January – March 2008

Perspective 1

MG Russell J. Czerw

The Moral Imperative: Reflecting Back and Looking Forward 5

BG Michael S. Tucker

The Comprehensive Care Plan: Building the Strength to Do Well Tomorrow 8

LTC(P) Marie A. Dominguez, MC, USA

Ensuring Excellence: The Warrior Transition Unit Staff Training Program 17

Sherri A. Emerich, MA

The Role of Occupational Therapy in Warrior Transition Units 21

COL Mary W. Erickson, SP, USA

What Can Social Workers Do for Warriors in Transition? 25

René J. Robichaux, PhD, LCSW; COL Nicole M. Keesee, MS, USA

Facilities Maintenance: Uncovering the “Black Hole” 27

MAJ Ricky Smith, USAR

Medical Care for Army Reserve and National Guard Soldiers 32

in the Global War on Terror

COL Susan Durham, AN, USA; COL Anne Bauer, AN, USA

The Brooke Army Medical Center Experience with a 35

Focused Medication Reconciliation Program

CPT Jesse W. Neeley, MC, USA; Sara J. Pastoor, MD, MHA

The Enhanced Reintegration Action Plan: The Madigan Experience 38

LTC Karl Bolton, MS, USA; et al

Offering Hope for our Wounded Warriors: 45

An Overview of the Womack Army Medical Center Pain Medicine Clinic

MAJ Thomas Weber, MC, USA; MAJ Anthony Dragovich, MC, USA

ALSO IN THIS ISSUE

The “Silent Killer”: Hyperventilation in the Brain Injured 50

LTC(P) Lorne H. Blackbourne, MC, USA; et al

Joseph Lister, Noncompressible Arterial Hemorrhage, and the 56

Next Generation of “Tourniquets”?

LTC(P) Lorne H. Blackbourne, MC, USA; et al

Maximizing Patient Thermoregulation in US Army Forward Surgical Teams 60

LTC(P) Lorne H. Blackbourne, MC, USA; et al

Defining Combat Damage Control Surgery 67

LTC(P) Lorne H. Blackbourne, MC, USA

Warriors in Transition

healing with dignity and determination
LTG Eric B. Schoomaker

The Surgeon General

Commander, US Army Medical Command

MG Russell J. Czerw

Commanding General

US Army Medical Department Center and School

January – March 2008 The Army Medical Department Center & School PB 8-08-1/2/3

0801501

GEORGE W. CASEY, JR

General, United States Army

Chief of Staff

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Online issues of the AMEDD Journal are available at https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

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The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for

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Views expressed are those of the author(s) and do not necessarily reflect official US

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January – March 2008 1

A major shortcoming in the military’s approach in

caring for our critically ill or wounded Warriors,

resulting from the Global War on Terror, was the lack

of an established and supported organizational

structure ensuring each Warrior is afforded the best

possible opportunity to complete their mission: to heal

and prosper in his or her life. Fortunately, a proven

characteristic of the US military is the ability to

quickly and efficiently organize, mobilize, and attack a

problem in times of crisis. That strength became a

major factor in addressing this need. The focus of this

issue of the Army Medical Department Journal is the

Army’s multidimensional response to our obligation to

those least able to speak for themselves—our Warriors

who have paid a major price for their dedication and

selfless service in defense of freedom and human

dignity.

As BG Michael Tucker discusses in his excellent

introductory article, even as immediate corrections

were made to the more obvious problems, DoD rapidly

put into motion a much larger and more complex

effort. This undertaking had to encompass every aspect

of care for those Warriors whose needs are extensive,

complex, and long term. From his perspective as the

first Assistant Surgeon General for Warrior Care and

Transition, BG Tucker describes the reorientation of

the Army’s understanding of the dynamics of recovery

to the perspective of the Warrior in Transition. No

consideration remained unaddressed: physical

environment, conveniences, Family participation,

treatment, rehabilitation, life skills, and much more.

An Armywide template was created; requirements,

doctrine, and procedures established; resource needs

identified and fulfilled; and training developed and

delivered. Although the results to date have been

impressive, as BG Tucker points out, there is still

much to be done as there is always room for

improvement. He finishes his article with descriptions

of the ongoing proactive efforts and interagency

initiatives across both military medicine and external

resources.

The Warrior Transition Unit (WTU) is the foundation

of the Army’s efforts to address the needs of those

Soldiers. LTC(P) Marie Dominguez presents a

thorough description of the organization, staffing,

philosophy, and working relationships of the WTU.

Her article details the procedures involved in the

evaluation of a Warrior in Transition (WT) upon

arrival at the WTU, the phases of the rehabilitation

process as he or she progresses toward the ultimate

goals, whether they involve continued military service

or a new start in the civilian world. The road map for

the Soldier’s journey through the rehabilitation process

is the Comprehensive Care Plan, the overall,

personalized scheme created by the WT and the WTU

cadre which defines all aspects of the Warrior’s

activities in the WTU. LTC(P) Dominguez’s article

provides an excellent insight into the thoroughness and

attention to detail invested in the development and

planning of the WTU model and the Care Plan, and the

commitment by all of the dedicated professionals

involved in the rehabilitation process.

Successful recovery and rehabilitation of WTs under

the Army Medical Action Plan is directly dependent

on the effectiveness of the WTU, which, by extension,

means the effectiveness of the staff in performing their

roles. As planning and development of the WTU

structure evolved, the requirement for standardized

training was formalized and delegated. In her article,

Sherri Emerich describes the Army Medical

Department Center and School’s superb response to

this extremely important tasking. In a remarkable

Perspective

Major General Russell J. Czerw
2 www.cs.amedd.army.mil/references_publications.aspx

effort by the Academy of Health Sciences (AHS), the

immediate need was filled in a very short time with 3

comprehensive distributed learning WTU orientation

courses. The training experts then quickly turned their

attention to the development of a resident course to

ensure that the principal cadres of the WTUs are as

well prepared for their responsibilities as possible.

Also, to address training requirements before the first

resident course convenes in October 2008, the AHS

built and delivered a suite of courses to the WTUs for

their local training purposes. The response by the AHS

is yet another example of the teamwork and

mobilization of resources to address a critical need that

has long been the hallmark of Army medicine.

As described in an article in an earlier issue of the

AMEDD Journal,* occupational therapy has long been

a recognized and respected part of the US military

treatment regimen for recovering Warriors. Therefore,

it is no surprise that occupational therapy (OT) is an

integral component of the rehabilitative resources of

the WTU. COL Mary Erickson’s article is a detailed

description of the goals and considerations driving the

OT role in the WTU, and the various aspects of the

professional and life skills and attitudes addressed by

OT specialists who work with the WTs. COL Erickson

makes it very clear how occupational therapy is such a

vital element of the rehabilitation process. Indeed,

restoration of the Soldier’s confidence and competence

is critical for him or her to regain the independence

which is absolutely essential for a productive and

fulfilling life in any environment. Our dedicated

occupational therapy professionals work very hard to

make this happen.

Whereas the occupational therapist’s focus is on the

WT’s innate skills, abilities, and interests to restore

self-confidence and a positive attitude about their own

capabilities, the social worker’s role is to assist the WT

in his or her reintegration into the environment

surrounding them. In their succinct, well-presented

article, Dr René Robichaux and COL Nicole Keesee

describe the social worker’s approach to the WT’s

recovery process, and the contributions made in the

overall rehabilitation program. It is extremely important that the social worker’s insights and perspectives

are included in development of the WT’s Comprehensive Care Plan. Although the importance of healing

the WT’s body and restoring his or her psyche and

social skills is obvious, it is equally as important to

accomplish that with a view toward the community

outside of the isolation (and comfort) of the WTU’s

facilities, staff, and fellow WTs. This is why the social

worker’s early involvement in each WT’s evaluation

and Care Plan development is vital to his or her future,

no matter the path followed after leaving the WTU.

Many factors contribute to an individual’s overall

attitude and opinion of self-worth. This becomes

especially important when the individual is in a

situation where he or she has very little control over

the surrounding environment, as is the case of a

military member recovering from serious injury or

disease. Therefore, it follows that the physical

environment within which our WTs live and work is

an extremely important factor in their recovery. This

priority has been communicated across the Army.

Commanders of installations and medical facilities

have committed tremendous time and resources to

ensure that recovering Soldiers are housed and treated

in the best environment we can offer. MAJ Ricky

Smith’s timely article addresses facility maintenance

from the commander’s perspective. He calls upon his

many years of experience to provide insights for

responsible officers who may be unfamiliar with the

inner workings of maintenance management of

buildings and other facility components. His

information and recommendations should be

extremely helpful in efforts to ensure our medical

facilities, no matter the size and complexity, remain

safe, clean, functional, and aesthetically acceptable.

This is important not only to our WTs, but to our staff

members and all other users of our facilities.

As we all know, the Global War on Terror involves

large numbers of activated Army Reserve and National

Guard Soldiers. Many of them have returned from

combat theaters with serious injuries or lingering

effects from disease or psychological stress. Others

may be injured or become sick while on active duty,

but not mobilized to a combat theater. In either case,

the readiness of their units for future activations and

deployments is directly affected by the physical

readiness of every member. In their informative

article, COL Susan Durham and COL Anne Bauer

describe the 2 Army programs which were established

to support the readiness posture of the Reserve and

National Guard units by allowing their members

Perspective

*Newton S. The growth of the profession of occupational

therapy. Army Med Dept J. January-March 2007:51-58.
January – March 2008 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

access to military medical care while deactivated. The

Medical Retention Processing 2 and the Active Duty

Medical Extension programs are vehicles by which

Reservists and National Guard Soldiers may apply for

active duty status in order to receive the medical care

necessary to return them to retention status and back to

duty with their respective units as soon as possible.

The Army Reserve and National Guard are

increasingly important components to the defense of

the United States, and therefore the health, welfare,

and readiness of their Soldiers at all times is a major

concern. These programs are important tools in

maintaining the personnel readiness of these critical

resources.

As a wounded or seriously ill Soldier moves from the

battlefield through the medical care and support

system, he or she receives care for different conditions

from multiple providers at different locations.

Therefore, it is not uncommon for a Warrior to arrive

at the WTU with a “stock” of surplus medications,

most of which are no longer required for the

conditions, or which had been replaced in the

Warrior’s medication plan by other prescriptions. CPT

Jesse Neeley and Dr Sara Pastoor have contributed an

important article which gives us an insight into the

scope of this problem. Their description of the

medication reconciliation program implemented within

the Brooke Army Medical Center’s Warrior Transition

Battalion highlights a situation which exists for every

WTU in the Army. The importance of gaining control

over the medication situation and plan for the

individual WT cannot be overemphasized. As CPT

Neeley and Dr Pastoor clearly demonstrate,

medication reconciliation is vital to the health and

safety of both the Warrior and the Family as they

progress along the extended road to recovery.

Before the implementation of the Army Medical

Action Plan in June 2007, the Army’s medical

treatment facilities and installations developed various

programs and organizational structures at the local

level to assist Warriors in Transition with their

treatment and recovery. In their article, LTC Karl

Bolton and his team describe one excellent example of

initiative, creative thinking, and cooperation developed at the Madigan Army Medical Center and Fort

Lewis. The Reintegration Action Plan (RAP) was

developed to assist Warriors in the identification and

pursuit of their goals, as well as to manage the

resources available to them. This program was

initiated in January 2007 and was of major assistance

in organizing and focusing the efforts of both the

Warriors under treatment and the attending staff. The

true measure of success of the RAP is the fact that it

was upgraded and smoothly incorporated into the

Army Medical Plan structure in the summer of 2007 as

the Enhanced Reintegration Action Plan (ERAP).

Indeed, as LTC Bolton et al describe, the RAP and

ERAP provided the Madigan/Fort Lewis team a

significant head start—a proven structure within which

caregivers were experienced, comfortable, and overwhelmingly successful, thereby greatly assisting the

implementation of the WTU and Comprehensive Care

Plan at their installation. The ERAP is just another

example of the initiative, creativity, and teamwork

demonstrated by Army medical professionals in their

untiring efforts to assist those entrusted into their care.

Unfortunately, one condition often attendant to

recovery from traumatic injuries such as those suffered

in combat is chronic pain, which sometimes continues

long after recovery from the primary injury. In their

excellent, informative article, MAJ Thomas Weber and

MAJ Anthony Dragovich discuss the character of such

pain and the problems it poses for practitioners who

work to mitigate it. As would be expected, Warriors in

Transition present a population with a significant

number of complex patients with chronic pain due to

difficult-to-treat conditions. The article describes the

close working relationship between the Womack Army

Medical Center’s state-of-the-art interventional pain

clinic and the Warrior Transition Battalion, and the

various approaches to pain management for our WTs.

Led by the Womack and Walter Reed Army Medical

Centers, Army medicine is collaborating with the

finest civilian medical research and educational

institutions to address the many difficult issues

associated with the treatment and management of

chronic pain for our wounded and injured Warriors.

These efforts are especially important to those

providing care and assistance to the WTs, as chronic

pain can result in depression and a sense of

helplessness. Motivation and a positive outlook are

essential for a successful recovery and transition. For

many WTs, pain management is the first step in their

personal Comprehensive Care Plan.

All of the articles discussed above focus on the vital

care provided to Warriors at or near the end of a long
4 www.cs.amedd.army.mil/references_publications.aspx

path of treatment that usually begins on the battlefield.

Those multiskilled medical professionals who save the

lives of our wounded Warriors on the battlefield are

only the first of many who will be involved in the

Soldiers’ treatment and recovery, but their skills and

judgments make possible everything that follows. We

close out this issue of the AMEDD Journal with four

very important articles that address some of the most

current concepts and experiences in traumatic wound

care. LTC(P) Lorne Blackbourne of the Army’s

Institute of Surgical Research and his colleagues have

been regular contributors to the Journal, and once

again their well written, extensively researched articles

demonstrate the level of professional expertise,

initiative, and dedication that is the signature of Army

medicine today.

The first article is particularly relevant to the Warrior

in Transition focus of this issue. Traumatic brain

injury often results in extended long-term care and

rehabilitation. LTC(P) Blackbourne and his team

describe the hazards of hyperventilation to those with

severe brain injury, with detailed descriptions of the

physiology involved. The article proposes changes to

protocol and the use of relative simple technology to

mitigate as much as possible the serious aftereffects of

this serious injury. This article is must reading for

those involved in providing early stage care to our

seriously injured Warriors. It also should be carefully

read by those involved in training those caregivers.

The tourniquet is one of the oldest battlefield treatment

tools known to man. Military medicine is always

looking to improve its effectiveness, ease of

application, portability, etc. However, one limitation is

its utility to control hemorrhage from those injuries to

body areas which do not allow circumferential

pressure. The second article looks into history and

develops an innovative adaptation of an old concept,

using a common workshop tool to demonstrate the

potential to achieve compression where a standard

tourniquet cannot. This is an interesting and ultimately

practical approach to an age-old problem.

It has long been understood by those involved in

trauma control surgery that hypothermia is a condition

that has a deleterious affect on the patient. The third

article delves into the complexities of hypothermia,

examines statistical evidence of its importance to

survivability, and explores various techniques and

technologies to stabilize patient core body

temperature. The article emphasizes the importance of

managing hypothermia at the Forward Surgical Team

level, as well as during helicopter transport. This is an

important look at a situation that our combat deployed

medical personnel experience every day.

The last article is an informative comparison of

damage control surgery as practiced in the military and

civilian environments. Civilian damage control surgery

is a clearly defined process that is well understood by

all involved in its application. On the other hand,

combat damage control surgery is very difficult to

define and quantify, primarily due to the dynamic

conditions of the battlefield, the multiple transports

required, and the various levels of stabilization,

surgery, and care involved as the patient is moved

through increasingly sophisticated facilities. LTC(P)

Blackbourne’s article is a clear, well organized

description of the complexities and consideration of

damage control surgery as we must practice it,

wherever and whenever our Warriors serve.

The cover picture emphatically summarizes the

content of this issue. SSG Chris Pettaway can walk for

himself in a 5 kilometer walk/run with his physical

therapist, Mark Heniser (Center for the Intrepid,

Brooke Army Medical Center) because battlefield

medics and surgeons saved his life, dedicated medical

caregivers worked to heal his wounds, and Warrior

Transition professionals teamed with him as he

continues to dedicate himself to accomplish his

mission—To Heal ! There is no compromise when

the welfare of US Army Soldiers is concerned,

whether on the battlefield, in the long-term aftermath

of serious injury or disease, or anywhere else. They are

the only reason that we are here.

Perspective
January – March 2008 5

As we approached the one-year anniversary of the

Washington Post article on Walter Reed, I was asked

numerous times to reflect on all that we have accomplished over the past year. These accomplishments

came about through a coordinated, compassionate,

synchronized team effort. Just as it takes more than a

single medic, physician, or nurse to heal a wounded,

ill, or injured Warrior, it has required contributions

from several Army staff agencies, as well as assistance

from other federal, state, and private agencies to

achieve the progress we have attained. We have made

tremendous strides forward in the care and transition

of Soldiers who have become wounded, ill, or injured

in the line of duty, but there is still much work to be

done.

First, we as an Army very quickly understood that this

was not a medical problem—it was an Army problem.

We built and renovated barracks, yet we did nothing

for the Medical Hold and Medical Holdover barracks;

we fixed that by taking Soldiers out of barracks that

were the worst on post and putting them in the best on

post. We combined the separate and unequally

supported Medical Hold (Active Army, commanded

and controlled by the Medical Command) and Medical

Holdover (Reserve Component, commanded and

controlled by the installation management command)

into a single Warrior Transition Unit under the

Medical Command and provided it with an approved

Table of Distribution and Allowances.* Where we had

less than 400 untrained cadre members, we now have

2463 trained and certified cadre and staff. We have

hired an additional 26 doctors, an additional 157 nurse

case managers, 72 social workers, 7 occupational

therapists, and 13 occupational therapy technicians.

We resisted a culture of “haves” and “have-nots” by

avoiding the separation of care into categories that

would imply one Soldier was more deserving than

another (Soldiers with combat wounds versus Soldiers

with disease or nonbattle injury; seriously injured or ill

versus not seriously injured or ill). We recognized that

the Soldier who sustained an amputation in a tactical

vehicle accident in training was just as deserving as

the Soldier who sustained an amputation in a vehicle

accident in Iraq, who was just as deserving as the

Soldier who sustained an amputation in a combat

attack. We recognized that the Soldier that developed

an illness in combat was no less deserving than the

Soldier who sustained a shrapnel injury.

We recognized that it was not just the Soldier who had

suffered a loss, but the Family as well, and we

improved the support we provide Families. We gained

authorization to transport wounded, ill, and injured

Soldiers and their Families in government vehicles.

We now meet Family members arriving on invitational

travel orders at the airport. We established Soldier and

Family Assistance Centers so Soldiers and Families

can get support in a single location without having to

The Moral Imperative: Reflecting Back and

Looking Forward

Brigadier General Michael S. Tucker

BG Tucker, a career Armor officer,

is the Assistant Surgeon General for

Warrior Care and Transition, US

Army Medical Command.

*Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to perform

a specific mission for which there is no appropriate table of organization and equipment.
6 www.cs.amedd.army.mil/references_publications.aspx

negotiate a strange post to find a dozen different

places. These centers offer one-stop access to essential

services such as pay, legal, health benefits, and

housing. We removed bureaucratic barriers to

assigning nonfamily members as nonmedical

attendants. We authorized single Soldiers with

nonmedical attendants to live in family housing. We

produced a video to orient Family members of

severely injured Service Members to their “new

normal,” helping them to understand the challenging

road of recovery that they face.

We worked to improve the Physical Disability

Evaluation System (PDES) within the constraints of

current law. We gave Soldiers electronic access to

monitor the status of their Medical Evaluation Board

and Physical Evaluation Board through their Army

Knowledge Online accounts. We reduced the number

of forms required for a Medical Evaluation Board. We

are conducting a triservice PDES pilot in the National

Capitol Area that provides for a single physical exam

and gives the Soldier both VA and Army ratings prior

to separation from the Service, allowing him or her to

more expeditiously apply for VA benefits and

healthcare. We improved the ratio of Physical

Evaluation Board liaisons (PEBLOs) and Medical

Evaluation Board physicians. We standardized the

training for the PEBLOs and certified them.

We have recognized concussive injury and post

traumatic stress as particular challenges, and have

made improvements in our culture towards the

acceptance of treatment for mental health disorders

without incurring stigma. We have begun baseline

cognitive screening of Service Members before they

deploy to a combat zone, screen for exposures and

symptoms while they are in the combat zone, and

screen for symptoms upon return. We produced a

chain-teach* video on the recognition of symptoms

that could be consistent with traumatic brain injury or

post traumatic stress disorder. We produced a second

version to be viewed by Family members.

We have recognized that Warriors in Transition have a

mission—To Heal! And everything they do during

their duty day must support that mission. To promote

healing, we have restricted access to alcohol. We have

recognized that many of our Warriors in Transition

need mentorship and guidance, and therefore we are

training all of our squad leaders to be life coaches who

will encourage them in the accomplishment of their

goals and objectives as they progress through their

personal Comprehensive Care Plan. The Plan requires

the Warrior in Transition to spend their 9-hour duty

day decisively engaged in activities that promote their

healing—medical appointments, classes, group

therapy, therapeutic exercises and activities, vocational

training, or educational activity. In this effort we have

partnered with several institutions of higher learning to

enable Warriors in Transition to achieve their personal

education goals.

We provided commanders with the tools required to

address the needs of their Warriors in Transition with

an ombudsman and a Wounded Soldier and Family

Hot-Line number (1-800-984-8523). In addition, we

provided the commanders with tools that would enable

them to see themselves with a Warrior Transition Unit

Status Report and Quarterly Training Brief.

While it is personally satisfying to consider our

accomplishments, we will not continue to move

forward if we lose sight of what we still must do. We

have made tremendous progress in the last year, but

we cannot rest on our laurels. There is still much to

accomplish. We must continue to push forward.

There are things yet to be shaped within the Army’s

battle space. We must continue to refine our

management of high risk Warriors in Transition,

particularly with respect to mind- and consciousnessaltering medications. We must continue to make

improvements in our culture so that Soldiers

understand that they can ask for help without perceived detriment to their career.

We must continue to develop digital solutions. In

particular we must fully automate our profile system to

improve the communication between doctors and

commanders. We must improve the consistency of

documenting all deployed traumatic events, military

acute concussion evaluations, and deployed healthcare

in the theater AHLTA†application, thereby improving

our health data record for post-deployment treatment

and, if needed, for the physical disability evaluation.

The Moral Imperative: Reflecting Back and Looking Forward

†The US military electronic medical record

*Chain-teach is a method of unit training in which designated

unit members first receive the training, after which it is their

responsibility to train another level of personnel, who in turn

will continue training others. The training continues in a

pyramid fashion until all personnel requiring such training

have received it.
January – March 2008 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

We must continue to refine the diagnosis and treatment

of concussive injury (also called mild traumatic brain

injury) and post traumatic stress disorder. We must

continue to refine and fully implement our

Comprehensive Care Plan policy, and reassess our

staffing models to ensure we have the appropriate staff

to perform the required work.

We must optimize our relationship with the

Department of Veterans Affairs (VA) so that every

Soldier transitioning out of the military is enrolled

with the Veterans Health Administration, and, where

appropriate, has a prearranged appointment with their

VA provider. In addition, we must cooperate with the

Veterans Benefits Administration to ensure all

Warriors in Transition submit their application for VA

benefits prior to their separation. We must continue

efforts with the VA to modernize and improve the

physical disability evaluation system.

We still must develop a single resource identifying

nongovernmental and veterans service organizations

that provide benefits to Soldiers. We continue to

struggle with the coordination of matching

organizations wishing to offer jobs to Veterans with

Soldiers who wish to interview for those jobs.

While we remain vigilant in our cause, we will

continue to foster relationships with the VA, sister

services, veteran’s service organizations, and other

intragovernment agencies. Our efforts at transparency

and keeping Congress informed has forged a new trust

and confidence which must be preserved. Finally, the

momentum must be maintained and, as we have from

the beginning, we must continue to make decisions

based on what best supports the healing of our

Warriors in Transition and their Families.
8 www.cs.amedd.army.mil/references_publications.aspx

OVERVIEW

The Army established the Warrior Transition Units

(WTUs) for Soldiers requiring ongoing, timeintensive, medical, surgical, or psychiatric treatment.

The WTU sets the conditions and establishes a

framework for healing to enable the Soldier to regain

function and productivity. Soldiers assigned or

attached to a WTU are called Warriors in Transition

(WTs), because they are at a transition point; their

lives have been changed by injury or illness and they

are working to recover and return to duty or return to

life as a vocationally enabled Veteran. The Comprehensive Care Plan utilizes a holistic approach; the WT

is encouraged to set goals for healing within 4 life

domains: physical (body), mental (mind), social

(heart), and spiritual (spirit). The holistic approach is

based on the following principles:

 Be responsible for one’s own future

 Gain more control over one’s life

 Promote health and sense of well-being

 Maintain a positive self identity

 Shape satisfying social relationships

 Overcome social and cultural barriers

When a person’s body or mind suffers illness or injury,

the heart and spirit are often affected. To fully

implement a Comprehensive Care Plan, attention must

be given to all 4 life domains. Family members, care

givers, and significant others play an integral role in

WT rehabilitation; therefore, it is important to

encourage their participation in all levels of care. For

WTs who are geographically separated from their

Family members or significant others, this may

involve the inclusion of Family members or significant

others in meetings, use of video or telephone

conferencing.

To achieve the principles of holistic healing, it is

imperative that WTs spend their duty days gainfully

engaged in purposeful activities that promote healing

in all 4 life domains. To promote a sense of

responsibility and control, every WT (with aid and

guidance from an integrated WTU team) will develop

a Comprehensive Care Plan that addresses all 4 life

domains, and is goal directed and milestone driven.

Goals and milestones must be measurable and have a

timeline for attainment. The WTU triad (primary care

manager, nurse case manager, and squad leader) and

the WT must set a target transition date. To facilitate

the Comprehensive Care Plan, the WT (with guidance

and encouragement from the WTU cadre, clinical

staff, and support staff) must develop a long-term,

weekly, and daily WT training calendar that accounts

for medical appointments and other activities related to

healing. A standard duty day is 9 hours. All WTs must

spend their duty day decisively engaged in activities

designed to promote healing which may include:

 Medical and rehabilitation appointments, classes,

or activities

 Cognitively enhancing activities (ie, military

education distance learning courses, college

courses, foreign language study)

 Vocational training or enhancement program (ie,

duty in a unit in a military occupational specialty

for which the WT is qualified, or hopes to qualify

for, on-the-job training or internship program

designed to complement the WT’s vocational

interests and further enhance vocational skills)

Upon completion of the WT’s tenure in the WTU, the

WT will:

 Be physically, mentally, socially, and spiritually

strengthened

 Be vocationally enabled to the maximum extent

possible and/or have life-care plans in place

 Be equipped with the tools to maintain personal

and professional relationships

 Be proud of their service to the nation

The Comprehensive Care Plan: Building the

Strength to Do Well Tomorrow

LTC(P) Marie A. Dominguez, MC, USA
January – March 2008 9

THE TEAM CONCEPT

The Warrior in Transition is at the center of the

Comprehensive Care Plan and is the central team

member. Early in the development of the Warrior

Transition Unit, the term “triad” of support was

coined. The WTU triad consists of the WT’s primary

care manager, nurse case manager, and squad leader.

With support from other key staff, the WTU triad

provides critical longitudinal and conceptual

integration of the Comprehensive Care Plan and

supports the Warrior in Transition. To gain synergy

from the integration of medical management and

command and control, key cadre and support staff

must be aligned into habitual team relationships as

illustrated in the Figure. A squad leader should interact

with a single nurse case manager (due to increased

nurse case manager staffing at medical treatment

facilities, one squad leader may need to interact with 2

nurse case managers). The nurse case manager

interacts with one primary care manager, one social

worker, and one occupational therapist.

The company commander guides and directs the

leadership, administrative, and support processes. The

primary care manager guides and directs the medical

treatment and clinical support plan. The nurse case

manager oversees the implementation and

coordination of the medical treatment and clinical

support. The platoon sergeant and squad leader serve

as mentors and life coaches. In addition, they are

responsible for daily implementation of leadership and

coordination for administrative support. To be

successful, the WTU triad relies on a host of other

clinical and installation support staff to fully promote

healing. Two key members of the team are the social

worker who assists with the evaluation for and

coordination of social and community support

services, and the occupational therapist who assists

with the evaluation of the WT for vocational interests

Team Organization of a standard Warrior Transition Unit Company serving 216

Warriors in Transition.

Glossary

CO Commanding officer XO Executive officer

1SG First sergeant PCM Primary care manager

NCM Nurse case manager PSG Platoon sergeant

SL Squad leader WTs Warriors in Transition

WTU Warrior Transition Unit OT Occupational therapy

MTF Medical treatment facility (military) MEDCEN Medical center (military)
10 www.cs.amedd.army.mil/references_publications.aspx

and capabilities, and the coordination of purposeful

activities in the vocational or educational realm.

TEAM COMMUNICATION AND COORDINATION

Communication and coordination are essential to

effective team function. There are recurring communication episodes that occur between various team

members. The squad leader and the WT interact on a

daily basis to continually assess for obstacles.

Formations. Warrior Transition Units may require

their Warriors in Transition to attend formations.

Formations are an efficient and effective means of

accounting for Soldiers, communicating command and

general information, developing team identification,

maintaining Soldier standards, and assessing the

interactions of WTs with peers and supervisors. When

planning formations, WTU leadership must consider

mobility limitations of their WTs.

Daily Squad Leader–WT interaction. The SL will

have interaction with each WT in his or her squad

every duty day to assess potential problems, gauge the

WT’s well-being, provide mentorship and guidance,

and monitor progress with the Comprehensive Care

Plan goals and milestones. If the commander or the

WTU triad determines that a WT is at high risk for

suicide, medication error, or other risk to life or health,

the squad leader or his clearly designated representtative (such as a staff duty noncommissioned officer)

is required to make nonduty day contact with the WT

for a well-being assessment.

Weekly Nurse Case Manager–WT interaction.

The nurse case manager will meet with the WT at least

once weekly to assess for problems, gauge the WT’s

well-being, provide mentorship and guidance, and

monitor progress with the Comprehensive Care Plan

goals and milestones.

The WTU Triad Meeting. The WT, the primary care

manager, the nurse case manager, the squad leader,

Family members (or significant others) and other team

members (as appropriate) will gather occasionally to

develop, define, and assess goals. At a minimum, a full

WTU triad meeting is held during the goal-setting

phase and at decision points. WTU triad meetings may

be called at other times as necessary.

WTU Triad Synchronization Meeting. It is imperative that the WTU triad and supporting healthcare and

support services function as a team. To facilitate such

teamwork, it is suggested that weekly synchronization

meetings be held to achieve synergy between the

medical management and command and control

elements. Unfortunately many WTUs are using these

valuable opportunities primarily as meetings to gauge

the progress of the Medical Evaluation Board (MEB),

and, in many places, the WTU commander or the

primary care manager is not present. With MEB

duration as the main yardstick and indicator of whether

to present a WT or not, the team is not focused on the

most at-risk Soldiers. Instead of MEB duration, I

recommend the nurse case manager and platoon

sergeant present updates on WTs who are new (in the

reception phase), in the final transition phase, in

recovery (very ill or debilitated), at a decision point, or

any other WT about whom they have concerns. The

commander can then provide guidance on leadership,

administrative, and support issues, and the primary

care manager can provide guidance on clinical care

and coordination, thus achieving synergy from

combining command and control with medical

management.

The WTs are not present and these meetings are not

meant to be in-depth reviews or coordination efforts. If

the team finds itself spending more than two or three

minutes discussing a Soldier, it is an indication that a

separate WTU triad meeting dedicated to that WT is

required. Ideally the meeting will last one, or at most 2

hours. During the initial 50 minutes (90 minutes for a

2-hour meeting), the nurse case managers and platoon

sergeants present progress and issues encountered by

their WTs. Other staff with training in the Health

Insurance Portability and Accountability Act1

(HIPAA) also attend the synchronization meetings and

provide input as necessary. The last 10 to 30 minutes

are reserved for non-HIPAA trained personnel to join

and have an opportunity to bring their observations

and concerns to the WTU triad. These individuals

remain available after the meetings to facilitate oneon-one coordination efforts.

PHASES OF THE REHABILITATION PROCESS

The rehabilitation process is divided into 6 contiguous

phases with boundaries that often overlap, eg, medical

assessments may begin while the Soldier is still

officially in the reception phase. Assessments for

Family assistance and support and referrals for

nonmedical benefits and services will occur

throughout all phases of the rehabilitation process.

The Comprehensive Care Plan: Building the Strength to Do Well Tomorrow
January – March 2008 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

Reception Phase

During the reception phase, the cadre and the

designated Battle Buddy* welcome and orient the new

WT to the WTU. The cadre introduce themselves,

complete initial intake interviews, and assess the WT

for risks related to his medical condition, mental

health, mobility limitations, cognitive abilities,

medications and other drugs. The risk assessment is

used to determine the WT’s housing assignment and

urgent medical and behavior health appointments.

During this phase, the WT completes administrative

and financial inprocessing. The cadre members orient

the WT to his or her rights and responsibilities and set

expectations (initial counseling), orient the WT to the

goal-setting concept, and introduce the concept of the

WT training calendar. With guidance from the cadre,

the WT will develop, update, and maintain a personal

training calendar which is reviewed at nurse case

manager and squad leader meetings.

Initial Assessment Phase

During this phase the WT, WTU triad, and other

healthcare professionals assess the current condition,

abilities, and capabilities in the domains of body,

mind, heart, and spirit. As shown in Table 1, the

assessment phase includes an appraisal of the WT’s

level of function, need for services (medical, surgical,

behavioral health, and community), Family needs,

vocational and educational goals, abilities, self-care

capability, and lifestyle. Army Community Service

now provides a career assessment tool that will assist

the WT in determining his or her interests.

Assessments are made in the 4 life domains and

tailored to the needs of the WT.

It is important to note that assessment of the WT does

not stop at the end of this phase. This phase allows an

in-depth initial assessment. Continued reassessments

occur throughout the remainder of the rehabilitation

process. General assessments are made with each

squad leader and nurse case manager meeting. Specific

assessments are made along the timeline for goal and

milestone achievement.

Goal-Setting Phase

Many WTs will begin to formulate ideas about their

goals and objectives as they progress through the

assessment phase and may have already started

working towards those goals. The WT, WTU triad,

and Family (if available) will meet and the WT will

formally set his or her goals, with intermediate

objectives, a timeline, and a defined plan to achieve

them. Consideration should be given whether to focus

on skills for a successful return to duty, or skills for a

transition to a healthy, successful Veteran. The cadre

members guide the WT in the development of goals

with a focus on healing and the development of

positive life-skills and habits, for improvement in

body, mind, heart, and spirit. Depending on needs, the

WT may establish goals in the areas of functional

independence and mobility, community mobility

(transportation), return to duty, and other vocational

skills, education, social interaction, leisure, and

recreation. Injury or illness is particularly stressful to

relationships, therefore, all WTs are encouraged to

develop goals with relationship enhancement in mind.

Documenting the WT’s goals, objectives, timeline, and

plan in the electronic medical record (AHLTA)

facilitates communication among caregivers and

enables them to reinforce the plan.

Active Rehabilitation Phase

During this phase, WTs place activities on the training

calendars that will assist them in accomplishing the

goals and objectives each has set for him or herself.

Family members and caregivers are actively

encouraged to participate as full partners in the

process, along with ancillary healthcare professionals

and support staff. During their scheduled meetings

with the WT, the squad leader and nurse case manager

provide encouragement and oversight in monitoring

the achievement of milestones on the training calendar.

This phase is divided into 4 tiers:

Tier A: Recovery. Recovery may interrupt any phase

of the rehabilitation process, but it does not send the

WT back into any phase. Of course, a reassessment of

the goals and objectives is warranted after recovery.

WTs are placed in recovery only if they are unable to

participate in any physical, mental, relationship, or

spiritual strengthening programs. This is an unusual

situation for an outpatient setting, but some WTs may

be placed in Tier A for short periods in the immediate

*Defined as the person to whom the WT can turn in time of

need, stress, emotional highs and lows, that will not turn the

WT away, no matter what. This person knows exactly what the

WT is experiencing because he or she is currently going

through a similar experience or has been through a similar

experience and/or situation before.
12 www.cs.amedd.army.mil/references_publications.aspx

postoperative period, or during profoundly debilitating

therapy, such as chemotherapy.

Tier B: Basic Reset. The WT spends the entire

training day performing activities related to therapeutic

rehabilitation. He or she is actively engaged in medical

and therapeutic appointments; group and/or individual

therapy; and strengthening, range of motion, or

endurance exercises at the gym or pool. In addition to

specific therapeutic regimens, all WTs complete a

basic “reset” curriculum containing the following

programs of instruction:

 Transition rights and responsibilities

 Post traumatic stress disorder/traumatic brain

injury chain-teach* program

 Goal planning

 Maintaining healthy relationships

 Managing stress and energy

 Communication skills

 Maintaining a healthy weight and nutrition status

(including medication effects) while recovering

from injury or illness

 Managing/reestablishing cardiovascular fitness

 Conflict resolution

 Battle Buddy skills

 Financial benefits overview and basic money

management

*Chain-teach is a method of unit training in which designated unit members first receive the training, after which it is their

responsibility to train another level of personnel, who in turn will continue training others. The training continues in a pyramid

fashion until all personnel requiring such training have received it.

Table 1. Initial assessment of the Warrior in Transition normally includes the following areas

addressed across the 4 functional domains.

Body (physical)

Medical evaluations

Surgical evaluations

Psychiatric evaluations

Pain assessment

Physical abilities and limitations,

including profile limitations

Aerobic condition

Balance

Muscular strength

Fine and gross motor skills

Range of motion

Body fat & nutrition assessment

Functional assessment

Activities of Daily Living (ADLs)

Instrumental ADLs

Mobility

Transportation (commuting and

driving)

Addictions and misuse of substances

Quality of sleep

Mind (cognitive/vocational/emotional)

Vocational education status

Interests/assessments

Psychological testing

Cognitive assessments

Concentration skills

Attitude and motivation

Financial situation and skills

Leisure time management

Screening for traumatic brain injury

and post traumatic stress disorder

Language skills

Speech, hearing, reading, writing

Heart (social)

Interpersonal/ relationship skills

Support systems

Family dynamics/status

Parenting

Communication skills

Conflict resolution

Anger management

Intimacy

Socially acceptable behavior

Current/future living arrangements

Unit of assignment

Motivation: values, beliefs, goals

What provides meaning and

purpose to the WT’s life

Support systems

Religious/Cultural Support

Avocational pursuits

Recreation, sports, hobbies, music,

art, and leisure—activities that add

joy and depth to the WT’s life

Community service, volunteer

activities—ways to contribute to the

community, both now and in the

future

Spirit

The Comprehensive Care Plan: Building the Strength to Do Well Tomorrow
January – March 2008 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

 Educational benefits overview and career

development

 Understanding medications, safety, and avoiding

addictions

 Basic relaxation techniques and sleep hygiene

skills

 Time management skills

 Locations with Army Center for Enhanced

Performance* (ACEP) facilities will incorporate

the full ACEP curriculum into their basic reset

curriculum.

Tier C: Intermediate Reset. WTs spend part of

their duty day in vocational or educational activities,

but still dedicate a significant portion of their duty day

to activities specifically designed to rehabilitate their

body, mind, heart, and spirit. Tier C will generally

involve interventions targeted at addressing a specific

goal. Advanced training and intervention to address

individualized needs may be provided by various

medical specialists, including:

 Occupational therapy

 Physical therapy

 Social work

 Chaplain

 Soldier and Family assistance center

 Army Center for Enhanced Performance

 Education center

 Unit mentors (a Soldier that is part of a unit on

post that supervises the WT in a return to duty

skill such as a new military occupational

specialty)

Topics may include:

 Anger management

 Assertiveness/communication skills

 Specific nutrition and/or weight management

 Physical training

 Specific life-skills

 Targeted relationship coaching

 Functional activities

 Warrior basic skill training and return to duty

skills

 Military occupational specialty training

 Specific problem solving and goal setting

 Specific financial management skills training

 Specific leisure/time management skills training

 Work readiness skills (work habits, values,

interests, work skills, vocational exploration)

Tier D: Life Reset. Generally these WTs have completed their Medical Evaluation Boards and are

awaiting the findings of the Physical Evaluation

Boards, or are preparing for return to duty. They spend

the majority of their duty day in vocational or

educational activities, but may still require ongoing

medical treatment or rehabilitation. For many WTs,

their work assignment will be compatible with

established goals and within the confines of their

physical profile. An additional aspect of this phase is

an increased emphasis on Family and community

reintegration.

Final Transition Preparation Phase

The phase begins when the Soldier knows whether he

or she will return to duty or separate (or retire) from

the service. The WT and significant Family member(s)

are given up to 90 days to prepare for return to duty or

transition to life as a Veteran. WTs found fit for duty

must complete the necessary administrative tasks prior

to transfer to their next duty station. For the WT

returning to civilian life, final preparations must be

made to ensure a successful transition to Veteran status

and civilian life, with the Veteran fully integrated into

the community.

WTs returning to duty will complete the following

tasks:

 Army physical fitness test

 Update security clearance

 Update ORB/ERB†

*The Center for Enhanced Performance is a department of the US Military Academy Preparatory School, West Point, New York.

Information is available at http://www.usma.edu/USMAPS/pages/academics/cep_home.htm.

†The ORB (Officer Record Brief) and ERB (Enlisted Record Brief) are one page Army forms designed to provide a summary of the

Soldier’s qualifications and career history. The ORB and ERB are produced from data stored in the Soldier’s Master File at the

Army Personnel Center.2
14 www.cs.amedd.army.mil/references_publications.aspx

 Update official photo

 Discuss future assignments with branch manager

 Arrange to ship household goods and/or vehicles

 Arrangements for required durable medical

equipment

 Identification of a post-transition contact phone

number

WTs transitioning to Veteran status will make the final

preparations, which can include, but are not limited to:

 Applying for federal and state veteran’s benefits,

including disability

 Enrollment in the Veteran’s Health

Administration (VHA) and identification of a

VHA treatment facility near the Veteran’s

desired home to include an initial appointment

and identification of a Department of Veterans

Affairs (VA) case manager

 Application for social security benefits if

indicated

 Application and acceptance to educational

institutions

 Development of employment opportunities for

the Veteran and the Family member

 Arrangements for housing to include adaptive

modifications

 Healthcare enrollment for the Veteran and the

Family

 Transfer Servicemembers’ Group Life Insurance* to Veterans’ Group Life Insurance* or

other arrangements for life insurance

 Arranging school transfers for children

 Arrangements for required durable medical

equipment

 Identification of a post-transition contact phone

number

 Ensure that all paper records have been scanned

into the Soldier’s electronic medical record

 Ensure WT is provided with a copy of his

medical records

Transition/Post-Transition Phase

During this phase the WT completes administrative

and financial out-processing and confirms the

arrangements for the WT’s post-transition life. Thirty

days after the Soldier leaves the WTU, the nurse case

manager conducts a post-transition telephone survey to

assess how well the WT was prepared for the

transition. If the WT identifies problems, the nurse

case manager will coordinate with the VA or other

appropriate entity to resolve the problem.

DECISION POINTS

Decision points should not be confused with progress

assessments which are guided by the goals and

milestones that the WT set during the goal-setting

phase. Decision points are specific points on the

timeline where the WTU triad, in consultation with the

Soldier and the multidisciplinary team, formally assess

the Soldier’s return to duty potential and document the

assessment in his/her electronic medical record. These

return to duty assessments are conducted every 3

months, with the first decision point at 3 months after

initial assignment or attachment to the WTU.

At 3 months after assignment (or attachment) to the

WTU, the WTU triad will hold a formal meeting with

the WT and Family with the focus on the question,

“Has the Soldier’s condition and function improved

sufficiently to meet retention standards in accordance

with the Army’s Standards of Medical Fitness?

3

” If

the answer is yes, appropriate steps to return the

Soldier to duty, either in the same or a new military

occupational specialty, should be pursued. If the

answer is no, the WTU triad and Soldier must decide

whether to continue treatment and rehabilitation in the

WTU, or to prepare for ongoing treatment and

rehabilitation as a Veteran.

At 6 months, the WTU triad holds a meeting with the

WT and Family with the focus on the question, “Has

the Soldier’s condition and function improved

*Servicemembers’ Group Life Insurance (SGLI) is a program of low cost group life insurance for service members on active duty,

ready reservists, and members of the National Guard. Veterans’ Group Life Insurance (VGLI) is a program of post-separation

insurance which allows service members to convert their SGLI coverage to renewable term insurance. Members with full-time

SGLI coverage are eligible for VGLI upon release from service. Source: VA website, available at http://www.insurance.va.gov/

sgisite/SGLI/SGLI.htm

The Comprehensive Care Plan: Building the Strength to Do Well Tomorrow
January – March 2008 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

sufficiently to meet retention standards in accordance

with the Army’s Standards of Medical Fitness?

3

” If

the answer is yes, appropriate steps to return the

Soldier to duty, either in the same or a new military

occupational specialty should be pursued. If the

answer is no, the Soldier and the WTU triad must then

consider, “Within the next 6 months, will the Soldier’s

condition and function improve sufficiently to meet

retention standards in accordance with the Army’s

Standards of Medical Fitness,

3

or will he be a

candidate to either continue on active duty or continue

on active reserve?” If further treatment and

rehabilitation will definitely or potentially return the

Soldier to a condition that meets medical retention

standards, further rehabilitation in the WTU is

warranted. If further rehabilitation or treatment will

not bring the Soldier to a condition that meets

retention standards, or bring the Soldier to a level of

function that will permit continuation on active duty,

then preparation for entry into the physical disability

evaluation system is warranted, and continued

rehabilitation and treatment in the WTU is indicated

only in extraordinary circumstances.4 Examples of

extraordinary circumstances include:

 A significant injury that warrants longer

rehabilitation effort (indicated by the receipt of

Traumatic Servicemembers’ Group Life Insurance*

or entry into the Army Wounded Warrior Program)

 A significant illness that medical staff determines

has a good prognosis for full recovery and return to

duty. In this case, the WT’s activities should be

directed towards return to duty skills and activities,

with vocational activity in an appropriate unit.

To facilitate assistance with possible transition to life

as a Veteran, WTs referred to the Medical Evaluation

Board should attend the Transition Assistance Program

(TAP) or Disabled TAP, while WTs referred to the

Physical Evaluation Board will meet with a Veterans

benefits counselor onsite or at the installation’s

Benefits Delivery at Discharge office.

Upon referral of the WT to the Medical Evaluation

Board, attention must be paid to transition services the

Family members may need, in addition to those

required by the WT. For example, if the WT has a

Family member with significant health concerns or

exceptional needs, consideration must be given to how

those needs will be met if the Soldier is separated from

the Army. Coordination for appropriate care and

services after the Soldier’s separation must be initiated

when the Soldier is referred to the Medical Evaluation

Board. Such coordination will significantly reduce the

Soldier and Family stress related to either the medical

or Physical Evaluation Board process.

PROFILES

To alleviate confusion upon assignment or attachment

to the WTU, the primary case manager evaluates the

WT’s profile and determines if it adequately addresses

all limiting conditions. The primary case manager may

choose to write a new temporary profile. Physicians

write profiles for 2 reasons:

1. To prevent the Soldier from causing an injury to

himself or others. The Soldier may be motivated, but

the risk of injury is too high or the consequences too

severe to not write the profile. An example might be a

helicopter pilot with a current seizure disorder. No

matter how motivated that Soldier may be, the

consequences would be too severe and a no-flying

duty profile would be required. Another example is a

Soldier that has mobility limitations that would

prevent him from evacuating a burning vehicle or

taking cover in the event of an attack. Another

example is the Soldier with post-concussive syndrome

(often called mild traumatic brain injury). To protect

the brain while it is healing, the physician may opt to

write a no-alcohol profile. No-alcohol profiles may

also be considered when a Soldier has other diagnoses

or is taking certain medications.

2. To protect the Soldier from undo pain and

suffering. Only the Soldier can determine what is

unreasonable for him or her with respect to pain. Not

all Soldiers with knee pain need a profile that

necessitates a Medical Evaluation Board and

separation from the Service. The Soldier must

understand that they are the best judges of what they

are capable of. To facilitate retention, the Soldier

should strive to meet the following minimum

standards5:

 Be able to take an aerobic fitness event (run, walk,

bike, or swim).

*Traumatic Servicemembers' Group Life Insurance is a traumatic injury protection rider under SGLI that provides for payment to

any member of the uniformed services covered by SGLI who sustains a traumatic injury that results in certain severe losses.

Source: VA website, available at http://www.insurance.va.gov/sglisite/tsgli/tsglifaq.htm.
16 www.cs.amedd.army.mil/references_publications.aspx

 Be able to fire a personal weapon, either shoulderfired or handheld.

 Be able to wear the personal protective equipment

(chemical protective gear, helmet, individual body

armor vest).

PLANNING FACTORS

A WTU in a steady state—the standard number of 216

Warriors in Transition who stay an average of 180

days—will gain an average of 36 new Soldiers every

month. The primary care manager and one of the nurse

case managers will perform the intake processing for

these 36 Soldiers (36 hours a month), attend 36 goalsetting WTU triad meetings per month (36 hours a

month), and attend 36 decision point meetings (18

hours a month). The steady state workload for the

primary care manager is summarized in Table 2. The

occupational therapist and social worker will also need

to perform new intakes for these 36 Soldiers and may

be requested to attend goal-setting and decision point

meetings for certain Soldiers. The military treatment

facility should consider the workload requirements

when providing their clinical staff with adjunctive

personnel and support staff. WTUs that have attained a

steady state can calculate their requirements by

reviewing the number of new WTs received each

month.

SUMMARY

The Warrior Transition Units provide Soldiers an

opportunity to focus fully on healing, with the goal of

returning to duty or returning to civilian life as a

successful Veteran, with success defined as employable (or a life-care plan established), capable of

maintaining relationships, and proud of their service to

the nation. The success of the individual Warrior

Transition Unit will be determined by how well they

assist their Warriors in Transition. The Warrior

Transition Unit cadre must ask:

Is our WTU doing everything it can to build-up

our Warriors?

Are we providing them with the tools to develop

their Strength to Do Well Tomorrow?

REFERENCES

1. Public Law 104-191 Health Insurance Portability

And Accountability Act Of 1996. August 21, 1996:

Available at: http://aspe.hhs.gov/admnsimp/

pl104191.htm.

2. Army Pamphlet 640-1: Officer’s Guide to the Officer

Record Brief. Washington, DC: US Dept of the

Army; April 1, 1987.

3. Army Regulation 40-501: Standards of Medical

Fitness. Washington, DC: US Dept of the Army;

December 14, 2007.

4. Department of Defense Instruction 1332.38: Physical

Disability Evaluation. Washington, DC: US Dept of

Defense; November 14, 1996.

5. Army Regulation 600-60: Physical Performance

Evaluation System. Washington, DC: US Dept of the

Army; June 25, 2002.

AUTHOR

LTC(P) Dominguez is the Executive Officer to the

Assistant Surgeon General for Warrior Care and

Transition, Office of The Surgeon General, Alexandria,

Virginia.

The Comprehensive Care Plan: Building the Strength to Do Well Tomorrow

Table 2. Monthly workload for the Warrior

Transition Unit primary care manager in a 216

member unit accessing 36 new arrivals each month.

36 new intakes

1 hour each 36 hours

36 WTU triad goal-setting meetings

1 hour each 36 hours

36 decision point meetings

0.5 hours each 18 hours

4 WTU triad synchronization meetings

2 hours each 8 hours

Total hours required for new arrivals

and standing meetings 98 hours

Available hours:

21 duty days @ 8 hours 168 hours

Remaining total hours for all other

appointments throughout the month 70 hours

The primary care manager will therefore have 3.3 hours

each day during the month for all other appointments,

including sick call (acute care), medication reconciliation,

profile evaluation, routine appointments, and meetings

with other healthcare providers.
January – March 2008 17

BACKGROUND

The Army Medical Action Plan established the

development and delivery of standardized training for

the staff of the Warrior Transition Units (WTU), with

special focus on the “WTU Triad.” The triad consists

of the squad leader, the nurse case manager, and the

primary care manager. Every Warrior in Transition

(WT) is assigned to a triad upon joining the WTU.

While training is not the entire solution to progress and

improvement, it is a key component in the change

process. Indeed, standardized training for WTU staff

was one of the 10 “quick wins” established by the

Army Assistant Surgeon General for Warrior Care and

Transition when the Army Medical Action Plan was

unveiled in June 2007.

In August 2007, the Academy of Health Sciences

(AHS) at the Army Medical Department (AMEDD)

Center and School was tasked to accomplish the new

training requirement. Very quickly, great things began

to happen. When an Army need for training is

combined with overwhelming support and subject

matter expertise, the result is exceptional quality

training.

DISTRIBUTED LEARNING

The training mission was initiated with a request for

the development and delivery of distributed learning

on a variety of subjects. The first suspense was short.

The team included subject matter experts, distributed

learning developers and deliverers, instructional

systems specialists, AHS quality assurance personnel,

and training systems specialists. The initial training

product was the short-term, short-suspense solution.

This product has since been improved. The AHS is

currently working on the third revision. Future phases

of improvement include producing a Sharable Content

Object Reference Model* compliant product which

will improve sequencing and standardization.

Two distributed learning training courses were

developed to provide an overview of the WTU and all

its services and functions. Recently it was determined

that all staff members of a WTU would benefit from

the information and training provided by both courses.

Therefore, these courses were combined into a single

course, the Warrior Transition Unit Cadre Orientation

course.†It is located on the Army Learning

Management System. Soldiers can enroll in this course

via the Army Training Requirements and Resources

System as a self-development course.

The WTU Cadre Orientation course encompasses 28

lessons as shown in Table 1. Additional lesson topics

have been identified for consideration and

development.

In addition to the overview course, nurse case

managers are also required to take the Warrior

Transition Unit Nurse Case Management course.‡ This

course covers nurse case management roles and

responsibilities with special attention to the WTU

patient population. Distributed learning modules on

case management, ambulatory care guidelines,

utilization management, post-traumatic stress disorder,

and traumatic brain injury are integrated.

BRIDGING THE GAP

Further into the Army Medical Action Plan, it was

determined that the WTU triad and platoon sergeants

should attend resident training in addition to the

distributed learning. The resident course will be

launched in October 2008. However, to provide

resident-type training as soon as possible, interim

types of training were established to bridge the gap

between distributed learning and the resident course.

LOCALLY CONDUCTED TRAINING

At a January 2008 conference in San Antonio, 7

lessons were delivered to designated trainers or

Ensuring Excellence: The Warrior Transition

Unit Staff Training Program

Sherri A. Emerich, MA

*A Dept of Defense set of standards and specifications for

development and delivery of electronic learning.

†Army Training Course 6I-F8/300-F36

‡Army Training Course 6E-F2
18 www.cs.amedd.army.mil/references_publications.aspx

training coordinators from each WTU. The designated

trainers will either deliver the training or coordinate

the training employing local subject matter experts.

The training must be provided to the WTU staff by the

end of September 2008. Documentation is completed

in the Digital Training Management System (DTMS).

The 7 lessons are designed to engage the staff through

discussions, videos, practical exercises, and scenariobased training. The training topics include:

 Post traumatic stress disorder and traumatic brain

injury

 Pain management

 Drug and alcohol awareness

 Suicide prevention

 Army physical disability evaluation system

 Personal goal setting

 Basic medical terminology

 Command and control/personal accountability

The medical terminology training is intended for

nonmedical staff. Many of the squad leaders and

platoon sergeants in the WTUs and community based

healthcare organizations (CBHCOs) are not medical

professionals. While the lesson on command and

control is beneficial to all, its focal point is the squad

leader and platoon sergeant.

ARMY CENTER FOR ENHANCED PERFORMANCE

TRAINING MODULES

The Army Center for Enhanced Performance* (ACEP)

will send training teams to each of the WTUs and

CBHCOs between February and September 2008.

Training from the ACEP teams takes a more holistic

approach to training, using advanced performance

psychology and academic strategies to enhance

personal and professional performance and strength.

Training is provided at the mental and emotional level

of human performance. Physical, technical, and

tactical training are already done well by the Army.

The training modules embrace the following:  Life coaching awareness and providing strength to

others

 Psychology of injury and healing

 Mental skills foundations to better use the mind to

enhance performance

*The Army Center for Enhanced Performance is a department

of the US Military Academy Preparatory School, West Point,

New York. Information is available at: http://www.usma.edu/

USMAPS/pages/academics/cep_home.htm.

1 Orientation

2 WTU Integrated Management Team

3 Service Support

4 WT Integration and Disposition

5 Army Wounded Warrior Program

6 Compassionate Leader

7 Cadre (staff) Resiliency

8 Army Career and Alumni Program

9 Soldier Financial Readiness Visibility System

10 Physical Profiles

11 Community Based Healthcare Organization

12 Assisting Veterans with Traumatic Brain Injury

13 Seamless Transition

14 Transition Assistance Advisors

15 Veterans Administration

16 Veterans Benefits Administration Compensation

and Pension Services

17 Vocational Rehabilitation and Employment

18 Women Veterans Program

19 Combat-related Injury Rehabilitation Pay

20 Computer-Electronic Accommodations Program

21 Mobilization Process

22 Tricare† Overview

23 Traumatic Servicemenbers’ Group Life Insurance

24 Medical Evaluation Boards

25 Physical Disability Evaluation System

26 Human Resources Command

27 Ombudsman

28 Suicide Awareness

Table 1. The current composition of the Warrior

Transition Unit Cadre Orientation Course.*

*Army Training Course 6IF8-300-F36

† TRICARE is the DoD health care program for members of

the uniformed services, their families, and their survivors.

Information available at http://www.tricare.mil.

Ensuring Excellence: The Warrior Transition Unit Staff Training Program
January – March 2008 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

 Confidence building

 Goal setting

 Integrating imagery

 Attention control and active listening

 Energy management

 Team building

SENSITIVITY TRAINING

Sensitivity training will be delivered via unit ministry

teams. They will emphasize the provision of

compassionate and sensitive care in support of the

WTs and their Families. Squad leaders and platoon

sergeants find themselves in an atypical leadership role

in a WTU. Firm, yet compassionate leadership is

required.

RISK COMMUNICATION TRAINING

Professional Risk Communication training will be

delivered to the WTUs by the Army Center for Health

Promotion and Preventive Medicine (CHPPM). This

training uses education and scenarios to help the staff

to better plan and execute communications in high

risk/low trust environments. Learning to apply the

principles of risk communication is a fundamental

imperative for the triad. A single bad communicator,

albeit someone with really good intentions, can affect

the healing process. The training is excellent and is

highly recommended for anyone, especially those

whose job entails complex interactions and communication in a trusting environment.

RESIDENT COURSE

The first resident course will be presented in October

2008. Two weeks are blocked for this course, although

the program of instruction is not final. All members of

the WTU triad and all platoon sergeants will attend.

The ACEP team is responsible for the first week of the

course which will be devoted to coaching, mentoring,

and education. The training is a more thorough version

of the current interim training package. The ACEP

team at Fort Sam Houston is presently developing

curriculum specifically for this course.

The second week will include a 6-hour, comprehensive

lesson in Risk Communication. The course will also

include sensitivity training and an overview of the

DTMS. The lessons previously delivered by WTU

designated trainers will be provided by the subject

matter experts that designed and developed the

lessons. Professional videos have been scripted and are

under production for training in both suicide

prevention and suicide intervention. The AHS Soldier

and Family Support Branch, AMEDD television

production specialists, and CHPPM are collaborating

on this project. The last part of the course will involve

breakout groups similar to technical track training.

Squad leaders and platoon sergeants, along with nurse

case managers and primary care managers, will receive

role-specific training. The AMEDD Noncommissioned

Officers Academy will play a vital role in squad leader

and platoon sergeant training.

TRAINING SUMMARY

The current training requirements for WTU staff are

shown in Table 2. It should be noted that after

September 30, 2008, there is no longer any mandatory

requirement for the local classroom training shown in

Table 2, as the learning objectives covered in that

training are included in the resident course described

above. However, this does not preclude local

commands from presenting such related training as

they deem necessary.

THE ROAD AHEAD

The WTU Triad Training Program is evolving.

Recently, as directed by the Army Training and

Doctrine Command, a WTU overview training support

package was developed for implementation into Army

leadership courses. A WTU breakout session was just

established for the AMEDD Pre-Command Course.

The WTU Triad Training Program website was

established. The mission is expanding. Additional

distributed learning content is under development for

the orientation course which will cover Family

Readiness Support Assistants. Lessons in Personnel

(S1) and Comprehensive Care Planning are in the

analysis phase. Professional expertise and suggestions

are common resources during this planning and

development evolution.

Although there is a vast amount of expertise within the

schoolhouse, involvement extends above and beyond

the AHS. Professional expertise is not limited to

schoolhouse resources. Knowledgeable and practiced

professionals outside of the AHS, such as ACEP and
20 www.cs.amedd.army.mil/references_publications.aspx

CHPPM, are integral contributors to this program,. We

will continue with interviews of WTU staff and

commanders to sustain a program of instruction that is

current and relevant. As the program progresses, we

will use survey tools, observations, interviews, and

other forms of evaluation and analysis to preserve a

quality training program.

As the population of experienced WTU staff members

grows, we must capture their tacit and explicit

knowledge and find a way to proliferate it, creating an

educational circle among the incoming and outgoing

members of the WTU triad. The power of knowledge

can only achieve its full potential if we share it with as

many people as possible. Imagine 100 people in a

room with probes and wires interconnecting their

brains. Then, with the flip of a switch, all of the

information and knowledge in each brain is shared

with the others. While our program includes no probes

or wires, we do want our training program to share

knowledge in an interactive and engaging manner. We

want to do more than train; we want to improve human

performance.

AUTHOR

Ms Emerich is the Program Director of the Warrior

Transition Unit Training Program, Academy of Health

Sciences, AMEDD Center and School, Fort Sam

Houston, Texas.

*Either the Warrior Transition Unit Cadre Support course (Army Training Course 6I-F6/300-F34) and the Warrior Transition

Unit Support Orientation course (6I-F7/300-F35), or the Warrior Transition Unit Cadre Orientation course (6I-F8/300-F36)

†Army Training Course 6E-F2(P)

‡Course mandatory until September 30, 2008. After that date, personnel assigned as squad leaders, primary care

managers, nurse case managers, and platoon sergeants must attend the resident WTU training course presented at the

AMEDD Center and School, Fort Sam Houston, Texas.

§ Not required after September 30, 2008

Table 2. Current mandatory training requirements for staff personnel assigned to all US Army

Warrior Training Units.

Distributed Learning Courses Classroom Training at Local Installation

Warrior Transition

Unit Orientation*

Nurse Case

Management†

ACEP Mobile

Training‡

Unit Ministry

Team Sensitivity

Training‡

Locally

Conducted

Training‡

Risk

Communication

Mobile Training‡

Squad

leader     

Primary care

manager

    

Nurse case

manager

     

Platoon

sergeant     

All other

WTU staff     

§ § § §

Ensuring Excellence: The Warrior Transition Unit Staff Training Program
January – March 2008 21

The primary mission of a Soldier assigned to a Warrior

Transition Unit (WTU) is to heal. The combination of

a familiar military living environment, medical and

rehabilitation services, and set daily routines with

individualized goals help Warriors in transition focus

on activities that promote healing in the physical,

mental, social, and spiritual domains of life.

The role of occupational therapy (OT) within a WTU

is to help Soldiers attain optimal occupational

performance and gain a sense of mastery as they

transition back to independent, productive living. The

WTU OT promotes the Soldier’s return to the role of

worker, whether military or civilian. Occupational

therapy practitioners promote, improve, conserve, and

restore the skills, abilities, and aptitudes of the Warrior

in Transition. They help guide Soldiers toward

reasonable short and long-term goals that reflect the

Soldier’s avocational (nonpaid or volunteer) and

vocational interests. A supportive military

environment combines with engagement in purposeful

work activities that match the Soldier’s interests and

skills to help them overcome physical, mental, or

emotional barriers and view themselves as competent

workers. This perspective is absolutely essential for

them to gain control over their daily lives and take

personal responsibility for their future.

Occupational therapy is designed to achieve functional

outcomes through a focus on the therapeutic use of

occupation—tasks and activities within one’s daily life

which provide meaning and purpose. Occupational

performance may be related to areas of work, play,

education, leisure, self-care, or social participation.

Engaging the Soldier in therapeutic occupations that

are based on his/her current functional ability helps

build a sense of competence and self-confidence.

“Engagement in occupation includes both the

subjective (emotional or psychological) aspects of

performance and the objective (physically observable)

aspects of performance.”1 Occupational therapy

practitioners consider the interplay between the

environment, the person, and occupational

performance in matching interests, skills, and abilities

with intervention options. Occupational therapy

practitioners address occupational patterns such as

roles, routines, and habits within a broad context:

cultural, physical, social, temporal, spiritual, and

virtual. Engagement in Soldier tasks and duty

responsibilities as early as possible helps the Warrior

in Transition maintain the ingrained habits that support

the role of being a Soldier.

Occupational therapy practitioners incorporate

therapeutic use of self, consultation, and educational

approaches to help meet the needs of Warriors in

Transition. The WTU OT staff includes a licensed,

registered occupational therapist, who holds a

bachelor’s or master’s degree and certified

occupational therapy assistants who hold associate

degrees. Occupational therapy practitioners must

complete supervised clinical internships in a variety of

health care settings, pass a national certification

examination, and complete licensure requirements in

most states. They are trained in human growth and

development with specific emphasis on the social,

emotional, and physiological implications of illness

and injury. Occupational therapy practitioners

facilitate increased Soldier involvement in productive

activity while addressing safety, physical tolerance,

and functional abilities. They are able to develop and

guide job-specific programs of graded activity, job

task analysis, job station modifications, and can

identify and address work behaviors.2

Occupational therapy practitioners provide

consultation and collaboration support in many areas.

They partner with the Computer/Electronics

Accommodations Program to provide assistive

technology assessments for Soldiers demonstrating

functional deficits. Occupational therapy practitioners

provide consultation support to help the WTU address

ergonomic issues, meet Americans with Disabilities

Act3requirements, and create safe barrier-free

environments. They help identify the need for specific

life skills training/classes and interface with the

The Role of Occupational Therapy in Warrior

Transition Units

COL Mary W. Erickson, SP, USA
22 www.cs.amedd.army.mil/references_publications.aspx

Army’s Center for Enhanced Performance,*

incorporating a peak performance model to build

Warrior performance skills. In addition, OT

practitioners may provide cognitive and behavioral

health assessment and intervention strategies; ensure

that an interface with the Department of Defense, the

Department of Veterans Affairs (VA), and civilian

providers exists; connect with VA vocational

assessment resources, work adjustment, and work

transition resources; and work closely with Family and

community resources.

The interactive nature of occupational therapy requires

a close working relationship with the Soldier and the

“WTU triad” (primary care manager, nurse case

manager, and squad leader). Regular contact with the

social worker, chaplain, and the WTU command team,

as well as the military treatment facility (MTF) staff

assures continuity of care. A close working

relationship is maintained with the VA Vocational

Readiness and Employment branch that addresses

return to work. An early interface with vocational

rehabilitation counselors for those who will be

entering the VA system assures a smoother transition.

Occupational therapy practitioners work closely with

the WTU triad to incorporate specific therapeutic

activities into the Soldier’s training calendar as part of

his or her duty day. Such activities may include

requirements of daily living (maintaining a military

appearance), educational activities (selected life skills

training or Soldier task training), work/productive

activities (duty assignments that match individual

interests, skills, and abilities), leisure/recreational

activities (participation in enjoyable, relaxing activities, games, and sports), and social participatory activities (cooperative/competitive sports, games,

ceremonies, or celebrations).4

Life skills training and education help prepare Soldiers

for successful reintegration into military duty, or for

return to their home and community living. A team

approach is used to identify and meet the needs of

Warriors in Transition. The OT staff collaborates with

the WTU operations staff, the MTF, and garrison

resources to implement basic and advanced training to

meet the Soldier’s basic skills needs in the following

areas:

 Goal planning

 Managing stress and energy

 Communication skills

 Managing a healthy weight and nutrition status

while recovering from injury or illness

 Managing/reestablishing cardiovascular fitness

 Conflict resolution

 Managing healthy relationships

 Financial management skills

 Basic relaxation techniques and sleep hygiene

 Maintaining balance/time management

 Basic introduction to illness and injury including

avoidance of addictions and medication

management

Advanced life skills training is provided according to

the Soldier’s needs, including

 anger management, assertiveness and

communication skills,

 concentration skills,

 Warrior basic skill training and return-to-duty

skills,

 specific problem solving, and

 goal setting.

Specific skills training in the area of work readiness

includes

 work habits,

 values,

 interests,

 work skills, and

 vocational exploration.

THE VALUE OF WORK

Duty is a Soldier’s work. It is expected of all Soldiers.

To a Warrior in Transition, work or duty assignments

are viewed as therapeutic and are designed to improve

health. The concept of work as a therapeutic medium

has been a core concept since the inception of

occupational therapy. Work programs for individuals

with mental illness began during the “Moral

Treatment” movement of the late 18th and early 19th

centuries. George Barton, one of the founders of

*The Center for Enhanced Performance is a department of the

US Military Academy Preparatory School, West Point, New

York. Information is available at http://www.usma.edu/

USMAPS/pages/academics/cep_home.htm.

The Role of Occupational Therapy in Warrior Transition Units
January – March 2008 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

occupational therapy, established a program in New

York in the early 19th century that incorporated the

use of occupations to return individuals recuperating

from illness or injury to productive living. He stated,

“The purpose of work was to divert the mind, exercise

the body, and relieve the monotony and boredom of

illness.”5In 1918, the Army’s Division of Orthopedic

Surgery organized a reconstruction program for

disabled soldiers and trained reconstruction aides to

use “work activities to return the injured soldiers to

military duty or civilian life to the highest degree

possible.” 4 Reconstruction aides were the precursors

of today’s occupational therapists.

Work often provides a sense of security, belonging,

and self-esteem; it is a role with which all Soldiers can

identify. The process of returning to work begins as

soon as the Soldier enters the medical system. It

requires a collaborative team approach as Soldiers

transition between acute rehabilitation and work

rehabilitation. When the Soldier enters the WTU, the

OT practitioner performs an initial screening to

address life skills, occupational performance, and

potential for work placement. During intake, a

collaborative assessment addresses the Soldier’s

occupational history (both military and civilian),

training and education, functional abilities and deficits,

and future plans and goals. This assessment helps the

Soldier identify occupational goals, identify avenues to

reach those goals, and instill the mindset to achieve the

stated goals. Occupational therapy assessments may

include, but are not limited to

 life skills assessments,

 cognitive assessments,

 vocational interest surveys,

 vocational aptitude and career assessments,

 occupational performance assessments,

 Warrior functional capacity evaluations, and

 use of driving or firearm training simulators.

Occupational therapy practitioners assess limitations

that prevent or delay the return to the worker role and

provide recommendations for modifications and/or

equipment needs.

Following the initial intake, eligible Soldiers are

assigned to a meaningful job that is within the limits of

their physical profile and commensurate with their

grade. The Soldiers are placed in duty assignments that

incorporate military occupational specialty related

tasks, training, and/or education toward an

occupational goal. Occupational therapy practitioners

work closely with the WTU triad to coordinate

vocational training, job skills training, and work

placement for Soldiers, with consideration given to the

skills and interests of the Soldier. The WTU will

maintain a file on each work reintegration site which

includes, but is not limited to the job description (duty/

work hours, dress code, and point of contact), a

memorandum of agreement, and the physical,

cognitive, and psycho-social job requirements. The

squad leader, in consultation with OT, will maintain

regular contact with the work site and will record/

report the Soldier’s work performance and satisfaction.

Community reintegration activities help prepare the

Soldier for successful daily life as an active participant

within the community. Duty assignments that involve

the VA work programs and/or other vocational or

work programs may help the Soldier identify and

access resources within the community. Addressing

community mobility, including public transportation or

driving skills, and practicing enrollment in educational

activities while still in the WTU help to ease the

Soldier’s transition back to community living.

Participation in recreational or sports activities and

community outings also helps maintain a link to the

community while preparing the Soldier to pursue

independent leisure activities. The Soldier’s Family or

care provider may be engaged in the development of a

transitional care plan and or life care plan when

additional or ongoing services are required. The OT

practitioner develops collaborations within the

community to determine resources and to prevent

duplication of services.

In summary, occupational therapy’s role in the WTU

applies a functional approach to healing through doing,

by matching the individual’s interests, skills, and

abilities with activities that have meaning and purpose,

along with the “just right” challenge. A focus on

occupational performance helps restore confidence and

competence. Life skills components promote

functional independence that will enhance future

quality of life, while preparing the Soldier for a

lifetime of productive living. Participation in work

reintegration promotes a sense of mastery, a positive

self-identity, and the acceptance of personal

responsibility and control over one’s own future.
24 www.cs.amedd.army.mil/references_publications.aspx

REFERENCES

1. American Occupational Therapy Association. Occupational therapy practice framework: domain and process. Am J

Occup Ther. 2002;56:609-639.

2. American Occupational Therapy Association. OT Services in Work Rehabilitation. Available at: http://www.aota.org/

practitioners/resources/docs/factsheets/conditions/39826.aspx. Accessed 23 February, 2008.

3. Americans with Disabilities Act, 42 USC §§ 12101-12213 (1990).

4. FM 4-02.51. Combat and Operational Stress Control. Washington, DC: US Dept of the Army; July 2006: chap

12, sec 12-6.

5. Pendleton HM, Schultz-Krohn W, eds. Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction.

6th ed. Burlington, Massachusetts; Elsevier: 2007:265-266.

AUTHOR

COL Erickson is IMA Chief, Occupational Therapy Proponency Office for Rehabilitation and Reintegration, Office of

The Surgeon General Health Policy and Services, Alexandria, Virginia.

The Role of Occupational Therapy in Warrior Transition Units

COL DEBBOUN IS THE NEW CHAIRMAN, AMEDD JOURNAL EDITORIAL REVIEW BOARD

COL PASQUARELLA JOINS THE BOARD

After seven years, COL James M. Lamiell, MC, USA, is leaving his position as Chairman of the

AMEDD Journal Editorial Review Board. COL Lamiell is an original member of the Board, joining

as Chairman in November, 1999. Throughout his tenure, COL Lamiell has been a steadfast advocate

for the Journal, and we thank him for his dedication to the high standards and professional quality of

this publication, and his years of leadership and support to our mission.

The new Chairman of the Editorial Review Board is COL Mustapha

Debboun, MS, USA. COL Debboun is Chief, Medical Zoology Branch,

Academy of Health Sciences, AMEDD Center & School, Fort Sam

Houston, Texas, and a current member of the Board.

The AMEDD Journal also welcomes

COL Michael A. Pasquarella, MC, USA

as a new member of the Editorial Review

Board. COL Pasquarella is Chief,

Department of Medical Science,

Academy of Health Sciences, AMEDD

Center & School, Fort Sam Houston,

Texas.

The Editors
January – March 2008 25

The Warrior Transition Units (WTU) are providing an

alternative to the traditional disease model which

suggests that individuals who are wounded, ill, or

injured can only achieve recovery and optimal health

by addressing the physical consequences of their

illness or injury. In the disease model, those Soldiers

whose physical conditions lead to a disability are often

treated as people who are incapable of becoming

healthy. The alternative social model describes

disability as a form of socially imposed restrictions

and barriers that can be removed to return the person

with disability to good health. The outcome of

combining the best aspects of both models results in a

holistic approach to caring for people. A holistic

model of recovery and rehabilitation focuses on the

social context of wounded, ill, and injured Soldiers

(Warriors in Transition) in addition to addressing their

medical needs. It is the responsibility of the

multidisciplinary treatment team, including the social

worker and “WTU triad” (primary care manager, nurse

case manager, and squad leader), to ensure the delivery

of optimal health care and also to collectively

eliminate barriers, restrictions, and the stigma

associated with injury, illness, and disability. By

adhering to these two responsibilities, Soldiers are able

to focus on both physical and psychological healing

and a return to good health.

Social workers are trained to view an individual as a

person-in-environment. In regards to the person, social

workers lead the way in assessing and addressing the

spiritual, intellectual, emotional, physical, and social

aspects which comprise the “whole” person. As for

environment, social workers are concerned about

living conditions impacting healing and recovery. In

short, social workers have 2 clients when working with

an individual—the person and their community. By

addressing both the person and their social community,

social workers are in a stronger position to help

Warriors in Transition and their families by shaping

their environment in order for them to achieve a full

recovery.

The holistic approach to healing and recovery is based

on the recognition that Warriors in Transition are

whole persons with complex psychosocial needs and

should not be defined solely by their medical

condition. Not all Warriors in Transition will require

social work services, but all will require a social work

assessment. This assessment helps the treatment team,

WTU triad, and Soldier identify and capitalize on the

Soldier’s strengths throughout the recovery and

healing process. Not only is the Soldier capable of

returning to good health, but he learns to gain more

control over his life, maintain a positive self image and

identity, improve and strengthen primary relationships,

develop self-care skills, and overcome social and

cultural obstacles.

Social workers take into account the diversity of the

population they serve, including service orientation,

rank, occupational specialty, age, race, ethnicity,

family structure, gender, religion, and sex.

Mackelprang and Salsgiver1present 6 guiding social

work principles associated with disability which I have

adapted to the Warrior in Transition population for the

purpose of this article:

1. Warriors in Transition are capable and have

potential.

2. Devaluation and the lack of resources are primary obstacles facing Warriors in Transition.

3. Social and political interventions must be

emphasized with Warriors in Transition.

4. There exists a negative attitude about injury and

illness within the military culture which

professionals should be aware of in order to

facilitate the empowerment of Warriors in

Transition.

What Can Social Workers Do for

Warriors in Transition?

René J. Robichaux, PhD, LCSW

COL Nicole M. Keesee, MS, USA
26 www.cs.amedd.army.mil/references_publications.aspx

5. There is joy and vitality to be found in being a

Warrior in Transition.

6. Warriors in Transition have the right to selfdetermination and the right to guide professionals’ involvement in their lives.

For more information about the medical, social, and

holistic approach to people with disability, I

recommend the article by Kim and Canda.2

The behavioral health social worker assigned to the

WTU provides a comprehensive behavioral health and

psychosocial assessment for all Warriors in Transition,

manages risks identified during the interview/

assessment, and documents into AHLTA* the actions

taken, ensures Soldier and/or Family member

counseling/treatment using the appropriate modality (if

indicated), collaborates with the WTU triad and other

members of the multidisciplinary treatment team, and

provides a variety of social work services as indicated.

The primary responsibility of the behavioral health

social worker is to provide the Soldier and the health

care team with a comprehensive psychosocial

assessment of the Soldier’s behavioral health needs at

the time of their attachment or assignment to the

WTU. Through self-assessment questions and

structured interviews, the behavioral health social

worker will be able to identify Soldiers who are

experiencing psychological distress such as

depression, anxiety, and post-traumatic stress disorder,

who may be struggling with alcohol abuse, sleep

disturbance, mood problems, excessive anger,

relationship problems, and feelings of hopelessness. In

addition, the assessment will help identify those

Soldiers in need of a more in-depth evaluation and/or

identify Soldiers who might not have been previously

diagnosed with mild traumatic brain injury. Once the

assessment is completed, the role of the social worker

is to manage the identified risks (problems) and ensure

that further specialty evaluations are initiated. The

social worker will work closely with the WTU nurse

case manager to ensure that a comprehensive

behavioral health treatment plan is developed and

initiated. While Warriors in Transition may see other

members of the behavioral health treatment team, such

as a psychiatrist for medication, and a psychologist for

cognitive behavioral therapy, the social worker can

help the Warrior in Transition with relationship

problems that have been created by or exacerbated by

their injuries. In order to best help the Warriors in

Transition, the social worker may need to involve their

spouses, family members, and/or significant others in

their treatment. There may also be times when the

social worker will need to intervene with other systems

on the Soldier’s behalf, to ensure the Warrior in

Transition receives the best care possible. To

maximize the effectiveness of the social worker in

providing comprehensive behavioral health services, it

is imperative for the WTU triad and multidisciplinary

team to refer the Soldier and/or Family members and

encourage full participation with the social work

assessment and follow-on services.

In summary, good health is often defined as the

absence of disease, injury, or impairment. The holistic

approach to treatment allows health care professionals

to view Warriors in Transition as capable of returning

to duty. Social workers are trained to excel in 4 areas:

advocacy, resourcing, networking, and the provision of

services. A social work presence within the WTU is

essential to the promotion of Soldier health and well

being.

REFERENCES

1. Mackelprang R, Salsgiver R. Disability: A Diversity

Model Approach in Human Service Practice. Pacific

Grove, CA: Brooks/Cole Publishing Company; 1999.

2. Kim KM, Canda ER. Toward a holistic view of

health and health promotion in social work with

people with disabilities. J Soc Work Disabil Rehabil.

2006;(2).49-67.

AUTHORS

Dr Robichaux is Social Work Programs Manager,

Behavioral Health Division, US Army Medical

Command, Fort Sam Houston, Texas.

COL Keesee is Coordinator, Continuum of Care and

Transition Services, Warrior Transition Office, Warrior

Care and Transition Directorate, Office of The Surgeon

*The US military electronic medical record General, Falls Church, Virginia.

What Can Social Workers Do for Warriors in Transition?
January – March 2008 27

YOUR DREAM JOB TURNS INTO YOUR WORST

NIGHTMARE

You have just landed that coveted commander or

deputy commander position and you are riding high.

You have great plans for the world of healthcare and

are planning how you will improve the care your MTF

provides its patients, when your world is turned upside

down by a major facility catastrophe. It doesn’t have to

be a front page article in a nationally read newspaper.

It could be a failing mark on a Joint Commission*

survey or other inspection. It could be an equipment

malfunction that prevents you from providing a key

service or, worse, results in injury or death to a patient

or staff member. Imagine the following scenarios:

Scenario #1: Your facility is undergoing an

inspection. As the investigation group enters your

older facility it seems to be well maintained. No one in

the facility manager’s office seems nervous. Everyone

seems professional and at ease. The inspection team

asks the facility manager to present specific facilities

metrics which he seems to know off the top of his

head, but readily pulls them from his computer. The

inspection team walks around and finds a facility that

is well-maintained. The team leaves with the

impression that the facility manager knows his job and

the facility is well maintained.

Scenario #2: Your facility is undergoing an inspecttion. As the investigation group enters your older

facility, the facility manager seems evasive and on

edge. When an investigator requests to see numerous

metrics, the facility manager states he will need to call

his “computer guy.” The computer guy comes in and is

still not able to produce the metrics, but does produce

a list of reasons why they did not have the data and

tells the group who was to blame for the system not

working correctly. The facility manager tells the group

the problem could be resolved within one week, but a

review of the records indicates very little data had

been entered for at least 7 years. The inspection team

walks around and finds a facility that is poorly

maintained. The team leaves with the impression that

the facility manager does not know his job and the

facility is poorly maintained.

Those are actual scenarios from Army Medical

Command (MEDCOM) inspections of MEDCOM

facilities. Obviously you want to be involved in

scenario #1, not scenario #2, but waiting until

inspection day to find out what scenario you represent

is probably not the wisest course of action. Most

facility managers know their business and will keep

the facility out of trouble, but how do you know you

have facility manager #1 and not facility manager #2?

You do not want to wait for a death or injury or for

your MTF to be on the front of the local news, or until

you are in the middle of an inspection to find out. You

don’t have to be an expert in facility maintenance

yourself to get an indication of the quality of your

maintenance program. This article will give you some

tools to assess your program.

FACILITY FACT:

Facilities found in good condition

always have good maintenance data.

Here are a few of questions you may want to ask your

facility manager when you first meet in his/her office:

What are our critical assets and how did you

determine them?

Answer: Critical assets should be ranked based on

risk which should be determined by the commander

with recommendations from the staff. The deputy

commanders should help identify which assets are

defined as critical. The highest risk asset may be one

that would cause loss of life or limb if it were to

functionally fail. The next highest risk assets would be

those that would prevent you from performing your

mission if they were to functionally fail. Functional

Facilities Maintenance: Uncovering the

“Black Hole”

MAJ Ricky Smith, USAR

*Joint Commission on Accreditation of Healthcare

Organizations, One Renaissance Blvd, Oakbrook Terrace,

Illinois 60181.
28 www.cs.amedd.army.mil/references_publications.aspx

failure means the asset is not meeting the needs of the

owner. An example of high risk may be a backup

generator for life support or fire protection system, or a

steam sterilizer required for surgical procedures. Most

facility managers will tell you that they “contract that

maintenance out.” That does not let them off the hook.

They are still responsible to know the status of the

maintenance and reliability of all assets, especially

critical assets.

What is the preventive maintenance compliance

percentage of our critical assets?

Answer: The preventive maintenance program

compliance (reported as a percentage of preventive

maintenance completed on time) for critical assets

should be reported monthly to the MTF commander.

The MTF commander should always be informed

when preventive maintenance compliance for critical

assets is less than 100% using the 10% Rule. The risk

may not be acceptable.

The 10% Rule of Preventive Maintenance simply

states that a preventive maintenance action scheduled

for an asset must be completed within 10% of the time

frequency. An example: If a preventive maintenance

procedure is to be performed every 30 days, it must be

completed within 3 days of that frequency or it is out

of compliance. I recommend you apply this rule only

to critical or high risk assets.

What metrics are you using to measure the

effectiveness of our preventive maintenance

program?

Answer: You are looking for metrics which show a

trend over time and are compared to other metrics

(Figure 1). This chart should be developed and

reported monthly to the MTF commander. In addition,

ensure your facility manager can show you 100% of

maintenance labor is covered by service or work

orders.

What percentage of the priority 1 service orders

are not completed within 24 hours?

Answer: The US Army standard is that priority 1

service orders are all completed within 24 hours. I

would require this metric to be trended and include all

priority 1 service orders on all assets. Do not accept

excuses.

WORRISOME COMMENTS FROM A FACILITY

MANAGER

“These reports cannot be developed with the

software they are currently using.” The current

software the US Army provides for maintenance of

facilities will provide these reports the data is

entered.

“The contract does not state that we must track

these metrics.” This may be correct. However, I

would immediately direct my contracting officer to

modify the contract and ensure the metrics are

tracked and used to determine contractor bonuses.

“Sir/Ma’am, let me do my job. You worry about

the medical stuff, I’ll worry about the maintenance

stuff.” You do want to let them do their job, but if

they are uncomfortable with your questions, how

much more uncomfortable will they be when an

inspector is asking the questions?

MAINTENANCE FALLACIES YOU WILL HEAR

Maintenance fallacies can result in failure. Have

you heard them in your organization? These

0

20

40

60

80

100

120

140

160

180

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

EM

PM

Figure 1. Chart illustrating the direct relationship between

preventive maintenance (PM) labor hours and emergency

maintenance (EM) labor hours. It is almost unavoidable

that a decrease in preventive maintenance will result in an

increase in emergency labor, with attendant disruptions in

productivity and increased operating costs for the

supported facility.

Facilities Maintenance: Uncovering the “Black Hole”
January – March 2008 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

excuses are a joke among proactive maintenance

organizations because they are not true.

No time for preventive maintenance

High frequencies of emergency repair seem to take

your available labor time away from preventive

maintenance.

To get out of that spiral, you must first identify high

priority assets, and restore them to a manageable

maintenance routine.

Next, apply preventive maintenance procedures on a

disciplined schedule. You will never overcome

emergency maintenance burdens until you get

preventive maintenance under control.

Emergency repair frequencies keep

going up for no known reason.

When you have so many problems you cannot deal

with them, you must step back and develop a good

plan to get them under control.

The first step is to track all failures by using a metric

called mean time between failure (MTBF). This metric

allows you to focus on the asset which is failing the

most.

You derive the metric by dividing units of time by the

number of emergency repair sequences occurring

during that time. For example, performing 3

emergency repair sequences in 24 hours gives you a

MTBF of eight.

Not enough money to hire an expert

I once visited a facility where the roof had failed

numerous times. Over the years during which the roof

failed, the organization repeatedly repaired or replaced

the ceiling, flooring, and walls. The maintenance

manager explained that the roof was not repaired

properly because the maintenance person was not

formally trained in roofing but was the best on staff,

and the manager could not afford to hire a roofing

company. This statement seemed to ask more

questions than it answered, since the cost of repeated

roof repair and room damage must have far exceeded

the cost of hiring a professional to repair it correctly in

the first place.

Not enough maintenance staff

You will never have enough maintenance staff if you

do not reduce your emergency repair requirements for

failing assets.

You also never will control the failures if you do not

develop and manage a true preventive maintenance

program focusing on critical assets first.

Skimping on maintenance is acceptable

because this building/equipment is

scheduled for retirement.

Are the demands or expectations on a piece of

equipment, or a facility, being reduced? If not, they

must be maintained to full capability and functionality.

US Army Medical Command criteria for maintaining

an asset is to follow reliability-centered maintenance

methodology which states that an asset must meet the

functional capability of the needs of the user. If the

asset or facility does not meet user needs, it has failed

functionally. Assets or facilities must be maintained to

full functionality until they are permanently closed,

retired, or deactivated.

SEEING IS BELIEVING: USE THE EYE TEST TO

CHECK YOUR FACILITIES

Start with you facility manager’s office. Is it well

maintained, clean, neat, and orderly? Can he or she

readily provide the data you request?

Do an unannounced “walk-through” of your medical

treatment facility and look for subtle hints of problems

with your preventive maintenance program which

could cause serious problems throughout your

command. Ask for someone who knows their way

around the facility (your facility manager will work) to

give you a tour. Make sure you direct the tour and go

where you want to go, to include any underground

tunnels, mechanical rooms, storage areas, and other

nonpublic areas. These rooms contain the air handlers

that move the conditioned air into and out of the MTF.

There may be pumping systems and pipes in those

locations. Visit numerous mechanical rooms

throughout the MTF and take notes, make no

comments, but ask questions. Look for trash, broken

insulation on pipes, cigarette butts, leaking water,

leaking air, used parts, broken equipment,

inappropriate storage, etc (Figure 2).
30 www.cs.amedd.army.mil/references_publications.aspx

Visit the roof to look for patches on the roof, places

where people have left parts, trash, etc. Look for signs

of rust on vents, etc. Ask the facility manager about

the roof replacement cycle and if he has a plan to

replace the roof, and a budget for the project. If he

says no, ask what is the expected life of the roof. Go

inside the facility and look for leaks, often indicated by

dark spots in the ceiling tile. Look for anything that

looks out of the ordinary as if it were your own home.

Walking around the facility once a week with different

leaders and the facility manager will bring big rewards

for everyone.

FACILITY ASSISTANCE AND ASSESSMENT

SUPPORT TEAM: A WELL KEPT SECRET

Supply Bulletin 8-75-11 requires MEDCOM to

perform an inspection of each MTF every 36 months

to ensure the MTF commanders and facility managers

have an outside organization identify risks in their

MTFs (not nonmedical

facilities).1 The Facility

Assistance and Assessment

Support Team (FAAST)

p r o v i d e s a s s i s t a n c e ,

assessment, feedback, and

oversight relative to the

Facilities/Logistics Command

Review Process.1(pp8-31-33)

The FAAST’s services include

the following:

 Provide comprehensive

expertise to facility

managers and commanders

of MEDCOM MTFs in

support of the facility

management function.

 Support commanders

against liabilities from

outside agencies, such as the

Occupational Safety and

Health Administration, the

Environmental Protection

Agency, etc.

 Assist and train the facility

management organization at

the MTF level on how to

meet and/or exceed the

required standards, and to

prepare for the Joint Commission and other

accreditation surveys.

 Provide organized management tools to identify,

prevent, or eliminate problem areas. Those tools

include identification of systemic issues and

problems to the facility directors.

CONCLUSION

Establish a proactive maintenance program in your

medical treatment facility where everyone is

accountable for maintenance of the facility. Here are

the steps I would follow:

1. Identify critical assets. Direct your deputies to

establish a team to identify critical assets in your

facility. These should include fire chief, safety

officer, facility manager, the electrician who has

been at the facility the longest, and maybe

Facilities Maintenance: Uncovering the “Black Hole”

Figure 2. Examples of potentially serious maintenance problems that can

be easily identified by simply walking throughout a facility, including all

of its mechanical rooms and spaces, and looking for such discrepancies.

A water leak near a high voltage electrical

panel has the potential to cause a deadly

explosion.

A stair tread in need of immediate repair.

The unrepaired tread is a serious trip

hazard on a busy stairwell.

The stain indicates a leaking pipe in the

ceiling. Such leaks can create the

environment for growth of mold and mildew,

some of which can be toxic.

A steam leak in an electrical area could

result in a power outage, along with other

failures and damage.
January – March 2008 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

someone from MEDCOM facilities engineering.

Clinical staff must identify equipment that halts

mission accomplishment if it fails.

2. Monitor metrics. Establish a facilities

maintenance dashboard with trends posted

somewhere in your office. Require that the same

metrics are posted in the maintenance shop and

in the facility manager’s office.

3. Watch for “warning comments” (page 28).

4. Watch for “maintenance fallacies” (page 29).

5. Do unannounced walk-arounds. Seeing is

believing.

6. Request a Facility Assistance and Assessment

Support Team inspection of your facilities from

the MEDCOM Facilities Group.

I have coauthored 2 books which deal directly and in

greater detail with the topics discussed in this article,

Rules of Thumb for Maintenance and Reliability

Engineers2(one chapter of this book is focused strictly

on ranking assets based on risk) and Lean

Maintenance.

3 Both books have lists of metrics which

are used by some of the leading companies in the

world to manage their maintenance.

REFERENCES

1. Department of the Army Supply Bulletin 8-75-11.

Washington, DC: US Dept of the Army; 20

November 2007: chap 8.

2. Smith R, Mobley RK. Rules of Thumb for

Maintenance and Reliability Engineers. Burlington,

Massachusetts; Elsevier: 2008.

3. Smith R, Hawkins B. Lean Maintenance. Burlington,

Massachusetts; Elsevier: 2004.

AUTHOR

At the time this article was written, MAJ Smith was

Director of the Process Improvement Team, Army

Medical Action Plan, Office of The Surgeon General,

Alexandria, Virginia.
32 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

For the past 5 years the Army has been heavily

engaged in operations in support of the Global War on

Terror (GWOT) and has increased efforts to manage

the health, welfare, and readiness of Reserve and

National Guard Soldiers who are injured or become ill

while serving in the line of duty. The Army has

enacted programs to ensure care is available and

provided for GWOT connected illness and injury, as

well as injuries, illness, or disease incurred while in a

nonmobilized active duty status.This article provides a

brief overview of two of these programs, Medical

Retention Processing 2 (MRP2) and Active Duty

Medical Extension (ADME) respectively. The

majority of this information is taken directly from the

Warriors in Transition Consolidated Guidance issued

by the Department of the Army.1

BACKGROUND

The ADME program was established to place Reserve

and National Guard Soldiers on orders to undergo

medical care. This program is available to drilling

Reserve Component Soldiers who have incurred a

non-GWOT related injury. Historically, this program

was managed by Headquarters, Department of the

Army (HQDA) G-1 until October 2006. Applications

were submitted to a medical policy team in G-1, who

reviewed the packet and published the orders. After

October 2006, program management was moved to a

mobilization team. The policy oversight for the ADME

program continues to be maintained at HQDA G-1.

The Soldier submits an application packet through his

or her unit to the mobilization team, located at the

Army Human Resources Command in Alexandria,

Virginia. The mobilization team reviews the packet to

assure all information is complete. They forward the

packet to a 3-person medical review board for

evaluation.

The MRP2 program was established on 17 April, 2006

by the Assistant Secretary of the Army, Manpower and

Reserve Affairs, to provide an opportunity for

demobilized Reserve and National Guard Soldiers who

had been injured in GWOT to be placed on active duty

orders for medical care and treatment. The Soldier’s

application process includes review by a medical

review board.

OVERVIEW

Both the MRP2 and ADME programs are designed to

expeditiously, effectively, and compassionately

evaluate and treat Army Reserve and National Guard

Soldiers who have a line-of-duty incurred illness,

injury, disease, or aggravated preexisting condition. A

military medical authority must find that the Soldier

has an unresolved line-of-duty (service connected)

medical condition, meets program eligibility criteria,

and voluntarily requests participation in either of the

MRP2 or ADME programs. The programs are

designed to provide ongoing, acute, interventional

care to return the Soldier to retention status and back

to duty with his or her respective Army Reserve or

National Guard unit as soon as possible. If return to

duty is not possible, the Soldier will be processed

through the Army Physical Disability Evaluation

System (PDES).

The programs apply to both inpatient and outpatient

treatment.

MEDICAL RETENTION PROCESSING 2

The MRP2 program provides for the temporary return

to active duty of Army Reserve and National Guard

Soldiers previously mobilized in support of GWOT.

Under MRP2, Soldiers may voluntarily return to active

duty specifically for medical evaluation and treatment,

and, if necessary, processing through the PDES for

injury or illness incurred or aggravated during a

previous period of mobilization in support of GWOT.1

To be eligible, the Soldier must submit an application

through his or her current chain of command, and have

documented, unresolved line-of-duty medical issues.

Medical Care for Army Reserve and National

Guard Soldiers in the Global War on Terror

COL Susan Durham, AN, USA

COL Anne Bauer, AN, USA
January – March 2008 33

The Reserve Component Soldier has 6 months from

the date of release from active duty to submit the

application. The Soldier must remain a member of the

Selected Reserves or the Individual Ready Reserve.

For certain circumstances, HQDA G1 is authorized to

grant exceptions to policy.1 A medical review board

will determine the Soldier’s eligibility for MRP2.

The Soldier must be counseled by his or her unit on

the MRP2 program and incapacitation pay before

submitting an application to the program. The Soldier

must also volunteer for recall to active duty for

medical assessment and treatment. Orders are issued

for 179 days and may be renewed, if medically

indicated. A Soldier may decline MRP2 up to the time

of publication of the MRP2 order. If the Soldier wishes

to withdraw the application, he or she must sign a

declination statement. He or she may decline MRP2

without prejudice prior to the publication of orders.

ACTIVE DUTY MEDICAL EXTENSION

The ADME program is designed to place Army

Reserve or National Guard Soldiers on voluntary

temporary active duty for evaluation or treatment of

line-of-duty service-connected medical conditions or

injuries, and return them to duty within their respective

units as soon as possible. If return to duty is not

possible under ADME, the Soldier will be processed

through the Army PDES.1

The medical condition must have been incurred or

aggravated while in an Individual Duty for Training or

nonmobilization active duty status, and the

requirement for medical care must extend beyond 30

days. The medical condition must prevent the Soldier

from performing his or her military specialty duties

within the confines of a physical profile (DA Form

3349) issued by a military medical authority. A

medical review board will determine the Soldier’s

eligibility for ADME.

The Soldier must be counseled by his or her unit on

the ADME program and incapacitation pay before

submitting an application to the program.

APPLICATION PROCESS

The application process is similar for both programs,

and has both administrative and medical channels. The

Soldier’s unit submits application packets via FAX to

the Army Human Resources Command in Alexandria,

Virginia. The packet is reviewed for administrative

eligibility and completeness. If administrative criteria

are met, the packet is sent to the ADME/MRP2

Medical Review Board for medical review and an

eligibility decision. The ADME/MRP2 Medical

Review Board is an electronic board of 3 members

representing the National Guard Bureau, Army

Reserve, and the Office of The Surgeon General/US

Army Medical Command, respectively. All board

members must be licensed providers (physician, nurse

practitioner, or physician’s assistant). One member

must be a physician, and there must be one member

with the rank of colonel.

Each packet is reviewed by the board to determine if

sufficient documentation is included to make a sound

clinical decision to return the Soldier to active duty.

Decisions are made using professional clinical

judgment in accordance with policy guidelines/criteria

set forth in the Warriors in Transition Consolidated

Guidance.1 Two of the board members must

recommend approval before a Soldier is offered

ADME or MRP2 orders.

If a Soldier is not recommended by the board, he or

she may resubmit or appeal the decision.

Resubmission is a request by the Soldier to have the

original packet reviewed again by the board, with the

inclusion of additional clinical documentation and

information. Appeal is a request by the Soldier to have

the original packet reviewed by a higher level

authority. The packet will include all originally

submitted documentation only. It may not include any

additional clinical or medical information.

Key components for medical review are a definitive

treatment plan, which includes diagnosis and

prognosis, and a specific treatment plan which may

include physical therapy, surgery, rehabilitation,

medications, etc. The packet must also include an

approved Statement of Medical Examination and Duty

Status (DA Form 2173). A Soldier whose applications

is already in the medical evaluation board process is

not usually brought into the ADME or MRP2

programs until the board action is complete.

CONCLUSION

The ADME and MRP2 programs continue to evolve

and be refined as the needs of the Soldiers and the

Army emerge. Never before has our military been

faced with the numbers of ill or injured Reserve

Component Soldiers, or the severity and long-term
34 www.cs.amedd.army.mil/references_publications.aspx

consequences of their wounds. Wounds that can be

seen are often more easily addressed and treated.

Nonvisible wounds are a much greater challenge, and

are sometimes not immediately evident. This is the

greatest challenge in treating the Army Reserve and

National Guard Soldiers. With ongoing dedication and

vigilance, the Army will continue to meet the ever

changing and challenging needs of these Soldiers.

Medical Care for Army Reserve and National Guard Soldiers

in the Global War on Terror

REFERENCE

1. Warriors in Transition Consolidated Guidance. Washington, DC: US Dept of the Army; December 2007.

AUTHORS

COL Durham is Deputy Director, ADME/MRP2, Warrior Transition Office, Warrior Care and Transition Directorate,

Office of The Surgeon General, Falls Church, Virginia.

COL Bauer is Deputy Surgeon, Office of the Chief of the Army Reserve (Forward) in Washington DC.
January – March 2008 35

The mission of the Warrior Transition Battalion is to

provide the best possible care to Soldiers as they make

the transition to civilian life or undergo rehabilitation

to return to fit-for-duty status. All Warrior Transition

Battalion patients have medical conditions serious

enough to potentially prevent them from performing

their military duties and therefore inherently require

and deserve the best medical care and oversight the

Army Medical Department has to offer. To do so, the

Commanding General of Brooke Army Medical

Center assembled a medication reconciliation team

tasked with auditing medication risk for all Brooke

Army Medical Center Warriors in Transition.

The medication reconciliation team consisted of 3

physicians, 3 clinical pharmacists, and support staff.

The project took place over a month, during which a

pharmacist and physician performed face to face

medication reconciliation for every Warrior in

Transition, eliminated unnecessary medications and

simplified medication regimens, updated the patient’s

electronic medication record, screened for substance

abuse, educated patients about their medications, and

ensured the primary care manager received a final,

updated medication list. The process is illustrated in

Figure 1. A number of medication discrepancies and

issues were identified, and it became evident that there

was room for implementation of new processes and

programs in order to decrease medication-related risk

and improve patient safety.

MEDICATION RECONCILIATION PROCESS

Over 500 Warriors in Transition (WTs) at the Brooke

Army Medical Center were seen for medication

reconciliation. Each patient brought all prescription

medications, herbals, over the counter medications,

and supplements in his or her possession to the

appointment. Patients were asked about the quality of

their pain control, existence of a sole provider, adverse

drug reactions, prescription medication abuse, alcohol

abuse, illegal “street” drug use, and any knowledge or

participation in trafficking or diversion of prescription

or street drugs. Excess or discontinued medications

were collected and disposed of or returned with

tracking receipts to the pharmacy (Figure 2). Patients

were educated about their medications and each

patient was given a pocket card list of all his or her

current medications to carry and bring to future

appointments. Modifications to the existing treatment

plan were avoided unless absolutely necessary.

Results generated 114 referrals: 4 to the Army

Substance Abuse Program, 17 to primary care

managers to address complaints of uncontrolled pain,

24 to primary care managers for lack of a sole

provider, and 69 to primary care managers for

miscellaneous concerns.

RESULTS

The work of the medication reconciliation team

identified several issues:

 The majority of patients had incorrect medication

profiles in their electronic medical records.

 Many WTs were in possession of medications they

did not need or were no longer taking, to include

controlled substances.

 The process for the return or disposal of excess

medication was unclear to both the patients and

the health care providers.

 Some WTs reported witnessing simultaneous

alcohol and narcotic use.

 There were also reports of pill or “pharm parties”

and medications being used as poker chips.

A number of the WTs also reported witnessing the

The Brooke Army Medical Center Experience

with a Focused Medication Reconciliation

Program

CPT Jesse W. Neeley, MC, USA

Sara J. Pastoor, MD, MHA
36 www.cs.amedd.army.mil/references_publications.aspx

The Brooke Army Medical Center Experience with a Focused

Medication Reconciliation Program

Figure 2. Excess medications returned to the Brooke Army Medical Center

pharmacy as a result of the medication reconciliation team’s actions.

Figure 1. The process of the Brooke Army Medical Center Medication Reconciliation Program.

The Warrior in Transition brings all

medications to the Medication

Reconciliation Clinic and reviews

the medication history in his/her

electronic medical record.

Physician Interview

1. Compliance

2. Substance abuse

3. Pain control

4. Adverse drug reactions

5. Diversion

6. Pain contract/sole prescriber

Management Options

1. Patient Education

2. Referral to Army Substance Abuse program

3. Referral to primary care manager

4. Return of excess medications

5. Notification of chain of command

6. Offer interview with Criminal Investigation Division

7. Change medications

Any questions and/or

r e c o m m e n d a t i o n s

from the pharmacist

Clinical Pharmacist Interview

1. Drug interactions/duplicates

2. Update electronic medical record list

3. Generate pocket card

4. Print updated list for primary care manager

The Warrior in Transition returns

to the primary care manager for

follow up, issue management,

pain contract, etc.
January – March 2008 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

trading, sharing, and selling of controlled prescription

medication as well as illicit drugs within the Warrior

Transition Battalion barracks and lodging facilities.

Multiple Soldiers reported witnessing the use and sale

of cocaine, marijuana, and mushrooms within the

Warrior Transition Battalion barracks. One individual

admitted to personally using street drugs while

assigned to the Warrior Transition Battalion. This

individual described at length the subculture of illicit

drug users in the Warrior Transition Battalion. The

same set of individuals using street drugs was reported

as also using prescription medications and/or alcohol

in combination. Warriors in Transition were offered

the opportunity to discuss what they knew with the

Army Criminal Investigation Division, but all

declined. The Warrior Transition Battalion leadership

was informed of the reports in a general manner, but

no identification of the WTs making the reports was

provided to the chain of command.

This project highlighted a clear medication-related risk

for Brooke Army Medical Center’s Warriors in

Transition, and provided an opportunity to increase

situational awareness for all members of the WTU

triad. The issues ranged in severity from mere process

inefficiency to flagrant health hazards and illegal

activity. Recommendations to improve came from

many sources, including the Warriors themselves, and

involved process improvement, enhanced programs,

and greater focus on the screening and mitigation of

medication-related risk. In response, Brooke Army

Medical Center has implemented an aggressive and

thorough ongoing medication reconciliation program

for all Warriors in Transition. The pharmacy has

developed a user-friendly medication turn-in process.

The sole provider program is receiving heightened

attention and emphasis. The Warrior Transition

Battalion chain of command has taken steps to

increase unit activities intended to fight boredom. New

educational programs are increasing awareness for

both Warrior Transition Battalion patients and staff

regarding medication safety, self and buddy-referral

for help with substance abuse, and unit policies and

guidelines.

AUTHORS

CPT Neeley is the Medication Reconciliation Specialist

in the Warriors in Transition Clinic, Brooke Army

Medical Center, Fort Sam Houston, Texas.

Dr Pastoor is Chief, Department of Family and

Community Medicine, Brooke Army Medical Center,

Fort Sam Houston, Texas.
38 www.cs.amedd.army.mil/references_publications.aspx

BACKGROUND

The Army Medical Action Plan, implemented in June

of 2007, directed broad, sweeping changes to ensure

wounded and injured warriors receive top priority for

care services, housing, and command support. As a

result of these directives, Warrior Transition Units

(WTUs) were established to provide command and

control, primary care, case management, and transition

support services. The formation of WTUs addressed a

void in existing organizational structures and resources

for Warriors in Transition (WTs), those Warriors who

have unique requirements to either prepare them for

return to the fighting force, or assist them in

transitioning to serve in their communities.

The Fort Lewis Garrison and its subordinate Joint

Mobilization Brigade had developed the Reintegration

Action Plan (RAP) program for Fort Lewis Soldiers on

Medical Hold status in January 2007. The program

matched Soldier input regarding future goals with

resources available. In August of 2007, as part of the

Madigan Army Medical Center (MAMC)

implementation of the Army Medical Action Plan, the

Warrior Transition Battalion built directly upon the

success of the RAP program to create a timeline for

the projected care plan, use of available resources, and

meeting the goals of each Warrior. It also made the

process visual and truly multidisciplinary. The

Enhanced Reintegration Action Plan (ERAP) became

the foundation for the establishment of the WTU

structure and the Comprehensive Care Plan* process at

Madigan and Fort Lewis.

Many WTs can ably serve in uniform upon release

from the WTU. However, some can no longer serve as

a Soldier due to their injury or illness. This is

particularly troubling if the Warrior is a National

Guard or Reserve Component Soldier who must return

to their community and reenter civilian life. As a

result, WTUs must look beyond the primary mission

of healing toward facilitating the transition process for

each Warrior. The ERAP is designed to address this

transition period, engaging the Warrior in developing

goals and measures of success for their tenure in the

unit and beyond. It consists of a multidisciplinary

support team: the Warrior, the Warrior’s Family, and

tailored support agencies working in concert to

achieve the established goals. Warrior care plans and

other goals are put on a milestone (eg, Gantt) chart

with input from social work, case managers,

occupational therapy, and other team members. More

than 600 Warriors in Transition have benefited from

this comprehensive approach at MAMC. The

successful implementation of ERAP and its integration

directly into the Army’s Comprehensive Care Plan

concept can serve as the model for other commands

interested in adopting ERAP within their WTUs.

PROGRAM TENETS

The ERAP process seeks to interactively engage the

Warrior in “next steps” planning. It is an

individualized, goal driven, visual, interactive,

digitized process that maps out care plan and life goal

milestones. Designed to accommodate Warriors

suffering from mild traumatic brain injury and post

traumatic stress disorder along with other types of

injury, the process uses common resources such as

white boards and computers to establish, manage, and

facilitate goals set by the Warrior.

The key tenets of the ERAP:

1. Each WT has a multidisciplinary team. The core

stakeholders of the ERAP program are resources

The Enhanced Reintegration Action Plan:

The Madigan Experience

LTC Karl Bolton, MS, USA

1LT Sherri Zimmerman, USA

Ms Ellen Bloom, MSW, LCSW

CPT Michael Hunter, USA

MAJ Kenneth West, USA

LTC Ali Hunt, AN, USAR

MAJ Michael Lawrence, USA

*See related article on page 8
January – March 2008 39

Inprocessing Squad Leader: Introduction

Licensed Clinical Social Worker/Nurse Case Manager: Administer intake

questionnaire

0–1

Assessment Nurse Case Manager, Primary Care Manager: Plan of Care

Multidisciplinary team led by Licensed Clinical Social Worker assess WT*

responses on intake questionnaire. Team identifies goals with projected achievable

dates. Sets date for ERAP goal-setting Scrimmage with unit.

1–7

8–14

ERAP Goalsetting

Scrimmage

 Visualization of goal-setting process using white board medium

 ERAP†Team, WT, and Family set additional goals

 Goals/milestones are placed on a timeline

 Results are placed in digital format for archives/ease of use

30

Follow-up Squad Leader and ERAP team: Follow-up plan execution. Every 30 days

or as needed

Function Responsibility: Activity Days After

Reporting

to WTU

Figure 1. Enhanced Reintegration Action Plan† execution timeline for the Warrior in Transition* after he or she

reports to the Madigan Army Medical Center Warrior Transition Unit.

Figure 2. Example of an Enhanced Reintegration Action Plan Scrimmage storyboard.
40 www.cs.amedd.army.mil/references_publications.aspx

of the existing WTU Table of Distribution and

Allowances,* and include licensed independent

clinical social workers, nurse case managers, the

primary care manager, occupational therapists or

technicians, the squad leader, the WTs themselves,

and their Families. Other stakeholders on the team

include the Soldier and Family Assistance Center

team dedicated to each WTU, nongovernmental

support organizations, physical therapists, and

fitness experts.

2. A single, electronic, intake questionnaire is completed by the WT during arrival processing. This

questionnaire is a compilation of questions from

each discipline which cover all key appraisal

indicators necessary for the ERAP Team to

establish initial care, mental health, career, and life

skills plan/goals for each WT.

3. Visualization of the goal-setting process with

transference to digital medium.

4. A formal work, vocational rehabilitation, and education/training program tailored for each WT

consistent with their care plan.

5. Periodic review of milestone accomplishment.

ERAP EXECUTION

The WT’s involvement with ERAP at MAMC starts

with the arrival processing (inprocessing). As

mentioned above, each WT completes a computerized

intake questionnaire which populates the ERAP

database with basic information on the Warrior, and

develops a “hot sheet” of answers for the social work

section of the unit as a primer for the initial ERAP

scrimmage (goal-setting meeting). The goal-setting

process, roughly 30 days after arrival in the unit,

assists the WT with linking internal and external

resources by bringing the full expertise of the

multidisciplinary team onboard to help guide the

process. Each goal within functional domains is

published on a white board as a milestone. Subsequent

tracking of goal accomplishment is managed by the

whole team with the squad leader serving as the

primary manager of the process. Goal-oriented

management of each WT’s tenure in the unit has

proven to maximize utilization of resources and

provide a template for that Warrior’s key events within

the unit. The nominal ERAP process timeline at

MAMC is illustrated in Figure 1.

Inprocessing

ERAP is embedded in the MAMC WTU’s

inprocessing phase. Upon arrival in the unit, the WT’s

squad leader educates the Warrior on the ERAP

program. The assigned nurse case manager or the

WT’s dedicated licensed clinical social worker

establishes an appointment to complete the intake

questionnaire. Also during inprocessing, the nurse case

manager assigned to the WT and their primary care

manager complete the initial care plan for that

Warrior. The completed questionnaire and care plan

are reviewed by the Warrior’s multidisciplinary ERAP

team. The team establishes a date for the ERAP goalsetting “scrimmage,” a meeting in which the team, the

Warrior (and Family if available), and the squad leader

review goals set by the team and coach the WT to

establish goals of their own.

Goal-Setting Scrimmage Delivers All

Elements

The ERAP scrimmage is the heart of the program. It

produces a visual record and timeline of goals,

synchronized parallel to care plan key events so that

the Warrior will understand all aspects of what to

expect while in the WTU, and how to reach the next

phase of their life.

Shortly after the WT joins the unit, the WT’s care

plan, developed by the nurse case manager and

primary care manager, is coupled with recommended

goals from the rest of the ERAP team based on the

intake questionnaire. The care plan and the suggested

goals are placed on a large wall/white board. The goals

are grouped by domains, such as career, behavioral,

etc. The WT is coached through the process to identify

their personal goals, with the ERAP team’s input.

These goals are then put on a large, digitized white

board across a timeline, in a “storyboard” fashion (see

Figure 2), with participation of the entire ERAP team,

the WT, and the Family. The visual display of goals

across the domains with associated milestones

reinforces the methodology and garners WT

acceptance of their own transition plan. Digitizing the

results of the goal-setting meeting allows rapid reset of

the goals and milestones for periodic review, as well as

*Prescribes the organizational structure, personnel and

equipment authorizations, and requirements of a military unit

to perform a specific mission for which there is no appropriate

table of organization and equipment.

The Enhanced Reintegration Action Plan: The Madigan Experience
January – March 2008 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

facilitating the update of changes to the plan as they

occur.

The process has proven to be successful at

reenergizing even those Warriors who have extended

lengths of stay in the MAMC WTU. One Warrior had

spent more than 14 months in the Fort Lewis Medical

HoldOver company and then the Warrior Transition

Battalion before he was introduced to the ERAP

scrimmage process. At the end of the session he stated,

“For the first time since being in the unit I can call my

wife and tell her when to expect me back home.”

The process accommodates both those Warriors

expected to return to duty (RTD) as well as those who

will not be able to continue service in uniform (see

Figure 3). For those who will RTD, ERAP establishes

a plan to ensure military occupational specialty skills

are retrained and sustained. Towards the end of the

Warrior’s expected stay in the MAMC WTU, Army

Warrior Tasks, weapons qualifications, and a

diagnostic physical fitness test can be administered.

The WTU’s goal is to return each Warrior to the force

in the highest condition of deployable readiness as

possible. For those who cannot continue to serve in

Figure 3. Career analysis flow chart reflecting the fit for duty determination and subsequent career

decision process for each Soldier’s progress through the Warrior Transition Unit.

Glossary

FFD—Fit for duty MOA—Memorandum of agreement (work programs)

MOS—Military occupational specialty ACES—Army Continuing Education System
42 www.cs.amedd.army.mil/references_publications.aspx

The Enhanced Reintegration Action Plan: The Madigan Experience

E

R

A

P

Pro

c

e

s

s

e

s

Lines of Effort Tier 1 Difficulty

Tier 2

Difficulty

Tier 3

Difficulty

Maximize ERAP Utilization

Percentage of WTs with ERAP-SNumber of ERAP-S per week

Number of remote WTs with ERAP resources Number of remotes with ERAP plan

Number of ERAP-S involving Families Percentage applications for VBA

Streamline ERAP processes

Average time/Scrim

mage Number of timelines digitized

ERAP-S within 30 days of inprocessing

Pro

vide meaningful w

ork

opportunities

Reduction of clinic no-shows Number of WTs filling FLW BM

M slots Percentage of MOSs which match to work

Number of WTs with MOA or ACES

W

arrior O

utc

o

m

e

s

Pro

m

ote personal and professional

gro

wth

Number of WTs enrolled in ACES WT GPA improvement Number of WTs with certificationsPW satisfaction survey scores

Pro

vide transition safety net

Number of ERAP referrals to SFAC Number of non-RTD WTs with job interviews Number of WTs with job offers

Number with first VA appointment scheduled

while in WTU

Impro

ve Warrior health and fitness

Length of stay in unit Reduction in WCC utilization rate Reduced suicidal eventsPW self-score on improved health

Support the Global War on Terror

Percentage RTD in current or new

MOS

Number & percentage of WTs returned to

parent unit

Number returned to duty with basic AWT

skills

Number RTD in current MOS

Support or impro

ve unit METL Care/support/transition tasks “P” Care/support/transition tasks “T”

Impro

ve Family

well-being Number of ERAP-S with Family referrals Reduced rate of domestic violence

Figure

4. An e

xam

ple

of the Enhance

d

R

eintegration Action Plan Lines of Effort m

etrics m

o

d

el.

Glossary

ACES — Army Continuing Education System

MOA —

memorandum of agreement (work programs)

AWT — Army Warrior training MOS —

military occupational specialty

BM

M

— borrowed military manpower RTD — return to duty

ERAP — Enhanced reintegration action plan SFAC — Soldier and Family assistance centerERAP-S — ERAP goal-setting scrim

mage VA — US Department of Veterans Affairs

FLW

— Fort Lewis, Washington VBA — Veterans Benefits Administration

GPA — grade point average WCC —

Warrior care clinic

METL —

mission essential task list WT —

Warrior in Transition
January – March 2008 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

uniform, ERAP tailors support services, introduces

Army Continuing Education System resources,

initiates Department of Veterans Affairs enrollment

and benefits processing, and presents other Army and

civilian transitioning programs. The milestone

timeline/storyboarding approach allows Warriors to

visualize when each major task should occur, and

prepares them with a plan of action.

ERAP METRICS: TRACKING PROGRAM

PERFORMANCE AND EFFECTIVENESS

Like other initiatives, it is important to gauge the

ERAP program’s performance and effectiveness.

Using a line-of-effort (LOE) model, critical tasks of

the ERAP program can be tracked. Each LOE has

specific metrics, segmented into Measures of

Performance and Measures of Effectiveness. Measures

of Performance assess the implementation of ERAP

processes, while Measures of Effectiveness address

Warrior outcomes.

The LOEs of Measures of Performance include:

 Maximize ERAP utilization

 Streamline ERAP processes

 Provide meaningful work opportunities

Metrics within these LOEs could include tracking the

number of scrimmages executed, the percentage of

Warriors with an ERAP plan in place, and similar

statistical measures.

The LOEs of Measures of Effectiveness include:

 Promote personal and professional growth

 Provide transition safety net

 Improve Warrior health and fitness

 Support the Global War on Terror

 Sustain or improve the WTU mission essential

task list

 Improve Family well-being

Metrics within these LOEs could include, for example,

the Warrior’s self-assessment of health status since

enrollment in the program, the number of Warriors

enrolled in the Army Continuing Education System

who have had improvement in grade point average,

Figure 5. An example of the organization and information access screens available in the database which

was developed to create a full record of each Soldier’s involvement and progress in the Enhanced

Reintegration Action Plan.
44 www.cs.amedd.army.mil/references_publications.aspx

and the percentage of Warriors who are returned to

their originating unit. Figure 4 illustrates the ERAP

LOE approach to tracking and evaluating a program’s

effectiveness.

ERAP EVOLUTION: THE WAY AHEAD

The complexity and comprehensiveness of ERAP

dictate that technology enablers sustain an effective

program. While many project management software

programs can emulate the timeline aspect of the goalsetting scrimmage, those programs are often not user

friendly and can be cumbersome to maintain. They

also do not provide effective assistance in tracking

metrics. As a result, a relational database was

developed locally at the Madigan Army Medical

Center to present milestones in useful timelines, and

create a full record of each Warrior’s ERAP

involvement. The database allows quick entry of

Warrior demographics and each established goal or

milestone, and tracks execution of each milestone. An

example of the database pages is shown in Figure 5.

Data mining allows extraction of overall program

measurement data which can be sorted by various

demographics to identify gaps in execution of the

ERAP.

Many Warriors are assigned to WTUs which are not

physically located at their respective installations. This

presents a problem: how do WTUs remotely provide

transition services to Warriors? The future could

involve the use of telehealth technologies, with each

Warrior using a donated laptop and a suite of software

and peripherals to allow remote execution of the

multidisciplinary team’s ERAP goal-setting

scrimmage. The remote execution of ERAP ensures

that all assigned Warriors in Transition have access to

the same benefits as those on the installation. It will

also facilitate, in a more meaningful way, the

interaction of the Warrior, the Family, the assigned

case manager, squad leader, and primary care

manager.

CONCLUSION

The experience of the Madigan Army Medical Center

WTU validates the Enhanced Reintegration Action

Plan as a comprehensive approach to maximize each

WT’s tenure in the WTU. The program formalizes

execution of the entire WTU mission essential task

list. MAMC’s experience is repeatable across WTUs

in the Army Medical Command using the existing

WTU/Warrior Transition Battalion and Soldier and

Family Assistance Center structures, laptops, and

regular white boards or a blank wall. The

multidisciplinary team creation of a unique ERAP plan

for each WT should be embedded in unit standard

operating procedures. As a result, productivity will be

increased for the entire ERAP team because its role in

the WTU is clearly defined, and the use of a single,

combined intake questionnaire reduces duplication of

efforts within the ERAP team. ERAP provides a

clearly understood and sustainable program for

integrating internal and external resources and

agencies to support Warriors and their Families. ERAP

participants at the MAMC WTU have strongly

recommended that this program be required for all

Warriors in Transition—it has empowered each

Warrior to take charge of his or her own transition

plan, and has provided the assistance they need to

serve in a greater, more rewarding capacity upon their

return to service, or release into civilian life.

AUTHORS

LTC Bolton is Commander, Warrior Transition

Battalion, Madigan Army Medical Center, Fort Lewis,

Washington.

1LT Zimmerman, an Adjutant General Corps officer, is

Commander, Bravo Company, Warrior Transition

Battalion, Madigan Army Medical Center, Fort Lewis,

Washington.

Ms Bloom is Chief, Warrior Transition Battalion Social

Work Clinic, Madigan Army Medical Center, Fort

Lewis, Washington.

CPT Hunter, an Armor officer, is Assistant Operations

Officer, Warrior Transition Battalion, Madigan Army

Medical Center, Fort Lewis, Washington.

MAJ West, a Finance officer, is ERAP Program

Manager, Warrior Transition Battalion, Madigan Army

Medical Center, Fort Lewis, Washington.

LTC Hunt is Chief, Clinical Operations, Warrior

Transition Battalion, Madigan Army Medical Center,

Fort Lewis, Washington, and Senior Case Manager for

the Western Regional Medical Command.

MAJ Lawrence, an Intelligence officer, is Executive

Officer, Warrior Transition Battalion, Madigan Army

Medical Center, Fort Lewis, Washington.

The Enhanced Reintegration Action Plan: The Madigan Experience
January – March 2008 45

Chronic Pain is a disease state that is just now being

recognized as a significant independent clinical entity.

Unmitigated chronic pain can be as destructive as any

chronic medical condition. Pain is not a monolithic

entity such as a fracture or deficiency of some

essential nutrient. Pain is, rather, a concept used to

focus and label a group of sensations, thoughts,

emotions, and behaviors. Since there are many facets

to pain, it should be obvious that no single treatment is

available in the majority of cases.

Our experience with Soldiers involved in our current

conflict is consistent with injuries that have been

reported since the 16th century. The French military

surgeon Ambrose Pare first described phantom limb

pain, phantom sensations, and stump pain, all of which

we regularly see today.1 The American civil war

surgeon, S. Weir Mitchel, who coined the term

“causalgia,” stated:

Perhaps few persons who are not physicians can realize

the influence which long-continued and unendurable

pain may have on both body and mind.... Under such

torments the temper changes, the most amiable grow

irritable, the bravest Soldier becomes a coward, and the

strongest man is scarcely less nervous than the most

hysterical girl. Nothing can better illustrate the extent to

which these statements may be true than the cases of

burning pain, or, as I prefer to term it, Causalgia, the

most terrible of all tortures which a nerve wound may

inflict.2

Dr Mitchel poignantly illustrated the physical and

emotional toll that is extracted by chronic, unremitting

pain. Surprisingly however, the most common causes

of chronic pain during our recent and current military

conflicts are still ordinary conditions, such as accidents

and musculoskeletal complaints, with low back pain

accounting for over 50% of presenting pain complaints

in Soldiers from Operations Iraqi Freedom and

Enduring Freedom.3-7 Consequently our patient

population is composed of polytrauma patients as well

as patients that are typically seen in civilian practice,

where 17% of patients in an average primary care

practice present with chronic pain complaints.8

Pain theory has evolved over time from Descartes’

proposed theory in 1634, to the gate control theory of

Melzak and Wall in 1964, to our current understanding

of pain. Descartes’ theory stated that pain is

transmitted through a single channel from the skin to

the brain. This theory has directed the study and

treatment of pain for 330 years and unfortunately is

still described in some physiology and neuroscience

textbooks as fact rather than theory. It is also the

predominate pain paradigm of patients. Melzak and

Wall’s description of the gate control theory9

rejuvenated pain study and has led to our current

understanding of the complex neural-humeral processing that take place at 3 distinct locations as an

impulse travels from its origin to the brain. At each

level—the periphery, the spinal cord, and the supraspinal levels (brainstem and cortex)—the pain impulse

can be augmented or diminished.10 Therefore, effective

treatment must act at one or more of these levels.

The supra-spinal level is the most complex and least

understood region. In spite of this, any program or

treatment course must take into account the complex

subjective dimensions of pain that originate in the

brain, described as the

 sensory-discriminative (where and what the pain

“feels like”),

 affective-motivational (how the pain makes you

feel/what that feeling makes you do), and

 cognitive-evaluative dimensions (what do you

believe is the etiology of your pain).11

Offering Hope for our Wounded Warriors: An

Overview of the Womack Army Medical

Center Pain Medicine Clinic

MAJ Thomas Weber, MC, USA

MAJ Anthony Dragovich, MC, USA
46 www.cs.amedd.army.mil/references_publications.aspx

The emotional/cognitive aspects of pain must be

recognized and treated appropriately for all patients

with chronic pain, but it is even more paramount in our

patient population, many of whom also have post

traumatic stress disorder (PTSD) and/or traumatic

brain injury (TBI).12 It is well recognized that patients

with TBI and PTSD have heightened experiences of

pain, impaired coping mechanisms caused by

catastrophic interpretations of pain, elevated anxiety

levels, and diminished attentional control which

impairs the use of cognitive-behavioral therapies.13-16

Womack Army Medical Center (WAMC) recognized

the need for excellent pain treatment for our Soldiers

and now boasts a state of the art interventional pain

clinic that closely collaborates with world renowned

pain medicine physicians at the Johns Hopkins School

of Medicine in order to provide all of our Soldiers with

the best possible medical care. Many Soldiers with

acute or subacute pain conditions are treated. The vast

majority of patients who receive treatment remain on

active duty. This is indeed a testament to the quality

and character of our Soldiers. The remainder of this

article, however, will focus on the complex patient

with chronic pain due to difficult-to-treat conditions.

In response to this complexity, the WAMC Warrior

Transition Battalion (WTB) has been instrumental in

coordinating the care for these wounded warriors.

Given the enormous breadth of pain etiologies, ranging

from polytrauma to more mundane but still potentially

debilitating conditions such as low back pain, it is not

surprising that simple algorithmic approaches to

treatment are not successful. Some conservative

chronic pain treatments have good evidence of

efficacy, such as cognitive-behavioral therapy, aerobic

exercise, spinal manipulation, and interdisciplinary

rehabilitation.17 Often these treatments must be

combined in a cohesive program with interventional

and/or medical treatments to achieve optimal

success.18,19 The WTB is the structural center of our

multidisciplinary approach.

The pain medicine clinic provides interventional and

medical treatments to patients who are already

involved in other multidisciplinary pain treatment/

rehabilitation programs, as well as recommendations

for multidisciplinary treatment regimens. Early

identification and treatment of pain are known to

reduce the incidence and severity of chronic pain and

therefore conserve healthcare resources.20 Early,

effective intervention is key to successful long-term

outcomes. We are working to become even more

effective as we initiate our pain surveillance program

which is reviewed later in this article.

Successful pain treatment, even if short term, improves

affective dimensions of pain and improves the efficacy

of all other treatment modalities. The most stunning

success was a Soldier with complex regional pain

syndrome (ie, Dr Mitchel’s causalgia2) who was

treated with a spinal cord stimulator (SCS) implantation . There is good evidence for the efficacy of this

treatment for complex regional pain syndrome,21-23 as

well as a recent trial of 10 consecutive Marine Corps

and Navy personnel who obtained greater than 80%

pain relief with SCS implantation.24

The Soldier had failed conservative therapy and

common interventional techniques. His pain was

debilitating with marked effects on mood, sleep, and

basic daily function, however, he greatly desired to

continue on active duty and remain deployable. He had

a successful trial and the device was implanted. To

date, he is now the only Soldier known to be deployed

with a SCS. Overall, he reports very few limitations

and his activities include push-ups, sit-ups, running,

weight lifting, scuba diving, hiking, backpacking,

ruck-marching, and combat operations. He has also

made modifications to his clothing and equipment to

accommodate the SCS programmer so he can change

modes as needed. This Soldier represents the optimal

outcome for our wounded Warriors with chronic pain

from polytrauma.

Unfortunately, the Soldier discussed above does not

represent a typical outcome. Currently, the WTB has

over 400 Soldiers, 25% of whom are seen in the pain

medicine clinic. This proportion is consistent with

reported VA statistics that 47% of Veterans reported at

least mild pain, and 28% reported pain severe enough

to be associated with functional interference.7 Many of

these patients have conditions that are only well

treated acutely with opioids. However, since there is

no evidence that long-term opioid therapy is an

effective pain treatment strategy, every effort is made

to develop a plan to limit the use of opioids in the

patient’s future treatment. Common interventional

techniques, such as epidural steroid injections and

radiofrequency nerve ablations, as well as tricyclic

antidepressants and anticonvulsants have been used as

part of a comprehensive treatment plan in many

Offering Hope for our Wounded Warriors: An Overview of the

Womack Army Medical Center Pain Medicine Clinic
January – March 2008 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

patients. Effective, early nonopioid pain treatment is

absolutely critical to avoid the development of harmful

affective-motivational and cognitive-evaluative

dimensions of pain, eg, depression and catastrophizing

ideations.

The predominate reason to limit chronic opioid use is a

basic risk/benefit analysis. Opioids have not been

shown to provide clinically significant long-term

(more than 3 months) pain relief in the published

literature. Anecdotally, once patients pass through the

acute pain stage of tissue damage (ie, muscle, bone,

tendon/ligament) weaning from opioids may not result

in an increase in pain. There is a marked increase in

affective symptoms (anxiety, stress, catastrophizing)

when opioid withdrawal is contemplated. Many

Soldiers have experienced terrible pain. Some have

PTSD and/or TBI associated with their pain

symptoms. No Soldier ever wishes to experience that

level of pain again. Opioids are commonly the

medication that initially alleviated the pain and the

Soldier believes that they are the reason the pain has

not returned. A great deal of trust is required for

Soldiers to agree to wean from the medication that

they believe is the reason that they are no longer in

excruciating pain.

The risks of long-term (more than 2 years) opioid

therapy are much clearer. The risk of physical

dependence is 100%. Chronic constipation is common,

as is sedation, nausea, pruritis, and urinary retention,

but these tend to wane with time. The 2 most

concerning complications of opioid therapy in Soldiers

are abuse/addiction and hypogonadotroichypogonadism.

The risk of abuse/addiction is reported from 10% to

18.9% in the literature.25,26 The rate in our Soldiers is

likely near the upper end of the range given that males

and younger adults are more likely to develop opioid

abuse/dependence.27

Long-term (more than 2 years) opioid therapy is

clearly associated with hypogonadotropichypogonadism. This results in depression of anabolic

hormones to include growth hormone, testosterone,

and dihydoepiandosterone. In unpublished data, 12

Soldiers had free and total testosterone levels drawn.

All 12 Soldiers were on over 30 mg of morphine or

equivalent per day and were found to have low free

testosterone levels. This finding is consistent with the

reported literature.28 Hypogonadism results in

depression, lethargy, irritability, impaired wound

healing, immunosuppresion, osteoporosis, decreased

libido, and impotence. All of these symptoms are

concerning, especially in young Soldiers with

concomitant PTSD or TBI. Opioid therapy and, more

directly, side-effects of opioid therapy exacerbate

PTSD and TBI. We strongly recommend screening all

patients with any of these symptoms who are on opioid

therapy for evidence of hypogonadism.

The appropriate use of opioids for patients with

chronic pain is an enormously difficult, complex

clinical decision. On one hand, you have a Soldier who

has been through a traumatic experience and has clear

reasons to potentially still have pain responsive to

opioids and a psychological affinity for the

medication. On the other hand, you have a medication

that will clearly be harmful to many patients over the

long-term.

Our policy is to have all patients sign an opioid

consent statement and opioid conduct agreement prior

to the initiation of opioid therapy. The consent

statement informs the patient of the known risks of the

medication. The conduct agreement defines the

“ground rules” for continued opioid management.

Soldiers are required to bring their medication bottles

to every appointment for random pill counts. They are

also subject to random urine toxicology screening. All

Soldiers are counseled that periodic “opioid holidays”

may be required to determine if opioids are still

effective pain therapy. If the Soldier does not

experience an increase in pain off opioids, they are not

reinitiated.

It is clearly evident that pain treatment is a complex,

resource-intensive endeavor without clear empiric

evidence to serve as a guide. A key first step in

treatment is identifying individuals who are

experiencing pain or who are at risk of developing a

pain condition. All WTB patients referred to the pain

medicine clinic will complete screening tools

consistent with the recommendations of the

IMMPACT consensus conference.29 Four chronic pain

domains will be evaluated:

 Pain intensity—McGill pain questionnaire

 Physical functioning—brief pain inventory and

Epworth sleepiness scales
48 www.cs.amedd.army.mil/references_publications.aspx

 Emotional functioning—Beck depression

inventory

 Patients rating of overall improvement—patient

global impression of change scale

These evaluations will be completed on the initial

encounter and then every 6 months subsequently. This

data will be used to tailor the patient’s treatment and

ensure that they receive the level of care required.

Multidisciplinary care will provided at WAMC on an

outpatient basis. Select patients who require inpatient

comprehensive pain rehabilitation are referred as

appropriate. A central focus is pain control with

selective use of opioids as modeled after the

procedures used at the James A. Haley Veterans’

Hospital in Tampa, Florida.

Since resources are limited, we have outlined 3 key

components that will most effectively leverage our

current capital. First, we will improve primary care

provider knowledge through our lecture series in an

effort to push effective pain techniques to the front

lines. Second, in cooperation with Walter Reed Army

Medical Center and Johns Hopkins University School

of Medicine, we have initiated cutting edge research

protocols that have the potential to redefine how some

pain conditions are treated. Finally, every effort is

made to provide excellent, nonopioid analgesia with

peripheral nerve catheters for all Soldiers who are

amenable to the technique. Peripheral nerve catheters

have proven to be an excellent method of analgesia

with the enormous benefit of avoidance of opioid

tolerance, dependence, and side effects. These are

resource intensive efforts, currently in their infancy at

WAMC, which have the potential to mitigate longterm disability due to chronic pain. The results will be

decreased health care utilization, decreased health care

cost, and, most importantly, improved patient quality

of life and function.

Over the next several years, the Army Medical

Department will be experiencing the daunting

challenge of taking care of our wounded warriors.

Early and effective pain treatment is of paramount

importance. Early intervention will decrease the longterm risk of disability in this patient population and

will also allow our Soldiers to return quickly to the

fight. It is essential that a multidisciplinary approach is

used that takes into account the physical and mental

aspects of each Soldier’s care. Our Soldiers are giving

their best to protect and defend this great nation of

ours. We owe them our best.

REFERENCES

1. Pare A, Johnson T. The apologie and treatise of

Ambroise Pare containing the voyages made into

divers places with many of his writings upon surgery.

London: Cotes and Young; 1634.

2. Mitchell S. On the diseases of nerves, resulting from

injuries. In: Flint A, ed. Contributions Relating to the

Causation and Prevention of Disease, and to Camp

Disease. New York: US Sanitary Commission

Memoirs; 1867.

3. White R, Cohen S. Diagnosis, treatment, and returnto-duty rates in soldiers treated in a forward deployed

pain management center. Anesthesiology.

2007;107:1003-1008.

4. Hoeffler D, Melton L. Changes in the distribution of

Navy and Marine Corp Causalties from World War I

through the Vietnam conflict. Mil Med.

1981;146:776-779.

5. Writer J, DeFraites R, Keep L. Non-battle injury

casualties during the Persian Gulf War and other

deployments. Am J Prev Med. 2000;18:64-70.

6. Cohen S, Griffith S, Villena F. Presentation,

diagnoses, mechanisms of injury, and treatment in

soldiers injured in Operation Iraqi Freedom: an

epidemiological study conducted at two military pain

management centers. Anesth Analg. 2005;101:1098-

1103.

7. Gironda R, Clark M, Massengale A, Walker R. Pain

among veterans of Operation Enduring Freedom and

Iraqi Freedom. Pain Med. 2006;7:339-343.

8. Gureje O. Persistent pain and well-being: a World

Health Organization study in primary care. JAMA.

1998;280:147-151.

9. Melzack R, Wall P. Pain mechanisms: a new theory.

Science. 1965;150:971-979.

10. De Leo J. Basic science of pain. J Bone Joint Surg

Am. 2006;88(suppl 2):58-62.

11. Melzack R, Katz J. The gate control theory: reaching

for the brain. In: Hadjistavropoulos T, Craig KD, eds.

Pain: Psychological Perspectives. New York:

Lawrence Erlbaum; 2004:13-34.

12. Bryant R, Marosszeky J, Crooks J, Baguley I, Gurka

J. Interaction of posttraumatic stress disorder and

chronic pain following traumatic brain injury. J Head

Trauma Rehabil. 1999;14:588-594.

Offering Hope for our Wounded Warriors: An Overview of the

Womack Army Medical Center Pain Medicine Clinic
January – March 2008 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

13. Drottning M, Staff P, Levin L. Acute emotional

responses to common whiplash predicts subsequent

pain complaints. A prospective study of 107 subjects

sustaining whiplash injury. Nordic J Psychiatry.

1995;49:293-299.

14. Smith T, Aberger E, Follick M. Cognitive distortion

and disability in chronic low back pain. J Consult

Clin Psychol. 1986;54:573-575.

15. Difede J, Jaffe A, Musngi G. Determinants of pain

expression in hospitalized burn patients. Pain.

1997;72:245-251.

16. Bryant R, Harvey A. Processing threatening

information in post-traumatic stress disorder. J

Abnorm Psychol. 1995;104:537-541.

17. Chou R, Huffman L. Nonpharmacologic therapies for

acute and chronic low back pain: A review of the

evidence for an American pain society/American

College of Physicians clinical practice guideline. Ann

Intern Med. 2007;147:492-504.

18. Fairbank J, Frost H, Wilson-MacDonald J, Yu L,

Barker K, Collins R. Randomised controlled trial to

compare surgical stabilisation of the lumbar spine

with an intensive rehabilitation programme for

patients with chronic low back pain: the MRC spine

stabilisation trial. BMJ. 2005;330(7502):1233-1238.

19. Brox JI, Sorensen R, Friis A, et al. Randomized

clinical trial of lumbar instrumented fusion and

cognitive intervention and exercises in patients with

chronic low back pain and disc degeneration. Spine.

2003;28(17):1913-1921.

20. Turk D. Clinical effectiveness and cost-effectiveness

of treatments for patients with chronic pain. Clin J

Pain. 2002;18:355-365.

21. Kemler MA, de Vet H, Barendse GA, van den

Wildenberg F, van Kleef M. Spinal cord stimulation

for chronic reflex sympathetic dystrophy-five-year

follow-up. N Engl J Med. 2006;354:2394-2396.

22. Kemler MA, Barendse GA, van Kleef M, et al. Spinal

cord simulation in patients with chronic reflex

sympathetic dystropy. N Engl J Med. 2000;343:618-

624.

23. Grabow TS, Tella PK, Srinivasa N. Raja M. Spinal

cord stimulation for complex regional pain syndrome:

an evidence-based medicine review of the literature.

Clin J Pain. 2003;19:371-383.

24. Verdolin M, Stedje-Larsen E, Hickey A. Ten

consecutive cases of complex regional pain syndrome

of less than 12 months duration in active duty United

States Military Personnel treated with spinal cord

stimulation. Anesth Analg. 2007;104:1557-1560.

25. Fishbain D, Rosomoff H, Rosomoff R. Drug abuse,

dependence, and addiction in chronic pain patients.

Clin J Pain. 1992; 8:77-85.

26. Portenoy R, Foley K. Chronic use of opioid

analgesics in non-malignant pain: report of 38 cases.

Pain. 1986;25:171-86.

27. Edlund M, Steffick D, Hudson T, Harris K, Sullivan

M. Risk factors for clinically recognized opioid abuse

and dependence among veterans using opioids for

chronic non-cancer pain. Pain. 2007;129:355-362.

28. Daniell H. Hypogonadism in men consuming

sustained-action oral opioids. J Pain. 2002;3:377-

384.

29. Dworkin R, Turk D, Wyrwich K, Beaton D.

Interpreting the clinical importance of treatment

outcomes in chronic pain clinical trials: IMMPACT

recommendations. J Pain. In press.

AUTHORS

MAJ Weber is Chief, Anesthesiology Service,

Department of Surgery, Womack Army Medical

Center, Fort Bragg, North Carolina.

MAJ Dragovich is Medical Director of the Pain

Medicine Clinic, Department of Surgery, Womack

Army Medical Center, Fort Bragg, North Carolina.
50 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

The ability of modern medicine to effect a “cure” for

severely brain-injured patients is limited. The initial

impact or insult represents the primary injury and

intervention for this injury is purely preventive.

Secondary injury represents the deleterious cascade of

events which occur after the initial insult, some

portions of which can be mitigated by intervention.

The most important goal of treating brain-injured

patients is avoidance of secondary injury. Multiple

strategies to minimize secondary insult include

maintaining oxygenation, and maintaining a normal

blood pressure and attendant cerebral perfusion

pressure. Maintenance of blood flow and associated

delivery of oxygen and nutrients helps keep tissue

viable and is one way to avoid secondary injury.1

Prehospital hypotension (systolic blood pressure less

than 90 mm Hg) and low oxyhemaglobin saturation

(below 90%) have been documented as risk factors for

death and poor outcome in brain-injured patients

transported to civilian trauma centers.2,3 The avoidance

of hypotension in the brain-injured is of particular

significance to military medics as the use of

“hypotensive resuscitation” in penetrating injury must

be abandoned in the brain-injured patient. The skull is

typically a fixed volume structure. Increased

intracranial pressure (ICP) results in decreased

cerebral blood flow and may result in brain tissue

ischemia and necrosis. One method to rapidly decrease

ICP commonly employed in the past was

hyperventilation. Hyperventilation has been found to

be detrimental to the brain-injured patient in all but the

most dire situations (eg, brain herniation).4It is now

established that cerebral vasoconstriction due to

profound hypocarbia (low carbon dioxide blood levels)

from hyperventilation results in deleterious brain tissue

hypoxia and may increase mediators of secondary

brain injury.5-7

Hyperventilation and extreme hypocarbia are

especially worrisome as most medics and many

transfer personnel do not have a means to monitor

carbon dioxide levels, making hyperventilation in the

brain-injured potentially a “silent iatrogenic killer.”

OXYGENATION

Oxygenation is the delivery of oxygen to the lungs and

is not effected by ventilation except at very low rates

of gas exchange. Oxygenation is related to the amount

of oxygen delivered in the inspired gas to the alveoli.

Atmospheric air is 21% oxygen. The brain-injured

patient often requires an increase in the inspired

oxygen content (FiO2) to have adequate saturation of

the arterial hemoglobin (SaO2). An increase in oxygen

concentration can be obtained with bottled oxygen, a

fire hazard as oxygen is a fire accelerant. The other

option for increasing the FiO2 is an oxygen

concentrator to concentrate the oxygen in inspired gas.

Adequate oxygenation is important in avoiding

ischemia (lack of adequate oxygen) of the injured

brain.

While the majority of combat wounded will not benefit

from supplemental oxygenation, the subset of the

severely head injured may benefit from it.5-8

HYPERVENTILATION AND HYPOVENTILATION

Ventilation is the process by which gases are moved

into and out of the lungs which, among other things,

results in carbon dioxide (CO2) gas exchange.

Ventilation is separate from oxygenation. The amount

The “Silent Killer”: Hyperventilation in the

Brain Injured

LTC(P) Lorne H. Blackbourne, MC, USA

MAJ John Cole, MC, USA

MAJ Robert Mabry, MC, USA

MAJ Andrew Morgan, MC, USA

LTC Paul Barras, AN, USA

COL Brian Eastridge, MC, USA

COL John B. Holcomb, MC, USA
January – March 2008 51

of gas passed through the lungs by bag valve mask or a

ventilator results in a loss of CO2 directly correlated

with the rate of ventilation. The amount of CO2 is then

reflected in the amount of CO2 present in the arterial

blood, known as PaCO2 (normal PaCO2 is 35 to 45

mm Hg). If ventilation is increased, the PaCO2 will

fall. If ventilation is slowed, the PaCO2 will rise. A

low PaCO2 is termed hypocarbia, and an elevated

PaCO2 is termed hypercarbia.

CO2 AND THE BRAIN

The cerebral arteries are very sensitive to levels of CO2

in the blood stream. The response of cerebral arteries

to increasing levels of PaCO2 in the blood is

vasodilation. This results in a larger cerebral blood

volume and (due to the fixed space of the skull) results

in an increase in ICP (known as the Monroe-Kellie

hypothesis). The response to lower levels of PaCO2 is

opposite. A reduction in PaCO2 causes cerebral arterial

vasoconstriction resulting in lower brain blood volume

and lower intracranial pressure. However this occurs at

the theoretical expense of blood flow (with oxygen and

nutrients) to the areas of injured brain. The response of

cerebral arteries to different levels of CO2 in the

bloodstream may even be exaggerated in ischemic,

injured cerebral vessels.9-12 The early post-injury

period is especially significant as cerebral blood flow

during the first day after injury is markedly reduced

and is often less than half that of normal

individuals.13,14 This results in a potentially increased

susceptibility to secondary insult.

METHODS FOR MONITORING BLOOD CO2

LEVELS

There are no clinical signs to help determine blood

levels of CO2. The “gold standard” for PaCO2 is an

arterial blood gas evaluation.15 The next best method is

a venous blood gas. Although this method is less

accurate, it will help in ruling out the extremes of

PaCO2 levels.16 The best noninvasive method to

determine the PaCO2 is end-tidal PaCO2, also known

as capnometry. End-tidal PaCO2 monitors measure the

CO2 level of exhaled gases and usually give a value

slightly lower value than the arterial PaCO2 due to

mixing with dead space air.17 End-tidal PaCO2

monitoring is most accurate in intubated and ventilated

patients. However, the utility of this monitoring

modality is limited to the avoidance of extremely low

or high PaCO2 levels.18,19 Specifically, end-tidal CO2

determinations have been documented to be of benefit

in avoiding hyperventilation in ventilated head injured

patients.15,20 Additionally, patients have also been

successfully monitored with end-tidal PaCO2 monitors

in the nonintubated state.21 End-tidal CO2 monitors

have the added benefit of helping to determine if

inadvertent esophageal intubation has occurred.22-24

BRAIN HERNIATION

The only clinical indication for iatrogenic

hyperventilation with the goal of hypocarbia is

cerebral herniation. Herniation occurs when the brain

is forced out of the skull through the foramen magnum

or assumes an abnormal intracranial position

secondary to severe elevation in intracranial pressure

(eg, transtentorial uncal herniation). The signs of brain

herniation include flexor or extensor posturing and/or

asymmetric or nonreactive (blown) pupil. The Brain

Injury Foundation guidelines recommend doubling the

prehospital normal ventilation rate (20 breaths/minute

in adults) in patients with clinical signs of brain

herniation to achieve iatrogenic hyperventilation and

attendant hypocarbia.25

CIVILIAN PARAMEDIC AND TRANSPORT OF

BRAIN-INJURED DATA

Prehospital hypotension and hypoxia in the braininjured patients are established risk factors for

increased mortality and poor outcomes. Additionally,

hyperventilation and hypocarbia are recognized as a

preventable cause of iatrogenic secondary brain injury.

The use of orotracheal intubation without end-tidal

PaCO2 monitoring prehospital by US civilian

paramedics has been associated with an increase in

mortality and deleterious effect on survivors.26,27 This

increase in mortality and poor neurologic outcomes of

intubated and ventilated brain-injured patients is

thought to be due to hypocarbia from

hyperventilation.27-29 The optimal PaCO2 during

transport has not been clearly defined although

admission PaCO2 levels from 30 to 39 mm Hg have

been associated with lower mortality and better

survival outcomes.30,31 The use of end-tidal

capnometry has been demonstrated to be effective in

avoiding prehospital hyperventilation and hypocarbia

in intubated head-injured patients.15,21,32-34 Replacing

the bag valve mask in the intubated patient with a

mobile ventilator removes the human error and has

been demonstrated to produce more uniform PaCO2

levels and better outcomes.35 Hyperventilation is often

the result of low saturations en route to the hospital

where the paramedic treats hypoxia with the natural

response of more vigorous ventilation.36
52 www.cs.amedd.army.mil/references_publications.aspx

OPTIMAL HAND-BAG VENTILATION OF

BRAIN-INJURED PATIENTS

Currently, hand-bagging ventilation is an imprecise art

allowing for a wide range of minute ventilations and

resultant PaCO2 levels. The natural response in

ventilating severely injured patients is aggressive overventilation. Hand strength, single hand-bagging, 2-

handed hand-bagging, and frequency of bag

compressions are all factors in the use of the bag valve

mask.37 In one study, squeezing a standard one-liter

bag with a single hand gives a different mean amount

of gas ventilation (694 cm3per compression) when

compared to a mean 2-hand squeeze of the same oneliter bag (827 cm3

per compression).38 The standard

minute ventilation (the amount of gas ventilated per

minute) for a normal PaCO2 in a 70 kg patient is

approximately 10 times the body weight in kilograms.

Thus a 70 kg patient will have a minute ventilation of

approximately 700 cm3, and the Brain Injury

Foundation recommends 10 breaths per minute

ventilation in brain-injured patients prehospital.5 With

a goal of 10 cm3/kg as a guide, the optimal gas

exchange will use a different frequency of bag

compressions, depending on whether the patient is

single hand-bagged (approximately 10 compressions

per minute if 70 kg) or hand-bagged by 2 hands

(approximately 8 compressions per minute if 70 kg).

This variability can prove detrimental if it results in

iatrogenic hypocarbia.

MAXIMIZING EN ROUTE CARE OF COMBAT

BRAIN-INJURED PATIENTS

The application of patient management strategies

derived from civilian studies to the battlefield is

limited because of significant differences between the

patient populations. There are substantive differences

between the populations in terms of injury pattern and

ballistics. However, until combat data contrary to the

civilian data are established, the practice of

transporting combat injured patients should mirror the

goals of civilian paramedics.

All efforts should be made to avoid the triad of

secondary brain injury (illustrated below).

While hypotension and hypoxia are routinely

considered, hypocarbia is often overlooked by combat

medics and transport personnel. All combat braininjured patients intubated and ventilated should have

an end-tidal CO2 monitor and every effort should be

made to provide mobile mechanical ventilators for

ventilation (to remove the imprecise hand-bagging

ventilation). All personnel involved with the bag valve

mask should be trained in the correct hand-bagging

frequency, tidal volume, and technique. Optimally, the

brain-injured should be ventilated with an additional

oxygen supply—in the safest way, possibly with a

small oxygen concentrator to avoid the hazards of

bottled oxygen—to avoid the deleterious effects of

hypoxia and the resultant increase in the frequency of

Adapted from Gabriel5and Knuth25

HYPOTENSION

Blood pressure must be

monitored, and systolic blood

pressure kept above 90 mm

Hg with judicious use of IV

fluids, hemostatic dressings,

and compression/tourniquets.

HYPOXIA

Oxygen saturations must be

monitored to maintain hemoglobin saturation greater than

90% by airway management,

reduction of pneumothorax, and

supplemental oxygen as needed.

HYPOCARBIA

Avoid hyperventilation with

end-tidal CO2 monitoring.

BRAIN

INJURY

LETHAL

TRIAD

The “Silent Killer”: Hyperventilation in the Brain Injured
January – March 2008 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

hand-bagging often triggered by the hypoxia that

causes or exacerbates hyperventilation. In this manner,

the detrimental effects of hyperventilation and its

resultant hypocarbia can be avoided.

FUTURE

The optimal care of brain injured may include

ventilation and oxygenation based upon minute-tominute computerized “feedback loop” analysis.39 A

computerized feedback loop on a ventilator would

implement changes in delivered oxygen levels based

on the hemoglobin saturations. Additionally, the

ventilator rate and tidal volumes of positive pressure

ventilation would continuously adjust in response to

measurements of the end-tidal CO2 levels. Bag valve

mask ventilation could be improved in the near future

with a precise mechanism for measuring delivered

tidal volumes, and with an attached end-tidal CO2

monitor. The development of an accurate noninvasive

monitor of arterial PaCO2 would be optimal for

combat brain injured as well as a huge medical

advancement.

CONCLUSIONS

“First do no harm.” Prevention of iatrogenic secondary

brain injury in the combat environment is limited.

However, relatively simple protocol changes and

acquisition of simple and inexpensive technology can

potentially result in meaningful differences in

outcome. The ventilation status of combat brain

injured should be revisited by all care providers to

avoid inadvertent hyperventilation. End-tidal CO2

monitors should be placed on all casualty evacuation

and medical evacuation platforms, and level I and

level II military medical facilities, and used for all

intubated head-injured patients to avoid extreme

PaCO2 levels in this patient population.

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patients with severe traumatic brain injury. J Trauma.

2003;54(3):444-453.

27. Davis DP, Peay J, Sise MJ, et al. The impact of

prehospital endotracheal intubation on outcome in

moderate to severe traumatic brain injury. J Trauma.

2005;58(5):933-939.

28. Davis DP, Dunford JV, Poste JC, et al. The impact of

hypoxia and hyperventilation on outcome after

paramedic rapid sequence intubation of severely

head-injured patients. J Trauma. 2004;57(1):1-8.

29. Lal D, Weiland S, Newton M, Flaten A, Schurr M.

Prehospital hyperventilation after brain injury: a

prospective analysis of prehospital and early hospital

hyperventilation of the brain-injured patient.

Prehospital Disaster Med. 2003;18(1):20-23.

30. Davis DP, Stern J, Sise MJ, Hoyt DB. A follow-up

analysis of factors associated with head-injury

mortality after paramedic rapid sequence intubation. J

Trauma. 2005;59(2):486-490.

31. Warner K, Cushieri J, Copass M, Jurkovich G,

Bulger E. Emergency department ventilation effects

outcome in severe brain injury. Western Trauma

Association Abstract, 2007. Contact: http://

www.westerntraumaassociation.org/index.html.

32. Davis DP, Idris AH, Sise MJ, et al. Early ventilation

and outcome in patients with moderate to severe

traumatic brain injury. Crit Care Med. 2006;34

(4):1202-1208.

33. Poste JC, Davis DP, Ochs M, et al. Air medical

transport of severely head-injured patients

undergoing paramedic rapid sequence intubation. Air

Med J. 2004;23(4):36-40.

34. Bernard SA. Paramedic intubation of patients with

severe head injury: a review of current Australian

practice and recommendations for change. Emerg

Med Australas. 2006;18(3):221-228.

35. Davey AL, Macnab AJ, Green G. Changes in PaCO2

during air medical transport of children with closed

head injuries. Air Med J. 2001;20(4):27-30.

36. Davis DP, Douglas DJ, Koenig W, Carrison D,

Buono C, Dunford JV. Hyperventilation following

aero-medical rapid sequence intubation may be a

deliberate response to hypoxemia. Resuscitation.

2007;73(3):354-361.

37. Hess D, Spahr C. An evaluation of volumes delivered

by selected adult disposable resuscitators: the effects

of hand size, number of hands used, and use of

disposable medical gloves. Respir Care. 1990;35

(8):800-805.

38. McCabe SM, Smeltzer SC. Comparison of tidal

volumes obtained by one-handed and two-handed

ventilation techniques. Am J Crit Care. 1993;2

(6):467-473.

39. Hoskins SL, Elgjo GI, Lu J, et. al. Closed-loop

resuscitation of burn shock. J Burn Care Res.

2006;27(3):377-385.

The “Silent Killer”: Hyperventilation in the Brain Injured
January – March 2008 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

AUTHORS

LTC(P) Blackbourne is Chief, Trauma Service, Institute

of Surgical Research, Brooke Army Medical Center,

Fort Sam Houston, Texas.

MAJ Cole is a staff neurosurgeon, Brooke Army

Medical Center, Fort Sam Houston, Texas.

MAJ Mabry is the Emergency Medicine Fellow, US

Army Institute of Surgical Research, Brooke Army

Medical Center, Fort Sam Houston, Texas.

MAJ Morgan is the Battalion Surgeon, 3rd Special

Forces Group, Womack Army Medical Center, Fort

Bragg, North Carolina.

LTC Barras is the Assistant Chief Nurse Anesthetist,

Womack Army Medical Center, Fort Bragg, North

Carolina.

COL Eastridge is the Program Director, Surgical

Critical Care, US Army Institute of Surgical Research,

Brooke Army Medical Center, Fort Sam Houston,

Texas.

COL Holcomb is Commander, US Army Institute of

Surgical Research, Brooke Army Medical Center, Fort

Sam Houston, Texas, and Trauma Consultant to The

Army Surgeon General.

Brooke Army

Medical Center

Womack Army

Medical Center
56 www.cs.amedd.army.mil/references_publications.aspx

Hemorrhage remains the greatest threat to life on the

battlefield, accounting for half of all deaths.1In recent

military conflicts, newly designed and tested

tourniquets and more aggressive tourniquet use

guidelines, hemostatic dressings, fluids for

resuscitation, and innovative methods of resuscitation

are the current options available to military medics.

None of these treatments, however, are able to stop

bleeding from “noncompressible injuries.” Current

tourniquets can stop arterial hemorrhage distal to the

groin crease and axilla where the tourniquet can be

placed circumferentially. During evacuation and

before reaching definitive care, manual pressure and

hypotensive resuscitation, in which the patient’s blood

pressure is kept at approximately 90 mm Hg, is about

the only method at our disposal for handling noncompressible arterial hemorrhage in the groin and axilla.2

An intriguing device created by Joseph Lister in 1862

may be the starting point for an addition to the medic’s

armamentarium in the field to extend the anatomic

geography for mechanical hemostasis by compressing

the groin and axillary vessels.

Joseph Lister is best known for his introduction and

vigorous promotion of antiseptic surgical technique

and wound care, but he also made a number of

significant contributions to surgical technology3:

Abdominal tourniquet Chromic catgut suture

Cork aortic compressor Sinus forceps

Hernia bistouries Patella hook

Urethral forceps Suprapubic retractor

Tracheal retractor Wire hammer

Fracture steel pegs Bone forceps

Of interest to us here is a curious invention that he

called the “abdominal tourniquet,” shown in Figure 1.

Because extremity tourniquets could not stop proximal

arterial blood flow during hip surgery, Lister designed

a mechanical means of stopping the inflow of blood to

the hip. He commissioned W. B. Hilliard of Glasgow

to construct this “abdominal tourniquet,” based on the

common C-clamp, to his specifications for placement

externally above the aorta, compressing the aorta to

stop the flow of blood distally, as shown in his

illustration demonstrating its use (Figure 2).

It is unlikely, however, that Lister’s abdominal

tourniquet ever saw much action. Although no

physical evidence of the tool survived, a similar device

was designed and manufactured by Joseph Pancoast of

Philadelphia at about the same time that Lister’s was

produced. Pancoast reported several proximal thigh

and hip surgeries with very limited blood loss and no

interruption of respiration while the patient received

ether breathing spontaneously.4Several other similar

C-clamp extremity tourniquets were also invented

around the time of the American Civil War, mainly to

avoid circumferential compression and the resultant

gangrene. Dupuytren’s compressor and the Signori

tourniquets were clamp-like devices, such as that

shown in Figure 3, but were difficult to position

Figure 1. Joseph Lister’s Aortic Tourniquet (circa

1862).

Reprinted with permission. Copyright: Hunterian Museum at

The Royal College of Surgeons of England.

Joseph Lister, Noncompressible Arterial

Hemorrhage, and the Next Generation of

“Tourniquets”?

LTC(P) Lorne H. Blackbourne, MC, USA

MAJ Robert Mabry, MC, USA

LTC James Sebesta, MC, USA

COL John B. Holcomb, MC, USA
January – March 2008 57

effectively. These devices were eventually abandoned

in favor of the Petit tourniquet.5,6

POTENTIAL ROLE FOR MODIFYING THE

ABDOMINAL TOURNIQUET FOR THE

BATTLEFIELD

Inability to maintain hemostasis with manual pressure

in an exsanguinating groin injury was widely

publicized after the death of a US Soldier in Somalia

in 1993.7,8 Considerable time and thought have gone

into treating this injury, including several studies

exploring hemostatic agents that can be poured,

packed, or sprayed directly into the wound.9-12 Today’s

engineering capabilities, computer imaging, and high

tech materials could possibly make Lister’s 19th

century idea a reality. A version of Lister’s abdominal

tourniquet using a modified adjustable bar clamp

placed over the groin, axilla, or clavicle (as illustrated

in Figures 4, 5, 6, and 7) by medics on the battlefield

could possibly impede blood flow through the external

iliac, proximal femoral or axillary arteries, which may

allow a Soldier with a currently noncompressible

wound to reach definitive care alive.

Currently, mechanical hemostasis involving the groin

vessels is actually being successfully obtained by a

commercially available device for use after femoral

artery catheter puncture (Figure 8).

Using space age materials and engineering, such a

device could be shaped to conform to the pelvic outlet/

axilla and easily folded into a small mobile unit.

CONCLUSION

Joseph Lister was a unique individual who often took

unique approaches to problems. Now, more than 100

years after the use of his design for cessation of arterial

blood flow to the pelvis and groin, the idea may hold

answers to battlefield treatment of currently

noncompressible bleeding which is not amenable to

currently available tourniquet design. But first, we

must overcome the initial skepticism historically

associated with Joseph Lister’s work.

Figure 2. Watercolor painting by Joseph Lister

demonstrating the placement of the transabdominal abdominal tourniquet.

Reprinted with permission. Copyright: Hunterian Museum at

The Royal College of Surgeons of England.

Figure 3. C-clamp extremity tourniquet from the

era of the American Civil War

Figure 4. Modified adjustable bar clamp applied to

groin blood vessels.
58 www.cs.amedd.army.mil/references_publications.aspx

Figure 5. Modified adjustable bar clamp applied to

groin blood vessels.

Figure 6. Modified adjustable bar clamp applied to

compress infraclavicular axillary blood vessels.

Figure 7. Adjustable bar clamp applied to provide

compression of axillary blood vessels.

Figure 8. Commercially available femoral artery

puncture site compression device applied to the

groin.

Joseph Lister, Noncompressible Arterial Hemorrhage, and the

Next Generation of “Tourniquets”?
January – March 2008 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

REFERENCES

1. Bellamy RF. The causes of death in conventional

land warfare: implications for combat casualty care

research. Mil Med. 1984;149:55-62.

2. McSwain NE, et al. PHTLS Prehospital Trauma Life

Support: Military Edition. 5th ed. St Louis, MO:

MosbyJems/Elsevier; 2003.

3. Wangensteen OH, Wangensteen SD, Klinger CF.

Some pre-Listerian and post-Listerian antiseptic

wound practices and the emergence of asepsis. Surg

Gynecol Obstet. 1973;137:677-702.

4. Atkinson WB, Pancoast J. Physicians and Surgeons

of the United States. Philadelphia. PA: Charles

Robson: 1878:710.

5. Helling TS, McNabney K. The role of amputation in

the management of battlefield casualties: a history of

two millennia. J Trauma. 2000;49:930-939.

6. Welling DR, Burris D, Hutton J, Minken S, Rich N.

A balanced approach to tourniquet use: lessons

learned and relearned. J Am Col Surg. 2006;203:106-

115.

7. Mabry RL, Holcomb JB, Baker AM, et al. United

States Army Rangers in Somalia: an analysis of

combat casualties on an urban battlefield. J Trauma.

2000;49:515-528.

8. Kurzweg FT. Vascular injuries associated with

penetrating wounds of the groin. J Trauma.

1980;20:214-219.

9. Pusateri AE, Holcomb JB, Kheirabadi BS, et al.

Making sense of the preclinical literature on

advanced hemostatic products. J Trauma.

2006;60:674-682.

10. Ahuja N, Ostomel TA, Rhee P, et al. Testing of

modified zeolite hemostatic dressings in a large

animal model of lethal groin injury. J Trauma.

2006;61(6):1312-1320.

11. Alam HB, Chen Z, Jaskille A, et al. Application of a

zeolite hemostatic agent achieves 100% survival in a

lethal model of complex groin injury in swine. J

Trauma. 2004;56(5):974-983.

12. Alam HB, Uy GB, Miller D, et al. Comparative

analysis of hemostatic agents in a swine model of

lethal groin injury. J Trauma. 2003;54(6):1077-1082.

AUTHORS

LTC(P) Blackbourne is Chief, Trauma Service, at the

Institute of Surgical Research, Brooke Army Medical

Center, Fort Sam Houston, Texas.

MAJ Mabry is the Emergency Medicine Fellow, US

Army Institute of Surgical Research, Brooke Army

Medical Center, Fort Sam Houston, Texas.

LTC Sebesta is a General Surgeon at the Madigan

Army Medical Center, Fort Lewis, Washington.

COL Holcomb is Commander, US Army Institute of

Surgical Research, Brooke Army Medical Center, Fort

Sam Houston, Texas, and Trauma Consultant to The

Army Surgeon General.
60 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

The forward surgical team (FST), designed for

mobility, provides level II forward life saving and

resuscitative surgery. Resuscitative surgery includes

controlling hemorrhage from traumatic amputation, as

well as damage control surgery, usually an

“abbreviated” laparotomy or thoracotomy. The goals

of the abbreviated operation are to stop hemorrhage

and gastrointestinal soilage.1 The overall goal of

damage control surgery includes avoidance of

acidosis, coagulopathy, and hypothermia, also known

as the “lethal triad” or “bloody viscous cycle.”2

Trauma related hypothermia is defined by body core

temperature below 36°C. Hypothermia in trauma and

surgery patients (especially below 34°C) is an

independent risk factor and marker of mortality.3-7 The

isolated brain injury patients are the one group that

you must be careful rewarming. They should not be

rapidly rewarmed above a normal temperature. The

major pathophysiologic mechanism associated with

trauma and hypothermia related mortality is an

exacerbation of coagulopathy and platelet dysfunction,

as well as other life threatening complications

including infection, electrolyte disturbances, and

cardiac dysrhythmias.8-10 Studies of civilian patients

requiring damage control surgery who presented with

hypothermia that was subsequently treated with

rewarming demonstrated decreased mortality as well

as decreased blood and intravenous fluid requirements.11-13 In a trauma registry of trauma patients

evaluated at a Combat Support Hospital

(CSH) during Operation Iraqi Freedom,

mortality was also found to be independently associated with admission hypothermia (temperatures below 36°C).14

That correlation is presented in the

Figure.

Patients with admission hypothermia at

the CSH in this study also had a

significantly higher blood product and

factor VIIa requirements. The

prevention and correction of

hypothermia in damage control patients

at FSTs should decrease mortality, as

well as the volume of fluid and blood

products these patients require. This is

especially important in the logistically

challenged, austere environment of farforward combat surgery.

Currently, therapies to prevent and treat

hypothermia are not standardized and

vary between US Army FSTs and

Maximizing Patient Thermoregulation in

US Army Forward Surgical Teams

LTC(P) Lorne H. Blackbourne, MC, USA

LTC Kurt W. Grathwohl, MC, USA

LTC Paul Barras, AN, USA

COL Brian Eastridge, MC, USA

0

10

20

30

40

50

60

%

Mortality

<9090-90.991-91.992-92.993-93.994-94.9

Temperature °F

95-95.996-96.997-97.998-98.999-99.9100-100.9>101

Mortality rate of patients at the 31st Combat Support Hospital in

Iraq, correlated with body temperature upon arrival, January 31

through December 20, 2004.
January – March 2008 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

between the services (ie, US Navy and US Air Force

level II surgical facilities). During the development of

a joint theater-wide trauma system, the US military has

been challenged to:

1. Define the optimal measures to prevent and treat

hypothermia at level II surgical facilities.

2. Provide implementation and universal

application of these measures at all level II

military surgical facilities.

OPTIONS FOR PREVENTION OF HEAT LOSS

AND THERAPIES TO INCREASE CORE BODY

TEMPERATURE

Heat loss with decreases in core body temperature is

thought to result from one or a combination of 4

mechanisms:

 Radiation

 Evaporation

 Convection

 Conduction

Primary attention should focus on the prevention of

heat loss since rewarming patients can be difficult and

may require active measures which are invasive and

limited in the combat environment. Furthermore, once

hypothermia has occurred, patients may be subjected

to the self-propagating vortex of the lethal triad—

hypothermia causes coagulopathy, which then causes

more bleeding, which then results in heat loss, which

then causes more coagulopathy, which causes more—

and the cycle continues.

Options for preventing heat loss and warming surgical

patients involves everything that touches or goes into

the patient. Since a significant cause for the loss of

body temperature is radiation heat loss, the obvious

first area of concern is the ambient temperature in the

operating room.

AMBIENT OPERATING ROOM TEMPERATURE

The summer months in Southwest Asia are very warm,

the nights and winter however, especially in the desert

environment, can be surprisingly cold. Ambient

temperatures lower than 80°F in the operating room

are associated with the most common cause of heat

loss from radiation. Elevating ambient temperature in

the operating room to over 80°F is one of the most

important measures to prevent heat loss and decreases

in core body temperature in surgical patients.15-17

Limitations to this simple maneuver include the

inability to adequately heat the operating room.

However, environmental control units have

demonstrated the capability to effectively heat the

operating room and postoperative areas and should be

widely deployed with the FST whenever feasible.

INTRAVENOUS BLOOD AND FLUID WARMERS

Damage control procedures are usually associated with

the most critically injured patients. In some cases with

documented survival, the resuscitative intravenous

fluid requirement has exceeded several liters of

crystalloid and up to 40 to 50 units of blood and blood

products. These large amounts of refrigerated blood

and room temperature fluid can have a dramatic effect

on decreasing core body temperature. Infusion devices

that warm blood and intravenous (IV) fluid before

entering the patient have been documented to prevent

heat loss and maintain body core temperature.18,19

Furthermore, use of rapid infusion systems, in addition

to fluid warming, has been documented to decrease

fluid and blood requirements, preserve body

temperature, and decrease acidosis in hypovolemic

trauma patients (optimally after surgical hemostasis).20

The Belmont FMS-2000®(Belmont Instrument Corporation, 780 Boston Road, Billerica, MA 01821) rapid

infusion warming device has demonstrated the

capability to adequately warm and infuse rapid

amounts of blood and IV fluids.21

Currently, warming devices are not universally

deployed with the FST. Several field expedient and

other novel devices have been used to warm IV fluids.

These range from warming water baths to immersing

the fluids, utilizing the heating element of a mealready-to-eat (MRE), hand warmers, coffee makers,

and wrapping IV fluids in heat blankets. The

temperature of the fluid may be hard to control with

these field expedient methods and could result in

overheating, so these methods cannot be universally

endorsed.

CONVECTIVE HEAT BLANKETS

Heating blankets prevent radiation heat loss and

actively warm patients by convection, blowing air

warmed to 44°C through air columns within the

blankets. These systems require electricity and a

heating air flow generating unit, as well as disposable
62 www.cs.amedd.army.mil/references_publications.aspx

blankets. The requirements can limit its use in the

austere environment. Heating blankets are placed

strategically over the patient’s body areas that are not

undergoing the surgical procedure.

Unfortunately, patients who can benefit the most,

polytrauma patients, frequently remain uncovered

because several body areas require simultaneous

operative intervention to control hemorrhage. The

convective heat system most commonly used in

military facilities and civilian trauma centers within

the United States is the Bair Hugger® Blanket (Arizant

Healthcare Inc, 10393 West 70th Street, Eden Prairie,

MN 55344) system. Used intraoperatively, convective

warming devices have been shown to maintain body

temperature and avoid hypothermia.22-25 Despite the

logistical limitations, many FSTs use Bair Huggers in

the operating room and postoperative recovery areas.

The deployment of Bair Huggers or similar convective

warming devices should be universal at all level IIb

surgical facilities. Modifications to the device to limit

size and weight could be made with minimal industry

effort.

Conductive heat loss is another important cause of

decreased core body temperature in severely injured

patients when these patients are placed on cold

stretchers, gurneys, or operating room tables. Simple

actions such as the placement of wool blankets, sheets,

or other materials that conduct less heat can help

minimize heat loss.

Hemorrhagic shock and physiologic derangements

result in peripheral vasoconstriction to conserve core

body temperature. These homeostatic systems are

often overwhelmed in the postoperative resuscitative

period, resulting in vasodilation and may allow for

further potential body temperature loss. This potential

for postoperative heat loss further emphasizes the

importance of ambient room temperature, convective

heating devices, and the avoidance of conductive heat

loss in the immediate postoperative period.

IRRIGATION FLUID

While it is unusual to use copious irrigation fluid for

peritoneal washout during the initial abbreviated

laparotomy of damage control, many patients also

need irrigation of large soft-tissue wounds. Using

ambient temperature irrigation fluid can contribute to

hypothermia, while using irrigation fluid warmed close

to normal body temperature can help maintain

normothermia.26,27 There are several potential ways to

warm irrigation fluid, including the flameless MRE

heaters, microwave ovens, or modification of a

convective heater.28-30 For example, in 2002 a

convective Bair Hugger heating hose was used to heat

a box of IV and irrigation fluids during deployment to

the Afghanistan theater.31 Several other commercially

available heating devices for fluids, such as those

produced by Enthermics Medical Systems (W164

N9221 Water Street, Menomonee Falls, WI 53051),

are also available. A standard method for warming

irrigation and intravenous fluid should be field-tested

for universal use by all FSTs.

Evaporative heat losses are also important. Patients

with open abdomen may experience significant heat

losses. The abdomen should be protected with water

and airtight barriers, such as, Ioban 2TM (3M, St. Paul,

MN 55144-1000) to minimize evaporative heat losses.

Bair Hugger convection blanket in use in the

emergency department

Maximizing Patient Thermoregulation in US Army Forward Surgical Teams
January – March 2008 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

OPTIMAL MEASURES FOR HYPOTHERMIA

PREVENTION DURING HELICOPTER

EVACUATION

All patients undergoing surgery at the FST or level II

facility will be evacuated to the CSH or level III for

continuing care and more definitive operative

procedures. Intratheater patient movement is usually

accomplished by helicopter. Patient movement is

associated with environmental exposures, including

cooler air at altitude and wind chill.32 In a study of heat

loss during transport in a civilian intensive care unit,

patients transported to the radiology department for a

computed tomographic scan were found to lose up to

2°C of body temperature.33 Preventing hypothermia in

a postoperative damage control patient in a helicopter

is much more challenging than the intrahospital trip to

radiology. Air flow through the helicopter should be

minimized as much as possible within constraints of

security (ie, door gunner). Anecdotal reports indicate

that placing the postoperative patient in a “hot pocket”

consisting of a modified body bag with 2 wool

blankets and a reflective blanket has been used in both

Afghanistan and Iraq for retention of body heat.

Alternatively, the patient can be placed in a

commercially available NARP Hypothermia

Prevention and Management KitTM (HPMK) (North

American Rescue Products, Inc, 481 Garlington Road,

Suite A, Greenville SC 29615), which includes an

active heating element. Some have used the HPMK

inside the hot pocket as well. The major limitation of

both of these body temperature preservation

techniques is that they completely cover the patient,

which inhibits patient access and does not allow

observation of en route bleeding.

Further evidence to support the

technique of multiple layers for

transport is that layers of

insulating materials have been

shown to help decrease loss of

body heat in perioperative

civilian patients.34

While layers of insulating

materials decrease loss of body

heat, active warming via a

convective warming device has

been demonstrated to offer

o p t i m a l p r e v e n t i o n o f

hypothermia in civilian patients

during transfer.33 The addition of an active convective

heating device (eg, Bair Hugger, Thermal Angel®

[Estill Medical Technologies, Inc, 4144 N Central

Expressway, Suite 260, Dallas, TX 75204]) and layers

of insulating materials may offer the optimal

hypothermia prevention to patients undergoing

helicopter evacuation. Helicopter safety testing and

subsequent fielding of a convective heating system to

every helicopter evacuation platform should be

considered.

OPTIMAL ANESTHESIA FOR

THERMOREGULATION

General volatile anesthetics (ie, gas anesthetics)

further exacerbate hypothermia in trauma patients by

loss of normal thermoregulatory

vasoconstriction with resultant

vasodilation and redistribution of

heat to the skin and peripheral

tissues.35,36 One technique to

avoid anesthetic-related hypothermia may be the use of TIVA

(total intravenous anesthesia).

TIVA, which utilizes intravenous

medications such as propofol,

ketamine, and fentanyl, with or

without a paralytic, may be

associated with less peripheral

vasodilation and subsequent heat

loss.37,38 TIVA has been used in

thousands of civilian patients and

has been used by providers in the

Field expedient “hot pocket”

Hypothermia Prevention & Management kit
64 www.cs.amedd.army.mil/references_publications.aspx

Iraq theater.39 One of the authors, LTC Grathwohl,

used TIVA anesthesia for combat penetrating

neurological injury in over 125 patients, demonstrating

the safety and effectiveness of its use in the austere

environment.

TIVA should be considered for use in the majority of

patients undergoing damage control surgery at FSTs.

UNIVERSAL LEVEL IIb SUGGESTIONS

Suggestions for consideration for creating universal

thermoregulatory measures for Level IIb are listed in

the Table. We believe these measures will help

decrease the morbidity and mortality of damage

control patients, and decrease the logistic requirements

for each individual patient.

FUTURE MEASURES FOR FST

THERMOREGULATION

Currently, far-forward deployed ventilators have no

ability to heat ventilator gases. Warming of ventilator

gases has been documented to help conserve body core

temperature.40 Humidifier moisture exchangers have

also been demonstrated to prevent further respiratory

related heat loss. Future research and acquisition of

these specialized ventilators could help maintain body

temperature in the future.

A clear plastic hot pocket with multiple access points

would allow patient observation and access en route,

similar to the commercially available nuclear,

biological, and chemical contamination patient covers.

Improvements in convective warming devices,

including water-warmed body/bed pads, may represent

optimal body warming and replace warm air

convective devices in the future.41 The Arctic Sun is

another proprietary device that has demonstrated

promise in improving the ability to rapidly warm

patients. Some civilian trauma centers are using the

fluid rapid infusion device with adaptation to an

arterial-venous blood warming device in patients with

severe hypothermia. This may have future application

in the far-forward surgical platforms and level III

surgical facilities.11

Looking at long-term advances to provide

noninvasive, deep tissue warming using currently

unknown technology will provide rapid total body

warming to any desired temperature. While, at first

glance, one might conjure images of a science fiction

movie, this technology may include advances in

microwave heating or other deep radiating heat

sources. This could conceivably include regional

temperature gradients, for example, providing brain

cooling and truncal heating in the multiple system

injured patient. While this technology is probably far

in the future, the US military should provide

leadership in its development.

CONCLUSION

Creating universal minimal thermoregulation standards

for all FSTs may decrease morbidity and mortality of

combat damage control patients. These standards will

also decrease the blood and IV fluid requirements for

each individual patient, decreasing the logistical

challenges for the FSTs. The importance of

maintaining body core temperature in these combat

damage control surgery patients cannot be

overemphasized.

REFERENCES

1. Rotondo MF, Bard MR. Damage control surgery for

thoracic injuries. Injury. 2004;35(7):649-654.

2. De Waele JJ, Vermassen FE. Coagulopathy,

hypothermia and acidosis in trauma patients: the

rationale for damage control surgery. Acta Chir Belg.

2002;102(5):313-316.

Item Quantity

Bair Hugger warming unit 4

Bair Hugger convection blanket 20

Belmont FMS-2000 fluid warmer 3

Belmont FMS-2000 tubing 20

Body bags 10

Wool blankets 20

Reflective blankets 10

Environmental Control Unit 2

Enthermic Medical Systems

fluid warmer 1

Total Intravenous Anesthesia

infusion pump 2

Recommended Standard Thermoregulatory

Equipment for Level IIb Surgical Facilities

Maximizing Patient Thermoregulation in US Army Forward Surgical Teams
January – March 2008 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

3. Asensio JA, McDuffie L, Petrone P, et al. Reliable

variables in the exsanguinated patient which indicate

damage control and predict outcome. Am J Surg.

2001;182(6):743-751.

4. Tyburski JG, Wilson RF, Dente C, Steffes C, Carlin

AM. Factors affecting mortality rates in patients with

abdominal vascular injuries. J Trauma. 2001;50

(6):1020-1026.

5. Cushman JG, Feliciano DV, Renz BM, et al. Iliac

vessel injury: operative physiology related to

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6. Hoyt DB, Bulger EM, Knudson MM, et al. Death in

the operating room: an analysis of a multicenter

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7. Janczyk RJ, Howells GA, Bair HA, Huang R,

Bendick PJ, Zelenock GB. Hypothermia is an

independent predictor of mortality in ruptured

abdominal aortic aneurysms. Vasc Endovasc Surg.

2004;38(1):37-42.

8. Martini W, Pusateri A, Uscilwicz J, Delgado A,

Holcomb J. Independent contributions of

hypothermia and acidosis to coagulopathy in swine. J

Trauma. 2005;58:1002-1010.

9. Cosgriff N, Moore EE, Sauaia A, Kenny-Moynihan

M, Burch JM, Galloway B. Predicting lifethreatening coagulopathy in the massively transfused

trauma patient: hypothermia and acidosis revisited. J

Trauma. 1997;42(5):857-861.

10. Ferrara A, MacArthur JD, Wright HK, Modlin IM,

McMillen MA. Hypothermia and acidosis worsen

coagulopathy in the patient requiring massive

transfusion. Am J Surg. 1990;160(5):515-518.

11. Gentilello LM, Jurkovich GJ, Stark MS, Hassantash

SA, O'Keefe GE. Is hypothermia in the victim of

major trauma protective or harmful? A randomized,

prospective study. Ann Surg. 1997;226(4):439-447.

12. Johnson JW, Gracias VH, Schwab CW, et al.

Evolution in damage control for exsanguinating

penetrating abdominal injury. J Trauma. 2001;51

(2):261-269.

13. Bernabei AF, Levison MA, Bender JS. The effects of

hypothermia and injury severity on blood loss during

trauma laparotomy. J Trauma. 1992;33(6):835-839.

14. Arthurs Z, Cuadrado D, Beekley A, et al. The impact

of hypothermia on trauma care at the 31st Combat

Support Hospital. Am J Surg. 2006;191(5):610-614.

15. Macario A, Dexter F. What are the most important

risk factors for a patient's developing intraoperative

hypothermia? Anesth Analg. 2002;94(1):215-220.

16. Kean M. A patient temperature audit within a theatre

recovery unit. Br J Nurs. 2000;9(3):150-156.

17. Closs SJ, Macdonald IA, Hawthorn PJ. Factors

affecting perioperative body temperature. J Adv Nurs.

1986;11(6):739-744.

18. Smith CE, Desai R, Glorioso V, Cooper A, Pinchak

AC, Hagen KF. Preventing hypothermia: convective

and intravenous fluid warming versus convective

warming alone. J Clin Anesth. 1998;10(5):380-385.

19. Smith CE, Gerdes E, Sweda S, et al. Warming

intravenous fluids reduces perioperative hypothermia

in women undergoing ambulatory gynecological

surgery. Anesth Analg. 1998;87(1):37-41.

20. Dunham CM, Belzberg H, Lyles R. The rapid

infusion system: a superior method for the

resuscitation of hypovolemic trauma patients.

Resuscitation. 1991;21(2-3):207-227.

21. Dubick MA, Brooks DE, Macaitis JM, Bice TG,

Moreau AR, Holcomb JB. Evaluation of

commercially available fluid-warming devices for use

in forward surgical and combat areas. Mil Med.

2005;170(1):76-82.

22. Cassey J, Strezov V, Armstrong P, et al. Influence of

control variables on mannequin temperature in a

paediatric operating theatre. Paediatr Anaesth.

2004;14(2):130-134.

23. Kober A, Scheck T, Fulesdi B, et al. Effectiveness of

resistive heating compared with passive warming in

treating hypothermia associated with minor trauma: a

randomized trial. Mayo Clin Proc. 2001;76(4):369-

375.

24. Patel N, Smith CE, Knapke D, Pinchak AC, Hagen

JF. Heat conservation vs convective warming in

adults undergoing elective surgery. Can J Anaesth.

1997;44(6):669-673.

25. Borms SF, Engelen SL, Himpe DG, Suy MR,

Theunissen WJ. Bair Hugger forced-air warming

maintains normothermia more effectively than

thermolite insulation. J Clin Anesth. 1994;6(4):303-

307.

26. Moore SS, Green CR, Wang FL, Pandit SK, Hurd

WW. The role of irrigation in the development of

hypothermia during laparoscopic surgery. Am J

Obstet Gynecol. 1997;176(3):598-602.

27. Pit MJ, Tegelaar RJ, Venema PL. Isothermic

irrigation during transurethral resection of the

prostate: effects on perioperative hypothermia, blood

loss, resection time and patient satisfaction. Br J

Urol. 1996;78(1):99-103.
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28. Leaman PL, Martyak GG. Microwave warming of

resuscitation fluids. Ann Emerg Med. 1985;14

(9):876-879.

29. Anshus JS, Endahl GL, Mottley JL. Microwave

heating of intravenous fluids. Am J Emerg Med.

1985;3(4):316-319.

30. Garcia GD, Modesto VL, Lee KT. Avoiding

hypothermia in trauma: use of the flameless heater

pack, meal ready to eat, as a field-expedient means of

warming crystalloid fluid. Mil Med. 2000;165

(12):903-904.

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tested, and used for warming and maintaining

intravenous fluids in a forward surgical team during

Operation Enduring Freedom. Mil Med. 2006;171

(6):500-503.

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with the United States Army 102nd Forward Surgical

Team in Afghanistan. Am J Surg. 2004;187(5):652-

654.

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874.

AUTHORS

LTC(P) Blackbourne is Chief, Trauma Service, at the

Institute of Surgical Research, Brooke Army Medical

Center, Fort Sam Houston, Texas.

LTC(P) Grathwohl is the Chief of Anesthesia Critical

Care, and consultant to the Office of the Surgeon

General on Critical Care, Brooke Army Medical Center,

Fort Sam Houston, Texas.

LTC Barras is the Assistant Chief Nurse Anesthetist,

Womack Army Medical Center, Fort Bragg, North

Carolina.

COL Eastridge is the Program Director, Surgical

Critical Care, US Army Institute of Surgical Research,

Brooke Army Medical Center, Fort Sam Houston,

Texas.

Maximizing Patient Thermoregulation in US Army Forward Surgical Teams
January – March 2008 67

WHAT IS COMBAT DAMAGE CONTROL

SURGERY?

While civilian damage control surgery has been widely

defined, damage control surgery on the battlefield

(combat damage control surgery) has not. To define

combat damage control, it is imperative to first define

the philosophy of damage control surgery, and then

describe the current system for damage control in

civilian trauma centers. Combat damage control

surgery (as it is currently being employed in

Operations Iraqi Freedom and Enduring Freedom) can

then be defined in contrast. Needless to say,

performing damage control surgery in a combat zone

has many pitfalls and challenges, and it has even been

described as an almost impossible task.1-3 Nonetheless,

aggressive damage control surgery has been, is

currently, and will be carried out successfully by

combat surgical teams.4-7

Combat damage control consists of many stages due to

the multiple evacuations involved in moving combat

injured US military personnel

from the battlefield to,

ultimately, the continental

United States. Figure 1 provides

an overview of such evacuation

through the different levels of

military medical care.8

With the unique requirement for

intratheater and global

evacuation arises the similarly

unique requirement for a

modified, multistaged damage

control surgical approach.

Our goal is to define combat

damage control and its many

stages so as to provide a

platform for analysis of our

current capabilities. We must

challenge the current situation

to allow for maximum

improvement at each stage in

military combat damage control, in both current and

any future conflicts.

If one looks at the statistics of military personnel who

were wounded in combat and died of those wounds

after arrival at a surgical facility, then subtracts the

numbers for severe head injuries (approximately 15%

high-mortality) and all extremity wounds

(approximately 55% of combat wounds, lowmortality), one must conclude that improvement of the

mortality of damage control patients is the only way to

significantly decrease the overall mortality rate of

combat wounded in the near future.9,10

Acidosis, hypothermia, and coagulopathy following

damage control surgery have been documented as

predictive of mortality.11 Therefore, it is only logical to

conclude that, in order to decrease the rate of mortality

of damage control patients (and the overall mortality

rate of wounded reaching surgical facilities), the

ability of far forward surgical teams to stop bleeding,

stop gastrointestinal soilage, warm, resuscitate, and

correct coagulopathy must be

optimized, and these gains

m a i n t a i n e d t h r o u g h o u t

evacuation.

DAMAGE CONTROL

SURGERY

Damage control surgery is a

medical parallel to the US Navy

discipline focused on “the

capacity of a ship to absorb

damage and maintain mission

integrity.”12 When a Navy ship

has taken hostile fire—that is,

has been wounded—the sailors,

at all costs and as fast as

possible, immediately put out

all fires and stop any flooding.

The surgical analogy is to stop

all hemorrhaging and gastrointestinal soilage as fast as

possible.

Defining Combat Damage Control Surgery

LTC(P) Lorne H. Blackbourne, MC, USA

US Army Medical Center (Overseas)

Military Level IV

Forward Surgical Team

Military Level II

Combat Support Hospital

Military Level III

US Army Medical Center (US)

Military Level V

Battlefield

Military Level I

Figure 1. Evacuation route for Soldiers

injured in combat.
68 www.cs.amedd.army.mil/references_publications.aspx

The need for speed in obtaining these goals in severely

injured trauma patients is the avoidance of the trauma

“lethal triad.” The lethal triad is the vicious cycle of

hypothermia, acidosis, and coagulopathy.13 The

acidosis is from hypovolemic shock and inadequate

tissue perfusion.14 Hypothermia is from exsanguinations and loss of intrinsic thermoregulation.15,16

Coagulopathy is from hypothermia, acidosis,

consumption of clotting factors/platelets, and blood

loss.17-20 Coagulopathy, in turn, causes more

hemorrhage, and thus causes more acidosis and

hypothermia; so the “bloody vicious cycle” continues

as illustrated by Figure 2. When in full fruition, the

vicious cycle of the lethal triad is almost uniformly

fatal.

In a landmark paper in 1993, Rotondo et al 21 reported

the successful use of an abbreviated operation in

trauma patients to avoid the lethal triad, and coined the

phrase “damage control” with a mortality of 50% (prior

to using this approach these were near universally fatal

injuries). Many trauma centers have reported similarly

successful results using the damage control approach to

the severely injured trauma patient, and it is now

considered the standard of care.22-28

While originally reported as an approach to severe

abdominal trauma, the damage control process has

evolved to cover all anatomic regions, including

thoracic trauma, neurologic trauma, urologic trauma,

and extremity trauma. The damage control process is

especially applicable in the multiple system injured

trauma patient.29-36

CIVILIAN DAMAGE CONTROL SURGERY

Civilian damage control surgery is now well

established as the standard of care for severely injured

Intensive Care Unit

ICU RESUSCITATION

Administer packed red blood cells, fresh frozen

plasma, and platelets as needed using the tenets of

damage control resuscitation limiting crystalloid

fluids.39,40 The patient is rewarmed and full

laboratory analysis is undertaken with the basic

goal of “normalizing” the patient.41

When the patient is determined to be

hemodynamically stable with lab values, ventilator

status, and body temperature in close proximity to

“normal,” the patient is then returned to the

operating room for the definitive operation.

DEFINITIVE OPERATION

This second operative procedure most often occurs

24 to 36 hours after the initial operation. The

definitive operation would include bowel

anastomoses or colostomy maturation, definitive

vascular repair where an interposition vascular

shunt had been previously placed, removal of

hemostatic packing and closure of abdominal

fascia where feasible. The patient is then taken

back to the intensive care unit (ICU) and the

postoperative care progresses towards the ultimate

goal of discharge to home or rehabilitation center.

Operating Room

ABBREVIATED SURGICAL OPERATION

Stop all surgical hemorrhage and, secondarily,

stop all gastrointestinal succus soilage in the

shortest time possible.

Operating Room

patients in the United States. The civilian damage

control paradigm is based on the following “damage

control trilogy”37,38:

Figure 2. The trauma lethal triad of

conditions which can occur in severely

injured trauma patients.

ACIDOSIS

COAGULOPATHY HYPOTHERMIA

Defining Combat Damage Control Surgery
January – March 2008 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

Figure 3. The basic outline of the multiple necessary stages of combat damage control surgery.

Battlefield

Care

Abbreviated

Operation Level IIb

Level IIb Forward

Surgical Facility

Postoperative

Resuscitation

Fixed Wing Evacuation to US, Level V

Level V Definitive Operation or

Intensive Care Unit Care

Helicopter Air Evacuation

Resuscitation

Fixed Wing Global Evacuation

Level IV Definitive

Operation/Second Look

Operation or Intensive Care

Unit Care Resuscitation

Definitive or

Second Look

Abbreviated

Operation

Level III Combat Support

Hospital Preoperative

Resuscitation

Postoperative

Resuscitation
70 www.cs.amedd.army.mil/references_publications.aspx

Each patient undergoing these operative procedures

and ICU care require significant personnel and

logistics resources.

The documented mortality for the damage control

approach to patients requiring a damage control

laparotomy is approximately 50% with a documented

morbidity of approximately 40%.42

In review, the civilian level I trauma center damage

control model involves the damage control trilogy—

abbreviated operation, ICU resuscitation, and

definitive operation—all in the same surgical facility.

Military combat damage control surgery does not have

the luxury of performing all stages of damage control

surgery in a single facility, as the patient undergoes

global evacuation and stops at

several military surgical facilities.

US MILITARY DAMAGE

CONTROL SURGERY

In stark contrast to the civilian

damage control surgery trilogy,

combat damage control involves up

to 10 stages to allow for battlefield

evacuation, surgical operations, and

resuscitations. Figure 3 portrays the

basic outline for the multiple

necessary stages in combat damage

control. In comparison to civilian

damage control, the most notable

difference is the process of

resuscitation. Combat damage

control postoperative resuscitation

and rewarming occurs in several

facilities and multiple times during

en route air evacuation during the

combat damage control process.

CONCLUSION

Combat damage control is a unique

enterprise. As illustrated in Figure 4,

while civilian damage control

surgery can be described as a simple

trilogy in one hospital, combat

damage control surgery undertakes

many stages and involves multiple

facilities as the patient undergoes

global evacuation.

To improve combat damage control surgery, we must

first define the stages, and then assess the personnel,

logistics, techniques, complications, unique

challenges, and outcomes of each stage. Only then can

areas for improvement be defined by stage, and

patient care optimized.

Combat damage control is an amazing and very unique

process. The successful recovery, care, and transport

of a severely injured Soldier from the battlefield to

medical centers in the United States is an extremely

challenging undertaking. All military personnel involved in combat damage control surgery should be justifiably proud—and yet always striving to improve

further.

Abbreviated Operation Military Level II

Military Level II Resuscitation

Helicopter Evacuation/Resuscitation

Level III Preoperative Resuscitation

Definitive or Second Look Operation Level III

Postoperative Resuscitation Level III

Fixed Wing Evacuation/Resuscitation to

Level IV

Definitive Operation or ICU Care Level IV

Fixed Wing Global Evacuation to Level V

Level V Definitive Care

MILITARY DAMAGE CONTROL

Abbreviated Operation

Intensive Care Unit Resuscitation

Definitive Operation

CIVILIAN DAMAGE CONTROL

Figure 4. A comparison of the stages of care required in military

combat damage control surgery to that involved in civilian

damage control care.

Defining Combat Damage Control Surgery
January – March 2008 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

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13.

AUTHOR

LTC(P) Blackbourne is Chief, Trauma Service, at the Institute of Surgical Research, Brooke Army Medical Center,

Fort Sam Houston, Texas.

Defining Combat Damage Control Surgery
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the manuscript. Ideally, a manuscript should be no longer than 24 double-spaced pages. However, exceptions will always be 

considered on a case-by-case basis. 

2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles 

should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. 

Inclusion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged.

3. A complete list of references cited in the article must be provided with the manuscript, with the following required data: 

 Reference citations of published articles must include the authors’ surnames and initials, article title, publication title, 

year of publication, volume, and page numbers. 

 Reference citations of books must include the authors’ surnames and initials, book title, volume and/or edition if 

appropriate, place of publication, publisher, year of copyright, and specific page numbers if cited. 

 Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying 

information as possible (location, dates, presenters, sponsors, titles). 

4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproduction

quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, GIF, BMP) and MS Word 

photo files are preferred. Prints of photographs are acceptable. Please do not send photos embedded in PowerPoint. Images 

submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of each 

photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and 

photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript. 

5. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contact 

information must be included on the title page of the manuscript. 

6. Submit manuscripts to: 

US ARMY MEDICAL DEPARTMENT CENTER & SCHOOL

ATTN MCCS DT 

2419 HOOD ST STE C 

FORT SAM HOUSTON, TX 78234-7584 

DSN 471-6301 

Comm 210-221-6301 

Fax: DSN 471-2226 Comm 210-221-2226 

Email: richard.e.burton@amedd.army.mil