October – December 2012 

Perspectives 1 

MG Philip Volpe; COL Mustapha Debboun; Richard Burton 

Weight Change, Lifestyle, and Dietary Behavior in the US Military’s 6 

Warrior in Transition Units 

CPT Adam J Kieffer; MAJ Renee E. Cole 

Negative Health Behavior, A Personal Responsibility or Not? 14 

MAJ Derek Licina 

Synthetic Cannabinoid and Cathinone Use Among US Soldiers 19

Cristobal S. Berry-Caban, PhD; Paul E. Kleinschmidt, MD; et al 

Relationships Among Self-reported Shoe Type, Footstrike Pattern, and Injury Incidence 25

LTC Donald L. Goss; Michael T. Gross, PhD

The Effects of BleedArrest on Hemorrhage Control in a Porcine Model 31 

Brian Gegel, MSN; James Burgert, MSNA; et al 

The Effects of QuikClot Combat Gauze on Hemorrhage Control 36 

in the Presence of Hemodilution

Don Johnson, PhD; CPT Samantha Agee; CPT Amanda Reed; et al 

Myofibroma of the Mandible: A Case Report 40 

COL Collins T. Lyons; COL Preston Q. Welch; et al 

Dentistry’s Role in the History of the Walter Reed Army Medical Center 44 

COL Samuel A. Passo; Nolan A. Watson 

Developing an Operational Casualty Estimate in a Multinational Headquarters 51

to Inform and Drive Medical Resource Allocation

LTC Soo Lee Davis; Col Martin Bricknell, RMC, British Army 

Strategies to Support Nurse Work Reintegration After Deployment 59

Constructed from Analysis of Army Nurses’ Redeployment Experiences

COL Denise L. Hopkins-Chadwick 

Combat Casualty Care Nursing Research and the Joint Combat Casualty Research Team 64

LTC Laura L. Feider; Lynn S. Platteborze, MS, RAC; et al 

Registered Nurses as Permanent Members of Medical Evacuation Crews: The Critical Link 72

MAJ Michael W. Wissemann; MAJ Christopher A. VanFosson 

Clinical Nurse Leader: Emerging Role to Optimize Unit Level Performance 77

MAJ Scott Phillips; MAJ Pauline A. Swiger; et al 

Lessons Learned Small Unit Postdeployment Survey Results and Analysis 84

MAJ (Ret) David W. Cannon 

Army Medicine:

Maintaining, restoring, and improving health 
October – December 2012 The Army Medical Department Center & School PB 8-12-10/11/12 

By Order of the Secretary of the Army: 

Official: 

1220806 

RAYMOND T. ODIERNO 

General, United States Army 

Chief of Staff

DISTRIBUTION: Special 

Administrative Assistant to the 

Secretary of the Army 

JOYCE E. MORROW 

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx 

A Professional Publication 

of the AMEDD Community 

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

The Surgeon General by the US Army Medical Dept Center & School, Journal Office, AHS 

CDD Bldg 4011, 2377 Greeley RD STE T, Fort Sam Houston, TX 78234-7584. 

Articles published in The Army Medical Department Journal are listed and indexed in 

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

sciences and biomedical information. As such, the Journal’s articles are readily 

accessible to researchers and scholars throughout the global scientific and academic 

communities. 

CORRESPONDENCE: Manuscripts, photographs, official unit requests to receive 

copies, and unit address changes or deletions should be sent to the Journal at the 

above address. Telephone: (210) 221-6301, DSN 471-6301 

DISCLAIMER: The AMEDD Journal presents clinical and nonclinical professional 

information to expand knowledge of domestic & international military medical issues 

and technological advances; promote collaborative partnerships among Services, 

components, Corps, and specialties; convey clinical and health service support 

information; and provide a peer-reviewed, high quality, print medium to encourage 

dialogue concerning healthcare initiatives. 

Appearance or use of a commercial product name in an article published in the 

AMEDD Journal does not imply endorsement by the US Government. 

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

Army or US Army Medical Department positions, nor does the content change or 

supersede information in other Army Publications. The AMEDD Journal reserves the 

right to edit all material submitted for publication (see inside back cover). 

CONTENT: Content of this publication is not copyright protected. Material may be 

reprinted if credit is given to the author(s). 

OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical 

Department units and organizations, and other members of the medical community 

worldwide. 

LTG Patricia D. Horoho 

The Surgeon General 

Commander, US Army Medical Command 

MG Philip Volpe 

Commanding General 

US Army Medical Department Center & School 
Health is a state of complete physical, mental 

and social well-being and not merely the 

absence of disease or infi rmity.

That statement is the fi rst of the basic principles enumerated in the preamble to the Constitution of the 

World Health Organization, adopted on July 22, 1946.* 

The simplicity and clarity of those 21 words are as true 

today as 66 years ago, without a single amendment or 

elaboration. It is as applicable to an organization, a society, or a nation as it is to an individual. The interrelationship of those levels of health is clearly captured 

in the stated vision of Army Medicine:

Strengthening the health of our Nation by 

improving the health of our Army.

In the recently issued Army Medicine Strategy (August 10, 2012), The Surgeon General lays out a shift 

in perspective for our profession, “from a healthcare 

system to a system for health.” The history of Army 

Medicine is rich in groundbreaking success in research and proactive efforts in preventive medicine, 

public health, and health promotion for our forces. 

Routinely, these achievements are extended beyond 

the military and greatly benefi t the healthof people 

around the world. The transformation of our healthcare system will build on those achievements and 

expand the perspective to more directly address the 

health of the individual, indeed, the very lifestyle factors that affect personal health, and, by extension, the 

health of our Army and our nation.

Since its inception in 1994 by then Army Surgeon 

General LTG Alcide LaNoue, the AMEDD Journal

has been on the forefront, providing information supporting the three basic strategies for of health promotion: advocacy, enabling, and mediation as presented in the WHO Charter for Health Promotion. The 

Journal presents articles that cover the entire range 

of health and healthcare. Over the last 7 years, the 

AMEDD Journal has regularly featured articles dedicated to force health protection and public health, refl ecting the diverse skills and expertise of Army medical professionals.

This issue of the AMEDD Journal maintains the 

standard, incorporating articles on nutrition, personal 

health responsibility, physical fi tness, and drug abuse. 

It also contains articles on trauma care, operational 

planning, Army nursing, dentistry, and lessons learned 

from the combat theaters. Throughout theses pages, 

the Journal continues to showcase the diversity, 

sophistication, and talent of medical professionals 

who accept the responsibility for the health of our 

military personnel and their families, both today and 

tomorrow.

EDITOR’S PERSPECTIVE

The Warrior Transition Unit (WTU) program has 

been very successful in its primary mission, providing extended treatment and/or rehabilitation services to Wounded Warriors to return them to active 

duty or prepare them for the transition to civilian 

life. Their wounds are healed, they adapt to losses 

of limbs and other disabilities, and their psychological and behavioral health issues are addressed and 

treated. However, even as their bodies are being restored from combat injuries, their lifestyle choices 

may become detrimental to their overall health, 

both immediate, complicating the rehabilitation 

and treatment efforts, and over the long term, with 

weight-related chronic conditions such as diabetes. 

In the opening article in this issue, CPT Adam Kieffer and MAJ Renee Cole report on their study of nutrition choices and weight gain among Wounded Warriors assigned to WTUs at four Army medical centers. 

Their examination revealed that the Warrior recovery 

process presents a dichotomy in weight management: 

during healing the major concern is prevention of 

weight loss; following release to the WTU for outpatient treatment and rehabilitation, weight gain becomes problematic. The article presents detailed data 

gathered from Warfi ghters as to their body mass index, the nature of their injuries, and their self-assessments of their lifestyle choices related to nutrition and 

weight management. Further, the study subjects were 

asked their opinions of their own weight and physical *http://www.who.int/governance/eb/who_constitution_en.pdf

 October – December 2012 1

Perspectives

COMMANDER’S INTRODUCTION

MG Philip Volpe
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

condition. This article should be of great interest to 

those charged with assisting Wounded Warfi ghters 

through their recovery, rehabilitation, and transition 

periods, presenting another, more subtle aspect of 

restoring the health of those who have sacrifi ced so 

much.

MAJ Derek Licina opens his article with the 

following:

According to the World Health Organization, chronic 

diseases with preventable risk factors have surpassed 

infectious diseases as the major cause of morbidity 

and mortality worldwide.

That simple statement frames the ironic reality facing 

humankind: as successful as medical science has been 

in discovering and countering diseases, our personal 

lifestyle choices are becoming increasingly detrimental to our overall health and wellness. MAJ Licina’s 

article explores the quandary facing society, are individuals personally responsible for their negative 

lifestyle choices? On the surface, a simple question. 

But as explored in this excellent article, the answers 

are not so simple. MAJ Licina presents and develops 

several different, and often confl icting, philosophies 

of human responsibility. Today, those philosophies 

are clearly refl ected in political perspectives and positions, thus driving the debate as to how healthcare 

resources (which are undeniably fi nite at some point) 

should be fi nanced and allocated across the population 

as a whole. Who is ultimately at fault: the individual, 

the society, the environment, a combination? Further, 

important questions always arise when the discussion 

turns to public policy to address negative behaviors. 

Can a free society continue to exist if personal behavior becomes regulated and controlled? Should all 

potentially harmful nutritional and drug substances 

be banned, as well as activities which may result in 

chronic illness or injuries requiring long-term commitment of resources to treat? MAJ Licina’s article 

is a well-developed, thought-provoking examination 

of questions that are very relevant to the current national debate regarding healthcare and use of medical 

resources.

It is not easy to become a member of the US military. The physical, intellectual, and ethical standards 

are high, and strictly applied. Only a small percentage of the age-qualifi ed population can initially meet 

those standards, and even then, a number of them do 

not complete training and are eventually separated. 

The standards and screening process produce a Warrior force comprised of select individuals of the highest character, motivation, and ability, especially in 

comparison to the population as a whole. However, 

military people are still products of society, and it is 

inevitable that a certain percentage bring society’s 

ills into the service with them. Drug abuse is one of 

the more pernicious of those societal problems that 

the military must address on a continuing basis. Dr 

Cristobal Berry-Caban and his coauthors have contributed a sobering article describing one of the latest 

dangerous drug abuse practices to fi nd its way into 

the military. New types of synthetic hallucinogenic 

drugs, popularly known as “spice” and “bath salts,” 

have emerged over the last 8 years. Initially available 

for purchase in the open market because they purportedly were a mixture of legal herbs, they actually 

contain added synthetic drugs, a class of sophisticated 

designer drugs which produce euphoric highs, but 

also signifi cant adverse effects as well. In their article, 

Dr Berry-Caban et al detail the composition and effects of these compounds, as well as the efforts of the 

military to deal with their abuse by service members 

which has been identifi ed in recent years. This is an 

important article which should be must reading for 

leaders and supervisors at all levels.

Presenting the other (positive) end of the behavioral 

spectrum, the article by LTC Donald Goss and Dr 

Michael Gross discusses recent trends in running 

footware (including none), detailing the relationship 

of various footstrike patterns and injury incidence to 

footware preferences. Since military personnel must 

maintain a high level of physical fi tness throughout 

their careers, it is important that those responsible for 

requiring and supporting their exercise efforts remain 

current on both the benefi ts and risks associated with 

exercise techniques and equipment, especially any 

potential for debilitating injury. LTC Goss and Dr 

Gross conducted a detailed study of a cross-section 

of regular runners to explore the mechanics of various running techniques associated with footware, to 

determine if there were any injury trends, positive or 

negative, associated with either the style of running, 

the footware, runner experience, or a combination of 

factors. Their article presents the analysis of the extensive data collected during the study, and compares the 

various injury profi les related to styles and footware. 

This information contributes to the range of knowledge to support Army medicine’s move of emphasis 

to the achievement and preservation of health for all 

Warfi ghters.

Although a hemostatic agent may be effective in hemostasis and hemorrhage control, extensive loss of 

blood may dictate administration of intravenous fl uid in resuscitation efforts, whether at point-of-injury 

PERSPECTIVES
THE ARMY MEDICAL DEPARTMENT JOURNAL

 October – December 2012 3

or during evacuation. Unfortunately, introduction of 

such fl uid may dislodge newly developed clots with resulting renewed hemorrhage. Dr Don Johnson and his 

team examined the effectiveness of QuikClot Combat 

Gauze in maintaining control of serious bleeding in 

the presence of hemodilution from intravenous fl uids. 

As in the BleedArrest evaluation discussed above, 

they used the porcine model in a carefully planned 

laboratory setting to replicate hemodilution conditions, with meticulous data management throughout 

their procedures. Their article is a clear presentation 

of the planning, the process, the analysis, and the datasupported conclusions. These 2 articles are more excellent examples of the professionalism that is found 

throughout the Army Medical Department, from the 

battlefi eld to the laboratory.

COL Collins Lyons and his coauthors have contributed another excellent article from Army dentistry to 

join those that have been published in the AMEDD 

Journal throughout its history. They present a case in 

which they encountered, diagnosed, and removed a 

rare, fortunately benign, tumor from a patient’s mandible. The article meticulously describes the process 

from fi rst examination through tumor diagnosis and 

removal, and clearly articulates the variables and possible alternative diagnoses that should be considered 

when encountering similar symptom and condition 

presentations. This is a textbook example of dental 

professionalism at its best, another indication of the 

high level of skill, talent, and knowledge that is the 

standard of the Army Dental Corps.

On July 27, 2011, a 102 year chapter in the history 

of Army Medicine came to a close. The Walter Reed 

General Hospital opened in 1909 on the site that developed into one of the most respected medical complexes in the world. The campus of the Walter Reed 

Army Medical Center provided medical and dental 

care to many generations of military personnel and 

their families, including treatment and rehabilitation 

services for Wounded Warriors from every armed 

confl ict during those 10 decades. It also hosted world 

renowned research institutes, as well as education 

and training for medical and dental personnel of the 

US Army. COL Samuel Passo and Nolan Watson 

have written a very interesting and informative article chronicling specifi cally the history of dentistry, 

including patient care, dental research, and education 

and training at the Walter Reed campus. The evolution 

of the dental sciences at Walter Reed closely parallels 

that of the medical sciences, and the reader will recognize the value of the symbiotic relationships enabled 

by the collocation of top level resources of the two 

disciplines. This article captures an important component of the Army Dental Corps’ 101 year history, 

and presents it in a well-written and organized form. 

It is a good read.

Under the best of circumstances, planning for medical support of combat operations is a diffi cult and imprecise proposition, based on estimates, assumptions, 

intelligence reports, and historical data. The level of 

diffi culty is elevated when the planning involves a 

multinational force, due to the increased complexity 

of coordination, communication, command relationships, and variations in capabilities and resources. Existing doctrinal approaches and planning models are 

diffi cult to apply in such situations, since they often 

do not address the variables and peculiarities of the 

force structures. Even more problematic is the fact 

that most planning tools are classifi ed and/or only accessible by specifi c personnel. In their article, LTC 

Soo Lee Davis and Col Martin Bricknell describe the 

approach they used to develop an operational casualty 

estimate for a major multinational offensive operation 

in the area around Kandahar City in 2010. The article 

is a virtual tutorial on the medical planning process in 

a deployed combat environment, clearly articulating 

the necessary attention to detail across a broad scope 

of research, coordination, resource identifi cation, 

communication, and timing. It should be of great interest to all operational planners who are anticipating 

deployment as part of a multinational force, especially 

when their command will be responsible for the bulk 

of the deployed area medical resources.

As the deployments into and out of the combat theaters of Iraq and Afghanistan cycled in the years after 

January 2003, the Army Nurse Corps began to see 

an alarming trend among the returning Army nurses. More and more of the returning nurses began to 

express a desire to leave the Army Nurse Corps, the 

Army, and sometimes the nursing profession altogether. Based on extended periods of combat in our history, the nature of current combat operations is somewhat unusual in that military medical personnel at 

nondeploying commands, medical centers or facilities 

can be individually assigned to deploying units (perhaps several times), returning from each deployment 

to the facility or location from which they departed, 

and experiencing a “culture shock” at the different 

environment. COL Denise Hopkins-Chadwick describes a study chartered by the Army Nurse Corps to 

determine the deployment-related factors that prompt 

the negative attitudes toward continuing as a military 

nurse, or even a nurse at all. In her article, COL Hopkins-Chadwick focuses on one part of the study, that 
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

of the nurses’ experiences upon returning home. From 

that information, she derives evidence-based support 

strategies for both the returning nurses and those with 

whom they work upon return to smooth and ease the 

transition from the deployed environment back to 

“normal.” This and other results of the study have 

been integrated into orientation classes and content 

of the Army Nursing Leader Academy to ensure that 

current and future leaders, supervisors, and coworkers understand the complexities and stresses inherent in transitioning across such completely different 

working and living environments.

There is a history of advancements in medical science 

produced during wars and military confl icts. Unfortunately, as a rule, such progress was usually not realized for medicine in general until cessation of hostilities, as individual medical professionals came back to 

evaluate and develop the discoveries and techniques 

that were applied during the confl icts. Usually no formal research or distribution of information was applied in the combat environment, just innovation and 

trial-and-error to improve the situation of the moment. 

LTC Laura Feider and her coauthors have contributed 

an article describing how military medicine has instituted in-theater research teams to provide a formal 

structure for conducting “there and now” combat 

relevant medical research to benefi t both the theater 

operating forces in real time, and military medicine 

over the long term. Their article discusses in detail the 

role of military nurses in the Joint Combat Casualty 

Research Team, and presents the variety of nursing 

research protocols that have been evaluated, as well 

as those proposed for future investigation. This is an 

interesting and informative article that refl ects both 

the proactive attitude that frames modern military 

medicine in deployed combat environments, and the 

broad scope and very high level of capabilities, skills, 

experience, and motivation that is the standard of today’s Army Nurse Corps.

Articles in previous editions of the AMEDD Journal

have discussed at length the evolving capabilities and 

sophistication of military helicopter medical evacuation (MEDEVAC), and how it can and should be 

improved. The most recent combat operations have 

fostered positive changes in where and how stabilization and resuscitation of trauma patients is performed, 

which has also changed the character of many of the 

requirements for en route MEDEVAC care of those 

patients. Those requirements are being addressed in 

some ways, but MAJ Michael Wisseman and MAJ 

Christopher VanFossen do not think that those measures are suffi cient to provide the ever-increasing level 

of critical care expertise demanded during transportation of critically injured trauma patients. In their article, they describe the background of the current situation, and provide statistics illustrating the increase 

in the number of MEDEVAC missions during which 

critical care interventions were required. They then 

examine the changes in MEDEVAC medical crewmember training that have been instituted and explain 

the diffi culties inherent in such an approach, especially 

over the long term outside of combat operations. They 

develop an approach based on several years of intheater MEDEVAC operations during which nurses, 

and sometimes physicians, were required to provide 

the en route critical care necessary to keep the patient 

stable and/or perform resuscitation. Their proposal is 

the assignment of Army critical care or trauma nurses 

as permanent members of Army medical evacuation 

crews. They lay out the advantages, not only directly 

to the patients, but also to the professional capabilities 

of the evacuation unit as a whole. MAJs Wisseman 

and VanFossen develop their proposal carefully and 

logically, citing statistics and other documentation in 

support of their position. This article should be closely 

read by those charged with developing the doctrine 

and planning guidance that will create the MEDEVAC 

structure of the future. This capability has become an 

absolutely indispensable fi xture on the modern battlefi eld, and it should provide the best capabilities possible to maximize the potential for survival of our 

Warfi ghters who must go into harm’s way.

MAJ Scott Phillips and his coauthors have contributed an informative article presenting a relatively recent 

innovation in professional nursing roles which provides advanced generalist clinical skills for a defi ned 

group of patients at the unit of care level. The role, 

the Clinical Nurse Leader (CNL) was conceived and 

developed by the American Association of the Colleges of Nursing in conjunction with leaders in nursing education and other experts. The CNL is neither 

administrative nor management, but is intended to be 

an advanced generalist clinician, the “go to” person 

at the bedside when knowledge assistance and experienced guidance is required. MAJ Phillips et al build 

their case for adopting CNLs within AMEDD at the 5 

major Army medical centers (at a minimum), not only 

for the obvious benefi ts to direct patient care, but also 

as a key component in meeting the organizational and 

strategic objectives of both AMEDD and MEDCOM, 

in particular those articulated in the MEDCOM balanced scorecard approach to organization and function. The article discusses a pilot test of the CNL role 

within one unit at William Beaumont Army Medical 

Center to evaluate the various workplace dynamics 

PERSPECTIVES
THE ARMY MEDICAL DEPARTMENT JOURNAL

 October – December 2012 5

and parameters that will be involved in any institutional incorporation within AMEDD. The pros and 

cons of implementing this additional role into the 

existing manpower and organizational systems are 

examined and analyzed. This is a thought-provoking 

look at adopting a benefi cial innovation from the civilian sector into the military medical structure. It 

deserves careful consideration by those defi ning and 

shaping military medicine for the future.

It is a familiar occurrence for planning, instructions, 

guidelines, and important decisions involved in largescale evolutions of big organizations to be made from 

the macro perspective—necessarily so, to a point. 

Therefore, it is no surprise that those involved in executing that evolution at the other end of the spectrum, 

the smallest units and their individuals, often are 

mystifi ed at the direction they receive, some of which 

seems to have no correlation to the reality with which 

they must contend. This is, of course, the time-honored 

conundrum of the military member, especially when 

deploying into a fl uid, dynamic combat environment. 

However, during an extended period of deployment 

cycles such as those defi ning the US involvement in 

Iraq and Afghanistan over the last decade, the bigpicture aspects of operations should be institutionalized enough to allow inquiry into the “details” to see 

if attention is warranted, can improvements be made, 

and if there are any ideas or concerns among those 

individuals involved which should be addressed. MAJ 

(Ret) Dave Cannon of the AMEDD Lessons Learned 

Division describes an effort by Lessons Learned to 

do just that: upon their return, ask those deployers at 

the lowest common denominator, the small unit, for 

their individual feedback regarding their predeployment and operational experiences in theater. The responses were statistically correlated to spot trends, 

relationships, and outliers within the data to provide 

perspective and foundation for determining required 

actions. The article describes the implications of the 

responses, some corrective actions already completed 

or in process, as well as several changes to organizational structure to improve fl exibility and capability 

in the combat environment. Of interest are the correlation of some variables such as deployment location 

and time spent deployed to the resulting responses. 

Such information, ideas, and insight would likely 

not become visible at higher levels of the command 

structure, as the enormous workload of simply getting 

in and out of theater tends to overwhelm those who 

are making it happen. Further, when units return and 

are faced with adjusting to the new garrison environment, and personnel are often dispersed over time, it 

quickly becomes too late to obtain reliable information. This article is an interesting and insightful snapshot of a large, important effort to see the operational 

deployment from the perspective of those who make 

it happen.

Articles published in the Army Medical Department Journal are indexed in 

MEDLINE, the National Library of Medicine’s (NLM’s) bibliographic database 

of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to AMEDD Journal content will be identifi ed to 

researchers during searches for relevant information using any of several 

bibliographic search tools, including the NLM’s PubMed service.
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

A Warrior in Transition is a Soldier who is assigned/

attached in a Warrior Transition Unit and whose primary 

mission is to heal.

1

The Warrior in Transition Unit (WTU) program is a comprehensive continuum of care for service members and 

their families, with WTU units located at US military 

installations throughout the world. A Warfi ghter who 

requires signifi cant medical treatment or rehabilitation 

anticipated lasting 6 months or more in order to return 

to duty or successfully transition to veteran status is assigned to a WTU.2

 The WTU achieves individualized 

care by assigning a “triad” to each service member: the 

primary care manager, nurse case manager, and squad 

leader or platoon sergeant.3

 This collaboration of both 

military and civilian leadership ensures a centralized 

support network for the Warfi ghters and their families, 

streamlined appointments and treatments, and effi cient 

documentation.4

 The length of stay in the WTU is dependent on the severity of illness or injury and the extent of 

treatment required.3

 As of April 2010, there were 9,200 

Soldiers in the 32 WTUs throughout the United States.5

Body weight is a polarized issue in any hospital setting, 

depending on the stage of healing. Preventing weight 

loss is a concern for patients and Warfi ghters who have 

experienced severe trauma, burns, and/or amputation. 

They are encouraged to consume adequate calories 

to meet their increased resting metabolic demands.6,7

Once released from the inpatient setting and enrolled 

in the WTU, the concern becomes preventing unwanted 

weight gain as metabolic needs return to normal after 

healing. In the outpatient setting, excess body weight is 

detrimental, increasing the Warfi ghter’s risk for delayed 

wound healing, hyperlipidemia, type 2 diabetes, and 

cardiovascular disease.8,9

Department of Defense (DoD) Directive 1308.310 provides guidelines on body weight standards for the military services. The directive states that service members 

must maintain a combat-ready body weight and body fat. 

Assessment of this standard includes body fat testing, 

from which WTU participants are exempt while healing. Specifi cally for the Army, the Army Weight Control 

Program requires Soldiers to maintain a healthy weightWeight Change, Lifestyle, and Dietary

 Behavior in the US Military’s

 Warrior in Transition Units

CPT Adam J. Kieffer, SP, USA

MAJ Renee E. Cole, SP, USA

ABSTRACT

Objective: To identify lifestyle factors that may contribute to weight changes experienced by Warfi ghters assigned 

to Warrior in Transition Units (WTU).

Design: Multicenter, cross-sectional, descriptive study at 4 military installations (Fort Hood, TX; Fort Bliss, TX; 

Fort Sam Houston, TX; and Fort Gordon, GA). Participants completed a self-reported questionnaire regarding 

environmental, social, and dietary lifestyle behaviors. Study participants were recruited and data collected from 

February through July 2009.

Results: Four hundred twelve wounded Warfi ghters (97.6% Soldiers) participated; 51% indicated they were overweight and 61% desired weight loss. About 51% exceeded a normal body mass index (18.5 to 27.4 kg/m2) according 

to Army height and weight standards. Roughly 85% of all participants experienced weight change following their 

injury. Limited activity was self-reported as the main reason for weight gain (66.2%), and deployment as the main 

reason for weight loss (21.7%). Lifestyle factors that changed included skipping meals, eating snacks, eating at sitdown restaurants, performing aerobic and anaerobic physical activity. The majority of participants (more than 70%) 

consume 3 standard meals per day, with 25% reporting that the meal typically skipped was breakfast.

Conclusion: The WTU Soldiers saw themselves as overweight, desired to lose weight, and reported several changes 

in lifestyle factors upon entry into the WTU. There is a need for more focused nutrition-related and physical fi tnessoriented interventions to aid Warrior recovery, promote rehabilitation, and decrease length of time in the WTU.
 October – December 2012 7

for-height and body fat percentage based on age and gender.11 A healthy weight-for-height is assessed with the use 

of body mass index (BMI; kg/m2).12 The Army allows for 

a higher BMI (up to 27.5 kg/m2) in Soldiers compared 

to nationally accepted civilian classifi cation for normal 

BMI (up to 25 kg/m2) due to an expected higher lean 

body mass.11 Soldiers can face disciplinary action, including discharge, if they do not meet these standards. 

For example, in 2010 the Army released approximately 

1,200 initial enlistees within the fi rst year of service 

for not meeting weight for height standards.14 Gaining 

weight while in the WTU may have a negative effect on 

a Warrior’s transition back to duty. On the other hand, 

many WTU Warfi ghters are released from active duty 

and enter the national pool of veterans. Research assessing veteran weight status, including veterans from the 

Gulf, Iraq, and Afghanistan wars, indicates that veterans 

have a higher prevalence of overweight rates than the national norm with 73% of male and 54% of female veterans being overweight. Further, in those studies, veterans 

tended to gain 2.2 kg/year more than those still on active 

duty over a 6-year period of assessment.15-18

Although observations suggest that Warfi ghters gain 

weight while in the WTU, no published information 

currently exists regarding their dietary habits, lifestyle 

factors, and weight trends. It can be reasonably assumed 

that signifi cant changes in the Warfi ghter’s life (such as 

new residence, injuries, limited access to food preparation, inactivity) could dramatically affect lifestyle and 

eating behaviors. Weight gain can be detrimental to recovery and may contribute to health-related comorbidities, prolonging the Warfi ghter’s recovery.2

 By assessing 

the WTU weight change, lifestyle behaviors, attitudes, 

and access to healthy food and preparation equipment, 

a nutrition intervention can be tailored to the WTU to 

increase the speed of recovery. A tailored intervention 

could provide them with suffi cient tools to increase their 

quality of life while assigned to the WTU and assist in 

their transition back to duty or return to civilian life. The 

objective of this study was to determine what lifestyle 

factor changes, following injury and enrollment in the 

WTU, may affect their weight status.

SUBJECTS

Four hundred twelve Warfi ghters assigned to WTUs were 

recruited across 4 locations: San Antonio Military Medical Center (SAMMC), Fort Sam Houston, Texas; William 

Beaumont Army Medical Center (WBAMC), Fort Bliss, 

Texas; Carl Darnell Army Medical Center (CDAMC), 

Fort Hood, Texas; and Dwight D. Eisenhower Army 

Medical Center (EAMC), Fort Gordon, Georgia. These 

WTU locations were chosen to reduce geographical bias 

and increase diversity in the sample population. The only 

inclusion criterion for this study was age of 18 years or 

older. There was no exclusion criterion.

Study participants were recruited and data collected 

from February through July 2009.

METHODS

The study was a multicenter, cross-sectional, descriptive 

design. To assess weight change and lifestyle factors, a 

self-reported questionnaire was created. The survey 

consisted of 5 sections totaling 24 questions with 142 

possible variables: demographic (gender, height, weight, 

length of time in WTU, etc); living arrangements and 

transportation (such as access to transportation, type of 

lodging); tobacco habits; weight and lifestyle behaviors 

(for example, perceived weight, perceived weight gain 

or loss post injury, changes in lifestyle factors post injury, physical activity); and food and nutrition (number 

of meals consumed per day, location of consumption, 

changes to dietary habits post injury, etc). The WTU 

Warfi ghters were classifi ed above and below a BMI of 

27.5 kg/m2

 as well as by the National Heart, Lung, and 

Blood Institute’s (NHLBI) BMI classifi cations14: underweight (BMI <18.5 kg/m2

); normal weight (BMI 18.5 to 

24.9 kg/m2

); overweight (BMI 25.0 to 29.9 kg/m2); and 

obese (BMI ≥30.0 kg/m2

). Access to basic food preparation equipment was assessed through a 12-variable 

question to identify what aspects of food preparation 

were within the WTU Warfi ghter’s control, and ranged 

from no access beyond a dining facility to items such 

as refrigerator, microwave, cookware, silverware, and 

food storage area. The survey was pilot tested by subjects representative of the population and SAMMC 

health professionals to assess content validity prior to 

distribution. Recruitment occurred at primary care appointments and WTU information sessions. The study 

followed a protocol approved by the Institutional Review 

Boards at SAMMC (also covering CDAMC), WBAMC, 

and EAMC, and was classifi ed as an exempt protocol. 

Warfi ghters who volunteered to complete the survey received a free water bottle as an incentive, funded by the 

SAMMC Department of Clinical Investigation.

STATISTICAL ANALYSIS

The sample size was determined by a margin of error at the 

95% confi dence interval for a probability estimate of 50%. 

The 95% confi dence interval (CI) for a binomial probability 

was calculated from the Wald equation yielding the need 

for 384 subjects to estimate a probability of 0.50 with 

a 95% CI of 0.50±0.05 (5% error). To allow for a 5% 

margin of error, a target sample size of 400 completed 

surveys was chosen.
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

Data were analyzed using SPSS version 16.0 (SPSS Inc, Chicago, Illinois). 

Descriptive statistics and frequencies were utilized for nominal data. Chi-square 

analysis was conducted comparing BMI ≥27.5 kg/m2

 (overweight), BMI 

<27.5 kg/m2 (normal weight), and NHLBI BMI >25 kg/m2

, with current 

accommodations, injury, changes in lifestyle habits, amount of activity, 

food prep/cooking access, and Soldier demographics of those who gained 

weight compared to those who lost weight following injury. Spearman’s 

rho correlation analysis was completed on the continuous BMI scale data 

and various categorical data.

RESULTS

Demographics

The demographic descriptive results (Table 1) show that wounded Warfighters within the 4 locations were predominately US Army Soldiers 

(97.6%), most likely white males aged 23 to 43 years in the ranks of specialist (E-4) to staff sergeant (E-6). A variety of injuries were listed, with 

24% requiring assistance for ambulation, 30% with a traumatic brain injury, and 7% resulting in extremity amputation. The majority of participants 

(66.4%) reported having basic access to food preparation equipment such 

as a refrigerator, microwave, and cooking supplies, and that participants 

living in the barracks/billets were more likely to report insuffi cient access compared to Soldiers living off-post (P<.05). Location of residence 

differed greatly among installations, but overall, 50% were assigned to 

individual on-post housing (barracks/billets) and 50% to family housing.

Weight Change

Two hundred two participants (51.1%) had BMI values ≥27.5 kg/m2

 and 

did not meet height and weight standards specifi ed by Army Regulation 

600-9.

11 The BMI distribution across the WTU military installations is 

presented in the Figure. Using NHLBI criteria for categorizing BMI, 4% 

of participants were underweight, 23.1% were normal weight, 42.6% 

were overweight, and 33.2% were obese. The majority of participants 

(51.1%) self-reported themselves as overweight. The BMI was positively 

correlated with WTU length-of-stay (P=.017; r=0.121) and age (P=.002; 

r=0.157). Men were more likely to gain weight than women while in the 

WTU (P<.05).

No signifi cant trend was found to support that weight was only gained during deployment and following injury. Some participants reported weight 

gain while others reported weight loss before and after their injury/illness. 

Prior to entering the WTU, 37.5% of participants experienced weight 

change. Deployment, stress, desire to lose weight, and illness were the 

main reasons for weight loss; while stress, illness, medications, and limited activity were cited for causes of weight gain. The majority (85%) of 

participants experienced a weight change following their injury (n=342); 

63.3% gained weight while 21.9% lost weight. Limited activity and medication use were listed as the main reasons for weight gain (66% and 46% 

respectively). Deployment was listed as the main reason for weight loss 

prior to injury (21.7%).

Lifestyle Factors that May Contribute to Weight Change

Warfi ghters with a BMI ≥27.5 kg/m2

 were more likely to make lifestyle 

changes following injury (P=.000; r=-0.206). More than 50% of participants changed at least one of the following lifestyle factors (Table 2): 

Table 1. Demographics of WTU Warriors (N=412*)

Location n (%)

Fort Sam Houston, TX 134 (32.6)

Fort Gordon, GA 117 (28.5)

Fort Hood, TX 111 (27.0)

Fort Bliss, TX 49 (11.9)

Gender

Male 363 (89.0)

Female 45 (11.0)

Military Service

Army 402 (97.6)

Marine Corps 4 (1)

Air Force 1 (0.2)

Navy 1 (0.2)

Not indicated on survey 4 (1)

BMI (mean =28.3 kg/m2, SD ±5)

BMI < 27.5 kg/m2 (%)† 193 (48.9)

BMI ≥ 27.5 kg/m2 (%)‡ 202 (51.1)

Mean Age 33 years, SD±10)

Race/Ethnicity 

Black 75 (18.4)

White 229 (56.3)

Hispanic 66 (16.2)

Asian 4 (1.0)

Other 33 (8.1)

Length of stay in WTU

0–6 months 177 (44.3)

6 months–1 year 109 (27.3)

1 year–2 years 90 (22.5)

>2 years 24 (6.0)

Military Rank

E1–E3 32 (8.0)

E4–E6 298 (74.1)

E7–E9 50 (12.4)

O1–O3 13 (3.2)

O4–O6 7 (1.7)

WO1–WO5 2 (0.5)

Highest education attained

High school 125 (30.9)

Some college 183 (45.2)

Associates degree 42 (10.4)

Bachelors degree 45 (11.1)

Graduate degree 10 (2.5)

Residence

Barracks/Billets 195 (46.6)

On-post family housing 32 (7.8)

Fisher House 6 (1.5)

Guest house 25 (6.1)

Off-post family housing 151 (36.8)

Injury/Illness 

Traumatic brain injury (TBI) 29.5%

Burn 5.3%

Amputation 7.3%

No amputation 33.2%

Other 56.2%

Require assistance for moving 24.0%

*Not all questions in each category were completed by all participants. Percentages are calculated for total responses in the category.

†Allowable BMI per Army Regulation 600.9

‡Overweight BMI per Army Regulation 600.9

WEIGHT CHANGE, LIFESTYLE, AND DIETARY BEHAVIOR IN THE US MILITARY’S

WARRIOR IN TRANSITION UNITS
 October – December 2012 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

skipping meals, eating snacks, eating at sit-down restaurants, performing aerobic and anaerobic physical activity. Warfi ghters usually consumed 3 standard meals at 

their assigned housing (38% to 56%) or the dining facility (25% to 34%). They reported that the meal typically 

skipped was breakfast and about 50% consumed snacks 

throughout the day. Approximately 57% of participants 

reported ambulating daily, whereas only 20% of participants reported performing physical activity 4 to 5 times 

weekly. No statistical differences existed between lifestyle factors (dietary or physical activity) and residence, 

meal frequency, BMI, or other demographic variables.

Interest in Specifi c Health Topics

Sixty-one percent of participants reported wanting to 

lose weight. Participants were asked to rate their level of 

interest (none, somewhat, very) in the following topics: 

healthy foods, healthy shopping, cooking, meal planning, 

weight management, sports nutrition, healthy snacks, 

and supplements. All topics received interest (>50%), 

however, learning about healthy foods and snacks created the strongest interest.

COMMENT

The results from this study support the hypothesis that 

Warfi ghters experience weight change following injury; 

63% of Soldiers gained weight postinjury, and 61% were 

trying to lose weight. To date, this is the fi rst study published evaluating lifestyle factors contributing to weight 

change in the WTU following their injury. 

At the time of the study, DoD Directive 1308.310 did not 

address weight standard adjustments for excess weight 

gain during the rehabilitative process. It is unknown 

how an elevated BMI would affect a WTU Warfi ghter’s 

reintegration process especially when faced with the 

burden of negative administrative consequences of failing to meet current weight-for-height standards. This 

study found that nearly 51% of WTU Warfi ghters did 

Fort Sam Houston Fort Gordon Fort Hood Fort Bliss

0

15

5

10

25

20

35

30

40

45

Body Mass Index

Body mass index distribution of WTU study subjects by military installation.

Table 2. Percentage of subjects who indicated changes (or 

none) in lifestyle factors following injury.

More Less No

Change

Attend a weight loss program 5.5 7.3 86.7

Used diet/low calorie food 22.5 9.3 68.2

Ate smaller portions 37.0 11.6 51.4

Skipped meals* 38.1 13.6 48.3

Ate snacks* 23.6 26.4 50.0

Drank alcohol 8.3 24.5 67.2

Ate carbohydrates 20.0 20.8 59.2

Ate sweets 16.2 27.9 55.9

Drank sugary beverages 17.8 28.2 54.0

Ate high fat foods 17.2 25.9 56.9

Ate fruits 33.5 14.7 51.8

Ate vegetables 34.7 12.3 53.0

Ate at fast food restaurants 18.3 30.0 51.4

Used sugar-free sweeteners 15.5 10.9 73.6

Ate at buffets 8.4 30.9 60.7

Ate at sit-down restaurants* 22.6 28.7 48.7

Drank crystal light or sugar-free 

beverages 13.5 17.9 68.3

Took dietary supplements 7.3 11.4 81.3

Drank sports beverages 25.6 18.2 56.2

Performed aerobic activity* 26.3 35.5 38.2

Performed anaerobic/strength 

activity* 21.7 39.5 38.8

*50% or more of the subjects changed this lifestyle factor.
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

not meet Army standards for BMI and over 60% did not 

meet NHLBI criteria for normal weight BMI. It has been 

established that unintentional weight gain can affect 

the recovery of patients receiving treatments.8,9 Being 

overweight or obese (BMI ≥25 kg/m2

) can increase the 

risk for impaired glucose tolerance, hyperlipidemia, and 

cardiovascular disease and is associated with increased 

mortality and delayed wound healing.8,9,19-22 Nearly half 

of the WTU Warfi ghters believed that medications contributed to their weight change. Although some behavior health medications are shown to cause weight gain, 

obesity may be burdensome and require patients to take 

additional medications to combat side effects of that 

obesity.23-25 Recent research suggests that emotions, environmental triggers, stress, medication use, and sleep 

deprivations contribute to the weight management challenges by interrupting the homeostatic and hedonic 

system balance of food intake.19-20,26-35,50 It is plausible 

that all of these unconventional factors can effect WTU 

Warfi ghters in their recovery efforts and thus warrant 

further investigation.

Results showed that more than 50% of WTU Warfi ghters changed their meal patterns, timing, and frequency 

including skipping meals, eating snacks, and eating at 

sit-down restaurants. Skipping meals, especially breakfast, has been shown to hinder weight control.36-38 Additionally, regular frequency of meals and structured meal 

patterns have been associated with decreased appetite, 

increased nutrient utilization, and increased weight control compared to irregular eating patterns.39-49 Promotion of these behaviors may assist with weight control 

in the WTU.

Benefi cial changes are continually improving the WTU 

accommodations, but this study found that WTU Warfighters living in the barracks were less likely to have suffi cient access to food preparation equipment compared 

to WTU Soldiers living off-post or in family housing. 

Even though some WTU facilities have access to a central kitchen with adequate food preparation and cooking 

supplies, Warfi ghters may not have the cooking skills or 

adequate nutrition knowledge to develop healthy meal 

options. Although participants’ nutrition knowledge 

was not assessed, heavy marketing and access to quick, 

high calorie food outlets, such as fast food restaurants, 

have a direct effect on weight control balance.50 Future 

research could focus on how to encourage awareness of 

and use of food preparation in the barracks and assess 

effect on weight change following injury. Nutritional 

programs aimed at smaller meal consumption, inclusion 

of breakfast, making healthier food choices, and cooking with limited access to kitchen utilities could improve 

Warfi ghters’ rehabilitation while in the WTU. Dining 

facilities were reported as the second most common site 

for meal consumption, thus targeting the dining facility 

with programs such as the “Go for Green” nutrition performance program.51 The dining facility can indeed be a 

benefi cial resource for the WTU Warfi ghter in promoting healthier meal choices.

Physical activity plays a key role in weight management,52-54

and our study determined that less than 30% of Soldiers 

in the WTU met the minimum recommendation for 

physical activity (30 minutes of moderate-intensity exercise most days of the week) established by the American 

College of Sports Medicine.55 More than 50% of Soldiers indicated decreased physical activity as the main 

reason for their weight change. Physical activity should 

be promoted and tailored based upon factors such as injury and medical procedures. It is possible that a Soldier 

may have to learn to use unfamiliar exercise method and 

equipment to accommodate a specifi c injury. As wounded Warfi ghters transition to the WTU, physical activity 

alterations as part of their rehabilitation may assist their 

weight management efforts as well as promote healing. 

Limitations of this study include: biases associated with 

self-reported BMI, inability to adjust BMI for percent 

body weight amputations (7% of total injuries reported), 

differences in WTU accommodations among installations, and questionnaire-design inability to verify the 

motivation for lifestyle change. On the other hand, a 

major strength was multicenter WTU sampling.

Overall, this study found that lifestyle factors (dietary 

and physical activity) changed following injury regardless of reported weight gain or loss. Warfi ghters with 

a BMI ≥25 kg/m2

 made more lifestyle changes than 

Warfi ghters with a BMI <25 kg/m2

, possibly because 

overweight Warfi ghters were more likely to try different methods to lose weight. Understanding their motivation for lifestyle change would help tailor an intervention specifi c to their needs. The majority of Soldiers 

indicated the desire for classes or additional training/

information regarding weight management, healthy activities, and lifestyle changes. With the prevalence of 

weight change in the WTU and with weight gain being a 

health concern, optimal treatment should include weight 

management and physical activity strategies; providing 

individualized nutrition and physical education may 

promote a healthy lifestyle.

CONCLUSION

This study determined that Soldiers have signifi cant 

weight changes while in the WTU. A majority of Soldiers consider themselves overweight and want to lose 

weight. Lifestyle factors change upon entry into the 

WEIGHT CHANGE, LIFESTYLE, AND DIETARY BEHAVIOR IN THE US MILITARY’S

WARRIOR IN TRANSITION UNITS
 October – December 2012 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

WTU and specifi c reasons behind these changes should 

be further studied. Physical activity is signifi cantly reduced following injury and may contribute to weight 

gain. There is a need for more focused nutrition-related 

and physical fi tness-oriented interventions and program 

for Warriors to aid recovery, promote rehabilitation, and 

decrease length of time in the WTU. Although current 

healthcare practices for WTU Warfi ghters is praiseworthy, it is important to address the Warfi ghter’s weight 

gain and possible effects it may have on their return to 

duty. Dietitians reinforce nutritional supplements and 

adequate energy needs while inpatient to promote healing, but Warfi ghters are not necessarily educated on how 

to make adjustments in caloric intake as healing and 

energy needs subside, nor habits to support long-term 

proper weight management. Establishing a nutrition education intervention as the Warfi ghter transitions from 

inpatient to the WTU outpatient setting for rehabilitation may promote effective weight management and prevent interruptions to the reintegration process.

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AUTHORS

CPT Kieffer is Chief, Nutrition Care Division, Reynolds 

Army Community Hospital, Fort Sill, Oklahoma. When 

this study was conducted, he was a student in the US 

Military-Baylor Graduate Program in Nutrition, Fort 

Sam Houston, Texas.

MAJ Cole is Program Director, US Military Dietetic 

Internship Consortium, Army Medical Department 

Center and School, Fort Sam Houston, Texas. She is 

also an Associate Professor, Baylor University, at the US 

Military-Baylor Graduate Program in Nutrition.

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August 2011

$/11

USDA is an equal opportunity provider and employer.

Cut back on sodium 

and empty calories 

from solid fats and 

added sugars

Look out for salt (sodium) in foods 

you buy. Compare sodium in foods 

and choose those with a lower 

number.

Drink water instead of sugary drinks. 

Eat sugary desserts less often.

Make foods that are high in solid 

fats—such as cakes, cookies, ice 

cream, pizza, cheese, sausages, and 

hot dogs—occasional choices, not 

every day foods.

Limit empty calories to less than 

260 per day, based on a 2,000 

calorie diet.

Be physically active 

your way

Pick activities you like and do 

each for at least 10 minutes at a 

time. Every bit adds up, and health 

benefits increase as you spend more 

time being active.

Children and adolescents: get 

60 minutes or more a day.

Adults: get 2 hours and 30 minutes 

or more a week of activity that 

requires moderate effort, such as 

brisk walking. risk

minute

ds up, and health

e as you spend mor

ve.

d adolesce

s or more a

s: get 2 hours and 30 minutes

more a week of activity that 

equires moderate effort, such as 

brisk walking

en

a

s

Vegetables Fruits Grains Dairy Protein 

Foods

Eat more red, orange, 

and dark-green veggies like tomatoes, 

sweet potatoes, 

and broccoli in main 

dishes.

Add beans or peas 

to salads (kidney or 

chickpeas), soups 

(split peas or lentils), 

and side dishes (pinto 

or baked beans), or 

serve as a main dish.

Fresh, frozen, and 

canned vegetables 

all count. Choose 

“reduced sodium” 

or “no-salt-added” 

canned veggies.

Use fruits as snacks, 

salads, and desserts. 

At breakfast, top your 

cereal with bananas 

or strawberries; 

add blueberries to 

pancakes.

Buy fruits that are 

dried, frozen, and 

canned (in water or 

100% juice), as well as 

fresh fruits.

Select 100% fruit juice 

when choosing juices.

Substitute wholegrain choices for 

refined-grain breads, 

bagels, rolls, breakfast cereals, crackers, 

rice, and pasta.

Check the ingredients 

list on product labels 

for the words “whole” 

or “whole grain” 

before the grain 

ingredient name.

Choose products that 

name a whole grain 

first on the ingredients list.

Choose skim (fatfree) or 1% (low-fat) 

milk. They have the 

same amount of 

calcium and other 

essential nutrients as 

whole milk, but less 

fat and calories.

Top fruit salads and 

baked potatoes with 

low-fat yogurt.

If you are lactose 

intolerant, try 

lactose-free milk or 

fortified soymilk (soy 

beverage).

Eat a variety of foods 

from the protein food 

group each week, 

such as seafood, 

beans and peas, and 

nuts as well as lean 

meats, poultry, and 

eggs.

Twice a week, make 

seafood the protein 

on your plate.

Choose lean meats 

and ground beef that 

are at least 90% lean.

Trim or drain fat from 

meat and remove skin 

from poultry to cut 

fat and calories.

For a 2,000-calorie daily food plan, you need the amounts below from each food group. 

To find amounts personalized for you, go to ChooseMyPlate.gov.

Eat 21⁄2 cups 

every day

What counts as a cup? 

1 cup of raw or 

cooked vegetables 

or vegetable juice; 

2 cups of leafy 

salad greens

Eat 2 cups 

every day

What counts as a cup? 

1 cup of raw or 

cooked fruit or 

100% fruit juice; 

1⁄2 cup dried fruit

Eat 6 ounces 

every day

What counts as 

an ounce? 

1 slice of bread; 

1⁄2 cup of cooked rice, 

cereal, or pasta; 

1 ounce of ready-toeat cereal

Get 3 cups 

every day

What counts as a cup? 

1 cup of milk, yogurt, 

or fortified soymilk; 

11⁄2 ounces natural or 

2 ounces processed 

cheese

Eat 51⁄2 ounces 

every day

What counts as 

an ounce? 

1 ounce of lean meat, 

poultry, or fish; 1 egg; 

1 Tbsp peanut butter; 

1⁄2 ounce nuts or 

seeds; 1⁄4 cup beans 

or peas 
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

According to the World Health Organization, chronic 

diseases with preventable risk factors have surpassed 

infectious diseases as the major cause of morbidity and 

mortality worldwide.1

 Five of these diseases—cardiovascular diseases, diabetes, obesity, cancer, and respiratory diseases—kill more than 33 million people a year 

and account for over 46% of the global burden of disease. Out of this 33 million, 12 million people die as a 

result of heart attack and/or stroke each year. Furthermore, over one billion adults in both developing and developed countries worldwide are overweight, with 300 

million clinically obese.1

 The deaths of an additional 

5.4 million people annually are attributable to tobaccorelated illnesses.2

Within the United States, 7 of 10 Americans die each 

year as a result of chronic diseases.3

 Commensurate 

with international statistics of both developed and developing countries, heart disease, cancer, and stroke 

make up more than 50% of all deaths annually.4

 These 

3 diseases in conjunction with diabetes and arthritis are 

the most prevalent, costly, and preventable in the United 

States. Further exacerbating the current rate of US mortality is a growing obese population where one in every 

3 adults living here is clinically obese.5

 Additionally, 

the most recent empirical study by the Centers for Disease Control and Prevention using 2000-2004 US data 

estimated 443,000 individuals die each year,6

 including 

3,000 adult nonsmoker deaths as a result of exposure 

to secondhand smoke.7

 Beyond the human toll, the report found the economic impact of smoking-attributable 

health care costs to be approximately $96 billion, which 

did not include the estimated productivity losses of $97 

billion—collectively $193 billion annually.6

There are multiple factors leading to this increase in 

chronic diseases. One of the primary causes is the epidemiologic transition of developing countries driven 

by 3 major determinants: ecobiologic; socioeconomic, 

political, and cultural; and medical and public health 

interventions.8

 One example of these components is 

the migration of rural agrarian populations to more urban-based communities as a result of industrialization 

and economic development. This dramatic increase in 

chronic diseases is creating a double burden of disease 

as these countries and individuals continue to struggle 

with the impact of infectious diseases.9

 As individuals 

move between these environments, behaviors are modifi ed which could have a deleterious effect on those unaccustomed or without social and community networks to 

address new risk factors. Negative changes in dietary 

habits, reduced physical activity, and an increase in tobacco product use and alcohol consumption are the primary driving factors of this rapid increase of chronic 

diseases worldwide, including the United States.

In an effort to mitigate the rapid growth of these diseases and their associated costs, nations are looking at ways 

to address the root causes of these risk factors and associated behaviors. Simultaneously, they are determining 

how existing health care systems could be modifi ed to 

meet the growing demand due to these chronic diseases. 

As a result, the debate surrounding personal and social 

responsibility in relation to health behavior and negative outcomes has intensifi ed. Different philosophies 

have emerged, as well as methods to establish a role for 

responsibility in healthcare and develop appropriate intervention strategies to minimize unhealthy behaviors. 

Both are discussed as they identify the roles that individuals and societies play in addressing this growing 

health burden of global proportions.

PHILOSOPHY OF INDIVIDUAL RESPONSIBILITY

A US survey conducted in July 2006 found that 53% of 

Americans thought it would be fair to ask people with 

unhealthy lifestyles to pay higher insurance premiums 

than those with healthy lifestyles.10 In the United Kingdom, a June 2010 poll found 35% of the population surveyed believed higher taxes on alcohol, cigarettes, and 

unhealthy food would be the best way to reduce their 

National Health Service spending.11 Both of these national surveys indicate that their respective populations 

see a role for individual responsibility in negative health 

behavior as it relates to health insurance. However, 

much controversy revolves around individual rights to 

make independent choices and whether states or healthcare systems have the right to intervene by demanding 

personal responsibility for health.12

Negative Health Behavior:

 A Personal Responsibility or Not?

MAJ Derek Licina, MS, USA
 October – December 2012 15

Some Americans use car insurance as a proxy when 

discussing health insurance and the role of individual 

responsibility. For example, individuals must pass a 

driver’s license test to gain the right to drive, which requires some type of minimum insurance coverage. If 

over time individual failures such as speeding tickets 

or traffi c accidents accumulate, penalties in the form 

of higher deductibles or the potential of being dropped 

by an insurance company occur. Similarly, the idea that 

individuals must show a minimum level of preventive 

services conducted before using a warranty for larger 

vehicle repairs could be applied to health insurance.13

Most notably, Dr C. Everett Koop, a former US Surgeon 

General, stated “the plain fact is that we Americans do 

a better job of preventive maintenance on our cars than 

on ourselves” while noting car insurance does not cover 

preventive maintenance for vehicles.14 Both of these examples highlight the perceived need for individuals to be 

accountable in reducing and eliminating their negative 

health risks while investing in preventive services such 

as health promotion activities and vaccination programs. 

Others argue against the auto insurance comparison, 

stating that individuals can simply avoid speeding by 

deciding to do so which does not adversely impact their 

individual costs.15 Simply deciding to lose weight, stop 

smoking, or reduce cholesterol is not enough, as there 

are numerous individual and societal barriers. Those include a lack of fi tness center availability, poor smoking 

cessation program access, and a paucity of healthy food 

options coupled with unfortunate human genetics.15

As health reform is implemented in the United States, 

some maintain that since it is for the population, they 

must “become full participants and assume much greater responsibility for their actions if health benefi ts are 

to be maintained at an affordable cost.”13 Directly associated with cost is the issue of poor compliance by the 

individual patient which is commonly cited by physicians as an impediment to positive health outcomes.13

Encouraging individuals to assume responsibility for 

completing preventive screening tests, obtaining proper vaccinations, and taking prescribed medications by 

either incurring penalties or obtaining a cost savings 

are options available. It is perceived that responsible 

patients and communities support physicians by acting 

responsibly, which could have a direct impact on overall 

cost-effectiveness of the health care system.13

However, others acknowledge reasons may exist outside of individual control which directly and indirectly 

impact patient compliance with medical recommendations and their ability to keep individual appointments. 

Some of these factors include poor physician-patient 

communication, adverse side effects of medication, limited access to modes of transportation and child care, 

rigid work schedules, language barriers, and other cultural barriers.16-18 Additionally, it is argued that in order 

to encourage personal responsibility, more fundamental 

social and structural issues must be addressed.19

PHILOSOPHY OF SOCIETAL RESPONSIBILITY

The terms “lifestyle” and “health behavior” automatically imply individual culpability rather than considering the role social and physical environments may have 

in reinforcing individual negative behavior.20 Dr Koop 

acknowledged that American health problems are due 

more to society, “especially the shameful prevalence of 

poverty in this rich country,” than from problems with 

the healthcare system.14 Some posit that poverty is the 

single biggest factor underlying adverse health outcomes which worsen when poverty intensifi es.21 Within 

the United States, Medicaid is the program which supports the medical needs of the impoverished and has 

been the recent target of state efforts to address individual responsibility by imposing paternalistic health 

requirements, such as those in West Virginia. Enforcing 

individual responsibility will not necessarily improve 

the impoverished individual’s health coverage, access, 

or independence,19 but will more likely further exacerbate unhealthy behaviors and an already poor health status. This is highlighted today by the situation in which 

individuals living in poverty experience a higher rate 

of HIV/AIDS and are the least likely to have access to 

both the healthcare and treatment so desperately needed, 

even 25 years after the disease was fi rst recognized.22

To address this issue from a social inequalities perspective, studies indicate a higher prevalence of unhealthy 

behaviors among lower socioeconomic status individuals, which correlates directly to an overall worse health 

status among this group.23-25 Stringhini et al26 examined the British Whitehall II cohort established in 1985 

which included 10,308 civil servants stratifi ed by socioeconomic status, and assessed 4 risk factors (smoking, 

alcohol consumption, diet, and physical activity) over 

4 periods of time from 1985 to 2004 and found those 

within the lowest socioeconomic status had a 1.6 times 

higher risk of death due to preventable diseases than 

those in the highest socioeconomic status.26 However, 

do these individual decisions to participate in unhealthy 

behaviors alone result in the negative health outcomes in 

a form of causal responsibility?

Buyx argues that there are problems with the theory of 

causal responsibility.12 In order to hold an individual 

accountable for their behaviors, a direct link must be 
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

identifi ed and other external factors completely eliminated. She states the reality of most conditions which 

are cited as preventable (eg, diabetes, high blood pressure, some cancers) are multifactoral and infl uenced by 

individual behavior and environmental, societal, and 

even genetic components. Therefore, holding individuals responsible for a condition without one single causal 

factor is a “great challenge.”12 Her thoughts are similar 

to those of Daniels who rejects the concept of enforcing individual accountability through costs associated 

with risky lifestyle choices.

27 Daniels claims measuring 

causal contribution is practically unfeasible.

Further confounding the issue is the theory of freedom 

of health behavior. In order to show direct attribution 

for accountability purposes, individuals would have to 

exhibit complete control over the negative behavior and 

choose it freely. Buyx highlights the problem with the 

theory by stating many unhealthy behaviors are actually socially accepted norms.12 In Stinghini’s study of 

the British Whitehall II cohort, her group found a higher 

prevalence rate of smoking, unhealthy diet, and low levels of physical activity among participants in the lower 

socioeconomic status which directly correlated to higher 

rates of mortality.26 This would imply social acceptance 

of the unhealthy behaviors among the lower SES, thereby removing complete freedom of individual control. As 

a result, one would have to eliminate these externalities to defi ne what level of responsibility the individual 

should bear. Buyx does not use this argument to remove 

personal responsibility from the debate, rather to inform 

the substance of the deliberation. She acknowledges the 

need to appropriately manage scarce health resources 

and the role that personal responsibility has in leading 

to better health.12

PHILOSOPHY OF CORESPONSIBILITY

Anyone participating in the debate over individual versus societal responsibility for unhealthy behaviors can 

see merit to both arguments. Harlad Schmidt brings 

these 2 perspectives together in his concept of health 

responsibility as coresponsibility.28 First mentioned in 

Article 1 from Book V of the German Social Security 

Code, “coresponsibility” was bestowed upon citizens 

to lead healthy lifestyles and take an active role in prevention, treatment, and rehabilitation to avoid sickness 

and disability.29 Schmidt’s concept acknowledges health 

is affected by both individual behavior and factors beyond their immediate control, therefore, it is neither 

exclusively an individual nor social responsibility. He 

cites this as necessary to assess the causal factors, both 

prospective and retrospective, that result in the particular health state as well as determining attribution 

of praise or blame with associated positive or negative 

outcomes.28 The concept of health responsibility as coresponsibility is found in the ecological model of social 

behavior which targets health behaviors through multifaceted approaches in order to generate positive health 

outcomes. Although explicitly defi ned by Schmidt after 

the ecological model was developed, coresponsibility is 

evident in the construct.

ECOLOGICAL MODEL

An early framework which incorporated individual and 

environmental determinants in assessing behavior was 

proposed by Brofenbrenner.30 The signifi cance of this 

framework and other ecological models is their premise 

that individual behavior is affected by the social environment, and, in a symbiotic relationship, the individual 

can in turn affect the social environment. Leveraging 

the original work done by Brofenbrenner and other ecological model pioneers, McLeroy et al20 developed an 

ecological model for health promotion with patterned 

behavior as the outcome of concern as determined by 

the following 5 factors20:

1. Intrapersonal factors

2. Interpersonal process and primary groups

3. Institution factors

4. Community factors

5. Public policy

The unhealthy behavior of smoking which results in a 

signifi cant number of chronic diseases and high rate of 

mortality mentioned earlier in this article will be used 

to illuminate each of these factors and set precedence in 

determining where intervention could occur and where 

responsibility should reside.

Intrapersonal factors are the characteristics of the individual which are the target of intervention. It is assumed 

that the individual has control over his or her behavior 

and therefore should have both the responsibility and 

ability to make the necessary behavioral change. Smoking interventions such as educational programs through 

peer counseling or media campaigns can assist individuals in changing their knowledge, attitudes, and beliefs 

to bring about a positive health behavior change.

The second factor of interpersonal process and primary 

groups focuses around external infl uences of health related behaviors. Both positive and negative social norms 

are exuded by human networks which impact individuals within and outside of the groups.20 These networks 

also provide resources such as information and emotional support which could be leveraged to assist in 

modifying unhealthy individual behavior.31 Therefore, 

NEGATIVE HEALTH BEHAVIOR: A PERSONAL RESPONSIBILITY OR NOT?
 October – December 2012 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

interventions focused on these factors seek to modify 

group infl uences which could encourage and facilitate 

positive health behaviors of individuals. One example 

would be changing the acceptable norm of smoking 

within a network based on consistent messaging and 

modeling by the group against the toxic habit.

Third, institution factors, also referred to as organizational factors, are another level of environmental determinants that impact individual health behavior. Since 

individuals spend one-third to one-half of their lives in 

organizational settings ranging from school to the workplace, the role organizations can and do play in health 

related behaviors cannot be underestimated.20 In an effort to assuage the adverse impact smoking has on productivity and increased costs associated with medical 

support, organizations began to modify their cultural 

norms to discourage tobacco use. Examples include the 

enforcement of smoking bans and/or restrictions at the 

worksite and encouraging (with encentives) employee 

enrollment in smoking cessation programs. Although 

the impact of eliminating individual unhealthy behavior 

through these interventions is an outcome of this effort, 

a change in organizational culture which institutionalizes positive health behaviors is the objective.

According to McLeroy et al, the fourth factor of community has 3 meanings20:

1. Community refers to mediating structures 

such as families, friendship networks, and 

neighborhoods.

2. Community includes relationships among organizations in a defi ned area.

3. Community is defi ned in geographical and political terms

Each of these defi nitions defi nes communities as relationships and the role they perform in supporting individuals. In the case of smoking cessation programs, a 

disadvantaged community may not have the resources 

necessary to effectively implement the required intervention program. Therefore, strategies within this factor 

will focus on linking communities without resources to 

other community agencies such as regional health departments to close the requirement gap.

The fi nal factor in this ecological model for health promotion is public policy. Through the use of public policy 

interventions, national laws mandating the protection 

of society are enforced and other strategies to address 

health risks associated with diseases are developed. 

Laws derived as a result of public policy banning smoking in public facilities and increasing taxes on tobacco 

products highlight the role individual responsibility has 

in protecting the welfare of society. As a result, this ecological model reinforces the concept of coresponsibility 

in health by focusing interventions on 5 separate and 

overlapping factors from the individual to society and 

external environment.

This discussion concludes with the situation in the United States, where 443,000 individuals die each year as 

a result of smoking and $193 billion is spent for smoking-related healthcare costs.6

 What percentage of this 

economic burden should individuals carry as a result 

of unhealthy behavioral choices? As much of this disease burden is carried by the disenfranchised, what can 

they actually afford? Since individuals and their environments infl uence and impact health behavior, governments should develop intervention solutions impacting 

both. The ecological model for health promotion, in 

concert with the theory of coresponsibility, provides an 

actionable framework to address unhealthy risk behaviors in a multifaceted approach. The United States and 

its citizens cannot afford anything less.

REFERENCES

1. Ten facts about chronic diseases page. World 

Health Organization Web site. Available at: http://

www.who.int/dietphysicalactivity/publications/

facts/chronic/en/. Accessed August 7, 2012.

2. Global tobacco control. Smoking and tobacco use 

page, Centers for Disease Control and Prevention 

Web site. 2012. Available at: http://www.cdc.gov/to

bacco/global/index.htm. Accessed August 7, 2012.

3. Chronic diseases and health promotion. Chronic 

disease prevention and health promotion page, Centers for Disease Control and Prevention Web site. 

Available at: http://www.cdc.gov/chronicdisease/

overview/index.htm. Accessed August 7, 2012.

4. Kung HC, Hoyert DL, Xu J, Murphy SL. Deaths: fi -

nal data for 2005. Natl Vital Stat Rep. 2008;56(10):1-

120. 

5. Ogden CL, Carroll MD, McDowell MA, Flegal 

KM. Obesity among adults in the United States–

no statistically signifi cant change since 2003-2004. 

NCHS Data Brief. 2007;Nov(1):1-8. 

6. Smoking-attributable mortality, years of potential 

life lost, and productivity losses–United States, 

2000-2004. MMWR Morb Mortal Wkly Rep. 

2008;57(45):1226-1228. 

7. 2006 Surgeon General’s report–the health consequences of involuntary exposure to tobacco smoke. 

Smoking and tobacco use page, Centers for Disease Control and Prevention Web site. 2006. Available at: http://www.cdc.gov/tobacco/data_statistics/

sgr/2006/index.htm. Accessed August 7, 2012.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

8. Omran AR. The epidemiologic transition. a theory 

of the epidemiology of population change. Milbank 

Mem Fund Q. 1971;49(4):509-538. 

9. Merson MH, Black RE, Mills A. International 

Public Health: Diseases, Programs, Systems, and 

Policies. 2nd ed. Sudbury, MA: Jones and Bartlett; 

2006. 

10. Bright B. Many Americans back higher costs for 

people with unhealthy lifestyles. Wall Street Journal [serial online]. July 19, 2006. Available at: http://

online.wsj.com/article/SB115324313567509976.

html. Accessed August 7, 2012.

11. Kirby J. 35% back higher taxes on unhealthy lifestyles. The Independent [serial online]. June 13, 

2010. Available at: http://www.independent.co.uk/

life-style/health-and-families/health-news/35-

back-higher-taxes-on-unhealthy-lifestyles-1999357.

html. Accessed August 7, 2012.

12. Buyx AM. Personal responsibility for health as a 

rationing criterion: why we don’t like it and why 

maybe we should. J Med Ethics. 2008;34(12):871-

874. 

13. Brook RH. Rights and responsibilities in health 

care: striking a balance. JAMA. 2010;303(22):2289-

2290. 

14. Koop CE. A personal role in health care reform. 

Am J Public Health. 199;85(6):759-760. 

15. Schmidt H, Voigt K, Wikler D. Carrots, sticks, and 

health care reform–problems with wellness incentives. N Engl J Med. 2010;362(2):e3. 

16. Steinbrook R. Imposing personal responsibility for 

health. N Engl J Med. 2006;355(8):753-756.

17. Osterberg L, Blaschke T. Adherence to medication. 

N Engl J Med. 2005;353(5):487-497. 

18. Johnson MO. Meeting health care needs of a vulnerable population: perceived barriers. J Community Health Nurs. 2001;18(1):35-52. 

19. Hermer LD. Personal responsibility: a plausible social goal, but not for MEDICAID reform. Hastings 

Cent Rep. 2008;38(3):16-19. 

20. McLeroy KR, Bibeau D, Steckler A, Glanz K. An 

ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351-377. 

21. Foege WH. Social determinants of health and healthcare solutions. Public Health Rep. 2010;125(suppl 

4):8-10. 

22. Fee E, Parry M. Jonathan Mann, HIV/AIDS, and human rights. J Public Health Policy. 2008;29(1):54-

71.

23. Lynch JW, Kaplan GA, Salonen JT. Why do poor 

people behave poorly? variation in adult health behaviors and psychosocial characteristics by stages 

of the socioeconomic lifecourse. Soc Sci Med. 

1997;44(6):809-819. 

24. Martikainen P, Brunner E, Marmot M. Socioeconomic differences in dietary patterns among 

middle-aged men and women. Soc Sci Med. 

2003;56(7):1397-1410. 

25. Black D, Davidson N, Townsend P. Inequalities in 

Health: The Black Report. Harmondsworth, Middlesex, England: Penguin Books; 1982. 

26. Stringhini S, Sabia S, Shipley M, et al. Association 

of socioeconomic position with health behaviors 

and mortality. JAMA. 2010;303(12):1159-1166. 

27. Daniels N. Just Health: Meeting Health Needs 

Fairly. Cambridge, United Kingdom: Cambridge 

University Press: 2008. 

28. Schmidt H. Just health responsibility. J Med Ethics. 

2009;35(1):21-26. 

29. Schmidt H. Personal responsibility for health–developments under the German healthcare reform 

2007. Eur J Health Law. 2007;14(3):241-250. 

30. Bronfenbrenner U. The ecology of human development: experiments by nature and design. Cambridge, MA: Harvard University Press; 1979.

31. Cohen S, Syme SL. Social Support and Health. Orlando, FL: Academic Press; 1985. 

AUTHOR

MAJ Licina is pursuing a DrPH degree at the George 

Washington University, Washington, DC.

NEGATIVE HEALTH BEHAVIOR: A PERSONAL RESPONSIBILITY OR NOT?
 October – December 2012 19

New hallucinogenic drugs of abuse, known generically 

as “spice” and “bath salts,” have become readily available in the United States. Spice refers to a variety of synthetic cannabinoids that act on the body in a way similar 

to delta-9-tetrahydrocannabinol (THC). Bath salts refer 

to a group of hallucinogens that contains various cathinone-like chemicals.

Synthetic cannabinoids have been an area of research 

since the 1960s for both academia and industry.1

 This is 

understandable because compounds that mimic the antiinfl ammatory and analgesic properties of THC without 

the psychotropic effects could have signifi cant academic and industrial application.2

 Not surprisingly, these 

synthetic cannabinoids found their way into the world 

of recreational drug use. Synthetic cannabinoids were 

initially available in Europe in 2004 under the brand 

name Spice.3

 Since then, the substance has continued 

to increase in popularity. Over time, “spice” came to 

refer generically to all herbal mixtures with synthetic 

cannabinoids. There are a number of products marketed 

with different brand names that are still referred to as 

spice products.

When spice blends fi rst went on sale in the early 2000s, 

it was thought that they achieved an effect through a 

mixture of legal herbs. Subsequent laboratory analysis 

from Germany and Austria in 2008 showed this was 

not the case; in fact they contained added synthetic 

cannabinoids that act on the body in a way similar to 

cannabinoids found naturally in cannabis, such as THC. 

A large and complex variety of synthetic cannabinoids, 

most often cannabicyclohexanol, JWH-018, JWH-073, 

or HU-210, are used in an attempt to avoid the laws that 

make cannabis illegal, making synthetic cannabinoids 

designer drugs.4

Spice is used as an alternative to marijuana because 

of the similarity of their “high” effects. Depending on 

the synthetic compound in specifi c commercial brands, 

spice can be anywhere from 4 times to over 100 times 

more potent than THC. Furthermore, since their introduction, they have been undetectable by routine urine 

drug screens. This is a signifi cant draw for abusers. 

Only recently have specifi c tests for these drugs become 

available. Signifi cant adverse effects of spice have been 

documented, including seizure activity, agitation, hallucinations, myocarditis, and chest pain, as well as compulsive dosing to sustain effect. Redosing is common for 

both spice and bath salts.

Bath salts are distinguished by their packaging and locations for retail sale from the preparations that are traditionally used as bath or soaking preparations. The most 

common substances identifi ed in these products are 3,4-

methylenedioxypyrovalerone (MDPV), mephedrone, 

and derivatives of cathinone, all of which produce sympathomimetic effects. Bath salts pose signifi cant health 

risks and can cause severe symptoms, including death. 

Since the main ingredients can be compounds similar to 

3,4-methylenedioxy-N-methylamphetamine (“ecstasy”), 

other methamphetamines, Khat, or cocaine, there can be 

a wide variety of symptoms based on which compound 

predominates. These symptoms include severe paranoia, 

Synthetic Cannabinoid and Cathinone

 Use Among US Soldiers

Cristóbal S. Berry-Cabán, PhD

Paul E. Kleinschmidt, MD

Dinesh S. Rao, MD

Jamie Jenkins, BS

ABSTRACT

New hallucinogenic drugs of abuse, known generically as “spice” and “bath salts,” have become readily available in the United States. Spice is one of many names that refers to a variety of synthetic cannabinoids that act 

on the body in a way similar to delta-9-tetrahydrocannabinol (THC). A large and complex variety of synthetic 

cannabinoids, most often cannabicyclohexanol, JWH-018, JWH-073, or HU-210, are used in an attempt to 

avoid the laws that make cannabis illegal, making synthetic cannabis a designer drug. Bath salts, on the other 

hand, is one of many names for a group of cathinone-containing hallucinogens that produces sympathomimetic 

effects in its users. Both have become popular among those seeking chemical euphorias with decreased chance 

of detection. Consequently, both have become a problem for maintaining mentally fi t Soldiers, unit readiness, 

and morale in the US armed forces.
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

violent behavior, hallucinations, decreased need for 

sleep, lack of appetite, chest pain, and self-mutilation.

Both spice and bath salts are sold over the internet and 

in various retail locations under multiple brand names. 

Labels on packets of bath salts and spice state “not for 

human consumption” and inform consumers that the 

powder should not be smoked or used as snuff. Nonetheless, the drugs can be inhaled, ingested, smoked, or (in 

the case of bath salts) injected. Users may develop cardiac and circulatory disturbances, agitation, delirium, 

paranoia, and psychosis. There have been several cases 

in which users have attempted to infl ict injury on themselves or others. The agitation and delirium may persist 

for days to weeks. 

Similar to spice products, bath salts are sold online and 

in drug paraphernalia stores under a variety of names. 

Because these products are relatively new to the drug 

abuse scene, knowledge about their precise chemical 

composition and short-term and long-term effects is 

limited. In addition, because the main ingredients can 

mimic several different known hallucinogens and stimulants, it is diffi cult to predict the effect on the user from 

“brand to brand” or even from packet to packet.

Reports from users indicate the euphoric high of bath 

salts and spice typically lasts 2 to 4 hours with the letdown effects lasting several hours thereafter. Reported doses for bath salts range from 5 mg to 10 mg for 

the more lipophilic MDPV, and 100 mg to 250 mg for 

mephedrone.5

Since research on spice and bath salts is still developing, 

there are few published studies on how these synthetic 

drugs affect the user. However, case studies have been 

published that show the harmful side-effects of using 

spice and bath salts. These demonstrate that spice and 

bath salts differ in their clinical presentations. In these 

case studies the majority of the patients are young (18 

to 25 years of age), healthy males. Analyzing case studies is the only current way to differentiate the clinical 

presentations of these designer drugs. For example, in 

4 spice case reports, all patients were male, aged 19 to 

25 years.6,7 They all presented to the Emergency Department (ED) with symptoms of either unresponsiveness, 

paranoia, or seizure activity. All laboratory tests and 

drug screens proved unremarkable for the 4 patients, 

however 1 patient was tachycardic (122 bpm) and 3 patients were hypertensive. Also, one patient was combative and had to be restrained. Only upon interviewing 

the patients were the providers able to determine that 

the use of spice was the cause for the patients presenting 

symptoms.7,8 In an examination of 2 bath salt cases, both 

patients were female, aged 22 and 27 years respectively. 

One presented to the ED with symptoms of hallucinations/delusions, while the other presented with suicidal 

ideation. Upon examination, both were observed as being anxious and frightened, but apart from that all other 

vital signs, laboratory tests, and drug screens were unremarkable. The hallucinations/delusions experienced 

by one patient were so severe that she called the police 

and told them that someone was trying to break into her 

home. When the police arrived, the patient had barricaded herself in her bedroom because she thought she 

was about to be killed. She also told police that there 

was a dead body in her hallway, which was also part of 

her hallucination.8

 Of these 6 cases examined, 2 were 

Soldiers stationed at Fort Bragg, North Carolina.7

Spice and bath salts use among active duty military is 

mostly anecdotal. However, there have been several high 

profi le media reports. At the Naval Air Station, Pensacola, Florida, 28 Sailors were involved in incidents with 

spice over a 2-year period.9

 At Hill Air Force Base near 

Salt Lake City, Utah, the US Air Force discharged 7 Airmen in early 2010 for spice use, and another 11 Airmen 

were pending disciplinary action.10 In October 2011, it 

was reported that 64 Sailors were found to have either 

been using or distributing spice, and they were being 

processed for separation from the military.11

Poison control centers in the United States fi elded 304 

calls for bath salt exposures and 2,906 calls for spice 

exposures in 2010.12 In 2011, these increased to 6,138 

closed human exposure calls for bath salts and 6,959 exposure calls for spice. While bath salt calls to poison 

control centers appear to be declining, the number of 

spice related calls continues to increase.12 The distribution of these calls from January 2011 through May 2012 

is presented in the Figure.

Although synthetic cannabinoids do not produce positive 

results in routine urine drug tests for cannabis, it is possible to detect the metabolites in human urine. The Department of Defense Forensic Toxicology Drug Testing 

Laboratories (FTDTL) currently tests urine samples for 

spice and bath salts upon request. A downside to FTDTL 

testing is the approximately 3 weeks required to receive 

results, and the tests are only for known synthetic stimulant metabolites. The FTDTL does not currently test 

for spice and bath salt substances in routine urine drug 

screening due to technological and resource constraints.

The synthetic cannabinoids contained in the various 

spice products have been made illegal in many European countries.13 Responding to similar potential health 

concerns, on March 1, 2011, the US Drug Enforcement 

SYNTHETIC CANNABINOID AND SYNTHETIC CATHINONE USE AMONG US SOLDIERS
 October – December 2012 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

Agency published a fi nal order placing 5 synthetic cannabinoids into Schedule I of the Controlled Substances 

Act (CSA) (21 USC §801). This action was based on a 

fi nding by the Administrator that the placement of these 

synthetic cannabinoids into Schedule I of the CSA was 

necessary to avoid an imminent hazard to the public 

safety. As a result of this order, the full effect of the 

CSA and its implementing regulations including criminal, civil, and administrative penalties, sanctions, and 

regulatory controls of Schedule I substances were imposed on the manufacture, distribution, possession, importation, and exportation of these synthetic cannabinoids. Prior to this announcement, several US states had 

already made them illegal under state law.9

The Food and Drug Administration Safety and Innovation Act (S.3187, Title XI, Sec. 1152), enacted on July 9, 

2012, permanently bans the chemical compounds marketed and sold as bath salts in the United States.

The branches of the US Armed Forces set their own laws 

against these substances. Per Army Regulation 600-85,

14

both spice and bath salts fall in the category of substances that could cause impairment or intoxication, and the 

regulation states that Army personnel are not to use such 

substances. Soldiers may face disciplinary action under 

the Uniform Code of Military Justice (UCMJ)* and/or 

administrative action for using these illicit substances. 

Army Regulation 600-85 prohibits Soldiers from using 

substances:

for the purpose of inducing excitement, intoxication, or 

stupefaction of the central nervous system.14(p24)

These regulations are in place to protect Soldiers and 

to discourage them from jeopardizing their fi tness and 

mental readiness. In addition to spice and bath salts, the 

following substances are also specifi cally prohibited by 

the UCMJ: hemp or products containing hemp oil; controlled substance analogues (designer drugs); chemical 

propellants or inhalants (huffi ng); dietary supplements 

that are banned by the US Food and Drug Administration; prescription or over-the-counter drugs and medications (if illicit or excessive use beyond what is normal, 

suffi cient, or prescribed); and naturally occurring substances (to include but not limited to Salvia divinorium 

and jimson weed).14(pp24-25)

Outside of the use prohibition in Army Regulation 600-

85, the Army implements and enforces bans against 

the possession, distribution, and introduction of these 

products on an installation-by-installation basis. Until 

spice and bath salts were banned,15,16 the promulgation 

of an installation General Order banning the possession, 

use, sale, distribution, or introduction of these products 

was the most common solution to the spice dilemma. 

Fort Bragg, North Carolina, has adopted this policy 

*The Uniform Code of Military Justice (UCMJ), a federal law (64 Stat 109, 10 USC, chap 47) is the judicial code which pertains to 

members of the United States military. Under the UCMJ, military personnel can be charged, tried, and convicted of a range of 

crimes, including both common-law crimes (eg, arson) and military-specific crimes (eg, desertion)

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY

Bath Salts Spice

800

400

600

200

700

300

500

100

0

Calls to poison control centers in the United States for exposure to bath salts or spice, January 2011 through 

May 2012. Source: American Association of Poison Control Centers (bath salts data, synthetic marijuana data); 

http://www.aapcc.org/dnn/NewsandEvents/NewsMediaResources.aspx, accessed June 11, 2012.
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

concerning Soldiers using spice and 

bath salts. Under the Fort Bragg policy, 

Soldiers can be punished for possession 

or transfer of the drugs; they do not 

have to be using the drug to face regulatory action. Violators of the policy 

face punishment under the UCMJ.

METHODS

The target population included all active duty Soldiers presenting to the 

emergency department at Womack 

Army Medical Center, Fort Bragg, 

North Carolina, that reported that they had taken spice, 

bath salts, or were suspected of having ingested these 

drugs between October 2010 and September 2011. Statistical analyses were conducted using IBM SPSS Statistics version 18 (IBM Corporation, Armonk, NY). 

All values were statistically analyzed using frequency 

distributions with calculations of means and standard 

deviations. Continuous variables were assessed for normality of distribution and compared using 2-tailed t

tests. Categorical variables were compared using the χ2

test. Statistical signifi cance was established at a P value 

less than or equal to 0.05. This project was reviewed by 

the Womack Army Medical Center Institutional Review 

Board.

RESULTS

At the time of admission, 155 patients stated that they 

were using an illegal substance or were suspected by a 

provider of using an illegal substance including spice or 

bath salts (Table 1). The majority of patients were male 

(144, 92.3%) and under 30 years of age (mean age=25.6; 

range=20-52). Of the patients that were suspected of using spice or bath salts, 12 (7.7%) tested positive for spice 

and 13 (8.3%) tested positive for bath salts (Table 2).

Rates of spice use were greatest among individuals aged 

19 to 24 (75.0%). Comparatively, rates for bath salts 

use were also greatest among individuals aged 19 to 24 

(69.2%). All patients that tested positive for bath salts or 

spice were male.

Of the 26 admitted patients, 19.2% had used bath salts and 

11.5% had used spice. The majority of bath salt (46.2%) 

and spice patients (58.3%) were sent home and one bath 

salt patient was transferred to a different hospital.

COMMENT

Use of synthetic cannabinoids and synthetic stimulants/

hallucinogens within the Army is a problem that not 

only affects the individual Soldier, but also the Soldier’s 

unit and the Army as a whole. While seeking help for 

substance abuse may have been taboo 

among military personnel in the past, 

great strides have been made to create a better atmosphere for seeking 

assistance.17

Soldiers who use spice and bath salts 

will sometimes present to the ED due 

to the dangerous side effects of these 

substances. There are many medical 

challenges that should be addressed 

concerning these patients. Users tend 

to be panicked, diaphoretic, tachycardic, and/or hyperthermic. The substances may also 

trigger depression, restlessness, suicidal ideation or action, paranoia, or hallucinations. In severe cases, security 

personnel may be required to control the patient prior to 

sedation. It is important to also note that these patients 

may require high doses of sedatives to achieve control. 

Healthcare professionals with a long history in medicine 

and prehospital care may see these users as the modern 

day equivalent of the LSD abusers during the 1960s.

Military installations face many challenges when treating patients who have used spice and bath salts. First, 

only 5 military hospitals have inpatient drug rehabilitation facilities:

 Walter Reed National Military Medical Center, 

Bethesda, Maryland

 Eisenhower Army Medical Center, Fort Gordon, 

Georgia

 Fort Belvoir Community Hospital, Virginia

 Naval Medical Center, San Diego, California

 Malcolm Grow Medical Center, Joint Base Andrews Naval Air Facility, Maryland

Furthermore, military treatment facilities do not routinely perform illegal drug testing unless requested by the 

Soldier’s chain of command. In our study, patients in the 

Emergency Department who are suspected of synthetic drug use are tracked by the Womack Army Medical 

Center Department of Social Work and referred to the 

Department of Behavioral Health.

Unfortunately, there are no published guidelines for 

admission versus discharge. The provider should look 

for and consider potential complications from the sympathomimetic effects such as heat stroke, arrhythmias, 

and seizures. Also, providers should keep in mind that 

even patients without any critical physiologic abnormality can still be combative and agitated with active hallucinations, and may require sedation and observation. 

Physicians should also be aware of chronic issues like 

SYNTHETIC CANNABINOID AND SYNTHETIC CATHINONE USE AMONG US SOLDIERS

Table 1. Patient demographics.

Gender No.

(N=155)

Percentage

Male 144 92.3

Female 12 7.7

Age 

19-24 84 54.2

25-29 54 34.8

30-39 12 7.7

>40 5 3.2

Mean Age=25.59
 October – December 2012 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

insomnia, short-term memory loss, and persistent cognitive changes that can affect these patients. 

Upon discharge, patients are instructed to return to the 

ED if symptoms return or worsen. Also, patients are 

referred to the Army’s Alcohol and Substance Abuse 

Program (ASAP), and are not allowed to drive, handle 

weapons, or perform tasks that require critical thinking 

until they are cleared on a follow-up visit.

It is obvious that opportunities to obtain these drugs of 

abuse are widespread, and unfortunately many Soldiers 

are apparently availing themselves of these opportunities. From past experiences with other 

substance abuse, it is likely that the 

number of Soldiers presenting to the 

emergency department represents a 

minority of the Soldiers using these 

substances. With the apparent increasing opportunity for use and the 

rising number of cases, the military 

must be proactive in curbing this 

trend to maintain combat readiness.

Training, pamphlets, guidebooks, and 

posters are offered through the ASAP to assist commanders, Families, and Soldiers in identifying substance 

abuse problems and risk factors within themselves and 

others. Classes that address stress factors common to 

Soldiers are provided throughout normal duty, as well as 

during and immediately after deployments.

Resources are abundant and can be found online, 

through family readiness groups, and within the chain 

of command. Military OneSource (http://www.militaryonesource.mil) and ASAP are starting points for confi -

dential information and help. Military OneSource offers 

12 free counseling sessions per person, per issue. These 

are confi dential and not reported to the Soldier’s chain 

of command unless he or she presents a danger to himself/herself, or others. 

Little is known about the metabolism and toxicology of synthetic cannabinoid compounds. Furthermore, 

it cannot be assumed that the risks 

associated with the use of synthetic 

cannabinoids are comparable to those 

seen with THC. There is reason for 

concern that these drugs may have a 

greater potential to cause harm. Moreover, because of the lack of information on the synthetic cannabinoid and 

synthetic cathinone experience, dose 

intake, the interaction between other drug consumption, 

and prior psychiatric comorbidity, further studies to reliably assess these risks are warranted.

Table 2. Distribution of patient test 

results.

Detected Drug No.

(N=155)

Percentage

Alcohol 16 10.3

Bath Salts 13 8.3

Benzodiazepines 33 21.2

Cocaine 20 12.8

Spice 12 7.7

THC 26 16.7

Negative 36 23.0

REFERENCES

1. Rosenbaum CD, Carreiro SP, Babu KM. Here today, gone tomorrow...and back again? A review of herbal marijuana 

alternatives (K2, spice), synthetic cathinones (bath salts), kratom, Salvia divinorum, methoxetamine, and piperazines. J Med Toxicol. 2012;8(1):15-32.

2. Huffman JW. CB2 receptor ligands. Mini Rev Med Chem. 2005;5(7):641-649.

3. Dresen S, Ferreirós N, Pütz M, Westphal F, Zimmermann R, Auwärter V. Monitoring of herbal mixtures potentially 

containing synthetic cannabinoids as psychoactive compounds. J Mass Spectrom. 2010;45(10):1186-1194.

4. The European Monitoring Centre for Drugs and Drug Addiction. Understanding the ‘Spice’ phenomenon. 2009. 

Available at: http://www.emcdda.europa.eu/publications/thematic-papers/spice. Accessed April 5, 2012.

5. Zimmermann US, Winkelmann PR, Pilhatsch M, Nees JA, Spanagel R, Schulz K. Withdrawal phenomena and 

dependence syndrome after the consumption of spice gold. Dtsch Arztebl Int. 2009;106(27):464.

6. Simmons J, Cookman L, Kang C, Skinner C. Three cases of “spice” exposure. Clin Toxicol (Phila). 2011;49(5):431-

433.

7. Berry-Cabán CS, Berry CE, Ee J, Ingram V, Kim E. Synthetic cannabinoid overdose in a 20-year-old male US 

soldier. Subst Abus. 2012. In press.

8. Antonowicz JL, Metzger AK, Ramanujam SL. Paranoid psychosis induced by consumption of methylenedioxypyrovalerone: two cases. Gen Hosp Psychiatry. 2011;33(6):640.e5-640.e6.

9. Flor A. Spice-I want a new drug. The Army Lawyer. July 2010:23-25. Available at: http://www.loc.gov/rr/frd/Mili

tary_Law/pdf/07-2010.pdf. Accessed April 5, 2012.

10. Dougherty JM. 7 Hill airmen discharged for spice use. Deseret News. March 27, 2010. Available at: http://www.

deseretnews.com/article/700020576/7-Hill-airmen-discharged-for-spice-use.html. Accessed April 5, 2012.
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

11. Basu S. Air Force gets new instruments to test for synthetic marijuana. US Med. 2012;48(5):1,6

12. American Association of Poison Control Centers. Bath salts data & synthetic marijuana data information pages 

[updated June 8, 2012]. Available at: http://www.aapcc.org/dnn/NewsandEvents/NewsMediaResources.aspx. Accessed June 11, 2012.

13. Möller I, Wintermeyer A, Bender K, et al. Screening for the synthetic cannabinoid JWH-018 and its major metabolites in human doping controls. Drug Test Anal. 2011;3(9):609-620.

14. . Washington, DC: US Dept of the Army; February Army Regulation 600-85: The Army Substance Abuse Program

2, 2009 [December 2, 2009].

15. Chemicals used in “bath salts” now under federal control and regulation; DEA will study whether to permanently 

control three substances [press release]. Washington, DC: US Drug Enforcement Administration; October 21, 2011. 

Available at: http://www.justice.gov/dea/pubs/pressrel/pr102111.html. Accessed April 5, 2012.

16. Chemicals used in “spice” and “K2” type products under federal control and regulation for additional 6 months; 

DEA continues studies to determine whether to permanently control fi ve substances [press release]. Washington, 

DC: US Drug Enforcement Administration; February 29, 2012. Available at: http://www.justice.gov/dea/pubs/pressrel/pr022912.html. Accessed April 5, 2012.

17. McFarling L, D’Angelo M, Drain M, Gibbs DA, Olmsted KLR. Stigma as a barrier to substance abuse and mental 

health treatment. Mil Psychol. 2011;23(1):1-5.

AUTHORS

Dr Berry-Caban is a Clinical Researcher in the Department of Clinical Investigation, Womack Army Medical Center, 

Fort Bragg, North Carolina.

Dr Kleinschmidt is the Education Director, Department of Emergency Medicine, Womack Army Medical Center, Fort 

Bragg, North Carolina.

Dr Rao is a General Medical Offi cer and Clinical Research Associate, Womack Army Medical Center, Fort Bragg, North 

Carolina.

Ms Jenkins is a Clinical Research Coordinator for the Henry M. Jackson Foundation, Womack Army Medical Center, 

Fort Bragg, North Carolina.

SYNTHETIC CANNABINOID AND SYNTHETIC CATHINONE USE AMONG US SOLDIERS

To Order:

www.bordeninstitute.army.mil

Textbooks of Military Medicine

BORDEN

INSTITUTE

UNITED STATES ARMY

OFFICE OF THE SURGEON GENERAL

Under Fire, by Darrold Peters, Digital Oils/ArtRage 2.0, 2006 Art: Courtesy of the US Army Center of Military History

Elspeth Cameron Ritchie, MD, MPH, Colonel (Retired), Medical Corps, US Army

Combat and Operational

Behavioral Health

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0LOLWDU\&KLOGUHQDQG)DPLOLHV2SHUDWLRQDO%HKDYLRUDO+HDOWK2WKHU0LOLWDU\,VVXHV
 October – December 2012 25

Many healthcare providers have received questions regarding barefoot or minimalist shoe running from clients with or without a history of previous injury. In our 

recent review of literature,1

 we noted that little to no 

injury comparisons exist between runners wearing traditional running shoes and those running in minimalist 

footwear.

With annual injury incidence averaging 50% and the 

majority of injuries occurring at the knee,2

 several authors have suggested barefoot or minimalist shoe running as a possible method to reduce injury rates among 

runners.3-6 Rearfoot striking runners in traditional 

shoes contact the ground with a relatively dorsifl exed 

ankle and extended knee. This initial posture causes 

rearfoot strikers to rely heavily on the knee extensors 

to attenuate vertical ground reaction forces using eccentric muscle activation.7

 Increased activation of the knee 

extensors may increase patellofemoral compression 

and tibio-femoral joint loading. Barefoot runners have 

demonstrated a more anterior foot strike with slight 

plantar fl exion and increased knee fl exion,3,8,9 reduced 

initial vertical ground reaction forces,10 reduced stride 

length,9,11 and increased stride frequency9,11 compared 

with rearfoot strikers in traditional shoes. Runners who 

wear minimalist footwear may demonstrate running mechanics similar to those involved in barefoot running,9

or some runners wearing minimalist shoes may still use 

a rearfoot strike pattern.12,13

In an effort to assess injury incidence among foot strike 

patterns and shoe conditions, we developed and implemented an online survey instrument. The purposes of 

this survey were to assess the association of different 

shoe selection with reported foot strike patterns, to 

compare overall injury incidence associated with different shoe conditions and strike patterns, and to identify potential anatomic location differences in injury 

Relationships Among Self-reported Shoe Type,

 Footstrike Pattern, and Injury Incidence

LTC Donald L. Goss, SP, USA

Michael T. Gross, PhD

ABSTRACT

Context: Some runners are experimenting with barefoot or minimalist shoe running to reduce lower extremity 

overuse injuries. However, there has been little research to examine injury trends associated with barefoot or 

minimalist shoe running.

Objective: To assess the association of self-reported shoe selection with reported foot strike patterns, compare 

overall injury incidence associated with different shoe conditions, and identify differences in injury location 

between different shoe conditions.

Design: Retrospective descriptive epidemiology survey.

Methods: We recruited 2,509 runners (1,254 male, 1,255 female) aged 18 to 50 to complete an anonymous online survey. The survey assessed running tendencies, footstrike patterns, shoe preferences, and injury history. 

Reported footstrike patterns were compared among 3 shoe groups: traditionally shod, minimalist shoes, and 

barefoot runners. Overall and specifi c anatomical injury incidence was compared between traditionally shod 

and minimalist shoe-wearing runners. We did not include 1,605 runners in the analyses due to incomplete data 

or recent changes in footstrike patterns and/or shoe selection.

Results: Shoe selection was signifi cantly associated with reported footstrike (χ2

4

=143.4, P< .001). Barefoot and 

minimalist runners reported a more anterior footstrike than traditionally shod runners. Traditionally shod runners were 3.41 times more likely to report injuries than experienced minimalist shoe wearers (46.7% shod vs 

13.7% minimalist, χ2

1

=77.4, P< .001, n=888). Minimalist shoe wearers also reported fewer injuries at the hip, 

knee, lower leg, ankle, and foot than traditionally shod runners.

Conclusion: Barefoot and minimalist shoe wearers reported a more anterior footstrike than traditionally shod 

runners. Traditionally shod runners were more likely to report injuries of the lower extremities than runners who 

wear minimalist shoes. Additional longitudinal prospective research is required to examine injury incidence 

among various footstrike patterns and shoe preferences.
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

proportions between different shoe conditions. We hypothesized that barefoot 

and minimalist shoe runners would 

describe a more anterior foot strike pattern than traditionally shod runners. We 

also expected that experienced minimalist shoe runners would report fewer 

knee injuries and more foot and ankle 

injuries.

METHODS

Subjects

After receiving local approval from the 

institutional review board at our university and a local military facility, we 

recruited 2509 runners (1254 male and 

1255 female) aged 18 to 50 who reported 

running at least 6 miles per week. The 

recruiting was accomplished by posting messages on university, military, 

and local running club listservs; posting fl yers in local fi tness centers; and by 

posting a link to the survey on several 

websites frequently viewed by runners. 

We made an intentional effort to recruit 

additional barefoot and minimalist shoe 

wearing runners to draw conclusions 

based on these groups.

Data Collection

The survey consisted of a maximum of 

41 questions that participants completed based on responses to previous questions. We conducted pilot testing of the survey instrument with 10 physical therapy 

students and 10 military personnel. The mean survey 

completion time was 7 minutes. No questions were 

deemed ambiguous or offensive during pilot testing, so 

the composition of survey questions remained intact. 

We collected the survey data using an anonymous online survey posted on www.surveymonkey.com during 

a 16 month period from September 2010 through December 2011. Only “experienced” runners who reported 

using the same footstrike pattern and shoe condition 

for a minimum of one year were included in the injury 

comparisons.

Data Analysis

We used chi-squared analysis to compare reported 

footstrike proportions among runners wearing traditional shoes, barefoot runners, and runners who reported wearing minimalist shoes. We used chi-squared 

analyses to compare retrospective lower extremity injury incidence rates overall and at each anatomic region 

between runners in traditional and minimalist shoes. We also used chi-squared 

analysis to compare lower extremity 

injury incidence rates among reported 

footstrike groups regardless of shoe selection. We calculated relative risk ratios 

for incidences of lower extremity injuries when chi-squared analyses were signifi cant at the alpha=0.05 level. We also 

used chi-squared analysis to compare 

lower extremity injury incidence rates 

among 3 groups of runners with various 

levels of running experience. Finally, 

we described the proportion of runners 

who reported changing their footstrike 

pattern or shoe preferences over the preceding year. Even though these runners 

were not used in the injury analyses, we 

reported the reasons runners gave for 

making changes in their footstrike pattern or shoe preferences.

RESULTS

Of the 2509 individuals who initiated the 

survey, 2157 (86%) completed the survey. Not all participants answered every 

question. Some questions were skipped 

based on previous responses and some 

were skipped due to participant choice. 

Runners who reported changing their 

footstrike pattern or running shoe preference in the previous 12 months (n=1363) 

were excluded from further analyses. Since a large proportion of our sample reported changing their footstrike 

pattern or shoe preference or both, this reduced the size 

of our sample to 1146 for data analysis. From these runners, 904 completed all of the questions related to injury incidence and reported wearing traditional shoes or 

minimalist shoes, or running barefoot (Figure 1).

Seventy-three percent (662/904) of the participants 

in our survey reported using traditional shoes and not 

changing their footstrike pattern in the previous year, 

25% (226/904) reported wearing minimalist shoes and 

not changing their footstrike pattern in the previous year, 

and only 2% (16/904) reported running barefoot greater 

than 50% of the time and not changing their footstrike 

pattern for over a year. These 904 runners were used 

for comparisons of self-reported footstrike associations 

among shoe conditions. With only 16 primarily barefoot 

runners, we lacked suffi cient statistical power to draw 

injury associations from this group. We examined injury associations between the remaining 888 runners 

wearing traditional and minimalist shoes. We report 

RELATIONSHIPS AMONG SELF-REPORTED SHOE TYPE,

FOOTSTRIKE PATTERN, AND INJURY INCIDENCE

Figure 1. Derivation of analysis sample size (N=904).

Remove 1,363 runners who 

changed their footstrike 

pattern or shoe preferences

during the last year

Remove 102 runners 

who were unsure of their 

running shoe preference 

or footstrike pattern

Remove 140 runners 

who did not complete 

the injury question

2,509 runners

initiated surveys

Remaining 904 

surveys used for injury 

incidence χ2 analyses
 October – December 2012 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

sample sizes for each question because 

sample size varied from question to 

question based on subject qualifi cation 

and participation.

Runners in traditional shoes, minimalist 

shoes, and barefoot runners were similar 

in age, height, and mass. Most barefoot 

runner and runners who wore minimalist shoes were men. More minimalist 

shoe runners reported running faster 

and farther than those in other groups. 

Barefoot runners reported a greater 

number of total years running. Barefoot 

and minimalist shoe runners reported a 

shorter period of time in their current 

shoe condition (Table 1).

Footstrike

Irrespective of shoe type, 31% (280/904) 

of runners in our sample reported using a rearfoot strike, 43% (389/904) a 

midfoot strike, 20% (181/904) a forefoot strike, and 6% (54/904) reported 

being unsure of their footstrike tendencies. Fifty-eight percent (524/904) of runners surveyed 

reported using their preferred strike pattern exclusively. 

Twenty-three percent (208/904) of respondents stated 

that they varied their strike pattern and 19% (172/904) 

were unsure of the variability of their strike pattern.

Shoe Selection

Approximately 73% (662/904) of the runners in this 

sample reported wearing traditional running shoes 

(35.8% stability, 22.2% cushioned, and 15.1% motion 

control). Twenty-fi ve percent (226/904) reported using 

minimalist footwear, and 1.8% (16/904) reported running barefoot greater than 50% of the time. Shoe selection was signifi cantly associated with reported footstrike 

(χ2

4=143.4, P<.001). Barefoot and minimalist runners 

reported a more anterior footstrike than traditionally 

shod runners (Table 2, n=799).

Injuries

We asked runners:

If an injury is defi ned as something that caused you to 

modify your training schedule for at least 1 week due 

to pain or discomfort (with or without formal medical 

care), have you experienced any lower extremity injuries 

in the past 12 months that you believe were caused by 

running?

Runners who reported running greater than 50% of 

their mileage in bare feet represented a small portion 

of our sample (n=16). One third (5/16) of these runners reported wearing shoes for some portion of their 

weekly mileage. The mean length of time these runners 

reported running primarily barefoot in this group was 

25 months ±17 months. Due to the small sample size of 

barefoot runners, we were unable to make any injury 

associations from this group.

Runners wearing traditional shoes were 3.41 times more 

likely to report injuries than experienced minimalist 

shoe wearers (46.7% traditional vs 13.7% minimalist, 

χ2

1

=77.4, P<.001, n=888). Traditional shoe wearers were 

2.64 times more likely to report foot injuries (χ2

1

=10.11, 

P=.001), 2.84 times more likely to report ankle injuries 

(χ2

1

=7.24, P=.007), 3.2 times more likely to report lower leg injuries (χ2

1

=13.62, P<.001), 3.2 times more likely 

to report knee injuries (χ2

1

=19.3, P<.001), and 9.8 times 

more likely to report hip injuries (χ2

1=15.36, P<.001) 

than experienced minimalist shoe runners (Figure 2). 

The mean length of time the experienced minimalist 

Table 1. Demographics of questionnaire respondents.

Shoe

Preference Traditional Shoes Minimalist Shoes Barefoot

Number 662 226 16

Gender Male: 282, 42.6%

Female: 380, 57.4%

Male: 156, 69%

Female: 70, 31%

Male: 12, 75%

Female: 4, 25%

Age 37.2±8.5 years 39.0±8.4 years 37.3±9.0 years

Height 1.74±0.11 m 1.74±0.09 m 1.80±0.08 m

Mass 72.3±13.6 kg 76.5±10.2 kg 76.7±10.1 kg

Years Running 6.4±5.7 years 9.2±8.3 years 12.2±10.5 years

Years in Current 

Shoe Type 4.5±3.7 years 2.1±1.4 years 2.1±1.4 years

Years Using

Current Footstrike 4.2±3.8 years 3.4±3.4 years 2.7±2.4 years

Weekly Mileage

20.3% 6-10 mpw

34.2% 11-20 mpw

25.4% 21-30 mpw

12.5% 31-40 mpw

7.6% >40 mpw

20.8% 6-10 mpw

31.7% 11-20 mpw

24.6% 21-30 mpw

9.5% 31-40 mpw

13.4% >40 mpw

12.5% 6-10 mpw

33.3% 11-20 mpw

29.2% 21-30 mpw

20.8% 31-40 mpw

4.2% >40 mpw

Training Pace

20.7% <6 mph

35.4% 6.1-7 mph

28.2% 7.1-8 mph

11.2% 8.1-9 mph

4.5% >9 mph

12.7% <6 mph

26.5% 6.1-7 mph

33.9% 7.1-8 mph

17.7% 8.1-9 mph

9.2% >9 mph

12.5% <6 mph

45.8% 6.1-7 mph

33.3% 7.1-8 mph

8.3% 8.1-9 mph

0% >9 mph

Descriptive statistics reported as mean±SD.

“mpw” indicates miles per week.

“mph” indicates miles per hour.

Table 2: Associations of shoe type and self-reported 

footstrike.

Shoe Type Reported Footstrike

Rearfoot Midfoot Forefoot

Traditional 240 (41.4%) 266 (45.9%) 74 (12.7%)

Minimalist 12 (5.9%) 99 (48.5%) 93 (45.6%)

Barefoot 0 (0.0%) 9 (60.0%) 6 (40.0%)
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

shoe wearers reported 

wearing these shoes was 

26 months ±16 months. 

Injury incidence associations at the thigh and 

low back demonstrate 

a similar trend as with 

other anatomical regions, 

but chi-shared analyses 

were not statistically signifi cant between groups, 

likely due to a small 

number of reported thigh 

[4] and low back [1] injuries among minimalist 

shoe runners.

We combined shoe preference groups to examine injury incidence rates 

among footstrike groups. 

Runners reporting greater 

than one year of using a rearfoot strike pattern reported 

a one year injury incidence of 52.4%, while experienced 

midfoot strikers 34.7%, and experienced forefoot strikers reported an injury incidence of 22.8% (χ2

2=46.07, 

P<.001, n=881).

Injury incidence rates did not differ between high and 

low mileage groups. Respondents who ran more than 30 

miles per week reported overall injury incidence rates of 

41.4%. Those who reported running fewer than 20 miles 

per week reported injury incidence of 35.9% (χ2

1

=2.02, 

P=.16, n=765, power=0.79 for small effect size, 0.1). 

Injury rates were also similar among reported training 

pace groups.

Since minimalist shoe wearers and barefoot runners reported more overall years running, we conducted a secondary analysis to examine associations between running experience and injury incidence. Running experience was signifi cantly associated with injury incidence 

(χ2

2

=6.17, P=.046, n=721). Runners who reported more 

years experience running reported fewer injuries. Injury 

incidence in runners who reported 1 to 5 years experience with running was 55% (219/398); runners with 6 to 

10 years running experience reported injury incidence of 

48.7% (92/189); 43.3% (58/134) of runners with greater 

than 10 years experience running and reported injuries 

(Table 3).

Reasons for Change of Shoe or Footstrike Preferences

The runners described in this section were not used in 

any of the previous analyses, but we believe it is noteworthy to describe the reasons given for runners’ decisions to change shoe preference or footstrike pattern. 

Approximately 35% (866/2509) of the overall survey respondents reported changing their strike pattern in the 

previous 2 years. Eighty-two percent (707/866) of those 

who changed their footstrike reported formerly being a 

rearfoot striker. Of those who changed their strike pattern, 46% (397/866) did so because of injury. The 397 

runners who changed their footstrike pattern due to injury reported a total of 500 injuries. Fifty-three percent 

of those injuries occurred at the knee among 66% of the 

runners who reported knee injuries (264/397).

Approximately 34% (848/2509) of runners in the overall 

survey reported changing their primary shoe type in the 

last 2 years. Eighty-three percent (702/848) of those who 

changed their primary shoe type had worn traditional 

running shoes previously. Forty-four percent (372/848) 

of runners who changed shoes reported that they did so 

because of injuries. The 372 runners who changed their 

footstrike pattern due to injury reported a total of 411 

injuries. Forty-nine percent of these injuries occurred 

at the knee with 58% of these runners reporting a knee 

injury (214/372).

RELATIONSHIPS AMONG SELF-REPORTED SHOE TYPE,

FOOTSTRIKE PATTERN, AND INJURY INCIDENCE

Table 3. Associations of running experience and injury incidence.

Years Running Injury No Injury

1 to 5 years 219 (55.0%) 179 (45.0%)

6 to 10 years 92 (48.7%) 97 (51.3%)

>10 years 58 (43.3%) 76 (56.7%) Percent Injured

Anatomical Region

Figure 2. Self-reported injury rates by shoe type.
 October – December 2012 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

COMMENT

Little research has been conducted concerning injury 

trends that are associated with barefoot/minimalist 

shoe running or other alternative running styles. We 

hypothesized:

1. Barefoot and minimalist shoe runners would describe a more anterior foot strike pattern than 

traditionally shod runners.

2. Experienced minimalist shoe runners would report fewer knee injuries and a greater incidence 

of foot and ankle injuries.

Our data support our fi rst hypothesis. Reported footstrike pattern was associated with shoe selection. Barefoot and minimalist shoe wearers reported using a more 

anterior footstrike pattern. The second hypothesis was 

partially supported. Experienced minimalist shoe runners reported fewer knee injuries without an increase in 

reported foot and ankle injuries. While we did not form a 

hypothesis concerning overall injury incidence between 

shoe groups, minimalist shoe runners reported fewer injuries. Our results indicate that experienced minimalist 

shoe wearers who have been wearing minimalist shoes 

for more than one year reported fewer injuries at the hip, 

knee, lower leg, ankle, and foot.

While signifi cant associations were observed among reported footstrikes and injury incidence, the accuracy of 

self-reported footstrike has not been documented in the 

literature. Previous authors have reported a predominant prevalence of rearfoot strikers among traditionally 

shod runners.3,14,15 With the recent attention to a more 

anterior footstrike and minimalist shoe selection in the 

popular media after the publication of “Born to Run” by 

Christopher McDougall,5

 many runners have attempted 

to alter their footstrike tendencies or shoe preferences, 

or both. This point is evidenced by the many individuals who reported a change in their footstrike pattern or 

shoe preference in an attempt to reduce injuries, particularly knee injuries. Individual runners may or may not 

be able to report their own foot strike pattern accurately. 

We recently tested 87 runners using an instrumented 

treadmill and observed a self-reported accuracy of 69% 

for runners’ ability to discern between a rearfoot and a 

more anterior footstrike pattern.13 We readily admit that 

this is not excellent reliability, but hopefully it gives the 

reader a sense of context when interpreting our survey 

data.

Another limitation of this survey study is the reliability 

of self-reported shoe type worn by each respondent. In 

an effort to improve this reliability, we did not assess 

injury differences among motion control, stability, or 

cushioned shoe categories. Instead, we have combined 

these 3 groups into a “traditional shoe” category for 

comparisons to runners who wore minimalist shoes and 

to barefoot runners. We believe it is reasonable to assume that these runners knew if they were choosing to 

run barefoot, in a minimalist shoe, or in a traditional 

shoe since the average runner in this sample had been 

running for approximately 8 years. In our own recent 

laboratory sample of 87 runners, we have observed a 

self-reported accuracy of 98% for runners who reported 

wearing either traditional shoes or minimalist shoes.13

The proportions of minimalist runners and anterior foot 

strikers in this study should not be taken as representative of the US population as a whole since running clubs 

consisting of primarily barefoot and minimalist shoe 

runners were specifi cally recruited for participation.

We chose to use self-reported injury data instead of 

medical diagnostic information for its ease of collection 

and because we believe that many runners will simply 

alter their training schedule rather than seek medical attention for minor “overuse” injuries. Runners may report these injuries in a survey, but the injuries may not 

appear in a medical record. While injury surveys are 

commonly published in the literature,16-19 self-reported 

injury data may have limitations relative to the accuracy of the data. We chose to ask about injuries by body 

region and not trust reliability of self-report diagnoses 

(eg, “foot” injury vs plantar fasciitis or metatarsalgia; 

and “knee” injury vs patellofemoral pain syndrome or 

patellar tendonopathy). While this strategy limited the 

amount of information gathered, we believe keeping the 

choice regional and not diagnosis specifi c likely maintained some of the reliability of the self-reported data.

While age did not differ between our groups of traditional shoe and minimalist shoe runners in our sample, 

runners who wore minimalist shoes reported more years 

of running experience. This fact may be a potential confounder and may contribute to the lower injury incidence 

seen in minimalist shoe runners. Runners with more experience may have learned how to avoid injuries better 

than less experienced runners, and/or runners who are 

repeatedly injured over the fi rst several years of running 

may choose to quit running and pursue an alternative 

form of exercise.

In our survey study, shoe selection and reported footstrike pattern were both signifi cantly associated with 

reported injury incidence. We believe reported shoe selection is likely more reliable than reported footstrike 

pattern. These associations are preliminary in nature 

and do not imply cause and effect relationships. It is 

possible that this convenience sample of minimalist 
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

shoe wearing participants is biased and enthusiastic to 

share their experiences. Further research with prospective longitudinal samples is needed to investigate the injury prevention capabilities of alternative running styles 

with validated footstrike patterns compared to traditionally shod rearfoot striking running. For further description of the running mechanics of runners using different running styles, we refer the reader to our previously 

published review article.1

CONCLUSION

Self-reported footstrike pattern was associated with 

shoe selection. Barefoot runners and minimalist shoe 

wearers reported a more anterior footstrike than did traditionally shod runners. Experienced minimalist shoe 

runners reported fewer overall injuries and fewer injuries, specifi cally at the hip, knee, lower leg, ankle, and 

foot than did traditional shoe wearing runners. Runners 

who reported using a more anterior footstrike pattern 

reported fewer injuries than rearfoot striking runners. 

Additional prospective longitudinal research is needed 

to study injury incidence among runners using different 

footstrike patterns and shoe preferences.

ACKNOWLEDGEMENTS

We thank Dr Joseph Myers, Dr Charles Blake, Mr 

Amby Burfoot, Ms Shelly Schmidt, Mr Danny 

Dreyer, and Ms Renee Johnson for their assistance 

with subject recruitment.

REFERENCES

1. Goss DL, Gross MT. A review of the mechanics 

and injury trends among various running styles. 

US Army Med Dept J. 2012;2012(July-Sep.):62-71.

2. van Gent RN, Siem D, van Middelkoop M, van Os 

AG, Bierma-Zeinstra SM, Koes BW. Incidence and 

determinants of lower extremity running injuries 

in long distance runners: a systematic review. Br J 

Sports Med. 2007;41(8):469-480.

3. Lieberman DE, Venkadesan M, Werbel WA, et 

al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 

2010;463(7280):531-535.

4. Dreyer D. Chi Running. Vol 2. New York, NY: Fireside; 2009.

5. McDougall C. Born to Run. New York: Alfred A. 

Knopf; 2009.

6. Robbins S, Gouw GJ, McClaran J, Waked E. Protective sensation of the plantar aspect of the foot. 

Foot Ankle. 1993;14(6):347-352.

7. Arendse RE, Noakes TD, Azevedo LB, Romanov 

N, Schwellnus MP, Fletcher G. Reduced eccentric 

loading of the knee with the pose running method. 

Med Sci Sports Exerc. 2004;36(2):272-277.

8. De Wit B, De Clercq D, Aerts P. Biomechanical 

analysis of the stance phase during barefoot and 

shod running. J Biomech. 2000;33(3):269-278.

9. Squadrone R, Gallozzi C. Biomechanical and physiological comparison of barefoot and two shod conditions in experienced barefoot runners. J Sports 

Med Phys Fitness. 2009;49(1):6-13.

10. Divert C, Mornieux G, Baur H, Mayer F, Belli A. 

Mechanical comparison of barefoot and shod running. Int J Sports Med. 2005;26(7):593-598.

11. Divert C, Mornieux G, Freychat P, Baly L, Mayer F, 

Belli A. Barefoot-shod running differences: shoe or 

mass effect?. Int J Sports Med. 2008;29(6):512-518.

12. McCarthy C, Porcari JP, Kernozek T, Willson J, 

Foster C. Like barefoot, only better?. ACE Certifi ed News. 2011;September 2011:8-12.

13. Goss DL. A Comparison of Lower Extremity Joint 

Work and Initial Loading Rates among Four Different Running Styles [dissertation]. Chapel Hill, 

North Carolina: Dept of Allied Health, University 

of North Carolina; 2012.

14. Hasegawa H, Yamauchi T, Kraemer WJ. Foot 

strike patterns of runners at the 15-km point during an elite-level half marathon. J Strength Cond 

Res. 2007;21(3):888-893.

15. Larson P, Higgins E, Kaminski J, et al. Foot 

strike patterns of recreational and sub-elite runners in a long-distance road race. J Sports Sci. 

2011;29(15):1665-1673.

16. Marti B, Vader JP, Minder CE, Abelin T. On the 

epidemiology of running injuries. The 1984 Bern 

Grand-Prix study. Am J Sports Med. 1988;16(3):285-

294.

17. McKean KA, Manson NA, Stanish WD. Musculoskeletal injury in the masters runners. Clin J Sport 

Med. 2006;16(2):149-154.

18. RunningUSA Inc. Road Running Information Center Annual Marathon Report [2009]. RunningUSA.

org Web site. Available at: http://www.runningusa.

org/node/16414. Accessed February 16, 2012.

19. Taunton JE, Ryan MB, Clement DB, McKenzie DC, 

Lloyd-Smith DR, Zumbo BD. A prospective study 

of running injuries: the Vancouver sun run “in training” clinics. Br J Sports Med. 2003;37(3):239-244.

AUTHORS

LTC Goss is an Assistant Professor, US Army/Baylor 

University Doctoral Program in Physical Therapy, Fort 

Sam Houston, Texas.

Dr Gross is a Professor, Program in Human Movement 

Science, Division of Physical Therapy, University of 

North Carolina, Chapel Hill, North Carolina.

RELATIONSHIPS AMONG SELF-REPORTED SHOE TYPE,

FOOTSTRIKE PATTERN, AND INJURY INCIDENCE
 October – December 2012 31

Trauma represents the leading cause of morbidity and 

mortality in all populations with uncontrolled hemorrhage as the major cause of complications and death.1-6

Historically, 20% of combat casualties were killed in action. Ninety percent of those casualties never reached 

a fi eld hospital with hemorrhage as the major cause of 

death.5

 In Vietnam, almost 40% of Soldiers who died 

of exsanguination had a source of bleeding that could 

possibly have been controlled by a hemostatic agent.6

Uncontrolled hemorrhage accounts for almost 50% of 

the battlefi eld deaths prior to evacuation in the more recent confl icts of Iraq and Afghanistan.3

If trauma victims survive the initial blood loss and injury, they are prone to hypothermia, coagulopathy, acidosis, infection, and multiple organ failure. These complications result in an increase in morbidity and mortality 

even after successful resuscitation.1,2,7-9 Therefore, rapid 

hemostasis and control of bleeding is not only essential 

for initial survival, but also for optimal recovery.

Several hemostatic agents have been investigated in 

multiple animal models over the past decade with mixed 

and inconclusive results.7,10-26 The purpose of this study 

was to examine the effectiveness of the hemostatic agent 

BleedArrest (Hemostasis LLC, Saint Paul, MN). The 

mechanism of action of BleedArrest is based on the absorbance of plasma by amylopectin, a plant-based starch. 

The result is the concentration of platelets and coagulation factors at the site of injury supporting the formation of a robust clot. The research question guiding this 

study was: Is there a statistically signifi cant difference 

in the amount of bleeding between BleedArrest and the 

control group?

MATERIALS AND METHODS

This study was a within and between subjects experimental design employing an established porcine model 

of uncontrolled hemorrhage. The research protocol was 

approved by the Institutional Animal Care and Use Committee. The animals received care in accordance with the 

Animal Welfare Act and The Guide for the Care and Use 

of Laboratory Animals. Twenty male Yorkshire swine 

weighing between 70 kg and 89 kg were randomly assigned (n=10 per group) to one of 2 groups, BleedArrest or the control group. The rationale for using swine 

of this size was that they represent the average weight 

of the US Army Soldier.27 The swine were observed for 

3 days to ensure a good state of health, fed a standard 

diet, and were NPO [no food or water] after midnight 

the day of the experiment. This study was conducted in 

4 phases: induction/stabilization, hemorrhage, hemostasis, and blood loss.

INDUCTION/STABILIZATION PHASE

The induction phase started with an intramuscular injection of ketamine (20 mg/kg) and atropine (0.04 mg/kg). 

Subjects were placed supine on a litter and transported 

to an operating room followed by inhaled isofl urane (4% 

to 5%). After placement of an endotracheal tube, a peripheral IV catheter was inserted and the isofl urane concentration was reduced to 1% to 2% for the remainder 

The Effects of BleedArrest on Hemorrhage

 Control in a Porcine Model

Brian Gegel, MSN, CRNA

James Burgert, MSNA, CRNA

LTC Michael Loughren, AN, USA

Don Johnson, PhD

ABSTRACT

The purpose of this study was to examine the effectiveness of the hemostatic agent BleedArrest compared to 

control. This was a prospective, experimental design employing an established porcine model of uncontrolled 

hemorrhage. The minimum number of animals (n=10 per group) was used to obtain a statistically valid 

result. There were no statistically signifi cant differences between the groups (P>.05) indicating that the 

groups were equivalent on the following parameters: activating clotting time, the subject weights, core body 

temperatures, amount of one minute hemorrhage, arterial blood pressures, and the amount and percentage of 

total blood volume. There were signifi cant differences in the amount of hemorrhage (P=.033) between the 

BleedArrest (mean=72, SD±72 mL) and control (mean=317.30, SD±112.02 mL). BleedArrest is statistically 

and clinically superior at controlling hemorrhage compared to the standard pressure dressing control group. In 

conclusion, BleedArrest is an effective hemostatic agent for use in civilian and military trauma management.
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

of the experiment. The swine were ventilated with a 

standard Narkomed anesthesia machine (Dräger, Telford, PA). Heart rate, electrocardiography, blood pressure, oxygen saturation, end-tidal carbon dioxide, and 

rectal temperatures were continuously monitored for 

the remainder of the experiment. A Thermal Industries 

of Florida (TIF) scale, Model 9010A, (SPX Service Solutions, Owatonna, MN) was placed between the litter 

and operating room table. The TIF scale is an electronic scale that measures pressure applied in pounds per 

square inch and is precise within 0.5 oz and accurate 

within 0.5%. The scale was zeroed per manufacturer’s 

instructions. While manual pressure was applied to the 

wound during the experiment, the scale was observed to 

ensure pressure was maintained at 25 psi within ±0.5 oz 

to ensure continuity from subject to subject.

The left carotid artery was cannulated with a 20 guage 

(Ga) angio-catheter using a cut down technique. A 

central venous catheter was inserted using a modifi ed 

Seldinger technique for fl uid volume management and 

blood sampling. The catheters were attached to a hemodynamic monitoring system (Hewlett Packard, Palo 

Alto, CA) for continuous monitoring of the arterial blood 

pressures. All catheters were continuously fl ushed with 

0.9% saline solution (5 mL per hour) to maintain patency. Following line placement, the NPO fl uid defi cit 

was corrected with 0.9% normal saline, per the Holliday-Segar formula. The investigators used an activated 

clotting time (ACT) test to screen all subjects for coagulopathy prior to procedures. The upper limit in this 

study for all subjects was an ACT less than 150 seconds. 

Subjects were further monitored for 30 minutes to ensure hemodynamic stability prior to intervention. Body 

temperature was monitored via a rectal probe and maintained at greater than 36.0°C using a forced-air warming 

blanket. A complex groin injury as described by Alam 

and colleagues was generated to simulate a penetrating 

injury.12,13 The injury included dissection of the proximal thigh soft tissues including the skin, quadriceps, 

and adductor muscles to expose the femoral artery and 

vein just below the inguinal ligament. All subjects were 

hemodynamically stable prior to intervention.

HEMORRHAGE PHASE

Following the 30-minute stabilization period, the exposed femoral artery and vein were transected with a 

scalpel blade. The swine were allowed to hemorrhage 

for one minute simulating the response time of a battlefi eld health care provider. Blood was collected by gauze, 

absorbent pads underneath the animals, and in a suction 

canister by use of a suction tip catheter placed in the 

distal portion of the wound.

HEMOSTASIS PHASE

After one minute of hemorrhage, proximal pressure was 

applied to the transected femoral vessels, and 4 in by 4 

in gauze was used to blot the blood from the wound per 

the hemostatic agent manufacturer’s guidelines. At this 

time, the hemostatic agent was poured into the wound 

followed by standard wound packing including a layer 

of petroleum gauze and roller gauze (Kerlix, Covidien, 

Mansfi eld, MA). The control group received proximal 

pressure and standard wound packing. Firm manual 

pressure of 25 psi was applied for 5 minutes to the injury site as measured by the TIF scale.28 After 5 minutes, all groups received a pressure dressing of rolled 

gauze and a 10-pound sandbag. This dressing was left in 

place for 30 minutes. 500 mL of 6% Hextend in lactated 

ringer’s solution (Hospira, Inc., Lake Forest, IL) IV was 

administered to all subjects in accordance with current 

battlefi eld resuscitation protocol recommended by the 

Committee on Tactical Combat Casualty Care.29

BLOOD LOSS PHASE

After 35 minutes of pressure on the wound (5 minutes 

manual pressure plus 30 minutes with the pressure 

dressing), the standard pressure dressing was removed 

being careful to keep the clot intact. The rationale for 

using the petroleum gauze was that it allowed removal 

of the pressure dressing with minimal clot disruption. 

For the purposes of this study, hemostasis was defi ned 

as a clot formation with oozing of no more than 2% of 

the swine’s total blood volume over a 5-minute period 

(approximately 100 mL in a 70 kg pig). Blood loss was 

measured over 2 time periods: the initial injury to intervention and postintervention to the completion of the 

study. Blood loss was calculated by weighing the dressings, the absorbent pads underneath the animals, and 

blood suctioned from the distal portion of the wound 

before and after transection of the femoral vessels.

RESULTS AND COMMENT

The minimum number of animals was used to obtain a 

statistically valid result. A large effect size was determined for this experiment based upon previous work by 

Alam and Pusateri.7,13,19,30 Using G-Power 3.00 for Windows (Institut Für Experimentelle Psychologie, Dusseldorf, FRG), an effect size of 0.6, a power of 0.80, and 

an alpha of 0.05, it was determined that a sample size 

of 10 swine per group was needed for this study. Investigators evaluated coagulation studies with all subjects. 

There were no statistically signifi cant differences between the groups in reference to the amount of initial 

bleeding after one minute (P=.533): BleedArrest group 

ranged from 492 to 1569 mL (mean=789.22, SD±121.60 

THE EFFECTS OF BLEEDARREST ON HEMORRHAGE CONTROL IN A PORCINE MODEL
 October – December 2012 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

mL) and control group ranged from 100 to 992 mL 

(mean=601.50, SD±84.03 mL). The body weights, core 

body temperatures, amount of blood volume, and the 

amount of the initial one minute hemorrhage were analyzed using a multivariate analysis of variance. There 

were no statistically signifi cant differences between the 

groups (P>.05) indicating that the groups were equivalent on these parameters. Blood loss after 35 minutes of 

pressure on the wound (manual pressure and pressure 

dressing) was calculated for each group over a fi ve minute observation period following removal of dressings 

and exposure of the formed clot. The amount of bleeding 

BleedArrest group ranged from 0 to 648 mL (mean=72, 

SD±72 mL) and control group ranged from 0 to 1002 

mL (mean=317.30, SD±112.02 mL). A repeated analysis 

of variance test was used to analyze the data, the one 

minute and 5 minute hemorrhage postintervention, and 

indicated a signifi cant difference between the BleedArrest and control groups (P=.033). The results are summarized in the Figure.

The US Army’s goal is for each Soldier to carry a hemostatic agent, but research should be conducted to determine the most effi cacious and cost effective agent. In 

addition, many civilian disaster teams and fi rst responders are exploring the potential for hemostatic agent use 

in the prehospital setting. Pusateri outlined the ideal 

qualities of hemostatic agents for civilian and military 

use. These include (1) the ability to rapidly stop large 

vessel arterial and venous bleeding within 2 minutes of 

application when applied to an actively bleeding wound 

through a pool of blood; (2) no requirement for mixing or 

preapplication preparation; (3) simplicity of application 

by wounded victim, buddy, or medic; (4) lightweight and 

durable; (5) long shelf life in extreme environments; (6) 

safe to use with no risk of injury to tissues or transmission of infection; and (7) inexpensive.31 This study compared BleedArrest against a standard pressure dressing 

control in a porcine model of uncontrolled hemorrhage. 

A complex groin injury was generated simulating penetrating trauma in an anatomical area not protected by 

conventional body armor or amenable to use of a tourniquet. The hemostatic agent BleedArrest rapidly controlled arterial and venous bleeding. It was statistically 

and clinically superior at controlling hemorrhage compared to the standard pressure dressing control group. 

BleedArrest is packaged in a 250 g easy-to-open envelope. The investigators used enough of the hemostatic 

agent, mean weight of 24.3 g, to completely fi ll the groin 

injury cavity. Standard packaging of the agent in small 

waterproof packets would allow it to be easily carried 

by Soldiers, medics, and other healthcare providers in 

pockets, backpacks, or medic bags. BleedArrest has a 

shelf life of 3 years and is approved by the Federal Drug 

Administration (FDA). Investigators noted that the agent 

did not produce any exothermic reaction when applied 

to the wound, there were no obvious signs of tissue damage, and does not carry a risk of infection.This hemostatic agent is relatively inexpensive, costing less than 

$30.00 for a single application.32

CONCLUSION

BleedArrest was statistically and clinically superior at 

controlling hemorrhage compared to the standard pressure dressing control group. This hemostatic agent is 

simple to use, lightweight, demonstrates no known risk 

of tissue injury, has a long shelf life with FDA approval, 

and isrelatively inexpensive.Based on this study and the 

requirements outlined by Pusateri, BleedArrest is an effective hemostatic agent for use in the management of 

hemorrhage and trauma.

ACKNOWLEDGEMENTS

This research was sponsored by the TriService Nursing 

Research Program, Uniformed Services University of 

the Health Sciences. However, the information or content and conclusions do not necessarily represent the offi cial position or policy of, nor should there be any inference of offi cial endorsement by the TriService Nursing 

Research Program, Uniformed Services University of 

the Health Sciences, the Department of Defense, or the 

US Government.

The investigators acknowledge the following students 

in the US Army Graduate Program in Anesthesia who 

participated in the study:

Amount of bleeding (in mL) by group and time.
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

MAJ Travis Hawksley, AN, USA

MAJ Matthew Ruemmler, AN, USA

CPT Chris Angeles, AN, USA

CPT Frances Bradley, AN, USA

CPT William Corona, AN, USA

CPT Alenka Vale-Dominguez, AN, USA

1LT Elizabeth Hawksley, AN, USA

REFERENCES

1. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 

1995;38(2):185-193.

2. Sauaia A, Moore FA, Moore EE, Haenel JB, Read 

RA, Lezotte DC. Early predictors of postinjury multiple organ failure. Arch Surg. 1994;129(1):39-45.

3. Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A profi le of combat injury. J Trauma. 

2003;54(suppl 5):S13-S19.

4. Asensio JA, Petrone P, O’Shanahan G, Kuncir EJ. 

Managing exsanguination: what we know about 

damage control/bailout is not enough. Proc (Bayl 

Univ Med Cent). 2003;16(3):294-296.

5. Bellamy RF. The causes of death in conventional 

land warfare: implications for combat casualty care 

research. Mil Med. 1984;149(2):55-62.

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

States Army rangers in Somalia: an analysis of 

combat casualties on an urban battlefi eld. J Trauma. 

2000;49(3):515-529.

7. Alam HB, Burris D, DaCorta JA, Rhee P. Hemorrhage control in the battlefi eld: Role of new hemostatic agents. Mil Med. 2005;170(1):63-69.

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

M, Burch JM, Galloway B. Predicting life-threatening coagulopathy in the massively transfused 

trauma patient: hypothermia and acidoses revisited. 

J Trauma. 1997;42(5):857-862.

9. Heckbert SR, Vedder NB, Hoffman W, et al. Outcome after hemorrhagic shock in trauma patients. J 

Trauma. 1998;45(3):545-549.

10. Pusateri AE, Holcomb JB, Kheirabadi BS, Alam 

HB, Wade CE, Ryan KL. Making sense of the preclinical literature on advanced hemostatic products. 

J Trauma. 2006;60(3):674-682.

11. Sondeen JL, Coppes VG, Holcomb JB. Blood 

pressure at which rebleeding occurs after resuscitation in swine with aortic injury. J Trauma. 

2003;54(Suppl 5):S110-S117.

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

a zeolite hemostatic agent achieves 100% survival 

in a lethal model of complex groin injury in swine. 

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

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

analysis of hemostatic agents in a swine model 

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

1082.

14. Acheson EM, Kheirabadi BS, Deguzman R, Dick 

EJ,Jr, Holcomb JB. Comparison of hemorrhage 

control agents applied to lethal extremity arterial 

hemorrhages in swine. J Trauma. 2005;59(4):865-

875.

15. Kozen BG, Kircher SJ, Henao J, Godinez FS, Johnson AS. An alternative hemostatic dressing: Comparison of CELOX, HemCon, and QuikClot. Acad 

Emerg Med. 2008;15(1):74-81.

16. Gegel B, Burgert J, Cooley B, et al. The effects 

of BleedArrest, celox, and TraumaDex on hemorrhage control in a porcine model. J Surg Res. 

2010;164(1):e125-e129.

17. Gegel BT, Burgert JM, Lockhart C, et al. Effects of 

celox and TraumaDEX on hemorrhage control in a 

porcine model. AANA J. 2010;78(2):115-120.

18. Jewelewicz DD, Cohn SM, Crookes BA, Proctor 

KG. Modifi ed rapid deployment hemostat bandage reduces blood loss and mortality in coagulopathic pigs with severe liver injury. J Trauma. 

2003;55(2):275-281.

19. Pusateri AE, Modrow HE, Harris RA, et al. Advanced hemostatic dressing development program: 

animal model selection criteria and results of a 

study of nine hemostatic dressings in a model of 

severe large venous hemorrhage and hepatic injury 

in swine. J Trauma. 2003;55(3):518-526.

20. Littlejohn LF, Devlin JJ, Kircher SS, Lueken R, 

Melia MR, Johnson AS. Comparison of celox-A, 

ChitoFlex, WoundStat, and combat gauze hemostatic agents versus standard gauze dressing in control of hemorrhage in a swine model of penetrating 

trauma. Acad Emerg Med. 2011;18(4):340-350.

21. Kheirabadi BS. Evaluation of topical hemostatic 

agents for combat wound treatment. US Army Med 

Dep J. April-June 2011:25-37.

22. Kheirabadi BS, Acheson EM, Deguzman R, et al. 

Hemostatic effi cacy of two advanced dressings in 

an aortic hemorrhage model in swine. J Trauma. 

2005;59(1):25-34; discussion 34-35.

23. Kheirabadi BS, Arnaud F, McCarron R, et al. Development of a standard swine hemorrhage model 

for effi cacy assessment of topical hemostatic agents. 

J Trauma. 2011;71(suppl):S139-S146.

THE EFFECTS OF BLEEDARREST ON HEMORRHAGE CONTROL IN A PORCINE MODEL
 October – December 2012 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

24. Kheirabadi BS, Edens JW, Terrazas IB, et al. Comparison of new hemostatic granules/powders with 

currently deployed hemostatic products in a lethal 

model of extremity arterial hemorrhage in swine. J 

Trauma. 2009;66(2):316-328.

25. Kheirabadi BS, Scherer MR, Estep JS, Dubick MA, 

Holcomb JB. Determination of effi cacy of new hemostatic dressings in a model of extremity arterial 

hemorrhage in swine. J Trauma. 2009;67(3):450-

460.

26. Samudrala S. Topical hemostatic agents in surgery: 

A surgeon’s perspective. AORN J. 2008;88(3):S2-

S11.

27. The 1988 US Army Anthropometry Survey [database online]. http://ioe.engin.umich.edu/ioe491/

AthroData.html. Accessed 01/2012.

28. Operating Instructions, TIF9010 Certifi ed Weight 

Scale. Miami, FL: TIF Instruments, Inc. Available 

at: www.tequipment.net/pdf/TIF/TIF9010C.pdf. 

Accessed January 2012.

29. Tactical combat casualty care page [updated 2010]. 

US Military Health System Website. Available at: 

http://www.health.mil/Education_And_Training/

TCCC.aspx. Accessed January 2012.

30. Pusateri AE, Delgado AV, Dick EJ Jr, Martinez RS, 

Holcomb JB, Ryan KL. Application of a granular 

mineral-based hemostatic agent (QuikClot) to reduce blood loss after grade V liver injury in swine. 

J Trauma. 2004;57(3):555-562.

31. Pusateri AE, McCarthy SJ, Gregory KW, et al. Effect of a chitosan-based hemostatic dressing on 

blood loss and survival in a model of severe venous 

hemorrhage and hepatic injury in swine. J Trauma. 

2003;54(1):177-182.

32. BleedArrest Website. St Paul, MN: Hemostasis 

LLC. Available at: http://www.bleedarrest.com/

index.html. Accessed January 2012.

AUTHORS

Mr Gegel is co-owner of Veteran Anesthesia Services, 

PLLC, San Antonio, Texas.

Mr Burgert is a member of the Adjunct Clinical Faculty, 

Brooke Army Medical Center, Fort Sam Houston, Texas.

LTC Loughren is a member of the Faculty of the US 

Army Graduate Program in Anesthesia Nursing, Fort 

Sam Houston, Texas.

Dr Johnson is Director of Research of the US Army 

Graduate Program in Anesthesia, Fort Sam Houston, 

Texas.

Pediatric SURGERY & MEDICINE 

For Hostile Environments

Senior Editors:

Michael M. Fuenfer, MD and Kevin M. Creamer, MD

Resuscitation & Critical Care Medicine Surgery

Winner of 2011 Special Recognition Award from the American Medical Writers Association

To order: www.bordeninstitute.army.mil

BORDEN

INSTITUTE

UNITED STATES ARMY

OFFICE OF THE SURGEON GENERAL
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

Historically, approximately 20% of combat causalties 

were killed in action with hemorrhage as the major 

cause of death.1

 Uncontrollable hemorrhage accounts for 

50% of the battlefi eld deaths before evacuation in both 

Iraq and Afghanistan.1-3 Hemorrhage control and resuscitation are the top priorities in trauma care.4

 Uncontrolled hemorrhage is the leading cause of preventable 

death, not only in military, but also civilian trauma.4-7

Some clinicians recommend the administration of one 

to 2 liters of crystalloid fl uid resuscitation for patients in 

hypovolemic shock. Fluid resuscitation has the metabolic benefi t of replenishing the oxygen debt accumulated 

during hemorrhage.8

 However, resuscitation with intravenous fl uid may result in dislodging newly developed 

clots and hemorrhage. As rebleeding is a real potential 

because of resuscitation, the Committee on Tactical 

Combat Casualty Care advocates permissive hypotension, specifi cally low volume resuscitation, to keep the 

casualty alive with a palpable pulse or consciousness. 

In addition, they recommend that if there is a palpable 

radial pulse, no resuscitation fl uids should be administered until there is defi nitive hemorrhage control.9

Hemostatic agents may be effective in stopping bleeding but fail during resuscitation.5,9-13 It is theorized that 

the bleeding results from 2 reasons: hemodilution and 

an increased blood pressure which in turn dislodges a 

fragile clot.5,9-13 This was the fi rst study to investigate 

the effects of hemodilution on rebleeding when a hemostatic agent, QuikClot Combat Gauze (QCG), is used to 

control bleeding. The purpose of this study was to investigate the effects of QCG on rebleeding in a Class II 

hemorrhage in the presence of hemodilution in a lethal 

femoral injury. The research question that guided the 

study was: Is there a statistically signifi cant difference 

between the QCG group and the control group in hemorrhage after hemodilution?

The Effects of QuikClot Combat Gauze on

 Hemorrhage Control in the Presence of

 Hemodilution

 Don Johnson, PhD James Burgert, MSNA, CRNA

 CPT Samantha Agee, AN, USA John Gasko, DNP, CRNA

 CPT Amanda Reed, AN, USA LTC Michael Loughren, AN, USA

 Brian Gegel, MSN, CRNA

ABSTRACT

Introduction: Although hemostatic agents may be effective at stopping hemorrhage, they may fail because of hemodilution from intravenous fl uids. The purpose of this study was to investigate the effects of QuikClot Combat 

Gauze (QCG) on rebleeding in a class II hemorrhage in the presence of hemodilution in a lethal femoral injury.

Methods: This was a prospective experimental, between swine subjects design. Pigs were assigned to one of two 

groups: QCG (n=15) or control (n=15). Thirty percent of the pig’s blood was exsanguinated and then a 3:1 ratio of 

ringers lactate was administered. A groin injury was created by transecting the femoral artery and vein to simulate 

a battlefi eld injury and allowed to bleed for one minute. After one minute of hemorrhage, proximal pressure was 

applied to the injury, and QCG was placed into the wound followed by standard wound packing. The control group 

underwent the same procedures with the exception of the hemostatic agent. For both groups, 5 minutes of direct 

pressure was applied to the wound followed by a standard pressure dressing. Dressings were removed after 30 

minutes, and the amount of hemorrhage was calculated in milliliters for each group for a period of 5 minutes. An 

activated clotting time was used to exclude any pigs with coagulation pathology.

Results: A multivariate analysis of variance indicated that there were no signifi cant differences in the groups relative 

to weight, amount of one minute hemorrhage, fl uid defi cit replacement, blood volume, and the activated clotting time 

(P>.05) indicating that the groups were equivalent on these parameters. A t test indicated that there was signifi cantly 

less bleeding (P=.002) in the QCG group (36 mL±112 mL) compared to the control group (340 mL±297 ml).

Conclusion: QCG produces a robust clot that can more effectively tolerate hemodilution compared to a control 

group.

DISCLAIMER: This research was sponsored by the TriService Nursing Research Program, Uniformed Services University 

of the Health Sciences (USUHS). The information or content and conclusions do not necessarily represent the offi cial position or policy of, nor should there be any inference of offi cial endorsement by the TriService Nursing Research Program, 

USUHS, the Department of Defense, or the US Government.
 October – December 2012 37

BACKGROUND

Hemostatic agents have been investigated in multiple 

animal studies, including liver and complex groin injuries. These studies have produced inconsistent and 

mixed results regarding the effectiveness of hemostatic 

agents in controlling hemorrhage, indicating the need 

for additional investigation.11,14-21 Hemostatic agents may 

be effective at the time of use, however, rebleeding may 

occur with resuscitation. Several investigators have emphasized the metabolic benefi ts of fl uid resuscitation, 

however, the benefi ts must be weighed against the deleterious effects of rebleeding leading to death.7,13

Two agents that were widely used by the military, QuikClot (Z-Medica, Wallingford, CT) and WoundStat 

(TraumaCure, Bethesda, MD), have been removed from 

the US military inventory because of potential complications, specifi cally thermal tissue injury to patient and 

provider and microemboli formation.16,20 Hemostatic 

agents have evolved from fi rst generation granular or 

fi ne powders to second generation wafers and sponges. 

The newest agents are gauze dressings impregnated with 

a hemostatic agent designed to simplify application and 

decrease complications.

QCG is a rayon/polyester gauze impregnated with kaolin, a white aluminosilicate inert mineral. Kaolin promotes clotting by activation of factor XII, which in turn 

initiates the intrinsic clotting pathway via the activation 

of factor XI that ends with the formation of a fi brin clot. 

In addition, Kaolin promotes the activation of platelet 

associated factor XI which initiates the intrinsic clotting pathway in normal and factor XII defi cient patients. 

There are limited data demonstrating the effectiveness 

of the QCG and no studies evaluating the effectiveness 

of the agent in the presence of hemodilution.

MATERIALS AND METHODS

This study was a prospective, between subjects, experimental design using a porcine model. The protocol 

was approved by the Institutional Animal Care and Use 

Committee at the University of Texas Health Science 

Center, San Antonio, TX. The animals received care 

in compliance with the Animal Welfare Act, the Guide 

for the Use of Laboratory Animals, and the protocols 

of the University of Texas Health Science Center. Thirty Yorkshire swine weighing between 70 kg and 89 kg 

were randomly assigned (n=15 per group) to one of 2 

groups, the QCG group or the control group. Swine of 

this size were used to represent the average weight of 

the US Army Soldier.19 The swine were observed for at 

least 3 days to ensure good state of health, fed a standard 

diet, and remained NPO [no fl uid or food] after midnight 

the day of the experiment. Anesthesia was induced with 

an intramuscular injection of ketamine (20 mg/kg) and 

atropine (0.04 mg/kg), followed by inhaled isofl urane 

(4% to 5%). After placement of an endotracheal tube, 

the investigators inserted a peripheral intravenous catheter, and the isofl urane concentration was reduced to between 1% and 2% for the remainder of the experiment. 

The animals were ventilated (tidal volume 8-10 mL/kg) 

with a standard Narkomed anesthesia machine (Dräger, 

Telford, PA) and continuously monitored for the remainder of the experiment with the following standard monitors: heart rate, electrocardiography, blood pressure, 

oxygen saturation, end-tidal carbon dioxide, and rectal 

temperatures. Body temperature was maintained greater 

than 36.0°C. When necessary, the investigators used a 

forced-air warming blanket. A Thermal Industries of 

Florida (TIF) scale, Model 9010A, (SPX Service Solutions, Owatonna, MN) was placed between the litter and 

operating room table. The TIF scale is an electronic scale 

that measures pressure applied in pounds per square 

inch and is precise within 0.5 oz and accurate within 

0.5%. The scale was zeroed per manufacturer’s instructions. While manual pressure was applied to the wound 

during the experiment, the scale was observed to ensure 

pressure was maintained at 25 psi within ±0.5 oz to ensure continuity from subject to subject. The right carotid 

artery was cannulated with a 20 gauge angio-catheter 

using a cut down technique. A right triple-lumen central 

venous catheter was inserted using a modifi ed Seldinger 

technique for central venous pressure monitoring, fl uid 

volume management, and blood sampling. The catheters 

were attached to a hemodynamic monitoring system 

(Hewlett Packard, Paolo Alto, CA) for continuous monitoring of the arterial and central venous pressures. All 

of the catheters were continuously fl ushed with 0.9% 

saline solution (5 mL per hour) to maintain patency. Following line placement, the NPO fl uid defi cit replacement 

was initiated with Normal Saline per the 4-2-1 method 

(Segar Holliday formula). The investigators used an activated clotting time (ACT) test to screen all subjects 

for coagulopathy prior to procedures. The upper limit 

in this study for all subjects was an ACT less than 150 

seconds. All subjects were within this parameter.

An injury was made in one groin. The injury included 

dissection of the proximal thigh soft tissues (skin, quadriceps, and adductor muscles) to the femoral artery and 

vein without transection just below the inguinal ligament 

within the femoral crease. Subjects were then monitored 

for 30 minutes to ensure hemodynamic stability during 

which time the replacement of NPO fl uid defi cits were 

conducted. After the NPO defi cit was replaced, 30% of 

the animal’s blood volume was removed from the central 

line. A 3:1 replacement of Lactated Ringer’s was administered to replace the blood lost via the central line to 
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

dilute the blood. For example, if a pig weighed 70 kg, the 

blood volume was 4,900 mL; 30% exsanguination was 

1,470 mL; and the replacement was 4,410 mL. All subjects were stable prior to intervention. Following the stabilization period, a scalpel was used to simultaneously 

transect the femoral artery and vein. The animals were 

allowed to hemorrhage for one minute, simulating the response time of a combat life saver, medic, or health care 

provider. Blood was collected from the wound by use of 

a suction catheter placed distal to the transected vessels. 

After one minute of hemorrhage, the wound was packed 

with petroleum impregnated gauze and either standard 

gauze or QCG according to the group the animal was 

assigned. Pressure was applied to the injury and 4 in by 

4 in gauze was used to blot the blood from the wound 

per hemostatic agent manufacturer’s guidelines. Twentyfi ve psi of pressure was measured by the TIF scale for 5 

minutes, and then a 10 lb weight was applied for 30 minutes. After 35 minutes of pressure on the wound (manual 

pressure and the pressure dressing), the standard pressure dressing was removed, being careful to leave the 

clot intact. The petroleum gauze was used to allow removal of the pressure dressing with minimal clot disruption. For the purposes of this study, hemostasis was 

defi ned as a clot formation with oozing of no more than 

2% of the swine’s total blood volume over a 5-minute 

period (approximately 100 mL in a 70 kg pig). Swine 

blood volume approximates that of the adult human at 70 

mL per kg. Blood loss was measured over 2 time periods, 

the initial injury to intervention and the intervention to 

the completion of the study. Measurement was accomplished through gentle suctioning of the blood in the distal part of the wound and collection on absorbent pads 

underneath the animal. In addition, all the dressings and 

hemostatic agents were weighed before their application 

and again at the conclusion of the experiment to determine the amount of exsanguination. The blood loss from 

the initial injury was determined by the weight of dressings before and after the transection of the femoral vessels, as well as any blood collected through suctioning of 

the wound. To determine the effectiveness of the hemostatic agents, the investigators determined blood loss in 

the same manner after the intervention.

RESULTS

The minimum number of animals was used to obtain 

a statistically valid result. A large effect size was determined for this experiment based upon a review from 

previous work by Burgert et al. Using G-Power 3.00 

(Institut Fur Experimentelle Psychologie, Dusseldorf, 

FRG), an effect size of 0.60, a power of 0.80 and an alpha of 0.05, it was determined a sample size of 15 swine 

per group (30 total) was needed for this study.14 All 

subject specimens were within normal limits. Swine of 

similar size and weight were used in both groups. The 

QuikClot Combat Gauze group ranged from 70 to 89 

kg (mean=76.4, SD=±8.4 kg) and the control group 

ranged from 70 to 84 kg (mean=77.6, SD=±5.6 kg).

There were no statistically signifi cant differences between the groups in reference to the amount of initial 

one minute bleeding (P=.417). The QuikClot Combat 

Gauze group ranged from 300 to 900 mL (mean=541.6, 

SD±243 mL) and control group ranged from 205 to 

862 mL (mean=554.2, SD±305 mL). The body weights, 

NPO fl uid defect and replacement, core body temperatures, arterial blood pressures, amount of blood volume, 

and amount of the initial one minute hemorrhage after 

the injury were analyzed using a multivariate ANOVA. There were no signifi cant differences between the 

groups (P>.05). Blood loss after 35 minutes of pressure 

on the wound (manual pressure and the pressure dressing) was calculated for each group over a 5-minute period. The amount of bleeding for the QCG group ranged 

from 0 to 93 mL (mean=36±112 mL); and the control 

group ranged from 0 to 421 mL (mean=340±297 mL).

An independent t test used to analyze the data indicated 

there was a signifi cant difference between the groups 

(P=.002), the QCG was more effective than the control.

COMMENT

Research indicates that hemostatic agents are effective 

but may fail in the presence of hemodilution. This study 

compared the effects of QCG to a standard pressure 

dressing, the control, in a porcine model in the presence 

of hemodilution. Thirty percent of the subject’s blood 

volume was removed and replaced with a crystalloid 

fl uid bolus using 3:1 ratio to obtain hemodilution. A 

complex groin injury was generated simulating a blast 

type injury which is common in combat, the anatomical 

areas are not protected by conventional body armor, and 

a tourniquet cannot be placed to control hemorrhage. 

Both interventions were able to rapidly stop large vessel 

arterial and venous bleeding when applied to an actively 

bleeding wound through a pool of blood. The QCG performed signifi cantly better than standard pressure dressing control group indicating that the agent is effective in 

the presence of hemodilution. This is the fi rst study to 

investigate the effectiveness of a hemostatic agent in the 

presence of hemodilution. The QCG was easy to open, 

simple to use to pack the wound, and did not require 

premixing. This agent could be easily used by physicians, nurses, and ordinary citizens in providing care to 

trauma victims in both the military and civilian sectors. 

In this study, investigators noted the agent did not produce heat with application, and there were no obvious 

signs of tissue damage. There is signifi cant concern and 

reports of thermal injury to human tissue with other hemostatic agents.

THE EFFECTS OF QUIKCLOT COMBAT GAUZE ON HEMORRHAGE CONTROL

IN THE PRESENCE OF HEMODILUTION
 October – December 2012 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

CONCLUSION

Based on this study, hemodilution does not alter the formation of a robust clot when QCG is used, thereby minimizing the risk of rebleeding in a class II hemorrhage. 

Further research should be conducted to determine the 

maximum effective limits of hemodilution and its effects in a class III hemorrhage with hemostatic agents. 

Other hemostatic agents should be investigated using 

the same model.

REFERENCES

1. Bellamy RF. The causes of death in conventional 

land warfare: implications for combat casualty care 

research. Mil Med. 1984;149(2):55-62.

2. Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A profi le of combat injury. J Trauma. 

2003;54(suppl 5):S13-S19.

3. Champion HR. Combat fl uid resuscitation: introduction and overview of conferences. J Trauma. 

2003;54(suppl 5):S7-S12.

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

States Army Rangers in Somalia: an analysis of 

combat casualties on an urban battlefi eld. J Trauma. 

2000;49(3):515-529.

5. Alam HB, Burris D, DaCorta JA, Rhee P. Hemorrhage control in the battlefi eld: role of new hemostatic agents. Mil Med. 2005;170(1):63-69.

6. Alam HB, Koustova E, Rhee P. Combat casualty 

care research: from bench to the battlefi eld. World 

J Surg. 2005;29(suppl 1):S7-S11.

7. Alam HB, Uy GB, Miller D, et al. Comparative analysis of hemostatic agents in a swine model of lethal 

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

8. Santibanez-Gallerani AS, Barber AE, Williams SJ, 

Zhao BSY, Shires GT. Improved survival with early fl uid resuscitation following hemorrhagic shock. 

World J Surg. 2001;25(5):592-597.

9. Tactical combat casualty care page [updated 2010]. 

US Military Health System Website. Available at: 

http://www.health.mil/Education_And_Training/

TCCC.aspx. Accessed January 2012.

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

a zeolite hemostatic agent achieves 100% survival 

in a lethal model of complex groin injury in swine. 

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

11. Kheirabadi B. Evaluation of topical hemostatic 

agents for combat wound treatment. US Army Med 

Dep J. April-June 2011:25-37.

12. Pepe PE, Mosesso VN Jr, Falk JL. Prehospital fl uid 

resuscitation of the patient with major trauma. Prehosp Emerg Care. 2002;6(1):81-91.

13. Sondeen JL, Coppes VG, Holcomb JB. Blood pressure at which rebleeding occurs after resuscitation 

in swine with aortic injury. J Trauma. 2003;54(suppl 

5):S110-S117.

14. Gegel B, Burgert J, Cooley B, et al. The effects 

of BleedArrest, Celox, and TraumaDex on hemorrhage control in a porcine model. J Surg Res. 

2010;164(1):e125-e129.

15. Karsli ED, Erdogan O, Esen E, Acarturk E. Comparison of the effects of warfarin and heparin on bleeding caused by dental extraction: a clinical study. J 

Oral Maxillofac Surg. 2011;69(10):2500-2507.

16. Kheirabadi BS, Arnaud F, McCarron R, et al. Development of a standard swine hemorrhage model 

for effi cacy assessment of topical hemostatic agents. 

J Trauma. 2011;71(suppl 1):S139-S146.

17. Kheirabadi BS, Edens JW, Terrazas IB, et al. Comparison of new hemostatic granules/powders with 

currently deployed hemostatic products in a lethal 

model of extremity arterial hemorrhage in swine. J 

Trauma. 2009;66(2):316-328.

18. Kheirabadi BS, Scherer MR, Estep JS, Dubick MA, 

Holcomb JB. Determination of effi cacy of new hemostatic dressings in a model of extremity arterial 

hemorrhage in swine. J Trauma. 2009;67(3):450-

460.

19. Lipkin ME, Mancini JG, Simmons WN, et al. 

Pathologic evaluation of hemostatic agents in 

percutaneous nephrolithotomy tracts in a porcine 

model. J Endourol. 2011;25(8):1353-1357.

20. Ogle OE, Swantek J, Kamoh A. Hemostatic agents. 

Dent Clin North Am. 2011;55(3):433-439.

21. Rhee P, Brown C, Martin M, et al. QuikClot use in 

trauma for hemorrhage control: case series of 103 

documented uses. J Trauma. 2008;64(4):1093-1099.

22. Burgert J, Gegel B, Neal AR, et al. The effects 

of arterial blood pressure on rebleeding when 

BleedArrest, Celox and TraumaDex are used in 

a porcine model of lethal femoral injury. Mil Med. 

2012;177(3):340-344.

AUTHORS

Dr Johnson is Director of Research of the US Army 

Graduate Program in Anesthesia, Fort Sam Houston, 

Texas.

At the time this study was conducted, CPT Agee and CPT 

Reed were students in the US Army Graduate Program 

in Anesthesia Nursing, Fort Sam Houston, Texas.

Mr Gegel is co-owner of Veteran Anesthesia Services, 

PLLC, San Antonio, Texas.

Mr Burgert is a member of the Adjunct Clinical Faculty, 

Brooke Army Medical Center, Fort Sam Houston, Texas.

Mr Gasko and LTC Loughren are members of the Faculty 

of the US Army Graduate Program in Anesthesia Nursing, 

Fort Sam Houston, Texas.
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

CASE HISTORY

The patient was a white male aged 28 years whose medical history was noncontributory. He was afebrile with 

no lymphadenopathy or trismus. He presented to the 

dental clinic with a chief complaint of pain and swelling 

in the lower right jaw that was unresolved after scaling and root planing. The patient stated that the swelling 

started approximately 1 to 2 months prior to his reporting to the dental clinic. The oral examination revealed 

good oral hygiene, minimal gingival infl ammation, 

and no carious lesions. Teeth No. 30 and 31 had been 

restored with gold onlays that were in good condition. 

Buccal swelling was evident in the 30-31 area that was 

fi rm, fi brotic, and painful to palpation (Figure 1). Teeth 

No. 30 and 31 responded within normal limits to vitality testing and were negative to percussion. A complete 

periodontal examination was performed and the patient 

was periodontally healthy. A radiographic examination 

revealed a unilocular radiolucency that extended from 

the furcation entrance close to the apices of the mesial 

and distal root of tooth No. 30. The radiolucency did not 

involve tooth No. 31, and the periodontal ligament was 

intact around both molars (Figure 2). The differential 

diagnosis included: periodontal abscess, fi brotic lesions, 

and odontogenic tumor.

SURGICAL PROCEDURE

After administering an inferior alveolar nerve block in 

the right mandible, mucoperiosteal fl aps were elevated 

from teeth No. 28-31. Upon fl ap refl ection, extensive resorption of the buccal plate in tooth No. 30 area was revealed. An incisional biopsy was performed to diagnose 

the lesion and determine a course of treatment. The fl aps 

were closed with 4-0 vicryl and the patient scheduled for 

suture removal and a review of the oral pathology report. 

A week later the microscopic examination of the specimen confi rmed a diagnosis of myofi broma. The results 

were reviewed with the patient and subsequent removal 

of the lesion scheduled. Several weeks later the patient 

returned for removal of the myofi broma. An inferior 

alveolar nerve block was performed in the lower right 

mandible. Mucoperiosteal fl aps were refl ected exposing 

the fi brotic lesion and the severe erosion of the buccal 

plate (Figures 3 and 4). The interproximal bone levels 

were within normal limits and the buccal furcation was 

intact despite the missing buccal plate. The entity was 

surgically excised (excisional biopsy) and the specimen 

placed in 10% formalin. The area was thoroughly debrided and osteoplasty performed. The surgical site was 

closed with 4-0 vicryl and postoperative instructions reviewed. Acetaminophen with codeine and chlorhexidine 

mouth rinse was prescribed. An ice pack was given to 

the patient to minimize swelling. The patient returned 

one week later for suture removal.

GROSS AND MICROSCOPIC FINDINGS

The specimen was received in a container of 10% formalin and consisted of multiple soft tissue masses 

measuring from 0.3 cm to 1.5 cm at its greatest dimension. The largest specimen was serially sectioned (Figure 5). Microscopically, the tumors are well-defi ned or 

infi ltrative,1

 arranged in whorls or short interlacing fascicles of spindled shaped myofi broblastic cells (Figure 

6).2

 These cells appear intermediate between smooth 

Myofibroma of the Mandible: A Case Report

COL Collins T. Lyons, DC, USA

COL Preston Q. Welch, DC, USA

COL David C. Flint, DC, USA 

Harold B. Snyder, DDS, MS

ABSTRACT

This report describes the case of a male aged 28 years who presented with a chief complaint of discomfort and 

swelling in the mandibular right molar area. An incisional biopsy was performed with a preliminary differential diagnosis of periodontal abscess, fi brotic lesion, or odontogenic tumor. Subsequent excision of the lesion 

was performed and histologic analysis confi rmed the diagnosis of myofi broma.

Figure 1. Buccal swelling in the area of teeth No. 30 and 31.
 October – December 2012 41

muscle cells and fi broblasts1 and have pale pink cytoplasm. The nuclei are elongated and blunt-ended with 

a vesicular chromatin pattern and one or 2 small basophilic nucleoli. Interspersed between the whorls of eosinophilic myoid cells are more cellular areas of primitive rounded, polygonal, or somewhat spindled shaped 

cells. These cells have limited cytoplasm and larger 

hyperchromatic nuclei.2

 These areas are highly vascular 

with branching hemangiopericytoma-like endothelial 

lined vascular channels and are usually concentrated in 

the center of the tumor.3-6 At low power the pattern between the 2 cell types is described as having a biphasic or 

zoned appearance.3,4,6,7 Pleomorphism or atypia are not 

expected features, however, focal calcifi cation, stromal 

hyalinization, and necrosis are sometimes present. Mitotic activity is negligible.1,3 Tumor cells are reactive 

to vimentin, smooth muscle actin, and muscle specifi c 

actin, and are nonreactive to desmin, S-100 protein, epithelial membrane antigen, and keratins.3,4,8

COMMENT

This case presents an excellent opportunity to develop 

a differential diagnosis for buccal swellings in the oral 

cavity. Epithelial and mesenchymal lesions can produce 

soft tissue masses. The swellings may be developmental, infl ammatory, of neoplastic origin, or represent oral 

manifestations of a systemic disease. The radiolucent 

appearance of this lesion mitigates it being a calcifying 

odontogenic tumor. During the development of differential diagnoses, some factors to consider include location 

of the lesion, consistency, and the presence or absence 

of pain. An important component in diagnosis is to remember that the most commonly occurring lesions are 

most often what you encounter. The use of vitality testing and periodontal evaluations along with radiographic surveys can eliminate lesions of periapical 

or periodontal origin. The focus can now be shifted 

to the more common developmental odontogenic or 

neoplastic entities. In this case, fi rm fi brotic lesions 

to consider include myofi broma, irritation fi broma, 

neurofi broma, angiofi broma, myofi bromatosis, and 

fi brotic pyogenic granuloma.

Myofi bromatosis is an admixture of myofi broblasts 

and fi broblasts. Lesions fall into 2 categories: superfi cial myofi bromatosis with nodules confi ned 

to the subcutaneous and submucosal stroma with 

occasional involvement of skeletal muscle or bone; 

and generalized myofi bromatosis with visceral lesions.9

 Myofi bromatosis presents in the paraoral 

area as single or multiple submucosal nodules, usually in neonates and infants.

Figure 2. Periapical fi lm of of teeth No. 30 and 31. Figure 3. Myofi broma exposed.

Figure 4. Eroded buccal plate, area of tooth No. 30.
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

Traumatic fi broma may arise in any location and represents fi brous hyperplasia due to trauma. Traumatic 

fi broma may be clinically indistinguishable from true 

neoplasms, benign salivary tumors, or cysts.10

Odontogenic fi broma is a benign neoplasm that presents 

as a painless expansion of the cortical plates.11 This tumor occurs as frequently in the maxilla as it does in the 

mandible. Root resorption or divergence is common.

Neurofi broma arises from the sheath cells of nerves 

and the mandible is the most common site for central 

nerve sheath neoplasms.12 Expansion of the buccal plate 

is common with no associated pain. Paresthesia may or 

may not be present.

The pyogenic granuloma is a benign mass of exuberant 

granulation tissue produced after injury (or local infection) resulting in excess vascular tissue.10 The mass may 

become fi brous over time. The treatment is conservative 

surgical removal with a slight chance of recurrence.

Myofi broma is a rare benign soft tissue neoplasm of contractile myoid cells with predilection for the head and 

neck.5,9,13,14 It occurs over a wide age range but is usually seen in young adults, mean age 27.12 The most frequently affected areas are the cheeks, tongue, mandible, 

lips, palate, trunk, and extremities.13 Myofi bromatosis 

describes the multicentric and more aggressive form, 

usually seen in neonates and infants.3

 Solitary myofi -

bromas are more common than the multicentric form5

and typically present as a fi rm painless slow growing 

submucosal mass7

 which may exhibit rapid growth and 

can often spontaneously regress.4,12,14 The radiographic 

appearance is nonspecifi c and may appear as a welldemarcated or ill-defi ned radiolucency, with or without 

calcifi cations.15 Intraosseous tumors occur most commonly in the mandible.2,14

Figure 5. Serially sectioned tumor. Figure 6. Myofi broblastic cells, magnifi cation ×40.

REFERENCES

1. Sedghizadeh PP, Allen CM, Kalmar JR, Miloro M, 

Suster S. Solitary central myofi broma presenting in 

the gnathic region. Ann Diagn Pathol. 2004;5:284-

289

2. Allon I, Vered M, Buchner A, Dayan D. Central 

(intraosseos) myofi broma of the mandible: clinical, radiologic, and histopathologic features of a 

rare lesion. Oral Surg Oral Med Oral Pathol AOral 

Readiol Endod. 2007;103(4):e45-e53.

3. Jones AC, Freedman PD, Kerpel SM. Oral myofi -

bromas: a report of 13 cases and review of the literature. J Oral Maxillofac Surg. 1994;52:870-875.

4. Scheper MA, Difabio VE, Sauk JJ, Nikitakis NG. 

Myofi bromatosis: a case report with a unique clinical presentation. Oral Surg Oral Med Oral Pathol 

Oral Radiol Endod. 2005;99(3):325-330.

5. Vered M, Allon I, Buchner A, Dayan D. Clinicopathologic correlations of myofi broblastic tumors 

of the oral cavity. II. Myofi broma and myofi bromatosis of the oral soft tissues. J Oral Pathol Med. 

2007;36(5):304-314.

6. Oliver RJ, Coulthard P, Carre C, Sloan P. Solitary 

adult myofi broma of the mandible simulating an 

odontogenic cyst. Oral Oncol. 2003;39(6):626-629.

7. Lingen MW, Mostofi RS, Solt DB. Myofi bromas of 

the oral cavity. Oral Surg Oral Med Oral Pathol 

Oral Radiol Endod. 1995;80(3):297-302.

8. Montgomery E, Speight PM, Fisher C. Myofi bromas presenting in the oral cavity: a series of 9 cases. Oral Surg Oral Med Oral Pathol Oral Radiol 

Endod. 2000;89(3): 343-348.

MYOFIBROMA OF THE MANDIBLE: A CASE REPORT
 October – December 2012 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

9. Foss RD, Ellis GL. Myofi bromas and myofi bromatosis of the oral region: A clinicopathologic analysis of 79 cases. Oral Surg Oral Med Oral Pathol 

Oral Radiol Endod. 2000;89(1):57-65.

10. Eversole RL. Clinical Outline of Oral Pathology. 

Philadelphia: Lea and Febiger;1984:101.

11. Fowler CB. Benign and malignant neoplasms of the 

periodontium. Periodontol 2000. 1999;21:33-83.

12. Neville BW, Damm DD, Allen CM, Bouquot JU. 

Oral and Maxillofacial Pathology. Philadelphia: 

W.B. Saunders; 2002:457-461.

13. Fletcher CDM, Unni KK, Mertens F, eds. World 

Health Organization Classifi cation of Tumors. Pathology and Genetics of Tumours of Soft Tissue and 

Bone. Lyon, France: IARC Press; 2002:59-61.

14. Sugatani T, Inui M, Tagawa T, Seki Y, Mori A, 

Yoneda J. Myofi broma of the mandible. Clinicopathologic study and review of the literature. Oral 

Surg Oral Med Oral Pathol Oral Radiol Endod. 

1995;80(3):303-309.

15. Kempson RL, Fletcher CDM, Evans HL, Hendrickson MR, Sibley RK. Atlas of Tumor Pathology. Tumors of the Soft Tissues. Washington, DC: 

American Registry of Pathology, Armed Forces 

Institute of Pathology; 1998;64-67.

AUTHORS

COL Lyons is Chief, Periodontics and AEGD Mentor 

at the Fort Jackson Dental Activity, Fort Jackson, South 

Carolina.

When this article was written, COL Welch was Oral 

Pathologist at the Madigan Army Medical Center, Fort 

Lewis, Washington.

COL Flint is Oral Pathologist at the Walter Reed National 

Military Medical Center, Bethesda, Maryland.

Dr Snyder is in private practice in Frederick, Maryland.
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

The military tradition of “casing the colors” symbolizes the closing of a unit’s operations. When the Walter Reed Army Medical Center (WRAMC) cased its 

colors on July 27, 2011, the impact was a cessation of 

operations of the many tenant units associated with the 

WRAMC. Two of those units were dental services delivery commands: the US Army Northern Region Dental 

Command and the Walter Reed Dental Activity. This 

history of Army dentistry at the WRAMC was prepared 

in recognition of the historical signifi cance and legacy 

of its contribution to both the profession of dentistry and 

Army medicine as a whole.

In 1909, the fi rst patients were admitted to a new Walter 

Reed General Hospital. These were the beginnings of 

what would quickly grow into a medical center founded 

on principles that would integrate patient care, teaching 

and research.1

 In 1909, the dentistry profession was represented in the Army only in the form of 30 contracted 

civilian dental surgeons2(p203) (as explained later, there 

were no commissioned dental offi cers until 1911). There 

is no indication that any of the 30 were assigned to Walter Reed General Hospital. However, dental organizations evolved, including dental and maxillofacial treatment in the hospital, and oral pathology services in the 

Armed Forces Institute of Pathology. The Army Medical Center was established at the hospital campus area 

in 1923, and in 1951 the entire complex was redesignated Walter Reed Army Medical Center.1

 Tenant units 

at the facility over the years included dental activities, 

a regional dental command, an area dental laboratory, 

the Army Dental School, and the US Army Institute of 

Dental Research. Education and training programs were 

imbedded in these dental organizations.

FIRST CLINICAL DENTAL CARE

On March 3, 1911, Congress directed the Army to create 

a dental corps of commissioned dental offi cers. Hyson 

et al indicates that the fi rst mention of dental offi cers 

at Walter Reed General Hospital was April 1917, “One 

dental offi cer was on duty and gave dental service to 

the entire command.”2(p279) The declaration of war with 

Germany that same month changed this situation:

From three dental surgeons in 1918, the personnel of 

the department increased to nine dental offi cers.... 

Five female technicians were on duty in the hygienic 

department of the clinic. This permitted the dental 

offi cers to spend their entire time operating.2(p428)

Weed3 describes the organization of the Walter Reed 

General Hospital during World War I, including a dental 

department and a maxillofacial section in the Department of Professional Services. The following excerpts 

provide a good description of dental service at Walter 

Reed during the World War I era:

The chief of the dental department was responsible 

for the dental service rendered at the hospital, for the 

supervision and instruction of all personnel assigned 

to his division, and for all the public property under his 

control. All military patients admitted to the hospital were 

examined by the dental survey offi cer, who furnished a 

report to the chief of his department. The chief of the 

dental department furnished imperative dental attention 

whenever indicated and elective dental attention as far 

as possible.

Dental section. The dental service was divided into fi ve 

subsections: Dental hygiene; X-ray; operative; prosthetic 

and oral surgery; and one dental offi cer for the survey 

of patients. The completion of the new dental building 

in August and its immediate occupancy facilitated the 

successful detachment of the dental department. The new 

building consisted of a large operating room, adequate 

for nine operators, an oral surgery department, including 

an operating room, and an extracting and record room, 

and quarters for the offi cer of the day and sergeant in 

charge, together with necessary storage space. A dental 

X-ray laboratory and developing room were provided and 

an offi cer was detailed to care for this work. From three 

dental surgeons in 1918, the personnel of the department 

increased to nine dental offi cers, one of whom was 

on duty to render emergency treatment at all hours 

of the day and night. In January, 1919, the prosthetic 

department was organized for the construction of splints 

for maxillofacial cases and prosthetic restoration of all 

kinds....

Maxillofacial section. The fi rst maxillofacial patients 

arrived at the hospital on January 15, 1919, at which 

Dentistry’s Role in the History of the

 Walter Reed Army Medical Center

COL Samuel A. Passo, DC, USA

Nolan A. Watson
 October – December 2012 45

time Walter Reed General Hospital was one of the three 

hospitals designated by The Surgeon General’s Offi ce 

to receive this class of patients. They were scattered 

throughout the surgical wards at fi rst, until a chief 

of section was detailed to care for them, in February, 

when they were all assembled in three wards. Prior to 

March very little surgical operative work was done.... 

Coordination with the dental surgeon, necessary in the 

treatment of most of the cases, was early established.

At the end of the year 1918 the annual report for the 

hospital shows a capacity of 2,500 beds, and in the 

same report the record of the completion of temporary 

buildings, which includes the construction for the years 

1917 and 1918, stands as follows:... Dental building: 

One-story tile construction, 24 by 350 feet, occupied by 

the dental, eye, ear, nose, and throat clinics.

DENTAL COMMAND AND CONTROL

ORGANIZATIONS

Initially and for many decades, clinical dental care was 

delivered at Walter Reed under the direct command of 

the hospital commander. In 1973, Health Services Command was established along with installation level reorganization such that dental services were provided by a 

hospital dental company, but it also was controlled by 

the Walter Reed Army Medical Activity and hospital 

commander. Studies of dental management by Dental 

Corps Chiefs MG Edwin Smith and MG Surindar N. 

Bhaskar resulted in public law, implemented October 

20, 1978 that established the US Army Dental Activity 

(DENTAC) separate from the hospital and Medical Activity, and commanded by an Army Dental Corps offi -

cer4 (J. E. King, oral communication, July 2011). Prior to 

the closing of WRAMC in 2011, the Walter Reed Dental 

Activity (WR DENTAC) operated 4 

dental clinics supporting the National 

Capital Region: Walter Reed Hospital Clinic, Fort McNair, the Pentagon, 

and the Forest Glen-WRAMC Annex 

(T. R. Tempel Jr., written communication, July 2011).

As the Army Medical Department 

continued to adapt its command 

structure to the operational requirements of the Army, on 1 November 

1993 it established the US Army Dental Command (DENCOM) with the 

WR DENTAC as one of 31 dental 

activities and 20 dental clinic commands. There were 8 dental service 

support areas (DSSAs) organized to 

reduce the span of control required 

of DENCOM. The Commander, WR 

DENTAC reported directly to the 

Commander, DENCOM, and had additional responsibilities as commander of the new administrative layer, 

the North Atlantic Dental Service Support Area, which 

evolved into the Northern Regional Dental Command 

(NRDC) in 1998.4

 The NRDC encompasses 7 dental activities and 3 dental clinic commands in 21 states and 

Washington, DC (T. R. Tempel, Jr., written communication, July 2011).

The Northern Regional Dental Command and Walter 

Reed Dental Activity focused on the dental health and 

readiness of Soldiers. The command also had the mission 

of operating 4 graduate education programs in dentistry. 

These training programs produced highly trained dental 

offi cers in the fi elds of oral and maxillofacial surgery, 

endodontics, and comprehensive dentistry. Additionally, 

the Soldiers of the Northern Regional Dental Command 

support 10 installations which deploy, mobilize, and 

demobilize Soldiers in support of Operation Enduring 

Freedom and previously Operation Iraqi Freedom. (T. R. 

Tempel, Jr., written communication, July 2011).

GRADUATE DENTAL EDUCATION

By 1921, Walter Reed had been offering specialty residency programs in oral surgery, periodontics, endodontics, prosthodontics (fi xed and removable), and pedodontics/orthodontics for several years. It also provided 

the dental internship, a precursor to the 2-year general 

dentistry residency (T. R. Tempel, Jr., oral communication, July 2011). However, recognizing the need for advanced training of Army dental offi cers in both clinical specialties and basic science, in September of 1921, 

three Dental Corps offi cers were sent to Dewey School 

of Orthodontic Training at New York 

University, and one offi cer to the 

Army Medical School for bacteriology training.

DENTAL INTERNSHIP PROGRAM

During Colonel Frank P. Stone’s tenure as Dental Corps Chief, his offi ce 

announced that effective July 1, 1939, 

the War Department and Surgeon 

General had authorized 8 dental internships at Army general hospitals. 

The goal was to improve on the skills 

of dental offi cer candidates and provide familiarity with the unique requirements of military dentistry.

Three interns were assigned to 

the Walter Reed General Hospital, and one each was assigned to 

the Letterman General Hospital 

Commanders of the Walter Reed Dental 

Activity (DENTAC)

2010-2011 COL Thomas R. Tempel, Jr.

2008-2010 COL Priscilla Hamilton

2005-2008 COL M. Ted Wong

2002-2005 COL Lawrence Cook

1998-2002 COL Thomas Striano

1998 COL Brent Koudelka

1996-1998 COL Gary Allen

1993-1996 COL William Priddy

1990-1993 COL Charles Bole II

1989-1990 COL Jack Vincent

1988-1989 COL Robert Brady

1985-1988 COL Robert Webster

1984-1985 COL Harley Ellinger

1983-1984 COL Peter Taylor

1980-1983 COL Emery Russell, Jr.

1977-1980 COL Ronald L. Vanswol*

1976-1977 COL William Radentz†

*Became first commander of the new DENTAC 

October 20, 1978.

†COL Radentz directed dental activities during 

the MEDDAC dental management trials study.
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

(San Francisco), Fitzsimons General Hospital (Denver), 

Army and Navy General Hospital (Hot Springs, Arkansas), William Beaumont General Hospital (El Paso), and 

the Station Hospital (Fort Sam Houston, Texas). The 

Army Dental School at the Walter Reed Army Medical 

Center developed a standardized training program for 

the internships emphasizing clinical dentistry and oral 

surgery.2(pp814-815)

ARMY DENTAL SCHOOL

A new and critical link in the chain of professional development for dental offi cers was postgraduate level Army 

Dental School located on the grounds of Walter Reed 

General Hospital. Dental educators John Sayre Marshall 

and Robert Oliver conceived an Army dental school during meetings of the dental examining board in February 

1901. As Oliver later related, “The primal reason actuating the original thought of these two dental educators 

was the manifest necessity of preparing and training 

young dental men, just entering the Corps, to meet the 

new conditions of life—physical, mental, and professional—in which they were suddenly thrust.”2(pp720-723)

COL William H. G. Logan, who became the fi rst Chief 

of the US Army Dental Corps in 1917, strongly advocated such a school in February 1911.

However, it was not until January 6, 1922, that the Secretary of War authorized the new Army Dental School 

as a special service school of the War Department. The 

School’s fi rst commandant was COL Seibert D. Boak 

who had led the Dental Section of the Army Sanitary 

School at Langres, France during World War I. The 

Army Dental School’s mission was to:

teach newly appointed dental offi cers the practical 

application of approved methods of professional 

procedures in the military service, to furnish postgraduate courses in advanced military dental surgery to 

members of the Dental Corps, to provide an organization 

for the investigation, study and research of dental problems, 

a source of authoritative information on professional 

matters, and the training of enlisted personnel to meet 

the requirements of the dental service.2(p721)

MG Merritte W. Ireland, The Army Surgeon General, 

addressed the school’s formal opening on 9 January 

1922. Ireland’s speech strongly endorsed not only the 

Army Dental School but also the role of the Dental Corps 

within the Army Medical Department. According to the 

Annual Report of the Army Surgeon General, 1922,

9

 the 

opening of the Army Dental School corrected some of 

the most signifi cant defi ciencies in the development of 

the dental service and was one of the most important 

events in the history of the Dental Corps.2(pp720-723)

The Army Dental School was located in temporary 

World War I buildings from 1922 to 1930, when those 

buildings were condemned. In October 1932, the Army 

Dental School and Walter Reed Central Dental Laboratory occupied parts of the fi rst and second fl oors of the 

new north wing of the Army Medical School building 40. 

The new location contained the director’s offi ce, clerk’s 

room, executive offi ce, library, oral surgery amphitheater, bacteriology laboratory, preparation room, pathology laboratory, prosthetic laboratory (which housed 

the Walter Reed Central Dental Laboratory), chemical 

laboratory, mail room, X-ray dark room, photographic 

The Army Dental School was located in these temporary 

World War I buildings from 1922 to 1930 when the buildings 

were condemned and demolished. This photo was taken 

March 23, 1923. Source: Walter Reed Army Medical Center, 

Directorate of Public Works Archives.

Army Medical Schools Building 40 at the Army Medical 

Center in 1932. The Army Dental School and Walter Reed 

Central Dental Laboratory occupied parts of the fi rst and 

second fl oors of the north wing of the building. In 1962, 

the US Army Institute of Dental Research occupied these 

spaces. Reproduced from: A History of the Army Dental 

School, March 14, 1938–Sept. 17, 1940. Source: Research 

Collections, Offi ce of Medical History, US Army Medical 

Command, Fort Sam Houston, Texas.

DENTISTRY’S ROLE IN THE HISTORY OF THE WALTER REED ARMY MEDICAL CENTER
 October – December 2012 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

room, and oral hygiene clinic (6 chairs equipped with 

Ritter Tri-Dental units). During a visit to the school’s 

new facilities, Dr G. Walter Dittmar, then president of 

the American Dental Association, declared it to be one 

of the fi nest and most completely equipped that it had 

been his pleasure to inspect.

The Army Dental School was redesignated in 1948 as 

the Dental Division of the Army Medical Research and 

Graduate School, Army Medical Center, Washington, DC. 

Concurrently, the enlisted training school was moved to 

Fort Sam Houston. In 1955, the name was changed again 

to the Army Medical Service Graduate School. This redesignation resulted in the upgrading of the education 

programs to graduate and postgraduate levels.10

US ARMY INSTITUTE OF DENTAL RESEARCH

Agencies change, seeking new ways to become more effi cient and effective. Such is the case of the Army Dental School. In addition to the multiple personnel development missions with which the Army Dental School 

was founded on January 6, 1922, there were also the 

requirements:

to provide an organization for the investigation, 

study, and research of dental problems, and serve as 

a source of authoritative information on professional 

matters....2(p721)

As Chief of the Dental Corps, MG Joseph L. Bernier, realigned the focus to oral and dental research. On January 

1, 1962, the dental division of the school was completely 

reorganized and renamed the US Army Institute of Dental Research (USAIDR). It was given separate institute 

status as an element of US Army Medical Research and 

Development Command.10,11

The USAIDR developed simplifi ed techniques which 

allowed rapid and effective treatment of war-related 

maxillofacial injuries and dental diseases. It developed 

required military information on epidemiology, etiology, 

clinical treatment, the prevention and control of oral disease, and used the information as a basis for research. 

It conducted basic and clinical investigations on dental 

materials. It provided instruction as required for graduate education in the Advanced Theory and Science of 

Dental Practice Course and dental residency programs 

in clinical oral pathology, endodontics, and periodontics. USAIDR also conducted continuing education and 

training of dental personnel to maintain high professional treatment standards.10

Clinically relevant research designed to improve patient 

care was always the goal of USAIDR. Emphasis on clinical research began with the caries investigations of CPT 

Fernando Rodriguez in the 1920s, and was elaborated by 

those of MG Surindar N. Bhaskar and associates in the 

late 1960s and early 1970s.10

Between the time of CPT Rodriguez’s work and World 

War II, much of the research emphasized methods of 

emergency treatment and the improvement of dental 

materials. Following World War II, attention focused 

on the importance of decalcifi cation of teeth by bacteria. Investigations on Lactobacillus acidophilus and its 

decalcifying potential on sound enamel was a major 

project.10 During the 1950s, the interest shifted to the 

nutritional aspects of dental disease. Research since the 

middle 1960s has emphasized problems and treatment 

of maxillofacial combat wounds.10

In October 1993, the USAIDR was reorganized as the 

US Army Dental Research Detachment (DRD), subordinate to the Walter Reed Army Institute of Research, 

located at the Walter Reed Army Medical Center. By 

1997, the DRD had moved to the Great Lakes Naval 

Center near Chicago, ending the dental research and 

development presence at Walter Reed4

 (J. E. King, oral 

communication, July 2011).

At Great Lakes, the DRD collocated with the Navy’s Institute of Dental and Biomedical Research and the Air 

Force’s Detachment 1, Dental Evaluation and Consultation Service. Sometime between 1997 and 2010, the 

DRD was redesignated as the US Army Dental and 

Trauma Research Detachment (DTRD). On March 24, 

2010, DTRD and the Navy and Air Force activities 

moved from the Great Lakes Naval Center to Fort Sam 

Houston, Texas. The 3 military dental research units are 

collocated in a new, 25,000 sq ft facility, the Battlefi eld 

Health and Trauma Research Institute4,12 (J. E. King, oral 

communication, July 2011).

DENTAL AND ORAL PATHOLOGY

In May 1862, Army Surgeon General William Hammond ordered establishment of the Army Medical Museum. Renamed the Armed Forces Institute of Pathology in 1949, it was relocated to the Walter Reed Army 

Medical Center in 1955. The Armed Forces Institute of 

Pathology (AFIP) has become a world leader in pathology consultation, education, and research, including an 

important dental and oral pathology component.5(p3)

The fi rst Dental Corps offi cer was assigned to the Medical Museum/AFIP on July 1, 1926. In 1931, the American Dental Association designated the Dental Section 

of the Army Medical Museum as the offi cial museum 

of the dental profession in the United States.6(p18) Later, 

the National Dental Museum, a Smithsonian Institute 
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

facility, was established in Baltimore, Maryland.

The essential instrument that tied 

AFIP to the medical community 

it serves was the establishment of 

registries for various groupings 

of diseases. The Dental and Oral 

Pathology Register was added in 

1933, which served to reactivate an 

1895 arrangement with the American Dental Association (ADA) 

designating the Army Medical 

Museum as the national depository for the organization’s dental 

specimens.5(p69)

The Dental and Oral Pathology 

Register became part of the American Register of Pathology, formed 

in cooperation with the National 

Research Council Division of 

Medical Sciences in 1930. Within 

3 years, the Dental and Oral Pathology Register had 483 accessions. As time passed, accessions 

began to come from civilian dental 

professionals through the ADA as 

well as from Dental Corps offi cers. 

This collection provided signifi -

cant research material and allowed 

the resident dental offi cer at the 

Army Medical Museum to provide 

consultation services and to conduct important pathological research. LTC James B. Mann was the assigned 

dental offi cer through much of the 1930s and made major strides on periodontoclasia and its surgical treatment. 

CPT Joseph L. Bernier, a trained oral pathologist and 

future chief of the Dental Corps (1960-1967), followed 

Mann as chief of oral pathology at the museum in 1938. 

By 1941, the registry had grown to 2,485 items.2(pp789-800)

On May 26, 1955, AFIP Building #54 was dedicated at 

the Walter Reed Army Medical Center, with President 

Dwight D. Eisenhower speaking at the formal opening 

ceremony.

The Armed Forces Institute of Pathology continued to 

expand its advances in lifesaving diagnostic technologies by world-class pathologists and scientists. The many 

varied pathology branches conducted numerous research 

studies, education programs, and publications.5(pix)

The Institute prepared personnel, including forensically trained dental offi cers, in forensic pathology skills 

through training and hands-on experience. Repeatedly, 

AFIP oral pathologists dramatically demonstrated their capabilities 

in dental identifi cation while playing signifi cant roles in numerous 

mass casualty situations, including the 1985 air crash that killed 

248 Soldiers of the 101st Division 

near Gander Newfoundland, and, 

of course, the September 11, 2001 

attacks on the Pentagon and World 

Trade Center.4(pp18,22)

The congressionally mandated 

military Base Closure and Realignment cycle of 2005 disestablished AFIP and relocated its 

militarily relevant functions to the 

National Naval Medical Center, 

Bethesda, Maryland; Dover AFB, 

Delaware; and Fort Sam Houston, 

Texas.7

 In addition, the Joint Pathology Center, the federal government’s pathology resource center, 

was established in Silver Spring, 

Maryland.8

CENTRAL DENTAL LABORATORY 

Dental offi cers in the 1920s had 

to devote as much of their time 

as possible to their many patients, 

leaving them little time to work 

in their laboratories on prosthetic 

Commanders and Directors, Dental School and 

Dental Research Activities at Walter Reed

Commandants, US Army Dental School

COL Seibert D. Boak, DC 1922-1923

COL Franklin P. Wing, DC 1923-1925

MAJ William S. Rice, DC 1925-1929

LTC Frank L. K. Laflamme, DC 1929-1932

Directors, US Army Dental School

COL Robert H. Mills, DC 1932-1936

LTC John W. Scoval, DC 1936-1938

COL Terry P. Bull, DC 1938-1940

Dental school suspended with advent of World War II, used as field 

medicine training school

1940-1948

Directors, Dental Division, US Army Medical 

Research and Graduate School

COL John S. Oratel, DC 1948-1953

COL George T. Perkins, DC 1953-1954

COL Thomas A. McFall, DC 1954-1961

Directors, US Army Institute of Dental Research

COL George H. Timke, DC 1961-1966

COL George W. Burnett, DC 1966-1968

COL Peter M. Margetis, DC 1968-1969

COL Richard L. Howard, DC 1969-1970

BG Sirindar M. Bhaskar, DC 1970-1973

COL Simon Civjan, DC 1973-1974

COL Duane E. Cutright, DC 1974

Commanders, US Army Institute of Dental 

Research

COL Duane Cutright 1974-1980

COL Thomas Sweeney 1980-1985

COL Harold Plank 1987-1992

COL William Posey 1992-1996

COL Michael Rethman 1996-1999

COL Leslie Raulin 1999-2000

Source: Cutright and Daniels10

 J. E. King, oral communications, July 2011

The Armed Forces Institute of Pathology (AFIP) Building #54, 

completed in 1955. Source: National Museum of Health 

and Medicine, AFIP, WRAMC History Offi ce, PAO Historical 

Collection.

DENTISTRY’S ROLE IN THE HISTORY OF THE WALTER REED ARMY MEDICAL CENTER
 October – December 2012 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

appliances. It was not until fi scal year 1927 

that the Army Dental School produced a suffi cient number of well-trained enlisted dental 

mechanics who could make and also oversee 

the manufacture of prosthetics in a dental laboratory. This new resource relieved the dentists 

and their technicians of this time-consuming 

aspect of their work.

In 1926-1927, the dental division opened 3 new 

corps area dental laboratories that provided 

the same service to Army dentists as commercial laboratories provided to their civilian 

colleagues. The fi rst laboratory, Walter Reed 

Central Dental Laboratory, was opened at Walter Reed General Hospital and served all dental 

offi cers in the First through Seventh Corps areas. A similar laboratory at Letterman General 

Hospital supported the Ninth Corps Area, and another at 

the Station Hospital at Fort Sam Houston supported the 

Eight Corps Area.2(p734)

War Department Circular No. 42, dated August 3, 1938, 

redesignated the existing corps area dental laboratories 

as central dental laboratories and added new ones as follows: Army Medical Center, Washington, DC, serving 

the First, Second, and Third Corps areas; Fort McPherson, Georgia, serving the Fourth and Fifth Corps areas; 

Jefferson Barracks, Missouri, serving Fort Knox, Fort 

Benjamin Harrison, and Fort Hayes, and the Sixth and 

Seventh Corps areas; Fort Sam Houston, serving the 

Eighth Corps Area; and Presidio of San Francisco, serving the Ninth Corps Area.2(pp800-803)

The tenant central dental laboratories were exempt from 

the control of local post commanders, except for the purpose of “supply, inspection, and discipline.” The Army 

Dental School trained:

most of the enlisted supervisors and mechanics for the 

central dental laboratories.... No supplies and equipment 

for making dentures were to be given to other stations 

within the continental United States.2(pp800-803)

The trained enlisted personnel coming from the Army 

Dental School meant that the laboratories would “become a great asset to our expanding dental service....” 

Brigadier General Leigh Fairbank said:

The mechanical processes will now be delegated to 

properly trained enlisted men, under the supervision of 

a few dental offi cers. Now, the great majority of dental 

offi cers can devote their entire time to the dental health 

problems of a greater number of personnel.2(pp800-803)

The “central dental laboratory” designation was changed 

to “regional dental activity” in 1962, and to “area dental laboratory” in 1981. In 1991, the area dental laboratories at Alameda, California, and Walter Reed Army 

Medical Center were closed, leaving laboratories at Fort 

Gordon, Georgia, and Fort Sam Houston, Texas. On October 1, 1997, the laboratory at Fort Sam Houston was 

closed, leaving Fort Gordon’s laboratory as the only 

remaining facility for dental support. On July 1, 1998, 

that laboratory was redesignated as the Army Dental 

Laboratory.4(pp15,18,20,21)

CONCLUSION

The casing of the colors and closure of WRAMC on 

July 27, 2011, was an occasion of sadness, pride, and 

hope for the continued mission of excellence. A visitor 

to WRAMC is impressed with the relatively small size 

of the campus (easily walkable) and its enormous impact 

on development of patient care, teaching, and research 

in military (and civilian) medicine and dentistry. The 

caliber of clinicians, educators, researchers, and leaders 

that WRAMC produced is impressive. The innovations 

were numerous and spectacular, thinking “outside of the 

box.” Perhaps the relatively small size and close proximity of leaders and educators in medicine and dentistry 

encouraged “cross-pollination” that would be hard to 

duplicate today.

We have many wide-spread centers of patient care, 

teaching, and research “connected” by our digital electronic technology. Even so, one wonders what may be 

missed by the loss of frequent personal interactions of 

these diverse leaders in the “close” campus of WRAMC 

during walks in the hallways, staff meetings, or in the 

The Central Dental Laboratory moved from the Walter Reed Army Institute 

of Research into its own 9,500 sq ft building on February 23, 1954. Founded in 1927, the Laboratory’s mission was to provide military patients with 

the best possible prosthodontic therapy. Source: WRAMC History Offi ce, 

PAO Historical Collection.
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

cafeteria. The interaction of two early pioneers of Army 

medicine, Surgeon General Merritte Ireland and Chief 

of Dentistry Robert Oliver, at the WRAMC campus is 

an excellent example of such benefi ts. As we look to the 

bright future of the next phase of WRAMC relocations 

in Bethesda, Maryland and Fort Belvoir, Virginia, we 

hope for the same energy, innovation, and determination as in our past.

Today, “center of gravity” of the US Army Dental Corps 

is primarily the DENCOM Headquarters at Fort Sam 

Houston. There is also very strong multiservice presence and interaction at Fort Sam Houston. Perhaps we 

can learn from the WRAMC history and create “pockets” of intimate personal and professional relationships 

for the sharing of ideas and missions in our future.

ACKNOWLEDGEMENT

We appreciate the support and consultation of COL 

(Ret) John E. King, DC, USA, History Consultant 

for the Association of Army Dentistry.

REFERENCES

1. Fleek SL, Sorge CF. Walter Reed Army Medical 

Center. A Century of Service: 1909-2009. Washington, DC: Walter Reed Army Medical Center; 2011.

2. Hyson JM Jr, Whitehorne J, Greenwood JT. A 

History of Dentistry in the United States Army to 

World War II. Washington, DC: Borden Institute, 

Offi ce of The Surgeon General, US Dept of the 

Army; 2008.

3. Weed FW. Military Hospitals in the United States. 

Washington DC: US Army Medical Dept Offi ce 

of Medical History; 1923:287-307. Lynch C, Weed 

FW, McAfee L, eds. The Medical Department of 

the United States Army in the World War. Vol 5.

4. Passo SA, King JE. Highlights in the history of 

US Army dentistry. US Army Med Dept J. JanuaryMarch 2011:8-25. Available at: http://history.amedd.

army.mil/corps/dental/DCHighlights2012.pdf. Accessed July 30, 2011.

5. Stone P. Legacy of Excellence – The Armed Forces Institute of Pathology, 1862-2011. Fort Detrick, 

MD: Borden Institute, Offi ce of The Surgeon General, US Dept of the Army; 2011.

6. King JE, Hynson RG. Highlights in the History of 

U.S. Army Dentistry. Falls Church VA: Offi ce of the 

Chief, US Army Dental Corps, Offi ce of The Surgeon General, US Dept of the Army; 2007. Available at: http://history.amedd.army.mil/corps/dental/

general/highlights/Highlights.pdf. Accessed September 2, 2011.

7. Impact of Terminating, Relocating, or Outsourcing the Services of the Armed Forces Institute of 

Pathology. Washington, DC: US Government Accountability Offi ce; November 9, 2007. Report 

GAO-08-20 Military Base Realignments and Closures. Available at: http://www.gao.gov/products/

GAO-08-20. Accessed September 3, 2011.

8. The Joint Pathology Center. Available at: http://

www.jpc.capmed.mil/index.asp. Accessed September 5, 2011.

9. . Annual Report of the Army Surgeon General, 1922

Washington, DC: US War Dept; 1922.

10. Cutright DE, Daniels JL. The US Army Institute of 

Dental Research: fi fty-three years of dedicated research and education. Mil Med. 1977;142(1):45-48.

11. Bernier JL. Editorial views and news: military 

dental research and emergent science. J Dent Res.

1963;42(3):749-751.

12. Mellus DE, Amaya J. The US Army Dental and 

Trauma Research Detachment: Now Part of the 

Army Institute of Surgical Research. US Army Med 

Dept J. January–March 2011:68-69. Available at: 

http://www.cs.amedd.army.mil/amedd_ journal.

aspx. Accessed 4 September 2011.

AUTHORS

COL Passo is a Periodontist at the Fort Knox Dental 

Activity, Fort Knox, Kentucky. He is also Consultant for 

Dental History to the Chief of the Army Dental Corps.

Mr Watson is a historian with the Offi ce of Medical 

History, US Army Medical Command, Fort Sam Houston, 

Texas.

COL Thomas R. Tempel Jr., Commander, US Army Northern 

Region Dental Command and the Walter Reed Dental Activity, 1SG Kimberley Dubard, Walter Reed DENTAC, and SFC 

Guillermo Lugo-Beltre, color bearer and NCOIC of WRAMC 

Dental Clinic, case the colors during the closing ceremonies 

of Walter Reed Army Medical Center on July 27, 2011. Photo 

courtesy of the Department of the Army.

DENTISTRY’S ROLE IN THE HISTORY OF THE WALTER REED ARMY MEDICAL CENTER
 October – December 2012 51

Medical planners serving on multinational operational 

staffs need an easy-to-use, accurate, nonproprietary casualty estimate model to properly plan for operations. 

The estimate tool cannot be software specifi c because it 

can be diffi cult and costly to acquire the software. The 

software may require special technical hardware and 

system provisions to operate on NATO equipment, and 

such permission may not be granted. The underlying 

data and statistical assumptions must be readily accessible to any contributing nation. Oftentimes, US military-developed casualty estimate models are classifi ed 

or require US military accounts to access them. This 

article describes a methodology that the Regional Command South (RC(S)) developed to provide an operational casualty estimate for a critical operation in Kandahar 

Province. The guidance used to develop this model was 

NATO joint medical planning doctrine, an excerpt of 

which follows:

A thorough threat assessment and a proper analysis of 

the environment together with a comparison with former 

campaigns provide the basis for the estimate of severity 

and patterns of casualties to be expected.... Medical 

planners will have to cooperate with J2 and J5 staff 

from the beginning in order to receive early ideas of the 

concept to be developed. The casualty rate estimation on 

the timeline produces a diagram showing the estimated 

casualty fl ow during the phases and subphases of the 

operation.... A tool suitable for NATO casualty rate 

estimation has to be developed based on recent valid 

data gathered from all types of operations. Hence, a 

prerequisite for a suffi cient tool is a comprehensive 

database covering the whole spectrum of possible 

operations. A tool must be user-friendly, but take the 

complexity of the casualty rate estimation into account. 

In addition to this it has to be accessible for medical 

planners involved in NATO operations.1

OPERATIONAL BACKGROUND

RC(S) is one of 6 Afghanistan International Security Assistance Force (ISAF) regional commands. Four Afghan 

provinces fall under the responsibility of RC(S): Kandahar, Zabul, Uruzgan, and Daykundi. Kandahar Province is the largest, most populated, and was the most 

critical to ISAF strategic objectives at the time. The 

medical support in RC(S) was designed around a “hub 

and spoke” model, with Kandahar as the hub. Kandahar Airfi eld contained a NATO Role-3 Hospital.2(pp1-9–1-12)

Camp Hero, adjacent to Kandahar Airfi eld, included an 

Afghan National Army hospital, the Kandahar Regional 

Military Hospital (KRMH). Kandahar City was home 

to Mir Weis, an Afghan civilian hospital operated by the 

International Committee of the Red Cross. Zabul and 

Uruzgan Provinces served as two of the primary spokes 

from the hub of the healthcare system, both containing 

Role 2 healthcare facilities.

During the summer of 2010, Afghan National Security Forces (ANSF), supported by ISAF, embarked on 

security operations in and around Kandahar City. The 

operational objectives were to protect the civilian population from insurgent intimidation and violence and to 

promote stability and improved governance by the Government of the Islamic Republic of Afghanistan. The 

operation, designated Hamkari (meaning “cooperation” 

in Dari), consisted of 3 stages, the fi rst of which was the 

Developing an Operational Casualty Estimate

 in a Multinational Headquarters to Inform

 and Drive Medical Resource Allocation

LTC Soo Lee Davis, MS, USA

Col Martin Bricknell, RMC, British Army

ABSTRACT

This article presents a methodology to construct an operational casualty estimate for insurgent clearance operations conducted in 2 districts around Kandahar City appropriate for a multinational operational headquarters. 

It demonstrates how to identify relevant and recent historical data to establish a casualty rate, apply it against a 

tactical operational sequence and population at risk to get a daily casualty estimate, and compare that estimate 

to the capacity of the medical system. This allows medical planners from any contributing nation to express the 

medical risk and mitigation plan to operational leadership and the commander.
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

improvement of security and government presence in 

Kandahar City with the formation of a security ring protection force. This security ring consisted of a network 

of traffi c checkpoints and police substations manned by 

partnered ANSF and ISAF personnel. This stage was 

nonkinetic, with the focus on increasing the number of 

police and security forces available in Kandahar City to 

directly support the civilian population. Concurrent to 

this effort, RC(S) began receiving US brigade combat 

teams to augment the one Canadian battle group whose 

operational area covered districts south and east of Kandahar City.

The second stage focused on clearing the Arghandab 

district northwest of Kandahar City. It commenced once 

2nd Brigade, 101st Air Assault Division, Task Force 

Strike, was prepared to conduct deliberate operations 

in their area. Task Force Strike was successful in clearing key population areas and controlling major access 

routes into Kandahar City. This stage of the operation 

served as the anchor for the casualty estimate methodology outlined here.

Stage 3 required the clearance of 2 rural districts west 

and southwest of Kandahar City, Zhari and Panjwa’i. 

This stage was separated into phases 3A and 3B. Intelligence reports indicated the density of insurgent fi ghters 

was signifi cantly greater in these areas than in Arghandab District. It also contained major insurgent logistical 

bases, which were heavily protected and fortifi ed with 

defensive measures, such as improvised explosive device 

(IED) belts. The terrain, though rural, was much more 

diffi cult to operate in, and very conducive to concealing 

insurgent activities. One of the challenges of the terrain 

was the large number of grape fi elds, which consisted of 

undulating rows of dirt mounds, some as high as 6 feet. 

These grape fi elds were extremely diffi cult to maneuver 

through, and easily concealed tunnels, weapons caches, 

and antipersonnel mines, and channelized ISAF forces 

directly into IED belts emplaced by the insurgents.

The casualty rate in the Arghandab District operation 

was signifi cant. The intelligence reports of an increased 

insurgent threat, and the advantage the terrain gave the 

enemy, suggested the third stage of Hamkari would be 

very challenging. We anticipated a potential for a higher casualty rate than in Arghandab. Therefore, it was 

imperative to conduct a thorough casualty estimate in 

order to assess whether or not RC(S) possessed suffi -

cient medical capacity to support the potential casualty 

load. This analysis had to be completed early enough to 

give the healthcare system adequate time to shift assets 

if levels were determined to be insuffi cient. The analysis also had to be done quickly, because the operational 

plan unfolded rapidly and remained very dynamic. It 

required a casualty estimate methodology just as agile 

and effi cient.

METHODOLOGY

Applying Operational Understanding to Develop the 

Casualty Numbers and Flow Estimate

Casualty estimates are heavily data-driven and best informed through information about the current campaign. 

Therefore, it is absolutely imperative that as much data 

as possible is captured in a mineable format. Historically, the RC(S) Combined Joint Medical offi ce (CJMED) 

maintained a very comprehensive medical evacuation 

database for every patient handled by the ISAF system. 

This database has been in place since 2006 and has 

evolved as medical planners learned which fi elds were 

most relevant to inform future questions and analysis.

However, the casualty estimate cannot be generated using medical information alone, it must be coupled with 

operational information to provide the context for the 

casualty profi le. Operational information is stored within a system termed Combined Information Data Network 

Exchange (CIDNE), which has been established across 

the entire theater of Afghanistan. The RC(S) possessed 

a robust and comprehensive history of key operational 

information. This, in addition to relevant summary information captured in slides and spreadsheets, provided 

a robust data set for basic analysis.

Deliberate planning for Phase 3A began in mid July 

2010 with operations planned to commence in early 

September. CJMED planners actively participated in 

the military decision-making process and were aware of 

the potential for a much higher rate of casualties. We 

analyzed the medical capacity in RC(S) to determine its 

adequacy for increased casualties. To further compound 

the risk, Phase 3A was planned to commence prior to the 

Afghanistan elections. This had been a historically highrisk period, with increased insurgent activities intended 

to disrupt the democratic process through violence and 

intimidation.

CJMED established the relevant parameters to factor 

into the estimate. In order to account for the risk associated with the elections period, we analyzed recent RC(S) 

signifi cant activity data from CIDNE, concentrating on 

those signifi cant activities that were most likely to cause 

casualties.

We applied these statistics against the average number 

of signifi cant activities RC(S) experienced per day in 

the last month. Applying the intelligence estimate (Joint 

Staff J2) against this baseline and assuming a gradual 

DEVELOPING AN OPERATIONAL CASUALTY ESTIMATE IN A MULTINATIONAL HEADQUARTERS

TO INFORM AND DRIVE MEDICAL RESOURCE ALLOCATION
 October – December 2012 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

increase in the weeks preceding election day, the peak 

on election day, followed by a gradual decrease in the 

weeks after election day, we produced a regional casualty estimate that was based on historical data. This 

accounted for the risk associated with baseline activities 

and the elections period.

The next step was to account for the risk associated 

with Phase 3A operations. We consulted with the Combined Joint Operations section (CJ35) and agreed that 

the Arghandab clear operation (Stage 2) would be most 

similar to Phase 3A operations. We determined which 

units comprised the task force assigned to the Arghandab clear operations, the size of each of those individual 

units, and the timeline for the operation. This gave us the 

total size of the force, or population at risk (PAR)—the 

denominator—as well as the duration of the operation. 

In order to determine the attrition rate for the Arghandab clear operations, we queried the casualty reporting 

databases to pull the actual numbers for all categories 

of casualties for the Arghandab clear operation—the 

numerator. This attrition rate was used as the “anchor” 

for determining the estimated casualty rate for Phase 3A 

operations.

CJ35 then provided a sequence matrix of all events associated with Phase 3A operations, which listed the size 

of the force (PAR), as well as the planned start and end 

dates. Since the intelligence estimates indicated Phase 

3A operations would be much more intense, given the 

higher density of insurgent fi ghters and diffi cult terrain, 

CJ35 also added an increased intensity factor (IIF) to 

the Arghandab attrition rate (AAR). CJ35 applied the 

following IIF to each operational event: low, 10% more 

casualties (amber); medium, 20% more casualties (red); 

high, 30% more casualties (black).

The operational sequence was then placed into another 

matrix to determine the estimated number of casualties per day. The following formula was used for each 

event:

(AAR+(AARIIF))PAR=total number of casualƟ es

for the event

We then made assumptions about the distribution of 

those casualties over the duration of the event. We categorized each event into short (1 to 3 days), medium (4 

to 10 days), and long (11 to 21 days) durations. For short 

events, we expected only 10% of the total number of casualties would be suffered and all of the casualties would 

occur on the fi rst day of the event. For medium events, 

we assumed an even distribution of the total expected 

casualties across a 9-day period. For long events, we 

presumed casualties would be higher in the early days, 

and diminish towards the end. To get the total number of 

casualties expected on any given day, we calculated the 

number of casualties expected as a result of baseline and 

elections activities. We mapped the Phase 3A expected 

number of casualties by event to the actual day the event 

was to start. We then added across all the simultaneous 

activities for each day.

Matching The Casualty Numbers and Flow to the 

Capacity of the Medical System

The other component that must be understood is the capacity and effi ciency of the Role 3 hospitals and the air 

evacuation assets in RC(S). The CJMED operations section recorded, tracked, and analyzed trends of the hospital capacity and air evacuation performance in RC(S). 

Because there was rarely an indication that there was 

insuffi cient capacity in the air evacuation systems,3(p1-3)

we did not conduct in-depth analysis on these systems. 

However, we did know that hospital capacity could present an operational constraint and we sought to better understand the capacity and throughput of the hospital. 

In April 2010, the RC(S) Medical Director requested the 

US Joint Combat Casualty Research Team to conduct a 

study to analyze the resource utilization in the Kandahar 

Air Field Role 3 hospital (KAFR3). They were asked to 

examine operating room utilization, and intensive care 

unit (ICU) and intermediate care ward (ICW) lengths of 

stay. Their fi ndings provided a much better understanding of the fl ow of casualties through the hospital. Most 

signifi cantly, we determined that casualty rates should 

be estimated per day, as opposed to per week or per 

month, because the lengths of stay of all categories of 

patients was almost always measured in days, and there 

was a wide variability in the number of casualties in any 

given day. There was no casualty estimate tool or model 

already developed that we could fi nd which calculated 

number of casualties per day. This further necessitated 

the need for a locally developed methodology.

As expected, given the effi cient strategic medical 

evacuation system and availability of higher levels of 

care outside of Afghanistan, ISAF casualties spent one 

day or less in the hospital. There was very little variability around this statistic. Afghan National Security 

Force casualties spent approximately 2 to 3 days in hospital before they were stable enough to be transferred 

to an Afghan facility for care. There was much more 

variability with this statistic. Afghan civilians and Afghan detainees spent the longest time in hospital, 3 to 6 

days, and also had the most variability to their lengths 

of stay. This was primarily because it was not acceptable to transfer Afghan civilians away from their home 

province, and Afghan detainees that were still under the 
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

custody of ISAF forces could not be transferred out of 

ISAF facilities for security reasons. Of all the hospital 

capabilities, ICU bed capacity had to be managed the 

most carefully because it is a more resource intensive 

capability, the scarcest capability, and served our most 

critically injured casualties.

The Table depicts how the ISAF system of care describes 

the amount of capacity remaining in the hospital. It expresses the amount of risk in exceeding hospital capacity via the traditional military “stoplight” model. This 

table does not account for the surge capacity that all hospitals possessed to get through a casualty crisis. While 

BLACK does indicate the highest risk, it does not indicate 

that the hospital would not be able to manage casualties 

during that time. It was meant to communicate that the 

system was under a tremendous amount of pressure and 

perhaps should be considered an operational constraint. 

Understanding the dynamics of patient fl ow at KAFR3 

helped us understand the casualty profi le that the ISAF 

system of care could absorb in a day and the subsequent 

impact on available capacity the next day. We determined the range of casualty numbers for GREEN, AMBER, 

RED, and BLACK status (those numbers are intentionally 

not presented in this article). This calculation became 

very important in expressing the risk. Though it would 

have been ideal to understand the capacity and throughput of Kandahar Regional Military Hospital (KRMH), 

there was not the same capability to track and store data 

for later analysis. Given the ISAF system of care underwrites the risk in the Afghan system of care, we did not 

pursue a more deliberate analysis of KRMH.

RESULTS

Presenting the Analysis and Developing Mitigation 

Strategies

Graphing the total number of expected casualties per 

day, with the hospital capacity superimposed, gives a 

visual of where the high-risk periods are and the magnitude of the anticipated risk. The results of the analysis indicated that there was a signifi cant potential for 

medical risk. This risk could potentially become an operational constraint. We also anticipated days in which 

there was very little spare capacity in the system to deal 

with a mass casualty event. We briefed our analysis and 

risks to the combined medical team whose key stakeholders consisted of the KAFR3 hospital, the casualty 

aeromedevac staging facility (the aviation task forces 

providing rotary-wing air evacuation), the 62nd Medical 

Brigade, the Afghan National Army (ANA) 205 Corps 

Surgeon, and the ANA KRMH Commander, to ensure 

they all had the same operational information. We then 

worked together to develop mitigating strategies. 

We determined the most important method to mitigate 

risk was to affect the number of casualties the Role 3 

hospitals could take in a day and still have capacity left 

to handle the next day’s casualty profi le. The combined 

team agreed this would be the most powerful strategy. 

We reallocated resources from across the theater to increase the KAFR3 capacity to handle surgical cases, 

as well as staff additional ICU and ICW beds. Figure 1 

presents the casualty estimate per day, relative to hospital capacity, as well as the potential impact of hospital 

augmentation. While the ANA system of care attempted 

to do similar capacity increases, they were not able to 

obtain the resources to establish the extra capacity. They 

did have a contingency plan to set up a 40-bed minimal 

care ward in case of a large casualty surge.

The rotary-wing and fi xed-wing aviation task forces 

also increased their capacity to conduct air evacuations 

by adding additional crews and aircraft to support the 

increased tempo of operations. The combined medical 

team agreed to adopt aggressive bed clearing practices to ensure the medical system was best prepared to 

handle the next day’s events. Aggressive bed clearing 

was defi ned as maximum use of tactical evacuation to 

clear RC(S) of casualties by transferring them to other in-theater hospitals. It also included more frequent 

use of strategic evacuation assets for those casualties 

requiring evacuation out of theater. The casualty data 

pattern established 1 to 3 day peaks followed by 1 to 2 

day troughs. Because there was no historical evidence 

of a sustained period of peak casualty rates, we decided 

the mitigation strategies described would be appropriate 

and suffi cient.

Informing the Operational Leadership and the 

Commander

It is important to keep the operational leadership and 

commander informed about the medical risk associated 

with operations. This is especially true if the risk cannot be suffi ciently mitigated and remains an operational 

constraint. Current medical risk information allows 

commanders to decide if the operational plan should 

be adjusted to accommodate the constraint. Each headquarters will have a process for synchronizing the staff 

and gaining a forum with the commander to present 

DEVELOPING AN OPERATIONAL CASUALTY ESTIMATE IN A MULTINATIONAL HEADQUARTERS

TO INFORM AND DRIVE MEDICAL RESOURCE ALLOCATION

Hospital capacity expressed as risk.

Status ICU Fill ICW Fill Overall Fill Risk

Green 50% 50%

Most

Constrained 

of ICU vs 

ICW

Low

Amber 51% to 75% 51% to 75% Medium

Red 76% to 99% 76% to 99% High

Black 100% 100% Very High
 October – December 2012 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

information, seek guidance, or get decisions. RC(S) 

CJMED planners continued to stay integrated with the 

operational staff throughout the analysis and operational planning. We periodically briefed the results of 

the casualty estimate to operational leaders, the chief of 

staff, and the commander. This ensured the wider staff 

was informed of the analysis and gave the commander 

confi dence that the medical risk was properly evaluated 

and addressed. 

Refi ning the Model

As with any model, one must compare the assumptions 

and logic to determine its accuracy. When we plotted 

the estimate against the actual number of casualties that 

were handled by the augmented ISAF system of care, it 

was obvious that the assumptions built into the model 

overestimated the risk. We determined that because we 

used CIDNE data to drive the casualty estimate for baseline and the elections period, we built into the model the 

total number of casualties reported in the region, but not 

necessarily just those handled by the ISAF system. Kandahar City has 2 capable hospitals, one ANA and the 

other civilian. These hospitals handled a portion of the 

casualties that occurred in the region without ISAF involvement for evacuation or treatment. Figure 2 presents 

the actual data compared to the estimate.

We backed out the elections assumptions to assess the accuracy of the methodology associated with the Phase 3A 

operations. This is demonstrated on the left portion of 

Figure 3. Based on this review, we concluded that while 

the model does not necessarily predict the exact number of casualties per day (exceedingly diffi cult to do), 

it did indeed predict the magnitude of the risk we expected. Ultimately, this is what drives resource decisions. Given we had good confi dence in the assumptions, we used the same methodology and applied it 

against Phase 3B operations. The results indicated 

the amount of medical risk was manageable without 

external augmentation. Therefore, we released those 

assets back to their parent organizations and continued to monitor actual casualty rates. The right portion of Figure 3 displays these results. 

We note that the model overestimated the medical 

risk for Phase 3B, despite the improved accuracy 

the model demonstrated for Phase 3A. After studying the operational information, we concluded that 

ISAF used different tactics, techniques, and procedures than were used in Phase 2 operations in the 

Arghandab District to counter the most dangerous 

threat of IEDs. The intelligence estimates were correct; the terrain was extremely diffi cult and there 

Number of CasualƟ es

High Risk Period

Highest Risk Period High Risk Period Number of CasualƟ es With AugmentaƟ on

Figure 1. Phase 3A and election period casualty estimate per day relative to hospital capacity and associated medical risk, and

potential impact of augmentation on hospital capacity and associated medical risk.

Figure 2. Comparison of Phase 3A and election period casualty estimate with actual casualties handled by the augmented ISAF system and actual total number of casualties reported in the region.

Casualty estimate Actual total reported casualties Actual casualties into ISAF system

Number of CasualƟ es
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

were many IED belts. However, ISAF used special mine 

clearing and antipersonnel obstacle removal systems to 

clear maneuver pathways. A single removal effort often 

caused multiple sympathetic detonations of IEDs. These 

clearing systems were not used as frequently in the 

Arghandab District because the population density was 

higher and the risk of collateral damage was too great. 

The areas cleared in Phase 3B were much more rural 

and sparsely populated, allowing ISAF to use more aggressive tactics.

COMMENT

This methodology serves a very specifi c purpose not 

available in other casualty estimate models. It is an 

operational level casualty estimate that specifi cally addresses the daily medical capacity required within an 

area of responsibility. This is not the strategic process of 

assigning medical forces to the theater of operations to 

support the campaign. It is not the units’ tactical decisions, such as moving medical capabilities around the 

battlefi eld to support daily operations. It is not intended 

to determine type and amount of logistical supplies to 

treat specifi c wounds. This model does not predict the 

level of granularity that some casualty estimate models 

attempt to do, such as evacuation category,3(p1-10) battle 

injury vs disease or nonbattle injury, or nationality of 

the casualty. We balanced the precision of the information and amount of complicated analysis necessary to 

factor in these elements against the simplicity and agility of the model. Making an assessment of the amount 

of casualties the Role 3 hospitals could absorb in a day, 

and expressing that as a degree of risk, accommodated 

for these detailed elements well enough. It enabled us to 

make an informed decision without investing in perfecting the information. The leadership of RC(S) changed 

from British-led to US-led division headquarters on 

November 2, 2010, and both authors of this article concluded our analysis of this subject.

CONCLUSION

It is important for the medical planner to maintain excellent situational awareness of operational information 

and participate in the military decision-making process. 

This is achieved through membership in cross-functional planning teams and active listening at command-level 

summary briefs. Through this participation, a medical 

planner will develop an understanding of what operational information is relevant. This allows suffi cient data 

to be captured with much less diffi culty. Given the likelihood of future campaigns in a multinational environment, it is imperative to use simple and widely available 

software so that any contributing-nation medical planner can convert the discrete data into current medical 

planning information. The information can then be used 

to produce estimates and analysis to inform the medical 

risk and mitigation strategies. The steps outlined in this 

article are presented in Figure 4.

As stated in NATO medical support doctrine,

Casualty estimates are one of the core tools of medical 

plans, they are major resource drivers and, although an 

inexact science, accuracy is important.2(p1-32)

A mass casualty plan is appropriate for handling single 

or multiple catastrophic events (aircraft accident, suicide bomber, etc) that must be managed over a day or 

two. It is nearly impossible to predict when these events 

will occur, and every medical system must be prepared 

to surge to get through such a casualty crisis of relatively 

short duration. In contrast, a mass casualty plan is insuffi cient to contend with a high, sustained rate of casualties, 

and its inadequacies will result in an enormous amount 

DEVELOPING AN OPERATIONAL CASUALTY ESTIMATE IN A MULTINATIONAL HEADQUARTERS

TO INFORM AND DRIVE MEDICAL RESOURCE ALLOCATION

Figure 3. Phase 3A casualty estimate per day compared to actual casualties handled by the augmented ISAF system, and Phase 

3B casualty estimate per day compared to actual casualties handled by the unaugmented ISAF system. Number of CasualƟ es Number of CasualƟ es

Casualty esƟ mate Actual casualƟ es in augmented ISAF system Casualty esƟ mate Actual casualƟ es in unaugmented ISAF system

Phase 3A Phase 3B
 October – December 2012 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

of stress on the medical system and endanger probabilities of survival of casualties. Military medical planners 

can anticipate periods of sustained (measured in weeks) 

high levels of casualties with good casualty estimates. 

However, it is important to fully appreciate that augmentation of medical systems with personnel and/or equipment requires considerable time and coordination. This 

is especially true for projected personnel augmentation 

requirements. Healthcare is complex, and human–skill–

set-centric, so personnel augmentations must be initiated as early as possible to allow the additional personnel 

time to travel and integrate into their new environments. 

It is, therefore, vital that projected casualty planning 

is accomplished with as much lead time as possible to 

allow the medical system adequate time to respond to 

identifi ed augmentation requirements.

REFERENCES

1. STANAG 2542 MEDSTD (Edition 1)–Allied Joint 

Medical Planning Doctrine–AJMedP-1. Brussels: 

North Atlantic Treaty Organization Standardization Agency; November 3,2009:3-15–3-16. Available at: http://nsa.nato.int/nsa/zpublic/stanags/cur

rent/2542eed01.pdf. Accessed July 18, 2012.

2. AJP-4.10(A): Allied Joint Medical Support Doctrine. Brussels: North Atlantic Treaty Organization 

Standardization Agency; March 2006. Available at: 

http://nsa.nato.int/nsa/zPublic/ap/AJP-4.10(A).pdf. 

Accessed July 18, 2012.

3. STANAG 2546 MEDSTD (Edition 1–Allied Joint 

Doctrine for Medical Evacuation)–AJMedP-2. 

Brussels: North Atlantic Treaty Organization Standardization Agency; November 24, 2008. Available at: http://nsa.nato.int/nsa/zpublic/stanags/cur

rent/2546eed01.pdf. Accessed July 18, 2012.

AUTHORS

LTC Davis is Commander, 187th Medical Battalion, 

32nd Medical Brigade, Fort Sam Houston, Texas. When 

this article was written, she was Deputy Medical Advisor, 

Regional Command (South), Kandahar, Afghanistan.

Col Bricknell is Assistant Director Medical Capability, 

Army Medical Directorate, Great Britain. When this 

article was written, he was Medical Director, Regional 

Command (South), Kandahar, Afghanistan.

Figure 4. Diagrammatic presentation of the sequential steps involved in developing a casualty estimate, analyzing the medical risk, and developing mitigation strategies.
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

CONTENTS

Predicting Human Limits—The Special Relationship Between Physiology Research and the Army Mission

Modeling the Physiological and Medical Effects of Exposure to Environmental Extremes

Measuring and Predicting Sleep and Performance During Military Operations 

Performance-Maintaining and Performance-Enhancing Drugs and Food Components

In Vivo Diagnostics and Metrics in the Assessment of Laser-Induced Retinal Injury 

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(YDOXDWLRQRIWKH7KHUPDO(QYLURQPHQW3URWHFWLRQRIWKH6NLQ

%ODVW,QMXU\7UDQVODWLQJ5HVHDUFK,QWR2SHUDWLRQDO0HGLFLQH,QMXU\&RQWURO

Load Carriage in Military Operations: A Review of Historical, Physiological, Biomechanical, and Medical Aspects

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

William R. Santee, PhD

Research Physical Scientist

Biophysics and Biomedical Modeling Division

US Army Research Institute of Environmental Medicine

Karl E. Friedl, PhD

Colonel, Medical Service Corps, US Army

Director, Telemedicine and Advanced Technology Research Center

US Army Medical Research and Materiel Command

BORDEN

INSTITUTE

UNITED STATES ARMY

OFFICE OF THE SURGEON GENERAL

To Order:

www.bordeninstitute.army.mil
 October – December 2012 59

Since January 2003, the United States and its allies 

have been engaged in extended military operations with 

most military nurses deploying into and out of combat 

environments. During these deployments, nurses have 

operated under extreme conditions exposing them to 

both primary and secondary trauma. As early as 2004, 

emerging evidence from these deployments supported 

the correlation between trauma exposure, increased 

behavioral health symptoms, and premature military 

attrition for the military population in general.1,2 This 

evidence suggests that deployments have an impact on 

military personnel. Nurse work during deployment is 

different from nurse work after deployment, and most 

military personnel report an adjustment period after returning home from deployment.3

 With record numbers 

of military nurses returning from their fi rst, second, and 

third deployments, the author used data collected during 

a Nurse Deployment and Retention Study to construct 

evidence-based strategies to support nurses returning 

from deployment to nondeployed nurse work. The goal 

is to facilitate the transition of nurses to nondeployed 

nurse work using the proposed supportive strategies.

DEPLOYMENT NURSE WORK IS DIFFERENT

In a study of the most comparable deployed hospital, a 

full complement combat support hospital operating out 

of a fi xed facility, Filliung et al4

 reported that nurses 

were taking care of a broader spectrum of injuries and 

illnesses as well as contending with greater complexity than when not deployed. The most common type of 

battle injuries were blast (79.3%) and gunshots (20.7%). 

The most common type of nonbattle injuries were crush 

(21.2%), with vehicle accidents at 13.6%. No nondeployed military treatment facility would have a patient 

profi le that is comparable. If the patients are different, is 

the environment of providing care also different?

Mark et al 5

 designed a study which closely examined the 

research question, “What is the nature of deployment 

experiences as perceived by Army Medical Department 

personnel?” Using a qualitative design, she and the 

other investigators conducted 12 focus groups and one 

individual interview. Twenty-four hours of transcription 

yielded 3,429 passages that were analyzed. Three areas 

of differences emerged: leadership, readiness, and safety. The authors noted that in their literature review of 

9 other studies, the themes were consistent even when 

other studies included different services, branches, environments, and missions.

When it came to describing the actual environment, 

participants told investigators Scannell-Desch and Doherty6

 that living conditions were varied depending 

upon where the nurse was assigned, as well as how early 

or late in the military operations that they deployed. In 

the beginning, nurses would not shower for days, even 

weeks, living in dirty tents and containerized housing. 

However, nurses deploying later reported more mature 

housing and hygiene facilities. But most often, they report continuous nursing work with high levels of trauma 

and high levels of personal risk.6

 What are the effects of 

this different patient population and work environment 

on nurses once they return?

EFFECTS OF DEPLOYMENTS ON NURSES

Unfortunately, most studies concerning the effects of 

deployment do not report fi ndings by occupation. In fact, 

it has been noted that healthcare workers often do not 

Strategies to Support Nurse Work

 Reintegration After Deployment

 Constructed From an Analysis of Army

 Nurses’ Redeployment Experiences

COL Denise L. Hopkins-Chadwick, AN, USA

ABSTRACT

Many military nurses fi nd a period of transition is necessary in order to fully return to work after deployment. 

Coworkers and supervisors can be a positive or negative force in that transition. Using data from a larger study, 

evidence-based strategies to support nurses who return to nursing work after deployment were developed. 

Having an understanding of what returning nurses say about their “coming home” phase can help coworkers 

and supervisors be a positive force in work transition. A table of tasks with explanations is provided to assist 

coworkers and supervisors in facilitating the transition back to noncombat nurse work.
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

participate in the routine screenings for pre- and postdeployment health, especially when they are individual 

augmentees and do not return as part of a large group. 

A study by Akbayrak et al 7

 provides insight with its examination of the effects that witnessing trauma and being exposed to personal threat had on Turkish military 

healthcare workers. Turkish military healthcare workers 

are often exposed to higher levels of trauma than their 

US counterparts due to natural disasters, terrorism, and 

the high rate of traffi c accidents. Terrorism events have 

been common in parts of Turkey for the past 20 years. 

Military healthcare workers have witnessed the deaths 

of many people, including the loss of their loved ones, 

while under the threat of dying themselves. In the study, 

Turkish military healthcare workers were found to be at 

least as affected as their civilian counterparts by trauma 

exposure.

While studying military who had served in the Vietnam 

combat theatre of operations, Carson et al 8

 reported 

that nurses were more vulnerable to the negative effects of trauma exposure, possibly due to the feelings 

of inadequacy that overwhelming mass casualty situations cause. Kolkow et al 9

 found that in a population of 

healthcare workers responding to anonymous surveys 

after deployment, 9% met the criteria for posttraumatic 

stress disorder (PTSD) and 5% met the criteria for depression. They also found that threat of personal harm 

was the most predictive factor in PTSD. Scannell-Desch 

and Doherty6

 interviewed 37 Army, Navy, and Air Force 

nurses who had deployed to Iraq and/or Afghanistan on 

4 to 16 month tours from 2003 to 2009. They concluded 

that nurse work during a war is unique for those doing it, 

regardless of education, preparation, or training. They 

postulated that there are many variables that impact the 

response that nurses have, and that the variables are 

both personal and professional. Specifi cally, the nurses 

they interviewed recalled images, sounds, and smells 

years after returning. These nurses would all describe 

at least one lasting memory of a patient, a memory that 

they said would stay with them for the rest of their lives. 

They shared their feelings toward the children caught in 

the combat and the outrage they had still today for the 

circumstances. Under the theme of “my wartime stress–

I’m a different person now,” they talked about how the 

war changed them. Some talked about having anxiety 

and panic attacks at work once back home, while also 

noting that their capacity for empathy and compassion 

had diminished. Short-fused anger, guilt, depression, 

sleep problems, and fl ashbacks were also reported. So, 

if nurse work deployed is different and deployment has 

lasting effects, what is the best way to support nurses 

as they transition from combat nurse work to the nurse 

work they will do once they return home?

SUPPORT STRATEGIES

As each service and each branch within each service 

begins to examine the evidence and develop the best 

strategies to support reintegration after deployment, it 

is possible that some strategies will be the same for all 

and some may have service, branch, and gender specifi c 

implications. Doyle and Peterson10 reviewed case studies that reported successful reentry and found that successful reintegration was related to inclusion of families 

and communities early in the process. Nonmedicalization of distress along with easy access to mental health 

professionals was also found to be key. In a study of 

military reservists done by Mcnulty,11 organizational 

support was a good predictor of work adjustment. Specifi cally, organizational support in the form of job reassurance, differential pay, and reorientation training 

were meaningful.

DEPLOYMENT-RELATED NURSE RETENTION STUDY

A few years after the current military confl icts started, 

senior Army Nurse Corps (ANC) leadership approached 

the nurse scientists at Madigan Army Medical Center 

(noted in the acknowledgements) expressing their concerns over the redeploying nurses who were telling them 

that they wanted to leave the Army Nurse Corps, and in 

some cases leave nursing altogether. The scientists designed a descriptive qualitative study using Hursselian 

Phenomenology studying the research question, “what 

is it about deployment that makes a nurse want to stay or 

leave the Army Nurse Corps upon return?”

Study participants talked about their experiences in 3 

phases: preparing to deploy, being deployed, and coming home. The author uses the “coming home” data to 

construct evidence-based support strategies that redeployers and those who lead and work with them in medical treatment facilities can follow to facilitate the transition back to nondeployed nurse work.

“COMING HOME” RESULTS

Three focus groups were conducted, each with 4 participants for a total of 12 participants. The response rate 

was 57%. Of the 43% who did not participate: 9% declined to participate and 88% were unavailable due to 

work schedule confl icts. Four specialties (medical/surgical, emergency department, intensive care unit, and 

operating room) and 6 combat support hospitals were 

represented. Most of the participants were 1st lieutenants (44%), followed by majors (33%), captains (15%), 

and 2nd lieutenants (8%). Focus group discussions were 

guided by the following questions:

 What is it about deployment that affects a nurse’s 

decision to stay or leave the ANC?

STRATEGIES TO SUPPORT NURSE WORK REINTEGRATION AFTER DEPLOYMENT

CONSTRUCTED FROM AN ANALYSIS OF ARMY NURSES’ REDEPLOYMENT EXPERIENCES
 October – December 2012 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

 If you were the Chief of the ANC, what 2 or 3 

things would you fi x fi rst in order to have a huge 

impact on ANC retention?

The following probes were used:

 What made these positive/negative experiences?

 How would you make it better?

 Is there anyone in the room who has different 

views?

 Pre, during, post?

 Being deployed with a unit with which you did 

not train or were not stationed?

 Deployment work issues?

 Comfort/environment issues?

Five themes emerged when study participants discussed 

the “coming home” phase of their deployment:

1. Recognize us and our families with a “welcome 

home.”

2. Make an honest effort to give us assignments 

that move us forward in our career.

3. Treat us like we are staying in the military.

4. You make nursing work harder than it has to be 

at home.

5. Evaluate postdeployment health, suggest Army 

OneSource, collocate if possible.

Since 2005, these themes have been presented to countless nurses returning from deployment, and their input 

have resulted in only 2 modifi cations. The fi rst theme 

“Recognize us and our families with a ‘Welcome Home’” 

was changed to “Welcome Home for Everybody,” and 

one of the recommendations in that theme (see below) 

was changed to read negotiable leave instead of 30 days 

leave. The following information is presented fi rst with 

the theme followed by some representative quotes concluding with an explanation of the participants’ discussions. Lastly, these themes, representative quotes, and 

explanations are reworked to create a list of evidencebased support strategies that can be used by leaders and 

peers who are welcoming deployed nurses back to the 

workplace.

Recognize Us and Our Families With a “Welcome Home”

 When we came back, the leadership did nothing. 

It was just, “when do you want to come back to 

work?”

 It should be an immediate “welcome back,” not 

followed with “by the way, do you want to kill 

yourself?” 

 We were met by the commanding general. It was 

individualized. Recognition is important.

 Follow the recognition with 30 days of leave 

(individualized).

Nurses who had been individual augmentees or PROFIS* 

personnel expressed how awkward and lonely it was to 

walk off the plane for the fi rst time back on American 

soil at a place where they did not live or were not assigned, because no one they knew was there to greet 

them. They were irritated by the “check the box” feeling 

they got from redeployment screeners. They appreciated any recognition, although they acknowledged that 

they were hesitant to notify their supervisors back home 

about when they were returning. They feared being put 

back to work too soon, or they did not feel a relationship 

with them anymore since they did not hear from them 

while they were deployed. They wanted some automatic 

leave to “decompress,” but after that, they wanted to be 

able to negotiate their leave over the following year.

Make an Honest Effort to Give Us Assignments that 

Move Us Forward in Our Career

 We were ready for new challenges. It was insulting to resume a preceptorship or return to a lowspeed area.

 Even though I went back to the same fl oor, the 

paperwork had really changed.

 I was glad that I did not get a leadership position. 

I needed to decompress for a while.

 I wanted to go to the ICU but could not, at least let 

me freshen up my EKG skills or something.

Nurses expressed the frustration they felt when their coworkers and supervisors appeared to not understand the 

level of work they did while deployed. Some of them 

wanted to “decompress” and even take jobs outside of 

the emergency room or ICU for a while. Only on one occasion did a nurse indicate a desire to leave nursing altogether, but even then it was seen as a temporary emotion. 

Some of the nurses in these focus groups had deployed 

shortly after graduating from the Basic Offi cer Leader 

Course and were gone for a prolonged period of time. A 

few nurses discussed missing certain positions or opportunities while deployed that could have accelerated 

their career. Almost all of them expressed concern about 

their lack of connection and/or communication with 

their coworkers and supervisors back home. To them, 

they had been forgotten and even somewhat abandoned, 

which seemed to erect a wall with their leadership once 

they returned, making it all the more diffi cult to discuss 

*PROFIS predesignates qualifi ed Active Duty health professionals 

serving in other units to fi ll 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.
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

career advancement. They did not want to go back into 

an “orientation/preceptorship,” but many administrative 

procedures had changed and they felt frustrated with the 

status as behind on training.

Treat Us as if We Are Staying in the Military

 When I came back, the supervisors said I would 

be assigned to this fl oor until I left the Army. I 

don’t know where they got the idea that I was getting out.

 Everyone kept saying “you are getting out of the 

Army aren’t you?” 

 I asked to be stationed near my family but was 

informed that since I had indicated that I was getting out, I could not move. I was still thinking 

about staying in, but when that happened, I was 

discouraged.

Often nurses have not fi rmly decided whether to stay or 

leave the military or nursing. The best course of action 

for coworkers and supervisors is to treat all returnees as 

though they are staying— continue to coach, teach, and 

mentor, no matter what the returning nurse may say.

 In the states, nursing work seems to be made more 

diffi cult than it has to be.

 It was almost a black hole for me. Reintegration 

was as though I was immersed in a fog.

 I took care of Soldiers with body parts blown off; 

here I took care of chronic alcoholics and smokers 

who did this to themselves. I became more callous.

 The staff make everything bigger than it really was. 

“You need to be quicker,” and I would think that 

he’s not really dying.

 Supervisors said I did not understand how things 

worked on the inpatient unit. I had some apathy.

 I got busted out for being laissez faire.

 I learned to separate from the job; here, nurses are 

overly involved in their work.

 This job seems less important; there you have a 

sense of doing the ultimate job. You’re not worried 

about standard operating procedures. You’re doing 

what is important.

 You can’t ask the nurses here to be more sensitive 

to us, because they just don’t get it. They won’t 

understand.

 I don’t worry about the paperwork and stuff. That 

stuff will take care of itself.

Perhaps the worst job for a returning nurse is to be in 

charge of a Joint Commission task force. Returning 

nurses need time to disengage from the pace of deployment. One example given was a nurse who returned to 

a recovery room position. His supervisor noted that he 

was not using oxygen on all of his recovering patients 

and assumed that he was not providing quality nursing 

care because he had lost his “edge” postdeployment. But 

when questioned, the nurse explained that he felt like 

some of the patients were doing so well that they did 

not need the oxygen, after all, he had seen patients in 

combat who really needed oxygen. A good leader would 

facilitate the transition of the returning nurse through 

patient, gentle coaching and nonjudgmental reinforcement to readopt the nondeployed standards.

Evaluate postdeployment health, suggest Army 

Onesource, collocate if possible

 Immediately upon returning, we get tired of being 

asked if we are suicidal or homicidal.

 A few months after return, we need someone to 

check on us because that is when the issues surface.

 Recommend OneSource, let people know it is there 

at the 3 to 6 month mark.

 Chief Nurse interviews should be done 3 to 6 

months after deployment, and Head Nurses should 

always be checking their people.

 I would really have liked a meeting to talk about 

how to make it better for the next group.

 We need our postdeployment health evaluated, ie, 

hearing, mental health, asthma.

Three things were heavily discussed under this theme. 

First: as medical personnel or individual augmentees, 

the returnees often were overlooked in postdeployment 

screening. Some of them even admitted to avoiding the 

postdeployment screening and using getting back to work 

as an excuse to not attend the usual “cattle calls.” Second: 

they discussed the “honeymoon phase” of postdeployment, a time when they really had no negative reactions to 

deployment and were not really interested in thinking too 

deeply about the impact of deployment. But those feelings 

faded, most often in the 3 to 6 month postdeployment period. They did want to be “checked on,” and rejected the 

suggestions of mandatory support groups, especially if 

they are led by people who do not have deployment experience. Third: they related best to those who had also 

deployed and often looked to see if people were wearing 

the right shoulder patch, indicating deployment veterans 

with whom they would have more in common.

CONCLUSIONS

Taking the themes, representative quotes, and explanation given by one investigator, the author has constructed 

a list of tasks, presented in the Table, for coworkers and 

supervisors to use in supporting returning nurses. Since 

this study was completed, other nurse investigators have 

STRATEGIES TO SUPPORT NURSE WORK REINTEGRATION AFTER DEPLOYMENT

CONSTRUCTED FROM AN ANALYSIS OF ARMY NURSES’ REDEPLOYMENT EXPERIENCES
 October – December 2012 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

advanced postdeployment questions concerning returning nurses, classes have been added to hospital orientations, and content has been integrated into the Army 

Nursing Leader Academy which is made available to deploying and redeploying units and supplying units upon 

request.

ACKNOWLEDGEMENTS

The author acknowledges and thanks the investigators 

who conducted the Deployment Related Retention 

Study: COL (Ret) Laurie McNabb, Dr Lori Loan, Dr 

Mary McCarthy; and the support staff: Dr Bill Reeder, 

Ms Kathi Hamilton, and MAJ Jess Calohan.

REFERENCES

1. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems and barriers to 

care. N Engl J Med. 2004;351;13-22. 

2. Hoge CW, Auchterlonie JL, Milliken CS. Mental 

health problems, use of mental health services, 

and attrition from military service after returning 

from deployment to Iraq or Afghanistan. JAMA.

2006;296(5):1012-1032.

3. Blais A, Thompson MM, McCreary DR. The 

development and validation of the Army postdeployment reintegration scale. Mil Psychol. 

2009;21(3):365-386.

4. Filling DR, Bower LM, Hopkins-Chadwick DL, 

Leggett MK, Basca C, Harris K, Steele N. Characteristics of medical-surgical patients at the 86th 

Combat Support Hospital during Operation Iraqi 

Freedom. Mil Med. 2010;175(12):971-977.

5. Mark DD, Connelly LM, Hardy MD, Robison J, 

Jones CC, Street TA. Exploring deployment experiences of Army Medical Department personnel. Mil 

Med. 2009;174(6):631-636.

6. Scannell-Desch E, Doherty ME. Experiences of US 

military nurses in the Iraq and Afghanistan wars, 

2003-2009. J Nurs Scholarsh. 2010;42(1):3-12.

7. Akbayrak N, Ofl az F, Aslan O, Ozcan CT, Tastan S, 

Cicek HS. Post-traumatic stress disorder symptoms 

among military health professionals in Turkey. Mil 

Med. 2005;170(2):125-129.

8. Carson MA, Paulus LA, Lasko NB, et al. Psychophysiologic assessment of posttraumatic stress 

disorder in Vietnam nurse veterans who witnessed injury or death. J Consult Clin Psychol. 

2000;68:890-897.

9. Doyle ME, Peterson KA. Re-entry and reintegration: returning home after combat. Psychiatr Q. 

2005;76(4);361-370.

10. Kolkow TT, Spira JL, Morse JS, Grieger TA. Posttraumatic stress disorder and depression in healthcare providers returning from deployment to Iraq 

and Afghanistan. Mil Med. 2007;172(50):451-455.

11. McNulty PA. Reported stressors and healthcare 

needs of active duty Navy personnel during three 

phases of deployment in support of the war in Iraq. 

Mil Med. 2005;170:530-535.

AUTHOR

COL Hopkins-Chadwick is Chief, Department of 

Nursing Science, Army Medical Department Center and 

School, Fort Sam Houston, Texas.

How coworkers and supervisors can support and smooth the transition of redeploying nurses.

Task Notes

1. Provide recognition and welcome back (for everyone). Always say “welcome back.” If you are meeting them in a common 

area, greet everyone, even if you do not personally know them.

2. Approve negotiated leave unless the nurse requests something different.Better yet, contact them before they return and negotiate leave.

3. Evaluate postdeployment health (ongoing). Remind them and give them time to do all of the reverse deployment screening.

4. Negotiate job assignment. If unable to provide first choice, 

create a plan to move toward first choice. 

Best to begin conversation before they return. Be flexible, their 

aspirations will likely change.

5. Recognize that most people report the need for additional 

support at the 3 to 9 month postdeployment point, and that 

most people prefer an outside source or peers with the same 

experience.

After the “honeymoon phase,” asking someone how reintegrated 

he or she is today on a scale of 1 to 100 (%) helps to identify if and 

when they need additional support.

6. Understand that most people report a period of apathy and 

callousness that may be perceived as loss of motivation and 

the intent to leave the ANC; this usually resolves over time. 

The antidote for apathy and callousness at work is usually time, 

but if it is not gone at 9 months, support nurse in getting help 

and/or counseling.

7. Understand that personnel returning to the same work unit 

will find that things have changed while they were away. They 

may need a miniorientation.

Minimize labeling returning nurses as delinquent on training. 

Make reorientation fun and easy.

8. Provide time to re-inprocess, perhaps one or 2 days during 

the week.

Avoid immediate scheduling to rotating shifts.
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

The Mayo brothers are quoted as saying, “the only winner in war is medicine.”1

 Research within theaters of 

operations occurred in World War I, World War II, the 

Korean War, and the Vietnam War. There were no formal research teams during those wars, only healthcare 

providers seeking better ways to care for the wounded 

Soldiers. Many advances in medical care have been 

and are continuing to be made as a result of wars and 

confl icts—management of shock, psychology of combat stress, blood transfusions, resuscitation, behavioral 

health, and en route care just to name a few. However, 

there have been many shortcomings in evaluating and 

developing healthcare practices during these confl icts. 

Most advances were not based on formal research, they 

involved on-the-spot innovation and trial-and-error, and 

were based on personal experience and skills. New ideas 

were not easily or speedily shared, and often ideas were 

adopted after the confl ict, not in real time.

Combat casualties from Iraq and Afghanistan are provided world-class healthcare through innovative research. Combat casualty care in Operations Iraqi Freedom, New Dawn, and Enduring Freedom is better than 

or comparable to trauma systems in the United States.2

This article highlights the overall importance and effect 

on nursing of combat casualty care nursing research 

by the Joint Combat Casualty Research Team (JC2RT) 

since 2006.

The nurse members of the JC2RT directly support the 

mission of military nursing—the Nurse Corps of the US 

Army, Navy, and Air Force. All actions and tasks must 

lead and work toward promoting the wellness of Warriors and their Families, supporting the delivery of Warrior and Family healthcare to all those entrusted to our 

care, and ultimately positioning military nursing as a 

force multiplier for the future of military medicine. The 

JC2RT nursing team members consistently achieve performance excellence, foster innovation, build knowledge 

and capabilities, and ensure organizational credibility 

and sustainability.

TEAM DEVELOPMENT

In October 2006, the fi rst Deployed Combat Casualty 

Research Team (DC2RT) was deployed to Baghdad. 

The initial team consisted of one Army physician, one 

Army nurse (PhD), 3 Army nurses functioning as data 

collectors, and one noncommissioned offi cer-in-charge 

(lab technician) functioning in an administrative role. 

The team expanded to the Air Force Theater Hospital in 

Balad, Iraq, in 2008 when Air Force members joined the 

team. Figure 1 shows the locations of military hospitals 

in Iraq in 2006.

Six DC2RTs deployed to Iraq in support of Operation 

Iraqi Freedom from 2006 to 2009. One team deployed 

every 6 months to an Army theater combat support hospital, an Air Force theater hospital, or an Army forward 

operating base. In August 2009, the DC2RT formally 

transitioned to the Joint Combat Casualty Research 

Team with the headquarters moving from Baghdad, Iraq, 

to Bagram, Afghanistan, and satellite offi ces opened in 

Balad, Iraq, and Kandahar, Afghanistan. The JC2RT 

now includes 12 military professionals from the Army, 

Air Force, and Navy medical departments as delineated 

by the US Central Command (USCENTCOM) Assurance and Joint Manning Document.3

 The JC2RT 12 currently has 3 offi ces in Afghanistan: Bagram, Kandahar, 

and Camp Leatherneck (Figure 2).

The mission of the JC2RT is to “foster and facilitate 

combat relevant medical research within the USCENTCOM Joint Area of Operations.” The JC2RT’s guiding philosophy is “Joint Military Medical Research ... 

Keeping the force ready and relevant.”*

To fulfi ll this mission, healthcare providers and research scientists comprise the JC2RT. Typically, senior 

Combat Casualty Care Nursing Research and

 the Joint Combat Casualty Research Team

LTC Laura L. Feider, AN, USA

Lynn S. Platteborze, MS, RAC

Annette R. McClinton, RN, MA

LTC Betty K. Garner, AN, USA

*JC2RT STRATCOM, US Army Medical Command, February 2011. Internal military document not readily accessible by the general public.
 October – December 2012 65

healthcare providers such as physicians and PhD-level 

nurses are selected for the key positions of director and 

deputy director within the team. As the leader of the 

JC2RT, the director provides executive-level leadership 

to coordinate assigned JC2RT staff to develop, implement, manage, and regulate research activities within 

the theater of operations, as well as direct guidance and 

assistance to investigators initiating new research protocols to ensure the feasibility of in-theater research projects. In addition, the director is responsible for maintaining open lines of communication with USCENTCOM, 

their subordinate commanders, and the Institutional 

Review Board (IRB) of the US Army Medical Research 

and Materiel Command (USAMRMC) providing them 

with status of research and performance improvement 

activities in all theater of operations. The deputy director 

assists investigators in developing protocols, processing 

their protocols through the theater approval, and submitting the protocols to scientifi c review and the IRB for 

approval. The deputy director acts as the main conduit 

of communication among the IRB, the US Army Institute of Surgical Research (USAISR), deployed researchers, and JC2RT members.

Healthcare providers and other professionals with research interest or backgrounds have the opportunity to 

serve on the JC2RT as researchers and research liaison 

offi cers. Depending on their experience and background, 

researchers serve as on-site principal investigators (PIs) 

for select protocols, assist with data collection efforts, 

and mentor other investigators in protocol writing and 

processing.* They work directly with the deputy director to develop, facilitate, and conduct research in the 

Joint Area of Operations. They facilitate communication 

among their PI counterparts, the director, and the deputy 

director during protocol development and review.

Although not technically a member of the JC2RT, the 

in-theater human protections administrator (HPA) plays 

an important role in overseeing research in theater and 

works very closely with the JC2RT. The position is held 

by a research scientist (PhD level) who is responsible for 

ensuring compliance with the Human Research Protection Program Management Plan for all research conducted in theater. The HPA reviews and screens protocols 

during development and implementation to ensure that 

they comply with applicable laws and regulations, and 

that PIs document their plans for human subject protection. The HPA audits studies conducted in theater and 

assists PIs to resolve and/or minimize adverse effects 

and protocol deviations.

Army nurses can serve on the JC2RT in any role. Since 

2006, 37 Army Nurse Corps (ANC) offi cers have served 

in Iraq and/or Afghanistan in the following roles:

 Nine as deputy directors; six in the dual role of deputy directors and HPAs

 Five as senior researchers

 Twenty-three as researchers/data collectors

The nurse scientists and clinical experiences of Army 

nurses leverage the JC2RT’s value by facilitating onsite medical research in the deployed theater. The 

nurse scientists who serve as deputy directors or senior 

*The PI and assigned researchers must have current curriculum vitae and completed the human subject protection 

training of the University of Miami’s online Collaborative Institutional Training Initiative (for information see http://it.med.

miami.edu/x1654.xml).

Figure 1. Locations of US military hospitals in Iraq in 

2006.

Figure 2. Currently JC2RT Team 12 has offi ces in Bagram, Kandahar, and Camp Leatherneck (Helmand 

Province, southwest of Kandahar).
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

researchers are Army nurses with a minimum of one 

year of postdoctoral and IRB experience. The skills set 

of nurse scientists are invaluable to facilitate a smooth 

approval process among both internal (deployed theater) 

and external (United States) customers. The ability to 

apply a knowledge of protocol development and evaluation of scientifi c rigor in the deployed setting ensures 

a high quality, realistic protocol implementation. Junior offi cer Army nurses who are interested in research 

serve as facilitators of protocols during various stages 

of the research approval process, and/or as data collectors in approved research protocols. These positions 

provide ANC offi cers opportunities to learn more about 

conducting research while performing data collection 

vital to the effort. The clinical expertise in various areas (eg, critical care, emergency room, medical-surgical, 

maternal child health, public health nursing, advanced 

practice) possessed by most nurses can be an important 

asset to investigators.

Appointment of Army nurses to the JC2RT involve both 

selective and nominative processes. The deputy director is selected by the nursing research consultant to The 

Surgeon General with concurrence from the offi cer’s 

chain of command. All other Army nurses are selected for the JC2RT using the Army Medical Department 

Professional Offi cer Filler System. Army nurses must 

obtain written approval from their rater and all subsequent nursing leaders, and submit those approvals to the 

deputy commander for nursing or senior nurse executive 

who will forward recommendations for JC2RT membership to the regional nurse executive. The Commander, 

USAISR provides logistical and training support for 

the JC2RT, with operational support by the Command 

Surgeon, USCENTCOM. All JC2RT members may 

serve as deployed area PIs for researchers located in 

the United States. Additionally, team members spend 

approximately 20% of their time providing clinical care 

in the intensive care units, operating rooms, emergency 

rooms, clinics, and humanitarian outreach missions for 

the local Afghan people.

JC2RT RESEARCH SUBMISSION PROCESS

The necessity and feasibility of conducting a study in 

a combat zone are cornerstones of research in theater. 

Clearly, if a study can be conducted in the United States, 

it should not be conducted in the theater of operations. 

The individual PI (on-site or in the United States) works 

with the JC2RT deputy director and/or assigned researcher to develop the protocol using applicable templates. Once a draft protocol is developed, the JC2RT 

director, the deputy director, and the HPA review all 

protocols with a focus on the feasibility. The review 

evaluates the following:

 Whether the study is medically feasible within 

the operational area.

 Whether the study could hinder combat operations or clinical support of combat operations.

 Whether the study can only be conducted in 

theater.

 Whether the study has the potential to improve 

healthcare.

 Whether there are any local or cultural factors 

that may affect execution of the protocol.

The HPA conducts a review of all protocols to ensure 

that investigators document plans for human subject 

protection. The HPA or the JC2RT deputy director obtains letters of support and institutional offi cial signatures from the appropriate commanders on behalf of 

the PI. The deputy director forwards the protocol and 

supporting documents to the USAMRMC Offi ce of Research Protection and the IRB for scientifi c and ethical 

review and approval.

The protocol is expected to adhere to sound research 

and scientifi c principles, the USCENTCOM Human Research Protection Program, and all Department of Defense (DoD) and other US regulatory requirements. Formal scientifi c reviews are managed through the USAISR 

and are conducted by subject matter experts throughout 

DoD. Upon passing scientifi c review, the protocol is referred to the IRB for ethical review. The IRB may review protocols via full board or expedited review. Once 

the IRB approves the protocol, the USCENTCOM institutional offi cial issues the study start letter. Table 1 lists 

the steps and typical timeline for completing a research 

protocol. Table 2 presents the checklist of items for the 

PI to review prior to submitting a theater protocol.

Table 1. Typical timeline to complete a research protocol.

Step Average Time

Develop and write protocol Variable

PI/AIs completion of CITI/curriculum vitae Variable

JC2RT Executive Steering Committee review 3-7 days

Scientific review of protocol 2 weeks*

Review by USCENTCOM MRMC IRB 2-3 weeks†

2nd-level review and start letter 1-3 days

Approving Official Start letter 1-3 days

Average total time required 2-3 months‡

AI indicates assigned researcher.

CITI indicates Collaborative Institutional Training Initiative (University 

of Miami).

*Time spent in scientifi c review also dependent on the amount of 

time required for PI revisions.

†Review time dependent on the type of protocol, the IRB schedule, 

and the amount of time required for PI revisions.

‡Estimate, may be shorter or longer.

COMBAT CASUALTY CARE NURSING RESEARCH AND THE JOINT COMBAT CASUALTY RESEARCH TEAM
 October – December 2012 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

Table 2. Example of a checklist used by a Principal Investigator to ensure that the proposed protocol meets all requirements.

Complete N/A USAMRMC Institutional Review Board: Human Subjects Research Initial Protocol Application

Protocol

Prepared using the current version of the templates provided by RLNO

Part A

1. Study Contacts: Principal Investigator, Onsite Investigator, Associate Investigator, Consultants, and (if needed) Medical 

Monitor

2. Key Study Personnel: must provide all of the following information: names, addresses, rank & position, phone numbers, 

department work area, e-mail, unit, redeployment date

3. Study Facilities

4. Multisite Research

5. Scientifi c Review

6. Additional Approvals

7. Funding Information

8. Drugs, Dietary Supplements, Biologics, and Devices

9. Clinical Trial Registration

10. Target Population(s)

11. Waiver/Alterations of the Informed Consent/Assent Process

12. HIPAA Authorization

a. Request for HIPAA Waiver signed by principal investigator (if applicable)

b. Completed HIPAA Authorization for use and disclosure of protected health information

c. Completed HIPAA Application for Waiver

Part B

1. Responsibilities of the Principal Investigator in Human Subjects

Part C

1. Protocol Title

2. Abstract

3. Background and Signifi cance

4. Military Relevance

5. Objectives/Specifi c Aims/Research Questions

6. Research Design

7. Research Plan/Human Subjects Protection

a. Clearly and comprehensively describes the database and how the data from the data collection measures are 

transferred into an electronic or hard copy database. Use of audio and/or visual tapes and their disposition is 

explained.

b. Describes what HIPAA identifi ers that permit the association of the data with the individual are being collected.

c. Describes the method for maintenance of confi dentiality and security. Clearly delineates measures for coding 

of measures so that individual subject data is not identifi ed by name but by a coded system, the security of 

electronic data through use of password-protected and encrypted fi les, and the storage of paper records in 

locked fi le cabinets and rooms with access to only authorized personnel, both in theater and in transit.

d. Describes the method for transmission of data through use of password-protected and encrypted fi les.

e. Describes the status of data (ie, deletion of data) after completion of the research study.

f. Describes the risks and benefi ts from the study. If there were any identifi ers collected, discusses how the risk to 

potential loss of privacy/confi dentiality of data will be minimized.

g. If greater than minimal risk, Medical Monitor-identifi ed. Cannot be a subordinate in the PI’s rating chain. The IRB 

determines requirement.

8. Risks/Benefi ts Assessment

9. Adverse Events, Unanticipated Problems, and Deviations

a. Defi nition of adverse event

b. Reporting of unanticipated problems

c. Medical Monitor

10. Withdrawal From Study Participation

Table 2 continued on the following page.
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

NURSING RESEARCH PROTOCOLS AND THEMES

The type and complexity of in-theater research has 

evolved since 2005 when studies were mainly retrospective reviews. Research now covers the span from simple 

retrospective chart reviews to prospective observational 

and/or interventional studies. Data is collected by the 

PI or a designated on-site PI, who could be a member of 

the JC2RT, or other medical personnel working at the 

combat support hospital. Approximately 173 protocols 

have been reviewed since 2006, with 153 receiving IRB 

and institutional offi cial approval. As of this writing, 54 

protocols remain open in ongoing or data analysis status. 

The JC2RT research priorities in the combat zone have 

evolved, but continue to focus on trauma care, concussion/traumatic brain injury, preventive medicine, and 

behavioral health.

Since the inception of DC2RT/JC2RT in 2006, 39 nursing research protocols have been submitted, representing 

28% of the JC2RT protocols submitted as of this writing. Prior to the 2010 nursing research agenda,* many 

of the protocols focused on the nurse’s area of interest 

or expertise and ability to conduct a feasible study in 

the combat zone based on the theater research priorities. 

The current nursing research agenda priorities set forth 

by the ANC include leadership, health promotion and 

*The nursing research agenda is an annual priority listing derived by the ANC Corps Chief’s Offi ce Campaign Plan.4 The priority list provides recognition of gaps in knowledge and the actions necessary to fi ll them. The policy outlines the plan to deliver evidence for decision making and formulation of solutions.

Table 2 (continued). Example of a checklist used by a Principal Investigator to ensure that the proposed protocol meets all 

requirements.

11. USAMRMC Volunteer Registry Database

12. References-Review of Literature

 a. Identifi ed date of search, period searched, sources searched, and key words of search.

 b. Literature supports the theoretical framework of the study.

 c. Interventions are supported by the literature.

 d. Use of chosen measurements/instruments are documented/validated in the literature.

13. Time required to complete study (expected start and end dates) (including data analysis)

Attachments

Signature Pages

1. Signature block entered for all PI(s), AI(s), medical monitor, and unit Commander; use following example for format:

 John Doe

 MAJ, MC

2. Signed and dated by principal investigator, associate investigator(s), unit commander, FOB/COB/garrison commander 

3. Theater signature page (to be completed by ESC)

4. Signed by all other individuals approving study

Consent Form

1. Informed Consent Document, unless a waiver is requested in the protocol

HIPAA Form/Waiver

1. HIPAA Form, unless a waiver is requested in the protocol

Appendices

1. Recruitment Flyer/Email/Script 

2. Study Instruments

3. Data Use Agreements

4. Product Information

5. Investigational Brochure

6. Device Manual

7. Database/Data Collection Sheets (how you will record your results)

8. Letter(s) of Support as appropriate

9. All applicable Impact Statements

CITI, CV, and COI

1. Current Curriculum Vitae for each investigator (including Medical Monitor)

2. Documentation of CITI within the last 3 years for each investigator (including Medical Monitor)

3. Confl ict of Interest form for each investigator (including Medical Monitor)

COMBAT CASUALTY CARE NURSING RESEARCH AND THE JOINT COMBAT CASUALTY RESEARCH TEAM
 October – December 2012 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

wellness, human capital, patient-centered and familycentered systems of care, deployment, anesthesiology, 

and informatics. Many of these research protocols fi t 

into the 2010 ANC research agenda focusing on improving Warrior care from the point of injury to arrival at 

medical facilities in the United States. The predominant 

themes of the JC2RT nursing research protocols (Table 

3) address 39 elements of military healthcare, with focus 

on Warrior care, in the numbers indicated:

 Warrior Care

 Healthcare delivery (11)

 Soldier health (7)

 Trauma (3)

 Behavioral health (3)

 Nursing/healthcare professional issues (15)

Table 3. Current ANC nursing research protocols of the Joint Combat Casualty Team.

Protocol

ANC

Research

Priority

Status

Evaluating the presence of compassion fatigue among healthcare providers High Closed

Use of paralytic agents during helicopter aeromedical transport during Operation Iraqi Freedom Medium Closed

Perceived readiness of healthcare providers to deliver palliative care in a combat environment Medium Closed

Evaluating pain management by examining documentation of pain relief interventions in a combat support 

hospital High Closed

Evaluating hand hygiene compliance in a combat support hospital High Closed

Evaluating compliance of semirecumbent head of bed positioning in mechanically ventilated patients in a combat support hospital Medium Closed

Early detection of combat operational stress among deployed Soldiers High Closed

Chlorine exposure during Operation Iraqi Freedom Low Closed

Variables to consider in assessing deployment-related health of combat support hospital nurses who are unexpectedly extended Medium Closed

Army Nurse Corps officers’ experience of nursing care and a nursing care evidence-base during deployment in 

support of combat operations High Closed

Medical-surgical nursing at a combat support hospital-Operation Iraqi Freedom Medium Closed

A women’s health intervention to decrease gynecologic problems in the deployed environment Medium Closed

Carbon monoxide exposure Low Closed

Oral care practices for the deployed military critical care nurse in orally intubated Soldiers Medium Closed

Burnout: measurement in a deployed combat hospital setting Medium Closed

Compassion fatigue in nurses caring for detainees in a deployed environment High Closed

Deployment nursing research priorities in a mature battlefield: a Delphi study Medium Closed

Taking care of Iraqis: Army nurses’ perception of nursing care for host nation patients at a combat support 

hospital Medium Closed

The use of a meditation intervention in deployed military medical personnel to decrease stress and anxiety and 

promote resilience: a pilot study Medium Closed

Dimensions of deployed nurses' experiences at a combat support hospital Medium Closed

Organizational properties of the self-concept: a cognitive vulnerability to PTSD symptoms in deployed military 

nursing personnel exposed to combat-related trauma and stressors Medium Open

Factors related to healthcare delivery among US military medical personnel at 3 different hospitals High Closed

Trauma team healthcare culture at Craig Joint Theater Hospital Low Closed

Arterial based and noninvasive functional hemodynamic indices in combat trauma resuscitation Medium Closed

Sleep disturbance in deployed Soldiers Medium Closed

Use of NIRS StO2 to detect occult hypoperfusion under field conditions Medium Open

Military women's health and illness behaviors in deployed settings Medium Open

Iron status of deployed military members Low Open

Use of N.O. Xplode by service members deployed in support of Operation Enduring Freedom Low Open

Interpersonal safety of US military women in the deployed environment of Bagram, Afghanistan: a grounded 

theory approach Medium Open

US military nurses in Afghanistan: anticipatory concerns about returning home High Open

Descriptive analysis of resuscitation and early clinical outcomes as a function of aeromedical platform in 

Afghanistan High Open

The immediate effects of yoga on wounded warriors in a deployed setting: a pilot study Medium Closed

Assessment of fatigue in deployed critical care air transport team crews Medium Open

Sleep and the use of energy products in a combat environment Medium Open

Patient safety in en route care survey Medium Open

Readiness and resilience in National Guard Soldiers project High Open

NIRS indicates near infrared spectroscopy.

StO2 indicates skeletal muscle tissue oxygenation.
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

EFFECT OF JC2RT NURSING RESEARCH INITIATIVES 

AND LESSONS LEARNED

The effect of nurses serving on the JC2RT has been very 

benefi cial for newly wounded Warriors. Some examples 

include improved delivery of fl uid resuscitation of trauma patients, standardization of tourniquet use, damage 

control laparotomy, development and implementation 

of clinical practice guidelines (ie, burns, hypothermia, 

pelvic fractures, trauma airway management, vascular 

injury), and the development of 39 nursing-driven research initiatives affecting war-wounded in real time. 

Additional evidence-based practice and performance 

improvement projects were also initiated. Nursing-driven research initiatives include “back-to-basics” clinical practices such as oral care for ventilated patients, 

documentation of pain management, and hand hygiene 

in an austere environment. Other important aspects of 

nursing-driven research protocols are the experiences 

and outcomes of nurses providing care to both wounded 

Warriors and Afghan local nationals, including insurgents. These studies are rich in data from the perspective of asymmetric warfare in a generation of nurses 

who have no experience in any previous combat environments. However, as the war continues with multiple 

deployments, these studies provide knowledge as a platform from which nurses can further build current nursing knowledge and clinical practices.

Nursing practice in the combat zone has changed, refl ecting advancements in Warrior care from research 

and performance improvement efforts. Numerous publications and presentations have been provided at national 

and international conferences. Many protocols are in 

data analysis, manuscript publication, or in-press phases. Innovations from JC2RT research protocols have had 

an effect on hemorrhage control, tourniquet use, damage control resuscitation, en route care during medical 

evacuation, critical care air transport, extremity care, 

and conversion of evidence into practice.5

FUTURE COMBAT CASUALTY CARE NURSING 

RESEARCH PROTOCOLS

Nursing research to improve combat casualty care during Operations Iraqi Freedom, New Dawn, and Enduring Freedom is unprecedented. Future combat casualty 

care nursing research may include topics that have an 

effect on trauma care provided in real time prehospital 

phases, and to compare with and translate to the civilian 

sector. Nursing research should also stimulate longitudinal outcome studies that support Warrior care, leader 

development, human capital, and evidence-based care. 

Their recommendations should be prioritized by the 

ANC and Army Medical Department as the next steps 

in combat casualty care nursing research.

Some of the future combat casualty care nursing research 

topics which have high or medium priority according to 

the nursing research agenda are listed in Table 4. Army 

nurses will continue to serve on the JC2RT in a variety of 

roles, signifi cantly assisting combat casualty care. Army 

nurses will remain at the tip of the spear, leading the path 

for medical innovations in real time—remembering the 

past, engaging the present, and envisioning the future.

Table 4. Topics for future protocols of combat casualty care 

nursing research.

En route care provided for nurses

Critical care nurse for intratheater evacuation patient outcomes

Outcomes of evidence-based clinical practice guidelines

Combat nurse survey of required and sustained go-to-war skill 

sets

Hemorrhage resuscitation: nursing implications and care

Prevention, burn care implications for nursing, trauma

Trauma resuscitation: nursing implications and care

Damage control resuscitation and surgery nursing implications

Burn Flight Team: nursing care implications

Pressure ulcer prevention from point of injury to the United 

States

Incidence and distribution of decubitus ulcers in civilian versus 

global transport of combat wounded

Complex battle wound healing

Traumatic brain injury research

Outcomes evaluation of Joint Theater Trauma Registry clinical 

practice guidelines

Predeployment nursing training and preparation

Stresses of flight

Longitudinal and rehabilitation nursing outcomes

Behavioral health of the care provider and Warriors

Outcomes information that may be applicable to civilian trauma 

setting and improvement of combat casualty care

REFERENCES

1. Haberman TM, Ziemer RE, Beck CS. The Mayo Brothers’ Heritage: Quotes and Pictures. Rochester, MN: Mayo 

Clinic Scientifi c Press;20021:6.

2. Eastridge BJ, Costanzo G, Jenkins DM, et al. Impact of joint theater trauma system initiatives on battlefi eld injury 

outcomes. Am J Surg. 2009;198:852-857.

3. Brosch L, Holcomb J, Thompson J, et al. Establishing a human research protection program in a combatant command. J Trauma. 2008;64(suppl 2):S9-S13.

COMBAT CASUALTY CARE NURSING RESEARCH AND THE JOINT COMBAT CASUALTY RESEARCH TEAM
 October – December 2012 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. Clark S, Brewer R. Building the Army nursing campaign plan. US Army Med Dept J. October-December 2011:

10-17.

5. Bridges E, Biever K. Advancing critical care: joint combat casualty research team and joint theater trauma system. AACN Adv Crit Care. 2010;21(3):260-276.

AUTHORS

LTC Feider is Regional Chief, Center for Nursing Science and Clinical Inquiry, Brooke Army Medical Center, Fort Sam 

Houston, Texas.

Ms Platteborze is Human Protections Administrator, Brooke Army Medical Center, Fort Sam Houston, Texas.

Ms McClinton is Chief, Regulatory Compliance, US Army Institute of Surgical Research, Fort Sam Houston, Texas.

LTC Garner is Deputy Chief, Center of Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center, 

Landstuhl, Germany.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

Aeromedical evacuation has been a staple in the patient 

care pathway since the US Army Air Corps began evacuating patients from North Africa during World War 

II, when Army Nurses fi rst began escorting patients 

through the “chain of evacuation.”1

 By 1945, the Army 

Air Corps evacuated 1.25 million patients by aircraft 

and some Army Nurses earned their in-fl ight caregiver 

wings on a portion of these evacuation missions.2

 It was 

not until the Vietnam confl ict over 20 years later, however, that the chain of evacuation as we know it today—

dedicated helicopters and enlisted fl ight medics—became the standard in the Army.1

Successful evacuation of patients throughout the ensuing interval of relative peace proved the concept of dedicated aircraft and reinforced the use of enlisted fl ight 

medics to attend to the evacuees. While indicators were 

present shortly after the fi rst employment of forward 

surgical teams (FSTs) in Bosnia-Herzegovina and Kosovo in 1997,1

 the return of Army nurses to the chain 

of evacuation actually became a necessity as combat 

operations intensifi ed in Operations Enduring Freedom 

and Iraqi Freedom. Advances in body armor and battlefi eld medicine, coupled with the capabilities of nearly 

ubiquitous FSTs, led to unprecedented survival rates. 

Patients transported by theater medical evacuation assets were more care-intensive, requiring titration of vasoactive medications, sedative infusions, and paralytic 

agents while manipulating mechanical ventilation. At 

times, resuscitation was required en route.3

 Clinicians 

with critical care experience became a requirement for 

these evacuations.

As the executive agent for medical evacuation in theater, 

the Army must ensure the standard of care provided to 

the Soldiers, Marines, Sailors, and Airmen is the best 

available. To fulfi ll this clinical requirement, the best 

option is to assign Army nurses to medical evacuation 

helicopter units as nonrated members* of fl ight crews. 

Army nurses on the crew will undoubtedly help to ensure evacuees receive the best care achievable in theater, 

from the point of injury to the combat support hospital.

EN ROUTE CRITICAL CARE

Few statistics exist to demonstrate the need or effectiveness of intratheater critical care evacuation early in Operations Enduring Freedom and Iraqi Freedom. However, some information can be inferred from US Air Force 

intertheater data, which shows that from 2003 to 2006, 

the Air Force evacuated a total of 37,000 patients from 

the US Central Command area of operations. Of those, 

6,800 were battle injuries and 500 required Air Force 

critical care air transport team involvement.2

 A logical 

extension of that data indicates that Army critical care 

nurses and physicians were likely involved in the intratheater evacuation of at least 500 critically ill evacuees.

Early in Operation Iraqi Freedom, medical leaders in the 

theater of operations recognized that patient conditions 

were well beyond the scope of the original medical evacuation concept, which allowed for patient attendance by 

a single emergency medical technician-trained medic, 

and put the critically ill patient at serious risk for potentially lethal complications.1

 To mitigate this unforeseen risk, critical care nurses and physicians with little 

knowledge of aeromedical operations augmented the 

medical evacuation crews, sporadically and unoffi cially, 

providing the care necessary to successfully transport 

the patient to the next level of care. By 2006, the Army 

developed the Joint En Route Care Course (JECC) to 

provide “concise, realistic, relevant, and current training 

on en route trauma transport to care providers involved 

in” medical evacuation operations.1(p48) Graduates of the 

JECC (generally experienced critical care or trauma 

nurses, physicians, and licensed practical nurses) were 

prepared to care for the critical patient in the cramped, 

noisy environment of a medical evacuation helicopter.

As critical care clinicians became more involved in the 

medical evacuation process, quality improvement measures and patient outcomes measures were implemented 

Registered Nurses as Permanent Members

 of Medical Evacuation Crews:

 The Critical Link

MAJ Michael W. Wissemann, AN, USA

MAJ Christopher A. VanFosson, AN, USA

*A nonrated member of a flight crew is an officer or enlisted Soldier who does not have the aeronautical rating of Army aviator 

or flight surgeon.4
 October – December 2012 73

to further understand the impact of this new role in the 

chain of evacuation. In October 2005, the 30th Medical Brigade began tracking medical evacuation statistics. 

As the senior medical command in Iraq, the brigade reported that 10% to 20% of all medical evacuation patients between October 2005 and October 2007 required 

some sort of in-fl ight emergency intervention.1

 The 62nd 

Medical Brigade and the 86th Combat Support Hospital gathered data on evacuations in Iraq from 2007 to 

2009.1

 Over a 15-month period of time, over 700 patients 

required critical care escort during intratheater evacuation. Between September 2007 and September 2008, 

Army nurses provided en route care in approximately 

60% of all medical evacuation missions.5

 In nearly 10 

years, from the beginning of operations in Afghanistan 

and Iraq until 2010, the Army conducted more than 

20,000 medical evacuation fl ights in support of combat 

operations.1,3 Two-thirds of these fl ights were in support 

of “preoperative and postoperative resuscitation or surgery patients who had received care at a [FST] or combat 

support hospital.”3

As combat operations in Iraq and Afghanistan continued, it became obvious that more patients were critically 

ill at the point of injury and required greater care during 

intratheater transport. In 2004, the US Army Institute of 

Surgical Research established a clinical practice guideline (CPG) that details the roles and responsibilities of 

personnel assigned to establish intratheater medical 

evacuation. According to the CPG, the goal of intratheater evacuation is to “provide every patient who is injured on the battlefi eld or in the AOR [area of operations], 

the optimal opportunity for survival and the maximum 

potential for a functional recovery.”6

 The operational environment had changed over the years between the Vietnam confl ict and Operation Iraqi Freedom. American 

military prowess could not be matched. The enemy, seeing no other recourse, adopted a guerilla-style warfare 

that hinged on the use of improvised explosive devices 

(IEDs) to injure the relatively well-protected American 

military member. The employment of IEDs resulted in 

types of polytrauma patients unseen in previous American confl icts who required a higher level of care than 

normally provided by medical evacuation teams of the 

past.6

 To account for this change in patient severity, the 

Army Medical Department (AMEDD) implemented 

changes to provide more appropriate care to evacuated 

patients, beginning at the point of injury (POI).

PARAMEDIC CREW MEMBERS

Currently, all US Army fl ight medics are trained as an 

emergency medical technician-basic (EMT-B), which 

is supplemented by training in prehospital trauma life 

support. In 2011, Mabry and De Lorenzo posited that 

paramedic training would greatly enhance the role of 

the fl ight medic in providing initial care to those who 

suffer combat injuries. They proposed a 32-week training cycle that incorporated the fl ight medic course at 

Fort Rucker, Alabama, emergency medical technicianparamedic (EMT-P) training, and a ride-along program 

with civilian air ambulance services in the San Antonio 

area.7

 By September 2011, the Army had announced a 

$53 million plan to implement the Mabry and De Lorenzo concept, citing data which demonstrates that patients 

treated by Army National Guard fl ight medics, many of 

whom are also civilian fl ight paramedics, have a 66% 

higher survival rate.8

While the EMT-P program serves to fi ll the patient care 

gap identifi ed by the AMEDD, and it provides a level of 

clinical education to match the combat experiences of 

current Army fl ight medics, some concerns arise about 

the effi cacy of the Soldiers trained in this program. The 

civilian version of the EMT-B course is a 120-hour program focused on stabilization and transport. The civilian version of the EMT-P course is a 1,000-hour program that focuses on stabilizing medical and traumatic 

conditions as well as correcting the underlying clinical 

abnormalities. The Army National Guard fl ight medics 

who are civilian paramedics likely have several years 

of paramedic experience and would be well-versed in 

polytrauma critical care. Generally, to be hired as a civilian fl ight paramedic, one must demonstrate a signifi -

cant amount of ground-based experience. For example, 

a recent employment announcement by Hahnemann 

University Hospital in Philadelphia for fl ight paramedics specifi ed that applicants must have a minimum of 

5 years experience as a paramedic for consideration of 

a job application.9

 According to the National Registry 

of Emergency Medical Technicians, “paramedics represent the highest licensure level of prehospital emergency 

care in most states.”10 Without this extensive experience, 

novice paramedics may question their skills or miss the 

minute indicators that can lead to a detrimental patient 

outcome if not addressed. Their experiences and the time 

it takes to develop their skills in the civilian sector cannot be replicated in an EMT-P program of the AMEDD 

Center and Schools. Therefore, that success rate is an 

inappropriate benchmark for the newly-minted, EMT-P 

certifi ed Army fl ight medic.

As the pace of the operational environment slows and 

deployments decline, the EMT-P fl ight medics will have 

fewer opportunities to remain clinically prepared for 

combat medicine. In the United States, some EMT-P 

trained fl ight medics will have the opportunity to take 

part in evacuations from POI to a medical treatment facility because they are assigned to remote posts or to 
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

training facilities. Most fl ight medics, however, are assigned to units or posts where civilian medical evacuation capabilities cover the region. In the majority of geographic locations of large US Army installations, it will 

be diffi cult for EMT-P fl ight medics will struggle to gain 

the requisite clinical experience through ride-alongs 

and emergency room exposures. In those metropolitan 

healthcare markets that allow the needed ride-along 

experience, many restrict the ability of the observer to 

medically interact with the patient due to medical-legal 

considerations, thereby limiting the usefulness of such 

a program. This may be mitigated somewhat by assigning the fl ight medic to the medical facility-based emergency medical service on the Army post as borrowed 

manpower, fulfi lling an advanced life support role on 

the ambulance service. Even this experience, however, 

provides little comparable experience for the combatoriented fl ight medic as the Army emergency medical 

service generally has less trauma-focused work than a 

civilian air ambulance service.

REGISTERED NURSES ON EVACUATION CREWS

There is little question that the EMT-B trained fl ight 

medic is inadequately trained for today’s combat medical environment. The EMT-B training does not meet the 

scope and depth of clinical practice required in today’s 

environment.1

 Paramedic training helps fi ll this gap, 

but the limited clinical experience available to the new 

EMT-P fl ight medics and the diffi culty of keeping their 

skills current prevents EMT-P fl ight medics from being 

the ideal answer. In 70% of en route care provided in 

Iraq from 2007 to 2009, nurses were required to perform critical care interventions that are beyond the experience level of EMT-P trained fl ight medics.1

 A position paper published by The Air and Surface Transport 

Nurses Association states:

The Air & Surface Transport Nurses Association 

(ASTNA) believes that services providing critical 

care transport are functional extensions of hospital 

emergency departments, and specialty/critical care 

units. ASTNA further believes that staffi ng for 

these services minimally consist of at least one 

professional, registered nurse who has completed 

training specifi c to transport and possess extensive 

experience and expertise in caring for critically ill 

and injured patients. Finally, ASTNA believes that 

nurses employed by critical care transport services 

who respond to and transport patients from the 

scene of injury should have training in the unique 

aspects of prehospital care.11

Wirtz et al12 published a study of civilian medical evacuation crews which compared the outcomes of nearly 

1,200 patients cared for by nurse/nurse crews and nurse/

paramedic crews (a paramedic/paramedic crew does 

not exist in the civilian sector and therefore was not 

included in the study). The study found no statistically 

signifi cant difference in patient outcomes among the 

crews, reinforcing the paradigm that the typical fl ight 

crew should consist of at least one critical care or trauma 

trained registered nurse.

The seasoned Army critical care or trauma nurse (hereinafter referred to by their area of concentration designation 66HM5/8A) brings a level of clinical expertise 

rarely seen in a paramedic. The 66HM5/8A has undergone a 4-month course in emergency and/or critical care 

nursing and developed many of the clinical problemsolving skills that comes with being a registered nurse, 

in addition to the critical thinking skills gleaned through 

4 years of undergraduate study. Critical care experience 

does not end with completion of the emergency and/or 

critical care course. After the course, 66HM5/8As are 

mentored for 6 months prior to being eligible for deployment. This ensures that most 66HM5/8As have nearly 

2,000 hours of didactic and clinical experience before 

being deployed, and ensures that they have developed 

the instincts necessary to discern subtle changes in the 

back of a cramped, loud helicopter. Army Nurses who 

hold the 66HM5/8A designator serve in the critical care 

or emergency setting and maintain that clinical expertise on a daily basis. Seldom are they removed from the 

clinical mission for training purposes, counter to the 

reality that enlisted medics (EMT-B or EMT-P) experience on a daily basis. For nurses, daily clinical exposure 

is the norm, rather than the exception.

IMPLEMENTATION/PROPOSAL

It is time for Army nurses to become permanent, nonrated members of Army medical evacuation crews. In 

today’s Active Army, there are approximately 20 medical evacuation units staffed with EMT-B fl ight medics. 

To augment these units with the addition of one permanent 66HM5/8A per unit would require approximately 

20 Army nurses from the AMEDD. The critical nature 

of patient care in the aircraft requires the daily presence 

of nursing expertise. This nurse, acting as the senior 

critical care expert in the medical evacuation unit, is a 

clinical expert who can provide an unparalleled level of 

care for the patient and may also serve as a clinical advisor to the unit.

Army nurses, by the nature of their profession, are educators. While the aviation fl ight surgeon assigned to the 

medical evacuation unit is available for staff education 

and patient care, he or she is often not as experienced 

in the care of critically ill patients. The fl ight surgeon 

is generally focused on maintaining the health of the 

medical evacuation crew. The 66HM5/8A would focus 

REGISTERED NURSES AS PERMANENT MEMBERS OF

MEDICAL EVACUATION CREWS: THE CRITICAL LINK
 October – December 2012 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

on educating and training the fl ight medics, as well as 

facilitating a medical profi ciency training program at 

the local medical treatment facility, in preparation for 

their clinical role on the crew. The 66HM5/8A, who 

would split their time between keeping their skills current in a medical treatment facility and maintaining their 

fl ight currency (just as other Army Forces Command 

(FORSCOM)-assigned Army nurses do already), has 

the ability to facilitate clinical experiences for the fl ight 

medics in the emergency department, the critical care 

units, and the operating room. These efforts alone could 

justify the assignment of a 66HM5/8A to the medical 

evacuation units.

Deployment in support of combat operations is mentally 

and physically taxing on even the most seasoned military 

members. A single 66HM5/8A in the medical evacuation 

unit would not be able to withstand the intensity of the 

situations that require medical evacuation. The permanent 66HM5/8A would need augmentation through the 

AMEDD Professional Filler System (PROFIS),* adding 

an additional 5 or 6 nurses per medical evacuation unit, 

which would provide for a rotation of the 66HM5/8A 

in shifts with the accompanying fl ight medics. To reduce the total fl ight nurse requirement, the fl ight nurses 

could be deployed at half of the total expected requirement. Medical evacuation helicopters tend to work in 

tandem, allowing one fl ight nurse per pair of aircraft, 

which would reduce the overall PROFIS assignment requirement. To prepare for their new assignment, these 

PROFIS 66HM5/8As must attend the Combat Casualty 

Care Course and the Joint En Route Care Course, just as 

the assigned FORSCOM nurse, prior to arriving at the 

unit. Most senior company grade nurses already attend 

these courses prior to deployment, so this would not require a new process or cost increases associated with 

training. Prior to deployment, the PROFIS 66HM5/8A 

would join the unit for rotations at the Combat Training 

Centers at Fort Irwin, California or Fort Polk, Louisiana, 

where they would become familiarized with the unit’s 

standard operating procedures, equipment, and personnel. These rotations would help integrate the 66HM5/8A 

into the close-knit community of aviation medicine and 

allow fl ight crews to become familiar with the nurses’ 

clinical capabilities.

Some may argue that Army nurses are not prepared to 

be a part of the medical evacuation fl ight crew, conducting patient care at the point of injury in a potentially 

hostile fi re environment. Army Medical Department 

members receive extensive training throughout their careers in preparation for deployments to a combat zone. 

Once assigned to the position, to ensure their preparation for the medical evacuation mission, the 66HM5/8A 

should attend the Combat Casualty Care Course and the 

Joint En Route Care Course. The former is designed to 

give personnel the skills necessary to provide medical 

care under austere conditions. The latter provides attendees with a 2-week foundation in the fundamentals 

of operating in and around helicopters while also introducing experiential clinical learning based on the most 

current lessons learned from the CENTCOM theater of 

operations. Additionally, the 66HM5/8A will take part 

in multiple training exercises with the aircrew upon assignment to the team, gaining familiarity with the aircraft and the standard operating procedures of the crew.

With fewer deployments anticipated in the future, and 

budget constraints a persistent reality, the $53 million 

program to train EMT-P may be too costly to sustain. 

Use of the 66HM5/8A as a permanent member of the 

aircrew takes advantage of 3 programs of instruction 

already present in the AMEDD. In addition, because 

Army nurses are regularly involved in direct patient care, 

the skills and knowledge needed by a fl ight nurse are 

more easily sustainable than those required of a paramedic-trained fl ight medic. Furthermore, 66HM5/8A 

registered nurses who are assigned to medical evacuation units improve patient care throughout the unit by 

training the fl ight medics and fostering a team-based 

care environment.1

SUMMARY

Medical evacuation has changed from the experiences 

of the past decade of combat operations. Much of the 

focus of medical support in the combat zone is now critical care during evacuation, which is, and will continue 

to be, a very successful, life-saving asset.2

 The assignment of Army critical care or trauma nurses to medical 

evacuation units is consistent with the recognition that 

the medical evacuation system is a truly vital asset in 

the success of today’s American military. Our NATO 

allies, and our sister services, rely heavily on the availability, reliability, and especially the continuity of care 

of the Army medical evacuation system.5,13 It is time to 

upgrade the system of evacuation and provide our Warriors with the greatest possibilities of survival. Army 

nurses trained in critical care and trauma nursing are 

best suited to provide that continuity of care.

*PROFIS predesignates qualifi ed Active Duty health professionals serving in other units to fi ll 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.
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

REFERENCES

1. Davis RS, Connelly LK. Nursing and en route care: 

history in time of war. US Army Med Dep J. October-December 2011:45-50.

2. Roedig E. Aeromedical evacuation. Technical 

evaluation report summarizing the proceedings at 

the NATO specialist meeting 157, 2-3 December 

2008, in Sieburg, Germany. North Atlantic Treaty 

Organization; 2009. Available at: ftp://ftp.rta.nato.

int//pubfulltext/rto/mp/rto-mp-hfm-157/. Accessed 

May 4, 2012.

3. Hudson TL, Morton R. Critical care transport in 

a combat environment: building tactical trauma 

transport teams before and during deployment. 

Crit Care Nurse. 2010;30:57-66.

4. Army Regulation 600-106: Flying Status for Nonrated Army Aviation Personnel. Washington, DC: 

US Dept of the Army; December 8, 1998:9.

5. Nagra, M. Optimizing wartime en route nursing 

care in Operation Iraqi Freedom. US Army Med 

Dep J. October-December 2011:51-58.

6. US Army Institute of Surgical Research. Intratheater Transfer and Transport of Level II and III Critical Care Trauma Patients. November 2008. Available at: http://www.usaisr.amedd.army.mil/assets/

cpgs/Intratheater_Transfer_and_Transport_19_

Nov_2008.pdf. Accessed May 4, 2012.

7. Mabry RL, De Lorenzo RA. Improving role I battlefi eld casualty care from point of injury to surgery. 

US Army Med Dep J. April-June 2011:92-100.

8. Zoroya G. Top-fl ight medics: Army training moves 

to next level. USA Today. September 6, 2011. Available at: http://www.usatoday.com/news/military/

story/2011-09-06/Top-flight-medics-Army-training-moves-to-next-level/50286806/1. Accessed 

May 4, 2012.

9. Tenet Healthcare Corporation. Job Search: Flight 

paramedic–full time–med evac–841–7365-1205006

939. Available at: https://tenet.taleo.net/careersec

tion/10100/jobdetail.ftl. Accessed May 7, 2012.

10. National Registry of Emergency Medical Technicians. What is EMS?. https://www.nremt.org/nremt/

about/What_is_EMS.asp. Accessed May 7, 2012.

11. Air & Surface Transport Nurses Association. Staffi ng 

of Critical Care Transport Services. 2010. Available 

at: http://www.astna.org/documents/STAFFINGOF

CRITICALCARETRANSPORTSERVICES_

000.pdf. Accessed May 7, 2012

12. Wirtz MH, Cayten CG, Kohrs DA, Atwater R, 

Larsen EA. Paramedic versus nurse crews in the 

helicopter transport of trauma patients. Air Med J.

2002;21(1):17-21.

13. Hartenstein I. Medical evacuation in Afghanistan. 

Technical evaluation report summarizing the proceedings at the NATO specialist meeting 157, 2-3 

December 2008, in Sieburg, Germany. North Atlantic Treaty Organization; 2009. Available at: ftp://

ftp.rta.nato.int//PubFullText/RTO/MP/RTO-MPHFM-157/. Accessed May 4, 2012.

AUTHORS

MAJ Wissemann is Chief Nurse, McAfee Army Health 

Clinic, White Sands Missile Range, New Mexico.

MAJ VanFosson is a Clinical Staff Nurse, Burn Intensive 

Care Unit, US Army Institute of Surgical Research, Fort 

Sam Houston, Texas.

REGISTERED NURSES AS PERMANENT MEMBERS OF

MEDICAL EVACUATION CREWS: THE CRITICAL LINK
 October – December 2012 77

Patient care delivery in complex healthcare delivery systems calls for emerging professional roles to navigate the 

labyrinth of quality and safety imperatives. The Clinical 

Nurse Leader® (CNL®) is one such emerging nursing 

role. This important role was developed by The American Association of the Colleges of Nursing (AACN) in 

collaboration with key nursing education leaders and 

stakeholders.1

 This article describes the CNL role as 

a means for achieving US Army Medical Department 

strategic outcomes, distinguish the CNL role from the 

Clinical Nurse Specialist role, give a case example, and 

recommend considerations for implementation in the US 

Army Medical Department. While others 2

 have studied 

this new role in civilian settings,the unique contribution 

of this article is its application to the US Army setting.

DEFINING THE CLINICAL NURSE LEADER

The CNL is a registered nurse with a master’s degree 

from a CNL education program who serves as an advanced generalist clinician. The CNL provides oversight 

of care coordination and integration of care for a defi ned 

group of patients at the microsystem (unit) level. The 

CNL is in a pivotal leadership role to incorporate evidence-based practice, quality improvement, and patient 

safety initiatives to ensure the Institute of Medicine’s3

(IOM) quality aims are met. The IOM’s 6 aims for improvement are focused on healthcare being (1) safe, (2) 

timely, (3) effective, (4) effi cient, (5) equitable, and (6) 

patient-centered.

The AACN1(p10) lists the following fundamental aspects 

of the CNL role:

 Leadership in the care of patients in and across all 

environments.

 Design and provision of health promotion and risk 

reduction services for diverse populations.

 Provision of evidence-based practice.

 Population-appropriate health care to individuals, 

clinical groups/units, and communities.

 Clinical decision-making.

 Design and implementation of plans of care.

 Risk anticipation.

 Participation in identifi cation and collection of 

care outcomes.

 Accountability for evaluation and improvement of 

point-of-care outcomes.

 Mass customization of care.

 Client and community advocacy.

 Education and information management.

 Delegation and oversight of care delivery and 

outcomes.

 Team management and collaboration with other 

health professional team members.

 Development and leveraging of human, environmental, and material resources.

 Management and use of client-care and information technology.

 Lateral integration of care for a specifi ed group 

of patients.

THE CNL ROLE IN RELATION TO OTHER NURSING 

ROLES IN THE CLINICAL MICROSYSTEM

The CNL is not an administrative or management role. 

The CNL partners with the administrative and management staff and is a vital member of the interprofessional 

healthcare team. The AACN highlights the similarities, 

differences, and shared characteristics of the CNL and 

nurse manager roles.4

 In collaboration, the CNL and the 

nurse manager focus on improving the quality of care 

delivered in the healthcare system. The CNL and Clinical Nurse Specialist (CNS) roles are also complementary and collaborative. The AACN published a working 

statement5

 comparing the CNL and CNS roles, highlighting the similarities, differences, and complementary characteristics. Table 1 summarizes these similarities 

and differences in terms of education, certifi cation title, 

clinical practice area, and value.

Regardless of specialty and focus, the CNS incorporates 

both the microsystems and the macrosystem into the 

care of the patient, staff and organization as described in 

the AACN6

 synergy model spheres. This model includes 

Clinical Nurse Leader: Emerging Role to

 Optimize Unit Level Performance

MAJ Scott Phillips, AN, USA

MAJ Pauline A. Swiger, AN, USA

MAJ Robert Flores, AN, USA

Paula Clutter, PhD, RN, CNL

Carol Reineck, PhD, RN
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

these interrelated systems: the 

client/patient, the personnel/staff, 

and the organization/system. The 

spheres are incorporated into each 

of the 5 main roles of the CNS: 

clinical expert, consultant, educator, researcher, and clinical leader. 

Whether the CNS functions as a 

licensed independent provider or 

blends into the team, he or she 

uses the focus, specialty, and 

spheres to provide holistic care to 

the end user, our patients. By way 

of contrast, the CNL is an advanced generalist in nursing who is prepared to be a direct care provider accountable for the care outcomes of a clinical population or a 

specifi ed group of patients/clients in a healthcare system. 

The CNL provides for lateral integration at the point of 

care (bedside) that promotes quality care outcomes. The 

CNL master’s level curriculum is offered in response 

to the profound changes in the increasingly complex 

healthcare system mandating change to improve quality 

of care while reducing costs, improving access, eliminating disparities, and promoting safe practice. The 

CNL oversees the care coordination of a distinct group 

of patients and actively provides direct care in complex 

situations. As an advanced generalist, the CNL incorporates evidence-based practice, patient safety, and quality improvement to optimize healthcare outcomes. The 

CNL provides leadership to assure safe, timely, effi cient, 

effective, and equitable patient-centered care.

Both roles require master’s preparation and each role 

has a clear domain of infl uence and skills. The CNL 

and CNS roles are distinct in their respective preparation and collaborate in the mission to benefi t the patient, 

staff, and system. In Thompson and Lulham’s article,7 

these 2 master’s degree-prepared roles have both demonstrated clear benefi ts. For example, the CNLs and 

CNSs who serve a cardiac population of patients within 

a university healthcare system together, have developed 

a collaborative relationship that benefi ts both staff and 

patients. Both worked together to differentiate role expectations, functions, and outcomes. In making patient 

care decisions, there are role similarities and overlaps, 

such as working with the multidisciplinary team, using 

advanced nursing skills for patient assessment, performing complex problem analysis, and supporting bedside 

staff. Despite these similarities, there are differences 

that reinforce the need for separate roles. The CNL 

manages a distinct population group through day-byday management of clinical issues and decisions. The 

focus is on evaluating and supporting evidence-based 

decisions to ensure best possible outcomes. By contrast, 

the CNS aims to help staff deal 

with disease processes and treatments from a broader perspective, 

focusing on a group such as patients with cardiac diagnoses and 

solving problems at the macrosystem level. The CNLs directly assist staff to implement evidencebased or patient care changes 

with each individual patient at the 

microsystem level. The CNS may 

coordinate hospital-wide orientation programs and provide formal 

staff education, such as teaching new employees in the 

skills laboratories. The CNL assists with staff development and education but deals mainly with individual 

staff members at the bedside. According to Thompson 

and Lulham,7

 they collaborate to build staff nurses’ skills 

and abilities, especially with regard to critical thinking 

and fostering patient education.

PROGRAM OF STUDY

The CNS program of study focuses on one of several 

specialties: (1) medical-surgical, (2) critical care, (3) geriatric, (4) pediatric, (5) mental health, (6) oncology, or (7) 

community health nursing. Within these populations, the 

CNS may also focus on patients with a particular diagnosis or condition such as heart failure, wounds, or pain.

The CNL major at the School of Nursing, University of 

Texas Health Science Center at San Antonio was initiated during the fall of 2010. The CNL curriculum was 

developed using the CNL Essential Curriculum Elements 4

 as a guide and is congruent with the AACN’s Essentials of Masters Education.8

 The CNL major consists 

of 40 semester credit hours and 495 clinical practicum 

hours. Table 2 presents course names, numbers, respective semester credit hours, and clinical hours. During the 

last semester, and at the conclusion of the CNL capstone 

clinical experience, the student is eligible for the AACN 

Commission on Nurse Certifi cation CNL credentialing 

examination to obtain national CNL certifi cation.

APPLICATION OF THE CNL ROLE IN THE US ARMY

The Clinical Nurse Leader (CNL) is key to meeting both 

the Army Medical Department (AMEDD) macrosystem 

objectives and the Army Medical Command’s (MEDCOM) strategic objectives. The MEDCOM created a 

balanced scorecard (BSC) to align all Army medical organizations toward “achieving its overarching strategic 

objectives.” 9

 The BSC builds on the AMEDD’s mission 

(why we exist), vision (where we want to be), and strategic themes (“pillars of excellence”).10(p7) In 2009, the 

MEDCOM Chief of Strategic Planning noted that:

CLINICAL NURSE LEADER: EMERGING ROLE TO OPTIMIZE UNIT LEVEL PERFORMANCE

Table 1. Clinical nurse leader and clinical nurse 

specialist compared by education, practice, and 

value.

Clinical Nurse 

Leader

Clinical Nurse 

Specialist

Master’s Prepared Yes Yes

Advanced Practice 

Registered Nurse No Yes

Advanced Generalist 

Clinician Yes No

Vital member of the 

interprofessional 

healthcare team

Yes Yes
 October – December 2012 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

The Surgeon General likes to use the muddy stream 

analogy: sometimes our organization can appear mired 

and moving in multiple, random directions. The balanced 

scorecard is our way of getting everyone moving in the 

same direction; gathering momentum as we go.9

The skills of a CNL can clear that “muddy water” at 

the individual hospital unit level while keeping the 

AMEDD’s BSC in the forefront. The CNL can help focus the staff while implementing strategic objectives.

The AMEDD Balanced Scorecard was last updated in 

March of 2011 and states the AMEDD’s vision is to 

“bring value and inspire trust.”10 Two strategic themes 

and desired results are particularly well-suited to the 

skills of the CNL: (1) maximize value in health services, 

and (2) balance innovation with standardization. The 

fi rst, maximize value, seeks a result of “effectively and 

effi ciently provide(ing) the right care at the right time”10 

which is a primary goal of the CNL. Units within the 

Department of Veterans Affairs that employ the use of 

a CNL reported that “integration of the CNL role in all 

areas of practice in every care setting has the promise of 

streamlining coordination of care”11(p382) which 

would lead to improved effi ciency. The CNL 

can aid in the second strategic theme, balancing “innovation with standardization,”11(p382) by 

maximizing the use of best practices resulting 

in optimal patient outcomes, also in accordance with the MEDCOM BSC. The CNL is 

best positioned to implement evidence-based 

practices on the unit because “as a master’s 

prepared nurse generalist, the CNL is prepared 

to deliver and direct evidence-based practice, 

evaluate patient outcomes, and assess risk, 

while improving the overall coordination and 

delivery of care for an individual/ group of patients at the microsystem level.”1

 Upon review 

of the BSC, depicted in the Figure, the authors 

noted, by outlining in red, the ends, ways, and 

means of positive effect by CNLs.

The military healthcare workforce faces a 

unique situation of scheduled transition into 

and out of its facilities. This creates challenges 

with continuity around which a CNL can navigate using evidence-based practice with care 

coordination improving overall patient satisfaction. The following case example illustrates 

pilot implementation of the CNL role by an 

Army Nurse Corps offi cer prior to formal graduate education. The example points out the importance of graduate education and appropriate 

structural decisions pertaining to the role.

CASE EXAMPLE: IMPLEMENTING THE CNL ROLE

The Clinical Nurse Leader role was piloted on one nursing unit at William Beaumont Army Medical Center 

(WBAMC), Fort Bliss, Texas. The WBAMC is a Phase 

II site for the BG (R) Anna Mae Hays Clinical Nurse 

Transition Program (CNTP), which is designed to ensure the readiness of the Army’s new registered nurses 

(RNs). From this program, the new RNs are assigned to 

Army military treatment facilities or medical centers.

The CNTP requires one year, combining didactic and 

clinical orientation for the novice RN. The program affords each new RN similar experiences and exposure 

to large numbers of diagnoses and patient volume. By 

planned preparation of the RN prior to moving to a potentially smaller duty station or a deployed setting, the 

training opportunities actually benefi t the overall military healthcare system.

Once the 12-month program is complete, the nurse offi -

cer is eligible for a permanent change of station reassignment. This is a core difference in current Army Nurse 

Table 2. Clinical nurse leader curriculum (required courses), School of 

Nursing, University of Texas Health Science Center, San Antonio.

Theoretical Core Courses for all Graduate Students:

NURS 5339 Leadership for Quality, Safety, and Health 

Policy 3 semester credits

NURS 5306 Advanced Theory for the Practice of 

Nursing 3 semester credits

NURS 5307 Using Research for the Practice of Nursing 3 semester credits

NURS 5356 Financial and Economic Evidence in 

Healthcare 3 semester credits

Clinical Nurse Leader Major Courses

NURS 6317 Healthcare Information Systems and

Patient Care Technology 3 semester credits

NURS 6380 Foundations of Epidemiology 3 semester credits

NURS 5338 Advanced Pathophysiology 3 semester credits

NURS 6210 Advanced Health Assessment and Clinical 

Reasoning 2 semester credits 

NURS 6110 Advanced Health Assessment and Clinical 

Reasoning: Clinical Application

1 semester credit

45 clinical hours

NURS 6302 Advanced Pharmacotherapeutics 3 semester credits

NURS 6230 Clinical Nurse Leader (CNL) I: Role of the 

Advanced Generalist in Healthcare Microsystems 2 semester credits

NURS 6233 Clinical Nurse Leader (CNL) I: Role of the 

Advanced Generalist in Healthcare Microsystems:

Clinical Application

2 semester credits

90 clinical hours

NURS 6120 Clinical Nurse Leader Role II: Seminar 1 semester credit

NURS 6822 Clinical Nurse Leader Role (CNL) II:Clinical 

Application for the Advanced Nursing Generalist

8 semester credits

360 clinical hours

Total Semester Credit Hours: 40

Total Clinical Hours: 495
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

CLINICAL NURSE LEADER: EMERGING ROLE TO OPTIMIZE UNIT LEVEL PERFORMANCE

The Army Medicine Strategy Map. Source: US Army Medical Department, http://www.armymedicine.army.mil/news/scope/Summer_2011_Scope.pdf
 October – December 2012 81

THE ARMY MEDICAL DEPARTMENT JOURNAL

Corps utilization policy compared with that prior to the 

CNTP. Historically, the RN may have been assigned for 

11⁄2 to 21⁄2 years on a medical-surgical nursing unit. This 

allowed more time to fully progress from novice to (at 

least) advanced beginner. The secondary organizational 

benefi t was additional time for staff to progress through 

more of Benner’s novice to expert stages12 while having access to staff at higher stages as mentors. While 

the Army provides no defi nite time line for progression 

through Benner’s novice to expert stages, Kaminski 

reported that it takes approximately 5 years to move 

through the 5 stages, but also noted that not all novices 

become experts.13

The WBAMC medical surgical section is small in comparison to other major medical centers. The CNTP posed 

a challenge to the section because the program’s new 

RNs arrive and depart in groups. On average, the program’s RNs are at WBAMC for 15 months, since most 

leave 3 months after completing CNTP. Their presence 

results in less experienced RNs making up a larger percentage of the overall staff. Further, the staged rotation 

means that nurses who become the most knowledgeable 

leave and few remain to precept. These 2 circumstances 

decreased the effectiveness of the CNTP at WBAMC 

because there was less knowledge being passed to incoming nurses during preceptorship, and less expertise 

to access when clinical questions arose. WBAMC chose 

to fi ll this knowledge gap with the CNL.

For the CNL on the surgical nursing unit at WBAMC, 

the fi rst task was role creation. The nurse researcher and 

section chief assisted with literature research, job description creation, and rating scheme development. At 

that time, there was not a long-term health education 

training opportunity to be a CNL, nor was the CNL incumbent master’s prepared. Leaders selected the CNL 

based on clinical expertise and leadership ability. The 

CNL had 10 years RN experience within the medical, 

surgical, critical care, and teaching environments combined, and had just returned from a deployment to Operation Iraqi Freedom.

OUTCOMES MEASUREMENT

The metrics for effectiveness will always be established 

by the facility. Some of these metrics are highlighted in 

this article. The metrics employed could be infl uenced by 

increasing communication and attention to the nursing 

process. The effective evaluation and implementation 

of the nursing process is essential to success as a CNL. 

The nursing process is the foundation for effective nursing care, and, by extension, improves the measurable 

metrics. For example, a thorough pain assessment with 

proper planning, implementation, and reassessment may 

decrease falls and length of stay while increasing patient 

satisfaction. The CNL provides expertise in each step of 

the process for the staff RNs.

To this end, the fi rst performance improvement (PI) 

project at WBAMC assessed communication handoff 

and determined that reports were incomplete during the 

morning report and pertinent information was not being 

relayed. It also became clear that absence of communication was a measure of decreased understanding of 

the nursing process. The PI project used observational 

and descriptive cross-sectional analysis of communication data. Point measures were the communication of 

code status, assessment fi ndings, vital signs, laboratory 

values, intravenous access points, and the plan of care. 

Data were collected one month before education and 31⁄2 

months after education. Increases in percentage points 

are shown in Table 3. Dramatic improvements were noted in all aspects of communication during patient care 

transitions. Those improvements were directly associated with CNL role implementation.

These improvements were a measurable function of the 

CNL working within the clinical microsystems, rounding on and interacting with patients, inquiring about the 

plan of care with the RN, and functioning as a clinical 

resource. The CNL is a generalist, but, at the same time, 

an expert—the “go to” person at the point of care when 

knowledge gaps are present. They bring the expert assessment to the bedside, help the staff create a plan, foster communication from that plan to the physician staff, 

and work to implement and reevaluate the patient care. 

Through these capabilities and actions, the CNL benefi ts 

the staff and the organization. They are the constant resource and an integral team member. The CNL role became a recognized success at WBAMC when the staff 

began to regularly ask for input and help. The phrases 

(from the staff) “can you explain this?” and “can you 

help me with...?” and “can you take a look at this patient 

with me?” became success measures.

Table 3. Improvements in communication during patient 

care transitions and handoffs associated with CNL role 

implementation at one military medical center.

Metric

One Month

Before

Education

31⁄2 Months

After

Education

Increase in

Percentage

Points

Code status 63% 87% +24

Assessment 79% 94% +15

Vital signs 73% 82% +9

Lab values 67% 73% +6

Intravenous (IV)

access and fluids 20% 95% +75

Plan of care 60% 93% +33
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

RECOMMENDATIONS

Due to the complex nature of changes within personnel 

proponency, planning for force structure integration of 

the CNL must begin immediately. The positions identifi ed for the CNL should be fi lled with nurses who are 

master’s prepared as CNLs, whether Department of 

the Army civilian or major or lieutenant colonel Army 

nurses.

For the CNL to be most effective within the individual 

units, we recommend that they work in partnership with, 

but are not rated by, the head nurse (HN). This arrangement could prevent “mission creep” in that the HN may 

want to assign workload to the CNL instead of working 

together toward a common goal while staying in their 

respective roles. The HN should be focused on future 

planning, organizational level goals, and employee ratings and awards. The CNL should focus on interdisciplinary collaboration, improvement science, and policy 

development. The delineation between the HN and the 

CNL will be of paramount importance, requiring education of the hospital staff on the appropriate role of the 

CNL. Without this, the CNL could be perceived as a 

“ghost” head nurse and spend his or her time attending 

inappropriate meetings in place of the HN. The section 

chief would be an appropriate choice as a rater given 

that some head nurses may be outranked by the CNL 

assigned to their unit. For a captain (promotable) or major, the senior rater must be at least a colonel. In most 

situations, the CNL should be rated by the section chief 

and senior rated by the assistant chief nurse, providing 

that person is a colonel. If the assistant chief nurse is not 

a colonel, then the chief nurse would be the appropriate 

senior rater.

To create the standardization that the BSC seeks, the 

AMEDD would have to adopt the goal of placing CNLs 

in at least the 5 major medical centers. If the positions 

are not delineated on the Table of Distribution and Allowances, they may be reabsorbed into the staff of a given unit. Annual meetings or conferences of all clinical 

nurse leaders assigned to medical centers, in person or 

via video teleconference, would decrease variability in 

role performance across the medical centers, and highlight any trends to misassign CNLs within the clinical 

environment.

The ratio of head nurses to CNLs in the medical center 

would be optimal at one to one. That is, a CNL on each 

nursing unit will be a force multiplier for every head 

nurse. The CNL would be an advocate and conduit for 

implementing best practices and evidence-based practice within the AMEDD facilities. To aid in this role, the 

CNL should have access to library databases such as 

EBSCO (EBSCO Information Services, Birmingham, 

Alabama). The introduction of any new role will have 

challenges. Decreasing confusion and role clarifi cation 

must be priority one when implementing a CNL into the 

practice setting. The following are suggestions on initial 

implementation:

1. Clearly defi ne the role and be completely comfortable 

articulating it. This communication is important up and 

down the chain of command. It is essential that senior 

leaders and RN staff know the CNL’s role and goals.

2. Know everyone and become known in the clinical 

environment. As with any new job or facility, the incumbent in a new role must establish a baseline within 

the inner workings of the facility. Working with staff 

members as their mentor provides familiarity with all 

tasks, locations, code combinations, and processes within a unit or ward. Spending 2 day periods with several 

different members of the nursing staff, a combination of 

stronger and weaker nurses, is advisable. Thus, the CNL 

can begin to quietly evaluate the staff while showing an 

ability and willingness to “get my hands dirty” in the 

course of caring for patients. During CNL interactions 

with physicians, it is important to explain the CNL roles 

in care coordination, clinical improvement in care delivery, and enhanced communication between the physician and nursing staff.

3. The duty location of a CNL is in the nursing unit, at the 

bedside and overtly available to the staff. The CNL is 

their resource. The CNL’s ability to act as such is diminished by absences from the care environment for meetings. While some may be necessary, most will not. Have 

the support of the senior leader to say no, and remain at 

the bedside.

In order for the CNL position to realize its potential as 

a valuable resource in the provision of healthcare within 

AMEDD, CNLs must be given the proper tools and responsibilities to demonstrate their value and effectiveness. Only then can they successfully educate the hospital staff, both leadership and those directly involved in 

patient care, about the important role of the CNL in their 

facility operations. With careful planning prior to implementation of the CNL positions, AMEDD will fi nd 

that the CNL quickly becomes indispensable to meeting 

many of their strategic objectives.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge Dr Mary “Kelly” 

Dunn for editorial review and Ms Cecelia Dornfi eld for 

clerical assistance.

CLINICAL NURSE LEADER: EMERGING ROLE TO OPTIMIZE UNIT LEVEL PERFORMANCE
 October – December 2012 83

THE ARMY MEDICAL DEPARTMENT JOURNAL

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21, 2012.

2. Moore L, Leahy C. Implementing the new clinical 

nurse leader role while gleaning insights from the 

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3. Institute of Medicine. Crossing the Quality 

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books/0309072808/html/. Accessed June 21, 2012.

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statement comparing the clinical nurse leader and 

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21, 2012.

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Nurses website. Available at: http://www.aacn.

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armymedicine.army.mil/news/scope/

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the Veteran’s Health Administration. Nur Econ.

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12. Benner P, Tanner C, Chesla C. From beginner to expert: gaining a differentiated clinical world in critical care nursing. ANS Adv Nurs Sci. 1992;14(3):13-

28.

13. Kaminski J. Theory applied to nursing informaticsnovice to expert. Can J Nurs Inform. 2011;5(4):1-3. 

Available at: http://cjni.net/journal/?p=967. Accessed August 3, 2012.

AUTHORS

MAJ Phillips is Clinical Nurse Specialist and Education 

Offi cer, US Army Burn Center, US Army Institute of 

Surgical Research, Fort Sam Houston, Texas.

MAJ Swiger and MAJ Flores are master’s degree 

students at the School of Nursing, University of Texas 

Health Science Center at San Antonio.

Dr Clutter is an Assistant Professor, Department of 

Health Restoration and Care Systems Management, 

School of Nursing, University of Texas Health Science 

Center at San Antonio. A Major in the USAFR Nurse 

Corps, Dr Clutter is Deputy Chief Nurse of the 433rd 

Medical Squadron, Lackland AFB, Texas.

Dr Reineck is Chair and Professor, Department of Health 

Restoration and Care Systems Management, School of 

Nursing, University of Texas Health Science Center at 

San Antonio. Dr Reineck is a retired Colonel, US Army 

Nurse Corps.
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

Small units of the Army Medical Department (AMEDD) 

play a vital role in providing combat health support 

within a theater of operations. For example, combat and 

operational stress control, forward surgical care, and 

preventive medicine functions are performed by teams 

that operate in remote locations such as forward and contingency operating bases. Despite the widespread use of 

these units on the battlefi eld, there is a paucity of after 

action reviews (AARs) and reports from operations and 

training exercises in the lessons learned databases. The 

small unit survey discussed herein was designed to fi ll 

this gap and provide unit members the opportunity to 

provide input on their deployment experiences.

METHODS

The survey targeted small units such as preventive medicine teams, medical logistics companies, area support 

medical companies, dental companies, forward surgical teams, and other similar-sized units that redeployed 

from Operations New Dawn, Enduring Freedom, and 

Iraqi Freedom from July 2010 to July 2011. The survey 

questions were developed from the AMEDD Lessons 

Learned Division’s postdeployment questionnaire used 

for end-of-tour AAR video teleconferences and information collections from other redeployed medical units. 

Over 100 small unit members completed the online survey. This number represented a completion rate of 10% 

of the total number of emails sent to small unit members 

via Army Knowledge Online group email accounts established on the basis of redeployment dates and unit 

identifi cation codes.

Respondents provided anonymous demographic information including military rank, Army service component,* 

and other similar data, followed by a 22-item questionnaire. The questionnaire used a Likert-style format with 

a score point scale that ranged from 1 (strongly agree) 

to 5 (strongly disagree). The questions were designed to 

determine what operational challenges units faced during predeployment activities and deployment operations. 

The questions were reversed on some items so that a numerical low score of 1, indicating strong agreement, was 

sometimes associated with a positive view (for example, 

“our unit had adequate training”) and other times with 

a negative view (“our unit had communications challenges”). In addition to the scaled questions, respondents could expand their answers and provide additional 

details about their training, preparations, and medical 

support experiences in free-text blocks.

DATA ANALYSIS

The results of the correlation data analysis revealed several small but signifi cant correlations at the 0.05 level 

between the independent variables and the respondents’ 

answers on the questions. Higher military rank was negatively correlated to ratings on 3 questions indicating 

strong agreement with the following statements: “the 

medical supply process, including automation systems, 

posed challenges/diffi culties”; “Advanced Leadership 

Course (ALC)/Senior Leadership Course (SLC) training prepared our NCOs†

 for the deployment,” and “predeployment training for Soldiers was relevant to meet 

our needs.”

Older respondents showed strong agreement with the 

statement “during the deployment our unit faced challenges in the area of life support.” Time in service (TIS) 

produced 2 signifi cant effects on respondents’ answers. 

Those individuals with more TIS expressed strong 

Lessons Learned Small Unit Postdeployment

 Survey Results and Analysis

MAJ (Ret) David W. Cannon, MS, USA

ABSTRACT

The Army Medical Department Lessons Learned Division conducted a survey of small unit service members 

from July through September 2011 to obtain feedback on the challenges they faced during recent deployment 

operations. Personnel assigned to selected company-sized units, teams, and detachments that redeployed within the past 12 months were asked to complete an online survey of questions regarding their predeployment and 

operational experiences. The results revealed a number of variables such as respondents’ service component, 

assigned unit, and geographic location that infl uenced views on the issues. The implications of the fi ndings are 

discussed, along with recommendations for future work designed to collect small unit observations, insights, 

and lessons.

*Active Army, Army Reserve, National Guard, Active Guard/

Reserve

†Noncommissioned offi cers
 October – December 2012 85

disagreement with the statements “predeployment training for professional fi ller system (PROFIS)* personnel 

was adequate for their roles and responsibilities” and 

“our unit utilized nonstandard (non-Department of Defense) automated equipment and/or commercial systems 

and programs for operations.” Respondents who spent 

more months in theater were much more likely than 

those with fewer months to have favorable views of their 

units’ predeployment training and the use of updated 

materials from lessons learned. Similarly, respondents 

with more months in theater held more positive views 

than those with fewer months of their units’ ability to 

provide a wide range of coverage.

The analysis of variance data showed no signifi cant differences in responses based on the respondents’ deployment 

theaters. However, the results indicated that respondents’ 

geographic/environmental location within the theater of 

operations had an effect on unit members’ responses on 

a number of questions. The questions about the degree 

to which ALC/SLC training prepared the units’ NCOs 

for deployment, whether or not the unit was correctly 

structured for its mission, the adequacy of the medical 

supply process, challenges with the Medical Communications for Combat Casualty Care (MC4) system, challenges with theater-provided equipment, and additional 

materiel and equipment needs to meet operational demands all produced F scores with high degrees of confi -

dence. These results indicate that the geographic area to 

which the respondent was deployed was a key variable 

affecting his or her perceptions on these questions.

The type of unit with which the individuals were deployed was a key factor in respondents’ answers on the 

following 2 areas of inquiry (questions paraphrased):

 Did unit predeployment training include both updated lessons learned and tactics, techniques, and 

procedures from deployed units?

 Was the unit correctly structured for its mission in 

terms of personnel and equipment and was it able to 

adapt to rapidly changing situations?

Respondents’ answers on those 2 questions varied signifi cantly, depending on the type of unit with which they 

deployed.

Individuals from the 4 Army service components responded with signifi cant differences on the question of 

their unit’s wide-range mission capability.

Respondents provided additional details to emphasize 

or expand answers to the survey. These responses highlighted issues with forward surgical team (FST) splitbased operations, PROFIS, and medical refresher training. For example, MC4 was a signifi cant concern for a 

number of the small unit members, and respondents provided comments about challenges associated with the 

system. Surveys reported issues with the network connectivity of the MC4 system and image version. While 

some respondents wrote they had useful MC4 training 

prior to deployment, the MC4 system’s status often varied widely and went from operational to nonoperational 

throughout the deployment.

Other respondents noted that units operating on forward 

operating bases (FOBs) and contingency operating bases 

(COBs) had to improvise ways to receive medical supplies via MC4 and rely on resupply help from other units 

to accomplish the mission. One survey indicated that it 

took at least 60 days for supplies to arrive, and another 

recommended additional MC4-trained “super users” in 

theater since contract support for MC4 was limited to 

certain areas. Unreliable and slow internet connectivity exacerbated this issue because connectivity was 

dependent on each FOB`s signal capabilities. In some 

instances, this made MC4 virtually a standalone system 

with little support for ongoing system failures in remote 

areas. However, MC4 is designed to function as a standalone system in areas of low to no connectivity, ensuring continuous documentation of electronic medical recording with data transfers occurring when a unit gains 

internet connectivity. Patient transfer and accountability 

functions were hampered since paperwork often had to 

be re-created each time a patient was moved to a new 

facility due to system fi rewalls or lack of connectivity. A 

respondent who served in an FST wrote that MC4 information did not upload in real time to the Theater Medical Data Store or other higher level servers and noted 

that Role 3 medical treatment facilities could not review 

their records digitally. According to MC4, when internet 

connectivity is secured, data entered into MC4 fl ows to 

the Theater Medical Data Store every 2 to 3 minutes on 

average. Users indicated that MC4 was also inadequate 

in its current form for the documentation of anesthesia 

intraoperative reports, however; MC4 applications do 

provide this capability using a software workaround.

Post hoc multiple comparison test results on the data are 

available and may be requested from the author (210-

221-6174).

COMMENT

The data analysis provides an insightful view of AMEDD 

small units that redeployed over the past year and complements fi ndings from recent Operation Enduring 

*PROFIS predesignates qualifi ed Active Duty health professionals 

serving in other units to fi ll 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.
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

Freedom medical task force AARs. The survey results 

indicate that higher ranking respondents rated their units 

as having diffi culties with the medical supply process 

and believed that automation systems posed challenges 

and diffi culties to their units. This fi nding is not surprising in light of free-text comments that reported defi ciencies in application capabilities developed for the MC4 

system. The MC4 challenges have been recognized in 

past AARs and changes are ongoing to resolve systemic 

issues in the current deployed environment. For example, MC4 has instituted training opportunities at the 

CONUS* Replacement Center, Fort Benning, Georgia, 

to ensure PROFIS personnel are trained prior to arriving 

in theater. The MC4 has also institutionalized classes 

at the AMEDD Center and School, injected system use 

in more than 50 annual exercises, and, to build system 

profi ciency, installed it as a sick-call tool and train-asyou-fi ght mechanism at battalion aid stations and brigade medical supply offi ces in garrison. Additionally, 

MC4 has been added to various in-theater networks to 

enable remote technical support delivery to FOBs without contractor or organic support personnel. At the same 

time, the results indicate that respondents with higher 

rank believed that ALC/SLC training prepared their 

units’ NCOs for deployment missions, and that Soldiers’ 

predeployment training was relevant to meet the units’ 

needs. These fi ndings may refl ect leadership beliefs that 

their unit personnel received the proper predeployment 

training and had the necessary skills and training to 

carry out their duties. Despite these overall positive attitudes of unit leadership about predeployment training, 

medical supply and automation systems remain concerns that warrant continued command emphasis and 

actions to facilitate small unit operations.

Age and TIS correlations produced mixed results. In 

general, respondents with more TIS were likely to view 

the predeployment training of their unit’s PROFIS personnel as inadequate for their roles and responsibilities, 

but these respondents also have positive feelings and 

rate their units as not requiring nonstandard automation 

equipment or commercial systems and programs for operations. On the other hand, older respondents were more 

likely to rate their units as having greater challenges in 

the area of life support than were younger respondents.

The data produced several signifi cant correlations between respondents’ length of time in theater and their 

answers about predeployment training, including updated lessons learned materials and the ability of their units 

to provide a wide range of area coverage, including remote FOBs and COBs. The data suggest that the longer 

individuals stayed in theater, the more likely they were 

to develop positive views of the adequacy of predeployment training and the units’ ability to meet challenges in 

providing support to remote locations. 

The results show a signifi cant difference based on type 

of unit to which respondents were assigned in their 

views on the question dealing with predeployment training and availability of lessons learned and tactics, techniques, and procedures from units already deployed. 

Follow-up action will ensure these materials are readily available for units prior to deployment. Respondents 

also differed signifi cantly in perceptions of their unit’s 

structure for its mission and ability to adapt rapidly to 

changes in mission. These differences may refl ect the 

need to determine how to update small unit equipment 

and organizational structure to best meet the situational 

demands within a given theater, to ensure these units 

remain fl exible and capable of accomplishing full spectrum operations.

Respondents’ free-text comments about PROFIS, theater-provided equipment, and medical refresher training produced positive comments that showed how small 

unit personnel were proactive and worked through personnel and equipment shortages to support numerous 

FOBs and COBs, as well as detention facilities. To quote 

one respondent, “we arrived in theater with ten personnel; we successfully completed our mission with eight.” 

There were challenges to overcome and issues that needed resolution, but units perservered through innovation 

and team effort to accomplish their missions. 

This small unit survey represents a new initiative within 

the lessons learned collection process. The survey results along with other observations, insights, and lessons 

were entered into the AMEDD lessons learned database 

and shared with both combat and training developers. 

The free-text responses about the limitations of the FST 

conducting split-based operations were combined with 

other FST observations, insights, and lessons, and provided to Directorate of Combat and Doctrine Development (DCDD), FST Integrated Process Action Team 

(IPAT). The FST IPAT conducted a capabilities-based 

assessment designed to determine what doctrine, organizational, training, materiel, leadership, personnel, 

and facilities solutions were required to meet capability 

shortfalls. 

The capabilities-based assessment identifi ed 10 capability gaps that were primarily generated from the need to 

design a more fl exible and scalable future capability that 

allows the FST to separate into 2 teams, each of which 

can effectively function independently. The recommendations identifi ed that all of the capability gaps can be *CONUS indicates continental United States

LESSONS LEARNED SMALL UNIT POSTDEPLOYMENT SURVEY RESULTS AND ANALYSIS
 October – December 2012 87

THE ARMY MEDICAL DEPARTMENT JOURNAL

addressed with nonmaterial solutions. The proposed 

capability structure consists of a mission command element, 2 surgical elements, and 2 resuscitation elements, 

and remains within the current FST force structure level 

of 20 personnel. In this way, the FST survey responses 

and other deployment lessons were used to determine 

ways to improve the provision of forward surgery in the 

years 2016 through 2028.

The AMEDD Lessons Learned staff also participates in 

other DCDD IPATs, including telehealth, mild traumatic brain injury and concussion recovery care, advanced 

trauma management, prehospital medical informatics, 

battlefi eld oxygen requirements, and en route critical 

care. Recent issues like feral animal management rely 

on lessons learned to provide insights on animal control measures and command responsibility for animal 

control, and emphasis on the policies prohibiting pets or 

mascots. Failure to act on previous lessons has consequences and can lead to outbreaks of vector-borne and/

or zoonotic diseases, especially rabies. Lessons collected through the survey process and operational AARs 

aid in current deployments by providing recommended 

practices, as well as to identify and fi ll gaps through the 

capabilities development process.

The Lessons Learned staff works with the DCDD Force 

Protection Branch to facilitate data collections through 

online surveys, setup assistance, and conducting in-person interviews during brigade combat team (BCT) umbrella week collections. The survey focus areas include 

nutritional intake from both military and civilian provided sources, feral animal control and rabies prevention, 

and mental health stability, including access to combat 

stress control teams. The surveys are disseminated to 

returning BCT personnel during the week-long collection activities that target all personnel within the BCT. 

Those surveys are compiled once by Lessons Learned 

and submitted to the Force Protection Branch for review 

and analysis.

CONCLUSION

The author received an overwhelmingly positive response from leaders and unit members who participated 

in the survey, their willingness to share experiences, and 

desire to receive feedback on the results. The survey 

gave AMEDD small unit members a unique opportunity 

to express views on a range of important issues. A number of respondents indicated it was the fi rst time anyone 

asked questions about their deployment experiences. The 

fi ndings of small but signifi cant correlations point to the 

need for further study to determine how variables such 

as rank, length of deployment, and time in service interact to affect both attitudes and responses on issues. The 

survey results indicate several strong effects of the unit’s 

geographic location while deployed as a key factor in the 

survey responses, as well as the need to fi ne-tune a unit’s 

predeployment training and overall organization and capabilities required for specifi c geographic locations.

The Lessons Learned Division recently published 2 

guides to lessons learned that provide unit members 

with a wealth of information and advice on what does 

and does not work in various deployment settings; one 

guide for the combat support hospital and the other for 

the forward surgical team. A lessons learned guide for 

the brigade surgeon section is in development, and there 

are plans to publish guides for veterinary and dental 

units. The Lessons Learned Division has already integrated recommended practices into prepackaged lessons 

learned documents for brigade combat teams which are 

distributed through medical observers and controllers at 

the US Army Combat Training Centers. The collection 

process is being streamlined by identifying returning 

units and ensuring their lessons learned and reports are 

obtained in a timely manner to assist other small units 

in the deployment schedule. This will improve predeployment training and enhance a small unit’s ability to 

conduct split-based operations in support of decisive 

action. Future initiatives will involve contacting small 

units prior to deployment and providing them with lessons learned and recommended practices based on similar units’ deployment experiences. Follow-on surveys 

will focus on specifi c AMEDD small units with the 

goal of identifying ways to improve AMEDD battlefi eld 

capabilities.

AUTHOR

MAJ (Ret) Cannon, an employee of OUTSOURCE 

Consulting Services, is a Combat Medical Systems 

and Lessons Learned Analyst for the Lessons Learned 

Division, Combat and Doctrine Development Directorate, 

AMEDD Center and School, Fort Sam Houston, Texas.
88 http://www.cs.amedd.army.mil/amedd_journal.aspx
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

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