) electrodes.

EMG electrodes detect electrical activity caused by the contraction of muscles close to where the prosthesis is attached. The electrodes send the electrical signals to a computer processor in the prosthesis that translates them to a specific movement or movements.

The EMG electrodes in the Deka Arm System convert electrical signals into up to 10 powered movements, and the system is the same shape and weight as an adult arm. In addition to the EMG electrodes, the Deka Arm System contains a combination of mechanisms including switches, movement sensors and force sensors that cause the prosthesis to move.

“This innovative prosthesis provides a new option for people with certain kinds of arm amputations,” said Christy Foreman, director of the Office of Device Evaluation at the FDA’s Center for Devices and Radiological Health. “The Deka Arm System may allow some people to perform more complex tasks than they can with current prostheses in a way that more closely resembles the natural motion of the arm.”

The FDA reviewed clinical information relating to the device, including a four-site Department of Veterans Affairs study in which 36 Deka Arm System study participants provided data on how the arm performed in common household and self-care tasks. The study found that approximately 90 percent of study participants were able to perform activities with the Deka Arm System that they were not able to perform with their current prosthesis, such as using keys and locks, preparing food, feeding oneself, using zippers, and brushing and combing hair.

The Deka Arm System can be configured for people with limb loss occurring at the shoulder joint, mid-upper arm or mid-lower arm. It cannot be configured for limb loss at the elbow or wrist joint.

Data reviewed by the FDA also included testing of software and electrical and battery systems, mitigations to prevent or stop unintended movements of the arm and hand mechanisms, durability testing (ability to withstand exposure to common environmental factors such as dust and light rain), and impact testing.

The FDA reviewed the Deka Arm System through its de novo classification process, a regulatory pathway for some novel low- to moderaterisk medical devices that are first-of-a-kind.

Surgical Simulation Platforms Available on iOS Red Llama Inc. announced that the SimPraxis surgical simulation platform applications now available on iOS include the SimPraxis Laparoscopic Cholecystectomy and SimPraxis Laparoscopic Nissen Fundoplication

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procedures. These apps are authored by University of Washington surgeons Mika Sinanan, M.D.; Carlos Pellegrini, M.D.; and Roger Tatum, M.D. These trainers, and the SimPraxis Total Laparoscopic Hysterectomy Trainer, can be

purchased from the iTunes App Store on a computer, from the App Store on an iPad, and at http://appstore.com/redllamainc on a Web browser.

“We are excited to be able to offer general surgeons and general surgery residents the flexibility of using the SimPraxis Trainers on both the Windows and iOS platforms. The ease of downloading and the video quality on the iPad, iPad Air and iPad Mini continues to exceed our expectations,” said David Robison, MLIS, Red Llama vice president of product management.

The learning objectives of the SimPraxis Trainers are to orient the user to the roles of the surgical team; learn the relevant anatomy; learn the specific steps of the procedure; understand the required port placements; become familiar with the necessary instruments; and master the key risks of the laparoscopic hysterectomy. Users also have the opportunity to review the potential errors, injuries and complications associated with each step.

All actions and decisions made in each trainer are captured for complete formative tracking and summative scoring in order to provide meaningful and accurate assessment.

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Compiled by KMI Media Group staff

135,000 M50 Mask Systems Ordered Avon Protection announced an order of 135,000 M50 mask systems from the U.S. Department of Defense under the additional requirements option of its sole source U.S. Joint Services General Purpose Mask (JSGPM) program contract.

The order is valued at $33 million and brings orders for the JSGPN mask system under this program to a total of 1.4 million systems.

Last year the company won a contract with DoD to develop a modified version of its M53 mask

to provide protection to a wide range of operators in its fleet of fixed wing aircraft. The modified full face mask will provide the DoD aircrew community with upgraded CBRNE respiratory protection under the Joint Service Aircrew Mask program.

Peter Slabbert, CEO of Avon Rubber PLC, commented: “This $33 million order demonstrates DoD’s continued commitment to Avon’s market-leading, high-technology M50 mask to meet their complex operational requirements.”

Interoperability for Disaster Relief Operations The U.S. Pacific Command has invited Mutualink to demonstrate its interoperability platform at Pacific Endeavor (PE14), which will take place this summer in Kathmandu, Nepal. Pacific Endeavor is an annual multinational, multiservice workshop in which independent countries learn how to support disaster relief operations by using a broad range of technologies to coordinate inter-country communications. Critical communication systems such as satellite, video, radio, telephone and other technologies are included.

More than 20 nations’ military forces in the pacific area of operations will participate in PE14, which is the capstone event of the Multinational Communications Interoperability Program (MCIP).

The aim of MCIP and Pacific Endeavor 2014 is to enhance interoperability between participant nations, non-government organizations, and the international humanitarian community for effective and rapid collaboration during humanitarian assistance and disaster relief operations.

Disaster relief operations often experience interoperability shortfalls because of diverse military and civilian participants’ systems and equipment. Mutualink’s interoperability solution enables users with disparate systems to quickly, easily and securely establish a communications backbone to share vital information and increase situational awareness.

Mutualink’s platform bridges all forms of multimedia resource sharing—to include radio, telephony, video, text, file and data—so participants can securely collaborate with each other, operations centers, and with partner nations in real time. Moreover, Mutualink is the only solution on the market that does not use a central server, or switch; thus, allowing participants to maintain complete control of their respective resources.

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$6.4 Million Contract Modification Analytic Services Inc. of Falls Church, Va., is being awarded a $6,490,089 modification to a previously awarded firm-fixed-price contract to provide the following support to the Office of the Under Secretary of Defense for Acquisition, Technology, and Logistics: medical program support; physical program support; planning, programming, budgeting, executing and financial support; international and interagency strategic relations support; science and technology support; and

operations and administrative support. Work will be performed in Arlington, Va., with an expected completion date of December 31, 2016. Fiscal 2014 research, development, test and evaluation funds in the amount of $6,490,089 are being obligated on this award and will expire at the end of the current fiscal year. This contract was competitively procured, with three proposals received. Washington Headquarters Services, Arlington, Va., is the contracting activity.

Veterans Affairs Selects Company to Modernize Electronic Health Records ASM Research, an Accenture Federal Services company, has been awarded a three-year, $162 million contract from the U.S. Department of Veterans Affairs to support the Veterans Health Information Systems and Technology Architecture (VistA) clinical application and enterprise core services. VistA is the VA’s awardwinning health information technology system, providing an integrated inpatient and outpatient electronic health record to optimize quality medical care for veterans and their families.

The VistA Core project work is designed to strengthen and expand veteran health care services. Work under the contract enables greater interoperability of systems and health care records and will meet the highest security standards.

ASM also will update VistA’s Computerized Patient Record System (CPRS), providing a modern, Web-based access to patient records. CPRS is a critical component of VistA that provides clinicians, managers, support staff and researchers an integrated patient record management system which provides a single interface for physicians to manage patient care and records.

Work under the contract also will help improve data sharing across the VA, including care transitions and implementation of standards of care. ASM will deliver technical architecture, clinical analysis, software development, engineering management and training to support VistA modernization. This work will help the VA build the next level of patient care capabilities within VistA.

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Global Facilitator

Q& A

Establishing an Inclusive Coalition and Framework for Global Health Engagement Dr. Jonathan Woodson Assistant Secretary of Defense for Health Affairs Dr. Jonathan Woodson is the assistant secretary of defense for Health Affairs (ASD (HA)). In this role, he administers the more than $50 billion Military Health System (MHS) budget and serves as principal advisor to the secretary of defense for health issues.

The MHS comprises over 133,000 military and civilian doctors, nurses, medical educators, researchers, health care providers, allied health professionals and health administration personnel worldwide, providing our nation with an unequalled integrated health care delivery, expeditionary medical, educational and research capability.

Woodson ensures the effective execution of the DoD medical mission. He oversees the development of medical policies, analyses and recommendations to the secretary of defense and the undersecretary for Personnel and Readiness, and issues guidance to DoD components on medical matters. He also serves as the principal advisor to the undersecretary for Personnel and Readiness on matters of chemical, biological, radiological and nuclear (CBRN) medical defense programs and deployment matters pertaining to force health.

Woodson co-chairs the Armed Services Biomedical Research Evaluation and Management Committee, which facilitates oversight of DoD biomedical research. In addition, Woodson exercises authority, direction and control over the Defense Health Agency (DHA); the Uniformed Services University of the Health Sciences; the Armed Forces Radiobiology Research Institute; the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury; the Armed Forces Institute of Pathology; and the Armed Services Blood Program Office.

Prior to his appointment by President Obama, Woodson served as associate dean for Students and Diversity and professor of surgery at the Boston University School of Medicine, and senior attending vascular surgeon at Boston Medical Center. Woodson holds the rank of brigadier general in the U.S. Army Reserve, and served as assistant surgeon general for Reserve Affairs, Force Structure and Mobilization in the Office of the Surgeon General, and as deputy commander of the Army Reserve Medical Command.

Woodson is a graduate of the City College of New York and the New York University School of Medicine. He received his postgraduate medical education at the Massachusetts General Hospital and Harvard Medical School, and completed residency training in internal medicine, and general and vascular surgery.

He is board-certified in internal medicine, general surgery, vascular surgery and critical care surgery. He also holds a master’s degree in strategic studies (concentration in strategic leadership) from the U.S. Army War College.

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In 1992, he was awarded a research fellowship at the Association of American Medical Colleges Health Services Research Institute. He has authored/coauthored a number of publications and book chapters on vascular trauma and outcomes in vascular limb salvage surgery.

His prior military assignments include deployments to Saudi Arabia (Operation Desert Storm), Kosovo, Operation Enduring Freedom and Operation Iraqi Freedom. He has also served as a senior medical officer with the National Disaster Management System, where he responded to the September 11 attack in New York City. Woodson’s military awards and decorations include the Legion of Merit, the Bronze Star Medal, and the Meritorious Service Medal (with oak leaf cluster).

In 2007, he was named one of the top vascular surgeons in Boston, and in 2008 was listed as one of the top surgeons in the United States. He is the recipient of the 2009 Gold Humanism in Medicine Award from the Association of American Medical Colleges.

Q: Before we talk about your experience at the U.S. President’s Emergency Plan for AIDS Relief Conference last month, could you give the readers a quick breakdown of what global health engagement means, and what it looks like at DoD? A: Global health engagement is the provision of aid, support, humanitarian assistance, disaster relief, or training and education www.M2VA-kmi.com

to foreign nations that lack the necessary capabilities to combat health crises, epidemics, or other emerging issues.

Global health engagement is a strategy within DoD that has a distinctive lens and set of goals that are tied to our overall national security strategy.

Within DoD, global health engagement supports both of our medical readiness goals—maintaining a medically-ready force and a ready medical force. It elevates the visibility of the United States and increases our influence in positive ways, and it can provide our country’s political and military leaders with strategic opportunities to engage other nations and leaders that may have been otherwise uninterested in working with the U.S. military. Collectively, these aims are achieved through three primary initiative lanes.

The first core initiative focuses on stabilization, which encompasses a wide array of targeted missions. Stability operations are authorized to contribute to social well-being, rule of law, governance, sustainable economy and safe and secure environment. All are vital facets of a well-functioning society, and pivotal to avoiding discord within a nation, region or the world.

The second core initiative is called a cooperation engagement.

These operations are centered on mutually-beneficial collaborative efforts and interoperability, predominantly with foreign militaries.

Many of these missions are focused on humanitarian preparedness or military-to-military exercises.

The third core initiative is called a capacity development. If a nation has an underdeveloped capacity in certain medical areas, we can leverage our expertise to develop or enhance partner capabilities—helping increase self-reliance.

We bring comprehensive capabilities to carry out the three core missions. Our ability to serve for the global good by providing vital assistance to allies and partners increases security and stability.

There are three important points I would want readers to understand about this description of global health engagement.

First, even though we outline three core types of initiatives, any given mission may include one, two or all three initiatives. Second, our advanced capabilities are not a guarantor of success.

Cooperation and partnership are the critical elements. Whether it’s cooperation between U.S. government agencies, partnernations or non-governmental organizations (NGOs), cooperation is fundamental to a successful global health engagement mission.

Finally, it’s important to remember that in most global health engagement efforts, DoD takes a supporting role—while other government agencies have the lead—making collaborative relationships even more essential. This is the crux of the U.S. global health engagement strategy, and it’s conferences like this one that elevate its importance to a rightful place.

Q: You went to South Africa for an important conference—the PEPFAR annual meeting. Can you give some background as to what PEPFAR is, and what role you, as well as DoD, took in the conference?

A: PEPFAR is short for the U.S. President’s Emergency Plan for AIDS Relief, and it’s the largest program within the president’s Global Health Initiative. It’s a U.S. government-wide project, featuring close collaboration among the U.S. Agency for International Development (USAID), the Department of State, the Department of Health and Human Services, Peace Corps, DoD and other www.M2VA-kmi.com

U.S. government agencies. The goal is to help stop the spread of HIV/AIDS and other diseases, and alleviate the suffering of those afflicted with said diseases.

Over the course of four days, project heads and leaders from the various U.S. government agencies involved in PEPFAR came together to share what progress they’ve all made, and what can be done to improve our collective efforts. As with all global health engagement efforts, cooperation and communication between all actors involved isn’t just a best practice, but also a necessity for the success of any program. We covered a number of topics in a short period of time—everything from working with NGOs, implementing partners and partner nations, to family planning and treatment methods. As always, all of the presenters from other U.S. government agencies, the U.N. and African nations were impressive and deeply committed to creating an HIV/AIDS-free world.

DoD took on various roles within the conference itself, as speakers, moderators and participants in each session. Dr. Vienna Nightingale, the deputy principal of the DoD PEPFAR program moderated a compelling panel on integration models for family planning and maternal health. Our Angola expert Bilibela Billy Paul spoke on the utilization of long-term strategies and technology in countries for sustainability efforts. The Navy’s Director of Prevention, and Education and Training for HIV/AIDS prevention, care and treatment programs, Dr. Michael P. Grillo, led the panel on the impact, efficiency and sustaining efforts in HIV prevention.

Antonio Langa and Anne Thomas were both involved with the

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voluntary medical male circumcision program panel. Dr. John Kahemele presented on tuberculosis and HIV integration models in his resident expert host-nation, Tanzania. And I was pleased to moderate a panel on transparency and oversight. In addition, our group of DoD experts met for our own special breakout session.

With experts in more than 18 countries working tirelessly on PEPFAR projects, we rarely have the opportunity to sit down together to discuss progress, address concerns and find new, unique ways to collaborate across the enterprise. This is what we accomplished in South Africa—the opportunity to take a step back and see how our community was performing across the continent.

The feedback and insights that I heard help me in my role as ASD (HA). For that, I’m extremely grateful.

Q: Beyond the conference itself, what kind of capabilities does DoD provide to this important mission?

A: DoD brings both extraordinary logistics capabilities, and leading medical research and health care delivery expertise in almost any environment imaginable. DoD’s global presence also contributes in more indirect ways. DoD also brings unique military-to-military relationships that can be utilized where other relationships may not exist.

We have a surveillance system in place for HIV/AIDS monitoring called the Defense HIV/AIDS Prevention Program (DHAPP)— specifically for military hospitals in Africa—which is under the PEPFAR umbrella of relief efforts. This system is unique to DoD as other U.S. agencies are not provided with access to most hostnation military hospitals. Under DHAPP, we train more than 3,000 health care workers a year about HIV/AIDS preventive measures, such as safe sex education, and debunk myths surrounding the disease. Circumcision procedures are provided for more than 50,000 men annually; over 500,000 military and family members are tested for HIV/AIDS; and more than 4,000 women received antiretroviral drugs.

Q. Could you expand on some of the surveillance programs that the department has, and why they mainly fall under stabilityfocused missions?

A: Whether we are talking about HIV rates, SARS, bird flu or a few hundred other potential health scenarios, DoD recognizes that the security threats from health catastrophes are real, and the spillover effects from breakdowns in health systems can often be harder to contain than armed conflicts. In such a globally interconnected world, it’s essential that we continuously monitor disease threats (again, along with our federal health partners, as well as global organizations). The sophistication and capabilities of our six overseas DoD laboratories contribute mightily to helping us detect, prepare, prevent and respond to crises.

These laboratories conduct routine and emerging disease surveillance and response missions through regional partnerships with local ministries of agriculture, defense, health and academia.

In conjunction with our partners, we are able to monitor and plan how best to respond to emerging threats before they become global epidemics.

Now, I am sure that all sounds fine when you read it. But, I can’t stress enough the gravity, the importance of what these men and women do overseas and at home. One of our surveillance 18 | M2VA 18.3

centers held the first reference case of Middle Eastern Respiratory Syndrome, also known as MERS-CoV, which has been a big news item recently. Our network has worked tirelessly to monitor the new breakouts of ebola. It was the first to isolate the Rift Valley fever virus, and identify new strains of dengue fever. In San Diego, Calif., our lab was the first in the world to characterize H1N1, commonly called swine flu, which helped the rest of the world truncate the effects of the subsequent H1N1 epidemic. It is truly a cutting-edge network that benefits us all.

An advancement of particular pride to the military health system resides with our doctors at another one of our health labs in Africa. These members of the military enterprise were the first in the world to conduct a successful HIV/AIDS vaccine trial. This is particularly relevant to our conversation as the lab was part of our Defense HIV/AIDS Prevention Program.

Q: You said before that global health engagement is more than strictly a stabilization mission. Can you explain to readers what cooperation initiatives look like?

A: Cooperation missions provide excellent opportunities for the U.S. military abroad, as they revolve around building upon or creating new relationships with other nations’ militaries, agencies and NGOs. However, the benefits are two-fold; cooperation initiatives also provide our military medical forces with field training, which is essential to maintaining a medically prepared force. As we draw down forces in Afghanistan, opportunities for our medical forces to have real-life trauma and crisis experience are more important than ever.

Our military hospital ships, the USNS Mercy and the USNS Comfort, are at the forefront of cooperation efforts for U.S. military humanitarian missions. Secondary to its wartime medical support mission, our hospital ship often deploys, providing relief and medical support to nations in times of crisis or with underdeveloped medical capabilities. The USNS Mercy has expanded in its collaborative efforts over the past few years. New policy has granted the USNS Mercy permission to allow NGO medical staff on board to help provide care, a huge benefit to all groups involved.

NGOs don’t have the capabilities that the U.S. military has in resources and transport methods, and our military medical forces don’t have the same level of nuanced knowledge of certain nations or populations that NGO staff spent decades creating. The USNS Mercy has been, and continues to be, a hub for collaboration and an access builder for the U.S. military. It’s interesting to note that China has implicitly acknowledged the value of such platforms, and has created their own hospital ship—the Peace Ark. Speaking of China, for the first time, in July of this year, China participated with the Peace Ark in the Rim of the Pacific Exercise alongside our hospital ship, the USNS Mercy. We conducted crossdeck operations that consisted of patient movement, personnel best practice exchanges and general relationship-building initiatives. These medical exercises performed with China were mutually beneficial—elevating each other’s medical knowledge, while building mutual respect. Increased interaction like this during RIMPAC can help in the mitigation of future disagreements— which is vital to our nation’s security.

One last great example of a cooperation effort is Southern Command’s Beyond the Horizon & New Horizons missions.

From April through June 2014, U.S. military personnel deployed www.M2VA-kmi.com

Defense Health Agency

Directors

Maj. Gen. Richard Thomas Director Healthcare Operations

Rear Adm. Bruce Doll Director Research & Development

Lt. Gen. Douglas Robb Director

Allen Middleton Deputy Director

David Bowen Director Health IT

Rear Adm. William Roberts Director Education & Training

2014

Vacant Acting Director Business Support

Rear Adm. Raquel Bono Director National Capital Region Medical

to Belize, the Dominican Republic and Guatemala to conduct comprehensive humanitarian and civic assistance. During the exercises, U.S. troops worked with a variety of government organizations and NGOs to build important relationships with partner nations, while receiving valuable deployment training in civil-military operations through medical aid, dental care and engineering support to local populations.

It’s important to remember, however, that even though DoD and partner nations are able to provide vast resources for global health, one of the key tenants of our global engagement is to empower host-nations through capacity-building domestically.

Q: Since you brought up the idea of self-reliance and capabilities, I know that most DoD missions address capacity needs. Can you go into some detail about why these projects are important, and why this kind of engagement is central to the other keystone projects?

A: I think the more important point you make here surrounds the issue of self-reliance. When we send our medical forces and military members to help a host-nation build capability, we don’t just do it because it’s the right thing to do; we do it because it helps create a far more stable global environment for our troops and citizens. Every time another nation is able to support itself during a natural disaster or medical catastrophe, it means the United States is safer. Extremism can be cultivated in societies unable to manage natural disasters effectively; diseases can spread like wildfire globally. A more medically capable world makes for a safer United States.

Q: Could you give a couple of examples of these kinds of capacity programs?

A: There are three programs in particular that come to mind for me when I discuss programs revolving around capability-building: the pandemic and disaster response planning programs, aeromedical/patient movement capacity building, and blood safety health engagement. To better highlight each of these capacity programs, it’s best to highlight individual projects themselves from each to show how interconnected they are to the DoD global health mission.

Though they are technically two separate programs, the pandemic and disaster response planning programs run in tandem with each other, and take place in the same countries. Led by Africa Command, these programs exist in 19 African countries and focus on teaching national and regional institutions our best practices in pandemic and disaster response. The programs work on a five-year timeframe, which allows the host-nations adequate time to adapt our models to fit their needs and develop a structuralized response framework. Not only does this approach build strong relationships for our military with civilian groups in host-nations, it also fosters regional capabilities throughout the participating countries that could avert unrest during times of outbreak or catastrophe.

The strength of the U.S. Air Force isn’t just measured in tactical strikes, but also number of lives saved on the battlefield. During the past 13 years we’ve become experts at aeromedical lifts due to our interventions in Iraq and Afghanistan. U.S. and coalition forces knew that when we started leaving Afghanistan, their medical abilities would be weakened by a lack of patient-movement 20 | M2VA 18.3

assets. The decision was made to introduce military medical mentors who trained the Afghan Air Force to develop an entire aeromedical system as well as casualty evacuation standards. A huge success, the program has been credited with increasing confidence within Afghan ranks, decreasing desertion, and creating a more able medical force in lieu of a U.S. medical presence.

Another example of a successful aeromedical program is our work with the Royal Thai Air Force. It’s one of my favorite examples to bring up, not only because it strengthened the bonds between our militaries, but because of the tremendous job the Thais did applying this knowledge in the face of tragedy. In 2011, Bangkok was severely flooded during a terrible storm—leaving citizens stranded and injured throughout the city. The members of Royal Thai Air Force were able to utilize their patient movement training with U.S. medical forces, and airlifted more than 110 patients to local hospitals—some of whom were critically ill. Their success will only grow as they build on this experience.

Some of the most impressive innovations we’ve developed internally through our wartime efforts in Iraq and Afghanistan have been ways to transport and maintain blood for transfusions.

Our blood safety program led by the Pacific Combat Control Center is a multi-year collaborative effort with the Centers for Disease Control and Prevention and USAID. The program works to build sustainable blood programs in support of disaster response within the nations of Laos, Cambodia and Vietnam. All of these programs have been successful, and have aided much-strained U.N. and relief capabilities in the host-nations due to their increased capacity. It was also an important program because it opened the door for future engagement with Laos, a nation we haven’t partnered with in any capacity prior to blood safety engagement.

As you can see, all of these programs not only relax some of the burden from the shoulders of the U.S. military and NGOs, but they also directly impact our national security by increasing both access and influence.

Q: Now that you’ve given us background on what global health engagement is, what DoD wants to accomplish, and examples of stability, cooperation and capacity missions—do you have any final words on why global health engagement should be at the forefront of the defense community’s mind?

A: The importance of global health engagement to our national security can’t be understated. It’s one of the department’s most effective tools in securing strategic access, maintaining a medically-ready force, elevating U.S. visibility, and increasing global influence internationally.

Helping medically stabilize foreign nations prevents possible uncontainable spillovers of conflict or disease. In our cooperation with other nations and NGOs we are able to build bridges of mutual understanding where once there could be conflict. When we build medical capacity of other nations, our forces and resources are freed for other emergencies or needs. All of these initiatives are also beneficial to the readiness of our medical forces, making all of our forces medically-ready.

The benefits of our involvement in global health engagement are irrefutable. DoD’s breadth and depth of mobile medical assets—people and equipment—are unique in the world, and indispensable to the protection of our military personnel and the American people—and that mustn’t be overlooked. O www.M2VA-kmi.com

SPECIAL SECTION

Advances in combat care are saving the lives of the wounded warrior.

By Peter Buxbaum, M2VA Correspondent The decade-plus that the United States has been at war has produced dramatic advancements in tactical combat casualty care. These improvements can be seen on two fronts: The military itself has developed new structures and strategies through which to provide the quickest and best possible care to wounded warriors. And the private sector has made its contributions by developing products never seen before on the battlefield.

Among the products that have been introduced in the last few years, multi-functional monitors record vital signs and help medics and other personnel perform their jobs better; gauze impregnated with substances helps stop bleeding; and litters and other similar products help personnel move www.M2VA-kmi.com

overarching system that coordinates the patients safely and efficiently. All of these care of those injured in combat,” said Rasproducts are subject to processes involving mussen. “JTS functions to reduce morbidcontinuous improvement. ity and mortality from combat wounds by “In some ways we adopted the clinical getting the right patient in the right facility care system we were familiar with in the for the right treatment at the United States for civilian care right time and to institute and took it to the battlefield,” processes to improve caresaid Colonel Todd Rasmussen, giving.” director of combat casualty JTS was not in place care at the U.S. Army Medical when the U.S. military went Research and Materiel Comto war 10 or 12 years ago. mand (USAMRMC).

“We recognized when we One of the key advancewere fighting in two theaters ments in tactical combat of war that we needed to betcasualty care was the estabter coordinate patient care,” lishment of the Joint Trauma Col. Todd Rasmussen said Rasmussen.

System (JTS). “JTS is an M2VA 18.3 | 21

SPECIAL SECTION The products designed and manufactured by private-sector companies have also served to improve casualty care, Rasmussen noted. “Some of these products have come out of our research programs,” he said.

“They represent some of the advances that have come out of the wars in Afghanistan and Iraq.”

JTS operates on three levels. JTS operates the Joint Trauma Registry, which collects injury and injury management information from the battlefield and all the way through higher levels of care in Landstuhl, Germany, and eventually the United States. “This electronic registry is the largest repository of injury and injury management information ever assembled,” said Rasmussen. “It has information on 60,000 injured service personnel who have been stewarded or overseen by the Joint Trauma System.”

Another operational pillar of JTS is its active process improvement activity. “JTS monitors the care of every U.S. service person injured in combat,” said Rasmussen.

“Each week we go through the list of those injured and in a methodical and intentional way troubleshoot that care. If a patient

wasn’t given his meds on time or if a patient was moved at the wrong time, we discuss how this can be corrected immediately and in real time.”

These reviews take place in a teleconference that has been convened every week since 2004. “It lasts 60 to 120 minutes, and all representatives of the whole spectrum of combat casualty care are on the line,” said Rasmussen. “They hear from everyone who has cared for a patient from the point of injury to the forward surgical team to medevac personnel and all the way to Landstuhl and Walter Reed. The intent is not to find fault or to be critical, but to find areas for improvement.”

JTS also issues clinical practice guidelines. “There are over 30 of these and we continually update them,” said Rasmussen. “The guidelines are based on evidence presented by research and inform caregivers how to perform procedures in an optimal fashion.”

On the products side of the ledger, monitors come to automate both the measurement and the recording of vital signs.

These monitors are moving past the area of vital signs to automate and facilitate a

range of other important combat casualty care procedures.

“The RDT Tempus Pro vital signs monitor has the ability to easily document and share all patient data electronically from the battlefield across the continuum of care back to CONUS,” said Barnie Howell, U.S. military director of business development at RDT. “Tempus Pro software enables the creation of an electronic version of the TCCC card that is automatically populated with vital signs. The touch display facilitates entering of drugs, fluids, interventions and notes.”

The patient record of care can then be transmitted to the next level of care before the patient arrives. “When the patient arrives at the battalion aid station, combat support hospital, or back in the United States, there is often no record of the patient’s vital signs data, encounters or interventions,” said Howell. “Studies have shown that patient outcomes can be improved if the full patient data is transmitted to the receiving facility prior to patient arrival.”

RDT has applied for clearance from the Food and Drug Administration to incorporate ultrasound and video laryngoscopy

Medical Simulation Recent advancements in combat casualty training have resulted in fragment injuries on various parts of the body. The simulations allow training on thousands of lives saved. This success is attributable to the advanced and procedures that are not seen every day. These are situations a medical resident innovative training of military medics and surgeons, and training for tactical is not going to learn hanging around the hospital.” combat casualty care has increasingly made use of simulators.

Skedco recently entered the market with a simulation for hemorrhage CAE’s Caesar manikin was developed for the Army’s TCCC course. Caesar control. “This is a simulation meant to be worn by a live actor,” said Calkin. comes out of the box with an amputated leg and with a fully-functional airway “The patient can be screaming and combative. This is something new medfor training on trikes, inserting needles in the chest, and other such procedures. ics have to go through before they head for the battlefield. They don’t have “Caesar is suitable for TCCC training because it is rugtime to panic there.” Using the simulation, new medics have gedized,” said Paul Bernal, director, global business developreduced their procedure times from 30 minutes to two minment government & military at CAE. “Most of the components utes in short order, according to Calkin. are housed in steel casing. That way it can be dragged around Strategic Operations also markets a human-worn simuad exposed to the elements without adverse effect.” lation, known as a Cut-Suit. That product was on full display CAE manikins can be ordered with different types of last May when the company hosted students from the injuries, such as traumatic amputations, so that they can be Rocky Vista University College of Osteopathic Medicine, an used to practice TCCC. The physiology of the manikins can institution that trains many military medical personnel, at be adjusted to mimic trauma and the manikin’s vital signs its fully-equipped emergency room in San Diego. The ER respond when fluids are administered. was inundated with trauma casualties from overturned cars, “We are in the process of enhancing Caesar to provide shooters, and improvised explosive devices as well as sick Kit Lavell more realism and to provide a more feature-rich product,” patients requiring surgery. said Bernal. These enhancements are planned for the end The exercise was designed to provide hands-on experiof this year. ence through the use of the Cut-Suit in an immersive atmosphere. Rocky Operative Experience Inc. produces simulations for training of specific proVista is the first medical school to incorporate the Cut-Suit into medical cedures likely to be encountered by military medics and surgeons. “Amputation student education. is a major procedure downrange,” said Bob Buckman, the company’s vice Many live-action simulations were created, immersing the participants from president for sales and marketing. “Our manikins can also simulate blast and point of injury all the way through the ER and OR. “Medical students commonly

22 | M2VA 18.3

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capabilities into the Tempus Pro. Ultrasound and video laryngoscopy can help ensure and document proper tube placement. In addition, RDT has also applied to incorporate algorithms into its device that would calculate the necessary level of fluids for patients experiencing blood loss or suffering with burns.

“We expect these new clearances in the very near future,” said Howell. “It is our philosophy to grow the device based on the Tempus Pro platform. The capabilities of the platform are growing so that the military doesn’t have to replace its devices every three to five years.” The Army is currently conducting a competition for the acquisition of a new vital signs monitor. The Tempus Pro is one of three finalists currently undergoing evaluations.

Research has shown that a many as 25 percent of those killed in action in the recent wars had survivable injuries, and that most of those deaths occurred due to bleeding before the casualty made it to a hospital. “Based on this data, one focus must be controlling hemorrhage at the point of injury outside of the hospital setting,” said Rasmussen.

A team of multinational special operations forces medics from Hungary, Croatia and Ukraine evacuates simulated casualties to a Croatian Mi-17 helicopter during a field training exercise as part of the Tactical Combat Casualty Care course held in Udbina, Croatia.

[Photo courtesy of the U.S. Army/by Master Sergeant Donald Sparks]

Z-Medica introduced gauze impregnated with kaolin, an inert mineral substance, to deal with that very situation. Z-Medica’s products, known as QuikClot and Combat Gauze, have been available to the U.S. military since 2008.

“Kaolin activates two of the clotting factors in the blood, and this reduces the time in which bleeding can be stopped,” said Scott

state that they do not truly understand or recognize a textbook description of a disease or a syndrome until they experience the clinically applicable version of it,” said Kit Lavell, executive vice president of Strategic Operations.

Laerdal Medical develops simulators that run the gamut of combat procedures applicable both to first responders to clinicians delivering services at higher levels of care. “We make ruggedized simulators for tactical combat casualty care,” said Mark Owens, a military strategic account manager at Laerdal Medical.

Laerdal manikins come with modules designed to teach specific tasks such as treatment of gunshot wounds and performing amputations and chest decompressions. “The learner goes through the vital procedures and the manikin responds based on what he or she does or doesn’t do,” said Owen.

“Once the learner completes the task, the simulation can be stopped to allow for a debriefing or after-action review.”

Laerdal is currently developing a unified instructor application that will be Justin Maestri able to control all high-fidelity simulations regardless of vendor from a single device.

SimIS takes a mentoring approach to simulated training through the use of the Microsoft Kinect camera used in gaming systems. SimIS uses Kinect to compare the actions of a trainee against those of an expert performing the same procedure. SimIS records procedures executed by established experts and its software maps the actions of a trainee against those of the expert.

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Garrett, vice president for military and tactical programs at Z-Medica. In studies at the U.S. Army Institute of Surgical Research, QuikClot caused hemostasis, or a stoppage of bleeding, typically in five minutes, according to Garrett.

Z-Medica came up with the idea of using kaolin toward the beginning of recent conflicts, when warfighters were subject to IED

SimIS is currently working with U.S. Navy personnel to develop a simulation of endotracheostomies, according to Justin Maestri, product manager for health care simulations at SimIS. The company also plans on leveraging developments to smartphones and tablets to allow its simulations to be controlled by those devices.

Aptima is approaching casualty care from somewhat of a different angle by developing ACLAMATE, the Automated Cognitive Load Assessment for Medical Staff Training and Evaluation, funded by the USAMRMC. The thrust is not to record whether learning objectives have been met but to measure the effectiveness of the training experience.

“Most simulation-based training is very linear,” said Jeff Beaubien, ACLAMATE principal investigator for Aptima.

“Participants go through a scenario, but some teams might be overwhelmed by the exercise and others underwhelmed.”

ACLAMATE analyzes data such as heart rate, brain activity and conversation patterns during a medical scenario to measures trainees’ cognitive workload.

Jeff Beaubien These are processed through algorithms to assess individual and team workload.

The instructor is automatically alerted to changes in cognitive load and can adjust the exercise accordingly.

Aptima is awaiting a Phase 2 decision from the Telemedicine & Advanced Technology Research Center that will allow it to proceed to full research and development and prototype building.

M2VA 18.3 | 23

SPECIAL SECTION attacks that tore tissue apart and caused profuse bleeding. “Kaolin has been known to stop bleeding as far back as the 1950s and 1960s,” said Garrett. “We tested kaolin against other options and found it to be far superior than anything else we were looking at.”

One advantage of Quick Clot and Combat Gauze is that they look, feel and work like normal gauze. “People already know how to use it,” said Garrett. “There is not much of a learning curve on how to use it correctly.”

Z-Medica continues to investigate ways to enhance its products to meet military requirements. “The military is looking for a gauze that can break down naturally over time,” said Garrett. “They are also looking for products that can control bleeding when it is impossible to apply or tourniquet or pressure.”

Skedco’s Tactical Sked has become a staple of battlefield care because of its ability to handle patients efficiently. The stretcher weighs 9 pounds with all its accessories.

Traumatic Brain Injury Traumatic brain injury emerged as a major Brain health concerns are currently spread military medical concern in the conflicts in over three areas: physical injury, which includes Southwest Asia. One U.S. Army study indicated neural damage and TBI; the psychological that 22 percent of injured warfighters suffer aspects of TBI, such as post-traumatic stress from TBI, and 10 percent of those have moderdisorder; and brain fitness. ate to severe cases.

“There is so much overlap between the According to research conducted by the physical and psychological in terms of pathology, Brain Trauma Foundation, TBI occurs when a symptoms and effects,” said Hack. “We are likely blast causes a rapid rotation in the neck and to achieve better results with those who have head, leading to the tearing of tissue in the injuries by looking at all these things together.” brain’s interior and resulting Among Hack’s goals in his in a reduced ability to connew job is to help execute on centrate. the National Research Action Colonel Dallas Hack, up Plan for TBI, a document which until recently the Army’s direche helped author. “Federal tor of combat casualty care, agencies were directed by recently took on a new assignexecutive order to start making ment of running the Army’s things happen,” he said. “I’m brain health program. going to be working hard to “We spend a lot of time in start making major progress on the military on physical fitness,” this effort.”

Col. Dallas Hack said Hack. “But research shows One key to jump-starting that we also can do things to the search for TBI therapies is train the brain to function better. This can help to standardize a definition of TBI so that clinical with things like memory, attention span and trials of potential therapies can be more sucreaction time.” cessful. “Right now we have such gross meaHack’s efforts include, but are not limited to, sures of classifying mild, moderate and severe helping those who have suffered brain injuries brain trauma that we don’t know which patients in combat. “Brain fitness helps servicemembers to enroll in a study,” said Hack. “Developing perform their jobs better,” he said. “If they should standards will allow us to study homogeneous be injured, brain fitness will help them recover groups with a common trajectory so that we can quicker. The physically fit recover from illness measure the effects of the interventions being and injury quicker. The same is true of the brain.” studied.”

Hack’s job is essentially to integrate the Potential pharmaceutical advancements are activities of the various components of Army being held up by this lack of organization in the medicine that deal with brain health so that they clinical studies. “Several big pharmaceutical all advance a common strategy. “By integrating companies have called to ask about the progthose, we can achieve some power that the portress of this effort,” said Hack. “Once we solve folios themselves are not able to achieve without this problem they can enter this arena and start integration,” he explained. developing treatments.”

24 | M2VA 18.3

The Tactical Sked is secured across a ruck and is made of rugged plastic for durability in extreme environments.

“When it is carried or hoisted, it keeps the patient’s body straight,” said Bud Calkin, the company’s vice president and founder.

“It will not bend in the middle. Because it is narrow, it forms an anatomical splint around the legs when the straps are pulled tight.”

Skedco also produces other types of products used for casualty care. The company has sold several thousand of its Mout Lifeline Bags. “It contains 30 feet of rope in a small bag and is worn on the chest,” said Calkin. “If someone goes down in the line of fire they open the flap and with a flick of the wrist can throw the rope 30 feet. Then someone else can drag the casualty out of the line of fire without exposing himself.”

“I am a physician, surgeon and researcher,” said Rasmussen. “Products like these are an important part of the material solutions for patients. We can’t operate on a patient without moving them.”

As the military winds down from the conflicts in Southwest Asia, it must consider how it will confront the next conflict with which it will be challenged. The same is true of tactical combat casualty care.

Time factors in the care of battlefield casualties will likely be different in future.

If the U.S. military deploys small units in dispersed areas of the world, it will take longer for casualties to be evacuated to higher echelons of care. This requires thought on how battlefield casualty care will have to adapt to these changing conditions.

“Medics will have to control bleeding, manage airways and be capable of handling more complex injuries, as they will be with the patient for longer periods of time,” said Garrett.

“We are actively pursuing research efforts on how best to treat more dispersed and smaller units of injured troops,” said Rasmussen. “If we envision longer transport times for wider dispersed troops in small units a long way from traditional care, then we need to find a way to being critical care to the patient.” O

For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

www.M2VA-kmi.com

Managing health care acquisitions for the Department of Veterans Affairs.

Associate Deputy Assistant Secretary for National Healthcare Acquisitions Craig Robinson discusses the work of the Office of Acquisition and Logistic/National Acquisition Center.

Q: I’d like to start with an overview of Office of Acquisition and Logistics (OAL)/National Acquisition Center (NAC). Can you tell me about the size of the organization, its budget, number of contracts handled annually, variety of supply chains, etc.?

the largest single factor that lends itself to and contributes to price reductions.

Another factor that is specific to NAC is that we administer Public Law 102585, which is the Veterans Healthcare Act of 1992. In Section 603 of that act, the law applies to prices that certain agencies pay for pharmaceuticals, and we administer that part of the law. The law gives very favorable pricing to four governmental entities. They are VA, DoD, Health and Human Services (to include the Indian Healthcare Service), and the U.S. Coast Guard.

It’s a law that helps us administer pricing for covered drugs—FDA drugs that have not come out of protection yet. They are drugs that do not have generic equivalents.

Additionally, another way we drive down costs for the department is by putting national contracts in place. It helps reduce the amount of work done by VHA contractors going out and soliciting new contracts. Instead, they can look at the existing contracts and place delivery orders based on those contracts.

This is less administratively burdensome for them.

A: The NAC actually is comprised of the facility here in Hines, Ill. It’s in the western suburbs of Chicago. It’s collocated on the campus of Hines Medical Center. I’m also responsible for the Denver acquisitions center in Golden, Colo.

[I have] 291 full-time equivalent employees [between those two facilities]. I have a number of vacancies right now that we’re working to fill. Our operating budget is approximately $870 million. The number is a bit misleading because $830 million [of that] is for costs of goods.

We have over 2,200 active contract vehicles. Our Q: Looking out over the next 12 months, what are the largest commodity based on dollars is pharmaceumajor contracts you expect to be issuing or awarding? ticals. We also purchase high-tech medical equipment including diagnostic equipment. This includes A: The biggest group of contracts that we’re working MRIs, CT-scans and a variety of different modalities on over the next 12 months will put primary care conthat provide diagnostics. tracts in place to support access to care issues that the Hearing aids and batteries are provided out of department is currently experiencing. the Denver, Colo. office. That’s a very large product Craig Robinson I mentioned the patient-centered care contract for line for us. We probably purchase 20 percent of the specialty care for in-patient and out-patient services. It total domestic market for hearing aids. covers the gamut of gastroenterology, cardiology and psychiatry. It’s We’re also responsible for our prime vendor contract, which all specialty care. What it doesn’t include is primary care. Specifically, is our distribution type of contract for pharmaceuticals, medical/ what we’re working on now is for veterans to have the ability to seek surgical and subsistence items to support VA dietary needs. Out of primary care in the community through contracts. the Denver office we’re also responsible for non-VA health care— this means contracts for health care provided outside the walls of Q: Tell me about the contracting process. Is the timeframe from the VA hospital. The larger contracts there are for non-VA dialysis, start to time of award the right amount of time or are you looking which is essentially referral to an outside dialysis clinic. We have for ways to make the process more efficient and therefore shorter? a new contract focusing on patient-centered care, and that it is for specialty care that is both in-patient and out-patient.

A: The contracting process takes the form of two major types of contracts. We are responsible for Federal Supply Schedules. Those are Q: Health care costs, both in the civilian and veteran communimultiple award schedules that are similar to the contracts done by the ties, are growing every year. What is OAL/NAC’s biggest conGeneral Services Administration (GSA). tribution to helping manage those costs at an institutional and As a matter of fact, our authority to do schedules is a delegaindividual level? tion from GSA and we are the only governmental entity that does schedules besides GSA. We were delegated the federal supply classes A: Let’s look at this from a couple of fronts. From the perspective of related to medical. In those situations we have open and continuous cost of goods, we try to make sure we have competitive contractual allowance for the submission of offers. Vendors, manufacturers and instruments wherever possible. We have found [that competition] is www.M2VA-kmi.com

M2VA 18.3 | 25

suppliers are allowed to come in and offer the same commercial offerings that they provide to the commercial community.

They’re required to submit commercial sales practice data and our intent there is to award contracts for commercial items that give us most favored pricing for like customers in the commercial market. For example, if we’re going to buy medical/surgical supplies from a provider like Cardinal Health, we look to see if they deal with a similarly-sized group purchasing organization that represents hospital systems, and then do a price comparison to make sure they’re selling products to us at the same price or lower.

When it comes to awarding contracts, we shoot for 180 days from receipt of the complete and properly submitted offer. Additional time may be required depending on the estimated dollar value, and some of the submissions require a pre-award pricing audit. Anything that exceeds an estimated $5 million a year cost will require a pre-award pricing audit.

We also have commercial contracting where the customer has identified a requirement. We solicit the requirement, we have vendors compete for it and then we award it. Those contracts also have a timeframe of 180 days.

For the most part, the things we do on the national level are always going to be in the millions of dollars. In some situations where we have more complex, high-dollar items, 180 days is not the norm. We sit down with our customer and in the acquisition planning process develop milestones to create the expectation for both parties for what the lead time will actually be.

For us the biggest single factor for reducing the timeframe is being adequately staffed. As I mentioned before, we have numerous vacancies that we continue to work to fill. There is a lot of competition out there for people with the right kind of background and qualifications.

Denver we have a team that travels around the country and sets up shows at medical centers. They are also a good point for outreach.

We contribute to and participate in VA’s small and disadvantaged business plan in goal setting for the department. We are also reviewed every two years by the Small Business Administration for how we are carrying out our actions and the responsibilities we have in adhering to small business rules and regulations.

Small business standards are defined by North American Industry Class Standards. It’s not uniform when designating a business a small business since it varies by commodity class.

Q: How does NAC contract for outside hospital staff and how do you meet the Department of Veterans Affairs’ staffing needs and fill them on a short- or long-term basis?

A: I think as it relates to businesses coming in and talking to us about new and innovative products, one of the misconceptions is that you go in and talk to the contracting guys. That really is not the case at all.

What I recommend to small businesses is that they reach out to the clinical leads in the Veterans Health Administration. The clinical leads are the ones who are qualified to look at the products and say that they provide clinical benefit or meet a need that the department is not currently meeting.

One of the vehicles used for that is requests for information, or RFIs. RFIs are submitted through FedBizOpps, which is the same platform by which we advertise open solicitations.

Essentially, the RFIs go out to the world and say that we’re looking for companies to send commercial information related to a specific item or service. Typically, the department puts out an RFI before issuing some large requirements as a part of its market research.

A: As I mentioned before, we’ve awarded and are going through the implementation stage of the patient-centered care contract that will allow VA hospitals to refer care out to our contractors so that veterans can get care. It’s very similar to an HMO. We have two contractors who received awards to work throughout the United States.

Additionally we have national contracts for professional and allied services that allow for medical centers to place orders for specialty care providers. In some situations, those providers are working within the walls of the hospital. It’s a way to supplement VA staff.

Q: How does OAL/NAC partner with small businesses? Are they an important part of your acquisition process?

Q: With recently announced plans for additional staff, locations and services, how is that affecting your acquisition plan, budget and inventory forecasting?

A: We will be involved in the sense that some of those points of care will be derived based on the patient-centered care contract. As it relates to supporting and facilitating the delivery of care at those points of care, our contracts are pretty scalable. We’ve put those contracts in place and I don’t think there would be an increase in needs that would go beyond the scope of those contracts as it pertains to pharmaceutical, medical/surgical supplies or anything else.

As it relates to an addition of staff, we may facilitate that to a certain extent, in that they may be contracted staff, but beyond that it won’t affect our planning and budgeting. This is because we’re not the budgeting organization related to the Veterans Health Administration’s dollars. Essentially, we’re a player, but we’re not the determining party for the budgeting.

Q: What are your recommendations for businesses wanting to talk to you about new and innovative products they are offering?

Q: Any closing thoughts?

A: They are an important part of our acquisition process. There are requirements in the federal acquisition regulations that set up a priority or preference for different types of socioeconomically defined small businesses. In addition to that, VA has its own unique requirements such as Public Law 109461, which requires us to consider disabled veteran- owned small businesses whenever they’re available to provide goods and services. This public law applies to VA only.

Outside of the regulatory process we do take on several outreach efforts that include our website, where we conduct webinars to educate small businesses. We also hold outreach marketing events. In 26 | M2VA 18.3

A: As things change with regard to the need for more care, from an acquisition perspective we’re seeking to assist our customer. We’re here as a support mechanism. Our goal remains to support the customer and to be his or her business adviser where contracting matters exist. O For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

www.M2VA-kmi.com

The advertisers index is provided as a service to our readers. KMI cannot be held responsible for discrepancies due to last-minute changes or alterations.

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M2VA 18.3 | 27

INDUSTRY INTERVIEW

Military Medical & Veterans Affairs Forum

Greg Borecki Vice President of Strategic National Accounts Stanley Healthcare Greg Borecki is the vice president of strategic national accounts for Stanley Healthcare. Greg is a results-oriented, trusted leader with 10 years of experience working with government customers, both VA and military health.

Q: Could you tell our readers about some of the solutions Stanley Healthcare offers to the Military Health System and Veterans Affairs?

A: Thank you for this opportunity. We are pleased to speak to Military Medical & Veterans Affairs Forum, because our government customers are a key driver for innovation across the health care system.

As our President Jason Santamaria has shared in the past, Stanley Healthcare (a division of Stanley Black & Decker) has solutions deployed across many military health and Veterans Affairs facilities to improve patient and staff safety, facility security, environmental monitoring, clinical workflow, and the tracking of equipment and other high-value items.

As an example, our wander management products are deployed at 52 sites across Veterans Affairs.

Q: What are some interesting new programs or initiatives at Stanley Healthcare?

A: Stanley Healthcare has long been recognized as the industry leading real-time location system provider through our AeroScout solutions, but our customers are ready to take these capabilities to the next level. We believe it is our responsibility to ensure our customers are able to leverage data in an effective way, to maximize the investment that has been made in technology solutions. As we have also seen in the civilian health care sector, putting systems in place to locate staff or patients, or to safeguard assets through improved tracking capabilities is only the first step.

Our MobileView Analytics platform features business intelligence dashboards 28 | M2VA 18.3

that include intuitive views of key performance indicators, and the ability to drill down to specific data points. The analytics tools allow health care organizations to understand trends in asset utilization, temperature and humidity conditions, the flow of patients and staff, and more.

Q: How is Stanley Healthcare positioned in the market for expansion?

A: An area I would like to focus on today is in supply chain and asset management.

In most hospitals, customers are continually addressing the challenges of managing thousands of items to ensure that necessary supplies are not only available, but are also easy to store and locate when needed.

Our SpaceTRAX solution is an advanced, Web-based inventory management system, used by hundreds of hospitals worldwide to increase charge capture, reduce excess inventory and identify usage trends. With the visibility and analytics that SpaceTRAX provides, we’ve seen hospitals significantly reduce on-hand inventory, reduce labor costs for tracking inventory, minimize expired items and reduce loss charges. For example, we had a customer experience direct cost savings of $150,000 within just the first 90 days.

Q: Can you provide a few success stories?

A: Certainly. One of our VA customers recently faced a related situation in how they were managing supplies. The hospital’s primary goal was to efficiently provide service areas with access to supplies they need for care delivery while still optimizing space and costs. Until recently, they had used a decentralized inventory management model—with 14 supply locations across nine floors, and much of the inventory duplicated across services areas. While this approach was effective for meeting clinical supply needs, it was also expensive and unwieldy to manage.

By using Stanley Healthcare’s InnerSpace Supply Chain Storage Solutions, they are now gaining additional value from their supply chain storage floor track and shelving systems; they store, manage and optimize items for nine primary services and several secondary service locations, including outpatient clinics and procedural areas. What’s more, the system can now store 60 percent more supplies in the same space, with at least 10 days of inventory on-hand at all times.

I believe it goes without saying that this brings tangible efficiencies and cost reductions for this facility, and that in turn supports improved patient care.

Q: Is there anything I haven’t asked that you’d like to discuss?

A: On a personal note, I know that many feel saddened or discouraged by some of the media reports about veterans facing long waits for appointments or in the emergency department. At Stanley Healthcare, we believe that improvement to both efficiency and workflow processes, as well as reducing costs, are key drivers in improving care. And at Stanley Black & Decker, we show our support every day to soldiers and veterans through our partnership with Wounded Warrior Project. So we are extremely proud to work with the many professionals in the Military Health System and VA to enable a better patient experience. O www.M2VA-kmi.com

NEXT ISSUE Dedicated to the Military Medical & VA Community

October 2014 Vol. 18, Issue 4

Cover and In-Depth Interview with:

Lt. Gen. Patricia Horoho Army Surgeon General Invited

Features Mobile Health IT The mobile health care IT market is steadily growing. Health care applications are some of the most commonly used applications on today’s smartphones.

Traumatic Brain Injury More commonly known as TBI, this affliction affects both veterans and active duty servicemembers.

Careers in Health With a little more education, veterans returning with combat medical skills have access to a wide range of careers in medicine.

Who’s Who: Army Medicine A pictorial review of the leadership and command structure of Army Medicine.

Special Section: Preventing Sexual Assault Senior medical leaders of the services discuss the impact of sexual assault in the military, and how it can be prevented.

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