July – September 2010 

Commander’s Introduction 1 

MG David A. Rubenstein 

Transforming US Army Trauma Care: 4 

An Evidence-Based Review of the Trauma Literature 

LTC Kyle N. Remick; LTC James A. Dickerson II; LTC Shawn C. Nessen; 

COL Robert M. Rush; COL Greg J. Beilman 

Experience with Mild Traumatic Brain Injuries and 22 

Postconcussion Syndrome at Kandahar, Afghanistan 

LTC Ralph D. Caldroney; CAPT James Radike, USN 

The Road to Recovery and Rehabilitation for Injured Service 31 

Members with Limb Loss: A Focus on Iraq and Afghanistan 

Brad M. Isaacson; Sharon R. Weeks; COL Paul F. Pasquina; Joseph B. Webster 

James P Beck; Roy D. Bloebaum 

Family Advocacy: A Program to Support an Expeditionary Army 37 

COL Derrick Arincorayan; Larry Applewhite, PhD; Rene Robichaux, PhD 

Increasing our Access to Care: A View from Middle Management 43 

COL Robert A. Smith 

Access to Care Initiatives 48 

LTC Ivan D. Speights; MAJ Cindy S. Renaker; MAJ Huy Luu; Jeremy Schneider 

Case Study: Realignment of US Army Medical Activity, Heidelberg 54 

Assets During US Army Europe Transformation-Driven Health Clinic Closures 

LTC Raymond L. Gundry; MAJ Christoph A. Hillmer 

Evaluating the Impact of Investments in Information Technology on 58 

Structural Inertia in Health Organizations 

LTC Lee W. Bewley 

Nutritional Care of Detained Persons in Operation Iraqi Freedom 64 

LTC Beverly D. Patton 

Abstracts from the US Army-Baylor University 70 

Doctoral Program in Physical Therapy 
LTG Eric B. Schoomaker 

The Surgeon General 

Commander, US Army Medical Command 

MG David A. Rubenstein 

Commanding General 

US Army Medical Department Center and 

School 

July – September 2010 The Army Medical Department Center & School PB 8-10-7/8/9 

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1 

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JOYCE E. MORROW 
 July – September 2010 1

In my remarks introducing the previous issue of the 

AMEDD Journal, I pointed out the distinct, symbiotic 

relationships of healthcare services across the military 

and civilian settings. Those invaluable links include 

education, certifications, delivery practices and experiences, facility design, and research and development. 

Understandably, the availability of easily identifiable and 

accessible information from both types of healthcare 

systems is vital to stimulating and advancing the practice 

of medical science for everyone. Again fulfilling its 

important and unique role as a resource for such 

information from military medicine, this issue of the 

Journal contains a number of articles on subjects which 

have direct corollaries in civilian medical science and 

healthcare delivery. 

The first article is an ideal example of the exploitation of 

the broad range of available information sources to 

develop a focused look at what is arguably military 

medicine’s most important responsibility, battlefield 

trauma care. LTC Kyle Remick led an impressive group 

of highly skilled, broadly experienced Army surgeons in 

an extensive literature review to evaluate available 

information on multiple aspects of trauma care. The 

review parameters were carefully defined in focus and 

scope, and rigorously followed, ensuring study results are 

scientifically sound, balanced, and evidence-based. The 

article presents the extensive information derived during 

the review in a carefully organized, easily understood 

structure which supports 5 specific recommendations for 

transformation of Army trauma care. The concept 

development, design, execution, and analysis presented 

in this study once again demonstrates the exceptionally 

high caliber of talent, skill, and dedication that is typical 

of our military medical professionals. Their study results 

should absolutely be a part of the ongoing development 

of protocols, procedures, organization, and training 

which will define trauma care in combat environments of 

the future. 

Number 4 on the recently promulgated list of The Army 

Surgeon General’s top 10 issues is “Implementation of 

mild Traumatic Brain Injury (mTBI)/Concussive Injury 

Protocols.” As is so often the case, our military medical 

professionals in the combat theater have recognized the 

import of an increasingly encountered serious condition, 

and are directly addressing it within the capabilities of 

their environment and resources. LTC Ralph Caldroney 

and Navy CAPT James Radike have contributed a timely, 

important article describing their experiences in 

Afghanistan (2009-2010) in the development and 

implementation of protocols and guidelines for 

recognition, screening, evaluation, and management of 

mTBI at the Kandahar hospital. Their article presents 

well-researched, detailed information about the 

presentation of symptoms of brain injury, and the various 

screening techniques and tools that are used to gauge the 

severity of indicated TBI. They explain the various 

approaches to treatment that were adopted at Kandahar. 

Perhaps most importantly, they detail their focus on 

repetitive brain injuries as a vital factor in determining a 

patient’s potential susceptibility to more severe, perhaps 

permanent, damage from further exposure. This article is 

a valuable contribution in support of one of The Surgeon 

General’s most urgent priorities. 

The historically high survival rate of wounded US 

Warriors from current conflicts has resulted in a 

proportionally larger number of combat Veterans who 

require extended follow-on care as their external wounds 

heal and they seek to return to as normal a lifestyle as 

possible. Loss of limbs is one of the more common of the 

conditions faced by these valiant Warriors. Lead author 

Brad Issacson and a group of highly qualified 

orthopaedic and rehabilitation professionals from the 

Department of Veterans Affairs, Walter Reed, and 

university medical schools have contributed a timely, 

important article which clearly synopsizes the major 

concerns involved in the recovery and rehabilitation of 

military amputees. Their extensively-researched article 

consolidates data and experiences from a broad range of 

sources to present the latest information concerning 

amputation wound care, residual limb complications, 

prosthesis technology, and approaches to physical and 

occupational therapy which are available for recovering 

Warriors. This article is yet another example of the wide 

range of dedicated healthcare professionals who 

collaborate time and again to advance the state-of-the-art 

of care for our Warriors who willingly go into harm’s 

way in defense of our freedom and way of life. 

It is obvious that the extended nature of the current 

combat operational tempo has taxed our Warriors, both 

physically and psychologically. Throughout these 

commitments, military medicine has continued to make 

tremendous advances with trauma injuries, saving lives 

COMMANDER’S INTRODUCTION

MG David A. Rubenstein 
2 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

and restoring the injured to amazing levels of recovery. 

The behavioral and mental health professionals have 

worked tirelessly to develop techniques and approaches 

to care for those Soldiers suffering from mental and 

psychological disorders. One of the undesirable 

consequences of the psychological pressures and stresses 

that affect Soldiers in a combat environment is the 

negative impact they can have on the Warrior’s family 

relationships. Dissolutions of marriages and family 

breakups following return from deployment are far too 

common. At the extreme, we see the reports of physical 

abuse, including the death of one or both spouses, and 

sometimes children. The family advocacy approach to 

address the stresses of military life on the family was 

developed in the 1980s. It is by necessity an evolutionary 

methodology as the nature of combat changes, while at 

the same time the very character and structure of 

American society itself are constantly in flux. COL 

Derrick Arincorayan teamed with Dr Larry Applewhite 

and Dr Rene Robichaux to look at an adaptation of the 

family advocacy approach to address the domestic 

stresses inherent in an multiple deployment environment. 

Their article makes a very strong case for providing (in 

effect extending) family advocacy support to the forward 

operating areas with deploying units, and ensuring such 

support is closely coordinated with each unit’s home 

station. The availability of such resources accomplishes 

many things, most importantly ensuring continuity of 

support for those deploying personnel who were already 

receiving family advocacy services, and providing 

immediate, onsite services for those encountering 

difficulties, either from home or at the deployed location. 

This article is another indication of the dedication and 

commitment of our healthcare professionals to the 

“whole” Soldier, proactively adapting to the times and 

places as required. 

Of the many benchmarks with which we gauge the 

quality of military medicine, perhaps the one most widely 

discussed by healthcare beneficiaries is access to care. 

This is nothing new, access to healthcare services by 

dependents and other beneficiaries has long been a major 

concern for military medical planners and policy makers. 

Indeed, efforts to directly address dependent healthcare 

began with the Dependents Medical Care Act in 1956, 

which evolved into CHAMPUS in 1966 and is now 

TRICARE, which serves all eligible beneficiaries. The 

program functions well within the United States, but the 

biggest challenges for military healthcare providers are 

overseas. This issue of the Journal contains 3 articles 

dealing with the difficulties presented in Europe by the 

reduction of forces permanently assigned there, 

combined with the demands of the ongoing combat 

operations in Afghanistan and Iraq. In the first article 

COL Robert Smith provides a manager’s overview of the 

circumstances which complicate the ability of the 

military to meet the demands, and expectations, of the 

eligible beneficiary population. His discussion examines 

the difficulties presented by not only the operational and 

resource reduction requirements, but also the internally 

imposed demands on the time of providers, which directly translates into less time for patient care. He offers 

suggestions to mitigate the problems and increase access, 

most of which will have to be addressed at the policy 

level because they would be applicable across the entire 

Military Health System. COL Smith’s article is a clear, 

well-reasoned look at the realities of providing healthcare 

services to our eligible beneficiaries around the world. 

Next, LTC Ivan Speights and his coauthors describe the 

actions they implemented at the Army Health Clinic, 

Mannheim, in 2008 to address the combined challenges 

of the transformation of the US forces in Europe, combat 

theater deployments, and the normal personnel 

turbulence of a military medical organization. The first 

step was a statistical analysis of the users of the clinic’s 

services, segregated by type of beneficiary and the nature 

of services used, which was then used to adjust service 

and resource assignment schedules. They implemented a 

telephone screening and consultation process to focus 

provider appointments towards those for which actual 

caregiver contact was necessary. The clinic itself was 

remodeled after an analysis determined the optimum, 

standardized layout to support the processes and services 

required by the user community. Finally, since nothing in 

the provision of medical services is static, the clinic’s 

operational data are reviewed every quarter to adjust 

schedules and resources as necessary. This is a wonderful example of the initiative and resourcefulness of 

our military medical professionals as they face a 

challenge head-on, roll up their sleeves, and make it work 

for the benefit of their supported population. 

In the earlier two articles, access to care was discussed 

from a broad perspective, then it was considered in the 

efforts of a single clinic to optimize its operations to 

ensure access was not compromised. LTC Raymond 

Gundry and MAJ Christoph Hillmer have contributed an 

excellent article discussing the challenges of realigning 

medical assets across an entire region of responsibility in 

response to the reduction of forces and other resources in 

Europe. Unfortunately, strategic planning for the 

reduction of support services, including medical support, 

was not detailed as part of the overall planning of the 

force transformation. Further, there was no 

documentation or lessons-learned available from the last 

Commander’s Introduction 
July – September 2010 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

major force downsizing in the early 1990s. Adding to that 

mix was the turmoil of the constant deployment rotations 

of medical personnel and resources into the combat 

theaters. Consequently, the realignment of medical 

support across their area of responsibility was initially 

reactive, but was successful because of the skill, 

knowledge, and sheer hard work of those responsible for 

making it happen. LTC Gundry and MAJ Hillmer 

describe the numerous considerations and problems, 

many unexpected of course, they encountered as they 

contended with the myriad of responsibilities involving 

personnel, logistics, facilities, budget, host nation 

concerns, and transportation involved in this enormous 

undertaking. At the end of the article, they have provided 

5 points of planning guidance derived from their 

experience to assist future, similar efforts. The 

experiences detailed in this article, and especially the 

invaluable planning guidance, should be incorporated as 

part of contingency planning process for future 

realignment of overseas medical support assets. 

Throughout history, advances in medical science have 

been the result of scholarship, experimentation, and 

technology, elements which themselves are absolutely 

interdependent. Indeed, great strides in one area drive the 

other areas, and the cycle builds momentum. Over the 

past century, the accelerated breakthroughs in various 

areas of technology have stimulated stunning 

advancements in medical science as researchers and 

engineers quickly developed medical applications, which 

then redirected technological development in entirely 

new directions. However, sometimes the assumed 

omnipotence of technology may lead to unwise decisions 

with detrimental results. In his well-researched article, 

LTC Lee Bewley investigates an area of technology that 

is one of those assumed mainstays of American business 

success, and focuses on its actual efficacy in healthcare 

organizations. Some form of information management is 

absolutely essential for any successful enterprise, and, 

unquestionably, digital technology has revolutionized our 

ability to organize, analyze, research, archive, and access 

information—but management should understand that 

technical expansion can reach a point of diminishing 

returns. LTC Bewley presents a strategic analysis of the 

investment and productivity returns for investment in 

information management technology, and develops some 

cautionary perspectives for those charged with 

responsibility of such systems. His clearly presented 

analysis of a complex subject, along with the detailed 

findings and recommendations are yet another indication 

of the high level of scholarship and expertise which is 

characteristic of our military medical professionals. 

Previous issues of the AMEDD Journal have presented 

articles discussing various aspects of the provision of 

healthcare services to prisoners and detainees in the 

combat theaters of Iraq and Afghanistan. LTC Beverly 

Patton has contributed an interesting and informative 

article which details an important, related consideration 

of detainee management which is much more complex 

than it may appear on the surface. The provision of 

nutritional meals in keeping with the customary diet of 

internees is not just the obligation of a civilized nation, it 

is also specified in the 1949 Geneva protocols. However, 

it is not as straightforward as distributing pallets of 

military rations among the detainees. Not only should the 

dietary patterns of the general internee population be 

understood and followed, but the specific dietary 

considerations for those with certain health conditions 

must be addressed. The article discusses the efforts made 

to ensure pregnant, diabetic, or injured detainees, as well 

as infants, malnourished children, and hospitalized 

internees were provided nutrition suitable to their 

conditions as much as possible. Further, provision of 

special meals was hampered by the forced segregation of 

the population by ethnic groups (to minimize tension and 

conflict), and the separation of adolescents from the 

adults. LTC Patton has not only done an excellent job of 

describing the difficulties and complexities involved in 

this effort, she has also cited the governing regulations 

and helpful references, and presented a valuable list of 

lessons-learned for planners of future, similar operations. 

This issue of the AMEDD Journal closes with a 

collection of abstracts prepared by the 2011 class of 

doctoral students of the US Army-Baylor University 

Doctoral Program in Physical Therapy. The 9 abstracts 

report the results of the students’ research projects which 

were conducted as part of their curriculum and in support 

of the Neuromusculoskeletal Injury Prevention and 

Rehabilitation Research Program. These abstracts are 

representative of the outstanding opportunities for 

professional education and career enhancement available 

in military medicine. 
4 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

Much has changed in US military combat operations 

between September 11, 2001, and today. Operation 

Enduring Freedom (OEF) has changed from a special 

operations mission to remove the Taliban from control 

of Afghanistan to one of full-spectrum operations. The 

United States conducted a war to overthrow Sadam 

Hussein’s Iraq regime and is now, in Operation Iraqi 

Freedom (OIF), dealing with stability and 

counterinsurgency operations. Just in these 2 respects, 

the US Army is tasked with fighting concurrently in 

many different ways. None of this resembles our prior 

planning for a large-scale, conventional war against an 

opposing superpower. 

During this same period, there has been significant 

progress regarding the development of our military 

trauma system. Well-documented improvements since 

2001 include research into prevention of combat 

injuries with new types of body armor, improved 

hemorrhage control techniques at the point-of-injury, 

information management systems to enable continuity 

of care between facilities within the theater and on 

different continents, development of the Joint Theater 

Trauma Registry to compile data that will provide 

insight into future improvements, and a leadership 

system to ensure better joint and combined medical 

resource cooperation and utilization.1

To build upon this success and to prepare for the 

future, we must first know what we face. In 2004, the 

Chairman of the Joint Chiefs of Staff described our 

current security environment as including a wider 

range of adversaries and a more complex and 

distributed battlespace from austere to urban 

environments with anticipated conflicts including 

“traditional” (other nations), “irregular” (terrorist 

organizations), “catastrophic” (weapons of mass 

destruction), and “disruptive” (technology use against 

stronger opponents).2

Transforming US Army Trauma Care: 

 An Evidence-Based Review of the 

 Trauma Literature 

LTC Kyle N. Remick, MC, USA 

LTC James A. Dickerson II, MC, USA 

LTC Shawn C. Nessen, MC, USA 

COL Robert M. Rush, MC, USA 

COL Greg J. Beilman, MC, USAR 

ABSTRACT

The US Army has been charged to transform to meet the demands of current and anticipated near-future combat needs, 

covering a full spectrum of military operations. The US Army combat trauma care system was created to deliver combat 

casualty care in a variety of situations and has been adapted to meet the needs of such care in both Operations Enduring 

Freedom and Iraqi Freedom. Questions related to our current system include the use and positioning of medical 

evacuation assets, the type of training for our trauma care providers, the positioning of these providers in proximity to 

the battlefield, and the type of units most suited to the wide variety of medical operations required of today’s military 

medical team. The review was performed to evaluate available information in light of anticipated future needs to ensure 

preparedness. We reviewed trauma literature regarding the areas of civilian trauma systems, military trauma systems, 

presurgical trauma care, medical evacuation times, and the medical evacuation system. Among the conclusions drawn 

from the reviewed data include the following: regional trauma systems improve outcomes in significantly-injured 

patients; rural trauma care as part of a trauma system yields improved results compared to nontrauma hospitals and 

comparable results to those at a higher level center; and delivery of advanced trauma life support care has the potential 

to extend the period of time of safe medical evacuation to surgical capabilities. These lessons are used to discuss 

components of an improved system of trauma care, flexible for the varied needs of modern battlefield trauma and 

adaptable to provide support for anticipated future conflicts. 
 July – September 2010 5

So the question at hand is not how to adapt our 

military (including our medical support) to our current 

conflicts (OEF and OIF). Quite the opposite, we 

should determine how the military can transform to 

meet the predicted near-future threats. In 2005, the 

Army Chief of Staff clearly articulated our charge: 

Modularity is the Army’s major force transformation 

initiative which involves the total redesign of the 

operational Army into a larger, more powerful, flexible, 

and deployable force...An operational Army organized 

around modular Brigade Combat Teams and support 

forces will better meet the challenge of the 21st Century 

security environment...3

As military surgeons, we want the Army Medical 

Department to keep pace with this necessary 

transformation along with the rest of the Army. Our 

current theater trauma assets, including the battalion 

aid station, medical evacuation, the forward surgical 

team, and the combat support hospital, are working 

adequately after several years of focused development. 

However, these components alone may be inadequate 

to meet our future needs. An evidence-based literature 

review was performed and a modular, theater-based 

hospital system utilizing a comprehensive trauma 

system model is suggested. This review articulates an 

evidence-based, proactive solution, one that can be 

applied in near-future, anticipated operational 

environments. 

METHODS

A literature search was performed covering topics 

relevant to military and civilian trauma systems, 

battlefield and combat casualty care, timing of trauma 

care, the “golden hour” concept, helicopter evacuation, 

and published reviews of world trauma experiences 

over the past 30 years. Over 100 articles from the 

literature were reviewed, 50 of which were determined 

to contain the most pertinent data. Articles were 

categorized as related to (a) civilian trauma systems, 

(b) military trauma systems, (c) presurgical trauma 

care, (d) medical evacuation times, and (e) medical 

evacuation system. 

 Civilian trauma system lessons are taken from 

articles discussing Level I urban trauma centers, 

rural trauma centers, and how the different level 

trauma centers function together as a coherent 

system of trauma care. 

 Military trauma system lessons are taken from 

articles that discuss the recent US experience and 

the experience of other nations with developed 

military trauma capabilities. 

 Presurgical trauma care articles evaluated the role 

of the emergency medicine physician, advanced 

trauma life support (ATLS) interventions, triage 

criteria, and the components of a military trauma 

system. 

 Medical evacuation articles deal with times to 

ATLS intervention versus surgical intervention, 

physiologic parameters, mortality curves based on 

injury type, the golden hour fallacy, the composition of the medical evacuation team, and prehospital triage. 

Lessons from the literature are summarized by 

category. We provide recommendations for change of 

the US Army trauma system to meet future challenges. 

RESULTS

Literature search results are divided into topics 

relevant to US Army combat trauma care. Topics 

include civilian trauma systems, military trauma 

systems, presurgical trauma care, medical evacuation 

times, and medical evacuation system. Evidence-based 

lessons for each category are listed in Table 1. 

Civilian Trauma Systems 

The origin of the civilian trauma system is welldocumented in the literature1,35,42 and can be traced to 

the National Highway Safety Act of 1966 (Public Law 

89-564) which mandates that 

...coordination, transportation, and communication are 

necessary to bring the injured person and definitive 

medical care together in the shortest practical time...42

This has been a noble goal of both military trauma care 

and civilian trauma care since that time. The American 

College of Surgeons established state systems in 1976 

with the initial publication of Resources for Optimal 

Care of the Injured Patient (2006 version available at: 

https://web4.facs.org/ebusiness/ProductCatalog/

product.aspx?ID=194). 

The benefit of trauma systems is decreased mortality. 

Injured persons treated at a designated trauma center 

have a lower mortality, but exactly why is unknown.35

Is it the presence of a trauma surgeon, the integrated 

and well-practiced trauma team, the decreased time to 

treatment and time to the operating room, or the 
6 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Transforming US Army Trauma Care: An Evidence-Based Review of the Trauma Literature 

Table 1. Evidence-based lessons about trauma care derived from the literature. 

Civilian Trauma Systems 

1. Trauma systems improve mortality.4-7

2. Integration of designated trauma centers within a state improves outcomes.4-7

3. Initial treatment by ATLS-trained physicians at rural level III trauma centers decreases preventable deaths.8-10

4. Initial transport to a rural level III trauma center with only an ATLS physician does not increase mortality and may 

decrease mortality in rural areas even with delays of up to 4 hours to reach the level I trauma center.6,11-13

5. RTS <6.00 and hypotension in patients with chest or abdominal injury predicts a need for DCS prior to transfer to a 

level I center.14

Military Trauma Systems 

1. Battlefields and tactics change over time and modern battlefields may contain multiple types of conflict 

simultaneously within the same battle-space.15-18

2. Combat trauma system contingency planning is important to remain prepared for future complex battlefields.1

3. Proper utilization of surgical resources within a trauma system improves survival within the system and up to 50% of 

potentially survivable injuries are surgical.19,20

4. The FST is proven in rapid, modern maneuver warfare and with modifications has succeeded in providing surgical and 

nonsurgical trauma care for stability and counterinsurgency operations in our current theaters.21

5. Current Army trauma system surgical and presurgical (ATLS) assets need increased modularly and flexibility to rapidly 

tailor trauma care for changing conflict types within a single, complex battlefield.1,16-18,22

Presurgical Trauma Care 

1. Prehospital paramedic care decreases mortality and increases trauma system efficiency.23

2. A large portion of trauma patients can be treated or temporized by EM physicians performing ATLS level LSIs.24-26

3. EM physicians are currently underutilized within the Army trauma system.24,25

4. Using EM and highly-trained ATLS physicians in the presurgical portion of the trauma system can increase system 

efficiency and resource utilization.24-27

5. Certain patients always need early surgeon involvement for life-saving surgery (hypotension with penetrating neck and 

torso trauma).27,28

Medical Evacuation Times 

1. The golden hour was a “best guess” rule-of-thumb created 30 years ago and was not based on data.29

2. Combat trauma deaths likely occur in a bimodal distribution with the first peak of death from immediately after 

wounding to 15 minutes and the second peak at 60 to 180 minutes.19,30-32

3. The time distribution of death is highly dependent on type of injury and not all injuries produce temporal-based peaks 

of death (specifically severe head injury).32

4. High-level enroute care may decrease mortality despite longer evacuation times.33

5. Prehospital care in the military system is divided into ATLS facility care and surgical facility care.33,34

6. By reviewing TPtoA and TPtoS data, we can begin to describe which injuries require rapid initial ATLS care versus 

surgical care.32,35,36

Medical Evacuation System 

1. Advanced care (paramedic-level and above) during transport of the severely wounded improves survival.37-39

2. A template for each type of conflict with specific MEDEVAC triage criteria to determine appropriate enroute and 

presurgical treatment is needed.22,34,39

3. Research is needed to determine the physiologic and anatomic parameters for appropriate enroute treatment and 

triage (ATLS versus surgical).39-41

GLOSSARY 

ATLS - advanced trauma life support MEDEVAC - military medical evacuation 

DCS - damage control surgery RTS - revised trauma score 

EM - emergency medicine TPtoA - time from point-of-injury to the first ATLS facility 

FST - forward surgical team TPtoS - time from point-of-injury to first surgical facility 

LSIs - lifesaving interventions 
 July – September 2010 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

mature intensive care unit staff and protocols? It is 

unknown which of these components is the most important for improvement in outcome. The applicability 

of results from civilian trauma systems to the military 

situation is unclear. There are several differences between these 2 types of trauma. Military trauma produces more complex injuries than those seen at modern urban trauma centers. Military injuries often occur 

in larger numbers and in more austere locations than 

even the most rural parts of the United States. Despite 

these differences, it is still reasonable to evaluate 

civilian data for its applicability to the military setting. 

In 1979, West, Trunkey, and Lim studied trauma in the 

city of San Francisco versus the much larger suburban 

land area of Orange County, California.15 There were 

more preventable deaths in Orange County, an area 

without a trauma system, than in San Francisco. In a 

further review of trauma system development in 1985, 

Cales and Trunkey found that studies of trauma systems showed improved outcomes over areas that did 

not have organized systems.43 Other recent studies 

continue to show decreased mortality of 15% to 25% 

in designated trauma centers and trauma systems.4-7

Surgeons who trained in urban medical centers prior to 

the era of the trauma system and then went to work at 

other hospitals observed that it was: 

...impossible to deliver optimal care to injured patients 

outside urban trauma hospitals; a surgeon’s individual 

effort was not enough when a systematic approach to 

trauma care did not exist in an area.42

In 1991, the University of Michigan Medical Center 

compiled its 4-year data to determine if patients still 

benefited from the trauma center if they were first seen 

at an outlying center, then transferred to the level I 

center after initial treatment. Survival of 469 blunt 

trauma patients received from outlying centers after an 

average of 4.7 hours was identical to predicted survival when compared to national norms.11

A similar study in Vermont in 1999 concluded that 

initial stabilization of trauma patients at an outlying 

facility does not increase mortality. Their data showed 

an average time of 182 minutes at the referring 

hospital with an average transfer transport time to the 

level I center in Vermont of 72 minutes. Patient injury 

severity score (ISS) and age contributed to mortality 

(P = .0001), but transfer times did not (P = .473).12

A study of 2003 data from Rhode Island demonstrated 

that hypotensive patients who were transported to the 

level I trauma center from an outlying hospital had a 

38% mortality versus a 5.1% mortality for transferred 

patients who were normotensive (P  .001). The 2 

groups had a similar emergency department (ED) time 

at the referring hospital (134.3 minutes versus 167 

minutes, P = .114), but the hypotensive group had a 

significantly higher ISS (29.6 versus 15.6, P  .001) 

and lower Glasgow Coma Score* (8.1 versus 12.7, 

P = .001).44

Data from the Carolinas Medical Center collected over 

a 7-year period from 1996 to 2003 regarding transfers 

from level III facilities compared with other nondesignated facilities showed significantly improved outcomes in patients treated first at level III designated 

centers prior to transfer. Average scene time for these 

patients was 18.6 minutes, average transport time was 

12.0 minutes, and average stay in the level III ED was 

120 minutes. Despite the long ED times at the outlying 

level III referral centers, patients did better when seen 

in these facilities first as compared to other nondesignated referral hospitals.6

Most recently, the literature and the focus of the trauma community has shifted to an examination of the 

quality of rural trauma care.14 A 1995 preventable 

death study in rural Montana concluded that “factors 

such as time to definitive care may not be as important 

as the type of care rendered during that time...”8

 The 

study found a preventable death rate of 13% and a rate 

of inappropriate care of 32%. Fifty-nine percent of 

preventable deaths occurred in the ED and were the 

result of poor initial trauma management techniques 

dealing with airway control, the recognition of chest 

trauma, volume replacement, hemorrhage control, and 

delayed surgical intervention. It was hypothesized that 

such deficiencies were attributable to lack of 

knowledge of ATLS among physicians working in the 

rural EDs.8

A 1996 study in rural northern Michigan showed 

results similar to the Montana study. The preventable 

death rate was 12.9% and included primarily inappropriate prehospital care (23%) and inappropriate ED 

*The Glasgow Coma Scale is a quick, practical, standardized 

system for assessing the degree of consciousness in the 

critically ill and for predicting the duration and ultimate 

outcome of coma, primarily in patients with head injuries. The 

system involves eye opening, verbal response, and motor 

response, all of which are evaluated independently according 

to a rank order that indicates the level of consciousness and 

degree of dysfunction. Source: Mosby’s Medical Dictionary. 

8th ed. St Louis, MO: Mosby-Year Book, Inc; 2009. 
8 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

trauma evaluation and treatment, especially regarding 

airway and hemorrhage control (39%).9

 This study 

again highlighted the importance of adequate ATLS 

skills in initial trauma treatment in the ED. 

A 2002 study comparing data from Oregon and 

Washington during the period January 1991 to December 1994 highlighted that centers designated as level 

III and those preparing for designation both have 24-

hour coverage in the ED by ATLS trained physicians 

and have equal risk-adjusted odds of death. When 

probability of death was compared with observed 

deaths, both of these hospital categories had more 

excess survivors than level IV and level V centers that 

did not maintain ATLS trained physician coverage.10

A publication in 2003 provides data on patients undergoing damage control surgery (DCS), specifically exploratory laparotomy, at a rural hospital prior to 

transfer to a regional trauma center. It concluded that 

DCS at a rural center prior to transfer does not affect 

mortality.13

A study from rural Missouri level III centers in 2007 

indicates that approximately 1% of trauma patients at 

these centers will need a chest or abdominal operation. 

Approximately 3% of patients had a revised trauma 

score (RTS) below 6.00, and approximately 2% were 

hypotensive on admission. The data indicated a potential need for DCS prior to transfer to a level I center.14

In conclusion, the implementation of trauma systems 

in the civilian sector has resulted in improved outcomes for trauma patients. The presence of level III 

centers that have ATLS-trained physicians on duty 24 

hours a day decreases preventable deaths in rural 

areas. The transportation of a patient to a designated 

level III center with the subsequent delay in arrival at a 

level I center, even up to 4 hours, does not increase 

mortality, and may decrease mortality in rural areas. 

An RTS less than 6.00 and hypotension in patients 

with chest or abdominal injury may determine a need 

for DCS prior to transfer to a level I center. 

Military Trauma Systems 

Civilian and military trauma have a shared history over 

the past century as lessons learned from major wars 

and conflicts have translated into advances in civilian 

trauma care. Complimentary advances in civilian 

trauma care during times of peace have affected the 

way we manage military trauma. There have been 4 

significant areas of development in the past century: 

wound care, control and correction of blood loss, 

prevention and treatment of organ failure, and 

organization of surgical care.16

In World War I, the US Army fought a major war 

against an opposing nation on a continental scale. 

Trench warfare and artillery use were prevalent tactics. 

Removal of injured soldiers from “no-man’s land” was 

difficult, and evacuation times to first physician 

medical care averaged 12 to 18 hours.15 World War II 

brought motorized vehicles and tanks with rapid 

maneuver warfare. Transportation advances resulted in 

a decrease in casualty transport times of more than 

50%.15 Additionally, injured soldiers were resuscitated 

with fluids and blood, and there were advances in 

surgical care. Starting in 1942, auxiliary surgical 

groups treated casualties at locations which, by that 

day’s standards, were considered close to the front 

lines.17

During the Korean Conflict, helicopters were used for 

the first time to bring battle casualties directly to the 

mobile army surgical hospital (MASH), decreasing 

time from injury to surgical treatment to 4 to 6 hours. 

In Vietnam, transport time was further decreased to 1.2 

to 5 hours from the point-of-injury.16 During Operation 

Desert Storm, the MASH was not able to keep pace 

with the rapidly advancing ground assault. Portions of 

the MASH were used as smaller surgical teams and 

moved forward more rapidly in support of the forward 

edge of the battle area.18 Modern technology and tactics used for this large-scale invasion outpaced surgical 

support assets. Recognizing this shortfall in surgical 

support, the Army created the forward surgical team 

(FST). 

During the initial phases of Operations Enduring 

Freedom and Iraqi Freedom, FSTs were used to 

provide combat surgical support. OEF was primarily a 

special operations fight in an austere and geographically challenging environment (Afghanistan). Initial 

life- and limb-saving surgery was performed by 2 

FSTs. The battlefield slowly shifted to conventional 

units performing full-spectrum operations after the 

initial downfall of the Taliban. Change in conflict type 

created a change in optimal FST utilization. Efficient 

placement of surgical assets in this theater continues to 

be influenced by medical evacuation limitations, 

Transforming US Army Trauma Care: An Evidence-Based Review of the Trauma Literature 
 July – September 2010 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

including a rugged geography and difficult winter 

weather. 

During the initial phase of OIF, FSTs successfully 

provided surgical support for a rapidly advancing 

conventional force. After the capture of Baghdad, the 

establishment of the combat support hospital (CSH) 

and the freedom of movement for medical evacuation 

helicopters minimized time from injury to arrival at 

surgical care throughout the theater. The 17 surgical 

units (including FSTs and US Navy surgical units in 

support of Marine forces) still under the operational 

control of combat commanders were no longer 

needed.18 In this theater, reevaluation of surgical resource utilization did not occur immediately after 

completion of the maneuver phase. Both of these 

recent conflicts demonstrate the lack of well-defined 

planning parameters by which to determine the optimal trauma resource utilization for support of the 

Army as it rapidly transitions between various stages 

of warfare and between various conflict types. 

In 2004, the US military jointly collaborated to 

introduce a theater trauma system for OEF and OIF. 

Along with appointing a trauma director over the 2 

theaters, improvements included recommendations for 

optimal placement of surgical assets, effective 

utilization of surgical assets, development of triage 

criteria for casualty evacuation, and implementation of 

trauma clinical practice guidelines. Since that time, 

there have been marked improvements. Noteworthy 

advances have occurred regarding prevention of 

injury, point-of-injury battlefield care by the combat 

medic, information management systems, data gathering and research, and predeployment education.1

Our current experience in OIF compares favorably to 

Vietnam and World War II. In 2007, Bellamy45

compared the killed-in-action statistic (see inset) of 

16.1% in OIF versus 21.1% in Vietnam. Interestingly, 

the died-of-wounds statistic (see inset) of 5.3% in OIF 

was higher than in Vietnam (3.3%). Likely 

contributing factors for this difference are improved 

body armor and advances in battlefield care decreasing 

immediate KIA numbers. These results beg the 

question of the best design of a military trauma system 

that provides optimal point-of-injury care, the most 

rapid evacuation to ATLS care or surgical care, and 

rational utilization of scarce trauma resources to 

produce the best outcomes for casualties of war. 

Insightful data regarding causes of mortality in 

patients with potentially salvageable injury is available 

in 2 papers. Champion et al note that 50% of 

battlefield deaths are due to exsanguinating 

hemorrhage using all data from World War I to the 

Somalia combat. Of these, 80% are in 

noncompressible torso areas. They also show that 25% 

of the Vietnam ground combat KIA died of surgicallyuncorrectable torso injury, 10% died of surgicallycorrectable torso injury, and 9% died of 

exsanguinating extremity wounds.19 Kelly et al 

compare deaths from 2003 and 2004 to deaths in 2006 

in OEF and OIF. Among potentially survivable 

injuries, 83% were due to hemorrhage. Among these, 

49% were noncompressible torso hemorrhage, 21% 

were hemorrhage not amenable to tourniquet 

placement (axillary, neck and groin regions), and 33% 

were hemorrhage amenable to tourniquet placement.20

Overall, this data suggest that some KIA from 

penetrating torso injury, possibly up to 50%, are 

potentially salvageable by an immediately available 

and appropriately placed surgical team. 

Most recently, Eastridge et al reviewed Joint Theater 

Trauma Registry data from April 2004 to April 2006. 

They compared outcomes for US military battle 

casualties that were admitted first to the FST versus a 

CSH. With comparable ISS scores, he found no 

significant difference in DOW rates between the 2 

groups. They conclude that both the FST and the CSH 

have equivalent trauma outcomes.21

It is useful to also examine the combat trauma system 

of the Israeli Defense Forces (IDF) as they are a 

modern military and have been engaged in multiple 

conflicts of a varying nature throughout the last half 

century. Their military medical support is structured 

around 3 types of conflict. In a full-scale war, they 

place nonsurgeon physicians, trained in “military 

trauma life support” (MTLS), their version of ATLS 

adapted to battlefield conditions, at battalion and 

Killed in Action: percentage of immediate deaths 

among all seriously injured (those injured not 

returning to duty within 72 hours). 

Died of Wounds: percentage of deaths following 

admission to a medical treatment facility among 

all seriously injured (those injured not returning 

to duty within 72 hours). 

Source: Holcomb et al46
10 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

brigade levels. They also train paramedics for combat 

and for medical evacuation helicopters. Their small 

surgical units remain part of their field hospitals until 

needed for specific missions or for an unexpected 

event. During low-intensity conflicts, medical teams 

with MTLS-trained physicians deploy along their 

border. Civilian level I trauma centers are used as 

military surgical support. Wounds are treated and 

temporized by the border MTLS teams if the 

evacuation time to the trauma center is more than 30 

minutes. The IDF finds no benefit in delaying 

transport to the trauma center to stabilize the patient if 

evacuation time is less than 30 minutes. “Team-10” is 

the Israeli mobile surgical unit developed for support 

of IDF special operations missions. It can be recalled 

and moved by helicopter or by small boat within 30 

minutes of notification.22

In summary, military battlefields and tactics change 

over time. Our combat trauma systems and components must change to keep pace with the changing 

requirements of the modern battlefield. The FST has 

proven itself successful as a supporting trauma surgical asset for modern, rapidly advancing, conventional 

warfare. With modifications, the FST has also successfully filled the role of providing surgical and nonsurgical trauma care at below the theater military role III 

setting for current stabilization and counterinsurgency 

operations with proven equivalent outcomes when 

compared to the role III CSH facilities. Placement and 

appropriate utilization of surgical assets within the 

current battle environment is of the utmost importance 

as up to 50% of potentially survivable KIA injuries 

may be surgically correctable. The appropriate mobile 

surgical asset capable of maintaining modularity and 

flexibility for the rapid shifts in conflict type within a 

single, complex battlefield has yet to be designed. 

Providing a theater trauma system with the capability 

to rapidly and seamlessly blend surgical and nonsurgical trauma capabilities to support these rapid 

shifts is the next challenge. 

Presurgical Trauma Care 

The care of civilian trauma patients starts with the first 

responders and proceeds through evacuation to a 

trauma facility. Civilian level I/II trauma centers will 

have emergency medicine (EM) physicians and trauma 

surgeon teams available at all times for serious 

injuries, comparable to the capabilities of the theater 

CSH. A civilian level III trauma center will have an 

EM physician with a plan for trauma surgeon recall if 

needed. The military equivalent of the civilian level III 

trauma center includes treatment at both an ATLS 

facility (the level III emergency department) and a 

surgical facility (the level III with surgeon activation). 

Thus, in the military it is possible to render presurgical 

lifesaving interventions (LSIs)47 at an ATLS trauma 

facility without necessarily having the trauma surgical 

capabilities at the same location. 

Several reports in the literature focus on military 

presurgical care. In a 1999 article, Husum cites data 

from the battle of Jalalabad (1989-1992). Comparing 

the effect of untrained first responders in 1989 to data 

collected after the institution of paramedics in the 

battle zone, prehospital mortality decreased from 

26.1% to 13.6%. These paramedics were trained to 

provide basic lifesaving techniques plus intubations, 

chest tubes, bleeding control, intravenous fluid, 

antibiotics and analgesia. They were also trained to 

determine if a patient was unstable and needed 

immediate surgical intervention, and those patients 

were immediately diverted to the surgical hospital in 

Peshawar, Pakistan, arriving in 5 to 7 hours. Other 

patients were treated on-scene and arrived at the 

nearest clinic in an average of 20 minutes as compared 

to the previous 90 minutes.23

A 2008 report of a US Marine Corps shock trauma 

platoon (STP) by Sallee et al describes the work of a 

military role 1, contingency-based, initial trauma response team. The team is designed to be staffed with 2 

EM physicians as well as a physician’s assistant, a 

registered nurse, and 11 corpsmen. During OIF II in 

March 2004, STP-2 treated 141 combat related 

casualties with only 3 DOW. Interventions included 2 

emergency thoracotomies, intubations, chest tubes, 

blood transfusions, central lines, and FAST exams. 

This unit provided initial LSIs, allowing many patients 

to survive to reach the nearest surgeon.24

Gerhardt et al reports the unique experience over one 

year in OIF during which time Gerhardt was the 

emergency medicine physician at a battalion aid 

station (BAS) (military role I). Standard BAS 

equipment was available which did not include laboratory and x-ray capabilities or blood products. The 

article compares patients seen at the BAS versus 

aggregate OIF data over the same time period, with 

favorable results. With ISS equal between the 2 

groups, the article notes a battle-casualty rate of 22.2% 

(versus 6.7% aggregate) and a DOW mortality of 2.8% 

Transforming US Army Trauma Care: An Evidence-Based Review of the Trauma Literature 
 July – September 2010 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

(versus 5.3% aggregate). The 5 DOW patients 

included one exsanguination from lower extremity 

amputations at the BAS, and 4 patients that survived to 

reach the next level of care but died later. Two patients 

had gunshot wounds to the head and two had gunshot 

wounds to the torso with reported “protracted” 

evacuation times to the BAS.25

The integration of care at the civilian level III trauma 

center with care at the level I trauma center is 

comparable to the integration of military trauma units 

forward of the CSH with the CSH. This equivalent 

military system of care can draw lessons from civilian 

data examining this relationship. The previouslymentioned study from Rhode Island in 2003 examined 

trauma victims brought directly to the level I trauma 

center (transport time < 20 minutes) and compared 

them to those brought to the nearest facility ( > 20 

minutes transport to level I center).44 The data showed 

that overall hypotensive patients had a higher mortality 

(38% versus 5.1%). However, there was no association 

between ED time and mortality. The authors conclude 

that patients with severe trauma (ISS > 40) may benefit 

from ATLS at outlying EDs if evacuation time to the 

level I trauma center is long. In a commentary on the 

article, J. W. Meredith, MD, also notes that: 

There is...a degree of preventable injury, preventable 

death, which cannot be addressed by simply having a 

good trauma center in the middle of a population. That 

is the part where a trauma system comes in.44

Another key component of the civilian trauma system 

is the EM physician who is trained to provide the 

ATLS LSIs in every civilian level I trauma center. 

Before the creation of the EM physician, emergency 

rooms were staffed with physicians without appropriate trauma training to provide the stopgap measures 

needed to temporize the patient until seen by a trauma 

surgeon. Thus, trauma surgeons evaluated and treated 

all trauma patients regardless of need for surgery or 

continued intensive care. Additionally, operative 

management was much more common prior to the 

development of the CT (computed tomography) 

scanner. Today, well-trained EM physicians are 

capable of initially managing and treating a majority of 

moderately injured trauma patients and provide 

important ATLS interventions in conjunction with or 

prior to arrival of the trauma surgeon, or sometimes 

even independently at certain trauma centers.26

Although many military trauma patients will eventually require surgery, most such surgeries are not lifeor limb-saving and can wait up to several hours. Thus, 

most combat surgery can be performed later at the 

theater trauma hospital after the patient is seen by an 

EM physician shortly after being wounded. 

The American College of Surgeons mandates surgeon 

presence for major criteria that include hypotension, 

respiratory compromise, penetrating gunshot wounds 

to the neck, chest, abdomen, or pelvis, and a Glasgow 

Coma Score < 8.27 However, Green argues in a 2006 

article for the use of “secondary triage criteria.” This 

allows primary triage on the scene and then secondary 

triage at the trauma center to determine the need for 

the presence of the surgical trauma team. He rightly 

argues that for certain traumas, a surgeon may not be 

needed immediately. For example, an EM physician 

can manage a head injury requiring intubation, initial 

ATLS, and a head CT before neurosurgeon consultation.26 There is little role for the surgeon in this case. 

In his commentary on Green’s article, Moore supports 

this premise but also reaffirms the overarching role of 

the trauma surgeon in the care of trauma patients: 

I submit the strategic question is when the surgeon 

should assume responsibility for the patient with 

potential significant injuries in the ED, not if the 

surgeon should be involved during the ED phase of 

trauma care...I strongly believe that the trauma surgeon 

must be present for the resuscitation and decision 

making for patients who may need early operative 

intervention because this will save them.28

In 2007, Markovchick and Moore wrote that protocols 

for trauma surgeon presence should be created with the 

goal: 

...to have a trauma surgeon present on arrival for those 

patients who have a high likelihood of going to an 

operating room immediately for life- or limbthreatening injuries.27

They summarize that a “needs assessment” should be 

done in communities to determine how many and of 

what level trauma centers are needed to support the 

population. The creation of new trauma centers should 

be: 

...limited so that the valuable resources and expense of 

trauma care can be kept to a minimum while at the 

same time ensuring optimum outcome.27

To summarize, our Army trauma system does not have 

a modular, fixed facility system that provides both the 

central theater care (civilian level I-type trauma center) 

and the outlying center care (level III-type, fixed-
12 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

facility). The military may benefit from a single unit 

that incorporates both of these aspects of the system. 

Beyond this level of care, specific presurgical trauma 

units and paramedics can provide near–point-of-injury 

(near-POI) ATLS care. Currently, only surgeons at 

FSTs are filling this ATLS role, in addition to their 

surgical role. 

A significant portion of trauma patients can be treated 

initially by EM physicians and paramedics performing 

ATLS level LSIs near the point-of-injury in outlying 

locations. Although most penetrating military trauma 

will eventually require surgical involvement, much of 

this trauma can be first stabilized with ATLS, 

extending the survival time until surgery at another 

location. Military EM physicians are currently 

underutilized in this role. Using EM physicians to their 

full potential may improve survival within this presurgical, near-POI portion of the military trauma system, 

and it may increase system efficiency and resource 

(especially surgical resource) utilization. 

Some EM physicians and trauma surgeons are advocating the development of secondary triage criteria for 

alert of the trauma surgeon teams. Still, a subset of 

trauma patients must have early trauma surgeon involvement to save life and limb. Specifically, these 

include hypotensive patients with penetrating neck and 

torso wounds. 

Medical Evacuation Times 

Bellamy et al point out that 80% to 90% of casualties 

that survive to evacuation have little chance of dying, 

and that military trauma has an “all-or-none nature.”48

In another article, Bellamy even asks whether there is 

only a “platinum 5 minutes.”49 Champion et al propose 

that: 

Those with ongoing hemorrhage of a rate that does not 

result in prompt exsanguination might benefit from 

resuscitation strategies, tactics, and techniques that aim 

to stretch the mythical golden hour to a 4- to 6-hour 

window before definitive care can be exercised.19

A review of the literature and how times affect our 

trauma system is more pertinent now than ever. 

The term “golden hour” is traced to Cowley, who in a 

1974 speech to the American Academy of Orthopedic 

Surgeons stated that “care given in the first hour 

determines the extent of organ damage.” He goes on to 

say that “it may even be that we should be talking 

about the first golden fifteen minutes as a vital 

period.”29 To be clear, there were no published data to 

support his statements. 

Turning to the literature, we find relatively sparse data 

regarding prehospital times and survival. A Swiss 

study published in 2002 reviews data on patients 

separated into 2 groups, the first with prehospital times 

< 60 minutes, and the second with times >60 minutes. 

Median ISS scores were similar and time to ED had no 

influence on mortality (P=.057). Although the P value 

approached significance, the “death < 1 day percentage” was actually higher for the < 60 minute group 

when compared to the > 60 minute group (73 deaths 

versus 40 deaths respectively). Also noteworthy was 

the fact that within the > 60 minute group, 91% of 

transports had an EM physician on the scene (scene 

time of 34 minutes) compared to the < 60 minute 

group that had an EM physician on the scene only 49% 

of the time (scene time of 17 minutes). In the > 60 

minute group, more EM physicians were on the scene 

and scene times were longer, but patients had a lower 

mortality that approached statistical significance.30

A 2002 study by Clark was significant in that it 

segregated times to the ED and times in the ED (prior 

to the operating room). Of 243 patients with a systolic 

blood pressure (SBP) < 90 from the Pennsylvania 

Trauma Systems Foundation trauma registry, total 

time from injury to the operating room was 28 to 938 

minutes, with a median of 110 minutes. The relative 

risk (RR) of death was significantly higher in those 

with SBP <60 (RR=2.40) versus those with SBP>80 

(RR=0.62) and a SBP>90 (RR=0.45). Risk of death 

was not influenced by the prehospital time. Risk of 

death was significantly increased at an ED time of 60 

to 90 minutes and with a total time (prehospital time 

plus ED time) of 60 to 90 minutes.31

A different review of penetrating torso injuries in 

patients aged 18 to 45 years from the Pennsylvania 

trauma registry was cited by Champion in 2003. It 

significantly related an increased risk of death and a 

decreased time to death with worsening hypotension as 

shown in Table 2. With a SBP <90, time to death was 

still 188 minutes, and with a SBP < 75 time to death 

was 161 minutes.19

An interesting article by Demetriades et al regarding 

data from Los Angeles County (California) was 

published in 2005. Data was collected on 3,549 trauma 

Transforming US Army Trauma Care: An Evidence-Based Review of the Trauma Literature 
 July – September 2010 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

center deaths and 602 scene deaths. Scene deaths 

reflected a significantly higher percentage of 

penetrating trauma deaths than blunt trauma deaths 

(24.8% versus 15.8%). The time distribution of 

penetrating trauma deaths showed 24.8% dead on the 

scene, 38.9% dead in less than one hour, 19.0% in one 

to 6 hours, 7.1% in 6 to 24 hours, and 10.2% in more 

than 24 hours (Figure 1). The authors conclude a 

bimodal death distribution supporting a less than and 

greater than one-hour division. However, they do not 

attempt to break down data based on times shorter than 

one-hour and the category of “one to 6 hours” is 

relatively broad. Additionally, they examined the 

temporal distribution of trauma deaths of severe 

(abbreviated injury score (AIS) ≥ 4) versus not severe 

chest trauma (AIS < 4) and concluded that a higher 

percentage of those with severe chest trauma died 

within the first hour (Figure 2). A similar analysis of 

severe versus not severe head trauma showed that 

there was no peak of death in those with severe head 

trauma (Figure 3). Adjusted odds ratios of death within 

one hour of injury were calculated and were found to 

be 2.21 for penetrating versus blunt trauma, and 4.35 

for severe chest trauma.32

Finally, in 2008 Haas et al studied patients with 

hypotensive penetrating trauma and blunt traumatic 

brain injury in trauma centers and nontrauma hospitals. 

They noted that the relative risk of death was lower at 

trauma centers versus nontrauma centers (RR= 0.61). 

The survival advantage was the largest for patients 

with penetrating trauma and shock (RR= 0.43) and 

with traumatic brain injury (TBI) with mass effect (RR

= 0.72). Interestingly, however, there was no difference in time to operation in patients with penetrating 

injury (61 minutes versus 41 minutes respectively, P

= .20) and no difference in times to assessment and 

intervention in patients with TBI (3.3 hours versus 3.6 

hours respectively, P = .17). This raises the question as 

to the cause of improved outcomes in trauma centers 

since more rapid transport, evaluation, and 

intervention were not present in trauma centers. The 

authors conclude that improved critical care, increased 

physician experience, and improved interdisciplinary 

communication at trauma centers may lower the 

relative risk of death.35

There is no published comprehensive US military 

review of prehospital or medical evacuation data. 

However, in 2007 McLeod et al discuss prehospital 

times for United Kingdom (UK) personnel in Afghanistan and Iraq during 2006 and 2007. They note that in 

the study group of 528 casualties, median times of 

Figure 1. Temporal distribution of trauma deaths according to mechanism of injury (Los Angeles 

County, January 2000 to December 2002). Data from Demetriades et al.32(p346)

63.7%

19.0%

7.1% 5.6%

2.0% 2.6%

34.8%

17.6%

11.7%

14.0%

8.9%

12.9%

0%

10%

20%

30%

40%

50%

60%

70%

Died at Scene

≤ 1 h

> 1 hour to

≤ 6 hours

> 6 hours to

≤ 24 hours

> 24 hours to

≤ 72 hours

> 3 days to

≤ 1 week

> 1 week

Penetrating Injury (n=1,521)

Blunt Injury(n=1,423)

Table 2. Risk of death and average time to death 

in civilian settings by systolic blood pressure*

Systolic Blood 

Pressure (mm Hg) Risk of Death Time to Death (min) 

90 + 0.042 419 

76-89 0.061 188 

50-75 0.458 161 

< 50 0.95 18 

*Data from Champion et al.19
14 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

injury to arrival of the medical emergency response 

team (MERT) was 80 minutes, median time on scene 

was 5 minutes, and median time of injury to handover 

at ED 120 minutes. For all UK military immediate 

(“T1”) patients, evacuation times were not different 

than civilian UK “Category A” calls (99 minutes 

versus 70-80 minutes). The author also notes the 

addition of a physician on the “MERT-enhanced” 

helicopter evacuation teams. Compared to the UK 

civilian system, 

The effect of a prehospital time extended over urban 

civilian models is ameliorated by the seniority of the 

attending clinical team and the range of advanced 

intervention that can be performed in transit.33

In another article from 2007, Parker reports a review 

by the UK military Consultant Orthopedic Surgeon of 

the military planning time rule of “1:2:4.” The 

battlefield casualty should have advanced first aid 

within one hour, resuscitative surgery if needed within 

Transforming US Army Trauma Care: An Evidence-Based Review of the Trauma Literature 

Figure 2. Temporal distribution of trauma deaths according to severity of chest trauma (Los Angeles County, January 2000 to December 2002). AIS indicates abbreviated injury score. 

Reproduced from Demetriades et al32(p347)with permission. 

0%

10%

20%

30%

40%

50%

60%

< 1 hour >1 hour to

≤ 6 hours

>6 hours to

≤ 24 hours

>1 day to

≤ 3 days

>3 days to

≤ 7 days

>7 days

Chest Trauma AIS < 4 (n=2,134)

Chest Trauma AIS ≥ 4 (n=863)

0%

10%

20%

30%

40%

50%

60%

< 1 hour >1 hour to

≤ 6 hours

>6 hours to

≤ 24 hours

>1 day to

≤ 3 days

>3 days to

≤ 7 days

>7 days

Head Trauma AIS < 4 (n=1,669)

Head Trauma AIS ≥ 4 (n=1,328)

Figure 3. Temporal distribution of trauma deaths according to severity of head trauma (Los Angeles County, January 2000 to December 2002). AIS indicates abbreviated injury score. 

Reproduced from Demetriades et al32(p347)with permission. 
 July – September 2010 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

2 hours, and definitive surgery within 4 hours. 

Although he concedes that no published data exists to 

back this doctrine, he did review the UK, Palestinian, 

and Israeli data. From this he notes that “a goal of less 

than 30 minutes is clearly simplistic, futile, and simply 

unachievable.” Also, 

Over 4 hours, the data now suggests that this is when 

the head injured succumb to secondary brain injury and 

the slow torso and junctional bleeders start to die. It is 

also when bacteria on superficial wound surfaces begin 

to divide and penetrate tissue. 

No further data is provided. He concludes that “We 

should aim to have the wounded soldier in the wellresourced operating theatre at the 2- to 3-hour point.”34

Finally, extraordinary data published in 1992 from 

Cutting and Agha describe Cutting’s experience over 

18 months as a surgeon in the Bourj al Borajneh 

refugee camp in Beirut, Lebanon in the late 1980s. Her 

surgical facility was within the camp and no farther 

than 250 meters from all of the wounded. Of 1200 

wounded, there were 160 deaths. Fifty-two percent 

were dead on arrival (< 5 minutes), 12% were dead 

prior to initializing interventions (5 to 15 minutes), 

11% had unsalvageable central nervous system injury, 

and 9% had uncontrollable hemorrhage. So despite 

having a surgical facility virtually at the location of 

injury, she concludes that 84% of deaths could not 

possibly be prevented.36

In summary, despite the classic description of the 

golden hour in trauma care, currently available 

evidence does not support such a concept for most 

injuries. Current data show a bimodal distribution of 

death after serious trauma with the first peak of death 

from immediately after wounding to 15 minutes, and 

the second peak between 60 and 180 minutes. 

Interestingly, mortality of severe head injury is not 

associated with a peak in occurrence of death and 

shows an even temporal distribution. 

The one category of injuries most likely to respond to 

early surgical intervention is penetrating thoracic and 

abdominal injuries with hypotension, which are 

predictive of earlier death. 

A higher level of enroute care may decrease mortality 

despite longer evacuation times. Risk of death is lower 

in trauma centers versus nontrauma centers due to factors that remain obscure but not related to time of care. 

It is likely that combat injuries can be divided into 

several groups: those that require rapid surgical evaluation and intervention (eg, penetrating torso injury 

with hypotension), those that require eventual surgery 

(major orthopedic injuries), and those that can be cared 

for without surgery (eg, severe head injury). 

Evacuation time can also be divided into 2 components 

in the military realm. They are time from point-ofinjury to the first ATLS facility (TPtoA), and time from 

point-of-injury to first surgical facility (TPtoS). By 

distinguishing between these different evacuation 

times, we may describe which injuries require more 

rapid ATLS care versus surgical care. This may help 

improve future triage criteria used by paramedics and 

EM physicians near the point-of-injury. 

Medical Evacuation System 

A trauma system will incorporate efficient medical 

evacuation. Identifying presurgical facility and preATLS facility treatment and triage criteria will 

markedly improve this system. In 1988, West et al 

commented on the current status of trauma systems 

and explained that to improve the system, prehospital 

care must include a medical control element, field 

treatment protocols, a communication method, and 

training for personnel. Furthermore, formalized triage 

criteria should be developed to bring the trauma 

patients with the worst injuries to the most appropriate 

facility.50 This was reemphasized by Johnson et al in 

2001 in an article examining data on patients with 

exsanguinating penetrating abdominal injuries. The authors noted that “...it is our belief that measures taken 

in the early minutes after injury may significantly impact patient outcome.” They defined this initial treatment as “damage control ground zero (DC0).”51 The 

Denver trauma system uses specific prehospital triage 

criteria (Table 3) based on physiologic and anatomic 

parameters.32 Development of this component of the 

military trauma system is exactly what Eastridge et al 

advocate and what the Joint Theater Trauma System 

continues to advocate with its motto, “Right Patient, 

Right Place, Right Time.”34

Military medical evacuation (MEDEVAC) from pointof-injury to ATLS or surgical facility involves more 

than simply care in a helicopter. Army Flight Medics 

(FMs) must be soldiers and aircraft crew-members 

trained to be proficient in hostile environments. Also 

FMs must work with limited available resources due to 
16 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

tactical constraints. Finally, although formally trained 

by the Army at the EMT-B level, most obtain the skills 

necessary to perform more advanced LSIs.37 Provision 

of advanced formal training for FMs and appropriate 

triage criteria may improve the overall Army trauma 

system. 

A 2007 article by Holcomb et al reviews causes of 

death among US Special Forces Soldiers. They 

conclude that 8 deaths may have been prevented with 

more rapid transport to a surgical facility.38

Unfortunately, rapid MEDEVAC in the special 

operations environment is not always possible, but 

the article does highlight that some deaths may be 

prevented by LSIs performed by Special Forces 

medics in the field, by LSIs at an ATLS facility, and 

by life-saving surgery at a surgical facility. Also, 

some deaths are simply not preventable. 

In a 2005 article, Holcomb et al advocate the use of 

initial SBP < 90 and Glasgow Coma Score (GCS) 

motor < 6 as a predictor of mortality and the need for 

advanced care.40 In 2006, Eastridge et al reviewed 

physiologic parameters in 1,127 wounded and determined that SBP, temperature, GCS, hematocrit, pH, 

base deficit, and ISS were all significantly different 

between survivor and nonsurvivor groups. The only 

parameter that was not different was heart rate. 

Furthermore, all of these parameters except GCS were 

significantly different in groups divided by those that 

needed an operation and those that did not.41 This data 

is evidence that supports use of the SBP as a triage 

parameter. 

In 2007, Davis et al reviewed the prehospital literature 

to determine the composition and benefit of the 

MEDEVAC team for the UK military. He concluded 

that a team with a physician with critical care skills 

will have improved outcomes in patients with major 

trauma, earlier intubation and ventilation in severe 

head-injured patients improves survival, and the use of 

chest tube drainage and controlled ventilation will 

improve outcomes of patients with severe thoracic 

injury. The authors note that the UK system uses a 

flight nurse and flight paramedic on its MERT.39

The Israeli Defense Force (IDF) also uses personnel 

with advanced training on its MEDEVAC teams. 

Based on the Israeli Surgeon General’s review of the 

literature, he advocates training for all military 

physicians in military trauma life support (MTLS). 

The team of an MTLS-trained physician and a 

paramedic makes up the IDF MEDEVAC team. IDF 

evacuation policy separates wounded by those with or 

without hemorrhagic shock. If hemorrhagic shock is 

controlled and evacuation time is less than one hour, 

the team will secure airway and breathing, “scoop and 

run,” and start an IV enroute. If the evacuation time is 

more than one hour in the same scenario, the team will 

secure airway and breathing and start an IV with fluids 

at the scene first. In those cases with hemorrhagic 

shock with uncontrolled hemorrhage, the team will 

“scoop and run” and start an IV enroute after 

controlling the airway and breathing in cases where 

evacuation time is less than one hour. If evacuation 

time is more than one hour, the team will do the same 

but will give minimal colloid IV fluid until surgical 

intervention is available.22 The British characterize this 

Israeli approach that is used in their low-intensity 

conflicts centered around their own country’s level I 

trauma centers as a “zero-echelon medical plan” with 

the motto “don’t stop, ever!”34

In summary, the literature recognizes that advanced 

care above the EMT-B level during transport of the 

severely wounded improves survival. Other modern 

nations are placing physicians with special training 

and paramedics on their military evacuation teams. A 

template for each type of conflict with specific triage 

Transforming US Army Trauma Care: An Evidence-Based Review of the Trauma Literature 

Table 3. Prehospital triage criteria for transport to a level I 

trauma center.*

Physiologic Parameters Anatomic Parameters 

Intubation Penetrating injuries – head, 

neck, torso, pelvis 

SBP < 90 mm Hg, or Flail chest 

Respiratory rate <10 or > 29 

with distress, or Bilateral femur fractures 

GCS motor score  5 Unstable pelvis or suspected 

significant pelvic fracture 

 Paralysis or evidence of spinal 

cord injury 

 Amputation above the wrist or 

ankle 

 Significant burns 

 Unreactive or unequal pupils 

*Data from Demetriades et al.32
 July – September 2010 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

criteria to determine the appropriate enroute and 

presurgical treatment is needed. 

Physiologic parameters to use for the system include 

SBP which has been linked to mortality and the need 

for rapid triage to advanced care. Further research and 

development is needed regarding best anatomic and 

physiologic triage parameters. An example triage 

template is included as Table 4. 

RECOMMENDATIONS

Based on the above lessons from the literature as 

summarized in Table 1, the following recommendations will help transform the current US Army 

combat trauma system to keep it relevant for our 

military’s future needs. 

1. Increase training of combat medics and FMs to

provide higher level of care at point‐of‐injury and

during transport of patients. The temporal distribution 

of combat death is likely bimodal with the first peak of 

death at 0 to 15 minutes. Thus, of utmost importance 

to immediate survival is provision of ATLS care at the 

point-of-injury (akin to the described DC0). Combat 

medics and FMs should progress in training from EMTB to EMT-P (based on tactical combat casualty care 

adaptations for the combat zone) during their 

progression to noncommissioned officers. 

2. Develop MEDEVAC contingency plans detailing

conflict‐specific treatment and transfer triage

protocols. Combat casualties enter the military trauma 

system most frequently via helicopter evacuation. 

Clear treatment protocols and transfer triage criteria 

should be developed to determine the patient’s destination (ATLS trauma team, surgical team, or theater 

trauma center). These contingency plans, based on various conflict types, will best prepare MEDEVAC assets to rapidly assume maximum efficiency operations 

within the trauma system, even in unique theaters. 

3. Augment current BAS to provide ATLS level of care.

The ATLS facility should reflect our current civilian 

system of care by EM physicians at US civilian level I 

trauma centers. The BAS already exists as a framework within the combat battalions and should transTable 4. Example template for MEDEVAC triage criteria. 

Ground Point of Injury Triage 

1. If patient can be transported by ground MEDEVAC to nearest ATLS facility < 20 minutes from time of injury (or within 

shorter time than air MEDEVAC time to transport to nearest facility), transport to ATLS facility by ground MEDEVAC. 

2. If ground MEDEVAC > 20 minutes from time of injury to nearest ATLS facility (or longer than air MEDEVAC time), 

call for air MEDEVAC. 

Air MEDEVAC Triage 

1. If uncontrollable hemorrhage from penetrating neck or torso injury, transport to nearest surgical facility with 

the “don’t stop, ever!” paradigm. 

2. If initial SBP < 90 with controlled or controllable extremity bleeding, transport to nearest ATLS facility for resuscitation 

per ATLS guidelines, then on to surgeon at theater hospital 

3. If initial SBP > 90 with controlled or controllable extremity bleeding, transport to surgeon at theater hospital 

4. For 2 and 3 above – if tourniquet in place and time to theater hospital > 3 hours, transport to nearest surgical 

facility to preserve limb 

5. If GCS < 15 with isolated head injury, transport to nearest ATLS facility for resuscitation per ATLS guidelines, 

then to CT scanner and neurosurgeon at theater hospital 

6. If blunt trauma only, transport to nearest ATLS facility for evaluation per ATLS guidelines. 

After ATLS evaluation: 

 if SBP< 90, transport to nearest surgical facility 

 if SBP>90, transport to surgeon and CT scanner at theater hospital 

GLOSSARY 

ATLS - advanced trauma life support MEDEVAC - military medical evacuation 

CT - computed tomography SBP - Systolic blood pressure 

GCS - Glasgow Coma Scale 
18 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

form to be a “Battalion Aid and Trauma” team or 

“BAT” team. To meet this capability, it should include 

EM physicians (or highly-trained ATLS physicians 

such as in the IDF), EM-trained midlevel providers 

(nurse practitioners and physician’s assistants), emergency medicine and/or intensive care unit RNs, and 

combat medics. Its equipment should be equivalent to 

the current FST ATLS section. It should also have 

blood and blood products available for resuscitations, 

portable ultrasound capability, portable laboratory 

capability, and portable x-ray capability. The BAT 

team must be relevant to the combat environment, 

meaning it should be properly placed and accessible by 

ground or air MEDEVAC, even in difficult terrain 

such as in Afghanistan. The team should be mobile to 

accommodate changing operational needs at the 

battalion level. Effective use of BAT teams will 

decrease or eliminate the need for fixed surgical teams 

forward of the CSH in a mature theater. 

4. Optimize the current FST surgical trauma concept

for modularity and flexibility. The surgical resuscitation unit (SRU) should replace the current FST as the 

surgical capability designed to support the full 

spectrum of operations (rapid maneuver phase, 

stability, counterinsurgency, special operations). It 

should consist of 2 general surgeons, an anesthesia 

provider, 2 operating room technicians, an emergency 

room or intensive care unit RN, a licensed practical 

nurse, and a combat medic. The 8-soldier SRU should 

be mobile by tactical vehicle, but also airmobile if 

needed. It should carry a basic laboratory capability, 

an ultrasound machine, and blood products. Its 

flexibility and modularity are its advantages over the 

current FST design, enabling it to rapidly adapt to a 

changing environment. For example, it can operate 

independently (like a split FST), as augmentation of a 

BAT team at a battalion level, or with another SRU 

and a BAT team (like a full FST) during large 

maneuver warfare operations. Its design enables it to 

rapidly shift a surgical capability based on changing 

operational environments within a single theater. 

5. Augment the current CSH to provide the full‐

spectrum theater trauma system. The theater trauma 

system can be based on the current US Army CSH 

design. The CSH-Combat Trauma System (CSH-CTS) 

should provide command and control of the entire 

theater trauma system. One-half of the CSH-CTS 

should be the military equivalent of a civilian level Itrauma center for the theater. The other half should be 

modular. This modular portion should be designed to 

tailor the trauma system based on the specific theater 

needs, and it does this by splitting from the main portion and moving to cover up to 2 outlying locations, 

assuming the equivalent role of civilian level II/III 

trauma centers. These modular portions should still be 

commanded by the CSH-CTS commander to ensure a 

smoothly operating theater trauma system comparable 

to the leadership in the civilian trauma system model. 

In summary, the scheme of support of the CSH-CTS 

should entail: 

 Initial ATLS-level trauma support by the BAT 

teams at the battalion level providing LSIs to 

prolong acceptable time to surgical care, 

 Outlying CSH-CTS surgical facilities placed based 

on individual theater analysis to perform life- and 

limb-saving surgical interventions, 

 The main CSH-CTS as the “theater trauma 

center,” 

 An efficient, protocol-driven treatment and transfer triage criteria MEDEVAC system, and 

 Two contingency-based, centrally located SRUs 

under the operational command and control of the 

CSH-CTS. 

Finally, through collection and assessment of data 

from current military operations, by proactive 

assessment of near-future military operational needs, 

and by a continuous review of relevant trauma 

literature, we can optimally transform our current 

combat trauma system for future operational environments. This paper provides an evidence-based review 

of key aspects of the trauma literature relevant to our 

goal of trauma system transformation. As US Army 

surgeons and physicians, we must remain proactive 

and prepared to provide the optimum combat trauma 

care for our American Soldiers wherever and 

whenever they must go. 

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 July – September 2010 19

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Transforming US Army Trauma Care: An Evidence-Based Review of the Trauma Literature 
 July – September 2010 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

AUTHORS

LTC Remick is Chief of General Surgery, Blanchfield 

Army Community Hospital, Fort Campbell, Kentucky. 

Previously he was Commander, 772nd Forward 

Surgical Team deployed to Afghanistan for 15 months 

in support of Operation Enduring Freedom. 

LTC Dickerson is a Fellow in Minimally Invasive and 

Bariatric Surgery at Duke University Hospital, Durham, 

North Carolina. He has made deployments as a general 

surgeon to both Iraq and Afghanistan. 

LTC Nessen is a Trauma and Critical Care Fellow at 

the University of Nevada Medical Center, Las Vegas, 

Nevada. Previously he was the Commander, 541st 

Forward Surgical Team (Airborne) deployed to 

Afghanistan for 15 months in support of Operation 

Enduring Freedom. 

COL Rush is Chief of Surgery, Madigan Army Medical 

Center, Tacoma, Washington. He is also an assistant 

professor of surgery at the Uniformed Services 

University of the Health Sciences, Bethesda, Maryland, 

and clinical instructor in surgery at the University of 

Washington, Seattle. Previously he was the Deputy 

Commander for Clinical Services of RC East and the 

Craig Joint Theater Hospital, Bagram, Afghanistan. 

COL Beilman is Chief of General Surgery and Division 

Head of Critical Care and Acute Care Surgery at the 

University of Minnesota. He was previously deployed 

as the US Central Command Joint Theater Trauma 

Director in Iraq and Afghanistan. 

Photo courtesy of LTC Kyle Remick. 
22 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

In this article, we describe the in-theater experience 

with mild traumatic brain injuries (TBIs) and the 

changing approach to management, with the emphasis 

on in-theater evaluation that maximizes return to duty 

status and minimizes evacuation to Germany or to the 

United States. We also discuss the incidence, pathophysiology, recognition, and treatment of both TBI 

and its aftermath, postconcussion syndrome. 

BACKGROUND

Every war seems to have its singular pattern of 

distinctive injuries or illnesses. Examples include the 

extremity amputations of our American Civil War and 

the cold weather injuries that were so prevalent during 

the Korean conflict. For Operation Enduring Freedom 

(OEF) [Afghanistan], the signature injury has become 

TBIs secondary to improvised explosive device (IED) 

exposures.1

 This situation is the result of a variety of 

reasons, but the additional protection provided by the 

enhanced body armor and the greater protection provided by the newer armored vehicles have reduced the 

number of fatalities from these blasts, and increased 

the number who suffer blast effects and survive. 

The Department of Defense definition (below) of TBI 

is one of many available2

: 

A traumatically induced structural injury and/or physiological disruption of brain function as a result of an 

external force that is indicated by the new onset or 

worsening of at least one of the following clinical signs, 

immediately following the event: 

 Any period of loss or a decrease in the level 

of consciousness. 

 Any loss of memory for events immediately 

before or after the injury. 

 Any alteration in mental state at the time of 

the injury (confusion, disorientation, slowed 

thinking, etc). 

 Neurological deficits (weakness, loss of 

balance, change in vision, praxis, paresis/

plegia, sensory loss, aphasia, etc) that may or 

may not be transient. 

 Intracranial lesion. 

We favor the above definition for its cause and effect 

relationship and the fact that it is reliant upon input not 

just from the affected individual, but requires input 

from a trained, objective provider. 

Published data from the mid phases of the Iraq conflict 

show an incidence of 5% of Soldiers suffered a TBI 

with some effect on the loss of consciousness (LOC) 

and up to 10% suffered a TBI without any effect on 

LOC.3

 These reports are likely an underrepresentation 

since this was drawn from retrospective and selfreported data. Current efforts are underway to improve 

real-time tracking and reporting, but we feel the 

incidence in OEF is even higher, especially as troops 

are subject to multiple tours and repeated exposures to 

IEDs. The exposure to IED blast is a very common 

event among actively patrolling troops. We expect that 

eventually the published figures will show numbers 

beyond that experienced in Operation Iraqi Freedom.4

An empirical observation is that repetitive subclinical 

injury from prior event(s) over time, often suffered 

over multiple tours, lowers the threshold for induction 

of TBIs by the next blast. 

PATHOPHYSIOLOGY

A long term assumption was that since typical central 

nervous system imaging studies (ie, computerized 

tomography (CT) scans of the head) are normal in the 

vast majority of those with mild TBI, no structural 

damage had occurred. We now know from a variety of 

sources that microscopic level damage occurs diffusely 

throughout the brain.5

 This has been confirmed in 

examinations of pathologic specimens and is also 

evident in functional central nervous system imaging 

Experience with Mild Traumatic 

 Brain Injuries and Postconcussion 

 Syndrome at Kandahar, Afghanistan 

LTC Ralph D. Caldroney, MC, USAR 

CAPT James Radike, MC, USN 
 July – September 2010 23

studies, such as single photon emission computed 

tomography and positron emission tomography scans. 

The damage is to the level of the axons and often 

involves axonal stretching or even separation. 

Additionally, numerous excitatory neurotransmitters 

are released, as well as the typical acute phase 

reactants of tissue injury.6

 While recovery of the 

structural and biochemical damage is anticipated, the 

central point is that this is not a feigned injury. The 

damage is quite real. 

SYMPTOMATOLOGY

The cardinal immediate phase symptoms can be 

defined into neurocognitive, somatic, and behavioral 

categories as follows: 

Neurocognitive – attention deficit, reduced speed 

in processing new information, or language 

dysfunction in the form of difficulty in finding 

words for expression. 

Somatic – focal neurologic deficits, headache, nausea with or without vomiting, sleep disturbance, 

visual complaints, fatigue, seizures, or vestibular 

symptoms, usually in the form of a sense of 

imbalance. 

Behavioral – depression, anxiety, irritability, impulsive behavior (including disinhibition) and, on 

rare occasion, symptoms of mania or psychosis.7

The cardinal symptoms are confusion and amnesia. 

Amnesia is typically for the period immediately 

following the injury. It is generally measured in 

minutes but can be retrograde and encompass longer 

time frames. The confusion is typically more evident 

to observers than the victim. The simplest 

approach is to ask the squad members: is this 

the same person or is he/she acting differently?8

Simple questions as to whom, what, and why 

(ie, the sideline sports screen used for decades), 

are poor screening tools and suffer considerably 

in terms of sensitivity. More formalized 

screening tools are strongly suggested. In the 

civilian sector, the best validated tool is the 

Westmead Posttraumatic Amnesia Scale9

(Figure 1), but the military now uses the 

Military Acute Concussion Evaluation10

(MACE) (Figure 2). No head-to-head 

comparisons of the 2 tools are available, but the 

Westmead is more subjective while the MACE 

is more quantitative. In addition, the MACE 

scale can be used to follow serial responses and after 

physical exertion to see if replication of the physical 

stressors that a Soldier faces will cause worsening of 

the neurocognitive symptoms. The postexertional 

MACE functions as a poor man’s central nervous 

system “stress test.” 

Other symptoms seen in the first 24 hours can include 

a constellation of complaints including escalating 

headaches, dizziness, true vertigo, insomnia, tinnitus, 

nonspecific visual complaints, nausea and vomiting 

(primarily in the first 24 hours), difficulty concentrating, short-term memory dysfunction, and a sense of 

imbalance. Our experience is that a grief reaction is 

frequently intertwined as the blasts often involve 

others in the squad who have been wounded-in-action/

killed-in-action (WIA/KIA). Some component of 

immediate posttraumatic stress disorder is common in 

the form of flashbacks and nightmares. Effects of 

secondary soft tissue injuries are often more noticeable 

in the delayed phase as the fright and flight response 

begins to wane. 

Signs can include a multitude of findings including the 

“thousand-yard stare,” delayed verbal responses, an 

apparent concentration deficit, alterations in speech 

pattern, visible but subtle cerebellar findings, and 

emotional responses that are atypical or disproportionate for the individual. Many of these parallel what 

would be seen in a driving under the influence setting. 

Since the medical observers at the scene are typically 

medics and may not know the baseline appearance and 

function of the individual Soldier, the question should 

be posed to the battle buddies: is this the same guy you 

saw before the injury? 

What is your name? 

What is the name of the place you are in now? 

Why are you here? 

What month is this? 

What year are we in now? 

In what town/area are you from? 

How old are you? 

What is your date of birth? 

What time of day is it? (morning, afternoon, evening) 

Show three pictures and ask for delayed recall. (within one to two minutes) 

Figure 1. The Westmead Posttraumatic Amnesia Scale questions 

used by civilian healthcare providers to screen patients with 

possible traumatic brain injury.9
24 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Since presentation may be delayed to a 

medical treatment facility, the evaluation is 

best begun in the field by the medic or 

corpsman. MACE cards for use in the field 

are becoming available. The importance of 

the field evaluation is that it establishes an 

immediate baseline that then can be 

referenced as the casualty moves though the 

various echelons of the evacuation system. 

In particular, the MACE questionnaire 

provides an index that is quantifiable and 

simple to administer. If the MACE scores 

are regressing versus improving, it is a “red 

flag” to all concerned, and serves as a 

prompt to search for a reversible structural 

central nervous system injury, eg, a subdural hematoma. 

While discussed in detail in prior TBI 

literature, prospective data shows seizures 

are relatively rare events, in mild to moderate TBI patients with an incidence of no 

greater than 5%.11 Of those who suffer seizures, most are seen in the first 24 hours. 

The earlier seizures occur, however, the 

greater the likelihood of recurrences long 

term. Prophylactic antiepileptics have not 

been shown to be effective in prior prospective studies. Onset of seizures, however, is 

a red flag and should prompt immediate 

neuroimaging, even if previously done. 

Prior reviews show CT head scan 

abnormalities in about 5% of those who 

present with a Glasgow Coma Scale* 

(GSC) score of 15 and are routinely 

scanned, as is often the case in civilian 

settings. As anticipated, the percentage of 

abnormal scans goes up as the severity of 

injury worsens, with up to 30 % of those 

with GSC of 13 (or less) showing 

demonstrable CT changes. Even these latter 

figures may be misleading in that only 1% 

of patients scanned have an abnormality 

that warrants neurosurgical intervention.13

Sensitivity is excellent for CT scanning but 

specificity is poor. This has lead to criteria 

such as the Canadian CT head rule that help 

*The Glasgow Coma Scale is a quick, practical, standardized system for assessing the degree of consciousness in the critically ill and for predicting 

the duration and ultimate outcome of coma, primarily in patients with head injuries. The system involves eye opening, verbal response, and motor 

response, all of which are evaluated independently according to a rank order that indicates the level of consciousness and degree of 

dysfunction.12 

Experience with Mild Traumatic Brain Injuries and 

Postconcussion Syndrome at Kandahar, Afghanistan 

Orientation: 

Month 0  1 

Date 0  1 

Day of Week 0  1 

Year 0  1 

Time 0  1 

Orientation Score _______ / 5 

Immediate Memory 

List Trial One Trial Two Trial Three 

Elbow 0  1  0  1  0  1 

Apple 0  1  0  1  0  1 

Carpet 0  1  0  1  0  1 

Saddle 0  1  0  1  0  1 

Bubble 0  1  0  1  0  1 

Trial Score _______ / 5 _______ / 5 _______ / 5 

Neurological Screening: (no points) 

Concentration

4 - 9 - 3 6 - 2 - 9 0  1 

3 - 8 - 1 - 4 3 - 2 - 7 - 9 0  1 

6 - 2 - 9 - 7 - 10 1 - 5 - 2 - 8 - 5 0  1 

7 - 1 - 8 - 4 - 6 - 20 5 - 3 - 9 - 1 - 4 - 8 0  1 

Months in reverse order (1 point for entire sequence) 

Concentration Total Score _______ / 5 

Delayed Recall: (1 point each) 

Ask the patient recall the 5 words from the earlier memory test. 

 (Do NOT reread the word list) 

Elbow 0  1 

Apple 0  1 

Carpet 0  1 

Saddle 0  1 

Bubble 0  1 

Delayed Recall Total Score _______ / 5 

Total MACE Score __________ / 30 

Diagnosis: (circle one or write in diagnosis) 

850.0 Concussion without loss of consciousness 

850.1 Concussion with loss of consciousness 

Other diagnoses 

Figure 2. Sample of the Military Acute Concussion Evaluation form 

used to screen patients with possible traumatic brain injury.10
 July – September 2010 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

to select those who warrant scanning for lesions that 

have immediate clinical import.14 The Canadian rules 

suggest scanning based on the following presenting 

clinical criteria: 

GSC score of less than 15 at 2 hours postinjury. 

The emphasis is on the individual who is failing to 

show signs of improvement in the immediate 

postinjury phase. 

Suspected skull fracture, especially with a history 

of blunt trauma. 

Physical findings of basilar skull fracture, such as 

hemotympanum, raccoon eyes, Battle’s sign, or 

evidence of a cerebrospinal leak. 

Repetitive vomiting, defined as 2 or more episodes 

in the first 24 hours. 

Aged 65 years or older. 

A mechanism of injury that involves projection or 

a fall from a significant height, typically 3 feet or 

more, or a fall down 5 or more stairs. 

We are not aware of any studies that have validated the 

Canadian rule in military field settings, but the rule has 

held up well in civilian trauma centers. CT scans may 

be difficult to access in theater, and we think the 

Canadian criteria provide an excellent triage tool. 

Patients can and will deteriorate after a seemingly 

benign initial presentation. A variety of intracranial 

catastrophes can occur in the hours following initial 

presentation. Fortunately, these declines are rare. The 

key to recognition is the initially stable patient who 

deteriorates for no obvious and apparent reason. Then, 

immediate central nervous system imaging is 

mandatory to exclude treatable abnormalities such as 

epidural and/or subdural hematomas and/or 

intracranial hemorrhage.15

Although much discussed in the civilian literature, 

such postpresentation degradation is rarely seen and 

reported. The presentation is one of a seemingly 

benign TBI, typically seen in the context of a sports 

participant who suffers a mild TBI, returns to 

competition, and suffers a second concussion, in short 

succession. The affected patient then undergoes a rapid 

downhill course with features of diffuse cerebral 

edema and often suffers either death or severe 

disability.16 Since many mild TBI patients have 

returned to play or duty and not suffered this sequence 

of events, the question remains as to whether there is 

some preceding genetic or structural process that 

makes these individuals uniquely susceptible. Since 

one cannot predict who is at higher or lower risk for 

this rare event, no one should be exposed to further 

risk of head trauma, in short sequence, unless it is 

absolutely unavoidable. The sports equivalent of 

“shake it off and get back in” no longer applies, either 

in the military or civilian sectors. 

TREATMENT APPROACHES

No specific drug interventions are typically suggested 

in the immediate phase outside of simple analgesics as 

needed. The time-honored dictum of avoiding drugs 

with central nervous system depressant effects remains 

true as they may color interpretation of evolving signs 

and symptoms. In fact primum non nocere [first do no 

harm] holds especially true as no drug interventions, 

including systemic steroids, have proven effective in 

ameliorating brain damage, even in those with the 

most severe of injuries. It remains best to keep any and 

all drugs to a minimum until stability is insured over 

the first 24 hours.17

Beyond the window of the first day, one can be more 

liberal with medications, though drug use remains 

reactionary and treats the symptoms but not the root 

cause, the injured brain. The intervention we have 

found to be of greatest benefit after the first 24 hours 

of insured stability are efforts at restoration of a more 

normal sleep-wake cycle. For a variety of reasons, 

insomnia is extremely common in the field setting and 

is typically a combination of difficulty with sleep 

initiation and sleep maintenance. We are not aware of 

any direct drug trials, but we have had empiric success 

with the older sedating antidepressants such as amitriptyline or trazodone. The most important thing for 

the injured brain is time and rest. 

As anticipated, the earlier in the course we were able 

to see the patient and intervene, the better the outcome, 

with the vast majority returning to duty. If presentation 

was delayed to the care level of the combat support 

hospital, outcome was more suspect. Is this selection 

bias or a real phenomenon? We have no hard data to 

confirm this but observations from the field are by 

nature often empiric. 

Adjunctive therapies can be used in the immediate 

phase that is nonpharmacologic and therefore low risk, 
26 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

if not necessarily high reward. A concussion class and/

or Soldier directed handouts explain in common terminology the anticipated course of events. This helps 

reassure affected individuals that what they are experiencing is very real, and describes the expected course 

and progress in recovery of their symptoms. It also 

reemphasizes the idea to the patient that the goal is to 

return them to duty, but full recovery will take time. A 

20-year old Soldier is not blessed with the utmost of 

patience. We felt that the group rehabilitation milieu 

was beneficial because “misery loves company.” We 

had a low threshold to involve mental health and/or 

combat stress control, especially if fellow squad members were WIA/KIA or if the patient had preinjury 

mental health difficulties. In this situation, “talk is 

cheap,” and effective. If combat stress control resources are not available, chaplains can fill a similar role. 

We also used physical and occupational therapy for the 

secondary soft tissue injuries that are not uncommon, 

especially to the neck or back. Lastly, we had the 

luxury of having acupuncturists available who were 

helpful with soft tissue injuries and also helped with 

certain aspects of the of the postconcussion component, mainly cervical pain. Overall, we found the 

busier we kept the patients, the less they dwelled on 

the event, and the more quickly they recovered. Our 

TBI clinic kept the patients on base for as short a period as possible and aimed to return them to their forward operating base as soon as our “hard court press” 

was completed. In reality, our clinic was a program. 

In the immediate phase, the question is whether or not 

the individual should be hospitalized. We were liberal 

about initial hospitalization. Any hint of regression of 

GSC or MACE scores was a trigger. In addition, a 

history of blunt head trauma was often a trigger to 

hospitalize. Since these patients were often brought 

from outlying bases and were separated from their 

battle buddies,* we did not always have the luxury of 

using the civilian equivalent of sending them home 

with a head trauma sheet for a “family” to follow in 

the first 24 hours postinjury. With all of those 

provisos, the vast majority of those with a mild TBI, 

even in a battlefield environment, still do not need to 

be hospitalized, and their entire course of management 

can be performed on an outpatient basis. 

Unit leaders want their Soldiers, Marines, Sailors, and 

Airmen back to fill their ranks immediately. Although 

the goal must be to preserve the fighting strength, this 

must not trump the need for the brain to have adequate 

time to recover. As a general rule of thumb, we found 

that a minimum of 2 to 4 weeks was necessary to 

stabilize the injury. Recovery did not mean that the 

service member needed to stay at our facility or under 

our guise for the entire length of the rest and recovery 

phase. It did mean that they could not be exposed to 

potential head trauma during the minimal time frame 

of rest. Further, even if they did return to their forward 

operating base, they were not to go “beyond the wire” 

for whatever time period we determined to be necessary for recovery. 

An evolving and very important question is whether 

there is a point at which we must say too many 

cumulative injuries have occurred and a long-term 

modification of duties is absolutely necessary. The 

Marines have taken the lead in this regard. The current 

USMC intheater guidelines18 are: 

 First injury: “brain rest” for between 2 to 4 weeks. 

 Second injury: a minimum of 4 weeks (and 

possibly longer) of no risk or very low risk 

exposure. 

 Third injury: the line is drawn and that individual 

will not go beyond the wire for the remainder of 

his or her tour. 

The above guidelines are defined by injuries within a 

given tour. However, there are no current guidelines to 

address the common scenario of multiple exposures 

over multiple tours. In our experience, individuals 

were often not “back to baseline” by the time of their 

redeployment, and the next injury that occurred on the 

current tour was the breaking point. On occasion, the 3 

strikes rule was not exceeded, but the clinical line was 

undoubtedly crossed, and we had to insist that the 

individual be withdrawn from exposure on a 

permanent basis. This is a grave decision that affects 

the individual, the unit, and the higher command, and 

it is not taken lightly. We invoked such limitations 

only if we were convinced that return to preinjury 

status was unlikely, and that further exposures bring a 

high likelihood of an irrevocably injured brain. 

*Generally defined as the person to whom a Soldier can turn in time of need, stress, and emotional highs and lows who will not turn the Soldier 

away, no matter what. This person knows what the Soldier is experiencing because of experience with similar situations or conditions, either 

current, previous, or both.

Experience with Mild Traumatic Brain Injuries and 

Postconcussion Syndrome at Kandahar, Afghanistan 
 July – September 2010 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

DISCUSSION

There is no clear separation between the acute injury 

and the potential aftermath. Studies have shown that 

up to 80% of head injury patients have symptoms of a 

postconcussion syndrome.19 Unfortunately, we do not 

have good data from the battlefield environment, 

particularly for those with multiple blast exposures and 

head injuries over multiple tours. Most published data 

for postconcussion syndrome is drawn from the 

civilian sector, but we suspect that carefully gathered 

information from the current active theaters would 

show similarly high rates of occurrence. Only data 

from predeployment information which is compared to 

postdeployment information will be objective enough 

to qualify, since retrospective data is subject to considerable recall bias. 

Symptoms far outweigh signs, and nondynamic CNS 

imaging studies, if done, are typically normal. This 

means that the postconcussive syndrome is defined 

almost entirely based on subjective symptoms. There 

is no current objective test to separate those with 

superimposed secondary gain. Perhaps the currently 

used Automated Neuropsychological Assessment 

Metrics20 screening will help to fill this information 

gap, but since predeployment screening was only 

recently begun, it will not be of any use for the 

thousands who have been injured prior to late 2009. 

In our experience and that of others, the most frequent 

symptoms were headaches and cognitive dysfunction. 

Other symptoms include mood liability, continued 

sleep disturbance, and a residual sense of imbalance. 

To the previously invulnerable 20-year old, the most 

frightening symptom is cognitive dysfunction. The 

pattern most often seen is a combination of short-term 

memory difficulty and an overall sense of difficulty in 

concentration. These mimic in many ways the early 

stages of the memory dysfunction often seen in the 

elderly such as the subtle syndrome of mild cognitive 

disorder. A parallel exists in what has been observed in 

some former professional and amateur athletes, the 

worst being dementia pugilistica seen in professional 

boxers who have suffered repeated head trauma. A 

limited number of former professional football players 

have experienced a neuropathologic entity called 

chronic traumatic brain injury or chronic traumatic 

encephalopathy.21 The disturbing pathologic 

information is that the visible macro- and microscopic 

damage is quite similar to that seen in traditional 

dementia. While all of these tantalizing bits of 

information are nothing more than food for thought, 

the aggregate harkens back to the concept that 

structural damage does occur even with a mild TBI, 

the changes may not be fully reversible in all, and 

cumulative damage may occur. 

Treatment of the headaches includes a variety of 

therapies, both reactive as well as prophylactic in 

nature. Most of these have existed in the civilian 

literature for decades. As discussed previously, one 

caution is to avoid agents with sedative capacity, for 

obvious reasons, in field settings. Fortunately for most 

patients, the headaches do diminish in severity and 

frequency over time. 

Unchartered territory exists in terms of how to address 

the cognitive dysfunction. Are cholinergic agents such 

as donepezil appropriate for those with features of 

mild cognitive dysfunction? Are stimulant agents such 

as the amphetamine compounds of value for those with 

features of attention deficit disorder? Considerable 

research is ongoing to address these questions, but for 

now they remain unanswered and considerable 

empiricism is necessary. 

Our experience was that a considerable admixture of 

depression and posttraumatic stress disorder coexists 

in those who suffer long term symptoms.22,23 This 

raised a logical question as to the efficacy of any of a 

variety of psychotropic medications, in particular, antidepressants, in treatment of those individuals. Since 

these drugs are, in general, medications with excellent 

therapeutic/toxic ratios, we had little hesitation to use 

these medications, if the mood component was 

becoming dominant and time was not providing 

alleviation. Obviously, the hope is that the use of 

antidepressants is a short-term rather than a long-term 

requirement. We consider major and minor 

tranquilizers to be inappropriate at the front and more 

rear echelon type interventions, and consciously 

avoided their use. Psychiatric treatment, if available, 

can be of considerable help. However, it may be a 

limited resource, especially at the level of the forward 

operating base and the battalion aid station’s level 1 

care must by necessity often assume this role. Combat 

stress control assets can provide counseling, but again, 

availability may be limited. 

Both short- and long-term sleep disturbance is 

common. A variety of sopoforic agents are now 
28 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

available, most of which again have favorable side 

effect profiles and minimal capacity for dependence. 

Very few of us sleep well in-theater, but patients with 

structural and somatic overlay have an especially 

difficult time sleeping. The net debt from chronic sleep 

fragmentation is well-described. We felt that part of 

both the immediate and long-term treatment was 

liberal use of drugs, such as low dose trazodone, to 

restore some semblance of a more normalized sleep 

pattern. At low dose, those are drugs with low toxic 

risk, though we purposely limited the volume of the 

distributed medication to minimize risk of an 

intentional overdose. 

While not the intention of this article, some comments 

about the experience in the United States with severe 

TBI patients is not only of interest, but also relevant as 

we providers encounter such patients when we return 

to our US facilities, be they military, Veterans Affairs, 

or civilian. Severe injuries are more commonly caused 

by penetrating head injuries and are typically 

associated with very low Glasgow Coma Scores on 

presentation. Salient observations of this unfortunate 

subset of individuals include the following24: 

As anticipated, presenting Glasgow Coma Scores 

correlate with both survival and residual 

morbidity. 

However, severe injuries do not always equate to 

poor outcomes; the young and previously healthy 

brain can have amazing recuperative powers. 

Overall survival rates are high (95%) among those 

who survive long enough to be evacuated to the 

United States. 

In-hospital complication rates are high and include 

a variety of events that have both short- and longterm import. Some of these include: 

 Systemic infections are common (46%). 

 Pulmonary embolism is common, especially 

since anticoagulation prophylaxis is 

contraindicated (7%). 

 Cerebrospinal fluid leaks and infections are 

not infrequent (9%). 

 Early onset seizures are not infrequent (12%). 

 Spinal cord and column injuries often 

accompany the initial injury (10%). 

 Posttraumatic aneurysms and arteriovenous 

malformations are surprisingly common (8%). 

PATIENT DATA

From mid November of 2009 through mid April 2010, 

125 new patients were seen in the TBI clinic at the 

combat support hospital at Kandahar Air Field. Most 

were referrals from outlying forward operating bases 

(FOBs), and virtually all patients were seen for at least 

one follow-up visit. The time from initial injury to 

presentation to our clinic varied from days to months, 

but since the beginning of 2010, most were seen in the 

immediate phase, allowing better evaluation and 

treatment. A total of 360 patient encounters occurred 

prior to our departure. No patients required 

hospitalization, and well over 90% returned to duty 

and to their prior military occupation specialty 

functions and duty assignments, in particular the 

combat roles. The goal is to return to the referring 

FOB immediately, drawing from the model of combat 

stress control to make the recovery process FOBcentric. Whatever time is necessary for limited duties 

and activities inside the wire is best spent within the 

environment of the squad and unit. 

CONCLUSIONS

Traumatic brain injury is common in the current 

operational environment. Diffuse brain injury is the 

norm, though this condition cannot be readily 

measured by current means, including standard central 

nervous system imaging. Screening for a significant 

injury is best accomplished by a standardized format, 

such as the MACE scale, which can be initiated at the 

level of the squad medic. While recovery is 

anticipated, a significant percentage suffers long-term 

sequalae, especially in the form of mood disturbances 

and cognitive dysfunction. The point at which the 

individual must be removed, at least short-term if not 

permanently, from further blast exposures is a looming 

concern. For now, we concur with the “3 strikes and 

you’re out” policy practiced by the Marines. However, 

at present this is defined by exposures during a single 

tour and does not address the more common situation 

of multiple TBIs occurring in an interspersed manner 

over multiple tours. 

Treatment is largely supportive, though this is an area 

of intense interest for effective immediate phase 

therapies. Brain rest is imperative in the immediate 

phase of injury, and a minimum time spent inside the 

Experience with Mild Traumatic Brain Injuries and 

Postconcussion Syndrome at Kandahar, Afghanistan 
 July – September 2010 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

wire (at least 2 to 4 weeks) is absolutely mandatory. 

As one moves into the area of the postconcussion 

syndrome, long-term treatment involves maintenance 

of sleep and treatment of depression and posttraumatic 

stress syndrome, if they coexist. At present, no known 

and proven treatment exists for the neurocognitive 

sequalae. Whether use of dementia and attention deficit disorder drugs used in the civilian sector will be of 

benefit remains to be determined. As we move further 

away from the initial military TBI injuries of the early 

2000s, both military and civilian caregivers will likely 

be forced to use such therapies more and more in this 

atypical subset of young/old brains to maintain function. This will be necessary within both the military 

and civilian environments as the injured experience the 

lingering effects of cumulative damage and deterioration brought about by time and the aging process. 

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Intern Med. 1998;158(15):1617-1674. 

18. Defense and Veterans Brain Injury Center. Joint 

Theater Trauma System Clinical Practice Guideline. 

Management of Mild Traumatic Brain Injury (mTBI)/

Concussion in the Deployed Setting. November 2008. 

Available at: http://www.usaisr.amedd.army.mil/cpgs 

/Management%20of%20Mild%20TBI%20(mTBI)

Concussion%20in%20the%20Deployed%20 

Setting.pdf. Accessed June 25, 2010. 

19. Evans RW. Post concussion syndrome. Uptodate 

website. Available at: http://www.uptodate.com/ho 

me/index.html. Accessed September 3, 2009. 
30 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

20. Ivins BJ, Kane R, Schwab KA. Performance on the 

automated neuropsychological assessment metrics in 

a nonclinical sample of soldiers screened for mild 

TBI after returning from Iraq and Afghanistan: a descriptive analysis. J Head Trauma Rehabil. 2009;24

(1):24-31. 

21. Loosemore M, Knowles CH, Whyte GP. Amateur 

boxing and risk of chronic traumatic brain injury: 

systematic review of observational studies. Br Med J. 

2007;335(7624):809. 

22. McCauley SR, Boake C, Pedroza C, et al. Postconcussional disorder: are the DSM-IV criteria an 

improvement over the ICD-10?. J Nerv Ment Dis. 

2005;193(8);540-550. 

23. Hill JJ, Mobo BH, Cullen MR. Separating 

deployment-related traumatic brain injury and 

posttraumatic stress disorder in veterans: preliminary 

findings from the Veterans Affairs traumatic brain 

injury screening program. Am J Phys Med Rehabil. 

2009;88(8):605-614. 

24. Bell RS, Ho AH, Ned CJ, et al. Military traumatic 

brain and spinal column injury: a 5 year study of the 

impact blast and other military grade weaponry on 

the central nervous system. J Trauma Inj Infect Crit 

Care. 2009;66(suppl 4):S104-S111. 

AUTHORS

LTC Caldroney has been an internal medicine physician 

in Lexington, Kentucky, for 30 years. When this article 

was written, he was the Command Surgeon, 135th 

Expeditionary Sustainment Command, Kandahar Air 

Field, Afghanistan. 

CAPT Radike is an internist at the Naval Hospital, 

Pensacola, Florida. When this article was written, he 

was the Senior Medical Officer and Director of Clinical 

Services at the NATO Role 3 Hospital, Kandahar, 

Afghanistan. 

Experience with Mild Traumatic Brain Injuries and 

Postconcussion Syndrome at Kandahar, Afghanistan 
 July – September 2010 31

INTRODUCTION

The early ability to stabilize and transport injured 

servicemen and women from Operation Enduring 

Freedom (OEF) and Operation Iraqi Freedom (OIF) to 

specialized military centers in the United States has 

resulted in an approximate 92% survival rate, a higher 

percentage than any other major military conflict.1

 As 

a result, service members have been returning from 

theatre with multiple amputations that require 

extensive rehabilitation from medical centers within 

the Department of Defense and the Department of 

Veterans Affairs. Approximately 2% of injured 

military personnel returning from OEF and OIF have 

sustained limb loss.2 Military databases have indicated 

that as of April 2010, US medical centers have treated 

combatants with 992 major limb amputations (822 

from OIF and 170 from OEF) and 341 minor amputations (317 from OIF and 24 from OEF). The relative 

youth and high fitness level of injured service members with ampuations3

 make them an ideal population 

for aggressive rehabilitation, but have also exposed the 

limitations of today’s existing prosthetic technologies. 

Military personnel with amputations face unique challenges due to their short residual limbs,2

 unplanned 

amputations,4

 high incidences of multiple limb loss 

and accustomed activity levels prior to an amputation. 

NARRATIVE

Debridement, Wound Care & Revision 

The use of buried explosive devices such as land 

mines and improvised explosive devices (IEDs) have 

been used as a form of weaponry in every military 

conflict since World War II,5

 and a large portion of 

severe injuries occurring from military operations in 

Iraq and Afghanistan have resulted from blasts.6

 The 

use of explosive armaments generates extensive tissue 

trauma and disruption of vascular and neurological 

networks.7

 IED blasts expel the neighboring earth and 

shrapnel into the wound sites and require rapid wound 

care strategies.5,7

The meticulous debridement of injured tissues has 

remained of utmost importance in combat wounds as 

nonviable tissue has been known to create a nidus for 

infection and may impede the natural healing process.7

The risk of infection has demanded staged 

debridement strategies and may result in the decision 

to delay wound closure. One survey of 230 patients 

with transtibial amputations conducted during the 

Vietnam War indicated that 59% of wound closures 

were left open and 41% were closed in theater. For 

service members who returned to the United States 

with closed amputation sites, 56% failed due to gross 

The Road to Recovery and Rehabilitation for 

 Injured Service Members with Limb Loss: 

 A Focus on Iraq and Afghanistan 

Brad M. Isaacson, BS 

Sharon R. Weeks, BS 

COL Paul F. Pasquina, MC, USA 

Joseph B. Webster, MD 

James P. Beck, MD 

Roy D. Bloebaum, PhD 

ABSTRACT

Amputation of an extremity due to traumatic injury or a vascular occlusive disease is a life-altering event that occurs when 

limb salvage is not possible. While an amputation is viewed as a life saving procedure clinically, limb deficiency may result 

in an immediate loss in social, physical and financial well-being for the patient. Military personnel returning from Operation 

Enduring Freedom and Operation Iraqi Freedom face unique challenges due to short residual limbs, unplanned amputations, 

high incidences of multiple limb loss, and accustomed activity levels prior to an amputation. The primary rehabilitation goal 

for these individuals is to provide them with an expedited recovery and progressive reintroduction into the civilian or active 

duty population. It is the purpose of this review to discuss the most frequent rehabilitation hardships service members 

endure following combat related trauma and future of prosthetic limb technology. 
32 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

infection and required urgent surgical revision that 

reduced residual limb length.8

Infection Complications 

Traumatic amputations present unique problems for 

surgeons which may be made more difficult by 

bacterial colonization. Infections have been a 

particular concern for combat-related injuries since the 

disruption of vascular integrity and localized tissue 

necrosis prevents antibiotics from reaching the wound 

site. When this occurs, the bacteria in the affected 

region may become resistant to antibiotics, especially 

when dosages are below the minimal inhibitory 

concentration. Studies investigating the infection rate 

in ischemic lower-extremity amputees report a broad 

infection range which depends largely on anatomical 

location.9

 Reports of resilient infections have occurred 

in over 600 injured service members from OIF and 

OEF following an extremity amputation10 and include 

drug-resistant Acinetobacter baumannii, Pseudomonas 

aeruginosa, Klebsiella pneumoniae and 

Staphylococcus aureus.10 Cultures obtained from 

wound sites of 732 injured service members involved 

in OIF concluded that a plethora of both gram-negative 

and gram-positive bacteria cultured were resistant to 

broad spectrum antibiotic treatments (Figure 1).11

Additionally, blast injuries from IEDs often generate 

extensive burns and subsequent nosocomial infections 

because of multidrug resistant Acinetobacter 

baumannii.11 Aggressive debridement and antibiotic 

usage has remained the standard of care for preventing 

and treating infections, but multidrug resistant 

bacterial infections have been a dangerous concern for 

service members injured in Iraq and Afghanistan.11

Residual Limb Problems 

Skin Breakdown

Successful treatment of an 

amputation in theatre has been the 

first phase in a challenging road to 

recovery and rehabilitation. Residual 

limb skin breakdown following 

wound closure has often resulted in 

superficial infections, the inability to 

p r o p e r l y w e a r p r o s t h e s e s , 

interference with rehabilitation and 

the need for surgical revisions. The 

high frequency of skin-related socket 

complications has occurred from 

mechanical breakdown, since skin thickness at 

extremity amputation sites are considerably thinner 

than the palms and soles which are especially equipped 

for high load bearing regimens.12 Previous studies 

investigating skin breakdown in below-knee amputees 

revealed that one-third of patients suffered from 

unhealed wounds or damaged skin,13 and 40% of lower 

extremity amputees had at least one skin problem on 

the lower limb.14 To prevent breakdown at the skinprosthetic interface, mechanical forces exerted on 

newly formed residual limbs must be carefully 

controlled since excessive skin tension may trigger 

localized tissue necrosis. 

Skin breakdown in sockets has also been known to 

occur due to scar asymmetry and the suboptimum 

location of tissue reconstruction relative to weight 

bearing pressure. The location of the surgical closure 

scar in traumatic amputations has been commonly 

dictated by the initial injury and the attempt to retain 

as much residual limb length as possible. This situation has been further complicated by the dysvascular 

nature of mature scar tissue and the relative common 

attachment of scar tissue to the residual bone. 

Heterotopic Ossification

Heterotopic ossification (HO) has been a frequent 

complication following blast-related injuries and traumatic amputations.15 Ectopic bone has been reported to 

be variable in nature,16 metabolically active16 and results in mature osseous growth in the neighboring soft 

tissue17 (Figure 2). While HO has been known to be a 

consequence of muscle and bone injury, the exact 

pathological process of HO has not yet been fully 

understood.18 The development of HO has been 

strongly correlated with the presence of head, spine 

Figure 1. Biofilm formation of staphylococcus epidermidis present on an 

orthopaedic implant using scanning electron microscopy at 4,000x (A) and 

12,000x (B) magnification. 

The Road to Recovery and Rehabilitation for Injured Service Members with Limb Loss: 

A Focus on Iraq and Afghanistan 
 July – September 2010 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

and blast injuries.15 In fact, the frequency of HO in the 

residual limb of amputees with blast injuries returning 

from OIF and OEF has been reported as high as 63% 

in a study of 213 wounded service members.15

Large formations of ectopic 

bone have been especially 

disabling for service members 

who use sockets for prosthetic 

attachments. Rehabilitation of 

an amputee with HO may be 

challenging since wide 

variations in ectopic bone have 

been known to occur and may 

lead to an uncomfortable 

prosthetic fit.19 HO may also 

manifest months after a blast 

injury and has a maturation 

rate upwards of 18 months.20

As a result, poor prosthetic fit 

may occur and delay the 

rehabilitation for service 

members who require socket 

adjustments to compensate for 

HO formation. The interface 

between the residual limb and 

prosthetic socket overlying a 

bony prominence may also 

lead to skin breakdown and 

significantly restrict mobility 

of a patient with limb loss.2,21

Premature surgical resection 

of HO often results in more 

florid ectopic bone than before 

resection. For this reason, 

surgical resection of HO has 

often been delayed until 

complete HO maturation has 

occurred, along with the 

inflammatory stage of “myositis ossificans.” Surgical 

resection of HO may also result in neurovascular 

damage22 as these structures may be entwined in the 

bony deposits. While some studies have demonstrated 

success after removing HO 8 months from the initial 

amputation,15 others have cautioned that 18 months 

may be a more appropriate timeframe, especially when 

head injuries or comorbidities have been involved.16,23

Phantom Limb Pain

Phantom limb pain (PLP), the painful sensation that an 

amputated limb is still present, has been known to 

occur in up to 85% of amputees.24 Pain has been 

described as burning, itching, stabbing, cramping, 

throbbing, or feeling of “pins and needles.”25 While 

many causal factors have been proposed for PLP, 

including intrinsic residual 

limb pain, limb pain that was 

present prior to amputation, 

and the presence of neuromas 

formed after nerve transection, 

all of these correlations have 

been both supported and refuted by the literature.24,26,27

The incidence of PLP has 

shown to be independent of 

gender, age (in adults), 

location, and level of 

amputation.28

It is important to note that 

congenital amputees have also 

reported PLP, and it has been 

speculated that both central 

and peripheral nervous 

systems must be active in the 

pain mechanism.29 PLP has 

remained notoriously difficult 

to treat with few randomized 

controlled trials demonstrating 

significant results. Memantine, an oral NMDA receptor 

antagonist has demonstrated 

limited success in larger 

clinical trials for treating acute 

pain, but may be less effective 

for long-term established 

chronic neuropathic pain.30

Mirror therapy, in which the 

patient observes the movements of a reflection of their 

intact limb in a mirror while simultaneously moving 

their phantom limb has been demonstrated to 

significantly decrease PLP in a randomized shamcontrolled trial.31

Rehabilitation – Physical and Occupational Therapy 

The severe injuries sustained by OIF and OEF service 

members have frequently required complex 

rehabilitation management. Rehabilitation 

interventions should be designed to maximize 

functional outcomes and the needs of each individual. 

Following prosthetic fitting, physical therapy may 

Figure 2: Coronal computed tomography scan 

demonstrating a pronounced mass of HO in the 

residual limb of a returning service member. 
34 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

begin with simple standing and walking activities and 

slowly progress to higher level balance and mobility 

training, depending on the individuals’ goals and 

abilities. Specific techniques include strengthening 

exercises for the residual limb and intact body parts as 

well as cardiopulmonary conditioning. 

Rehabilitation for a service member with an amputation begins immediately following the amputation 

and includes education and training on skin care, 

residual limb desensitization, edema control and soft 

tissue mobilization.32 Another significant goal of the 

early stages of rehabilitation has been the use of a 

prosthetic limb to restore lost function. Management of 

both postoperative residual limb pain as well as 

phantom limb pain has remained vital.33 In order for an 

individual to return to functional independence, training has included strategies for activities of daily living 

such as dressing, bathing and other self-care activities. 

Prosthesis Fitting and Choices: Options Available for 

Upper and Lower Limb Amputees 

Historically, military conflicts and the associated 

trauma-related amputations have led to increased 

attention and advances in prosthetics.34 Numerous 

improvements over the past 10 to 20 years in 

prosthetic design and 

components have allowed 

individuals with amputations to 

achieve functional goals not 

previously possible. These 

advances have included 

improvements in the actual 

components of the prosthesis 

as well as artificial limb 

attachment systems and 

prosthetic control mechanisms.35 Newer socket designs 

utilizing lightweight carbon 

composites and flexible inner 

liners have provided better 

accommodation for fluctuations in residual limb 

volumes.35 Various materials 

including silicone, urethane 

and copolymer gels have 

provided an interface between the residual limb and 

the prosthetic socket to provide cushioning, stability 

and shear reduction to the skin.35 Patient specific liners 

may also be fabricated for residual limbs with unique 

shapes or pain considerations. Customized options for 

the suspension of the prosthesis to the residual limb 

have included various forms of suction and vacuum 

suspension. 

Developments in lower limb prosthetics have led to 

microprocessor controlled knee and foot devices 

capable of monitoring gait in real-time and making 

automatic adjustments based on changes in terrain and 

angular velocity of the prosthetic component.35

Targeted muscle reinnervation techniques, which 

specifically relocate nerves severed in an amputation 

to alternative muscles to improve control of a 

myoelectric prosthesis are now being implemented in 

individuals with upper limb loss.32 Additionally, newer 

foot and ankle prosthetic components are capable of 

energy storage and return during ambulation because 

of dynamic elastic response properties intrinsic to the 

materials.32,35 These foot and ankle components 

accommodate for uneven terrain, vertical shock 

absorption and allow service members the ability to 

return to military deployments. 

Recently, transcutaneous osseointegrated implants 

(TOI) have emerged as a viable option for amputees. 

Although currently available in Europe, TOI may 

assist service members in the United States in the near 

future following FDA 

approval.35,36 Osseointegration 

avoids common socket 

complications by using direct 

skeletal attachment of an 

exoprosthesis to the residual 

limb35 and has demonstrated 

success in transhumeral, 

transtibial and transfemoral 

amputations. 3 7 W i t h 

osseointegration, a metal 

fixation is surgically inserted 

directly into the bone of the 

residual limb and serves as an 

attachment system for 

connecting and suspending a 

prosthesis to the residual 

limb.18 This procedure may 

reduce skin irritation, enhance 

osseoperception and better 

serve individuals with limited residual limb length 

(Figure 3).18,38 However, before employing this 

operative procedure, solutions must be developed to 

accelerate rehabilitation regimens and prevent 

periprosthetic infections for future service members.38 

The Road to Recovery and Rehabilitation for Injured Service Members with Limb Loss: 

A Focus on Iraq and Afghanistan 

Figure 3: The distal residual limb of a transfemoral 

amputee with an osseointegrated implant. The 

transcutaneous post serves as the exoprosthetic 

docking mechanism for an artificial limb. (Photo 

courtesy of the University of Utah Dept of 

Orthopaedics.) 
 July – September 2010 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

CONCLUSION

Servicemen and women have been returning from 

combat with a higher percentage of amputations 

compared to other military conflicts2

 and require 

intensive follow-up care, extensive rehabilitation, and 

expensive prosthetic services. The primary 

rehabilitation goal for these individuals has been to 

provide them with an expedited recovery and 

progressive reintroduction into the civilian or active 

duty population.21 However, in order to continue to 

provide the best care for wounded service members, 

novel diagnostic tools and prosthetic devices must 

continue to be developed to address the many concerns 

and complications still present today. 

ACKNOWLEDGEMENTS

This material is based upon work supported by the Veterans 

Affairs Office of Research and Development, Rehabilitation 

R&D Service, DVA SLC Health Care System, Salt Lake City, 

UT; the Albert & Margaret Hofmann Chair and the Department 

of Orthopaedics, University of Utah School of Medicine, Salt 

Lake City, UT.

We thank Gwenevere Shaw for support with manuscript 

preparation and Dustin Williams for biofilm images. 

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9. Moller BN, Solund K, Hansen SL. Wound infection 

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11. Calhoun JH, Murray CK, Manring MM. Multidrugresistant organisms in military wounds from Iraq and 

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12. Tortora GJ, Nielsen MT. Structure of the skin. In: 

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13. Persson BM, Liedberg E. A clinical standard of 

stump measurement and classification in lower limb 

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14. Dudek NL, Marks MB, Marshall SC, Chardon JP. 

Dermatologic conditions associated with use of a 

lower-extremity prosthesis. Arch Phys Med Rehabil. 

2005;86(4):659-663. 

15. Potter BK, Burns TC, Lacap AP, Granville RR, 

Gajewski DA. Heterotopic ossification following 

traumatic and combat-related amputations. 

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16. Ahrengart L. Periarticular heterotopic ossification 

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Bloebaum RD. Developing a quantitative measurement 

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19. Dudek NL, DeHaan MN, Marks MB. Bone overgrowth in 

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20. Wharton GW. Heterotopic ossification. Clin Orthop Relat 

Res. 1975(112):142-149. 

21. Andersen R, Davis S, Scoville C. Rehabilitation of 

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Tuan RS. Putative heterotopic ossification progenitor cells 

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T. Resection of heterotopic ossification in the adult with 

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24. Sherman RA, Sherman CJ. Prevalence and characteristics 

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25. Weinstein S. Phantom limb pain and related disorders. 

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26. Jensen TS, Krebs B, Nielsen J, Rasmussen P. Immediate 

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TS. The influence of preamputation pain on postamputation stump and phantom pain. Pain. 1997;72(3):393-405. 

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29. Melzack R, Israel R, Lacroix R, Schultz G. Phantom limbs 

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30. Buvanendran A, Kroin JS. Early use of memantine for 

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34. Thurston AJ. Pare and prosthetics: the early history of 

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35. Marks LJ, Michael JW. Science, medicine, and the future: 

artificial limbs. Br Med J. 2001;323(7315):732-735. 

36. Isaacson BM, Vance RE, Rosenbaum Chou TG, 

Bloebaum RD, Bachus KN, Webster JB. The effectiveness 

of resonance frequency in predicting orthopedic implant 

strength and stability in an in vitro osseointegration model. 

J Rehabil Res Dev. 2009;46(9):1109-1120. 

37. Hagberg K, Branemark R, Gunterberg B, Rydevik B. 

Osseointegrated transfemoral amputation prostheses: 

prospective results of general and condition-specific 

quality of life in 18 patients at 2-year follow-up. Prosthet 

Orthot Int. 2008;32(1):29-41. 

38. Isaacson BM, Stinstra JG, MacLeod RS, Webster JB, 

Beck JP, Bloebaum RD. Bioelectric analyses of an 

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amputees. J Vis Exp. 2009(29):1-6. 

AUTHORS

Mr Isaacson serves as a research assistant for the Bone 

& Joint Research Laboratory in the Salt Lake City 

Department of Veterans Affairs, and the Integrated 

Department of Orthopaedics & Rehabilitation at the 

Walter Reed Army Medical Center, Washington, DC. 

Ms Weeks is a research assistant for the Integrated 

Department of Orthopaedics & Rehabilitation at the 

Walter Reed Army Medical Center, Washington, DC. 

COL Pasquina is Chief, Integrated Department of 

Orthopaedics & Rehabilitation, National Naval Medical 

Center, Silver Spring, MD, and the Walter Reed Army 

Medical Center, Washington, DC. 

Dr Webster is an Associate Professor in Rehabilitation 

Medicine at the University of Washington, and the 

Director for Regional Amputation Care for the Veterans 

Affairs Puget Sound Health Care System. 

Dr Beck is Adjunct Professor in the Department of 

Orthopaedics at the University of Utah, and is a board 

certified orthopaedic surgeon for the Department of 

Veterans Affairs. 

Dr Bloebaum is a career research scientist with the 

Department of Veterans Affairs and the Co-Director of 

the Bone & Joint Research Laboratory. He is also a 

Research Professor of Biology, Bioengineering, and 

Orthopaedics at the University of Utah and is the Albert 

and Margaret Hofmann Chair in Orthopaedics for the 

University of Utah School of Medicine. 

The Road to Recovery and Rehabilitation for Injured Service Members with Limb Loss: 

A Focus on Iraq and Afghanistan 
 July – September 2010 37

*MEDCOM Family Advocacy Program Interim Guidance for Handling Cases of Deployed Soldiers. MCHO-CL-H. September 27, 2007. Internal 

military document not generally accessible by the general public.

INTRODUCTION

Over the past several decades, the Army has grown to 

appreciate the important contributions Families make 

in maintaining the psychological health of Soldiers. 

The Army Family Covenant is a testament to the 

Army’s commitment to creating a strong supportive 

environment that promotes resiliency in Army 

Families.1

 These measures have become essential as 

large numbers of Soldiers deploy in support of 2 

continuing overseas contingency operations. This point 

was illustrated by the Presidential Task Force on 

Military Deployment Services for Youth, Families, 

and Service Members as it acknowledged that the 

demands of a robust deployment tempo place service 

members and their families at-risk for the development 

of significant emotional problems.2

 One disturbing 

manifestation of the distress experienced by Soldiers 

returning from a military deployment can be seen in 

the well publicized accounts of Soldiers physically 

assaulting, and in some cases killing, their spouses 

after returning home from combat duty.3-5 The Army 

Family Advocacy Program (FAP), which has 

responsibility for preventing abuse, protecting abuse 

victims, and treating all individuals impacted by 

family violence, currently does not routinely extend to 

combat zones.6

 Consequently, the present pace of 

deployments has created a gap in services that limits 

the program’s effectiveness in reaching those 

individuals who may be at greatest risk for family 

violence. Although the US Army Medical Command 

encourages family advocacy personnel to collaborate 

with forward deployed behavioral health assets,* a 

standardized process has yet to be implemented. After 

9 years of war, it is time to transform the program to 

more effectively meet the evolving needs of the most 

vulnerable Army Families. This article proposes 

expanding the FAP across all phases of the 

deployment cycle by the better use of behavioral 

health assets currently assigned to maneuver units. The 

experience of the 4th Infantry Division during 

Operation Iraqi Freedom (OIF) 05-07 offers insight 

into the types of family advocacy problems encountered during a deployment and provides examples of 

actions to address the issues. Moreover, recommendations are made for adapting policies and procedures 

to strengthen the partnership between the FAP and 

deployable units across all stages of the Army Force 

Generation (ARFORGEN) process (details, page 32). 

DOMESTIC VIOLENCE AND MILITARY DEPLOYMENTS

A growing body of evidence indicates that military 

deployments can disrupt family functioning by altering 

family roles,7

 stressing adaptive coping strategies8 and 

increasing the likelihood of child maltreatment.9

Frequent deployments are thought to be linked to the 

dramatic rise in divorce rates in Army marriages with 

infidelity, domestic violence, and substance abuse 

believed to be contributing to the increasing numbers.10 According to a study of the psychological 

effects of deployments on military families, feelings of 

loneliness, and problems communicating with deployed spouses stand out as prominent stressors 

reported by spouses left at home.11 Deployments also 

have been shown to place families at a heightened risk 

for domestic violence. McCarroll et al12 discovered 

that Soldiers who had deployed within the past year 

were more likely to report committing severe aggression towards their spouses and that the longer the 

deployment, the more likely violence would occur. 

Similarly, deployment-induced family separation has 

been suggested as a contributing factor in the increased 

rates of spouse abuse among enlisted personnel.13

Particularly relevant to contemporary military operations is a study of families affected by Operation Desert Storm that found coping with residual aggression 

to be more problematic for war-time veterans and their 

families than for those who endured a routine deployment.14 This may be due, at least in part, to the 

Family Advocacy: A Program to Support 

 an Expeditionary Army 

COL Derrick Arincorayan, MS, USA 

Larry Applewhite, PhD, LCSW 

Rene Robichaux, PhD, LCSW 
38 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

introduction of psychological symptomatology, including posttraumatic stress disorder (PTSD), into the 

family dynamic. This possibility is supported by a 6-

year study of veterans who received couples therapy at 

a Veteran’s Affairs Medical Center which found that 

veterans diagnosed with PTSD were 26 times more 

likely to commit severe acts of violence towards their 

partners.15 Also, PTSD has been correlated with a 

greater likelihood of female Vietnam veterans 

becoming psychologically abusive in relationships 

with significant others.16 Interestingly, depression and 

PTSD symptoms have been found to be more closely 

linked to postdeployment aggression than the degree 

of actual combat exposure experienced by veterans.17

A connection between postdeployment psychological 

symptoms and an increased potential for violence may 

be especially disconcerting, given the estimated 17% 

of Soldiers that are at-risk for developing mental 

health problems, including PTSD, depression, and 

alcohol misuse, after returning home from combat duty 

in Afghanistan or Iraq.18

ARMY FORCE GENERATION MODEL AND FAMILY

ADVOCACY

Today’s Army finds itself confronted by persistent 

conflicts and protracted operations against an enemy 

that uses asymmetrical tactics such as those used in 

Afghanistan and Iraq. To counter these threats, the 

Army developed the ARFORGEN model to meet the 

demands of current operations and to prepare for 

future contingencies. A Department of the Army 

White Paper describes the ARFORGEN as: 

...a rotational readiness model that is designed to 

effectively and efficiently generate trained and ready 

forces for combatant commanders at sustainable 

rotational levels.19

The model categorizes the operational force into 3 

functional pools based upon recent deployment 

utilization: Train-Ready, Available, Reset. As units 

move through the ARFORGEN cycle, missionessential tasks must be completed to successfully 

transition from predeployment preparation to mission 

execution in a theater of operations, then return for 

postdeployment reconstitution. During the TrainReady phase, a unit trains to restore readiness levels to 

prepare for future contingency operations. Throughout 

this period, a unit prepares for deployment through 

individual and collective training that typically 

culminates in a mission readiness exercise conducted 

at either the Joint Readiness Training Center or 

National Training Center. At the pinnacle of the 

ARFORGEN cycle, a unit deploys to tactically 

implement national security strategy during the 

Available phase of the process. Afterwards, during the 

Reset phase, efforts are made to restore Soldiers and 

Families to predeployment levels of functioning. 

Reintegration programs, such as Battlemind 

postdeployment training, Strong Bonds, and Yellow 

Ribbon, help ease the transition from a war zone. 

Additionally, the postdeployment health assessment 

and postdeployment health reassessment, conducted 

during the first 180 days following a deployment, are 

used to gauge a Soldier’s biopsychosocial adjustment 

after returning home. Referrals for medical and 

psychological assistance are made as needed. 

The ARFORGEN model provides a logical framework 

for the design and implementation of family advocacy 

measures to support deploying units. Each stage 

presents distinct opportunities to target interventions to 

those Soldiers and Families that may be at-risk for 

domestic violence. Evidence-based prevention and 

treatment initiatives can be tailored to address the 

unique family stressors characteristic of each step in 

the deployment process. The establishment of a 

partnership between the military treatment facility’s 

family advocacy treatment team and the deploying 

unit’s behavioral health officer is essential to 

achieving this objective. More importantly, the 

benefits of working together become most evident 

during the deployment. 

THE 4TH INFANTRY DIVISION EXPERIENCE 

The 4th Infantry Division’s deployment to OIF 05-07 

provides insight into constructive actions to take, and 

obstacles to avoid, in the creation of an operational 

family advocacy program. Author Arincorayan, who 

was assigned to the 4th Sustainment Brigade at Fort 

Hood, Texas, about one month prior to deployment, 

proactively worked to structure a comprehensive 

behavioral health support plan that included family 

advocacy outreach and follow-up. Conceptually, 

activities were planned based on the unit’s immediate 

requirements and on the anticipated future needs of 

Soldiers. Special consideration was placed on the 

identification of high-risk populations that could 

emerge at each stage of the deployment. 

Train-Ready Phase (Predeployment)

To secure support for behavioral health initiatives, 

relationships were established with the division’s 

Family Advocacy: A Program to Support an Expeditionary Army 
 July – September 2010 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

senior leadership and the local family advocacy 

supervisor. Each endorsed the incorporation of family 

advocacy interventions into the behavioral health plan. 

In an effort to provide continuity of care during the 12-

month deployment, a list of 56 Soldiers who were 

actively receiving family advocacy services was 

obtained from the FAP supervisor. Shortly thereafter, 

the division surgeon was briefed on the status of highrisk Soldiers enrolled in FAP and brigade behavioral 

health officers were alerted so they could plan the 

provision of care to those assigned to their area of 

operations. Recognizing the importance of maintaining 

an efficient flow of communication between the 

theater of operations and the home station, one FAP 

staff member was designated the primary point of 

contact for the unit during the deployment. As an 

aside, although telephone and e-mail capabilities were 

readily available in Iraq, time zone differences and 

communication blackouts created challenges that 

mirrored the same frustrations Soldiers experienced 

trying to communicate with spouses back home. 

Much more could have been accomplished, had time 

permitted. Integrating into the unit as a provider from 

the Professional Filler System (PROFIS*) late in the 

Train-Ready phase hampered deployment preparation. 

Foremost, not training with the unit during the mission 

readiness exercise was a missed opportunity. The 

exercise, which usually lasts 30 to 45 days and 

simulates the deployment, provides an indication of 

how well Soldiers and spouses might cope during the 

year-long deployment and can be used to test the link 

between the behavioral health team and the supporting 

FAP staff. Additionally, time constraints made it 

difficult to establish credibility and develop trusting 

relationships with company commanders and first 

sergeants. Having limited access to company-grade 

leadership made it difficult to identify, and provide 

early intervention, to Soldiers at-risk for domestic 

violence based on a history of previous incidents of 

family violence, marital discord, alcohol abuse, or 

financial problems. In some instances, the behavioral 

health provider, in concert with the FAP staff, may 

need to recommend the delay of a Soldier’s 

deployment or suggest that he/she be assigned to the 

rear detachment to grant additional time to stabilize the 

family environment. Nevertheless, these 

recommendations should be used judiciously and only 

if sufficient evidence suggests that additional time at 

home will eventually produce a deployable Soldier. 

Available Phase (Deployment) 

While operating in a war zone, behavioral health 

providers primarily focus on the prevention and 

treatment of combat and operational stress reactions. 

However, the provision of FAP support is an 

important, if often overlooked, component of a 

comprehensive behavioral health program. This is 

particularly true since the Army broadly defines 

domestic violence as the use, or threat to use, force or 

violence against a current or former spouse, a person 

with whom one has a child, or a current or former 

intimate partner with whom a domicile has been 

shared.6

 With the composition of today’s military, 

many units have dual military couples who may share 

living quarters while deployed, and unmarried, 

cohabitating couples who deploy together with the 

same unit. Therefore, it is reasonable to expect that 

domestic violence incidents could occur in theater. It is 

prudent that the behavioral health officer prepare a 

protocol to respond to abuse allegations. 

Operationally, a forward-deployed family advocacy 

program would essentially involve the same activities 

as those found in garrison, namely, continued care for 

existing active cases; assessing reports of domestic 

violence that occur in theater; providing treatment to 

new cases and conducting secondary prevention for 

Soldiers who become at-risk due to marital conflict 

caused, or exacerbated, by deployment-related family 

separation. That being said, it is worth reiterating that 

the primary purpose of all deployed Soldiers, to 

include behavioral health providers, is to conduct 

potentially stressful military operations. Family 

advocacy intervention is a secondary objective. 

Nevertheless, an exception should apply to individuals 

who become victims while in theater. For them, 

implementation of a safety plan and the provision of 

emotional support become a priority. 

*PROFIS predesignates qualified Active Duty health professionals serving in Table of Distribution and Allowance† units to fill Active 

Duty and early deploying and forward deployed units of Forces Command, Western Command, and the medical commands 

outside of the continental United States upon mobilization or upon the execution of a contingency operation.

†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 document which defines the structure 

and equipment for a military organization or unit). 
40 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Behavioral health operations at Camp Taji during OIF 

05-07 reflect many of the challenges inherent in 

managing FAP cases during a combat deployment. 

Most notably, only 12 of the 56 Soldiers (21%) 

identified as enrolled in family advocacy treatment 

prior to deployment received follow-up in Iraq. Most 

could not access care because of assignment to 

outlying patrol bases throughout the Multi-National 

Division–Baghdad area of operations. Others could not 

make appointments because of mission requirements 

such as combat logistics patrols, command post duty, 

and other combat support activities. At about the 7-

month point of the deployment, 3 allegations of 

domestic violence were reported on Taji. In response 

to each incident, command was notified and safety 

plans were implemented, including temporary 

weapons restrictions for all involved Soldiers. Also, to 

remain compliant with the family advocacy regulation, 

law enforcement and the FAP reporting point of 

contact (RPOC) were notified. These steps in the FAP 

protocol were complicated by the fact that the RPOC 

was located at Fort Hood, and there was no clear 

guidance with regard to which law enforcement 

agency has jurisdiction over in-theater family 

advocacy reports. Frustratingly, neither the provost 

marshal at Camp Taji nor the military police at Fort 

Hood accepted responsibility for the report. 

Soldiers going home for environmental management 

leave, commonly known as R&R, presented an 

interesting and somewhat unexpected set of 

challenges. After returning to Taji from R&R, one 

female Soldier reported being physically assaulted by 

her civilian husband while on leave. Implementation of 

the FAP protocol with this allegation was made more 

difficult due to the Soldier’s assignment to a unit 

deployed from Fort Riley, Kansas. Unfortunately, no 

predeployment coordination had been arranged with 

the supporting FAP office. Initially, the RPOC at Fort 

Riley refused to accept the spouse abuse report, but 

relented only after consulting with the US Army 

Medical Command’s FAP program manager. While 

the Soldier entered treatment at Taji and continued 

services until redeploying 5 months later, the eventual 

outcome of the case is unknown. Also, in conjunction 

with R&R, 4 Soldiers with acute marital conflict were 

believed to be at-risk for committing family violence 

while on leave. Prior to each of them leaving Camp 

Taji, coordination was made with the rear detachment 

commander and FAP supervisor to have them 

evaluated by FAP personnel at Fort Hood before 

having contact with their spouses. These precautionary 

steps may have helped to prevent any incidents, as no 

abuse reports were received. 

The majority of the FAP work focused on providing 

secondary prevention to Soldiers experiencing marital 

problems with spouses back home. Twenty-five 

Soldiers, 21 male and 4 female, received supportive 

counseling for partner relational problems associated 

with infidelity or being told that their spouse wanted a 

divorce. Most presented to the clinic experiencing 

anger, depression, inability to concentrate on missions, 

sleep difficulties, and appetite disturbances. Some 

expressed suicidal ideations while others wanted 

desperately to go home so they could “fix” their 

marriages. Usually, once the initial crisis was stabilized, Soldiers received supportive intervention using 

individual and group modalities that emphasized stress 

management strategies, methods to cope with family 

separation, improving communication in a marriage, 

and restoring trust in a relationship. No one had to be 

redeployed early because of FAP related issues. 

Reset Phase (Postdeployment)

At this point in the deployment cycle, the primary 

responsibility for the unit’s family advocacy support 

reverts to the home station FAP. After the 4th Infantry 

Division redeployed from Iraq, the 3 abuse cases that 

occurred in-theater, including all documentation, were 

formally transferred to Fort Hood’s FAP supervisor. 

Of the cases that were active prior to deployment, 

written updates were provided on the 12 Soldiers who 

received follow-up in Iraq. Eleven of the Soldiers who 

received treatment for partner relational problems were 

recommended for continued follow-up by FAP 

clinicians due to lingering symptoms that placed them 

at-risk for family violence. Additionally, 8 Soldiers 

were referred to the outpatient Resilience and Restoration Center for further assessment and treatment of 

combat-related psychological symptomatology in 

hopes that any related family difficulties could be 

averted. As a PROFIS provider, the behavioral health 

officer did not accompany the unit to Fort Hood and 

thus was unable to personally ensure that Soldiers 

received recommended follow-up. This lack of continuity reinforces the importance of direct assignment of 

organic behavioral health providers to the brigades 

they support. Finally, redeployment is the time to 

review lessons-learned so that behavioral health serFamily Advocacy: A Program to Support an Expeditionary Army 
 July – September 2010 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

vices can be improved for future operations. The review should include the FAP protocol to determine if 

adjustments should be made to develop more effective 

family advocacy support for the next deployment. 

POLICY IMPLICATIONS

Although there are limited empirical data to help 

define the extent of family advocacy problems in the 

current theaters of operation, we believe that the 

anecdotal evidence inherent in the 4th Infantry 

Division’s experience during OIF 05-07 reflects the 

challenges confronted by most operational units. 

Presently, since no standardized approach to 

operational family advocacy exists, deploying units 

must rely on the professional experience and personal 

interests of its behavioral health officer for the design 

and implementation of a FAP support plan. 

Institutionalizing a systemic response, rather than 

relying on individual initiative, requires the 

modification of existing policy. We recommend 

consideration of the following policy initiatives: 

 Issue command guidance on which provisions of 

Army Regulation 608-18 6 apply to deployed units 

operating in a combat zone. 

 Assign the Chairperson, FAP Case Review 

Committee (CRC) as the responsible agent for 

ensuring that follow-up of all active cases is 

properly coordinated between the installation’s 

FAP and the deploying unit. 

 Modify the composition of the FAP CRC to 

include the brigade behavioral health officer for 

cases involving Soldiers assigned to his or her 

brigade. 

 Clearly designate one organization, either the 

deployed unit or home station, to take 

responsibility for the management of family 

advocacy cases that occur in theater, to include 

CRC review and records management. 

 Clarify whether the in-theater provost marshal or 

the law enforcement agency at the home 

installation has responsibility for spouse abuse 

reports from the deployment area. 

 Create a reporting mechanism to specifically track 

the number of spouse abuse incidents occurring in 

a theater of operations. 

 Extend the victim advocate program to support 

victims of domestic violence in theater. 

 Update the programs of instruction for the Family 

Advocacy Staff Training and Combat Operational 

Stress Control Courses, conducted at the Army 

Medical Department Center and School, to include 

family advocacy support for overseas contingency 

operations. 

 Reduce the reliance on PROFIS providers for 

filling behavioral health officer authorizations in 

the brigade combat teams. 

Other policy actions may be warranted as we learn 

more about the impact multiple deployments have on 

marriage and family relationships. To help target 

prevention efforts at critical junctures, domestic 

violence rates should be carefully monitored for 

increases associated with each phase of the 

deployment cycle. 

CONCLUSIONS

As the Army continues its transformation into an 

expeditionary force, new approaches to the delivery of 

behavioral healthcare to Soldiers and Families will be 

needed. The Army Campaign Plan for Health 

Promotion, Risk Reduction, and Suicide Prevention 

aims to improve existing programs and to ensure they 

are well coordinated to maximize effectiveness.20 For 

some, blending family advocacy functions into brigade 

behavioral health operations will not be a popular 

proposal, and it is arguable that active spouse abuse 

cases could be suspended during a deployment since 

the threat of physical harm is minimal. However, 

ensuring continuity of care for family advocacy cases 

sends a strong message that meeting the psychosocial 

needs of our Soldiers and the execution of operational 

missions can coexist. The provision of family 

advocacy support to forward operating areas, with its 

bureaucratic complexities and clinical challenges, 

requires innovative thinking that integrates 

contributions from behavioral health providers, family 

advocacy personnel, and unit commanders. 

Deployment area family advocacy procedures, at least 

those measures to protect and support victims in 

theater, will further solidify the Army’s commitment 

to provide for the psychological health and well-being 

of its Warriors and Families. 
42 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

REFERENCES

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[Army News Service website]. October 17, 2007. 

Available at: http://www.army.mil/-news/2007/10/17/ 

5641-army-leaders-sign-covenant-with-families/. 

Accessed April 1, 2010. 

2. Johnson SJ, Sherman MD, Hoffman JS, et al. The 

Psychological Needs of U.S. Military Service 

members and Their Families: A Preliminary Report. 

Washington, DC: American Psychological 

Association Presidential Task Force on Military 

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Service Members. Available at: http://www.apa.org/

about/governance/council/policy/military-deployment

-services.pdf. Accessed May 4, 2010. 

3. Alvarez L. Despite Army’s assurances, violence at 

home. New York Times. November 23, 2008;sect 

A:24. Available at: http://www.nytimes.com/2008/ 

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families turn deadly. New York Times. February 15, 

2008;sect A:1. Available at: \ http://www.nytimes. 

com/2008/02/15/us/15vets.html. Accessed April 1, 

2010. 

5. Perez R. Domestic violence in military might be 

bigger than Hawaii statistics suggest. Honolulu 

Advertiser [serial online]. December 18, 2008. 

Available at: http://www.honoluluadvertiser.com/

article/20081218/SPECIALS02/812180372/-1/

SPECIALS02&template=domesticviolence_story. 

Accessed April 1, 2010. 

6. Army Regulation 608-1: Army Family Advocacy 

Program, Washington, DC: US Dept of the Army; 

October 30, 2007. 

7. Di Nola GM. Stressors afflicting families during 

military deployment. Mil Med. 2008;173(5):v-vii. 

8. Tollefson TT. Supporting spouses during a military 

deployment. Fam Community Health. 2008;31(4):281-

286. 

9. Gibbs DA, Martin SL, Kupper LL, et al. Child maltreatment in enlisted soldiers’ families during combat 

related deployments. JAMA. 2007;298(5):528-535. 

Available at http://jama.ama-assn.org/cgi/content/

full/298/5/528. Accessed May 1, 2010. 

10. Anderson JR. 8 years of war take a toll on military 

marriages. Army Times [serial online]. February 17, 

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news/2010/02/offduty_marry_deploy_divorce_ 

021710w/. Accessed April 1, 2010. 

11. Warner CH, Appenzeller GN, Warner CM, Grieger 

T. Psychological effects of deployments on military 

families. Psychiatr Ann. 2009;39(2):56-63. 

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JH, Norwood AE, Fullerton CS. Deployment and the 

probability of spousal aggression by US Army 

Soldiers. Mil Med. 2000;165:41-44. 

13. Wasileski M, Callaghan-Chaffe JE, Chaffee RB. 

Spousal violence in military homes: an initial survey. 

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14. Peebles-Kleiger MJ, Kleiger JH. Reintegration stress 

for Desert Storm families: wartime deployments and 

family trauma. J Trauma Stress. 1994;7(2):173-193. 

15. Sherman MD, Sautter F, Jackson MH, Lyons JA, 

Hans S. Domestic violence in veterans with posttraumatic stress disorder who seek couples therapy. J 

Marital Fam Ther. 2006;32(4):479-490. 

16. Gold JI, Taft CT, Keehn MG, King DW, King LA, 

Samper RE. PTSD symptom severity and family 

adjustment among female Vietnam veterans. Mil 

Psychol. 2007;19(2):71-81. 

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BL. Aggression among combat veterans: 

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care. N Engl J Med. 2004;351(1):13-22. 

19. White Paper; Adapting our Aim: A Balanced Army 

for a Balanced Strategy. Washington DC: US Dept of 

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AUTHORS

COL Arincorayan is Chief, Department of Social Work, 

Tripler Army Medical Center, Honolulu, Hawaii, and 

Social Work Consultant to The Surgeon General of the 

Army. 

Dr Applewhite is Clinical Associate Professor, US 

Army-Fayetteville State University Master of Social 

Work Program, US Army Medical Department Center 

and School, Fort Sam Houston, Texas. 

Dr Robichaux is Social Work Programs Manager, 

Behavioral Health Division, US Army Medical 

Command, Fort Sam Houston, Texas. 

Family Advocacy: A Program to Support an Expeditionary Army 
 July – September 2010 43

Increasing access to care has been declared a priority 

of the US Army Medical Department.1

 Accomplishing 

this goal will take action on the strategic as well as the 

tactical level. The problems currently impeding access 

to care seem pervasive as there are several 

components: 

regional variations 

technology issues 

patient expectations 

current staffing levels 

The key to increasing access to care is to individually 

examine and address the identified components that 

presently stand in our way. This paper addresses 

several innovative ways to increase access to care in 

our current medical system. Some are currently being 

employed at the medical activity level, others will 

require bold moves by those in the US Army Medical 

Command leadership and involve major paradigm 

shifts in the way we approach the entitlement of free 

medical care in a system with finite financial 

limitations. 

The first issue is to identify if access to care is indeed a 

problem and, if so, at what level (national, regional, 

local) does the problem exist. The second issue is to 

find contributing factors to the problem. The third is to 

prioritize the solution(s). The fourth is acceptance 

from all those involved in patient care. 

Is access to care a problem? Many regions report data 

showing they are not meeting TRICARE* standards. 

When this data is elevated, it seems to take on a life of 

its own. All regions then respond to access to care with 

equal intensity, whether or not data supports that a 

region may, indeed, meet TRICARE access to care 

standards. This can be a distracter for those regions 

already meeting the standards. In addition, the politics 

and emotion of this issue seem to outpace reality. 

When we look at anecdotal cases from very distraught 

beneficiaries, such as “we cannot get appointments at 

my Army health clinic,” a nonissue can be blown out 

of proportion. 

Access to care begins with a patient’s phone call to the 

military treatment facility seeking an appointment. Our 

[US Army Medical Department Activity, Heidelberg] 

phone system is a hodge-podge of phone systems 

manned by central appointment clerks, office staff, 

clinic clerks, and Soldiers. Wait times, busy signals, 

and the like all degrade patient satisfaction. If a clinic 

phone system is manned by a single person, the loss of 

that clerk due to illness, leave, or transition of the 

position will have a deleterious effect on the clinic’s 

access to care. Perhaps it is time to establish Regional 

Medical Command level phone systems to provide a 

robust service to our beneficiaries. The Europe 

Regional Medical Command is currently investigating 

this option. 

The greatest challenge to military treatment facilities is 

the constant loss of providers and support staff to 

deployments. This not only degrades the number of 

staff personnel available, it also chronically affects the 

continuity of care. The loss of a single provider for a 

year in a large, 10-person clinic can lead to an annual 

loss of 10% in relative value units. Since the beginning 

of Operations Enduring Freedom and Iraqi Freedom, 

thousands of providers and support staff have 

deployed. It has proven difficult at times to replace lost 

staff as the Army Reserves have been decimated by 

years of activations. The acquisition of civilian hires to 

replace deployed physicians at some remote locations 

or at locations identified for closure has proven very 

challenging. Some military treatment facilities have 

occasionally offered extremely high salaries for 

providers to relocate to their areas. In addition, 

appointing patients to a primary care manager is not 

reflected in the current reality of military medicine. 

Appointing a primary care manager was difficult at 

best when providers routinely moved every 3 years. 

Now primary care managers not only rotate every 3 

Increasing Our Access to Care: A View From 

 Middle Management 

COL Robert A. Smith, MC, USA 

*TRICARE is the Department of Defense healthcare program for 

members of the uniformed services, their families, and their 

survivors. Information available at http://www.tricare.mil. 
44 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

years, they often deploy in the middle of most 

assignments. Some of our Soldiers and Families may 

rotate through 3 or 4 primary care managers in their 3-

year tour. Appointing patients to teams or clinics, such 

as the Red Team or the Pediatrics Clinic, is a more 

realistic goal due to the current transient nature of our 

military providers. This appointing system is allowed 

under the US Army Medical Command’s Access to 

Care Operation Order,1

 but it has proven difficult to 

execute due to the limitations of the Composite Health 

Care System Primary Care Manager appointment 

system. 

Our overseas military bases also deal with a large 

number of long-term nonbeneficiaries such as 

Department of Defense (DoD) civilians, DoD 

Dependents School teachers, DoD contractors, and 

retirees seeking medical care in our military treatment 

facilities. Our current military treatment facility 

staffing models do not account for these populations, 

and although they are entitled to purchased care, or 

free care for retirees, on a space-available basis, these 

employees and retirees have come to expect care from 

our military treatment facilities. Access to spaceavailable care varies greatly from clinic to clinic and 

from year to year. It is difficult to turn healthcare on 

and off for our chronically ill nonbeneficiaries and 

retirees. Most Army providers feel they are 

abandoning their chronic patients when continued care 

is denied due to access to care issues. 

Military physicians may work 60 hours or more per 

week, while civilian physicians under the National 

Security Personnel System (NSPS) are required to 

work 40-hour weeks. Although civilian physicians 

could work more than 40 hours per week, they would 

accumulate compensatory time for this overtime. The 

physicians would then use their compensatory time for 

additional days off, leading to fewer patient 

appointments and a decrease in access to care. The 

NSPS is attempting to correct this issue by eliminating 

overtime and compensatory time for physicians and 

dentists. NSPS physicians seem unaware of this 

transition as it is written only in 5 CFR §9901.361(e) 

(2009), not in an employee contract. The vision of the 

NSPS system is that physicians are hired to complete 

the mission and are not employees paid by the hour. 

Their salaries are supposed to reflect this change in 

work expectations and be negotiated to compensate 

employees for additional work such as, overtime, on 

call, shift work, holiday and weekend work. The NSPS 

system needs to establish written contracts for 

physicians that explain the mission-oriented work 

mentality before the employee begins working. 

Currently, this is not briefed, in writing or verbally, to 

these employees when they negotiate their initial 

salary.* 

Another factor that affects provider productivity is the 

military’s current electronic medical record system, 

AHLTA. This system has many outstanding features 

such as a lifetime continuous medical record, medical 

records that are viewable worldwide in all military 

treatment facilities, no legibility issues, and the ability 

to import medical summaries from outside the military 

treatment facilities. But these features come with a 

huge cost—provider time. The system is designed to 

make the provider enter the data. Data entry is a 

tremendous distracter, especially for those providers 

who cannot type or who are challenged by the use of 

computers. 

Providers who would see 30 patients a day when using 

a simple, paper-based medical record system see only 

half that number using AHLTA. The US Army 

Medical Activity, Heidelberg (USAMH), and now the 

Europe Regional Medical Command have sought to 

mitigate some of these documentation issues using 

some off-the-shelf technologies. These technologies 

use wireless laptops, medical dictation software, and 

pretyped text macros that make documentation quicker 

and more efficient. They have increased provider-level 

satisfaction with AHLTA and have improved the 

overall medical record. These best practices are now 

being taught throughout the Army Medical 

Department, but they are still of little help if the 

provider suffers from computer phobia. Until all our 

providers are truly computer literate, this form of data 

entry will come with a cost. Another issue with 

AHLTA is its instability. The system is chronically 

unavailable†

 and, since the main server is located in 

the US, it is extremely slow for many locations around 

the world. Clearly the benefits of this system do 

outweigh the problems, but AHLTA comes with a 

*Note: The National Defense Authorization Act of 2010 (PL 111-84) has eliminated the NSPS and requires the transition of all 

NSPS employees into non-NSPS personnel systems not later than January 1, 2012. The Editor 

†Data from Information Management Division. AHLTA/CHCS Actual and Scheduled Downtime for Central Europe; August 2008. 

Internal military information, limited access. 

Increasing Our Access to Care: A View From Middle Management 
 July – September 2010 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

technological tax on providers’ time. There is not a 

current solution, and the situation will continue to 

affect our overall access to care. 

Medicine itself has changed over the years. Changing 

Joint Commission* standards has increased the quality 

of medical care, but has also imposed many standards 

that demand large amounts of additional time from our 

providers and support staff. These Joint Commission 

standards force staff to address many issues, such as 

abuse, depression, learning issues, smoking, nutrition 

issues, deployment issues, medicine reconciliation, and 

patient safety discussions with every patient at every

visit. Although this data can be answered by the 

patient in a simple questionnaire, it can take a fair 

amount of the patient’s time. Further, that data must 

then be entered into AHLTA by the support staff and, 

if relevant, addressed by the provider. Yes, this is a 

very holistic practice of medicine, but the cost in time 

for patients, staff, and providers is tremendous. 

Screening patients for very simple medical issues is 

now a very complex process, absorbing time and thus 

affecting access to care. 

The issue in the Military Health System is that the 

structure of the healthcare benefit increases patient 

expectations and leads to overuse. The Army Medical 

Department defines access to care as the patient being 

seen by the right provider, at the right time, in the right 

venue. Many patients would define access to care in 

the Military Health System as being seen by their 

primary care manager when they want to be seen. 

Patient expectation of the Military Health System is 

very high and there is no other model for it in the 

world. If a patient pays out-of-pocket for all his 

medical care, he might wait until the last minute before 

seeking care. If there is no cost to the patient such as in 

the cases of socialized medicine, military healthcare, 

or Medicaid, the patient might expect immediate 

medical care for every ailment, whether it be 

hyperacute, “I vomited once this morning,” or only for 

simple convenience, “I just need a bottle of Tylenol for 

my baby.” The balance may be obtained in a copay 

system. A $5 to $10 copay weeds out many needless 

visits to a provider, thus reducing appointments 

booked into the system, decreasing demand, and 

increasing access to care. An additional method to 

reduce demand in the Military Health System is the 

use of phone triage. Nurses or nurse practitioners, 

using well-established algorithms, are highly skilled at 

phone triage. Military treatment facilities which have 

used this system have shown a significant decrease in 

patients seeking acute appointments, thus producing an 

increase in access to care by decreasing demand in a 

safe, cost-effective manner. The Stuttgart Army Health 

Clinic is currently using a contracted Nurse Advice 

Line to screen all acute appointments. Patients initially 

did not like the extra step in obtaining an appointment, 

but the system has reduced the need for a provider to 

see every patient who thinks he or she should be seen. 

The Europe Regional Medical Command is also 

looking into incorporating this service into its regional 

telephone appointment system. 

One way to increase patient flow and to reduce the 

time the patient spends in the clinic is to hire more 

support staff. Support staff personnel, like providers, 

vary in proficiency and must be carefully chosen. 

Computer-savvy support personnel who can complete 

patient questionnaires, take vital signs, and accurately 

complete the subjective part of the AHLTA note 

quickly and efficiently can greatly increase provider 

productivity and the overall system’s access to care. At 

the USAMH, we have sought to increase efficiency by 

linking a support staff member, medic or nurse, 

directly to a provider. This has resulted in a better flow 

of patients and increased provider and support staff 

work satisfaction. 

Patient no-show rates of 3% to 20% also have a huge 

impact on clinic predictability and the Army Medical 

Department’s access to care. Many civilian practices 

bill a patient for the full cost of a no-show. A nominal 

nuisance fee of $5 to $10 would produce a significant 

decrease in clinic no-show rates at our military 

treatment facilities. Electronic and phone reminder 

systems do make a positive difference in patients 

appearing on time for their appointments, but our 

penalty-free system is a very poor business practice 

and should be revised. 

The Military Health System must also determine the 

priority for access to care. The US Army Medical 

Department Center & School’s priority is to teach 

physicians. Our US Army Medical Activity’s priority 

is patient care. In 2009 the Army Medical Department 

*The Joint Commission (One Renaissance Blvd, Oakbrook Terrace, Illinois 60181) is a private sector, US-based, not-for-profit 

organization founded in 1951. The Joint Commission operates accreditation programs for a fee to subscriber hospitals and other 

healthcare organizations. 
46 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

published the aforementioned Access to Care 

Campaign Operations Order (OPORD).1

 Many tasks in 

this OPORD will help increase appointments and 

access to care if this remains the priority. Every time 

we task a provider for additional stovepipe training 

such as suicide prevention, provider resiliency 

training, sexual harassment, sexual assault, equal 

opportunity, equal employment opportunity, composite 

risk management, antiterrorism, or Health Insurance 

Portability and Accountability Act (Pub L No. 104-91 

110 Stat 1936 (1996)), we reduce our access to care. 

Each of these topics is individually a worthy endeavor, 

but when they are combined, they produce “death by 

1,000 paper cuts” on the support staff and providers’ 

time, and therefore affect access to care. Many military 

treatment facilities still attempt to set aside large 

blocks of time to accomplish this training, but the 

number of training hours may soon outnumber patient 

care hours. Every new training requirement should be 

properly vetted and have a price tag attached showing 

its true cost in time and money to our access to care. 

A way to increase access to care at the strategic level 

is to use the limited number of providers in the Army 

Medical Department in a more efficient manner. Many 

senior physicians serve in administrative positions and 

see a very limited number of patients. One recommendation is a reduction in the number of these positions, 

or simply reduce the administrative expectations of 

these providers and allow them all to practice medicine 

at least one day a week. This would be a bold move 

and provide an immediate and significant number of 

available patient appointments in the Army Medical 

Department. Middle management at the physician 

level of a military treatment facility is a challenge. 

Every physician, provider, nurse, and noncommissioned officer is considered a leader and should be 

in charge of something. This can be a double-edged 

sword and lead to an entire workforce seeing patients 

at a half-time equivalent. Consolidation of middle 

management can decrease administrative duties to a 

few select people while allowing others to see more 

patients and increase access to care. At the USAMH, 

we have eliminated the Department of Outlying 

Clinics and the Department of Primary Care and 

placed all those administrative duties under the Deputy 

Commander for Clinical Services. This allowed 2 

providers to return to the role of patient care. 

Finally, our providers’ paradigm needs to change. A 

number of providers serve selfishly—they decide that 

since military physician pay is less than civilian pay, 

they expect the military work to be less demanding. 

For some, a 40-hour work week that addresses both 

administrative and patient care duties is the norm. In a 

capitalist system, the incentive to work is directly tied 

to compensation; the more patients you see, the more 

you or your practice makes. In a salaried system, the 

amount of work one performs has no additional value 

and there is no monetary compensation to see more 

patients. Competition amongst providers for the 

number of patients seen per day, hours worked, and 

patient satisfaction will only go so far in increasing 

provider productivity. Many believe increasing the 

number of patients seen in a day will degrade the 

quality of patient care and lead to a decrease in patient 

satisfaction. The saying that you cannot have it all 

“good, fast, and cheap” holds some weight. Perhaps 

one of the many current physician bonus programs 

should be linked to the quantity and quality of care 

provided by the physician. 

Overall, increasing access to care can be accomplished 

if the problem is attacked from various angles. 

Provider and support staff deployments are not likely 

to decrease in the near future, so other strategies 

should be attempted. Phone systems can be centralized 

to help decrease call wait times and standardize access 

across regions. Using civilian, government-employee 

physicians and paying them fair compensation for time 

worked will allow the Army Medical Department 

civilian workforce to be more productive and increase 

access even in geographic areas where hiring 

additional staff may be difficult. Systems to make 

AHLTA more user-friendly will help make 

documentation easier, but will not increase the overall 

speed of the program. Attrition of our less computersavvy workforce will also help, over time, in this area. 

Appreciating the additional time it takes to enter data 

into the electronic medical record is the key to its 

success. Joint Commission medical standards have 

increased the quality of medical care over the years, 

but, again, the time it takes to fulfill these 

requirements must be programmed into each visit, and 

its effect on our access to care must be appreciated. 

Patient expectation can be met by using a skilled 

nursing triage system to help reduce demand on the 

Military Health System. The quickest wins could be 

Increasing Our Access to Care: A View From Middle Management 
 July – September 2010 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

obtained by shifting physician administrative duties to 

patient care and realigning bonuses to productivity. 

This would be a major paradigm shift for the Army 

Medical Department and would yield the biggest and 

quickest increase in access to care. 

Army medicine is at a crossroads. Its beneficiaries and 

stakeholders demand access to care. How the Army 

Medical Department addresses this challenge could 

determine its future. 

REFERENCE

1. US Army Medical Command Operation Order 09-36: 

Access to Care Campaign. March 30, 2009. Internal 

military document, limited availability. 

AUTHOR

COL Smith is the Deputy Commander for Clinical 

Services, US Army Medical Department Activity, 

Heidelberg, Germany. 
48 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INNOVATIONS IN ACCESS TO CARE

In the eyes of the beneficiary, how quickly can one 

obtain an appointment is a key benchmark of the 

success or failure of a clinic commander. Access to 

care was defined by a 2006 Joint Service Access to 

Care Committee consisting of the Deputy Surgeon 

Generals of each service and senior representatives of 

the TRICARE* Management Activity as “encompassing all of the necessary activities that will ensure 

our beneficiaries get to the right provider at the right 

time at the right place.”1

 At first glance, access to care 

can be as deceivingly simple as having enough 

appointments for the healthcare demands of the 

community. However, access to care within the 

Military Health System is an orchestration of distinct 

processes occurring before, during, and after every 

patient visit. A short-sighted, quick solution in one 

area can have great impact elsewhere in the system. If 

you want to maximize your potential for positive 

outcomes, it is important to identify and appreciate the 

impacts of one process on other processes. 

Access to care consists of interrelated components that 

address getting the patient into an appointment, having 

the right resources available to see the patient, and 

efficient processes to record, close, refer, or follow-up 

appropriate care. Not appreciating the impact of one 

area on another can cause great risk in creating 

redundancies and delays that hinder the efficiency and 

efficacy of completing a beneficiary’s episode of care. 

This access to care process within the US Army 

Europe Theater has an additional challenge: 

transformation. Transformation is a complete 

restructure of the location and size of US forces and 

supporting elements throughout the Europe Theater. 

My clinic, the US Army Health Clinic, Mannheim, our 

parent organization (the US Army Medical 

Department Activity, Heidelberg), and our supported 

communities have been designated for relocation and 

eventual closure. This article addresses some of the 

Army Health Clinic (USAHC), Mannheim initiatives 

to maintain access to care in a high operations-tempo 

community with decreasing healthcare resources and 

increasing healthcare demands of more than 6,000 

enrolled beneficiaries and more than 4,000 Soldiers 

rotating to and from various global contingencies. 

NO APPOINTMENTS AVAILABLE?! 

This was our projected crisis for the summer of 2008. 

We were losing available providers to a myriad of 

deployments, stateside medical boards, notices of 

termination, and civilian provider summer leaves 

bringing our clinic down from the 9 authorized fulltime providers to 2.5 available full-time providers. 

What were we going to do? The easy answer was to 

limit access to only Active Duty Soldiers. And this we 

were not willing to do...yet. 

Our first challenges were to identify replacement 

providers and discover how and where we could 

maximize the use of our available providers’ time and 

efficiency. We were fortunate to receive borrowed 

manpower from our higher medical organization, 

including providers from closed facilities and 2 

additional providers pulled back into service while 

they awaited their retirement dates. 

Our efforts to maximize the efficiency of our providers’ time continued. A healthcare provider’s time is 

any facility’s most valuable asset.1

 The critical common denominator for access is the available man-hours 

of our providers. I believe anything that takes the 

provider away from face-to-face contact with a patient 

is a distracter. Indeed, there are “necessary” distracters 

within the Military Health System—distracters which 

improve the providers’ ability to maintain and sustain 

their personal medical readiness and survive within a 

battlefield environment; to facilitate the medical readiness of deploying and returning Warriors; and to 

deliver urgent and compassionate services to nonactive 

Access to Care Initiatives 

LTC Ivan D. Speights, Sr, MS, USA 

MAJ Cindy S. Renaker, AN, USA 

MAJ Huy Luu, MC, USA 

Jeremy Schneider 

*TRICARE is the Department of Defense healthcare program 

for members of the uniformed services, their families, and 

their survivors. Information available at http://www.tricare.mil. 
 July – September 2010 49

duty beneficiaries. Beyond these, all other 

distracters were targeted for identification and 

resolution. 

Through the great work and efforts of many, we 

were able to find a variety of top-notch, credentialed providers who were quickly absorbed into 

the normal operational flow and soon cherished 

by the community. Our projected crisis of having 

no available providers was avoided, but we were 

still having access problems. We had providers, 

but still had limited available appointments. 

WHERE DID THEY GO? 

There is the old axiom that “healthcare is local.” 

This is most evident when you start looking at 

who is using the appointments. This will help 

you determine what services and types of 

appointments may be better for your given 

population. Figure 1 presents the charts depicting 

beneficiary utilization for the full fiscal years of 

2007 and 2008 and the first 2 quarters of FY 

2009 (October 2008 through March 2009) for the 

USAHC Mannheim. Comparison of the number 

of visits in FY 2007 to those in FY 2008 reveals 

a decrease of approximately one-third in every 

category: Family Members from 1248 to 940; 

Retirees from 469 to 298; Others (retiree family 

members) from 1871 to 1143; and Active Duty 

from 469 to 298. This is most likely a reflection 

of the US Army Europe transformation and 

major deployments of units. An alarming 

observation is that the number of Others is larger 

than Family Members. A significant change is 

noted when comparing FY 2008 to the first 2 

quarters of FY 2009. The categories of Retirees

and Others are half of the FY 2008 total visits as 

expected, but the Family Member total visits are 

two-thirds of the FY 2008 total. This is trending 

toward being one-third higher than the FY 2008 

total visits and the Active Duty visits for 2 quarters 

are nearly equal to the total FY 2008 number, 

which may result in double the total visits of FY 

2008 by year’s end. The positive aspect is that 

there appears to be increased visit accessibility 

for Active Duty and Family Members in FY 2009. 

Figure 2 depicts the monthly number of 

encounters and relative value units of acute, 

routine, and wellness appointments. The wellness 

Figure 1. Beneficiary utilization statistics at USAHC Mannheim for 

fiscal years 2007 and 2008, and the first half of fiscal year 2009. 

Source: Military Health System Management Analysis and Reporting Tool (http://www.tricare.mil/mhsophsc/mhs_supportcen 

ter/Library/1_M2.pdf). 

Family Members 

Retirees 

Other 

Active Duty 

Fiscal Year 2007 

n=901 (20%) 

n=1871 (42%) 

n=1248 (28%) 

n=469 (10%) 

Family Members 

Retirees 

Other 

Active Duty 

n=674 (22%) 

n=1143 (37%) 

n=940 (31%) 

n=298 (10%) 

Fiscal Year 2008 

Family Members 

Retirees 

Other 

Active Duty 

1st & 2nd Quarters, Fiscal Year 2009 

n=529 (26%) 

n=670 (33%) 

n=654 (33%) 

n=158 (8%) 
50 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

appointment increases align with major unit 

deployment and redeployment activities. Acute and 

routine appointments show a negative trend over the 

full period of the charts. However, it is important to 

note the significant increases in acute and wellness 

appointments starting from August 2008, but a 

decrease in the number of telephone consults being 

seen by providers. This decrease in telephone consults 

relates to the implementation of a telephone consult 

nurse initiative and additional processes to promote the 

“right care” to the right level of healthcare. Instituting 

a consult nurse option to review and, as appropriate, 

resolve less urgent beneficiary concerns (like 

prescription refills), as well as provide follow-up care 

as requested by providers increased the available manhours for providers to have face-to-face interaction 

with more urgent beneficiary concerns. 

The breakouts of utilization by beneficiary categories 

and actual appointment types seen are areas that 

warrant close review for any healthcare facility 

seeking not only increased access, but also increased 

access to the right care. Initial observations raise the 

consideration of decreasing access to the Others

beneficiary category to allow better access for the 

primary beneficiary category. Reviewing what 

appointments are actually seen in your facility helps 

determine if your providers’ time is being used 

efficiently and if lower-skilled healthcare providers 

could be better utilized in your facility. 

To dig more deeply, we looked objectively at the 

process of getting care, then implemented the 

following initiatives to promote not simply access to 

care, but access to the right care. 

TEMPLATE MANAGEMENT

It is critical to ensure your schedule templates reflect 

the demands of your community. The medical director 

and supervisor of central appointments have the best 

view of the realities of patient requests and provider 

concerns within the facility, and they used the previous 

year’s historical demand to develop our templates. 

Historical data showed the percentage of visits to be 

58% acute, 16% routine, 18% wellness, and 8% 

established patient appointments, where the patient 

had been seen in clinic before. Templates were then 

reviewed at least every 3 months and adjusted based 

on clinic operations tempo. There were many factors 

affecting access which drove the need for close 

supervision and the ability to adapt quickly to the 

following: 

Figure 2. The number of monthly encounters and relative value units of acute, routine, and wellness appointments at 

the USAHC, Mannheim. 

Source: Military Health System Management Analysis and Reporting Tool (http://www.tricare.mil/mhsophsc/mhs_ 

supportcenter/Library/1_M2.pdf)

1600 

Oct 06 

Dec 06 

Feb 07 

Apr 07 

Jun 07 

Aug 07 

Oct 07 

Dec 07 

Feb 08 

Apr 08 

Jun 08 

Aug 08 

Oct 08 

Dec 08 

Feb 09 

1400 

1200 

1000 

800 

600 

400 

200 

0 

Sum of Simple RVU – ACUT 

Sum of Simple RVU – T-CON 

Sum of Encounters – ACUT 

Sum of Encounters – T-CON 

RVU Relative value units 

ACUT Acute 

T-CON Telephone consult 

Access to Care Initiatives 
 July – September 2010 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

Number of providers available compared to needs 

shown in historical data. 

Support services and providers available. 

Season. In winter there were more appointments 

for common colds; in fall/spring there were more 

appointments for sports physicals; in summer there 

was a low overall acute demand as a result of more 

people being away. 

Operations tempo. Deployments and redeployments of large units affect access at an unpredictable pace. Priority of care must go to Active 

Duty service members. Templates should be 

adjusted to reflect additions caused by priority care 

to Active Duty. 

Historical daily demand. Monday and Tuesday 

were busiest for acute care appointments, and 

Friday was least busy overall. 

Other considerations are whether you want all 

providers to have similar templates (distribution of 

types of appointments) or whether you designate 

certain providers to see only patients for certain types 

of appointments, such as acute appointments. There 

are pros and cons with each type of template, and most 

providers would not want to see acute appointments all 

day. An equal distribution, adjusted as needed, is 

preferred. 

The number one issue within our clinic was the 

number of available providers, the second was the 

number of appointments available. Appointment types 

can be adjusted at the time of the request. For example, 

you could convert a routine appointment to an acute 

appointment. But without an available slot, there is no 

further option. 

THE TELEPHONE APPOINTMENT LINE

The telephone appointment line is the primary means 

that most patients use to access any healthcare system. 

Previously, there were more than 3 separate telephone 

numbers a patient could call for an appointment at our 

clinic. A patient would call one line, then call the 

second one, and then call the third in hope of getting 

into a shorter wait time for a human voice. This was 

changed to a single number, 385-CARE, which routes 

each caller to an automated system that cues calls into 

6 available lines. Our initial close review of the 

telephone script found an obsolete cue number that 

apparently was the source of complaints in that there 

was no answer on that appointment line. The 

establishment of a standard and easily remembered 

phone number was a proactive, value-adding 

innovation made by the previous clinic commander. 

Unfortunately, it did not help our situation of no 

available appointments. 

Our first innovation was to establish starting times for 

beneficiaries to call for appointments. Active Duty 

service members were given first priority for available 

appointments, calling as early as 7 AM for any 

available acute appointments. At 8 AM, Active Duty 

Family members could call for remaining available 

appointments, and any remaining appointments could 

be booked for retirees and retiree family members 

starting after 9 AM. The community’s compliance 

resulted in decreased initial traffic peaks on phone 

lines, reduced overall telephone wait times, and 

provided better consistency for central appointment 

personnel. Most importantly, it increased the 

opportunity for Active Duty Soldiers to be scheduled 

first for available appointments. 

Our second innovation was to establish a telephone 

consult nurse option within the telephone script. 

Providers stated that a number of their appointments 

could have been handled by a skilled healthcare 

provider such as a registered nurse. A registered nurse 

was designated to personally answer basic medical 

requests such as prescription refills and basic healthrelated queries, which reduced the necessity of 

patients’ 20 to 30 minute appointments with providers. 

This resulted in immediate positive feedback from 

patients who were now able to come directly to the 

pharmacy for their refills as opposed to first navigating 

the appointment system to see a provider for that 

renewal. The patient experienced less difficulty/

inconvenience and the clinic saved an appointment for 

a patient in potentially greater need. 

Suite Standardization 

Our clinic is structured as one long building with 

individual branches to either side which we call 

“suites.” In each of the 5 major suites are 2 provider 

offices with 4 treatment/exam rooms, a general waiting 

and front desk area. There had been a great variation in 

processes and equipment in each suite. A suite standardization project started in 2007 was reinstated as a 

priority. The goal of the suite standardization project 
52 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

was the implementation of a standardized process for 

medication reconciliation and medical record 

documentation, physical uniformity of the suites, and 

improved patient flow. The Plan, Do, Check, and Act 

performance improvement methodology was used to 

establish an organized approach: 

Plan 

The plan began with the establishment of a “Tiger 

Team” consisting of a cross section of clinical staff 

and providers. The team’s first mission was to review 

our clinic and parent organization’s policies concerning medication reconciliation, medical documentation, 

and patient flow recommendations. The team focused 

their planning on developing new processes, writing 

new policies, and communication of those policies 

with actual implementation of the new process. 

Do 

This phase focused on development and 

implementation of a pilot study of the new process. 

Initially, a template for prescreening was initiated 

based on the Joint Commission’s* focused questions. 

During our progression, we incorporated the Army 

Medical Command AHLTA†

 provider satisfaction 

automation initiatives as our foundation. Wireless 

networking and other technological innovations were 

simultaneously introduced to enable more efficient and 

accurate documentation. All patient treatment areas 

were outfitted with standardized equipment allowing 

screening and treatment to be performed in the same 

room, and all clinic staff were retrained on the current 

standardized processes. Realized benefits included 

increased third-party insurance compliance 

improvements, increased patient turnover rates and 

managed patient flow, and effective resource 

utilization, including one dedicated healthcare assistant 

for every physician. 

Check 

This phase monitored implementation through 

statistical data gathering and identifying successes, 

failures, and potential trends. Feedback was gathered 

from providers, medics, and nursing assistants on the 

effectiveness and compliance of the new processes. 

Root causes for failures were quickly identified, with 

solutions gathered and implemented. One root cause 

for inconsistent documentation was the continuous 

movement of personnel from one suite to another. This 

situation was improved by identifying suite teams with 

2 medics assigned to 2 physicians. Another issue was 

that administrative requirements in each suite were 

taking away from the critical time available for medics 

and nurses to screen and prepare patients for providers. 

This was improved by diverting the administrative 

duties of third-party insurance verification and the 

AHLTA check-in to a centralized check-in process at 

the entrance of the facility. The centralized check-in, 

collocated with the Patient Administrative Division, 

allowed the introduction of a greeter for traffic control, 

and each provider’s dedicated healthcare assistant 

personally escorted patients to their screening and 

treatment area. This process allowed the dedicated 

healthcare assistant to conduct a face-to-face handoff 

of each patient to the provider, an opportunity for 

provider-to-medic training, and a more personalized 

experience for each patient. 

Act 

This is our current phase which continues the 

monitoring of the check phase. The whole clinic is 

operating under the new processes. New policies and 

procedures were written and communicated 

throughout the clinic. Minor construction projects 

were programmed to facilitate better traffic control 

within the centralized check-in area, and opportunities 

for better patient education are being explored. These 

processes will continue to be monitored to identify 

successes, failures, and potential trends. 

Benefits noted within the first 4 months included: 

 Faster patient turnaround time gave physicians 

more time to see additional patients or to complete 

administrative duties. 

 Decreased patient congestion in the suite areas. 

 Medics and nursing assistants focus their energies 

on screening and assisting their assigned 

physicians. 

 Better utilization of enlisted medical specialists, 

healthcare assistants, and administrative personnel. 

 More consistent insurance checks with a 

compliance rate improvement from 45% to 95%. 

*The Joint Commission (One Renaissance Blvd, Oakbrook Terrace, Illinois 60181) is a private sector, US-based, not-forprofit organization founded in 1951. The Joint Commission 

operates accreditation programs for a fee to subscriber 

hospitals and other healthcare organizations. 

†AHLTA is the US military electronic medical record. 

Access to Care Initiatives 
 July – September 2010 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

 Improved accuracy of demographics, which is 

currently updated only 30% of time. 

 Patients verbalize satisfaction with less waiting 

time and more of a personal touch in the provision 

of healthcare. 

When the dust settled, the “number-crunchers” saw 

that workload and productivity looked fairly the same. 

However, I believe our efforts succeeded in that we 

maintained our access availability, avoided an access 

crisis, and started to align the right people to the right 

care. Hopefully, one or more of these initiatives will 

be helpful to another facility’s efforts to improve 

access to care. 

REFERENCE

1. Military Health System Guide to Access Success. 

TRICARE Management Activity Website. Available 

at: http://www.tricare.mil/tma/tai/cguide.aspx. 

Accessed June 26, 2010. 

AUTHORS

When this article was written, the authors were assigned as 

follows: 

LTC Speights was Commander, US Army Health 

Clinic, Mannheim, Germany. 

MAJ Renaker was Chief Nurse, US Army Health 

Clinic, Mannheim, Germany. 

MAJ Luu was Medical Director, US Army Health 

Clinic, Mannheim, Germany. 

Mr Schneider is a Health Systems Specialist, Europe 

Regional Medical Command, Heidelberg, Germany. 

COL PIERCE JOINS THE AMEDD JOURNAL EDITORIAL REVIEW BOARD

The AMEDD Journal welcomes COL Carol Pierce, AN, USA, as a 

member of the Editorial Review Board. COL Pierce has been 

selected to be the next Chief, Department of Nursing Science, 

Academy of Health Sciences, AMEDD Center and School, Fort 

Sam Houston, Texas. 

COL Pierce joins the board replacing COL Kathleen Dunemn, 

AN, USA. COL Dunemn has been a member of the Board since 

April, 2008. We thank COL Dunemn for her dedication to the high 

standards and professional quality of this publication, and her 

years of service and support to our mission. 

The Editor 
54 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

THE TASK AT HAND: THE PROBLEM OF CONDUCTING

ARMY HEALTHCARE TRANSFORMATION

Historical Perspective 

The European theater experienced significant changes 

after the Gulf War in the early 1990s, with downsizing 

of troops and withdrawal of the overall US Army 

presence. Although Army personnel were subjected to 

situational problems and conditions similar to the 

Army’s current transformation, the Army has retained 

no institutional knowledge of the downsizing process. 

No written or published record documenting closure 

procedures, problems encountered, or solutions 

developed has been discovered. The people who 

experienced and implemented the downsizing 

procedures conducted 15 years ago are either unknown 

or no longer available. 

Current Perspective 

The USAMH mission is to positively affect Soldier 

and family health through high quality, integrated 

healthcare while maximizing medical readiness. 

Healthcare services provided are seamless and 

uninterrupted during peacetime and war as well as 

during times of stability and during periods of turmoil, 

such as closure operations when units depart and 

Soldiers out-process from the community. 

When Army Transformation in Europe commenced, 

the Army was intensely involved in Operation Iraqi 

Freedom. Various troop populations were identified 

either for transfer to new locations, return to the 

United States, consolidation, or restructuring with 

other units or dissolution of member units and casing 

of the colors. When orders for transformation and 

movement of particular troop populations were 

publicized, it naturally followed that supporting 

services should also transform, but no orders could be 

generated or plans made until specifics of the troop 

movements became known. Most troop movement 

orders are appropriately handled as classified 

information, complicating actions and making it 

difficult for support services to establish a timeline for 

downsizing and eventually curtailing services. 

Case Study: Realignment of US Army 

 Medical Activity, Heidelberg Assets During 

 US Army Europe Transformation-Driven 

 Health Clinic Closures 

LTC Raymond L. Gundry, MC, USA 

MAJ Christoph A. Hillmer, MS, USA 

INTRODUCTION

Strategic planning for our nation is a dynamic process and is continually adapted to current situational information. 

As strategic plans are adapted, changes result which are then transmitted through operational channels to the tactical 

levels. In military healthcare, tactical medicine is the level where healthcare personnel provide direct care to 

beneficiaries, whether it is lifesaving care delivered to an injured Soldier by a medic on the battlefield, an operation 

performed by a surgeon on a beneficiary in a military treatment facility or health maintenance counseling to retired 

Soldiers in a primary care clinic. 

In 2004, the Army announced strategic planning with broad restructuring plans that included massive troop movements and resulted in a dramatic decrease in American troop presence in Europe and Korea. A natural follow-on to 

the decrease in supported population was a decrease in support services provided by the Army in Europe. Although 

the original troop movements were planned with proposed dates and number of troops to transfer, the specific plans 

for support services were not supplied. Due to the lack of advance planning for downsizing of supporting services, a 

reactive process developed, with support services curtailed as the supported population departed. 

This article reviews the Army Transformation, Europe, process as it has been conducted at US Army Medical Activity, Heidelberg (USAMH) with realignment of healthcare assets, describes problems encountered, and identifies 

best practices to improve the process as Army transformation continues now, and is included in future strategies. 
 July – September 2010 55

Information to plan for curtailment of support services 

was obtained by attending town hall meetings, 

communicating directly with line unit commanders, 

and reading the newspapers to gain insight into how to 

appropriately plan for clinic closure. 

The Army Health Clinic (Babenhausen) was closed in 

2006 when transformation established the departure of 

all remaining troops from Babenhausen, Germany (lst 

Battalion, 27th Field Artillery Regiment; 2 batteries of 

the 5th Battalion, 7th Air Defense Artillery Battalion; 

and the 71st Ordnance Battalion). The 1st Brigade 

Combat Team (BCT), 1st Armored Division was 

stationed with its supporting elements in the BadenWürttemberg area of Germany and received medical 

support from outlying healthcare clinics which had 

been established after World War II in communities 

with substantial troop concentrations. The clinics were 

supported and manned by the USAMH. On June 6, 

2006, it was publicly announced that the 1st BCT with 

all combat support units and beneficiaries had received 

orders to relocate to the United States. This 

announcement was the stimulus for a reassessment of 

healthcare services provided in the area of support. 

Executive analysis determined that the clinics that had 

been providing healthcare services in Buedingen, 

Friedberg, and Butzbach would no longer be required 

after the departure of the 1st BCT. The following year, 

2 additional installations, Hanau and Darmstadt, were 

marked for closure due to additional realignments and 

unit deactivations. 

As the beneficiary population declined, affected clinics 

continued to provide a full spectrum of services, 

including laboratory and radiological services. In order 

to continue to provide full services, the clinics were 

required to maintain basic staff and equipment until 

the last Soldier and beneficiary departed, rendering the 

provision of services inherently inefficient. Operating 

under the Performance Based Assessment Model 

recently adopted by the US Army Medical Department, no allowances exist for the inefficiencies of 

clinic closure, producing a negative contribution to the 

performance of the entire USAMH under this model. 

After bringing this issue to the attention of higher 

levels of the Army Medical Department, planned 

decrements to the operating budget were adjusted to 

compensate for the basic inefficiencies of clinic 

closure. This allowed the organization to continue 

normal operations and avoid drastic measures to stay 

within the budget for the remainder of the fiscal year. 

In addition to healthcare services, all other support 

services (housing, transportation, commissary, and 

post exchange) were curtailed as the last line Soldiers 

departed. When obtained information made it obvious 

that clinic closure was definite, medical personnel 

were instructed to request orders for transfer. In other 

words, Soldiers were ordered to leave the clinic and 

then directed to request permission for transfer. Since 

clinic closure actions were not initiated until unit 

movements were publicized, medical personnel were 

not able to submit requests for personnel actions to 

generate requests for orders until well after the 

supported units had initiated personnel actions. When 

requests for orders were ultimately generated for clinic 

personnel, they were submitted into a system that was 

already overwhelmed, resulting in last-minute orders 

and assignments. Subsequent movement of clinic 

personnel presented challenges in coordinating 

transportation of household goods from a service that 

was overwhelmed with supported unit moves, was 

already downsizing, or had ceased provision of 

services in the closing community, which necessitated 

the provision of support for moving personnel by an 

appropriate agency in another community. 

Since Operation Iraqi Freedom was at its peak at the 

start of Army Transformation, many clinic personnel 

were deployed in support of the war effort. In some 

cases, personnel were deployed from a community that 

was scheduled to close before they returned, so there 

would be no Army facility remaining when they 

arrived. Fortunately, clinic commanders anticipated 

the implications in all such situations and successfully 

managed each individual case. Due to the lack of a 

proper mechanism to process cases for clinic Soldiers 

who were deployed, commanders were challenged by 

a stodgy system that was unresponsive to the resulting 

unique, individual requirements. Each situation 

required active, persistent, and frequent interventions 

by commanders to properly move Soldiers and 

Families prior to deployment. 

TRICARE* Service Center enrollment and disenrollment of remaining beneficiaries, mostly retirees, 

proved particularly cumbersome. The remaining 

beneficiaries at the clinic were advised to transfer their 

care to the facility of their choice. Fortunately for the 

affected beneficiaries at Hanau, an Army clinic located 

nearby in Wiesbaden provided flexibility for 

beneficiaries remaining in the area to either transfer 

their enrollments and continue to obtain access to care 

and referrals for specialty care within the Army 

medical system, or move into the German host nation 

medical care system, as necessary. 

German host nation medical care facilities 

characteristically do not bill on a timely basis, and 

sometimes do not bill until a year or more after care is 

*TRICARE is the Department of Defense healthcare program for 

members of the uniformed services, their families, and their 

survivors. Information available at http://www.tricare.mil. 
56 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

provided, resulting in receipt of bills well after the 

clinic closure date. Intense efforts were made to 

contact all possible billing physicians and facilities to 

ensure they knew where to send their bills after closure 

of the Army clinics. The USAMH Managed Care 

Division was the central point of contact for resolution 

of all billing issues. 

One of the biggest challenges in transformation was 

taking care of the valued clinic personnel. There were 

3 basic categories of personnel supported by their 

respective personnel systems that required placement 

upon clinic closure: active duty Soldiers, supported by 

the military personnel system; Department of the 

Army civilians, supported by Civilian Personnel 

Office and Civilian Personnel Advisory Center; and 

local national employees, supported by the Works 

Council. Each of these systems presented a unique set 

of difficulties in either avoiding or overcoming the 

bureaucratic obstacles that existed in systems 

unprepared for massive personnel movements. Due to 

the sheer volume of personnel actions, the military 

personnel system was unable to efficiently process the 

enormous number of movements of Soldiers. The 

necessary actions placed an extreme strain on the 

military personnel system, overloaded the process, and 

produced extended delays in receipt of orders and 

assignments. The majority of civilian employees 

departed with active duty line unit spouses prior to 

cessation of support services, which compromised 

clinic staffing as unit departures occurred prior to 

clinic closure. Fortunately, all remaining civilian 

personnel were reassigned to existing vacant slots, thus 

eliminating the need for reduction in force action. 

Unique to Germany is the Works Council, a local 

national organization that is similar in function to a 

union. Since the system is an entity of the German 

social system, the Army has no direct control and little 

influence regarding prioritization or expedition of 

actions. Their thorough and methodical system of 

reassigning employees mandated extensive lead time 

to communicate and gain concurrence of the Works 

Council to process actions. 

FUTURE PERSPECTIVE

Army Transformation will continue, with further implications to the level and amount of healthcare provided in Europe. In order to use the lessons learned in 

previous clinic closures and to institute the best practices that were developed, the following planning guidance is provided to assist future transformation efforts. 

1. Upon learning of possible closure actions, 

immediately employ the Medical Command Medical 

Service Action Plan format to initiate clinic closure 

planning and provide chain of command visibility to 

the impacts of clinic closure on business operations. 

Receipt of the Medical Service Action Plan at the 

Medical Command is critical to accomplish closeout 

of the Unit Identification Code and to facilitate issuance of closure orders for the clinic. Additionally, generate an operations order to ensure synchronization of 

all staff sections during the closure process, and identify specified and implied tasks which are critical to 

the successful transition and facility closure. Also, 

establish adequate social services programs for the 

expanded requirements of redeploying Soldiers caused 

by the turmoil of transfer and Family movements. 

2. The Medical Command’s current model for 

business planning, the provision of funding and 

budgetary adjustments under the Performance Based 

Adjustment Model, penalizes organizations that have a 

decreasing enrollee population due to transformation. 

With enrollees departing with moving units, it is 

impossible for an organization to increase its 

productivity and workload and meet business plan 

productivity targets. Business plan projections are 

based on a 12-month baseline which includes the 

workload from closed clinics, and makes projections 

for future workload based on a population that no 

longer exists. As the fiscal years progress and the 

workload fails to materialize, the organization is 

penalized for at least 2 fiscal years after the clinic has 

closed. Enduring clinic operating budgets must include 

adjustments which anticipate significant Performance 

Based Adjustment Model decrements as money is 

taken away due to failure to meet workload and 

productivity targets. 

3. Maximize equipment redistribution/reutilization and 

maintain property accountability. Conduct frequent inprocess reviews with staff and closing clinic command 

teams, in person or via video teleconference as 

required, ensuring synchronization of efforts and 

adequate resourcing. Frequency and duration of inprocess reviews can be adjusted as planning 

progresses, but involvement of key and essential staff 

components are critical to successful clinic closure. 

During organizational transformation, establishment of 

teams focusing on strategic communications, 

personnel, facilities and logistics, and clinical 

operations is extremely beneficial in mission analysis, 

course of action development, and mission execution. 

Preparation for curtailment of services requires 

coordination of efforts so that equipment is not 

removed or facilities altered until they are no longer 

needed. The logistics section must conduct onsite 

preclosure visits to assess quantity and condition of 

property for turn-in and compile a list of hand receipts 

which can be reviewed and posted on the 

organization’s intranet for wide visibility to enable 

tracking of turn-in status. Advertising the lists to 

Case Study: Realignment of US Army Medical Activity, Heidelberg Assets During 

US Army Europe Transformation-Driven Health Clinic Closures 
 July – September 2010 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

prospective enduring clinic recipients provides 

advance awareness of the condition/life expectancy of 

the equipment inventory available for redistribution, 

aiding decision-making and procurement. Coordinate 

with garrison officials to comply with garrison 

guidance for clearing the installation, ensuring 

compliance with local standards for turn-in. Timely 

movement of assets requires advance arrangement of 

transportation and may require contracting additional 

services to facilitate turn-in from affected installations. 

4. Develop processes to manage staff within the 

individual personnel systems which are designed to 

provide efficient, timely services for future large troop 

movements. Develop flex within the systems that 

allow for surges in affected areas. Recommend that 

operational Army units avoid transferring entire units 

immediately upon redeployment. This will allow 

sufficient time for returning Soldiers to reunite with 

their Families prior to experiencing the compounded 

stress of relocating their Family while the entire unit is 

moving from overseas to stateside or to another 

overseas location. Ensure appropriate restationing of 

military healthcare personnel and their dependents by 

anticipating challenges and initiating actions prior to 

unit movements. Provide sufficient lead time for all 

personnel actions to ensure timely receipt of orders 

prior to closure of installation essential services. 

Advise line units to include support personnel in 

appropriate briefings to facilitate early planning. 

Classified information can be handled as appropriately 

by support personnel as line unit personnel. Such 

available information will serve to synchronize smooth 

movement of support personnel along with line unit 

personnel. Identify and retain valuable civilian 

performers and restation them within the local area or 

at next consecutive higher levels within the Army 

healthcare system. Establish and maintain frequent 

informative communications with Civilian Personnel 

Advisory Center to enable Department of Defense 

civilian and local national employee actions. 

5. Beneficiaries must be informed of the requirement 

to transfer enrollment to another healthcare facility. 

Transfer of enrollment must be closely coordinated by 

TRICARE Service Centers. Establish an enduring 

central billing point, develop a comprehensive 

communication plan with all host nation hospitals and 

providers, and educate all potential host nation 

providers of billing procedures to ensure they understand where to send bills after the closure of the clinic. 

CONCLUSIONS

Strategic planning is a dynamic process that reacts to 

global changes in international relationships and 

politics and will continue to change the way we 

provide healthcare, both in garrison and in the field. 

Previous experiences with population downsizing and 

curtailments of support services in Europe have 

provided little insight or lessons learned as no 

documented record of actions was found. Many of the 

problems and inefficiencies encountered with 

curtailment of support services in conjunction with 

Army Transformation in Europe would have been 

avoided if a documented record of lessons learned had 

been produced and retained. US Army Transformation 

in Europe continues to proceed and will continue to 

produce new challenges. Clinics and organizations 

which are reducing services in the closure process 

must immediately implement the Medical Command’s 

Medical Service Action Plan format to gain approval 

to close facilities and ensure that proper planning 

procedures are performed on a timely basis. 

Allowances must be made for the inefficiencies and 

costs incurred by closure as the current funding model, 

Performance Based Adjustment, does not apply to 

military operations in flux. Support service leaders 

must be involved in transformation and closure 

planning at the outset to ensure proper realignment of 

support services assets. Conducting transformation 

during a war with active deployment of personnel 

significantly complicates closure operations. As US 

Army Europe continues transformation, it will become 

increasingly difficult to facilitate the continued 

employment of many Department of the Army 

civilians and local national employees. Significant 

reduction in the number and type of jobs available will 

ultimately necessitate Reduction in Force actions. 

We hope that this case study will assist medical 

leaders as they face similar circumstances of 

downsizing or clinic closures in the future. 

ACKNOWLEDGEMENT

We thank USAMC Clinic Commanders LTC Mark 

Probus, MS, and LTC Karrie Fristoe, MS, for their 

contributions of information and perspective in 

preparation of this article. 

AUTHORS

LTC Gundry is Chief, Professional Services, 21st 

Combat Support Hospital, Al Asad Airbase, Iraq. 

During the transformation period described in the 

article, he was the Deputy Commander for Outlying 

Clinics, USAMH. 

MAJ Hillmer is Director of Business Operations, 

TRICARE Pacific, Okinawa, Japan. During the 

transformation period described in the article, he was 

the Executive Officer for Outlying Clinics, USAMH. 
58 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Executives have long considered investments 

in information management/information 

technology (IM/IT) to be essential for 

conducting business operations and maintaining viability in the marketplace. IM/IT 

resources, ranging from computers to 

consultants, conspicuously occupy offices 

across all industries and have been a major 

element of emphasis for strategic planning, 

capital investment, departmental design, and 

financial analyses. During the period 1970–

2002, approximately $23.9 trillion (1012) was 

invested in the US economy for IM/IT 

resources including hardware, software, staff, 

supplies, communications equipment, and 

research (Figure 1). By comparison, during 

that same period, about $29.6 trillion (1012) of 

healthcare services were consumed by the 

government and individuals (Figure 2).1

The healthcare industry has historically 

invested relatively conservatively in IM/IT; 

approximately 2% to 3% of healthcare revenues are directed toward these resources, 

while other industries such as financial services and technology firms spend 5% to 10% 

of revenues on technology.2,3 This level of 

resourcing relative to revenues indicates that 

healthcare executives may have invested as 

much as $694 billion (109

) in IM/IT over a 22-

year period since 1970 (Figure 3). 

Evaluating the Impact of Investments in 

 Information Technology on Structural 

 Inertia in Health Organizations 

LTC Lee W. Bewley, MS, USA 

ABSTRACT

Structural inertia is the overall capacity of an organization to adapt within a market environment. This paper 

reviews the impact of healthcare investments in information management/information technology (IM/IT) on 

the strategic management concept of structural inertia. Research indicates that healthcare executives should 

consider the relative state of structural inertia for their firms and match them with potential IM/IT solutions. 

Additionally, organizations should favorably consider IM/IT solutions that are comparatively less complex. 

Figure 1. Annual US investment in IM/IT, 1970–2002. Data from the 

US Department of Commerce, Bureau of Economic Analysis.1

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

$1,800

$2,000

$23.9 trillion (1012)

(cumulative, 1970–2002)

Billions (109) 

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

$1,800

$2,000

$29.6 trillion (1012)

(cumulative, 1970–2002)

Billions (109) Figure 2. Annual US healthcare expenditures (private sector and 

government), 1970–2002. Data from the US Department of Commerce, Bureau of Economic Analysis.1
 July – September 2010 59

Clearly, a central goal of a healthcare organization 

investment in IM/IT is to facilitate more effective 

and efficient operations for delivery or coordination 

of healthcare services to beneficiaries in a manner 

that will enable the firm to remain viable in the 

marketplace. A general collection of managerial 

expectations of IM/IT include faster 

communications, increased quantity and quality of 

data, “on-demand” solutions or services, reduced 

dependence on manual operations for analysis, and 

enhanced service efficiency. The track record for 

the utilization of IM/IT resources in healthcare 

includes numerous advancements in operational 

efficiency while enabling firms to be more 

responsive to changes in the market. Automation of 

common administrative tasks, electronic claims 

settlement, and digital medical records are a few 

key developments enabled by IM/IT investments. 

However, overtaxed appointment lines, bloated 

electronic mail inboxes, seemingly more data than 

analysis, and a generation of IM/IT assets that occupy 

space in our facilities while remaining comparatively 

idle are still pervasive within the industry. 

Given the current and historic levels of IM/IT investments by the healthcare industry and the counterbalancing aspects of progress and challenges resulting 

from these investments, executives must ask: what has 

been the net impact of these investments; what lessons 

can be learned from these investments; and, simply, 

have investments in IM/IT been worth it? In terms of 

strategic analysis, the overarching issue is how these 

investments have, on balance, impacted the ability of 

firms to compete in the healthcare marketplace. 

One specific area of organizational theory provides a 

basis to examine the effects of investments in IM/IT in 

terms of strategic impact in the healthcare market. 

Population ecology is an organizational-environment 

theory that generally holds that organizations survive 

or die in the marketplace based on their ability to adapt 

to the environment. A key concept of population 

ecology is structural inertia. Structural inertia can be 

simply defined as the capacity of a firm to adapt. 

Information plays a central role in determining the 

level of structural inertia within the organization. 

Consequently, by studying the impact of healthcare 

investments in IM/IT resources on structural inertia, 

we may be able to better explain whether firms 

survived or died within industries in a manner that is 

associated with IM/IT investments. Accordingly, the 

goal of this paper is to examine the impact of 

investments in IM/IT on structural inertia in the 

healthcare industry and to determine if we can explain 

or predict this effect. I intend to demonstrate this 

impact by examining the effects of IM/IT investments 

on structural inertia judged against a classical 

framework for strategic analysis. 

POPULATION ECOLOGY AND STRUCTURAL INERTIA

Hannan and Freeman developed the theory of 

population ecology in order to explain organizational 

change in the context of biological natural selection 

applied to the population of organizations.4,5

Organizations, like the many species of the animal 

kingdom, exist in a variety of different forms and 

characteristics. Like the natural world, these 

organizations inhabit different environments and 

compete for limited resources with other organizations 

in order to survive. Organizations that have 

characteristics ill-suited to a particular environment are 

more likely to be selected out or die unless they are 

able to adapt. Conversely, organizations with 

characteristics that are congruent with the environment 

or that demonstrate an ability to successfully adapt to 

environmental changes are more likely to survive. 

Structural inertia is a key concept within population 

ecology. It is basically the aggregate state of an 

organization in terms of ability to adapt to the 

environment. Hannan and Freeman describe the 

concept as “a correspondence between the behavioral 

capabilities of a class of organizations and their 

Figure 3. Estimated investments by the US healthcare industry in 

IM/IT as percentages of annual revenues.2,3

*Cumulative total at 3%, 1970–2002 

†Cumulative total at 2%, 1970–2002 

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90

$100

Billions (109) 

$694 billion (109)*

$463 billion (109)

†

3% 

2% 
60 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

environments.”6

 A further point regarding the concept 

illustrates that: 

...there are a number of processes that generate 

structural inertia. The stronger the pressures, the lower 

the adaptive flexibility and the more likely that the logic 

of environmental selection is appropriate.4

In later work, Alexander and Amburgey extended the 

impact of structural inertia to include the ability to 

generate foundings of new organizations based upon 

the level of inertial forces within organizations.7

Sources of structural inertia are both internal and 

external to organizations. Internal sources of inertial 

pressures include investments in plants, equipment, 

and specialized personnel that cannot be readily used 

for other purposes; information available to executives 

that result in business decisions being made with less 

than perfect information; internal politics that inhibit 

an organization’s ability to adapt; and organizational 

histories that preclude elements of change based upon 

long established operational processes. External 

sources of inertial forces are derived from legal and 

fiscal barriers that restrict entry into markets or 

specific operational processes; constraints on the 

availability of information about the environment that 

result in business decisions being made with less than 

perfect information; market legitimacy status that ties 

potential changes to the reputation held by external 

market forces of the organization; and maintaining 

market equilibrium when changes that an organization 

makes to adapt to the environment may be readily 

copied by other organizations.4

Hannan and Freeman further extended the concept of 

structural inertia by noting that organizational 

changeability varies from firm to firm depending on 

the relative relationship of the organization to the 

environment. They observed “organizations are often 

unable to match the content of their changes to 

environmental conditions in a timely manner.”6

 Reuf 

tested this hypothesis by examining attributes of 

healthcare organizations in relation to relative 

structural inertia. In his empirical study of hospital 

organizations in California,8

 Reuf studied size (in 

absolute and local market density terms), age, service 

specificity, for-profit/nonprofit status, and the impact 

that these organizational attributes had on structural 

inertia. He found that size, service specificity, and forprofit/nonprofit status were statistically significant 

attributes that impact the ability of hospital 

organizations to effect organizational change. 

Other researchers have contributed to the body of 

literature regarding structural inertia as they study the 

ability of organizations to adapt to market conditions. 

Concepts such as competitive posture, strategic 

flexibility, and organizational agility, among others, 

are used practically interchangeably to explain the 

concept of structural inertia.9-11

FRAMEWORK FOR STRATEGIC ANALYSIS

A thorough assessment of the level of competition in 

an environment or market requires a comprehensive 

evaluation of the critical determinants of 

organizational survival. Porter developed a classic 

framework of strategic analysis to study the 

competitive posture of an organization within a market 

in terms of propensity to survive or die.12 His 

framework for analysis encompassed the major 

determinants of an organization’s competitive standing 

in the market. The components of this framework 

include the following: threat of new entrants, 

bargaining power of customers, bargaining power of 

suppliers, threat of substitutes, and existing rivals. 

Each of these components is negatively associated 

with the competitive posture of an organization. For 

instance, as the threat of new market entrants and 

substitutes such as a new hospital in a health service 

area increases, the competitive posture and 

corresponding likelihood of survival diminish. On the 

other hand, if suppliers or customers have relatively 

little bargaining power, the organization should be 

expected to have a more favorable competitive 

standing in the market and therefore, be more likely to 

survive. 

Porter’s framework for strategic analysis is consistent 

with Hannan and Freeman’s description of the external 

sources of structural inertia.6

 The competitive posture 

of an organization is dependent upon the relative level 

of structural inertia of the firm compared to the 

environment. In each aspect of the framework for 

strategic analysis, it is intuitively essential that 

healthcare executives obtain information regarding 

aspects of their environment in order to gauge their 

competitive posture, and in order to develop adaptive 

processes to ensure the viability of their organization 

within the market. The critical component for securing 

Evaluating the Impact of Investments in Information Technology on 

Structural Inertia in Health Organizations 
 July – September 2010 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

this requirement is IM/IT resources that enable 

executives to obtain something closer to perfect 

knowledge about the internal and external 

environments in which their organization exists. 

Porter and Millar reinforced this premise by evaluating 

the impact of information technologies and systems on 

competition in the business environment.13 They found 

that technology impacted the market in 3 ways: alters 

industry structures, supports cost and differentiation 

strategies, and spawns entirely new businesses. Each 

of these impacts is completely consistent with the 

concepts of population ecology and the role of 

structural inertia in organizational change. The 

alteration of industry structures reflects adaptation and 

evolution within the business environment as 

organizations either appropriately change their internal 

and external processes and relationships, or be selected 

out in the market. The organization’s ability to 

accomplish this adaptation is clearly dependent upon 

the impact of IM/IT on structural inertia. Support of 

cost and differentiation strategies indicates that 

organizations implement IM/IT resources to reduce 

inertial forces within the organization via 

enhancements in operational processes, while seeking 

to reduce external inertial forces by increasing 

legitimacy status with relevant stakeholders. Spawning 

of new businesses reflects Alexander and Amburgey’s 

position that structural inertia can facilitate both 

organizational deaths and births.6

 In this case, IM/IT 

impacts structural inertia in a manner that facilitates 

the creation of an entirely new business line by 

facilitating an organizational adaptive response which 

yields an organizational genesis. 

At face value, an examination of Porter and Millar’s 

findings13 on the impact of IM/IT is that investments in 

IM/IT resources generate enabling effects that reduce 

the inertial forces of an organization and positively 

facilitate adaptive initiatives by healthcare executives. 

Again, this observation is consistent with the intuitive 

purpose of IM/IT and has been borne out by selected 

examples from IM/IT implementation in the field. 

However, it is important to review the entire spectrum 

of the IM/IT experience, particularly in the healthcare 

field, in order to achieve a fully balanced perspective 

of the impact and to be better able to explain, predict, 

and implement IM/IT solutions to maintain or enhance 

the viability of an organization. 

THE HEALTHCARE IM/IT EXPERIENCE

Numerous researchers and executives have studied the 

various impacts of IM/IT in the business world over 

the past 3 decades. Their findings span a broad range 

of IM/IT interfaces with business processes and have 

been derived from a variety of methods including 

observations, surveys, and tests. Two clear themes 

have emerged from a review the literature involving 

the healthcare IM/IT experience: there is a general 

underutilization of IM/IT capabilities across the market, and IM/IT complexity is positively associated with 

business failure. 

Underutilization 

General underutilization of IM/IT capabilities has been 

refined to 5 basic themes: management inexperience, 

poor communication/linkage between the IM/IT staff 

and the rest of the organization, resistance to change, 

lack of focus, and lack of metrics.14-16

Management inexperience contributes significantly to 

IM/IT underutilization because these individuals often 

lack the background, education, or basic fundamental 

knowledge of how to fully field, use, or promulgate 

IM/IT capabilities within organizations. Accordingly, 

and by extension, poor communication/linkage 

between the IM/IT staff and the rest of the 

organization also contributes to underutilization as key 

executives fail to properly synchronize and coordinate 

IM/IT staff activities with the rest of the operational 

divisions. Resistance to change and lack of focus 

obviously inhibit adoption of IM/IT capabilities and 

increase the likelihood that new technologies will be 

assimilated in a manner closer to compliance rather 

than commitment, thereby narrowing the opportunity 

for the full capabilities of new IM/IT resources to be 

exploited. Finally, lack of metrics exists as a major 

variable leading to underutilization of IM/IT resources, 

as executives are blind to the level of success that 

specific implemented elements of IM/IT are achieving 

within the organization. Executives cannot be fully 

certain if a specific resource is significantly or 

marginally enhancing or even inhibiting operations 

and therefore, most IM/IT applications or initiatives 

fail to achieve full utilization because their impact 

cannot be fully appreciated and exploited. 

Complexity and Failure 

Complexity of IM/IT systems has been demonstrated 

to be positively associated with business failure. As 
62 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

organizations attempt to assimilate or develop IM/IT 

capabilities within their organization, complexity has 

been found to be the key variable that contributes to 

organizational failure. Empirical studies by Kim and 

Michelman,17 and Singh18 illustrate aspects of IM/IT 

that increase the likelihood of organizational selection. 

Kim and Michelman surveyed several healthcare 

organizations that had applied IM/IT resources to 

strategic initiatives within the strategic framework 

articulated by Porter.12 Their assessment of the impact 

that IM/IT resources had on strategic initiatives was 

that new, complex systems often contributed to 

organizational failure while existing, legacy systems 

were more likely to yield organizational success and 

ultimately survival.17

Singh’s study of healthcare organizations that 

developed IM/IT solutions demonstrated that higher 

levels of complexity resulted in higher levels of 

business failure. His study indicated that the 2 central 

issues derived from complex systems that contributed 

to organizational failure were increased difficulty in 

developing and maintaining competencies to sustain 

complex systems and greater organizational costs for 

bringing complex IM/IT systems into operational or 

commercial status.18

The healthcare IM/IT experience appears to contrast 

Porter and Millar’s report13 on the impact of IM/IT 

resources in the business environment. Healthcare 

organizations have demonstrated experiences of 

increased inertial forces as result of IM/IT investments 

characterized by underutilization of capabilities and 

difficulties associated with complex systems. My view 

of these findings is that there should not be contention 

in terms of efficacy of conclusions, but rather that IM/

IT investments can either increase or decrease 

structural inertia within organizations, depending upon 

environmental factors that should be considered before 

IM/IT investments are executed. 

IMPLICATIONS FOR CURRENT APPLICATION AND FUTURE

STUDY OF HEALTHCARE IM/IT 

What can healthcare executives and researchers draw 

from the implications drawn from studies already 

conducted on the impact of IM/IT investments on 

structural inertia? Two key points for practical 

application within healthcare organizations are readily 

apparent: 

Executives should try to gauge the relative 

structural inertia of their organization against the 

market environment, then match a potential IM/IT 

investment to this assessment. Executives could 

assess organizational relative structural inertia in a 

manner similar to a strength, weakness, 

opportunities, and threats analysis by evaluating 

current IM/IT internal capabilities, competencies, 

and capacity, then comparing this evaluation to the 

external environment using Porter’s framework for 

strategic analysis.12 The comparison should 

illustrate the strategic/competitive posture of the 

organization in the market environment and serve 

as a measure for relative structural inertia. As an 

additional point of practical application, healthcare 

executives should favorably consider simple rather 

than complex IM/IT solutions as they evaluate 

potential initiatives for implementation. 

Future research regarding the impact of IM/IT 

investments on structural inertia could focus on 

more specific elements of IM/IT resources and 

their impact on the ability of an organization to 

adapt. For instance, what is the separate impact of 

office automation suites, electronic communication applications, mobile communication solutions, or in-house IM/IT staff on the ability of an 

organization to compete in the market environment? Additionally, a synthesis of the respective 

methods of Reuf8

 and Singh18 explaining the 

impact of IM/IT investments on structural inertia 

could be employed by combining Reuf’s examination of organizational attributes with Singh’s use 

of a panel of judges to evaluate the complexity 

level of IM/IT initiatives. Finally, a retrospective 

forensic study of the causes of healthcare 

organization failures could reveal other IM/IT 

considerations that may have increased inertial 

forces within the selected organization which 

contributed to or resulted in organizational failure. 

REFERENCES

1. US Department of Commerce, Bureau of Economic 

Analysis. National Economic Accounts. Available at: 

http://www.bea.gov/national/nipaweb/Select 

Table.asp?Selected=N. Accessed June 22, 2010. 

2. Is IT the cure?. Economist. 2003;367(8323):62. 

3. Healthcare Information and Management Systems 

Society. Final Report: The 11th Annual HIMSS 

Leadership Survey Sponsored by IBM. June 2000. 

Available at: http://www2.himss.org/survey/2000/

survey2000.html. Accessed June 22, 2010. 

Evaluating the Impact of Investments in Information Technology on 

Structural Inertia in Health Organizations 
 July – September 2010 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. Hannan MT, Freeman J. The population ecology of 

organizations. Am J Sociol. 1977;82(5):929-964. 

5. Hannan MT, Freeman J. Organizational Ecology. 

Cambridge, Massachusetts: Harvard University 

Press; 1989. 

6. Hannan MT, Freeman J. Structural inertia and organizational change. Am Socio Rev. 1984;49:149-164. 

7. Alexander JA, Amburgey TL. The dynamics of 

change in the American hospital industry: 

transformation or selection?. Med Care Rev. 1987;44

(2):279-321. 

8. Reuf M. Assessing organizational fitness on a 

dynamic landscape: an empirical test of the relative 

inertia thesis. Strat Manag J. 1997;18:837-853. 

9. Aaker D, Mascarenhas B. The need for strategic 

flexibility. J Bus Strat. 1984;5:74-82. 

10. Ginsberg A Venkatraman N. Investing in new 

information technology: the role of competitive 

posture and issue diagnosis. Strat Manag J. 

1992;13:37-53. 

11. Sambamurthy V, Bharadwaj A. Shaping agility 

through digital operations: reconceptualizing the role 

of information technology in contemporary firms. 

MIS Quarterly. 2003;27(2):237-263. 

12. Porter ME. How competitive forces shape strategy. 

Harv Bus Rev. March-April 1979:137-145. 

13. Porter ME, Millar VE. How information gives you 

competitive advantage. Harv Bus Rev. July-August 

1985:149-160. 

14. Bakos J, Treacy ME. Information technology and 

corporate strategy: a research perspective. MIS 

Quarterly. 1986;10(2):107-119. 

15. Keen J, Muris N. Information strategy in the NHS: 

issues and challenges. J Manag Med. 1995;9(2):57-

62. 

16. Smith HL, Bullers WI. Lessons about strategic 

information in home healthcare organizations: too 

busy focusing on today. Hosp Top. 1997;75(3):10-16. 

17. Kim KK, Michelman JE. An examination of factors 

for the strategic use of information systems in the 

healthcare industry. MIS Quarterly. 1990;14(2):201-

215. 

18. Singh K. The impact of technological complexity and 

interfirm cooperation on business survival. Acad 

Manag J. 1997;40(2):339-367. 

AUTHOR

LTC Bewley is the Program Director of the ArmyBaylor University Graduate Program in Health and 

Business Administration, Army Medical Department 

Center & School, Fort Sam Houston, Texas. 

Articles  published  in  the  Army Medical Department Journal  are  indexed  in 

MEDLINE,  the  National  Library  of  Medicine’s  bibliographic  database  of  life 

sciences  and  biomedical  information.  Inclusion  in  the  MEDLINE  database 

ensures that citations to AMEDD Journal content will be identified to researchers 

during  searches  for  relevant  information  using  any  of  several  bibliographic 

search tools, including PubMed. 
64 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

In the aftermath of the Iraqi invasion and the rapid 

increase in detained persons, the United States made 

concerted efforts to meet the tenets outlined in the 

1949 Geneva Conventions, Convention (IV).1

 Section 

IV (Regulations for the treatment of internees) of this 

Convention specifically delineates the housing, 

feeding, and medical care of all detained persons. 

Article 89 outlines nutritional requirements: 

Daily food rations for internees shall be sufficient in 

quantity, quality and variety to keep internees in a good 

state of health and prevent the development of 

nutritional deficiencies. Account shall also be taken of 

the customary diet of the internees.... Expectant and 

nursing mothers and children under fifteen years of age, 

shall be given additional food, in proportion to their 

physiological needs. 

Article 91 states: 

Every place of internment shall have an adequate 

infirmary, under the direction of a qualified doctor, 

where internees may have the attention they require, as 

well as an appropriate diet. 

According to Article 92: 

Medical inspections of internees shall be made at least 

once a month. Their purpose shall be, in particular, to 

supervise the general state of health, nutrition, and 

cleanliness of internees, and to detect contagious 

diseases, especially tuberculosis, malaria, and venereal 

diseases. Such inspections shall include, in particular, 

the checking of weight of each internee and, at least 

once a year, radioscopic examination. 

To meet these tenets, in 2005 the United States 

deployed the first of the series of medical assets, the 

115th Field Hospital, designated to provide care 

exclusively to detainees. Using split-based, taskorganized operations, augmented with additional 

medical assets (ambulance companies and forward 

medical support teams), the United States and its 

coalition partners staffed 2 hospitals at Camp Bucca, 

near Um Qasr, in the southern region of Iraq, and the 

Abu Ghraib detention center in Baghdad. In 2006, the 

latter internment camp was closed, and detainees and 

medical assets moved to Camp Cropper near the Baghdad International Airport. Both of these hospitals also 

moved from a deployable medical systems configuration and existing building to a modular fixed facility. 

In addition to upgrading the facilities, documents to 

guide the provision of healthcare to detained persons 

were written. Specific nutritional requirements based 

on recommended nutrient minimums were derived 

from the Dietary Reference Intakes: Food and 

Nutrition Board, of the Institute of Medicine:2

 Energy: 2500 cal 

 Protein: 75 g to 95 g 

 Vitamin A: 900 μg retinol equivalents 

 Vitamin C: 90 mg 

 Thiamin (B1): 1.2 mg 

 Riboflavin (B2): 1.3 mg 

 Niacin (B3): 16 mg 

 Calcium: 1,000 mg 

 Vitamin D: 5 mg 

 Iodine: 150 μg 

 Iron: 8 mg 

Later, with the growing number of adolescent 

detainees, increased requirements for calories and 

calcium for those male detainees aged 15 through 18 

years were addressed. Further practice guidelines for 

medical nutrition therapy as outlined in the military’s 

nutrition guide, The Manual of Clinical Dietetics3

 was 

used for inpatient treatment. 

Feeding of detainees, both within the hospital and in 

the theatre internment facility (TIF), had changed 

significantly since the onset of the conflict. Early on, 

the combat support hospitals, using organic personnel 

and equipment, prepared meals for detainees with 

American rations. Beginning in 2006, contracted meals 

Nutritional Care of Detained Persons in 

 Operation Iraqi Freedom 

LTC Beverly D. Patton, MS, USA 
 July – September 2010 65

were provided by foreign companies. These companies 

brought their own equipment and personnel, set up 

commercial kitchens, and served individual meals to 

inpatients and bulk meals to those in the TIF. Meal 

patterns were geared to the local dietary patterns and 

used local as well as foods obtained commercially. 

Contracts outlined guidance for the production of safe 

and wholesome foods and stipulated that certain 

nutritional requirements be met following the 

guidelines contained in Special Text 4.02-46: Medical 

Support to Detainee Operations.

4(pp4-4,4-5)

31ST COMBAT SUPPORT HOSPITAL NUTRITION CARE

OPERATIONS

The 31st Combat Support Hospital arrived in Kuwait 

in late March 2007, and assumed the detainee healthcare mission from the 21stCombat Support Hospital in 

the first week of April. Continuing the split-based 

operations, one section moved to Camp Bucca and the 

other to Camp Cropper in Baghdad. Each section had a 

dietitian and nutrition care specialists. While the 

hospitals no longer had an organic food production 

capability, they did have a microwave, blender, and 

food processor to modify the contracted meals. A 

variety of nutritional supplements or enteral feedings 

were available, and 2 premixed parenteral solutions 

and 2 lipid solutions were also available. 

The Iraqi diet contains a large amount of carbohydrates and consists of rice, potatoes, flatbread, fruits 

and vegetables, and smaller amounts of meat and dairy 

products. However, with travel and globalization, 

foods from other Middle Eastern countries became 

integrated with the Iraqi diet.5(p6),6(pp35-36,93-94),7(ppF1,F4)

The meals provided by the contract feeding mirrored 

those dietary patterns, but those hospital patients 

suffering trauma required more and higher biological 

value protein in the form of meat and dairy products. 

Thus, the patients at Camp Cropper hospital were 

changed to a diet with more meat and were given the 

high calorie, high protein supplement of Ensure Plus® 

(Abbott Nutrition, Columbus, OH). An evening snack 

of bread, 2 wedges of a soft processed cheese, and a 

piece of fruit was also offered to each patient by the 

nursing staff. Ensure Plus was initially provided to 

select patients with their meal, but it was a nursing 

suggestion that every patient receive Ensure Plus and it 

be dispensed between meals 3 times per day in an 

effort to increase consumption. Each patient who was 

admitted for greater than 24 hours was screened for 

nutritional risk and those deemed to be high risk were 

nutritionally assessed by the dietitian. A protein and 

calorie goal was set, and weekly weights and serial 

measures of visceral proteins were used to monitor 

nutritional status. Patients were reassessed for 

nutritional risk every 7 days per the Nutrition Care 

Department standard operating procedure (SOP). 

The dietitian had privileges to write orders in the 

medical record for enteral and parenteral feedings, and 

order appropriate monitoring laboratory studies, and 

weight measurements. While trauma was the most 

common admitting diagnosis for detainees, many of 

the detainees had preexisting medical conditions such 

as diabetes, cardiac disease, and hypertension. In 

addition, because the 31st Combat Support Hospital 

was the only level III medical facility within the large 

Victory Base Complex (comprising 5 forward 

operating bases, a US Air Force base, and a firing 

range), the medical personnel frequently provided care 

not only for American military, but also Coalition 

military, some Iraqi military and police, and civilian 

third country national contractors. Thus, these varied 

populations frequently had ongoing medical conditions 

which may have required more immediate attention, 

but not evacuation out of the country. 

Detainees in the TIF were provided bulk meals 

prepared in the contractor-provided kitchen. These 

kitchens were regularly inspected by preventive 

medicine specialists, and the later food service 

contracts required that all food be obtained from an 

approved source (foods for consumption by military 

members must be inspected and approved by the US 

military veterinarian food inspection teams). 

Eventually, separate food preparation trailers produced 

fresh flatbread and yoghurt daily, and there was no 

longer a need to obtain the bread on the economy. The 

meals were delivered in insulated containers to the 

various compounds within the TIF, and were 

distributed to the detainees. Each military unit with 

responsibility for overseeing the TIF had its own food 

production contract representative and small staff to 

oversee every aspect of the execution of the contract, 

and did facilitate the addition of culturally-appropriate 

foods. It should be noted that the medical nutrition 

specialist from the combat support hospital was also 

occasionally dispatched to monitor the commercial 

food production areas and storage. The nutritional 

adequacy of the diet was not only monitored by the 
66 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

contractor, but the dietitian used the contractor’s recipes to assess the compliance with nutrition standards 

and the tenets of the food production contract. 

The nutritional status of the detainees in the TIF was 

assessed through monthly weighing. A database was 

built, and the weights entered each month. By SOP, 

any detainee losing 10% or more of weight based on 

the last month’s or the last weight taken was 

reweighed. If the weight loss was confirmed, then he 

was referred to the outpatient detainee medical clinic 

for medical evaluation. Detainees themselves could 

request to be seen by the dietitian or be referred for 

nutritional assessment by one of the medical providers. 

Outpatients were brought to the hospital in the 

morning and afternoon for scheduled appointments. It 

was estimated that approximately 75% were weighed 

on a regular basis, and less than 0.5% demonstrated 

10% or more weight loss within a month’s duration. 

After rechecking those weights that suggested 

significant weight loss, the percentage often dropped 

below the 0.5% figure. In general, detainees gained 

weight during their detainment. Detainees who lost 

weight were referred to the dietitian for an individual 

appointment. If deemed necessary, the dietitian wrote 

a prescription for an enteral nutritional supplement, 

which was issued by the pharmacy and distributed by 

the guards in the TIF. 

ISSUES

Since 1995, Iraqis had received subsidized food commodities such as oil, tea, potatoes, rice, beans, and 

wheat.8

 Because of the long economic embargo and 

the later discovered widespread fraud by the Saddam 

Hussein government in the “Oil for Food Program,” it 

was assumed that nutritional status of patients and 

growth, particularly children and teenagers, was 

compromised. Neither the US standardized height and 

weight tables nor the World Health Organization standards, which are based on “healthy children living 

under conditions likely to favour achievement of their 

full genetic growth potential,”9

 provided a standard to 

assess growth status of children and adolescents. 

Additionally, many detainees did not know the year of 

their birth, so there was no definitive way to assess age 

related growth. 

Assessment of nutritional status and recovery was 

challenged by the limited availability of appropriate 

laboratory measures in theatre. The capability to test 

for urine urea nitrogen became available in Iraq only 

during the latter half of the deployment. However, 

results for short-phase protein tests from samples sent 

to Landstuhl, Germany, were always received too late 

to have any clinical relevance. Initially, there was no 

available method in which to assess weight for those 

nonambulatory patients as another method to assess 

health improvement. Eventually, a bed scale was obtained and nonambulatory patients were then weighed 

on a regular basis. Indeed, before the 31st CSH left 

Iraq, a routine was established which brought each TIF 

detainee with spinal cord injuries to the hospital once a 

month for weights. 

The traditional diet of Iraqis contains little or no fluid 

milk beyond childhood, and individuals instead 

consume a very sweet tea called chai, or even soft 

drinks. Thus, while every effort was made to both 

provide a culturally-appropriate diet, and meet the 

nutritional standards of Medical Support to Detainee 

Operations,

4

 it was a challenge when the particular 

nutrient was little consumed in the diet. The nutrient 

most commonly deficient in the diet was calcium, and 

the nutrient needs could not be met without 

supplementation. All hospital patients and detainees in 

the TIF received milk for breakfast and frequently 

were given a soft, processed cheese as a snack. Hospitalized adolescents and children were given milk at 

every meal and provided such cereals as Total Raisin 

Bran (General Mills, Inc, Golden Valley, MN) which 

contained additional calcium. Hospitalized detainees 

were also offered Ensure Plus 3 times per day. 

Patients with oral-maxillofacial injuries were fed 

Ensure Plus as a source of nutrition. There were 

patients who were able consume other types of liquids 

such as cream soups. However, there was no 

mechanism within theatre to order special dietary 

items or purchase them on the economy, even such 

mundane items as soup. Formerly, operational rations 

contained Medical B Rations, which contained broth 

and Carnation Instant Breakfast® (Nestlé HealthCare 

Nutrition, Minneapolis, MN), but this ration was 

discontinued. Another type of supplemental pack 

containing broth, Gatorade® (Pepsico, Inc, Purchase, 

NY), and other items was also fielded on a limited 

basis for trial, but had not been put into the ration 

supply system. Thus, while shelf-stable items such as 

Soup At Hand® (Campbell’s Soup Company, 

Camden, NJ) and Carnation Instant Breakfast were 

Nutritional Care of Detained Persons in Operation Iraqi Freedom 
 July – September 2010 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

available in the post exchanges (PX) on the forward 

operating bases, there was no method to purchase such 

items for detainees. 

By SOP, detainees in the TIF should be weighed 

monthly to assess weight status. However, the 

movement of individuals in and out of the compound 

for court appearances, release, movement to Camp 

Bucca, or to retard the development of agitator cells 

challenged the ability to weigh all detainees each 

month. Another mechanical challenge to weighing the 

detainees was an initial lack of home-use type weight 

scales on the central supply order catalog. As a result, 

attempts were made to buy them at the PX, if 

available, but some scales had to be initially purchased 

commercially via the internet. Digital home-type 

scales were not useful since the bright sunlight 

rendered the reading impossible. Sand and heat also 

quickly degraded the scales, which therefore had be 

obtained frequently because of mechanical failure. 

Provision of special diets was not possible in the TIF 

due to a variety of reasons. Although those detainees 

with special medical conditions such as cardiac 

disease, diabetes mellitus (all detainees with known 

insulin-dependent diabetes were kept at Camp 

Cropper), and hypertension were medically monitored 

and received medications, it was not possible to 

provide special diets. The detainees were grouped 

according to religious affiliation with Sunni, Shia, 

Takfiri, and Christians segregated from each other. 

Adolescents were also separated from the adult 

population. Thus, it was not possible to group 

detainees who required special dietary meals. The 

individuals with diabetes mellitus were given an 

evening snack of a piece of flatbread and 3 pieces of 

soft cheese. 

Four years after the onset of the conflict, automation 

and internet connectivity had significantly increased in 

theatre. However, the bandwidth was inadequate for 

the increasing demand, and the capability to access 

online references became limited. A copy of the 

Manual of Clinical Dietetics3

 was obtained from the 

Army Medical Department Center and School, along 

with references on sports nutrition, nutrition support, 

and nutrition and diet therapy. Additionally, references 

on the nutritional analysis of foods, and books5,6 on 

Middle Eastern cuisine and dietary patterns were 

purchased. Inadequate internet bandwidth and lack of a 

medical library made it difficult to obtain information 

or use the nutritional analysis software cited in the 

Medical Support to Detainee Operations4

 to analyze 

the diets offered in the TIF. Some reference texts did 

become available for order, but the selections offered 

few nutrition texts. 

LESSONS LEARNED

Initial planning guidance for the Iraq conflict 

estimated that Saddam Hussein would be quickly 

toppled, and American forces would be reduced to 

30,000 by August 2003, just 5 months after the 

initiation of hostilities.10 Consequently, there was little 

planning for a long-term conflict, including detention 

of large numbers of detainees. In the wake of the Abu 

Ghraib incidents, specific efforts were made to ensure 

that detainee operations absolutely met the tenets of 

the 1949 Geneva Conventions, including healthcare 

for detained persons. Feeding of detainees had 

progressed from providing American field rations to a 

culturally-appropriate diet prepared onsite by 

commercial catering companies and delivered for bulk 

feeding in a communal milieu. The 115th Field 

Hospital developed the core of the Medical Support to 

Detainee Operations,

4

 which incorporated practical 

experience with the tenets of the 1949 Geneva 

Convention (IV)1

 and other Army guides such as Army 

Regulation 190-8.

11 The initial Special Text 4-02.46: 

Medical Support to Detainee Operations has evolved 

into Field Manual Interim 4-02.46,

12 which is 

organized around each medical specialty with specific 

guidance for treatment. While the 31st Combat 

Support Hospital arrived 4 years after the initiation of 

hostilities, we realized that to meet the nutritional 

needs of the population, both detained persons as well 

as the local population, we must have available 

information sources such as Medical Support to 

Detainee Operations,

4,12 Technical Bulletin MED 

530,

13 and Natick Pamphlet 30-25,14 as planning 

guidance for feeding operations. Additional references 

may be obtained from the National Center for Medical 

Intelligence, which develops a variety of products 

including the Environmental Health Risk Assessment; 

Medical, Environmental, Disease Intelligence and 

Countermeasures; and Medical Intelligence Note. 

These documents can provide information concerning 

the overall health of the population, the state of the 

healthcare system, and potential health risks. For this 

particular conflict as well, there were also a limited 

number of journal articles about prisoner of war 
68 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

healthcare in Desert Storm. In 1991, articles by 

Dennan,15 and Longmire and Deshmukh16 concerning 

their experiences in Operation Desert Storm (1991) 

depicted precisely the conditions experienced in 

Operation Iraqi Freedom more than a decade later—

rapid arrival of large numbers of prisoners of war, 

many with chronic medical conditions which required 

attention. 

Often conflict planning initially plans only for the 

medical care of US and coalition military personnel. 

However, the reality of repeated experiences is that 

some of the first patients admitted to US military 

hospitals are detained persons and local civilians. 

Thus, the addition of the currently developing pediatric 

augmentee module can be readily used to treat child 

and adolescent patients. Pediatric enteral feedings and 

parenteral solutions, as well as baby formulas, should 

also be stocked and made readily available at the 

beginning of a conflict. 

Initial feeding of patients was performed with the same 

rations eaten by US Soldiers. When the responsibility 

for feeding patients passed to a contractor, the combat 

support hospitals ceased to have food production 

capability. While the numbers of hospital patients may 

have been small compared to the total number of 

Soldiers and contractors in theatre, maintaining a 

limited food production capability for patients is very 

important. It was difficult to modify pre-prepared 

meals for diverse medical conditions encountered 

among the detainees and local population. The Kosher/

Halal14(p43) rations designed for US military personnel 

who wish to adhere strictly to their religious diet are 

not designed to be used for detainees. The foods 

contained in the packages are designed specifically to 

be consumed by deployed, highly active American 

military personnel and are high in calories and 

relatively high in fat and sugars. Thus, while sufficient 

to meet caloric and protein needs for a short period of 

time, they are neither items of a standard, healthy diet 

nor appropriate for patients with diabetes mellitus. 

The senior dietitian in theatre became the de facto 

dietetics consultant. However, it would be very helpful 

to have a designated individual assigned to the theatre 

surgeon’s office. This officer would advise the theatre 

surgeon on nutritional issues, not only for detained 

persons, but also involving all Soldier nutrition 

readiness issues. The officer would facilitate the 

medical regulating process of moving enteral and 

parenteral solutions around theatre to facilitate care of 

patients requiring nutrition support. The officer would 

also serve as nutrition representative on the pharmacy 

and therapeutics committee, and facilitate acquisition 

of appropriate enteral and parenteral products, infant 

formulas, and pediatric vitamin/mineral supplements. 

Finally, the officer would serve as consultant to other 

dietitians in theatre, and work with food service 

contractors to provide nutrition information and direct 

Soldiers to healthy food choices. 

ACKNOWLEDGEMENTS

I thank LTC Charles Coe, COL (Ret) Keith Parker, and 

MAJ Christopher Lindner for their editorial comments 

and assistance with information for this article, and to 

LTC Anthony Cox for his encouragement to publish 

information regarding this unique aspect of conflict. 

REFERENCES

1. Diplomatic Conference of Geneva of 1949: 

Convention (IV) Relative to the Protection of 

Civilian Persons in Time of War. [International 

Committee of the Red Cross web site]. August 12, 

1949. Available at: http://www.icrc.org/ihl.nsf/

FULL/380?OpenDocument. Accessed 3 March 2009. 

2. Food and Nutrition Information Center. Dietary 

reference intakes: recommended intakes for 

individuals. US Dept of Agriculture, National 

Agricultural Library website. Available at: http://iom 

.edu/en/Global/News%20Announcements/~/media/

Files/Activity%20Files/Nutrition/DRIs/DRISum 

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3. Manual of Clinical Dietetics. Chicago, IL: American 

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4. Special Text 4-02.46: Medical Support to Detainee 

Operations. Washington, DC: US Dept of the Army, 

September 2005. Available at: http://www.cs.amedd 

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June 4, 2010. 

5. Bsisu MS. The Arab Table. New York, NY: 

HarperCollins; 2005. 

6. Zubaida S, Tapper R, eds. A Taste of Thyme: 

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NY: Tauris Parke Paperbacks; 2000. 

7. Schwaner-Albright O. A bit of old Baghdad with a 

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8. Schlep R. Iraq’s Agricultural Sector. Washington, 

DC: Congressional Research Service; 2003. 

Available at: http://www.cnie.org/nle/crsreports/

briefingbooks/Agriculture/Iraq. Accessed March 25, 

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10. Gordon MR, Trainor BE. Cobra II: The Inside Story 

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the Army; November 8, 2007. 

13. Technical Bulletin MED 530: Occupational and 

Environmental Health Food Sanitation. Washington, 

DC: US Dept of the Army; October 30, 2002. 

14. Natick Pamphlet 30-25: Operational Rations of the 

Department of Defense. Natick, MA: DoD Combat 

Feeding Directorate, US Dept of Defense; May 2010. 

Available at: http://www.natick.army.mil/soldier/

media/print/OP_Rations.pdf. Accessed June 4, 2010. 

15. Keenan WF. Nonsurgical medical care of enemy 

prisoners of war during Operation Desert Storm. Mil 

Med. 1991;156(12):648-651. Available at: http://

www.ncbi.nlm.gov/pubmed. Accessed March 19, 

2009. 

16. Longmire AW, Deshmukh N. The medical care of 

Iraqi enemy prisoners of war. Mil Med. 1991;156

(12):645-648. Available at: http://www.ncbi.nlm.gov/

pubmed. Accessed March 19, 2009. 

AUTHOR

LTC Patton is the Pacific Regional Medical Command 

Nutrition Consultant and Chief Dietitian, Tripler Army 

Medical Center, Honolulu, Hawaii. 
70 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Abstracts from the US Army-Baylor University 

 Doctoral Program in Physical Therapy 

The following research abstracts were presented on June 22, 2010, as part of US Army-Baylor University Doctoral Program 

in Physical Therapy Research Day at Fort Sam Houston, Texas. The research abstracts were prepared as part of a capstone 

event for the doctoral student Class of 2011 that highlights their involvement in faculty directed research. 

The research projects support the mission of the Neuromusculoskeletal Injury Prevention and Rehabilitation Research 

Program (NIPRRP): 

Promote Warrior readiness and human performance through systematic research and the 

advancement of evidence-based practice related to neuromusculoskeletal conditions. 

The NIPRRP focuses on optimal prevention, diagnostic, and intervention strategies associated with neuromusculoskeletal 

conditions. NIPRRP accomplishes this mission by integrating the results of clinical and applied research to help achieve the 

ultimate goal of minimizing disability and maximizing performance for beneficiaries of the military healthcare system and 

the overall population. Target populations include healthy individuals and patients with a broad range of 

neuromusculoskeletal conditions such as extremity overuse injuries, low back and neck pain, and neuropathic conditions. 

Median and Ulnar Neuropatheis in US Army Medical Command Band Members 

 Scott W. Shaffer* Nicholas R. Koreerat* Lindsay B. Rice*

 Douglas R. Santillo* Josef H. Moore* David G. Greathouse*

Purpose/Hypothesis: Musicians have been reported as having a high prevalence of upper-extremity musculoskeletal 

disorders, including carpal tunnel syndrome (CTS). Previous research has not involved professional military musicians. 

Therefore, the purpose of this study was to determine the presence of median and ulnar neuropathies in US Army Medical 

Command (MEDCOM) Band members, Fort Sam Houston, Texas. 

Subjects: Thirty-five US Army Soldiers (30 male, 5 female), in the MEDCOM Band volunteered to participate in the study. 

The mean age of the band members was 36 ± 8.4 years (range 22-51). There were 33 right handed musicians, and the mean 

length of time in the US Army MEDCOM Band was 12.2 years (range 1 to 30 years). 

Materials/Methods: Subjects completed a history form, were interviewed, and underwent a physical examination of the 

cervical spine and bilateral upper extremities. Nerve conduction studies of the bilateral median and ulnar nerves were 

performed. Electrophysiological variables served as the reference standard for median and ulnar neuropathy and included 

distal sensory latencies (DSL), distal motor latencies (DML), amplitudes, conduction velocities, and comparison study 

latencies. Descriptive statistics for subject demographics and nerve conduction study variables were also calculated. 

Results: Ten of the 35 subjects (29%) presented with abnormal electrophysiologic values suggestive of an upper extremity 

mononeuropathy. Nine of the subjects had abnormal median nerve electrophysiologic values at or distal to the wrist. Two of 

these 9 subjects had bilateral abnormal values. One subject had an abnormal ulnar nerve electrophysiologic assessment at 

the elbow. Nine of these 10 subjects had clinical examination findings consistent with the electrophysiological findings. 

Conclusion: The prevalence of mononeuropathies in this sample of MEDCOM Band members is similar to previous 

research involving civilian musicians (20% to 36%) and far exceeds that reported in the general population. Prospective 

research investigating screening, examination items and injury prevention measures in musicians appears to be warranted. 

Military/Clinical Relevance: Median mononeuropathy at or distal to the wrist has been reported to be of significant concern 

in musicians, and this concern is reinforced in our sample of professional military musicians. 

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program 

*US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas 
 July – September 2010 71

Functional Movement Screen: A Reliability Study in Service Members 

Deydre S. Teyhen* Scott W. Shaffer* Chelsea L. Lorenson* Joshua P. Halfpap*

 Dustin F. Donofry* Michael J. Walker* Jessica L. Dugan* John D. Childs*

Purpose/Hypothesis: The Functional Movement Screen (FMS) has demonstrated acceptable reliability and predictive 

validity (composite scores of < 14 points) for time loss injury in select populations. Unfortunately, extensive critical 

analysis of the FMS in diverse populations and among raters with limited experience is lacking. Therefore, the purpose of 

this initial study was to determine intrarater test-retest and interrater reliability of the FMS in a military setting by novice 

raters. 

Subjects: Sixty-four (53 male, 11 female) healthy active duty Soldiers (aged 25.2 ± 3.8 years, body mass index 25.1 ± 3.1 

kg/m2

) recruited while in training at Fort Sam Houston, Texas. 

Materials/Methods: Subjects completed the 7 component tests of the FMS in a counterbalanced order. Each component 

test was scored on an ordinal scale (0 to 3 points) resulting in a composite score from 0 to 21 points. Intrarater test-retest 

reliability was assessed between baseline scores and those obtained 48 hours later, while interrater reliability was assessed 

based on 2 raters assessing the same movements on day two. A total of 8 raters were used as part of the reliability analysis. 

In addition to descriptive statistics, weighted Kappa (kw) and percentage of agreement were calculated on all component 

scores and intraclass correlation coefficients (ICC) and standard error of the measurements (SEM) were calculated on all 

composite scores. 

Results: The average score on the FMS was 15.72 ± 0.24 points with 15.6% of the sample scoring ≤14 points. The 

intrarater test-retest and interrater reliability resulted in an ICC (1,1) of 0.76 (0.63-0.85) and an ICC (3,1) of 0.74 (0.60-

0.83) respectively. The SEM of the composite test was within one point on the 21 point scale for both inter- and intrarater 

reliability. The interrater reliability of the individual FMS components ranged from moderate to excellent (kw: 0.45 to 0.82). 

Conclusions: The results of this study demonstrated good interrater reliability, moderate intrarater test-retest reliability, and 

acceptable levels of measurement error for the FMS among novice raters. The interrater reliability of the weighted kappa 

was good to excellent for the pushup, quadruped, shoulder mobility, straight leg raise, squat, hurdle, and lunge. Only 15.6% 

of the sample was identified at-risk for injury based on previously published cut-off values. 

Military/Clinical Relevance: Findings suggest that the FMS is reliable when tested in a military population by novice raters 

and the FMS may be applicable in the military population for identifying a subgroup of individuals at risk of injury. Future 

research should assess the validity of the FMS in a larger sample population. 

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program 

Collaboration: This study was performed in collaboration with research assistants from the Physical Therapy Department, 

University of Texas Health Science Center, San Antonio, Texas. 

*Center for Physical Therapy Research, US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas 
72 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Abstracts from the US Army-Baylor University Doctoral Program in Physical Therapy 

Lower Extremity Measures Predictive of Functional Movement in Service Members 

Scott W. Shaffer* Deydre S. Teyhen* Sarah L. Villena* Kristen L. Zosel*

 Moshe D. Greenberg* Chelsea L. Lorenson* Christina M. Yost* John D. Childs*

Purpose/Hypothesis: To determine the association between measures of power, strength, flexibility, and endurance with 

functional movement as measured with the Functional Movement Screen (FMS) in healthy subjects. 

Subjects: Sixty-four (53 male, 11 female) healthy active duty service members (aged 25.2 ± 3.8 years, body mass index 

25.1 ± 3.1 kg/m2

) recruited at Fort Sam Houston, Texas. 

Materials/Methods: Measurements of strength (hip abduction and external rotation), power (6 meter and crossover hop 

test), flexibility (hamstrings, gastrocnemius, soleus, quadriceps, and iliotibial band / tensor fascia lata), endurance (trunk 

flexion, extension, lateral flexion muscular endurance), balance (Y-Balance test), and functional measures (FMS, lower 

extremity functional scale, and lateral step down) were assessed. A significant Pearson product moment correlation (r >0.2 

and P<0.01) was used to narrow the number of variables of interest. A hierarchical stepwise backwards regression analysis 

was then performed to determine the most parsimonious set of variables associated with the FMS performance scores. 

Results: Pearson product moment correlations yielded 22 variables of interest that entered the regression analysis. The 

resulting 4-variable model (F=11.813; P<0.001) was able to predict FMS scores (R=0.70, R2

=0.50) with a mean residual of 

0.0 ± 1.5 points. The Durbin-Watson score for the model was 1.96. Variables in the final model indicated an association 

between FMS scores an increased anterior reach on the YBT, distance measured for cross over hop test, hamstring 

flexibility and self-reported lower extremity function via the lower extremity functional scale. 

Conclusions: FMS scores at or below 14 points have been associated with an increase risk of injury. The multivariate model 

developed in this study helps to inform the clinician about the underlying clinical measures that are predictive of FMS 

performance. Future research should assess if improvements in these measures are associated with improvements in FMS 

performance. 

Military/Clinical Relevance: Musculoskeletal injures are a primary source of disability in the US military. Lower extremity 

prevention programs are necessary to reduce the impact of musculoskeletal injury. The FMS has been found to be predictive 

of injury; however there is scant evidence about its association with other physical performance measures. This study helps 

to inform the association between the FMS and common clinical measures of power, balance, flexibility, and self-reported 

function. 

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program 

Collaboration: This study was performed in collaboration with research assistants from the Physical Therapy Department, 

University of Texas Health Science Center, San Antonio, Texas. 

*US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas 
 July – September 2010 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

Reliability of Lower Quarter Physical Performance Measures 

in Healthy Service Members 

 Deydre S. Teyhen* Scott W. Shaffer* Chelsea L. Lorenson* Samantha L. Wood* 

 Jessica L. Dugan* Michael J. Walker* John D. Childs* 

Purpose/Hypothesis: Measures of endurance, flexibility, strength, power, and function may be of value in predicting injury 

risk; but application to the military setting has been limited. The purpose of this study was to assess the reliability and 

precision of lower quarter physical performance measures among novice raters. 

Subjects: Sixty-four (53 male, 11 female) healthy active duty Soldiers (aged 25.2 ± 3.8 years, body mass index 25.1 ± 3.1 

kg/m2) recruited while in training at Fort Sam Houston, Texas. 

Materials/Methods: Subjects completed 13 lower quarter physical performance measures in a counterbalanced order. 

Measures included indicators of lumbopelvic endurance (trunk flexor endurance, trunk extensor endurance, and lateral trunk 

endurance), lower extremity flexibility (gastrocnemiusm, soleus, iliotibial band, hamstring, and quadriceps), hip strength 

(abduction and external rotation), and lower extremity power (timed hop test and cross over hop test). Interrater test-retest 

reliability was assessed between baseline scores and those obtained 48 hours later. Intraclass correlation coefficients (ICC) 

and standard error of the measurements (SEM) were calculated to determine reliability and response stability. 

Results: Measures of lumbopelvic endurance had ICC (2,1) values ranging from 0.77 to 0.79 with SEM ranging from 18.3 

to 24.5 s. Measures of flexibility had ICC (2,2) values ranging from 0.27 to 0.59 with SEM ranging from 4.1 to 9.9°. 

Measures of hip strength had ICC (2,3) values ranging from 0.65 to 0.82 with SEMs from 2.9 to 6.5 lbs. Measures of power 

had ICC (2,3) values ranging from 0.78 to 0.93 with SEM values of 0.2s and 27.4 cm. 

Conclusions: The majority of measures assessed had adequate reliability in the military population when assessed by novice 

raters. The measures of strength and power had moderate to good reliability with small measurement error, indicating the 

possibility for these measures to detect change in a population overtime. The measures of lumbopelvic endurance had good 

reliability but had relatively large SEM values compared to the group mean, thus possibly limiting the ability of these tests 

to detect change over time. The measures of flexibility had limited reliability which may be associated with restriction in 

range. 

Military/Clinical Relevance: These results can help inform which physical performance measures should be used in future 

research studies that assess injury prediction and human performance optimization in a military setting. 

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program 

Collaboration: This study was performed in collaboration with research assistants from the Physical Therapy Department, 

University of Texas Health Science Center, San Antonio, Texas. 

*Center for Physical Therapy Research, US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas 
74 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Abstracts from the US Army-Baylor University Doctoral Program in Physical Therapy 

Lower Extremity Measures Predictive of Dynamic Balance in Service Members 

Scott W. Shaffer* Deydre S. Teyhen* Sarah L. Villena* Kristen L. Zosel*

 Moshe D. Greenberg* Chelsea L. Lorenson* Christina M. Yost* John D. Childs*

Purpose/Hypothesis: To determine the association between measures of power, strength, flexibility, and endurance with 

measures of dynamic balance as measured with the Y-Balance Test (YBT). 

Subjects: Sixty-four (53 male, 11 female) healthy active duty service members (aged 25.2 ± 3.8 years, body mass index 

25.1 ± 3.1 kg/m2

) recruited at Fort Sam Houston, Texas. 

Materials/Methods: Measurements of strength (hip abduction and external rotation), power (6 meter and crossover hop 

test), flexibility (hamstrings, gastrocnemius, soleus, quadriceps, and iliotibial band/tensor fascia lata), endurance (trunk 

flexion, extension, lateral flexion muscular endurance), balance (YBT), and functional measures (Functional Movement 

Screen, lower extremity functional scale, and lateral step down) were assessed. A significant Pearson product moment 

correlation (r >0.2 and P<0.01) was used to narrow the number of variables of interest. A hierarchical stepwise backwards 

regression analysis was then performed to determine the most parsimonious set of variables associated with the YBT 

performance scores. 

Results: Pearson product moment correlations (r >0.2) yielded 13 variables of interest that entered the regression analysis. 

The resulting 4 variable model (F = 13.413; P<0.001) was able to predict YBT scores (R = 0.72, R2

 = 0.51) with a mean 

residual of 0.0 ± 6.1 cm. The Durbin-Watson score for the model was 1.7. Variables in the final model indicated an 

association between YBT scores with an increase in performance on the FMS lunge and shoulder/upper trunk mobility tests, 

number of hops required during a 6 meter hop tests, and gastrocnemius flexibility. 

Conclusions: Decreased and asymmetrical YBT scores have been associated with an increase risk of injury. The 

multivariate model developed in this study helps to inform the clinician about the underlying clinical measures that are 

predictive of YBT performance. Future research should assess if improvements in these measures are associated with 

improvements in YBT performance. 

Military/Clinical Relevance: Musculoskeletal injures are a primary source of disability in the US military. Lower extremity 

prevention programs are necessary to reduce the impact of musculoskeletal injury. The YBT has been found to be predictive 

of injury; however there is scant evidence on its association with other physical performance measures. This study helps to 

inform the association between the YBT and common clinical measures of functional movement, power, and flexibility. 

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program 

Collaboration: This study was performed in collaboration with research assistants from the Physical Therapy Department, 

University of Texas Health Science Center, San Antonio, Texas. 

*US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas 
 July – September 2010 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

Y-Balance Test: A Reliability Study in Service Members

Scott W. Shaffer* Deydre S. Teyhen* Chelsea L. Lorenson* Ricky L. Warren*

 Crystal A. Straseske* Samantha L. Wood* Jessica L. Dugan* John D. Childs*

Purpose/Hypothesis: The Y-balance Test (YBT) has demonstrated acceptable reliability and predictive (anterior right/left 

reach distance difference >4 cm) validity for injury risk in high school athletes. Unfortunately critical analysis of the YBT 

in diverse populations and among raters with limited experience is lacking. Therefore, the purpose of this initial study was 

to determine interrater test-retest reliability of the YBT in a military setting using novice raters. 

Subjects: Sixty-four (53 male, 11 female) healthy active duty Soldiers (aged 25.2 ± 3.8 years, body mass index 25.1 ± 3.1 

kg/m2

) recruited while in training at Fort Sam Houston, Texas. 

Materials/Methods: Soldiers attending training at Ft Sam Houston without a current or prior history of lower extremity 

injury over the last 3 months or history of surgery were recruited. After completing a history form, subjects viewed an 

instructional video and performed 6 practice trials of the YBT to minimize the influence of a learning effect. Subjects stood 

on the center foot plate with the distal aspect of the foot at the starting line. While maintaining single leg stance, the subject 

reached with the free limb in the anterior, posteromedial, and posterolateral directions in relation to the stance foot by 

pushing the indicator box as far as possible. The maximal and average distance reached after 3 trials in each direction were 

recorded at baseline and 48 hours later by 2 different raters. A total of 7 raters were included as part of the reliability 

analysis. In addition to descriptive statistics, intraclass correlation coefficients (ICC) and standard error of the measurement 

(SEM) values were calculated on each reach direction and composite scores. 

Results: On average, service members demonstrated a 57.7 ± 7.3 cm anterior reach, 93.4 ± 8.8 cm posteromedial reach, and 

a 90.2 ± 9.0 cm posterolateral reach. Although there was no significance reach difference between limbs, 31.3% (n=20 of 

64) had an anterior reach asymmetry of >4cm suggesting an increased risk for injury. ICC (2,1) values for interrater 

reliability maximal reach ranged from 0.80 to 0.85 with an associated SEM ranging from 3.1 to 4.2 cm for each direction. 

ICC (2,3) values for interrater reliability average of 3 trials ranged from 0.85 to 0.93 with an associated SEM ranging from 

2.0 to 3.5 cm for each direction. 

Conclusions: Y-Balance reach distances in our sample of healthy young service members exhibited variable test 

performance. In addition, novice raters demonstrated good interrater reliability and an acceptable level of YBT 

measurement error. The average of 3 trials demonstrated superior reliability compared to maximal reach values. 

Military/Clinical Relevance: Findings suggests that the YBT was a reliable and stable measure of dynamic balance between 

raters and testing days in our sample of active duty service members. Future research should validate the associated risk for 

injuries based on poor performance on the YBT in the military population. 

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program 

Collaboration: This study was performed in collaboration with research assistants from the Physical Therapy Department, 

University of Texas Health Science Center, San Antonio, Texas. 

*Center for Physical Therapy Research, US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas 
76 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Abstracts from the US Army-Baylor University Doctoral Program in Physical Therapy 

Effects of Load Carriage on Foot Anthropometrics

 Stephen L. Goffar* Rett J. Reber* Bryan C. Christiansen* R. Benjamin Miller* 

 Jacob A. Naylor* Brittany M. Rodriguez* Michael J Walker* Deydre S. Teyhen* 

Purpose/Hypothesis: Understanding how military load carriage influences arch height (AH) and other foot 

anthropometrics, may influence the development of military footwear and orthoses. These developments could help mitigate 

the effects of load carriage and reduce the incidence of injuries related to military operations and training. The purpose of 

this study was to explore the effects of increasing levels of load carriage on foot anthropometrics. 

Subjects: Participants (n=117; 99 male, 18 female) were military members (aged 31.2 ± 5.5 years, body mass index 27.4 ± 

2.9 kg/m2

) who weighed at least 70 kg and had no limitations precluding them from lifting 40 kg. 

Materials/Methods: Heel-toe length (HTL), midfoot width (MFW), and AH were measured in 4 conditions: nonweight 

bearing (NWB), weight bearing (WB), 20 kg load (20 kg), 40 kg load (40 kg). The load conditions included an M16, body 

armor, helmet, and a weighted rucksack. The reliability of the foot measurements had an ICC (2, 1) ≥0.94. Subjects were 

divided into groups based on arch height index (AHI; high, normal, and low) and arch mobility (hypomobile, normal, 

hypermobile) for analysis. AHI was calculated by dividing the dorsal AH of the foot (taken at 50% of HTL) by HTL. Arch 

mobility was calculated by subtracting AH in WB from AH in NWB. 

Results: Classifications by AHI resulted in 28 high (AHI >0.267), 61 normal, and 28 low (AHI <0.229). Classification by 

arch mobility resulted in 20 hypomobile (<8.4mm), 77 normal, and 20 hypermobile (>13.8mm). The percent agreement 

between AHI and arch mobility groups was 52.1% (kappa=0.17). The interaction between AHI and load condition was 

significant for AH (F=7.15, P<.001) and MFW (F=5.72, P=.002) but not for HTL (F=2.27, P=.09). The main effect of load 

was significant for HTL (P<.001). The interaction between arch mobility and load condition was significant for AH 

(F=93.68, P<.001); and MFW (F=7.35, P<.001) but not for HTL (F=0.144, P=.91) values. The main effect of load was 

significant for HTL (P<.001). In general, as load increased AH decreased, MFW increased, and HTL increased regardless 

of foot classification system. AH decreased significantly with each increase in load (P<.014) except in low arched and 

hypermobile feet between 20 kg and 40 kg (P>.47). The mean decrease in AH was 12.4 ±2.7 mm from NWB to 40 kg load 

condition. MFW increased significantly from NWB to WB and from WB to 40 kg load (P<.03), regardless of foot 

classification system. Independent of group, HTL increased from NWB to WB and WB to 40 kg (P<0.02). The mean 

increase in HTL was 9.7 ± 4.3 mm from NWB to 40 kg load condition. 

Conclusions: Decreases in AH and increases in MFW appear to approach a maximal change with loads as small as 20 kg in 

most individuals. The greatest excursion in HTL occurred under the 40 kg condition. Future research should assess 

characteristics of combat boot and orthotic design to determine how these devices might mitigate the impact of load. 

Although the impact of load was similar when analyzed based on AHI and arch mobility, the differences between the 2 

classification systems warrant further research. 

Military/Clinical Relevance: The assumption that a high arched foot is hypomobile and a low arch foot is hypermobile is 

not supported by our findings. The impact of arch mobility on lower extremity injuries should be assessed. 

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program 

Acknowledgement: The research reported in this abstract was funded through the US Army Bone Health and Military 

Medical Readiness Program. 

*Center for Physical Therapy Research, US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas 
 July – September 2010 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

Dynamic Plantar Pressure Changes During Loaded Gait

Stephen L. Goffar* Rett J. Reber* Bryan C. Christiansen* R. Benjamin Miller*

 Jacob A. Naylor* Brittany M. Rodriguez* Michael J Walker* Deydre S. Teyhen*

Purpose/Hypothesis: Lower extremity overuse injuries are a detriment to military readiness. Extreme values of arch height 

and heavy loads carried by military personnel are associated with an increased risk of overuse injuries. Little is known 

regarding the impact of load carriage on plantar pressure distributions. This study was conducted to determine how load 

carriage affects plantar pressure distributions during gait in individuals with varying arch types. 

Subjects: Participants were 115 healthy service members (19 male, 18 female), aged 31.3 ± 5.6 years, body weight 86.0 ± 

11.0 kg, at least 70 kg. 

Materials/Methods: Participants were categorized by arch type based upon accepted cutoff values for Arch Height Index 

(AHI). AHI was calculated by dividing arch height by heel-toe length (28 high, 61 normal, 26 low arched right feet). Plantar 

pressure measurements were obtained using an in-shoe pressure measurement system while the subjects wore combat boots. 

Subjects walked for approximately 30 seconds at 3.0 mph on a treadmill under each of 3 levels of load: uniform without 

additional load, 20 kg, and 40 kg load. A mean of 9.8 ± 0.6 steps were analyzed for each load condition. Maximum force 

(MaxF) and force time integral (FTI) were calculated for the plantar foot using a 9 sector mask. Changes in each were 

analyzed with a 3×3 repeated measures ANOVA across the levels of load carriage and arch type. 

Results: There was a significant interaction between arch type and load for MaxF (P=.001) and FTI (P≤.005) in the medial 

midfoot. Although MaxF and FTI increased in all regions of the foot with load (p<.001) regardless of foot type, the forces 

in the medial midfoot were greater in those with low arches. There was a significant interaction between arch type and load 

for MaxF (P=.004) in the medial forefoot; indicating increased MaxF in high arched feet relative to normal and low arched 

feet (P<.001) across all loads. The reverse was true at the great toe region (P≤.004). The relative distribution of pressure 

increased proportionately in all regions of the foot regardless of foot type for all load conditions. 

Conclusions: Higher forces in the medial midfoot in low arched feet may be related to the increased surface area in this 

region or may represent increased pronation. However, the relative increases in medial midfoot forces in low arch feet did 

not increase disproportionately with increases in load compared to normal or high arched feet. Force distributions in the 1st 

ray differed based on foot type. Those with high arched feet had greater forces in the medial forefoot region, while those 

with normal or low arched feet had greater forces in the great toe region, regardless of load. These differences in force 

distributions may demonstrate different strategies to generate a rigid lever during toe-off. 

Military/Clinical Relevance: Regardless of foot type, increases in load did not alter the relative distribution of pressure over 

the plantar foot. These findings possibly indicate a negligible impact of loads ≤40 kg on footwear and orthoses prescription. 

However, differences in dynamic plantar pressure during gait based on foot type were supported. 

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program 

Acknowledgement: The research reported in this abstract was funded through the US Army Bone Health and Military 

Medical Readiness Program. 

*Center for Physical Therapy Research, US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas 
78 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Predictors of Web-Based Response Rate in the 

Prevention of Low Back Pain in the Military Trial

 John D. Childs* Samuel S. Wu† Josh Van Wyngaarden* Bryan J. Ladislas* 

 Brett F. Doughtery* Gary L. Helton* Deydre S. Teyhen* Steven Z. George‡

Purpose/Hypothesis: Follow-up in clinical trials is essential to establish the validity of the findings. Achieving adequate 

response rates reduces the amount of bias and helps to insure that the findings can be generalized to the population of 

interest. Therefore, the purpose of this study was to examine the influence of psychological, health status, physical activity,

injury status, attention/relationship effect, and demographic characteristics on one year response rates in the Prevention of 

Low Back Pain the Military (POLM) trial. 

Subjects: Subjects were 4,295 healthy Soldiers aged 18 to 35 years who were participating in Advanced Individualized 

Training and enrolled in the POLM trial. 

Materials/Methods: Twenty companies of Soldiers were cluster randomized to complete a traditional exercise program 

including situps with or without a psychosocial educational program (PSEP) or a core stabilization exercise program with or 

without PSEP. A subgroup of Soldiers (n=250) was randomized to receive a physical and ultrasound imaging examination 

of key trunk musculature. All Soldiers were encouraged to completed monthly surveys via email during the first year 

following completion of training to record incidence/severity of subsequent lower back pain episodes. Descriptive statistics 

of the demographic and clinical variables were obtained and compared between the responders and nonresponders using 

two sample t-tests or chi-square test, as appropriate. Generalized linear mixed models were subsequently fitted for the 

dichotomous outcomes to estimate the effects of independent variables and other explanatory variables. A random company 

effect was included in the models to accommodate for the correlation among Soldiers within the same company. The 

significance level was set at 0.05 a priori. 

Results: The overall response rate was 18.9% (811 subjects). Nonresponders and responders differed significantly in age, 

race, education, income, military status, length of service, depression, back beliefs, anxiety, health status, smoking history,

body mass index, and whether a Soldier received the physical/USI examination (P<.05). Income, time in army, depression, 

back beliefs, and health status became statistically nonsignificant after adjusting the previously stated factors. Lastly, the 

above findings were consistent with the results of a reduced model derived from a stepwise backward selection procedure 

that eliminates nonsignificant factors at alpha level of 0.10. 

Conclusions/Military Relevance: Response rate was significantly associated with psychological variables, demographic 

characteristics, and receiving individualized attention. Although the overall response rate was low compared to standard 

clinical trials, it was consistent with typical response rates observed in similar studies using web-based surveillance systems. 

Understanding which factors are associated with response rates can help to inform the design of clinical trials. Additional 

attention during a trial may improve response rates. 

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program 

Acknowledgement: The research reported in this abstract was funded by the Peer Reviewed Medical Research Program, 

Department of Defense Congressionally Directed Medical Research Program. 

*Center for Physical Therapy Research, US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas 

†Department of Epidemiology and Health Policy Research, University of Florida, Gainesville, Florida 

‡Department of Physical Therapy, University of Florida, Gainesville, Florida 

Abstracts from the US Army-Baylor University Doctoral Program in Physical Therapy 
 July – September 2010 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

THE US ARMY MEDICAL DEPARTMENT REGIMENT

The US Army Medical Department was formed on July 27, 1775, when the Continental Congress authorized a Medical 

Service for an army of 20,000 men. It created the Hospital Department and named Dr Benjamin Church of Boston as 

Director General and Chief Physician. On 14 April, 1818 the Congress passed an Act which reorganized the staff 

departments of the Army. The Act provided for a Medical Department to be headed by a Surgeon General. Dr Joseph 

Lovell, appointed Surgeon General of the United States Army in April 1818, was the first to hold this position in the new 

organization. The passage of this law marks the beginning of the modern Medical Department of the United States Army. 

Throughout its early history, the size and mission of the US Army Medical Department would wax and wane in response 

to military events around the world. There was, however, no formal regimental organization until World War I. Then, in 

the late 1950s, the brigade replaced the regiment as a tactical unit. In the reorganization that followed, some Army units 

lost their identity, their lineage, their history. This loss did not go unnoticed. The US Army Regimental System was 

created in 1981 to provide soldiers with continuous identification with a single regiment. Department of the Army 

Regulation 600-82, The US Army Regimental System, states the mission of the regiment is to enhance combat 

effectiveness through a framework that provides the opportunity for affiliation, develops loyalty and commitment, fosters 

a sense of belonging, improves unit esprit, and institutionalizes the war-fighting ethos. 

The US Army Medical Department Regiment was activated on July 28, 1986, during ceremonies at Fort Sam Houston in 

San Antonio, Texas, the “Home of Army Medicine.” Lieutenant General Quinn H. Becker, the US Army Surgeon 

General and AMEDD Regimental Commander, was the reviewing officer. He was joined by general officers of the US 

Army Reserves and the Army National Guard, representing the significant contributions and manpower of the reserve 

forces in the Total Army concept. 

INSIGNIA

The AMEDD Regimental Distinctive Insignia was designed by the Institute of Heraldry and is one of the oldest crests In 

the Army today. The 20 stars on the crest correspond to the number of states in the Union between December 10, 1817, 

and December 3, 1818. The origin of the crest dates from the Act of April 14, 1818, by which the Medical Department of 

the Army was first organized. 

The alternating red and white stripes on the left side of the shield are the 13 stripes of the American Flag. The green staff 

is the staff of Asclepius (according to Greek mythology, the first healer, the son of Apollo, the sun god); and green was a 

color associated with the Medical Corps during the last half of the 19th century. The phrase “To Conserve Fighting 

Strength” gives testimony to our mission as combat multipliers and guardians of our Nation's strength and peace. 

INFORMATION

The Regimental web site (http://ameddregiment.amedd.army.mil/default.asp) is designed to provide you with useful 

information about the US Army Medical Department (AMEDD) Regiment. Through the web site, you can learn the 

history of the AMEDD Regiment, the symbolism behind our heraldic items, how to wear the Regimental Distinctive 

insignia, and various programs available to you and your unit. 

The Office of the AMEDD Regiment is located in Aabel Hall, Building 2840, on Fort Sam Houston, Texas. The 

Regimental staff can provide further information pertaining to the history of the Army Medical Department and the 

AMEDD Regiment, and assist with any of the services described in the web page. 

For additional information please contact the Army Medical Department Regimental Office at the following address: 

Commander 

US Army Medical Department Regiment 

ATTN: MCCS-GAR 

2250 Stanley Road 

Fort Sam Houston, Texas 78234-6100 

The telephone number is (210) 221-8455 or DSN 471-8455, fax 8697. 

Internet: http://ameddregiment.amedd.army.mil/ 

Email: amedd.regiment@amedd.army.mil 
80 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The US Army Medical Department Center and School, Fort Sam Houston, Texas 
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

The  United States Army Medical Department Journal is  published  quarterly  to  expand  knowledge  of  domestic  and  international  military 

medical issues and  technological advances; promote collaborative partnerships among  the Services, components, Corps, and specialties; 

convey clinical and health service support information; and provide a professional, high quality, peer reviewed print medium to encourage 

dialogue concerning health care issues and initiatives. 

REVIEW POLICY

All manuscripts will be reviewed by members of the AMEDD Journal’s Editorial Review Board or forwarded to appropriate subject matter 

experts for further review and assessment. 

IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST

1. Related to individual authors’ commitments: Each  author  is  responsible  for  the  full  disclosure  of  all  financial  and  personal 

relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state explicitly 

whether potential conflicts do or do not exist. Authors should do so in the manuscript on a conflict‐of‐interest notification section on 

the title page, providing additional detail, if necessary, in a cover letter that accompanies the manuscript.

2. Assistance: Authors  should  identify  Individuals  who  provide  writing  or  other  assistance  and  disclose  the  funding  source  for  this 

assistance, if any.

3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done so in the 

manuscript.

4. Related to project support: Authors  should  describe  the  role  of  the  study  sponsor,  if  any,  in  study  design;  collection,  analysis,  and 

interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting source had no such 

involvement, the authors should so state. 

PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH

When  reporting  experiments  on  human  subjects,  authors must indicate  whether  the  procedures  followed  were in  accordance  with  the 

ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 

1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must 

explain the rationale for their approach and demonstrate that the institutional review body explicitly approved the doubtful aspects of the 

study. When reporting experiments on animals, authors should indicate whether the institutional and national guide for the care and use of 

laboratory animals was followed. 

GUIDELINES FOR MANUSCRIPT SUBMISSIONS

1. Manuscripts  should  be  submitted  in  digital  format,  preferably  an  MS  Word  document,  either  as  an  email  attachment  (with 

illustrations, etc), or by mail on CD or floppy disk accompanied by one printed copy of 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. In general, 4 double‐

spaced MS Word pages produce a single page of 2 column text in the AMEDD Journal production format.

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. The  following is a synopsis of  the American 

Medical Association reference format: 

 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: 

EDITOR, AMEDD JOURNAL 

ATTN MCCS HT 

2419 HOOD ST STE C 

FORT SAM HOUSTON, TX 78234-7584 

DSN 471-6301 

Comm 210-221-6301 

Email: amedd.journal@amedd.army.mil