July – September 2006

Perspective 1

MG Russell J. Czerw

Medical Operations in the Stryker Brigade Combat Team 3

LTC Ed Michaud, MC, USA; MAJ Mike Helwig, MC, USA; LTC John Glorioso, MC, USA;

LTC Keith Salzman, MC, USA

Medical Processing of Patients from Operations Enduring Freedom and 10

Iraqi Freedom: The Deployed Warrior Medical Management Center

MAJ Brent Johnson, BSC, USAF

Caring for Contractors in Our Midst: Lessons Learned from Operation Iraqi Freedom 17

MAJ Andrew Doyle, MC, USA

Thumb Opposition Restoration: A Case Study 22

CPT David Admire, SP, USA

Medical Support and Basketball-Related Sports Injury of US Soldiers in Afghanistan 27

LTC James Frizzi, MC, USA; MAJ Peter Ray, MC, USAR; CAPT John Raff, MC, USNR

Improving Soldier Care Through Outcomes Research: 30

The Accession Screening & Immunization Program

CPT Remington Nevin, MC, USA; LTC David Niebuhr, MC, USA;

Kevin Frick, PhD; COL John Grabenstein, MS, USA

Multidisciplinary Crisis Management Simulation-Based Training Program 39

Kevin Coonan, MD; LTC Joseph Miller, MC, USA; Michelle Martinez;

COL Pat Kelly, MC, USA

Elements of Leadership for the Successful Organization 47

COL George Turiansky, MC, USA

Mentors and Protégés: Simple Rules for Success 50

COL Mark Melanson, MS, USA

A Validation Study of a Commonly Used Military Assessment 59

of Personality Interactional Patterns

Susan Walley, MSW; COL (Ret) Kyle Pehrson, MS, USAR; Patrick Panos, PhD
LTG Kevin C. Kiley

The Army Surgeon General

Commander, US Army Medical Command

MG Russell J. Czerw

Commanding General

US Army Medical Department Center and School

July – September 2006 The Army Medical Department Center & School PB 8-06-7/8/9

0615605

PETER J. SCHOOMAKER

General, United States Army

Chief of Staff

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July – September 2006 1

It is my distinct pleasure to review my first issue of the

AMEDD Journal as the new Commanding General,

US Army Medical Department Center and School and

Fort Sam Houston. I look forward to every subsequent

issue with enthusiasm as we read, learn, and broaden

the knowledge of our Warrior Medics. The AMEDD

Journal exists for the specific purpose of reflecting

general perspectives on the conduct of our core

business. It serves to strengthen the concepts and

application of clinical, research, operational, and

administrative Army medicine. Furthermore, the

AMEDD Journal provides us great benefits as a peerreviewed publication. First, reviewing articles in your

field (and in general) keeps you abreast of dynamic

research and ideas. Secondly, the AMEDD Journal

provides you an excellent venue to contribute ideas

and information for those of us who look to the

AMEDD Journal to strengthen our education, research,

and service.

To our readers and contributors, all of us at the Center

and School thank you in advance and sincerely

appreciate your support and encouragement as you

continue to conduct and report on your research,

experiences, and lessons learned, while we do our very

best to expand the knowledge base of our Warrior

Medics.

I know you will find this edition of the AMEDD

Journal particularly useful and informative. It contains

some great research, observations, and ideas that cover

a myriad of diverse topics, all very applicable to

present-day AMEDD global operations.

This edition begins with an article titled “Medical

Operations in the Stryker Brigade Combat

Team” (SBCT) authored by a group of military

medical professionals led by LTC Ed Michaud. They

do a superb job highlighting the reality that the

contemporary operational environment dictates the

necessity for further refinements in the SBCT

modified table of organization and equipment. There

are some truly smart comparisons here regarding

medical support in the legacy brigade combat team and

the current transformed SBCT. The authors conclude

that the Brigade Surgeon Section should be more

robust and self-sufficient, thus eliminating the

requirement for critical augmentation. The article

brings to light a host of other issues with some very

supportive observations in this very easy read.

“Medical Processing of Patients from OEF and OIF:

The Deployed Warrior Medical Management

Center” (DWMMC) by MAJ Brent Johnson, USAF

explores the operations of the DWMMC at Landstuhl

Regional Medical Center. He articulates the

DWMMC’s many challenges and successes in coping

with the complexities of outpatient management across

the spectrum of multiple operations. The DWMMC at

Landstuhl is the model for our planners when they

consider the high demand of outpatient care for future

conflicts.

“Caring for Contractors in Our Midst: Lessons

Learned from Operation Iraqi Freedom” by MAJ

Andrew Doyle, takes a good look at the dilemma of

providing the proper care for our US contractors in

Perspective

Major General Russell J. Czerw
2 Army Medical Department Journal

OIF. He notes that the presence of contractors with our

forces is nothing new, however our Army field

medical units are structured to provide combat

casualty care to a mostly healthy, young, adult

population. Our contractors are often older and may

have medical conditions that are dramatically different

than those of the average frontline Soldier. He

concludes that our deploying medical units must take

this into account and plan and expand their service

accordingly. It is to the benefit of our deployed

warriors that we keep our contractors healthy while

they are serving with them.

“Thumb Opposition Restoration: A Case Study” by

CPT David Admire intricately examines the successful

outcome of a thumb injury sustained by an F-16 pilot.

After two successful operations, combined successful

occupational therapy and intensive rehab, the pilot was

able to return to duty, saving enormous amounts of

time and money while continuing to maintain

operational readiness.

“Medical Support and Basketball-Related Sports

Injury of US Soldiers in Afghanistan” by LTC James

Frizzi et al dutifully reminds us that although our

Soldiers truly enjoy and benefit from the improved

athletic and sports facilities at far-forward areas, the

presence of such facilities inevitably leads to an

increased requirement for crutches, casts, and cold

compresses. Our military should continue to provide

such facilities. However, medical support providers

must take into account the attendant impact on

supplies and capabilities during the planning process.

“Improving Soldier Care Through Outcomes

Research: The Accession Screening & Immunization

Program” (ASIP) by CPT Remington Nevin et al

provides a great look at the ASIP program as an

application of medical outcomes research, improving

Soldier care while providing evidenced-based

forecasted cost savings. He contends that

implementing serologic screening would most

certainly change current Army accession

immunization practices for the better; eliminating

innumerable unnecessary injections, reducing

needlestick injuries and saving big dollars. Perhaps we

can all say goodbye to the days of mass immunization.

“Multidisciplinary Crisis Management SimulationBased Training Program” by Dr Kevin Coonan et al is

a great read. It reinforces that simulation training is of

great value across the spectrum of health service. From

the foxhole to the ICU, simulation is an invaluable tool

for enhancing patient care team performance. The

article also emphasizes that further studies and

documentation are required to optimize that training.

More to come in the dynamic field of simulation

training.

“Elements of Leadership for the Successful

Organization” by COL George Turiansky is an

absorbing essay on a subject, leadership, which can

never be overemphasized. COL Turiansky

thoughtfully shares the pillars of his leadership

philosophy: vision, communication, courage,

developing subordinates, knowing yourself, and

passion. This article is an easy and important read

because we all have room for improvement in our role

as leaders.

“Mentors and Protégés: Simple Rules for Success” by

COL Mark Melanson is a clear, structured presentation

on an often overlooked tool that organizations have

available to nurture and grow their people. COL

Melanson delineates ten rules each for the mentor and

the protégé in a mentoring relationship. This concise

approach to the subject offers some great pearls of

wisdom on how mentoring, when used correctly, can

be of great benefit to our medical professionals,

augmenting their skills and knowledge while

optimizing the time and resources invested in the

effort.

Finally, “A Validation Study of a Commonly Used

Military Assessment of Personality Interactional

Patterns” by Ms Susan Walley et al is a comprehensive

study to evaluate if use of the PersogenicsTM

Personality Profile is an effective method of enhancing

mission accomplishment. Originally developed for

civilian use, it has been incorporated as a training

support tool within the military. This study looks again

at Myers-Briggs and other personality evaluation

instruments, describes the methodologies, and presents

the analysis of data. The authors conclude that,

although certain similarities do exist between our

civilian and military populations, further studies are

needed to assess direct and tangible benefits to military

personnel from use of the Persogenics tool.

Again, it is my pleasure to come aboard and I look

forward to your continued support. All of you have my

sincere thanks for what you do every day!

Perspective
July – September 2006 3

Army transformation involves a combination of

structural changes and the incorporation of new

technologies. The implications of information age

technology have special importance for the military,

not only in the ever-expanding capability to recognize,

understand, and adapt to the enemy’s resources and

actions, but also in the basic understanding of the

current condition and capabilities of our resources. As

Sun Tzu wrote over 2,000 years ago, “If you know the

enemy and know yourself, you need not fear the result

of a hundred battles.”1 The transformation of Army

medicine with new information technologies is a major

component in a commander’s ability to better know

the current condition of that most important resource,

the Soldier. Such expanded capability is becoming

especially important in the new operating environment

presented by the nonlinear battlefield.

The designation of combat health support under

combat service support is a relic of the legacy Army.

In the contemporary operating environment, medical

companies are no longer clustered in the brigade or

division support areas. They are dispersed to far

forward operating bases supporting the maneuver units

with minimal contact with the support battalion. As

such, medical assets should no longer fall under

logistics battalions, commanded and controlled by

logisticians. The brigade surgeon section is tasked to

provide the brigade commander, battalion

commanders, and the brigade combat medics with the

most robust medical support possible, including

realistic medical training, medical information

management implementation, current and accurate

medical intelligence, careful health service support

planning, responsible coordination for Class VIII

support, and competent execution of medical

operations. The Soldiers and medics of the maneuver

platoons must be prepared to stabilize a trauma patient

at his point of injury and evacuate him to a level III

hospital as soon as possible. Further, preservation of a

healthy force requires that Soldiers must be educated

to keep themselves healthy, from the basics of hygiene

to the food that they eat. This requires both a

centralized unity of effort within the medical

community and a decentralized execution down to the

medical platoons and the individual Soldier.

The roles of the brigade support medical company and

medical support operations of the brigade support

battalion have evolved under the new Stryker Brigade

Combat Team (SBCT) structure. These cells do less

medical planning, operations, treatment, and

evacuations than in legacy force structures. The

medical staff structure is already being modified by

necessity, both in garrison and in deployments to

Operation Iraqi Freedom, to reflect the new paradigm.

The brigade surgeon section is robust. The maneuver

battalion medical platoons and brigade support

medical company are more independent, yet more

interconnected by multiple information systems.

Soldiers are given increased training in first aid and

preventive medicine. The modified table of

organization and equipment of the objective brigade

combat team should be structured to reflect those

lessons learned, similar to the modern division which

has an independent medical company and a robust

surgeon section.

BRIGADE SUPPORT MEDICAL COMPANY:

A SEPARATE COMPANY

Historically, “Charlie Med” has been located in the

brigade support area with all of the combat service

support elements. Because of this traditional

collocation, it made sense to task organize the medical

company under the umbrella of the forward support

battalion. It was a very appropriate organization for the

legacy Army fighting on a linear battlefield, eg, to

defend the Fulda Gap. The enemy has changed. The

battlefield has changed. The Army has transformed.

Medical Operations in the

Stryker Brigade Combat Team

LTC Ed Michaud, MC, USA

MAJ Mike Helwig, MC, USA

LTC John Glorioso, MC, USA

LTC Keith Salzman, MC, USA
4 Army Medical Department Journal

The medical company assets are dispersed on today’s

nonlinear battlefield. For example, during an

Operation Iraqi Freedom deployment, the 296th

Brigade Support Medical Company (BSMC)

supported operations of the 3rd Brigade, 2nd Infantry

Division SBCT from 6 forward operating bases both

within and out of the brigade area of operations. Some

of the BSMC medics patrolled with and gave direct

medical support to infantry squads and companies in

combat operations. Only a single team was left with

the brigade support battalion (BSB) to provide level I

care to the battalion.

The brigade surgeon section rarely involved the S4

when planning combat operations. The medical plans

officer developed the medical plan in conjunction with

the S3 planning section. When the plan was executed,

coordination was done with the S3 operations section,

the air operations officer, and the fires and effects cell

for deconfliction. The medic on the line or the

treatment team augmenting a battalion is a far forward

combat multiplier. The medic is part of the team of an

infantry squad assaulting an objective. The forward aid

station is there when a battalion cordons a village.

These are not logistic support functions. Medical

support in combat is a combat support function. This is

not to argue that there is not a logistics element to

combat health support. Of course there is. However,

medical logistics is to combat health support as

moving Class I, III, and V supply is to an infantry

operation. Under the current structure, the

effectiveness of combat health support is far too

dependent on command philosophies, preferences, and

individual personalities, as illustrated in the

deployment experiences of two different SBCTs.

During the deployment discussed earlier, the 296th

BSMC supported the brigade magnificently — in spite

of the task organization, not because of it. The BSB

attempted to maintain control over all of its Soldiers

dispersed over 28,000 square miles in support of the

maneuver battalions. This attempt to maintain

command and control rendered the dispersed medical

assets less responsive to the rapidly changing needs of

the maneuver battalions. Both the brigade

environmental science and mental health officers

performed superbly, but their efforts were sometimes

hampered because they could not respond directly to

requests from brigade headquarters, or the individual

battalions to which they were attached. This occurred

because all requests required approval by the BSB

commander. Further, these health professionals were

required to submit reports of their assessments of

maneuver battalions to the BSB commander for

approval before providing the information to the

brigade surgeon to brief the brigade commander.

Indeed, the routing of support requests and the flow of

report information through the BSB was doctrinally

correct, but the mission of the BSMC is that of a

medical force and service provider to the brigade, not

to the BSB.

During their deployment, the 1st Brigade, 25th

Infantry Division SBCT enjoyed an excellent

relationship with the 25th Brigade Support Battalion.

This was due to a combination of strong and extremely

competent Captains at both the health support service

officer and medical logistics officer positions in the

BSMC, and a reverse migration of officers from the

brigade surgeon section (BSS) to the BSMC where

they brought a brigade level perspective to their

brigade support role. The BSMC commander had been

the BSS planner. While in Iraq, the 25th Brigade

Support Battalion was able to collect medical situation

reports and send them to the brigade surgeon via the

NIPRNET,* and was also very responsive to requests

from the BSS. Another positive factor during the

deployment was that the SBCT was overstaffed with

two Medical Service Corps officers in the brigade

surgeon section, and the BSMC had an Executive

Officer. However, this situation was unique for this

deployment and cannot be relied upon for future

operations.

The fact that the success of that deployment was not

experienced in previous deployments by this SBCT, or

during other SBCT deployments, demonstrates that the

current organization can be made to work with

experienced staffing greater than the allocation of the

modified table of organization and equipment.

Unfortunately that is the exception rather than the rule.

The usual situation under normal staffing levels almost

always involves Lieutenants in Captains’ billets and

medical officers diverted into nonmedical roles, with a

resulting net decrease in medical planning and

operational effectiveness.

In light of the changes in the Army, the enemy, and the

battlefield, combat health support should be removed

from the logistics umbrella. The BSMC should be a

separate company falling directly under the brigade.

Medical Operations in the Stryker Brigade Combat Team

*Nonclassified internet protocol router network
July – September 2006 5

The BSMC’s deployed operating environment is no

different than that of the Military Police and Civil

Affairs detachments, and the Signal, Military

Intelligence, Antitank, and Air Defense Artillery

companies, all of which have Soldiers dispersed across

the forward operating bases in the brigade area of

operations under the brigade troop battalion. A

separate BSMC at the brigade level can be used by the

brigade commander and staff to meet the needs of the

entire brigade without the perceived threat to battalion

operations and integrity.

CURRENT MEDICAL OPERATIONS

In the Army of Excellence legacy brigade combat

team, the medical company was the hub of medical

operations. Brigade medical planning was based

primarily on input and force health protection

estimates provided to the brigade S3 through the

forward support battalion. All patients were evacuated

from level I to level II. All medical logistics were

coordinated through the brigade support battalion

medical support operations, and all communications

w e n t t h r o u g h t h e m e d i c a l c o m p a n y .

As discussed earlier, that paradigm has changed.

Patients are now stabilized near their point of injury

and most are evacuated directly to the closest military

treatment facility (generally level III) for optimal

medical care. The BSS performs brigade medical

planning, coordinates with medical forces in those

echelons above brigade level, and coordinates with

host nation and nongovernmental organizations.

Medical informatics and implementation of the tactical

electronic medical record, both critical to

transformation of medical support in the SBCT, are

two of the new roles performed by the BSS. Brigade

level medical evacuations are coordinated and

managed by the brigade tactical operations center

(TOC). The brigade surgeon section has assumed these

new responsibilities out of necessity due to the

command and control structure which directs and

supports SBCT operations.

The SBCT brigade TOC is a remarkable powerhouse

for both the planning and execution of the combat

team’s missions. The S3 battle captain and the brigade

staff monitor operations around the clock. All forms of

communications are monitored, even down to the

individual vehicle. Unmanned aerial vehicle imagery

and intelligence data can be presented on monitors in

the TOC. Radar data on enemy mortar positions are

fed to the Force Effects Command Center (FECC)

where quick reaction forces are alerted to deal with the

identified threat. The air space controller sits next to

the Air Force Air Liaison Officer (ALO) who controls

all rotary and fixed wing air movement in the brigade

area of operations. Medical evacuation and

nonstandard casualty evacuation flights are

coordinated in the TOC among the intelligence (S2)

section (safety of landing zones), the FECC (clearance

of friendly and enemy fire), the ALO (assignment of

flight corridors), and the BSS which ensures that

patients are prepared for pickup at the designated

landing zones. The BSS receives medical situation

reports twice daily and sends patient status

information, medical intelligence, and operational

guidance to medical platoons using the TOC’s tactical

communications resources. Responsive, effective

combat health support would be impossible in today’s

battlefield environment without close, active interface

between the BSS and the brigade’s TOC.

On the other hand, the BSB’s health service support

officer and medical logistics officer are relatively

isolated from the brigade’s ongoing combat

operations. They do not participate in brigade medical

planning or operations at the TOC, but rather confine

their responsibilities to BSB medical operations.

Unfortunately, they are typically assigned to

nonmedical combat service support functions, to the

detriment of their force health protection

responsibilities. The misuse of these healthcare

professionals is especially egregious in view of the fact

that the modified table of organization and equipment

(M-TOE) assigns only 3 medical officers and 2

enlisted personnel to the brigade surgeon section to

perform the section’s extensive planning and

operational functions. Fortunately, as lessons learned

from actual combat operations have been considered in

deployment planning, at least 2 SBCT commanders

supported a more robust BSS. Those successes support

the idea that combat health support of brigade combat

operations would be better served by a permanent

change to the structure, ie, change the M-TOE to move

the health service support officer and the enlisted

assistant to the brigade surgeon section.

PREVENTIVE MEDICINE

In 2000 a preventive medicine section, consisting of an

environmental science officer and a preventive

medicine specialist, was added to the brigade support
6 Army Medical Department Journal

medical company of the SBCT to affect collection and

analysis of medical threat intelligence. The new

section provides the SBCT additional resources during

the intelligence preparation of the battlefield (IPB).

They work closely with the brigade S2 to develop

specific environmental and enemy medical threats.

Such threats have become ever more important in

current operational environments. Anticipating an

enemy’s decision process has always been vital to

success in combat. For commanders of today’s fast

moving, extremely flexible, and rapidly reactive SBCT

operations, such anticipation is of critical importance.

During the IPB, the preventive medicine

(PRVNTMED) section produces a PRVNTMED

estimate which is submitted through the brigade

support battalion for the brigade surgeon.2,3 The

Environmental Science Officer will also directly

participate in the preparation of the PRVNTMED or

medical annex in all brigade operations orders.

The PRVNTMED section is responsible to the brigade

commander for ensuring preventive medicine

measures are implemented to protect Soldiers against

food, water, insect borne diseases, and environmental

injuries (eg, weather). The scope of this responsibility

includes the brigade support area and units in forward

areas. The section’s activities are governed by the unit

employment and force health protection plans and

coordinated by the brigade surgeon section. The

PRVNTMED section provides consultation and advice

in the areas of environmental sanitation, epidemiology,

and entomology. It conducts occupational and

environmental health surveillance and provides limited

sanitary engineering and pest management services.

The section is charged with medical surveillance, ie,

monitoring the medical treatment requirements of

brigade Soldiers to identify injury and disease trends.

Such information is critical for both the SBCT surgeon

and commanders at all levels. It is vital to the combat

effectiveness of the fighting force to identify any

condition or activity that is detrimental to the health of

the Soldiers as soon as possible, and institute

corrective action. Medical surveillance has become

much more efficient with the advent of the tactical

electronic medical record,4,5 which allows the use of

data mining tools to quickly identify trends and

patterns in treatments. Data must be obtained and

reviewed during visits to aid stations, sent to the

brigade surgeon, analyzed for actionable information,

then transmitted to units for their use.

The PRVNTMED section has the capability to train

and supervise the brigade field sanitation teams and

ensure those teams’ effectiveness in their critical

mission of ensuring safe drinking water and food,

sanitary waste disposal, enforcement of hand washing

requirements, disease vector control, and other

measures to ensure the health and combat

effectiveness of the brigade’s Soldiers. Above all, the

PRVNTMED section provides education and training

to all SBCT Soldiers in preventive medicine measures,

ie, how to stay healthy.

Unfortunately, the conceptual and doctrinal application

and utilization of preventive medicine resources did

not materialize with the first two SBCTs. The

environmental science officer and preventive medicine

specialist were assigned to the brigade support medical

company in the BSB where they were employed in the

inspection of field feeding teams, rodent control, and

other BSB general responsibilities as assigned. As

such the PRVNTMED section’s skills and training

were marginalized, both doctrinally and practically.

The section should have trained and supervised

brigade field sanitation teams to perform those

functions, among others. The brigade surgeon is

charged with the coordination of all PRVNTMED

functions and services within the brigade, just as the

division surgeon does at the division level.6 The reality

is that for geographic, political, or personal reasons the

PRVNTMED section members were often tasked by

the BSMC and the BSB with nonmedical

responsibilities and assignments. Consequently, few of

the brigade level preventive medicine functions were

implemented. The 1st Brigade, 25th Infantry Division

SBCT did not experience the same misuse of the

PRVNTMED section during their deployment. The

brigade support medical company commander (who

had written the brigade preventive medicine policy

while assigned to the brigade surgeon section) ensured

that the PRVNTMED section performed its doctrinal

functions and submitted regular reports to the brigade

surgeon.

The above described problems have also been noted in

legacy divisions. The division PRVNTMED section is

doctrinally employed by the division surgeon. In many

cases the section is assigned to the division support

command, thereby eliminating their integration with

division medical planning, operations, and training.

This situation is being corrected as the PRVNTMED

Medical Operations in the Stryker Brigade Combat Team
July – September 2006 7

section is assigned to the division surgeon section in

division reorganizations,7thus ensuring doctrinal

application of this resource. Similar action should be

taken within the brigade structure to ensure that the

brigade surgeon has the resources necessary to

maintain the health of the force, assess and estimate

the health and medical conditions of the enemy’s

forces, and assist the host nation with health issues

among their population to the extent possible.

COMBAT STRESS CONTROL

A combat stress control (CSC) section, usually found

only in divisions,8is another new addition to the

SBCT’s medical resources. Similar to the preventive

medicine section, the CSC section is responsible for

preparing the CSC estimate3for the brigade surgeon.

The team also is charged with monitoring the mental

health of brigade Soldiers and developing

recommendations as to actions that may be taken to

mitigate stress related injury and improve the overall

mental health situation. The CSC officer must work

closely with the brigade chaplain and the command

sergeant major to maintain a sense of the attitudes and

morale of the troops and identify detrimental trends or

patterns. As discussed previously, the tactical

electronic medical record allows use of data mining

tools to research treatment records. The CSC section

also visits aid stations and conducts interviews with

individual Soldiers who typically have been referred

from their command or health care providers. The

CSC officer, whether a psychologist or social worker,

must train Soldiers and leaders at all levels in

individual and collective tasks that are used to avoid

stress injuries. They must train health care providers

and supervisors in treatment methods which are most

conducive to returning dysfunctional Soldiers to duty.

At the completion of deployment, the CSC section

must be integral in planning redeployment screening

and followup for Soldiers who have been traumatized

by combat. They must work closely with the chaplain

to develop and implement a suicide prevention

program. They must coordinate with family advocacy

programs at home to help strengthen families and

provide crisis intervention. The CSC team must also

coordinate closely with the Army Substance and

Alcohol Program to identify and assist Soldiers who

are abusing alcohol and drugs. The CSC section

should manage the cases of all brigade Soldiers with

mental health, substance abuse, or significant family

problems and advise the commanders on their

conditions and the assistance they require.

LEVEL II CARE IN THE STABILITY AND

SUPPORT OPERATIONS

The doctrinal level II facility (brigade support medical

company, legacy forward support medical company),

was traditionally the evacuation destination after initial

stabilization was performed at level I (point of injury,

aid station). At the level II site, patients were further

stabilized, then moved to a level III facility (hospital).

The BSMC also provided medical reinforcement to

maneuver units with augmentation treatment teams

and evacuation assets. This treatment and evacuation

model is seldom used in the nonlinear battlefield

environment. Patients are now taken directly from

either the point of injury or level I care to the level III

treatment facility. This is the standard method of

patient evacuation in the civilian sector and is only

logical for the major trauma injuries sustained in

combat. Depending on the location of the level III

facility, evacuation is done either with organic medical

evacuation vehicles or helicopter air ambulances.

Initially, forward surgical teams were envisioned to

augment medical companies at level II. With

augmentation of x-ray, laboratory, and patient hold

capabilities on the modified table of organization and

equipment, these teams could be fully functional, and

collocated with any battalion aid station if located a

great distance from a level III facility. In Iraq, the units

have evacuated their own casualties to level III

facilities as discussed previously. In that dangerous

and unstable environment, evacuation convoys are

impractical because routes generally cannot be

rehearsed, and ambulance exchange points are difficult

to establish, coordinate, and secure.

A registered nurse instead of the licensed practical

nurse is assigned to the SBCT. The intent is for these

nurses to assist with training of medics and other

brigade medical personnel. The brigade nurse has been

an effective educator for BSMC medics.

Unfortunately, similar training is not extended to

brigade medics assigned to combat maneuver

battalions. The brigade nurse has proven to be a

valuable organizer and implementation manager for

medical readiness, clinic organization, and patient

care. The nurse should be considered a shared
8 Army Medical Department Journal

resource, as are the environmental science and mental

health officers, to address planning and training

requirements across the brigade.

BRIGADE MEDICAL TRAINING

Our physicians, nurses, physician assistants, and

medics are better trained than ever before and are

expected to maintain their proficiency. Ensuring that

they maintain their skills and accreditations is a

daunting challenge, even in units with sufficient

resources. Medics have a real world mission of patient

care, are expected to provide medical coverage for all

unit training, maintain their equipment, and stay

proficient in their nonmedical military skills. The

medics must pass the EMT (emergency medical

technician) class, obtain EMT certification, pass

Trauma Aims and prehospital trauma life support

courses in their MOS 91W transition. At Fort Lewis,

SBCTs pooled training resources with Madigan Army

Medical Center at the Joint Medical Training Center.

Medics attached to the brigade surgeon section trained

the unit medics in their requirements quarterly,

resulting in over 90% conversion of 91W medics in

the Medical Operational Data Systems. Medics must

also take the semiannual skills validation training

which was conducted at the medical platoon level. The

Stryker brigades have given their medics and other

providers additional trauma training to ensure they are

prepared to care for our most severely wounded

Soldiers on the battlefield. The training was centrally

coordinated by the brigade surgeon section (BSS). The

training was conducted by BSS staff augmented by

external medical personnel, with invaluable support

from Madigan to create realistic trauma training during

a brigade level exercise. The training evolution was

repeated just prior to deployment.

The 1st Brigade, 25th Infantry Division and the 3rd

Brigade, 2nd Infantry Division SBCTs instituted an

effort to train 100% of their Soldiers in combat

lifesaving procedures and techniques because trauma

can occur to anyone at anytime on the battlefield.

Training everyone in combat lifesaving skills

dramatically increases the probability that there will be

someone available to initiate first aid and stabilization

of injuries immediately. Much of this training is

conducted at the battalion level, but some require a

centralized effort for improved quality and efficiency

of delivery. All of the individual training must be

supervised and documented.

ADDITIONAL STRYKER MEDICAL

EVACUATION VEHICLES

Stryker Medical Evacuation Vehicles (MEV) have

proven to be efficient and quiet while effectively

protecting the occupants. These MEVs allow a more

aggressive medical posture on the battlefield. Each

SBCT mobile treatment team should have a treatment

and evacuation MEV variant. More MEVs would

allow treatment teams to support maneuver companies

at the fight, as well as make additional vehicles

available to meet any increased requirements on the

dynamic battlefield, or to replace lost vehicles. The

Army Medical Department (AMEDD) submitted the

request for such a change to the Army Review Team

when the first SBCT was formed. The change was not

supported due to cost limitations and airlift constraints.

The need for the change is more acute now, and

solidly justifiable from many months of combat

experience. In addition, it is now clear that the front

line ambulances should be replaced with 4 to 8 MEVs

to augment evacuation capabilities throughout the

brigade area of operations.

CONCLUSION

Army transformation continues apace as the 172nd

SBCT completed its transition at Fort Wainwright and

deployed to Iraq, and a fourth Stryker brigade formed

at Fort Lewis. Medical transformation requires close

work between Stryker units and their supporting

military hospitals, along with continued assistance

from the AMEDD. The changes to the SBCT modified

table of organization and equipment (M-TOE) which

distinguish it from legacy brigades are appreciated, but

further refinements are necessary. The M-TOE should

be modified to make the BSS more robust and selfsufficient, eliminating the need to augment it with

personnel who are badly needed elsewhere. The BSS

must be able to conduct current and future medical

operations while being responsive to medical logistics

demands around the clock. It must also be able to

implement medical informatics, analyze and prepare

detailed medical intelligence, oversee medical

readiness levels, organize a comprehensive training

program for medical caregivers, and work closely with

host nation and other nongovernment medical

elements.

In 1795, a surgeon in Napoleon’s army, Dominique

Jean Larrey, perfected the use of the battlefield

Medical Operations in the Stryker Brigade Combat Team
July – September 2006 9

ambulance he had developed 3 years earlier. The

“ambulance volant” was one of the innovations in

military medical support developed and implemented

during the Napoleonic wars. During these campaigns,

Napoleon’s military also developed the concepts of

organized, sophisticated logistics support of an army in

combat. Since their inception, the two support

functions, medical operations and logistics, have been

separate entities, both conceptually and practically,

and should be so today. The SBCT brigade support

medical company (BSMC) should be moved from the

brigade support battalion (BSB) to the new brigade

troops battalion. The BSMC would then apply their

resources to brigade level medical support and avoid

the provincial concerns of the BSB. Army medicine

should be considered a combat support function rather

than a combat service support operation. Lessons

learned from SBCT combat deployments can be used

to demonstrate the need and justification for such

realignment.

REFERENCES

1. Sun Tzu. Chapter III, Attack By Stratagem. In: Giles

L, trans. The Art of War. 1910. Available at: http://

classics.mit.edu/Tzu/artwar.html.

2. Field Manual 8-55: Planning for Health Service

Support. Washington, DC: US Dept of the Army; 9

September 1994: chap 11, sect 1.

3. Field Manual 4-02: Force Health Protection in a

Global Environment. Washington, DC: US Dept of

the Army; 13 February 2003: chap 2, sect 2-3.

4. Field Manual 4-02.16: Army Medical Information

Management; Tactics, Techniques, and Procedures.

Washington, DC: US Dept of the Army; 22 August

2003: chaps 2 and 3.

5. Onley DS. Electronic medical records go into

combat. Govt Comput News [online]. November 22

2004. Available at: http://www.gcn.com/

print/23_33/27923-1.html.

6. Field Manual 4-02.17: Preventive Medicine Services.

Washington, DC: US Dept of the Army; 28 August

2000: chap 3.

7. Field Manual 4-02.21: Division and Brigade

Surgeons' Handbook (Digitized); Tactics,

Techniques, and Procedures. Washington, DC: US

Dept of the Army; 28 August 2000: chap 1.

8. Field Manual 8-51: Stress Control in a Theater of

Operations; Tactics, Techniques, and Procedures.

Washington, DC: US Dept of the Army; 29

September 1994: chap 2, sect 1.

AUTHORS

LTC Michaud has recently returned from deployment as the Civil Medical Affairs Director for Combined Joint Task Force

76 in Afghanistan. Previously he was the Brigade Surgeon for the 1st Battalion, 25th Infantry Division Striker Brigade

Combat Team.

MAJ Helwig is currently the Commander of the US Army Health Clinic, Friedberg, Germany. When this article was

written, he was the 3rd Brigade, 2nd Infantry Division SBCT Surgeon. From July to November 2004 while deployed to

OIF, he was the Area of Operations North Surgeon/Task Force Olympia Surgeon, responsible for provision of health care to

19,000 coalition troops and civilians, evacuation, and medical reconstruction over an area of 28,000 square miles in

northern Iraq.

LTC Glorioso is the Chief, Family Medicine Service, Tripler Army Medical Center, Honolulu, Hawaii. Previously he was

the Brigade Surgeon of the 3rd Brigade, 2nd Infantry Division Striker Brigade Combat Team.

LTC Salzman is the Chief, Informatics at the Madigan Army Medical Center, Fort Lewis, Washington. Previously he was

the Brigade Surgeon for the 3rd Battalion, 2nd Infantry Division Striker Brigade Combat Team.
10 Army Medical Department Journal

INTRODUCTION

Operation Enduring Freedom (OEF) began 7 October

2001 against the Taliban regime in Afghanistan.

Landstuhl Regional Medical Center (LRMC), the

largest American military medical center in Europe,

became the sole receiving fourth-echelon medical

facility for patients from OEF combat operations. The

Deployed Warrior Medical Management Center

(DWMMC) at Landstuhl was established to manage

the processing of patients before arrival and during

their time at Landstuhl. The DWMMC handles tasks

such as identification of incoming patient airlifts,

billeting arrangements, patient movement (from

DWMMC to geographically-separate billeting and to

the aeromedical staging facilities at nearby Ramstein

Air Base), accountability, and data input to the

DWMMC database, the Defense Enrollment Eligibility

Reporting System, the Composite Health Care System,

and the Army’s Patient Accounting and Reporting

Real-Time Tracking System. These tasks prepare

patients to either return to duty or be sent to their home

station for additional care. Patient numbers

dramatically increased in the months preceding the 20

March 2003 start of Operation Iraqi Freedom (OIF)

and remained significant through 2004. This paper

focuses on the medical section’s role and how the

DWMMC interfaced with the medical staff of LRMC

to prepare for, treat, and manage the disposition of

patients arriving from both OEF and OIF operations.

ACTIVE COMBAT PHASE

According to COL (now BG) D. A. Rubenstein

(written correspondence, March 2004), Chief of Staff,

European Regional Medical Command, prior to OIF,

DWMMC processed a daily average of 2 to 3 new

patients from US Central Command (CENTCOM),

arriving on 3 to 4 flights per week (maximum of 32

patients on any flight). Information about incoming

patients was monitored through the US Transportation

Command’s Regulating and Command & Control

Evacuation System website. The website provides a

Patient Movement Request (PMR) for each patient

manifested on a given mission. The PMR contains the

patient’s diagnosis, a brief clinical summary,

medications, allergies, and administrative information.

The PMRs were printed and distributed to the

DWMMC medical section for coordination with the

LRMC medical staff to determine inpatient versus

outpatient status, treating service, and inpatient bed

location if the patient was to be admitted. During the

Medical Processing of Patients from

Operations Enduring Freedom and

Iraqi Freedom: The Deployed Warrior

Medical Management Center

MAJ Brent A. Johnson, BSC, USAF

ABSTRACT

The Deployed Warrior Medical Management Center (DWMMC) at Landstuhl Regional Medical Center,

Germany, has played a pivotal role in patient management from Operations Enduring Freedom and Iraqi

Freedom. The DWMMC prepares for the arrival and management of these patients while they are treated at

Landstuhl, and coordinates either their return to duty or evacuation to the United States. DWMMC operations

and scope changed dramatically from the early days of Operation Enduring Freedom when an average of 2.5

new patients per day were received from 3 or 4 flights per week (maximum of 32 patients on any flight), to the

peak of Operations Enduring Freedom and Iraqi Freedom, when an average 57 new patients arrived on daily

flights averaging 30 to 40 patients per flight. Planners for the next major theater war should consider the high

demand of outpatient care evidenced by Landstuhl Regional Medical Center’s experience and incorporate plans

for a DWMMC to manage patient flow.
July – September 2006 11

early period of DWMMC operation, often less than 5

patients would arrive on any given flight so the

medical director could personally visit each clinic and

deliver the PMRs to the on-call physicians. As the

number of arriving patients increased proportionally

with the increasing numbers of in-theater personnel in

the few months prior to OIF (during the period 20 Mar

through 6 May 2003, LRMC received an average of 24

patients per day (ibid)), daily meetings to make such

decisions and assignments became a requirement.

The daily meetings were normally convened at 1300,

with additional meetings called to address any flights

with more than ten patients that were

scheduled to arrive before the following

day’s regular session. The regular meetings

were attended by the division chiefs for

surgery and medicine, a psychiatry/

psychology representative, the bed manager,

the Deputy Commander for Clinical Services

(DCCS), the receiving DWMMC doctor, and

the DWMMC chief. Each patient was

reviewed and the division chiefs decided on

ICU, inpatient or outpatient status, and

accepting service. Details about flight arrival

times were presented by the DWMMC

doctor, and any additional relevant

information was passed among divisions,

DCCS, and the DWMMC chief.

The disposition of patients was determined

based on the information available on the

PRMs. For example, severe neurosurgery patients,

some ocular injuries, and other severe acute patients

that were deemed to require care outside of LRMC’s

capabilities were triaged to the nearby German

university hospital at Homburg. Due to the often

incomplete clinical picture presented by the PMRs,

arriving patients were occasionally directed to the

emergency room where the on-call physician for the

accepting service provided an assessment and

disposition. Patients evacuated to LRMC for mental

health reasons were either triaged to inpatient status or

to the emergency room, where they would be

evaluated by the on-call psychiatrist or psychologist. If

considered safe, those patients would be sent to

outpatient status.

DWMMC physicians rotated the 24-hour “receiving”

and “reporting” call. The receiving physician was

responsible for obtaining PMRs and flight information

for arriving patients, organizing and preparing for the

daily meetings, and recording arrival information for

each patient at the meeting (inpatient or outpatient

status, receiving service, and bed location for

inpatients). Patient information was recorded on a

master spreadsheet that was emailed to DWMMC

staff, the LRMC commander, and inpatient wards. The

receiving physician oversaw patient arrival, ensured

movement to assigned locations, and evaluated

outpatients to ensure they could remain as outpatients

until the next duty day when they would be seen in the

outpatient clinics.

Patients were transported to LRMC from Ramstein Air

Base by ambulance or bus. When patients arrived at

the DWMMC, the receiving physician was briefed on

any in-flight changes by either the air evacuation crew

or the contingency aeromedical staging facility

personnel. Manpower pool members then transported

inpatients to their wards. Outpatients were sent to their

respective clinics if they arrived during duty hours.

Outpatients arriving at night or on a weekend were

taken to the Family Practice clinic where they were

inprocessed by DWMMC enlisted staff and then

evaluated by the DWMMC doctor. When there were

more than 10 outpatients, the reporting DWMMC

doctor, the on-call family practice physician, and the

on-call pediatrician were called-in incrementally to

assist in the evaluations. If there were more than 30

outpatients, as frequently was the case, all four

physicians could be involved. Evaluation of

outpatients was performed to ensure their conditions

matched the clinical information discussed at the daily

DWMMC meeting. Occasionally a patient was more

acute than previously indicated or on intravenous
12 Army Medical Department Journal

antibiotics or analgesics. In such situations the

DWMMC doctor coordinated with the bed manager

and division chief for the patient to be admitted.

Following evaluation, the outpatients would be

processed for billeting. Some were transported to

geographically-separate billeting while more acute

patients were kept in on-post billeting or, initially, as

“in-hospital boarders.” Such patients had to be mobile

enough to get to the dining facility without assistance

and require no nursing care. Patients assigned to this

type of billeting were those who could not ambulate

great distances or up stairs, who had minor eye injuries

that impaired their vision, and renal stone patients.

The reporting physician prepared a daily report on

LRMC’s CENTCOM patients. During the early phases

of OEF, the DWMMC medical director recorded

information about the 4 or 5 OEF patients that were in

the LRMC system at any one time for in-theater

commanders who desired information about their

evacuated Soldiers. As the operational tempo of the

two major operations increased, distribution of the

report also increased to multiple recipients throughout

Europe and Central Asia, including unit commanders;

the headquarters of the European Regional Medical

Command, the US European Command (EUCOM),

CENTCOM, the US Army Medical Command, and the

Army Surgeon General. During the period April to

July 2003, with approximately 250-350 outpatients

and inpatients at any one time, the report had expanded

into a hand-generated document of 30 pages or more.

Each day one of the DWMMC doctors was responsible

for the manual recording of all new arrivals. The

manifests for all air evacuation missions leaving for

the continental United States (CONUS), inpatient bed

reports, and several other reports were carefully

reviewed so departing patients could be manually

deleted from the LRMC report. The reporting doctor

also conducted rounds on the inpatients and collected

updates on each individual. Those comments were

entered into the Daily Update.

LOW-INTENSITY COMBAT PHASE

After the end of active ground combat on 1 May 2003,

the patient load arriving at LRMC steadily increased

through the summer and early fall. Some of this

increase was due to the closure and redeployment of

Naval Fleet Hospital, Rota, Spain. As an evacuation

hospital, this facility had managed approximately 20%

of troops evacuated from CENTCOM. The closure

occurred at a time of increasing patient loads and

continuing low-intensity combat. Therefore, LRMC

absorbed the additional patient load. It is also probable

that a portion of the increase was due to the fact that

some troops ignored their sub-acute injuries or

complaints during the buildup and active combat phase

of OIF. Once the combat mission was declared

complete and the environmental conditions in the Gulf

began to take a physical and emotional toll, these

courageous warriors began to present themselves for

care and eventually arrived at LRMC.

For the period of 7 May through 30 June 2004 an

average of 33 patients per day arrived at DWMMC.

The rate climbed to an average 42 new patients per day

during period 1 July through 15 September 2004.1 At

the peak of patient flow (an average of 57 new patients

each day) during this 75-day period, up to 5 air

evacuation flights arrived each day with approximately

30 to 40 patients per aircraft. During one 2-week

period in particular, daily arrivals of less than 100

patients occurred only 3 times. According to LRMC’s

statistics provided by COL Rubenstein (written

correspondence, March 2004), the largest number of

new patients received in a 24-hour period was 168.

Several key factors allowed DWMMC and LRMC to

meet the increased mission demands of this period.

DWMMC had a database for accountability and

patient tracking. Over time increased emphasis was

placed on its use, eventually resulting in the

production of an automated daily report in lieu of the

manually generated document that previously

consumed an entire day of a physician’s time for

preparation. The DWMMC database was used to

develop what arguably became the most important

report, the “Aging Report.” This document listed the

patients by name in descending order by length of stay

with the longest stay at the top. The report allowed

early identification and scrutiny of patients reaching

the 14-day limit. As is always the case, there were

some patients who purposely delayed the medical

disposition, case manager appointment, orders

generation, and air evacuation process and stayed in

Germany longer than necessary. The Aging Report

allowed rapid identification and disposition of these

individuals. Development of the DWMMC database to

adapt to the needs of the real-world operational tempo

resulted in an excellent tool that allows DWMMC staff

to select a name and view arrival information,

medications, appointment dates, billeting location, and

The Deployed Warrior Medical Management Center
July – September 2006 13

disposition. All information is carefully passwordprotected and meets HIPPA standards to ensure patient

privacy and coded so that each section only sees

information appropriate for their use. Electronic air

evacuation forms can also be generated from this

system. Soon, it will be possible to process patients

electronically from doctor completion through air

evacuation nurse/flight surgeon approval to inclusion

on the flight manifest.

Outpatients represented a significant percentage of

arrivals during all phases of OIF. As outpatient

numbers climbed to 40 or 50 or more per flight, three

or four physicians required increasing lengths of time

to personally evaluate each patient who arrived after

duty hours. To mitigate this situation, the DWMMC

implemented a self-evaluation questionnaire,

illustrated on page 14, that each patient completed

after an initial briefing. The questionnaire was later

redesigned so that appropriate “yes” and “no” answers

mandating an immediate visit were in the same column

for ease of identification. The large number of

outpatients who were arriving for chronic

musculoskeletal complaints and minor injuries were

stable and could safely remain as outpatients. Arriving

patients who indicated a need for pain medicine refills

(the most common reason to see a provider

immediately), had intravenous medication

requirements, or could not get themselves around in an

outpatient setting were identified and their problems

addressed. Patients who had sudden onset of chest pain

or other serious new-onset conditions were sent to the

emergency room for work-up. This expedited system

saved many significant hours and reduced medical

staff requirements with no compromise to patient

safety.

As the summer of 2003 passed, the mobilized or TDY

physicians assigned to the DWMMC neared the end of

their rotations at LRMC. It soon became clear that

replacement physicians would not be available for

DWMMC assignment and a significant gap in staffing

would occur. At one point this staffing

shortfall resulted in two physicians

alternating 24-hour call for receiving

missions. In late June and early July 2003 the

task of preparing and receiving air

evacuation missions was transitioned to a

staff of nurses and medical technicians, thus

allowing a larger staff of more available

career fields to handle this vital component

of the process. It also allowed subsequent

physicians, physician assistants, and nurse

practitioners delegated to the DWMMC to be

more appropriately used in the PostDeployment Clinic at LRMC. These

providers rotated call to assist with afterhours evaluation of arriving outpatients.

They also evaluated secondary complaints

and made specialty consults when

appropriate. This combination of shifting

nursing into the “receiving” mission, putting

credentialed providers back into the Post-Deployment

Clinic to clear arriving outpatients, and using the

questionnaire to reduce the total number of outpatients

needing immediate attention resulted in a safe, stable

system that had been in place for approximately 14

months at the end of my tour (June 2004). The need

for on-call family practice physicians and pediatricians

to assist the DWMMC mission was, for the most part,

eliminated. The importance and success of the nurses’

assumption of the receiving mission cannot be

overstated. Consummate professionals, they

enthusiastically adapted to an extremely demanding

and complex mission, making the whole system work.

DISCUSSION

The EUCOM in-theater policy allowed 14 days before

patients either had to return to duty or proceed to their

duty station. CENTCOM’s in-theater policy was 5 to 7

days. Neither period was enough for patients to

recover from chronic or acute injuries like meniscal

tears, shoulder instability, foot and ankle problems,
14 Army Medical Department Journal

back pain, etc. Although statistics are currently

unavailable, the LRMC staff anecdotally noted that a

significant percentage of chronic injuries presented by

patients existed prior to deployment. Some patients

with chronic injuries or diseases with initiated medical

board actions were deployed and underwent significant

exacerbation while in theater, and subsequently

required evacuation. These occurrences reflect the

difficult decisions commanders are forced to make

prior to deployments. Our experience showed that it

was not uncommon for commanders to take a Soldier

with an injury and use that individual for the short

term, only to have the Soldier’s condition worsen to

the extent that he or she becomes non-mission-ready in

the long term.

The European Regional Medical Command mandated

that all personnel entering the DWMMC system from

CENTCOM combat operations who would not return

to duty would go through a postdeployment health

evaluation. This evaluation included blood draw, HIV

labs, TB test, and evaluation for malaria prophylaxis

and exposure to depleted uranium. By doctrine this

mission is the responsibility of the home unit when

troops return. It was confirmed that MTFs in CONUS

were actively conducting postdeployment programs

and troops were reporting that the MTFs were

repeating blood draws and other interviews already

done at LRMC. This duplicate effort at Landstuhl

involved significant administrative and personnel

support, and undoubtedly consumed resources that

could have been better used elsewhere.

The Theater Patient Movement Requirements Center,

Europe (TPMRC-E) was the validating and approving

center for all air evacuations entering and leaving

EUCOM. An Air Force activity located at Ramstein

AB, the TPMRC-E was responsible for dissemination

of air evacuation policy and regulations, approving

requests for individual patient evacuation, arranging

additional flights in response to increased patient

numbers or unusual patient care needs, such as special

missions to the Burn Center at Brooke Army Medical

Center, Critical Care Air Transport Team missions for

Self-evaluation questionnaire for evacuated outpatients arriving at the Landstuhl Regional Medical

Center from Operation Enduring Freedom and Operation Iraqi Freedom.

Patient’s Name (Last, First)

SSN Rank

What medical problem are you here for? ___________________________________

Please circle

Do you have a medical problem that needs to be seen YES NO

right now instead of at your doctor appointment next duty day?

During the flight or now do you have chest pain? YES NO

During the flight or now do you have trouble breathing? YES NO

During the flight or now do you have a fever? YES NO

During the flight or now are you bleeding? YES NO

Do you have diabetes? YES NO

Do you have an IV or needle in you? YES NO

Are you currently having thoughts of injury to self or others? YES NO

If you have pain, does your pain medicine relieve it? YES NO

If you have pain, do you have enough pain medicine YES NO

to last until your clinic appointment next duty day?

Can you walk 100 yards on foot or YES NO

with crutches if you currently have them?

Are you able to eat and drink? YES NO

Do you feel safe to be an outpatient and seen next duty day? YES NO

Are you stationed in Germany? YES NO

Do not write below the line. This section is for provider’s use only.

This form has been reviewed, and this patient:

Is stable to be an outpatient Needs to be seen by a provider

The Deployed Warrior Medical Management Center
July – September 2006 15

ICU patients, etc. The DWMMC staff consulted often

with the TPMRC-E for air evacuation issues or to

expedite individual patient movement. The DWMMC

coordinated with them on the movement (in standby

contingency status) to CONUS of several specialinterest Iraqi civilians who were accepted by US

civilian hospitals for care. The DWMMC also was the

coordinating activity for wounded allied nation troops

who were brought to Ramstein for transfer to another

aircraft for transport to their home country. The

DWMMC was prepared to accept those patients if a

flight delay occurred during such “tail swap” missions.

The aeromedical staging facility was a vital

component in both the transportation of patients to

LRMC on arrival and the preparation of patients for

their flight to CONUS. A contingency

aeromedical staging facility (CASF) was

activated and sent to Ramstein prior to the

beginning of OIF. The CASF established

operations in the Southside Gym at Ramstein

Air Base and augmented the Ramstein

holding capacity with 100 beds. Midway

through the active combat phase the CASF

commander initiated a weekly processimprovement meeting that included LRMC,

the CASF, TPMRC-E, and various other

units that were involved in the patient

movement process. These meetings

continued during the period discussed in this

article and proved absolutely invaluable for

streamlining this complex multidepartment

mission. Numerous problems were solved on

the spot, and the professional relationships

that were established allowed simple phone

calls to quickly resolve many other problems, all of

which aided the mission tremendously. It is strongly

recommended that similar interagency structures and

procedures be established at the outset of any future

major military conflicts.

As mentioned previously, the EUCOM in-theater

policy for patient care was 14 days. However, some

consideration was given for patients with a high

return-to-duty potential. During the fall and winter of

2003, CENTCOM commanders began expressing

concern at the low return-to-duty rate — during the

first 6 months of OIF it was well under 5%. In

response, the DWMMC staff worked with the LRMC

medical staff to place emphasis on the return of

patients to duty. This resulted in some patients being

kept longer than 14 days. General Surgery developed a

protocol for herniorrhaphy and cholecystectomy

patients that involved a last follow-up at 2.5 to 3

weeks post-op and return to duty on a light-duty

profile for recovery. Patients evacuated for biopsyrelated issues (skin lesions, Pap smears, etc) were

routinely held over the 14-day limit to allow

finalization of biopsy results. LRMC’s return to duty

rate rose to approximately 30% by the early spring of

2004.

However, returning a patient to theater on a profile for

an ongoing medical problem is a complicated issue.

With mature medical assets in place in Iraq, clinical

situations arose which allowed subspecialty evaluation

at Landstuhl (for example, a chronic hand injury), after

which patients were given a plan, instructed on brace

wear and rehabilitation, and returned to duty on profile

limitations. Follow-up was then performed in theater.

Although not able to function at the squad level, a

profiled Soldier could perform some function at the

battalion level or higher (monitoring radios,

administrative tasks, etc), replacing a Soldier to return

the squad level, thus conserving unit strength.

Unfortunately, we discovered that it was very difficult

to coordinate with commanders high enough in the

chain to formalize such a program. The command

level that could usually be contacted was limited to the

platoon leader/company commander who, when given

the option, would reject the prospect of the return of
16 Army Medical Department Journal

any Soldier that could not perform the squad-level

mission. The in-theater battalion and division surgeons

must become very proactive and aggressively

communicate and coordinate with higher level

commanders to determine what limitations can be

supported, present the options and available sources of

information, and ensure all command levels

understand the benefits of such a return-to-duty

program.

The end to major combat operations was declared on

1 May 2003. Fourteen days were added to the

timeframe of the study1to ensure all casualties of the

active combat phase had reached LRMC and were

included. Of the 1,236 identified and tracked patients

that arrived from OIF during this period, 20.7% were

battle casualties, 41.3% sustained non-battle injuries,

and 38% were disease patients. This patient population

accounted for 620 inpatient admissions and 616

personnel treated as outpatients. Of the 620 inpatients,

77 were discharged to outpatient status prior to air

evacuation. Therefore, 56% of these patients were

outpatients at some point in their stay. As noted in

discussions with EUCOM medical planners following

completion of the active combat phase, outpatients

accounted for a significant portion of our care

responsibilities. Previously, medical planning was

discussed in terms of inpatient beds, but as medical

care in the US civilian and peacetime military world

has shifted to an outpatient paradigm, so too has

military wartime care.

CONCLUSION

Managing outpatients is fundamentally more difficult

than managing inpatients, both in terms of medical

care and administrative tracking and processing.

Future medical planners must anticipate a large

outpatient mission and plan scalable departments

similar to the Deployed Warrior Medical Management

Center to manage outpatients and assist in the prearrival planning, receiving, processing, and evacuation

of inpatients and outpatients. Landstuhl Regional

Medical Center was the first hospital to develop a

DWMMC. It should serve as the model for other

evacuation-chain MTFs in future combat operations.

ACKNOWLEDGEMENT

This article is dedicated with my profound thanks and

best wishes to the staff of the Landstuhl Regional

Medical Center and the Deployed Warrior Medical

Management Center. Your incredibly hard work not

only exceeded mission requirements but gave great

comfort and aid to the approximately 15,000 patients

from Operations Enduring Freedom and Iraqi Freedom

who passed through our doors during my tenure as

medical director. It was my pleasure and honor to

work with all of you.

REFERENCE

1. Johnson B, Carmack D, Neary M, Tenuta J, Chen J.

Operation Iraqi Freedom: the Landstuhl Regional

Medical Center experience. J Foot Ankle Surg.

2005;44;No. 3:177-183.

AUTHOR

Major Johnson is currently assigned to the Human

Effectiveness Directorate of the USAF Research

Laboratory, Wright-Patterson Air Force Base, Ohio.

Previously, he was the medical director of the DWMMC at

the Landstuhl Regional Medical Center from late April 2003

until June 2004.

LANDSTUHL REGIONAL MEDICAL CENTER

The Deployed Warrior Medical Management Center
July – September 2006 17

INTRODUCTION

In recent contingency operations, US Army medical

units have increasingly absorbed expanded

responsibilities beyond those of their doctrinal combat

health support mission. These new responsibilities

include the need to perform widespread humanitarian

assistance to local populations, the provision of health

care to US Army detainees, and supplying the health

support for Department of the Army civilians and

contracted personnel on the battlefield. In that these

missions extend beyond their doctrinal construction,

medical units are at a disadvantage in terms of

supplies, personnel, and practical experience when

attempting to meet these new requirements.1 This

situation, in turn, may result in inadequate care to

these special populations.

One specific, increasing demand being placed on

Army medical units deployed in Operation Iraqi

Freedom (OIF) is the growing presence of US

contractors on the battlefield. This can be an especially

difficult task for a unit to tackle. Army field medical

units are primarily structured to provide combat

casualty care and, to a limited extent, ongoing primary

health support to a mostly healthy, young, adult

population. In contrast, deployed contractors do not

easily fit into these categories. Contractors are often

older and may have medical conditions vastly different

than those of the average frontline soldier. To add to

the difficulties in supporting the deployed contractor,

there are a myriad of rules regulating which

government supplied health support deployed

contractors are, and often are not, eligible to receive.

On the other hand, units are hard pressed not to

provide health support to contractors in their midst

when they present for care.

To overcome these conflicts, medical units have had to

adapt their normal ways of doing business to meet

these needs. Unfortunately, these adaptations usually

occur ad hoc, after a unit has deployed to theater, and

without the benefit of learning from the experiences of

others. This article attempts to outline some of the

lessons learned by previous units deployed to OIF as

they have struggled to provide health support to

deployed contractors. To do so, it is necessary to

present a brief background of contractor support to the

US Army, both its history and its regulatory processes.

Following this overview, there is a discussion of

lessons learned by medical units previously deployed

to OIF. It should be noted that this article only

addresses US contractors, not third-country nationals

hired to support US armed forces.

HISTORICAL BACKGROUND

The US Army has relied upon contracted civilian

support since the Revolutionary war. Civilians have

been hired to provide transportation of troops and

supplies, build major engineering projects, and to

support communications equipment. In recent decades,

as active component forces have decreased in size, the

military has become increasing dependant upon

civilian contractors for support.2From the

Revolutionary War through Operation Desert Storm,

there was one civilian on the battlefield supporting

anywhere from 50 to 70 military personnel. By the

time of the Bosnian conflict this ratio was 1:10.3

While the current number of contractors involved in

OIF is unknown, it is likely that the number of

contractors on the battlefield is greater than ever. With

the increasingly technological nature of US armed

forces, contractors are involved in almost every aspect

of supporting deployed troops and can be found

imbedded with US armed forces at every level of the

battlefield. This increased presence is evidenced by

several measures. Current reports and after action

reviews are filled with anecdotes concerning the

increasing demands civilian contractors are placing

upon deployed medical units. Furthermore, at the Fort

Caring for Contractors in Our Midst:

Lessons Learned from Operation

Iraqi Freedom

MAJ Andrew Doyle, MC, USA
18 Army Medical Department Journal

Bliss CONUS (continental United States) Replacement

Center, civilians now account for over 60% of the

personnel processed for deployment to OIF.4

REGULATORY ISSUES

The first issue a medical unit must tackle is that of

eligibility. Is the contractor eligible for care in their

facility? As mentioned previously, the regulatory

controls governing deployed US civilian contractors

are vast, and at times contradicting. Contractors are

employees of their civilian employer, not the

government, and thus are generally not eligible for

government provided, nonemergency health care.

Traditionally, this policy has applied to contractors

deployed with the force. Current Department of

Defense policy holds that civilian employers are

responsible for providing all of the health support

required by their employees, including that required

while deployed with US armed forces. The employer

has the option of either providing that support directly,

contracting with non-US facilities, or through a

negotiated contract with the US government for

military supplied health care for which the employer

reimburses the government.5,6

That being said, other regulations and policies may

specify that the civilian contractor is eligible for

government supplied health care. While US policy

declares employers are responsible for providing for

the health care of their employees, it also states that

civilian contractors deployed with US forces will

receive the same level of care available to military

personnel. In contingency operations, often the only

health care that meets this standard is that provided by

the local military medical unit. In this case, Army

policy implies that civilian contractors may have

military supplied health care made available to them.

Additionally, certain contractors are eligible for care

based on the type of service they perform. For

example, civilian flight instructors and food service

employees are eligible for physical examinations.

Finally, many civilian contractors are either retired US

military personnel or veterans. While they are not

eligible for government provided health care as

contractors, they are eligible for care due to their

previous military status.7

Additional regulations apply to emergency and

evacuation care for deployed contractors, beyond the

setting of routine health support. Emergency care is

always available and rendered, considered to be a

reimbursable service. It should be noted, though, that

forward deployed medical units are neither equipped

nor organized to process billing. Thus, emergency

services in these settings are not captured.8 The same

standards apply to emergency evacuation, at least to

the Level IV medical facility (eg, Landstuhl Regional

Medical Center) and until the contractor is medically

stable. However, if the contractor patient then must be

returned to the continental United States for ongoing

care, transport is dependant upon the contract between

the government and the employer.

To further complicate the issue for medical personnel,

the presence of contractors with US forces is subject to

international law. In countries that have Status of

Forces Agreements with the United States, contractors

accompanying the military are also subject to those

agreements. In contingency operations, contractors are

civilian noncombatants and may fall under the

auspices of the Geneva Conventions and other Law of

War regulations.

The time to determine eligibility of care is not when

the contractor presents to the aid station. As medical

units deploying to OIF can expect to care for civilian

contractors, procedures for this care should be in place

prior to deployment. However, the interpretation of the

legal obligations and requirements is not the

responsibility of the medical unit. The medical unit’s

higher headquarters should sort through this legal

morass and develop policies and procedures for the

caregivers. If this does not occur prior to deployment,

the unit should request guidance as soon as possible.

The contractors’ eligibility for care should be

established prior to their arrival in theater. This will

include arrangements for care, both routine and

emergency, and will be stipulated in the contract. This

status will be annotated on the individual contractor’s

identification documents. All deployed contractors are

issued a Uniformed Services Identification and

Privilege Card (DD1173). This card should clearly

declare those services, including medical, to which the

contractor is entitled. In addition, the contractor will

receive a Letter of Authorization (LOA) from the

contracting officer. The LOA should also indicate

those services to which the contractor is entitled, and

how reimbursement, if indicated, is handled.9In lieu of

Caring for Contractors in our Midst
July – September 2006 19

this or other guidance, the medical providers are left to

their best judgment.

LESSONS LEARNED

Ideally, contractors deploying to OIF will undergo predeployment processing with the unit in which they will

be imbedded. However, contractors often deploy as

individuals and join their respective units in the field.

In these cases, contractors deploying to OIF will

usually process through a CONUS Replacement

Center (CRC) prior to deployment. At the CRC, they

will undergo the same medical and dental screening as

active duty soldiers prior to deployment. These

screenings will be performed by military physicians

and dentists. The screening process should include a

review of the contractor’s medical record,

identification of any disqualifying medical and dental

conditions, and the administration of any required

immunizations. Furthermore, the contractors should

deploy with at least a 90 day supply of any

medications, and additional pairs of eyeglasses, as

needed.

While this is the process, and deployed medical

providers can reasonably expect contractors have gone

through this process, nevertheless, there are several

areas that the medical unit must consider in

preparations to provide routine care for eligible

contractors.

Medical Records. Once a unit is identified as the

supporting medical unit for an eligible civilian

contractor, certain administrative records should be

kept by the unit. Primarily, the unit should be provided

a complete medical summary for the contractor. The

summary should include

 a description of all underlying medical

conditions and relevant past medical history,

 current immunization status,

 all existing prescriptions, to include

eyeglasses, and

 documentation of DNA sample testing and

dental panographic radiograph, for future

identification purposes.

In addition, copies of the contractor’s LOA,

emergency contact information, employer and

insurance contact information, and the name and

contact information of the contractor’s private

physician should also be kept on file by the medical

unit.

Pharmacy. The care of contractors is an expanded

mission responsibility resulting in a greater population

of care. Consequently, medical units may not have the

Class VIII supplies to meet this need. The most

significant deficiency is likely to be in the unit’s

pharmacy. In terms of overall patient workload,

contractors represent an additional drain on a unit’s

already limited pharmacy. Furthermore, the contractor

may require chronic medications that the unit does not

possess and may not be able to obtain. As soon as a

contractor is associated with a medical unit for care,

the unit should identify any chronic condition

medications the contractor requires, especially if this

includes medications not carried in the unit’s

pharmacy. Arrangements must then be made to either

acquire these medications, or change the medications

to ones the unit possesses. Also, the unit must begin to

arrange for the acquisition of refill medications, long

before they are needed, due to the substantial amount

of time it may take for them to arrive in theater.

Medical Evacuation. The contractor may require

medical evacuation in the case of severe injury or

illness. The usual evacuation route is to the combat

support hospital and then to Landstuhl Regional

Medical Center (LRMC). Once at LRMC, the

contractor may be transported to CONUS for further

care as necessary. Whether they continue to be cared

for in military treatment facilities beyond this point is

dependent upon the contractor’s eligibility for military

benefits.

Once the need for evacuation is recognized, initiate a

log to track all events and movement of the contractor.

Maintain a list of all contact information, including

medical units and facilities and the contractor’s family.

To facilitate further evacuation from LRMC to

CONUS, a copy of the LOA must accompany the

patient. Ensure that a copy of the LOA is sent with the

contractor’s medical records during evacuation.

Notification. Notification of severe injury, health

issues, or death follows two main paths; the first for

command and control, the second to facilitate care and
20 Army Medical Department Journal

evacuation. Initially, notification must be made to the

supported unit’s command and also the regional

command. These elements will provide official

notification to the employer and next-of-kin, if

necessary. The medical unit should have a pre-set plan

for notification of the unit’s chain-of-command.

Beyond notifying the chain-of-command, the

contractor’s family must also be notified. While this

will not be done by the medical unit directly, the unit’s

medical staff should be prepared to give detailed

information to the chain-of-command for

communication with the family.

CONCLUSION

Medical units deploying to OIF face many expanded

responsibilities beyond those of their traditional

combat health support mission. Chief among these

expanded responsibilities has been the provision of

care to civilian contractors deployed alongside US

armed forces. However, the health care support needs

of deployed contractors can be vastly different than

those which the unit is doctrinally prepared to provide.

Also, the increasing numbers of civilian contractors

can easily exhaust the capabilities of a standard

combat-equipped medical unit.

It is obvious that contractors will continue to be an

ever increasing presence on the modern battlefield.

Consequently, US Army medical units must be

prepared to care for them. Ideally, this preparation

occurs prior to a unit’s deployment, and involves

adjustment in the unit’s operating procedures,

anticipated workload, and needed supplies. This

preparation should also include, at a minimum, a

cursory knowledge of the rules regulating government

supplied health support to deployed contractors.

To accomplish these goals, deploying units should

learn the lessons from experiences of previously

deployed units. These lessons include the need to

maintain complete and relevant records, expand Class

VII and pharmacy supplies, and establish procedures

for medical evacuation of deployed contractor patients.

Previous experiences show that these simple steps, if

taken, will dramatically improve a unit’s ability to care

for contactor personnel deployed alongside US forces,

and result in a more successful mission overall.

Pre-deployment Preparation

 Plan for need to care for contractors

 Establish procedures to determine contractors’

eligibility for care

 Be prepared to increase Class VIII to meet

needs of contractors

Routine Care During Deployment

 Gather necessary medical and administrative

information for all contractors cared for by the

unit

 Proactively plan for re-supply of chronic

medications

In Case Of Medical Evacuation

 Immediately inform chain of command

 Initiate a log of all actions performed

 Maintain a database of contact information

 Send a copy of Letter of Authorization with the

contractor’s medical records

 Be prepared to provide detailed information to

command and the contractor’s family

Caring for Contractors in our Midst
July – September 2006 21

REFERENCES

1. Davis LM, et al. Army medical support for peace

operations and humanitarian assistance [abstract].

RAND Corporation; 1996. Available at: http://

www.rand.org/pubs/monograph_reports/MR773/.

Accessed December 2, 2005.

2. Manker JE, Williams KD. Contractors in contingency

operations: panacea or pain? Air Force J Logist [serial

online]. 2004;28(3):14-22. Available at: http://

www.aflma.hq.af.mil/lgj/Vol%2028_No3_WWW.pdf.

Accessed December 2, 2005.

3. Hammontree G. Contractors on the battlefield. In

Rainey JC, ed-in-chief; Scott BF, ed. 2003 Logistics

Dimensions: Strategy, Issues, and Analysis. Maxwell

Air Force Base, AL: Air Force Logistical Management

Agency; December 2002. Available at: http://

www.aflma.hq.af.mil/lgj/LogDim2003_3.pdf. Accessed

December 2, 2005.

4. Reece B. Deployment preparation; destination: Iraq.

Soldiers. 2005;60;No. 2:30-33.

5. DoD Instruction 3020.41, Contractor Personnel

Authorized to Accompany the United States Armed

Forces. Washington, DC: US Dept of Defense; October

3, 2005.

6. DA Pamphlet 715-16, Contractor Deployment Guide.

Washington, DC: US Dept of the Army; February 27,

1998.

7. Army Regulation 40-400, Patient Administration.

Washington, DC: US Dept of the Army; March 12,

2001.

8. Field Manual 3-100.21, Contractors on the Battlefield.

Washington, DC: US Dept of the Army; January 3,

2003.

9. Army Contractors Accompanying the Force Guidebook.

Washington, DC: US Dept of the Army, Office of the

Assistant Secretary of the Army; September, 2003.

AUTHOR

MAJ Doyle is currently the Medical Analyst at the Center

for Army Lessons Learned, Fort Leavenworth, Kansas.
22 Army Medical Department Journal

INTRODUCTION

Burkhalter et al1stated that the loss of opposition of

the thumb to the fingers is the most significant active

motion loss associated with an injury to the median

nerve. It is difficult to overstate the value of thumb

opposition in everyday activities. This is especially

true to the pilot of an F-16. The pilot is tasked to

perform many intricate operations with the left hand,

using a variety of controls that require precise, strong,

and true opposition.

The definition of opposition varies depending on

author and physician. In 1938 Bunnell stated in his

much referenced article2that, in opposition, the thumb

nail is parallel to the palm and the pulp of the thumb

faces the pulp of the fingers. Cooney, Linscheid, and

An introduce the ideas of abduction, flexion, and

rotation of the thumb carpometacarpal joint (CMCJ)

and metacarpal joint (MCPJ).3 This notion of the

thumb moving away from the fingers, supinating over

and coming face to face with the fingers (true

opposition) instead of just flexing at the

interphalangeal joint (IPJ) and MCPJ is requisite for

flying today’s jet fighter aircraft and countless other

routine daily tasks.

This article reports on a case of low median nerve

injury sustained by an F-16 pilot and his rapid and

complete return to the cockpit. Surgical repair,

rehabilitation course, and requirements to perform his

job with emphasis on left thumb opposition are

highlighted.

CASE REPORT

The Patient

In late March of 2001, a 28 year-old active duty male

USAF F-16 pilot fell while descending a wet, poorly

lit, shallow staircase. He attempted to break his

backwards fall with his dominant left hand while

holding a glass container. The container shattered upon

impact. The pilot sustained severe lacerations to Zone

III of his left palm. After examination at the local

military medical facility the patient was transported to

a nearby civilian Korean hospital where he underwent

microsurgery to repair severed tendons and nerves.

Surgical repair was performed on:

1. left thumb flexor pollicis longus (FPL) – 100%

lacerated;

2. left index finger flexor digitorum profundus and

superficilias (FDP and FDS) – both 100%

lacerated;

3. left middle finger FDP - 50% lacerated and

FDS – 100% lacerated;

4. left aductor pollicis (AP) – 60% lacerated;

5. left flexor pollicis brevis (FPB) – 100%

lacerated;

6. left opponens pollicis (OP) – 50% lacerated;

7. left abductor pollicis brevis (APB) – 50%

lacerated;

8. common distal nerve branches from the median

nerve to the thumb, index, and middle fingers

were also found to be severed.

Thumb Opposition Restoration:

A Case Study

CPT David Admire, SP, USA

ABSTRACT

A case of thumb opposition restoration by extensor indicis proprius (EIP) opponensplasty and rehabilitation is

presented. The patient was a male US Air Force (USAF) F-16 pilot in South Korea who sustained an injury to

his left palm severing multiple tendons and nerves. Successful surgical repair of the flexor tendons was

accomplished at a civilian Korean hospital without repair of the recurrent motor branch of the median nerve.

After a successful course of occupational therapy to restore finger function, a second procedure was performed

at Walter Reed Army Medical Center involving the transfer of the EIP tendon to the extensor pollicus longus

and abductor pollicis brevis in the thumb. Intensive rehabilitation at the 121st US Army General Hospital in

Seoul Korea resulted in early full restoration of function. Upon discharge from occupational therapy, evaluation

from USAF aeromedical personnel and return to the United States, the pilot returned to flight status.
July – September 2006 23

During the procedure, the recurrent motor branch of

the median nerve to the thenar muscles could not be

located. This 4-hour procedure was performed without

complication and the patient had an unremarkable

postoperative recovery.

Two weeks later the patient reported to the

Occupational Therapy (OT) clinic at the 121st US

Army General Hospital at Yongsan Garrison in Seoul,

Korea to begin a period of rehabilitation. The patient

was placed in a custom dynamic flexion splint and a

modified Kleinert protocol was begun as Stewart

describes in Stanley and Tribuzi.4 The splint used for

this treatment protocol utilizes rubber band traction on

the fingernails to provide passive flexion to the fingers

while allowing active extension and is designed to

achieve passive glide of the injured tendons to prevent

scar adhesions and joint contractures.4 During this

course of therapy the patient traveled to the United

States for a period of convalescent leave. Upon arrival

he reported to Walter Reed Army Medical Center

(WRAMC) in Washington, DC to continue his

rehabilitation. Recovery of function at WRAMC was

rapid and without complication, except for the

persistent inability to oppose his left thumb. Repeat

electrodiagnostic motor nerve studies revealed no

definite response in the APB suggesting a severe if not

complete median nerve neuropathy at the wrist.

The Surgical Repair

In late June of 2001 the patient was taken into the OR

(operating room) at WRAMC for exploration of the

median nerve and possible tendon transfer to restore

opposition. While dissecting the left median nerve

proximally the motor branch was not visualized and

explored no further. The attending surgeon then

decided to transfer the extensor indicis proprius (EIP)

tendon to the thumb to restore thumb opposition

motion. Several tendenous options are available for

transfer to restore motion. The mechanical and

anatomical benefits of each are well documented as in

Roach, Short, Werner and Fortino.5 Literature also

exists documenting the objective results from

comparisons of different types of opposition restoring

tendon transfers.6,7 The choice of donor tendon/muscle

is controversial and not every tendon transfer

procedure will produce the same result. Factors to be

considered include the patient’s functional

requirements, any associated deficits, tendon/muscle

donor availability, surgeon preference, and as, in this

case, previous injury and surgical history.8 Also as

Davis and Barton state in Green9and as Burkhalter1

outlines, EIP tendon transfers are many times favored

because there is no subsequent weakened grasp and no

resulting functional disability as sometimes happens

with opponensplastys using donated flexor tendons.

This patient had recently undergone repair to the flexor

tendons, necessitating using an alternative donor

tendon to restore opposition to the thumb.

In the OR, with the tendon transfer decision made, the

EIP tendon was located through an incision made

dorsally over the metacarpalphalangeal joint (MCPJ)

of the left index finger. The identified tendon to be

transferred was cut free and another incision was made

over the dorsoulnar aspect of the left wrist. Through

this wound the EIP was again identified and carried

back to the muscle belly. Next, a tunnel was made

between the more dorsal incision and an incision made

over the pisiform bone, and the EIP was delivered into

this. An additional incision was made over the

dorsoradial aspect of the left thumb and the tendon

was then brought into this opening. Through this last

incision, the EIP was passed through the center of the

APB tendon, underneath the dorsoradial digital nerve

and through the middle of the EPL tendon. The

patient’s wrist was then placed in 20 degrees of

flexion, with the thumb in maximum palmar abduction

and a horizontal mattress suture was used to secure the

transferred EIP to the EPL. The EIP was then passed

down and another stitch was used through this donated

tendon and the APB. Finally, the EIP was again

transferred underneath the digital nerve, through the

APB, and sutured again. After irrigation, all the

wounds were closed and a splint applied with the wrist

in 20 degrees of flexion and the thumb in maximum

palmar abduction. The patient was transferred to

recovery in satisfactory condition.

Postoperative Rehabilitation

Postoperative rehabilitation after this opponensplasty

was modeled after the three-phase approach as Stanley

outlines in Hunter8: Phase I is a period of

immobilization, during Phase II the patient begins

active motion, and Phase III is strength and

coordination training. The timing of internal healing

dictates the order and timing of these phases.8

Of course complete immobilization is initially required

to allow the tendon juncture to develop collagen

sufficient to withstand future stress with motion. The

patient was maintained in the position with the actual

splint that was utilized in the OR until followup with
24 Army Medical Department Journal

OT in Korea at approximately 3 weeks postoperative

care. Upon arrival at the OT clinic at the 121st General

Hospital in Korea, the existing splint was removed and

a custom molded hand based thermoplastic splint was

applied approximating the same position as was used

in the postoperative splint. The patient’s hand was

evaluated and the patient was instructed in active range

of motion for all uninvolved joints as well as gentle

scar massage. Although this patient was extremely

motivated and wished to begin active motion to the

thumb early, immobilization was emphasized as it is

extremely important to the overall success of the

repair. Jacobs and Thompson10 identified lack of

sufficient postoperative immobilization as a major

cause of failure after opponensplasty procedures and

recommend a full 6 weeks before attempting active

opposition of the injured thumb and today. Most

protocols recommend 3 to 4 weeks of complete

immobilization.1,8,9

After another week of continuous immobilization of

the thumb in the removable splint (up to week 5 after

surgery), the patient began gentle supervised active

motion of the thumb interphalangeal joint (IPJ), MCPJ

and carpometacarpal joint (CMCJ) with splint wear at

night and between therapy sessions. Active movement

was emphasized that would both retrain true

opposition using the new donated EIP tendon and also

to minimize scar adhesions that might potentially limit

final motion, without over-stressing the tendon repair

site. Goal directed activities such as whole hand

grasping and true oppositional pinch with the thumb

and small finger using putty and small flat objects

were used instead of rote exercise to hold the patient’s

attention and intrinsically motivate him to reach his

goals of returning to flying.

At this time more aggressive scar management

techniques were begun. Deep scar massage was

incorporated into the daily treatment regimen at the

OT clinic and also at home as part of the patient’s

home treatment program. Lanolin and vitamin E were

used to both moisturize the surface skin and combined

with deep pressure to soften subcutaneous scar.11

Research is limited on the effects of massage on scar

tissue but is thought to alter collagen through a

combination of mechanical and thermal effects.8,11

Mechanically, collagen organization is assisted by the

physical movement between the scar and surrounding

tissues and a local thermal effect is created resulting in

increased tissue extensibility.8 Ultrasound and paraffin

baths were also used in this case to effectively increase

the temperature of soft tissues prior to movement to

increase the extensibility of the tissues and increase the

potential for active range of motion (AROM).

Massage and tissue mobilization may also aid by

compressing the interstitial fluid content thereby

increasing extensibility.8 Massage was performed daily

in the clinic and reported by the patient to be repeated

3-4 times daily outside of OT. Elastomer polymer

inserts were custom molded, and worn underneath the

splint at night and also with compression wraps and

Coban tape throughout the day. These inserts provided

another means of compression and tissue extensibility

maximization. Although these techniques are not

strongly supported in the literature, anecdotal clinical

reports suggest their efficacy and usefulness in

managing scar formation and maximizing

postoperative AROM and function.

Gentle passive range of motion (PROM) was also

initiated to gently stress the soft tissues surrounding

the thumb. Specifically, efforts were focused on thumb

IPJ and MCPJ extension and flexion, thumb CMCJ

abduction and extension, and wrist extension and

flexion. The emphasis on PROM was gentle, pain-free

stretches after heat application, usually accomplished

with paraffin bath immersion. The patient was

instructed to only perform active motion exercises at

home and rely on OT clinical staff to supervise any

PROM to prevent possible attenuation or stretching of

the repair.

By week 7 following surgery, the patient had

discontinued daytime use of the splint in favor of

active use of his hand. The patient was continually

cautioned against overuse and overstressing the newly

transferred tendon to prevent rupture. He showed rapid

progress with return of active motion of the thumb and

very little scar adhesion formation. Initially, when

attempting opposition the thumb flexors would

overpower and pull the thumb on a plane parallel with

the palm towards the small finger. This would place

the pulp of the thumb perpendicular with the pulp of

the small finger without the rotational, abduction, or

pronation components of true opposition.

At this point the emphasis shifted from quantity to

quality of movement, focusing on supination and

Thumb Opposition Restoration: A Case Study
July – September 2006 25

abduction of the thumb in an effort to train true

opposition. The patient was encouraged to perform

opposition activities with both hands to match thumb

movements. He also performed countless repetitions of

gross grasping activities, and fine motor tasks that

required true opposition to be successful. The patient

continued daily therapy sessions, showing exceptional

motivation by traveling from an outlying Army camp

north of Seoul to the 121st General Hospital which has

the only US military OT clinic in Korea.

Over the next 5 weeks, once true opposition was

established, resistance was slowly introduced and

gradually more aggressive stretches with continued

aggressive scar management was performed. Therapy

sessions were cut down to 3 and then to 2 sessions per

week, with more emphasis placed on home selftreatment. Various commercially available hand

strengthening devices were issued with a continuing

focus on quality of motion.

At less than 14 weeks after surgery, the patient was

able to demonstrate full, true opposition with thumb

pad to small finger pad contact, including all

previously discussed components of thumb rotation

and abduction. He also demonstrated the ability to

maintain thumb pad contact to the base of the small

finger and, with effort and stretch, to the distal palmar

crease. In the clinic the patient produced a grip

strength averaging 65 pounds for the affected hand. It

was at this point that the patient was discharged from

OT with periodic follow-ups to monitor his condition.

Within 2 weeks of discharge from OT, the patient was

evaluated in a flight simulator and was recommended

for consideration for return to flight status by

observing officials. After subsequent, numerous

physical evaluations and a permanent change of station

back to the US, he was given approval to begin

requalification training in preparation for return to the

cockpit.

Job Requirements

In order to be successful in the cockpit of the F-16, the

pilot must perform many operations with the left hand

resting on the throttle and manipulate switches with

the hand on a panel as well. On the throttle and panel

are switches and buttons that require twisting and

turning motions utilizing the left thumb in a lateral

pinch with the thumb pad pressed against the radial

side of the index finger. Also, on the throttle itself are

buttons controlling numerous radar functions that

require the thumb to rise up off the side of the control

(abduction) and selectively slide or push a button with

the pulp of the thumb in a plane perpendicular with the

palm. These operations would be impossible without

the rotational and abduction components of true

opposition of the thumb. Simple flexion of the thumb

MCPJ would not provide the necessary range of

motion that is required to fly and operate effectively

the controls of the F-16 aircraft. It is safe to say that

without this opposition restoring procedure and an

excellent outcome, this pilot would be unable to return

to the cockpit and fly the F-16.

DISCUSSION

The majority of documented cases of opponensplastys

report good to excellent results. Unfortunately,

classification of results from opponensplasty

procedures is not consistent in the literature. Factors

such as strength, position of the thumb IPJ and

mobility are given differing priorities in various

studies. The patient in this study would rate excellent

in any system of classification. Using Jacobs and

Thompson’s10 criteria, he achieved at least 75% of

normal function and had <20 degrees difference

between the planes of the opposed thumbnail and the

palm with good power. Using criteria set by

Sundararaj and Mani,12 this patient achieved an

excellent result with the ability to oppose the thumb to

small finger with the thumb IP extended.

What is lacking in a review of the literature is the

factor of time of functional return. Anderson and

Sundararaj13 monitored results with EIP

opponensplasty patients out to one year. Burkhalter’s

study1has no mention of rate or timing of return of

function. Future studies of opponensplasty procedures

would do well to begin measuring the speed of

functional return as well as the overall ability of the

transferred tendon to oppose the thumb over time.

With a well executed opponensplaty procedure,

intensive postoperative occupational therapy, a

detailed and closely monitored self-care program, and

a motivated, hard working patient, this case was

brought to a successful closure in less than 14 weeks

with excellent results. The less than optimal result of

the pilot being unable to return to the cockpit was
26 Army Medical Department Journal

averted, saving the enormous amount of money

already invested in this individual in his extensive and

time consuming flight training.

REFERENCES

1. Burkhalter W, Christensen RC, Brown P. Extensor

indicis proprius opponensplasty. J Bone Joint Surg.

1973;55A:725-732.

2. Bunnell S. Opposition of the thumb. J Bone Joint Surg.

1938;20:269-284.

3. Cooney WP, Linscheid RL, An K. Opposition of the

thumb: an anatomic and biomechanical study of tendon

transfers. J Hand Surg. 1984;9A:777-786.

4. Stewart KM. Tendon Injuries. In: Stanley BG, Tribuzi

SM, eds. Concepts in Hand Rehabilitation.

Philadelphia, PA: FA Davis; 1992:353-394

5. Roach SS, Short WH, Werner FW, Fortino MD.

Biomechanical evaluation of thumb opposition transfer

insertion sites. J Hand Surg. 2001;26A:354-361.

6. Bindra RR, Bhandarkar DS, Taraporvala JC.

Opponensplasty-an experience of twenty-three cases

using three techniques. J Postgrad Med. 1990;36:9-12.

7. Mehta R, Malaviya GN. Evaluation of the results of

opponensplasty. J Hand Surg. 1996;21B:622-623.

8. Stanley BG. Preoperative and postoperative

management of tendon transfers after median nerve

injury. In: Hunter JM, Macklin EJ, Callahan AD, eds.

Rehabilitation of the Hand: Surgery and Therapy. 4th

ed. St Louis, MO; CV Mosby; 1995:765-778

9. Davis TRC, Barton NJ. Median nerve palsy. In: Green

DP, ed. Green’s Operative Hand Surgery. Philadelphia,

PA; Churchill Livingstone; 1999:1497-1525.

10. Jacobs B, Thompson TC. Opposition of the thumb and

it’s restoration. J Bone Joint Surg. 1960;42:1015-1026.

11. Walsh M, Muntzer E. Wound management. In: Stanley

BG, Tribuzi SM, eds. Concepts in Hand Rehabilitation.

Philadelphia, PA; FA David; 1992:171-175.

12. Sundararaj GD, Mani K. Surgical reconstruction of the

hand with triple nerve palsy. J Bone Joint Surg.

1984;66B:260-264.

13. Anderson GA, Lee V, Sundararaj GD. Extensor indicis

proprius opponensplasty. J Hand Surg. 1991;16B;334-

338.

AUTHOR

CPT Admire is an Occupational Therapist at the

Occupational Therapy Clinic, General Leonard Wood

Community Hospital, Fort Leonard Wood, Missouri.

18TH MEDICAL COMMAND 121ST GENERAL HOSPITAL

SEOUL, KOREA

Thumb Opposition Restoration: A Case Study
July – September 2006 27

INTRODUCTION

In the Global War on Terrorism, the United States has

deployed thousands of athletic Soldiers, Sailors,

Airmen and Marines to third-world nations. Part of

sustaining military operations in these areas requires

constant improvement in the area of operations.

Medical assets have been reconfigured into smaller

subunits to support these missions, often in forward

operating areas. Deployed Soldiers strive to maintain

their strength, flexibility, and peace of mind initially

by doing routine physical training or using make-shift

weights and gym equipment. Eventually, organized

sports such as soccer and basketball appear on base.

Participation in organized competitive sports in

theatre, just as in garrison at home bases, carries an

increased risk of injury. There are few risk assessment

guidelines to help a commander with the decision as to

whether to allow such activities.

Forward Operating Base (FOB) Salerno is a US

military installation in southeastern Afghanistan, near

the Pakistan border. The FOB is medically supported

by a forward surgical team augmented with 14

additional personnel to allow additional medical

holding capacity for injured Soldiers. The austere

location of FOB Salerno challenges current medical

logistic support systems. The majority of supplies must

be brought to FOB Salerno by air. Supplies and

personnel shortages occur with changes in the weather

and/or enemy activity. One way to improve morale in

such an austere environment is to continually increase

the recreational outlets for Soldiers. In May 2004, the

command of FOB Salerno welcomed the opening of a

concrete basketball court to improve both physical

fitness and the mental well-being of the Soldiers on the

FOB.

Based on statistical evidence,1the physicians on the

FOB postulated that a new basketball court may lead

to an overall increase in knee and ankle injury due to

the nature of the sport. Previous studies done in the

civilian sector have documented an injury rate of 18.3

per 1,000 participants, with the most common injury

being the ankle joint.2 This paper documents the

medical impact of opening a basketball court on a

forward operating base and provides commanders and

medical planners data with which to perform risk

assessment and logistical planning if such projects are

pursued in areas supported by Echelon II/III (-)

Medical Treatment Facilities.3

DATA ANALYSIS

A retrospective review of emergency room

consultations for the period 24 March through 26 June

2004 was conducted for all diagnoses of knee and/or

ankle injury occurring on Forward Operating Base

(FOB) Salerno. The patient data was further divided

into two groups – those injuries occurring prior to 10

May 2004 (the date the basketball court opened for

use), and those injuries occurring on or after 10 May

2004. Each subgroup thus sampled 47 days of

emergency room admission data. Only US Soldiers

stationed on the FOB were included in this study.

Fifty-two patients sustained knee and/or ankle injuries

on the FOB from 24 March through 26 June (Table 1).

The number of knee injuries increased following

introduction of the court, although only to a minor

degree (n=11 vs n=13). The number of ankle injuries

went up to a much greater degree (n=9 vs n=19). As

shown graphically in the chart, the proportion of knee

and ankle nonbattle injury (NBI) increased as well

(25% vs 44%). Thus, during the second time period, 2

out of every 5 NBI Soldiers were being seen for either

ankle or knee injury. This rapid increase was the

impetus for this paper. The subgroup analysis by

month is presented in Table 2.

Medical Support and Basketball-Related

Sports Injury of US Soldiers in

Afghanistan

LTC James D. Frizzi, MC, USA

MAJ Peter D. Ray, MC, USAR

CAPT John B. Raff, MC, USNR
28 Army Medical Department Journal

During the review period, the overall Soldier

population on FOB Salerno remained constant; the

tempo of military operations underwent no significant

changes. Aside from the basketball court, there were

no other new sports facilities constructed (soccer

fields, gymnasiums, etc) on FOB Salerno during the

period 24 March- 26 June 2004.

DISCUSSION

Knee and ankle injuries are a given in the active and

athletic population typically assigned to a FOB. Given

that football and basketball contribute to the highest

rates of injuries in male Soldiers,4 we propose, and the

data support, that the incidence of these injuries

increased when basketball was introduced on this

forward operating base. Establishing the degree to

which these injuries affected operational capability is

beyond the scope of this paper. However, a previous

study of the Armed Forces database which reviewed

13,861 hospital admissions over a 6 year period for

injuries related to sports or Army physical training did

conclude that these injuries account for a significant

number of lost duty days and have an impact on

military readiness.4

There is no intent by the authors to second guess the

decision to build the concrete basketball court on FOB

Salerno. It was an operational decision that took

multiple factors into consideration and concluded that

the presence of the court supported the overall FOB

mission. Our intent is to provide input that will assist

commanders with the risk-benefit analysis that is part

of making that decision. In this case, the incidence of

ankle injury doubled after the basketball court was

constructed. The need for medical supplies (Class VIII

supplies), namely crutches, ankle orthoses, and knee

immobilizers increased commensurately. Perhaps this

scenario had greater meaning to the medical providers

Comparison of knee and ankle injuries as

percentages of total nonbattle injuries for the 47 day

periods immediately preceding and following the

opening of the concrete basketball court at Forward

Operating Base Salerno, Afghanistan.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

47 Day

Period

Prior to

10May04

47 Day

Period

Beginning

10May04

Total Nonbattle Injuries

Other Nonbattle Injuries

Knee & Ankle Injuries

Medical Support and Basketball-Related Sports Injury of US Soldiers in Afghanistan

Table 1. Nonbattle Knee and Ankle Injuries as a

Percentage of All Nonbattle Injuries Incurred at FOB

Salerno in Periods Immediately Before and After

Opening of the Basketball Court on 10 May 2004

Timeframe Total

Injuries

Knee &

Ankle

Injuries

Percent

of

Total

47 day period

prior to

05/10/04

77 20 26%

47 day period

starting

05/10/04

72 32 44%

Table 2. Monthly Tabulation of Knee and Ankle

Injuries Over 94 Day Reporting Period

March April May June

Knee injuries 1 9 4 10

Ankle injuries 1 7 9 11

Percent of total

knee & ankle

injuries for the

94 day period

(n = 52)

4% 31% 25% 40%

Days in period

(percent of total

reporting period)

7

(7%)

30

(32%)

31

(31%)

26

(28%)
July – September 2006 29

as the facility’s supply of crutches and ankle boots was

depleted until new supply arrived. FOB Salerno was

ultimately able to continue the wartime mission

uninterrupted but adjustments in supply and personnel

assignments were absolutely necessary.

CONCLUSION

While improvements in the athletic and sports

facilities at far- forward areas of the US Global War on

Terrorism are lauded by Soldiers and commanders

alike, the medical impact of these facilities must be

addressed prior to construction. While a basketball

court may invoke memories of home to a Soldier, to

the deployed physician the presence of the court means

a need for crutches, casts, and cold compresses. If the

base commanders do not assign priority to medical

supplies needed to address sports injuries, they may

find their medical caregivers lacking those same

supplies when faced with battle injuries to the lower

extremities. We hope that our experience with the

introduction of a basketball court on a FOB will

influence other commands to take the impact on

medical support into account during the decisionmaking process. We recommend that the US military

continue to construct sports facilities for its deployed

troops and augment the medical facilities and supplies

at bases where such facilities exist. In this fashion, the

US Soldier may remain physically fit, mentally sharp,

and afforded the finest care America has to offer.

REFERENCES

1. Meeuwisse WH, Sellmer R, Hagel BE. Rates and

risks of injury during intercollegiate basketball. Am J

Sports Med. 2003;31;No. 3:379-385.

2. McKay GD, Goldie PA, Payne WR, Oakes BW,

Watson LF. A prospective study of injuries in

basketball: a total profile and comparison by gender

and standard of competition. J Sci Med Sport.

2001;4;No. 2:196-211.

3. Field Manual 4-02.10: Theater Hospitalization.

Washington, DC: US Dept of the Army; 29 Dec

2000: chap 1, sect 1-3.

4. Lauder TD, Baker SP, Smith GS, Lincoln AE. Sports

and physical training injury hospitalizations in the

Army. Am J Prev Med. 2000;18(3 suppl):118-128.

AUTHORS

LTC Frizzi is assigned to the General Surgery Service at the Eisenhower Army Medical Center, Fort Gordon, GA.

MAJ Ray is an associate professor in the Division of Plastic and Reconstructive Surgery, University of Alabama School of

Medicine, Birmingham, AL.

CAPT Raff is with Appalachian Orthopedic Associates in Kingsport, TN.
30 Army Medical Department Journal

CURRENT ARMY ACCESSION IMMUNIZATION

PRACTICES

The transformation from civilian to Soldier in today’s

all-volunteer Army is a complex one. The primary

responsibility for processing and managing new

Soldier accessions falls to the US Army Accessions

Command (USAAC). The USAAC processes over

130,000 enlisted accessions annually for assignments

in the Active Army, Army Reserve, and National

Guard. Army accessions are processed through a

decentralized network of 5 Adjutant General Corps

Reception Battalions (AG BN):

 30th AG BN – Fort Benning, GA

 43rd AG BN – Fort Leonard Wood, MO

 46th AG BN – Fort Knox, KY

 95th AG BN – Fort Sill, OK

 120th AG BN – Fort Jackson, SC

These sites each process from 10,000 to over 40,000

accessions annually. The 120th AG BN, the largest

Army site, processes a volume of accessions similar to

that of the entire US Navy or Air Force (USAF),

which each process their enlisted accession cohort at a

single location. A Soldier’s transformation takes place

over 3 to 4 days, during which time necessary

administrative and medical processing are performed

in preparation for the start of intensive Basic Combat

Training or One-Station Unit Training.

Immunization of new Soldiers against common

vaccine-preventable infections is an important part of

accession medical processing. The US Army Medical

Command (MEDCOM) supports the mission of

USAAC by providing necessary vaccines. MEDCOM

personnel, under the control of the installation military

treatment facility (MTF), administer these vaccines in

designated clinics for the AG BNs.

Soldiers processing through AG BN clinics are

immunized against up to 10 separate diseases. The

corresponding vaccines include measles-mumpsrubella (MMR), hepatitis B, inactivated poliovirus,

quadrivalent meningococcal A/C/Y/W-135, tetanusImproving Soldier Care Through

Outcomes Research: The Accession

Screening & Immunization Program

CPT Remington L. Nevin, MC, USA

LTC David W. Niebuhr, MC, USA

Kevin D. Frick, PhD

COL John D. Grabenstein, MS, USA

ABSTRACT

The US Army Accession Screening and Immunization Program (ASIP) is an application of the emerging field of

medical outcomes research to the improvement of Soldier care and the optimization of business practices in the

US Army Medical Command (MEDCOM). Informed by the results of mathematical decision analysis, the ASIP

business plan provides an evidence-based forecast of the cost-savings expected to be derived through reductions

in unnecessary vaccine administration by using serologic screening to assess preexisting immunity. Beginning in

FY2006, the ASIP will implement rapid serologic screening for preexisting immunity among Army accessions,

funded via the $4.7 million in projected initial cost savings from averted vaccine administration. Over the first 6

years of the program, the ASIP will avert the unnecessary administration of approximately $40 million in

vaccine product to accessions with serologically demonstrable immunity, eliminate over one million unnecessary

injections, and prevent approximately 100 occupational needlestick injuries among clinic staff. The evidencebased information provided to Army decision makers through the methods used in the ASIP business plan

argues for expansion of the role of outcomes research across the MEDCOM.
July – September 2006 31

diphtheria (Td), influenza, and varicella vaccines.

Influenza vaccine is administered seasonally, and

varicella vaccine is administered to a small number of

recruits on the basis of medical history. At some AG

BNs, hepatitis A vaccine is administered; often in

combination with hepatitis B vaccine as the bivalent

hepatitis A–hepatitis B vaccine, currently Twinrix®

(GlaxoSmithKline, Philadelphia, PA, 888 825 5249).

Soldiers return one month later during their training

for an additional medical encounter to receive needed

vaccine booster doses. The third dose of hepatitis B

vaccine is generally administered at the next duty

station, 6 months after the initial injection.

REDUCING UNNECESSARY IMMUNIZATION

THROUGH SEROLOGIC SCREENING

The practice of giving simultaneous immunizations at

first entry into military training is referred to as mass

immunization.1 The practice of mass immunization

dates back at least to World War II, when the

technique was developed to quickly facilitate the

administration of vaccine to large groups to prevent

outbreaks of disease.2

Although essential to preserving the health of Soldiers,

standard mass immunization practices may fail to

account for previously administered immunizations.

Serologic confirmation of immunity is one option that

can be used in mass immunization to reliably assess a

Soldier’s personal need for a given immunization.

Indeed, in an April, 2004 memorandum, the Armed

Forces Epidemiological Board concluded that

serologic screening was preferred over immunization

record review for this purpose and specifically

recommended serologic screening for preexisting

immunity prior to immunization.

Based on the current availability of common serologic

tests, the administration of 4 vaccines could be

selectively reduced through serologic screening prior

to immunization. These vaccines are hepatitis A,

hepatitis B, MMR, and varicella.

Under a pilot program, the General Leonard Wood

Army Community Hospital at Fort Leonard Wood

began conducting universal serologic screening for

preexisting immunity to hepatitis B in May of 2005.3

All 5 AG BNs also perform targeted varicella

screening based on the results of a medical history

questionnaire administered to new Soldiers. Those

who endorse a negative or unknown history of

chickenpox receive serologic screening for varicella,

and those found susceptible by titer are immunized.

The USAF, which conducts consolidated accession

processing at Lackland AFB, TX, successfully

implemented a universal serologic screening program

to reduce the administration of 3 vaccines: MMR,

varicella, and hepatitis B. The USAF benefits from

economies of scale and limited fixed costs by

performing all of its enlisted processing at a single

facility.

INVESTIGATING THE POTENTIAL FOR ARMY

ACCESSION SCREENING

Although the USAF had demonstrated that universal

serologic screening of accessions was cost-effective at

a single mass immunization site, little was known

about the feasibility of implementing such a policy

across the Army’s decentralized accession processing

system. The conventional wisdom held that

implementing such a policy would be impractical and

cost-prohibitive across processing centers whose

processing volumes varied significantly, and where the

traditionally high costs of serologic testing were

thought not to benefit from the economies of scale

achieved through centralized testing. Additionally, the

necessary fixed costs and staffing expenses to

implement screening were thought to exceed the

potential savings in vaccine that would result from

such a screening program.

At the direction of the Proponency Office for

Preventive Medicine, a detailed research project to

examine those issues was commissioned. Between

October and November 2004, site visits were

conducted at the 5 Army training installations that

receive enlisted accessions to gather data on actual

costs, outcomes, practices, procedures, and

capabilities. With the assistance of a health economist

at Johns Hopkins Bloomberg School of Public Health,

a rigorous cost-effectiveness analysis for

implementing serologic screening at these 5 sites was

also performed.

To best comply with the Armed Forces

Epidemiological Board’s recommendations to

maximize reductions in unnecessary immunizations,

models were constructed of the potential cost savings

that would be obtained through screening for

preexisting immunity to as many diseases as possible

for which common screening tests were readily

available, including hepatitis A, hepatitis B, measles,
32 Army Medical Department Journal

rubella, and varicella.4 Although implementation of

screening would incur both fixed and variable costs,

only the marginal costs associated with the screening

of an individual accession were examined. For the

purposes of this analysis, those costs include the cost

of vaccine product and of all the serology reagents

used to test for immunity.

Cost-effectiveness analysis was facilitated through the

creation of a mathematical model, implemented using

the industry leading decision-analytic software tool

TreeAgeTM Pro Healthcare (TreeAge Software, Inc.,

Williamstown, MA, 413-458-0104). Through the use

of Monte Carlo stochastic simulation, the model thus

created permitted calculation of multiple economic and

non-economic outcomes of interest, to include total

vaccine cost savings and vaccine cost savings per

installation. The model also calculated noneconomic

outcomes of interest, to include reductions in

injections, probability of missed immunization due to

false-positive screening tests, and probability of

complete seroconversion from each vaccine product.

The model automatically factored in the effects of

Soldier attrition, and of the age-specific dosing

strategies necessary for the use of the bivalent vaccine

Twinrix®, which is not licensed for use in 17-year

olds. In addition, through the use of first- and secondorder sensitivity analysis, the robustness of the

outcomes to changes in initial assumptions could be

modeled.

The model took as its input the rates of preexisting

immunity to each of these diseases obtained from

review of existing surveillance and research studies,

including a recent study of hepatitis B immunity

among military recruits.5 There was limited

availability of reliable seroprevalence information for

preexisting immunity to hepatitis A. To confirm the

mathematical analysis, a detailed seroprevalence study

of hepatitis A antibodies among approximately 2,800

recruits was performed in January, 2005 using banked

frozen serum obtained on accessions during calendar

year 2004.6

Costs of vaccine product were obtained from an

exhaustive review of actual pharmacy purchasing

records at the MTFs supporting Army AG BNs.

Rates of seroconversion for each vaccine, as well as

the sensitivity and specificity of screening and

serologic tests, were obtained from literature review.

Rates of attrition were obtained through a review of

USAAC data.

THE ECONOMIC BENEFITS OF SEROLOGIC

SCREENING

Due to high rates of preexisting immunity to measles,

rubella, varicella, hepatitis A and hepatitis B among

Army accessions, our model determined that, on

average, $43 of unnecessary vaccines were

administered to each new accession in FY2004. These

vaccines were “unnecessary” in that they were

administered to Soldiers with serologically

demonstrable immunity to one or more screened

diseases.

Although this amount may seem small per accession,

due to the large size of the annual accession cohort,

this represents a significant cumulative sum: over $5.3

million worth of unnecessary vaccines were

administered to Army accessions during FY2004. This

annual amount is equivalent to over $100,000 worth of

unnecessary vaccines weekly, the costs of which could

otherwise be used to fund improvements in medical

processing and immunization delivery.

As rates of preexisting immunity rise, due to the Army

enlisting recruits who are increasingly likely to have

received hepatitis B vaccine before accession, these

potential cost savings increase, to over $6 million

annually beginning in FY2006, and $7 million

annually beginning in FY2009.

THE US ARMY ACCESSION SCREENING AND

IMMUNIZATION PROGRAM

The end result of the site visits and the costeffectiveness modeling was the formulation of the US

Army Accession Screening and Immunization

Program (ASIP) business plan.7Following a lengthy

staffing process where the projected vaccine cost

savings were independently confirmed and the input of

the 5 servicing MTFs was obtained, the Army Surgeon

General approved the ASIP proposal and issued

implementation instructions in a memorandum dated

November 18, 2005.

Funded entirely through projected vaccine cost

savings, the ASIP has developed into a comprehensive

The Accession Screening and Immunization Program
July – September 2006 33

strategy for improving the quality of accession medical

processing and immunization delivery. The ASIP

implements the recommendations of the Armed Forces

Epidemiological Board to institute serologic screening

for preexisting immunity among Army enlisted

accessions, and provides numerous economic and noneconomic benefits.

Beginning with implementation across all 5 Army AG

BNs in FY2006, the ASIP will implement rapid

serologic screening for preexisting immunity among

Army accessions to hepatitis A, hepatitis B, measles,

rubella, and varicella, funded via the $4.7 million in

projected initial cost savings from averted unnecessary

vaccine administration (Figure 1). The ASIP will also

Figure 1. Immunization injection schedule for newly accessed personnel under the

Accession Screening and Immunization Program.

Universal Serologic

Screening for

presence of

antibodies for VZV,

rubella, measles,

HAV, and HbSAb

IPV, FLU

MGC, TD

PCN

In-processing

Varicella

non-immunes only VZV#1

MMR#1

Measles/Rubella

non-immunes only

Hepatitis A*

non-immunes only A#1

Hepatitis B*

non-immunes only B#1

1 Month

MMR#2

VZV#2

B#2

Im

munizations

Reception Battalion (AG BN)/

Basic Combat Training Training Phase

Timeline

Advanced Individual Training/

Soldier Readiness Program

B#3

6 to 12 Months

A#2

KEY TO ABBREVIATIONS

A – Hepatitis A vaccine

B – Hepatitis B vaccine

FLU – Influenza vaccine

HAV – Hepatitis A virus

HbSAb – Hepatitis B surface antibody

IPV – Inactivated poliovirus vaccine

MGC – Meningococcal A/C/Y/W-135 vaccine

MMR – Measles-mumps-rubella vaccine

PCN – Bicillin-LA (administered at 3 of 5 AG BNs)

TD – Tetanus-diphtheria toxoids (Td)

VZV – Varicella-Zoster vaccine

*Note: Hepatitis A and B vaccine delivered in bivalent

form to those 18 and older non-immune to both.
34 Army Medical Department Journal

institute other needed improvements in enlisted

accession medical processing. Over the first 6 years of

the program, the ASIP will avert the unnecessary

administration of approximately $40 million in vaccine

product to accessions with serologically demonstrable

immunity (Figure 2), eliminate over one million

unnecessary needle injections, and, based on current

estimates of injury rates, prevent approximately 100

occupational needlestick injuries among clinic staff.8

The ASIP will enable the funding of high-quality

medical processing and immunization clinics under the

direct control of the commander of the installation

MTF at each of the 5 AG BNs. Beginning in FY2006,

with the hiring of 29.5 full-time equivalents (FTEs)

and continuing with the hiring of an additional 30

FTEs through FY2010, the ASIP will free existing

military personnel by funding full civilian (civil

service) staffing of ASIP clinics with trained nurses,

phlebotomists, and clerical staff, under the supervision

of on-scene, credentialed medical directors. The ASIP

will provide for dedicated serologic screening

equipment within existing laboratories at these 5

installation MTFs, staffed with dedicated technicians,

providing the reliable and rapid turnaround of results

needed for successful program implementation.

The ASIP will provide funds for training, capital

improvements and equipment to assure compliance

with regulatory standards and to improve the

efficiency, reliability, and quality of medical

processing of the Army’s newest Soldiers.

The ASIP will also fully fund universal glucose-6-

phosphate dehydrogenase (G6PD) deficiency testing at

accession. Under the proposal, AG BNs will ship

whole blood specimens to the Brooke Army Medical

Center central reference laboratory, where centralized

testing and permanent electronic documentation of

results will occur, precluding the need for later costly

and repeat testing.9 Universal screening for G6PD at

accession is warranted given the high rate of

deployment of US Army personnel to areas of malaria

endemicity for which terminal malaria prophylaxis

may be required.

The ASIP will provide centralized oversight and

management of the accession medical processing and

immunization program through the establishment of a

Program Management Office (PMO) located at the

Military Vaccine Agency, responsible for overall

coordination and direction of the program (Figure 3).

The ASIP PMO will coordinate and synchronize

policy guidance from the US Army Training and

Doctrine Command, the Office of the

Surgeon General, and the MEDCOM

for accession medical processing and

immunization issues, and will direct

targeted analytic efforts toward

further improving mass screening

and immunization programs and

expanding the range of diseases for

which screening is feasible

The first 6 years of the ASIP program

will result in a total cumulative cost

savings to the MEDCOM of over

$10.4 million. The ASIP provides

these significant cost savings while

improving the quality, reliability, and

efficiency of enlisted accession

medical processing, and increasing

the confidence and trust of new

Soldiers in Army immunization

policies.

As shown in the Table, the ASIP

budget assumes multiple

Figure 2. Cumulative vaccine costs and potential vaccine savings

realized from implementation of the Accession Screening and

Immunization Program.

$0

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

$70,000,000

$80,000,000

$90,000,000

2006 2007 2008 2009 2010 2011

Fiscal Year

Cumulativ

e

V

accine

C

osts

Necessary Vaccine Potential Vaccine Savings

The Accession Screening and Immunization Program
July – September 2006 35

conservative cost estimates, including a per accession

serologic screening cost of $14 in FY06, decreasing to

$12 in subsequent years; and conservative cost-savings

figures, including total vaccine cost savings per

accession of $49 in FY2006, increasing to $63 per

accession by FY2011.

In recognition of the high cost of perishable vaccine

product kept on hand at ASIP clinics, the ASIP budget

contains funds to purchase redundant vaccine

refrigeration and freezer equipment, properly equipped

with remote alarms that will alert clinic staff of

equipment malfunction or power failures. ASIP clinic

The savings per new Soldier realized with each immunization series and at

completion of training under the Accession Screening and Immunization

Program when compared to the status quo.

FY2006 FY2007 FY2008 FY2009 FY2010 FY2011

Vaccine Cost per

Immunization

Series ($)

In-processing

Status quo 56 56 56 56 56 56

ASIP 28 27 26 25 24 23

Difference (28) (29) (30) (31) (32) (33)

1 Month

Status quo 28 28 28 28 28 28

ASIP 18 16 15 14 13 12

Difference (10) (12) (13) (14) (15) (16)

6 to 12 Months

Status quo 28 28 28 28 28 28

ASIP 17 18 17 16 15 14

Difference (11) (10) (11) (12) (13) (14)

Total Vaccine

Cost ($)

Status quo 112 112 112 112 112 112

ASIP 63 61 58 55 52 49

Difference (49) (51) (54) (57) (60) (63)

Serology Cost ($)

Status quo 1 1 1 1 1 1

ASIP 14 12 12 12 12 12

Difference 13 11 11 11 11 11

Total Cost ($)

Status quo 113 113 113 113 113 113

ASIP 77 73 70 67 64 61

Difference (36) (40) (43) (46) (49) (52)
36 Army Medical Department Journal

Figure 3. The US Army Accession Screening and Immunization Program established a standardized

structure and methodology across the 5 reception installations under the centralized direction of the Office

of the Surgeon General and the Army Medical Command.

Office of the Surgeon General

US Army Medical Command

Military Vaccine

Agency

ASIP

Program

Management

Office

Great Plains

Regional

Medical

Command

Southeast

Regional

Medical

Command

North Atlantic

Regional

Medical

Command

General Leonard Wood

Army Community

Hospital

Reynolds

Army Community

Hospital

Brooke Army

Medical Center

ASIP

Reference

Laboratory

Martin Army

Community Hospital

Moncrief Army

Community Hospital

ASIP

Laboratory

43rd

AG BN

ASIP Clinic

30th

AG BN

ASIP Clinic

46th

AG BN

ASIP Clinic

95th

AG BN

ASIP Clinic

ASIP

Laboratory

ASIP

Laboratory

120th

AG BN

ASIP Clinic

ASIP

Laboratory

Ireland Army

Community Hospital

ASIP

Laboratory

The Accession Screening and Immunization Program
July – September 2006 37

budget figures also include funds to provide for the

provision and installation of emergency power

generation equipment that would ensure the continued

operation of vaccine storage equipment in the event of

an emergency that would threaten vaccine potency.

Experience has demonstrated that plans to move large

vaccine stockpiles to MTF storage facilities in the

event of equipment malfunction or power failure are

impractical, necessitating the provision of both

redundant equipment and emergency power supplies.

FUTURE DIRECTIONS FOR OUTCOMES

RESEARCH

The ASIP represents the application of the fields of

outcomes research and decision-analytic modeling10 to

improve Soldier care and to optimize business

practices across the MEDCOM. The practice of

outcomes research requires access to large amounts of

linked medical data. Much of this data is already

available in the Defense Medical Surveillance System

(DMSS), operated by the Army Medical Surveillance

Activity.11 DMSS already contains relevant medical

outcomes and healthcare utilization data on members

of the armed forces. The addition of linked pharmacy,

laboratory, and radiology data would provide

additional outcomes research capability to the already

robust medical surveillance functions of DMSS,

improving the MEDCOM’s ability to plan for and

evaluate other large-scale public health interventions.

The Accession Screening and Immunization Program

has demonstrated that moderate investments in

outcomes research provide significant returns on

investment. Therefore, it is recommended that

outcomes research capabilities be incorporated as part

of the consolidation of military public health and

medical surveillance functions at the planned Armed

Forces Health Surveillance Center.

REFERENCES

1. Grabenstein JD, Nevin RL. Military mass immunization

programs: Principles and standards. In: Plotkin SA.

Mass Immunization. In press.

2. Benenson AS. Immunization and military medicine.

Rev Infect Dis. 1984;6:1-12.

3. Pablo K, Rooks P, Nevin R. Benefits of serologic

screening for hepatitis B immunity in military recruits.

J Infect Dis. 2005:192:2180-2181.

4. Nevin RL, Niebuhr DW, Frick KD. Cost-minimization

analysis of serologic screening policy options for US

Army accession immunizations. [Poster PHP47]. In:

Contributed Poster Presentations. Value in Health.

2005;8;No. 3:436.

5. Scott PT, Niebuhr DW, McGready JB, Gaydos JC.

Hepatitis B immunity in United States military recruits.

J Infect Dis. 2005;191:1835-1842.

6. Nevin RL, Niebuhr DW. Seroprevalence of hepatitis A

antibodies among new enlisted accessions to the US

military in 2004. [Poster 1026]. Presented at: 43rd

Annual Meeting of the Infectious Diseases Society of

America; October 8, 2005; San Francisco, CA.

7. Nevin RL. Technical Guide #310: The US Army

Accession Screening and Immunization Program.

Aberdeen Proving Ground, MD: US Army Center for

Health Promotion and Preventive Medicine; November

18, 2005 [limited distribution].

8. Nevin RL, Niebuhr DW, Frick KD. Mathematical

modeling of occupational needlestick injury reduction

in a US Army mass immunization program through

universal serologic screening for preexisting immunity.

Am J Infect Control. 2005;33;No. 5:e139-e140.

9. DoD Instruction 1645.1, Hemoglobin S and Erythrocyte

Glucose-6-Phosphate Dehydrogenase Deficiency

Testing Program. Washington, DC: US Dept of

Defense; July 29, 1981.

10. Weinstein MC, O'Brien B, Hornberger J, Jackson J,

Johannesson M, McCabe C, Luce BR. Principles of

good practice for decision analytic modeling in healthcare evaluation: report of the ISPOR Task Force on

Good Research Practices – Modeling Studies. Value

Health. 2003;6:9-17.

11. Rubertone MV, Brundage JF. The Defense Medical

Surveillance System and the Department of Defense

serum repository: glimpses of the future of public

health surveillance. Am J Public Health. 2002;12:1900-

1914.
38 Army Medical Department Journal

AUTHORS

CPT Nevin, is currently assigned to the Army Medical Surveillance Activity, US Army Center for Health Promotion and

Preventive Medicine, Washington, DC.

LTC Niebuhr is on the staff of the Division of Preventive Medicine, Walter Reed Army Institute of Research, Silver

Spring, Maryland.

Dr Frick is an associate professor in the Department of Health Policy and Management, Johns Hopkins Bloomberg School

of Public Health, Baltimore, Maryland.

COL Grabenstein is on the staff of the Military Vaccine Agency Office of the US Army Surgeon General, Falls Church,

Virginia.

The Accession Screening and Immunization Program

US ARMY CENTER FOR HEALTH

PROMOTION AND PREVENTIVE

MEDICINE

US Army Medical Research

and Materiel Command
July – September 2006 39

INTRODUCTION

Simulation has proven useful in a wide range of

applications where errors in human judgment or

performance can result in catastrophic consequences.

It is ubiquitous in aviation, nuclear power plant

operations, and modern military battlefield training.

Over the last decade the anesthesiology community

has adapted the principles of crisis management into a

standard curriculum, with global adoption.1,2 Several

centers are developing programs that follow a similar

pattern, including a recently well described adaptation

for emergency medicine.2-5 Most of these programs

focus on 1 or 2 physician or nurse anesthetists without

the involvement of the rest of their usual health care

team. However, in most health care environments care

is delivered by disparate teams, with outcomes and

performance largely affected by the interactions of the

team members, rather than the isolated responses of a

single practitioner.1,2 We report on the participant

response to the multidisciplinary team-based education

program at a military medical center. This program has

been adapted for a wide range of office, hospital and

prehospital providers, including combat field

conditions, weapons of mass destruction, and acute

patient decompensation due to iatrogenic

complications using the SimMan patient simulator

(Laerdal Medical Corporation, Wappingers Falls, NY,

877-523-7325).

METHODS

The simulator consists of a semiautomated manikin

that has visible respirations, variable airway

conditions, modifiable auscultation findings, palpable

pulses, and the ability to represent manual blood

pressures. A simulated monitor, used to display pulse

oximetry wave forms, oxygen saturation, and heart

rate when the finger probe is attached, is used with all

groups. Cardiac rhythm, heart rate, exhaled

capnography, arterial wave form with blood pressure

(BP), central venous waveform, respiratory rate, cyclic

noninvasive BP, core temperature and cardiac output

are variably displayed depending on the monitoring

capability and preferences of the individual teams. In

addition, the simulator can be attached to a standard

cardioverter/defibrillator via limb leads or the chest

electrodes used for electrical therapy delivery. The

simulator and the monitor are controlled by software

that is programmed to model disease processes and

respond to interventions or complications with

alterations in the vital signs, physical examination, or

audio cues (such as patient vomiting).

Participants were given a summary of the capabilities

of the simulator as well as some basic information on

facets of crisis management prior to participation. The

groups were then given a chance to familiarize

themselves with the available equipment and obtain

Multidisciplinary Crisis Management

Simulation-Based Training Program

Kevin M. Coonan, MD

LTC Joseph P. Miller, MC, USA

Michelle Martinez

COL Pat Kelly, MC, USA

ABSTRACT

This report describes our experiences with a simulation-based crisis management program used to train existing

teams comprised of physicians, nurses (LPN and RN), respiratory technicians and/or medics (EMT-B and EMTP). The 579 participants were trained using scenarios reflecting their clinical environment, including battlefield/

prehospital, ambulatory clinic, emergency department, field hospital, medical-surgical nursing, and intensive

care settings. Scenarios included iatrogenic decompensation, risk management issues, weapons of mass

destruction, and initial presentation of critical illness. The participants overwhelmingly found the training

valuable. Simulation can be adapted to, and is useful for, training a range of healthcare providers working

together in vastly differing settings.
40 Army Medical Department Journal

hands-on experience with the simulator to establish

baseline function and physical examination findings.

The participants were given a patient history tailored

to their work environment, and often supporting

information, such as electrocardiograms, radiographs,

prehospital reports, laboratory values, prior nursing

and physician notes, nursing flow sheets, and

anesthesia records. Equipment and medications were

provided in a manner to replicate their practice, eg, a

standard hospital crash cart. Prehospital teams are

encouraged to use their own equipment and supplies.

The teams were composed of a range of health care

workers including interns, residents, staff physicians,

practical nurses, medical-surgical registered nurses,

critical care and emergency nurses, respiratory

therapists, paramedics, and emergency medical

technicians-basic, who often were functioning in a role

of medical or nursing assistant. The teams were drawn

from existing patient care units and clinics. Table 1

lists several of the teams and the types of scenarios

used.

Following the simulation, we conducted a debriefing

session with the goal of having team participants relay

the events as they perceived them. Each scenario was

designed to have 7 critical actions that must be taken,

and 4 specific “pitfalls” which are detrimental or ill

advised. Participants were given a listing of the

educational goals and brief summaries of the problems

encountered and expected management, with current

references. We encouraged investigation of the

differing interpretations of findings and treatments

used in the simulation. The debriefings focused on

both medical care and team dynamics. We adapted a

previously validated team performance tool to serve as

a template, presented in the Appendix to this article,

for our review and future studies.9

Table 1. Settings, Team Compositions, and Training Scenarios used in Simulation Training Exercises

Setting Team Composition Scenarios

Medical oncology ward

Med-surgical ward

Step-down unit

Internal medicine residents

Nurses (RN and LPNs)

Aides

Respiratory therapists

Anaphylaxis to IV antibiotics

Narcotic induced respiratory depression

Ventricular tachycardia due to acute MI

Hyperkalemia

Hemolytic reaction to blood

Emergency department Emergency physicians

EMT-P

Nurses

EMT-B

Exsanguinating extremity hemorrhage

Prehospital esophageal intubation

Heatstroke

Nerve agent intoxication

Neck injury

Acute MI with RV extension

Multiple trauma

Hypothermia

Austere field environment

(battalion aid station)

Physicians

Physician assistants

Medics (EMT-B and some EMT-P)

Combined gunshot wound and nerve agent

intoxication

Airway burns

Tension pneumothorax

Critical care unit Physicians

Nurses

Respiratory therapists

Septic shock, anaphylaxis in patient with

pneumonia

ARDS with acute respiratory failure

Tension pneumothorax

Massive pulmonary embolus

Primary care clinic Physician

Nurse (RN)

Medical assistant or LPN

Anaphylaxis

Acute MI

Asthma

Multidisciplinary Crisis Management Simulation-Based Training Program
July – September 2006 41

RESULTS

Over a 12-month period, we provided 1,616

person-hours of team-based simulation to 579

health care providers. A variety of teams

participated, with mixed groups of providers

from various disciplines and training as

graphically depicted in the Figure. We polled

a convenience sample of 100 of the 579 users,

94 of which elected to complete a survey (3

surveys were discarded as they circled the

value 10 for every aspect of the simulation)

on their assessment. The resulting data is

presented in Table 2.

DISCUSSION

Crisis management is different from routine

care.6 We assume that performance in a crisis

can affect the outcome, possibly preventing

adverse effects or minimizing patient injury.

However, this requires optimal provider

performance, decision-making skills, and

overall integration and communication within

the team. Specific aspects of the crisis

management process have been quantified and

described as shown in Table 3. These elements can be

taught.1-4

The simulation program provided training, often

concurrently, on multiple levels. It allowed the

rehearsal and integration of algorithmic care, which

improves retention.7,8 A wide variety of procedures

were employed:

 endotracheal intubation

 surgical or needle cricothyrotomy

 chest compression

 mask ventilation

 chest-tube thoracostomy

 intravenous access

 IV drip titration

 cardioversion/defibrillation/pacing

Training in those procedures developed not only the

technical skills, but also the integration of those skills

with an overall picture of patient management.9,10

Patient care teams may be faced with critically ill or

decompensating patients without the benefit of

extensive experience. Thoroughly considered and

well-rehearsed plans for specific clinical emergencies

Team Composition by Type of Training

PA (16, 4%)

RT (13, 3%)

EMT (189, 45%)

LPN (33, 8%)

RN (111, 26%)

MD/DO (58, 14%)

Table 2. User Assessment of Multidisciplinary

Crisis Management Simulations

Question *Mean †SD

The simulation was realistic 8.5 1.7

The scenario was clinically applicable

to my field 8.8 1.3

There was sufficient time to perform

critical actions 8.8 1.3

Responses to interventions were

appropriate 8.5 1.6

The simulation will help me in future

critical situations 9.0 1.2

The simulation will help me prevent

errors

8.8 1.4

The simulation reviewed/taught

something useful 9.1 1.1

*Response scale:

1=disagree strongly, 10=agree strongly

†

Standard deviation
42 Army Medical Department Journal

are crucial to success. Many critical events may occur

so infrequently that members of the team have no

personal experience or recall of current management

options. Although typically considered a problem

faced by the military heath care system during conflict,

civilian practitioners in all disciplines are facing the

growing likelihood of providing care for victims of

weapons of mass destruction. Courses emphasizing

experience-based learning, such as the Advanced

Cardiac, Advanced Trauma, and Prehospital Trauma

Life-Support (ACLS, ATLS, and PTLS), offer some

support. They provide a common framework and an

approach that is likely to benefit most patients in a

given situation. Experience from the courses and

hands-on patient care solidify learning, unlike reading

instructions from a course manual.

Experience in evaluating and training aircraft pilots,

combat vehicle crew members, anesthesia personnel,

and nuclear power plant operators has led to a shared

model for dealing with critical incidents or crisis.

Some key behaviors have emerged from analysis of

airline crashes, battlefield disasters, and medical

malpractice cases. These skills have been identified

and can be taught and improved.2,11

Our approach has been to provide a shared experience,

via a simulated patient, to members of a health care

team. These are brief, but intense, critical events (eg,

acute respiratory distress) which require active

intervention by multiple providers. Errors are allowed

to occur, and the software component models the

patient’s response to the errors. For example,

administration of parenteral verapamil to a patient who

had already received parenteral beta-blockers results in

profound bradycardia and hypotension, which may

respond to appropriate therapy with atropine, calcium,

and glucagon.

The key goal of using a patient simulator is a safe,

flexible environment for learning at a variety of levels.

The adult learner’s basic didactic knowledge is

enhanced by case-based learning. In addition,

procedural skills can be taught in a safe, controlled

environment, without risk to patients from incorrect

performance. It allows the application of learning to

new clinical situations. In addition, the hands-on

nature of the simulator enhances the education of the

team—as a team. It is not only critical that individuals

know their specific skills and can perform their roles,

Table 3. Aspects of the Crisis Management Process

BE PREPARED. Anticipate and plan for medical crisis.

Know your environment. Conduct situational

planning. Have shared plans, policies and

procedures for emergencies.

COMMUNICATION. Be clear and precise. Ensure reception

of the intended data. Keep everyone in the loop.

Be polite. Let everyone know which plan is in

use. Use low voices.

LEADERSHIP. Establish role clarity. Delegate. Make sure

tasks are complete. Single person calls the shots

and gives orders. Address professional concerns

directly.

RESOURCE AWARENESS and options for implementation.

Everyone offers suggestions.

CALL FOR HELP early. Distribute workload and mobilize

additional resources. Declare an emergency/call

a code. Entire team shared in decision making.

RE-EVALUATION of situation is an ongoing process. Focus

on “big picture,” consider alternative approaches.

TEAM AWARENESS and utilization of all available

information. Avoid fixation errors. Call out

critical information during events. Cross monitor

others actions and behaviors. Notify team of

slips, lapses, and mistakes.

TRIAGE AND PRIORITIZATION. Focus on key goals — which

may change. Triage is an ongoing assessment of

the dynamic needs of patients against resources

available.

EFFICIENT MANAGEMENT of multiple patients. The sickest

patient may still be in the waiting room. Use

appropriate providers for specific problems.

COPE WITH DISRUPTIONS AND DISTRACTIONS. React to new

information but focus on the critical.

BE PREPARED. Anticipate and plan for medical crisis.

Know your environment. Conduct situational

planning. Have shared plans, policies and

procedures for emergencies.

COMMUNICATION. Be clear and precise. Ensure reception

of the intended data. Keep everyone in the loop.

Be polite. Let everyone know which plan is in

use. Use low voices.

Multidisciplinary Crisis Management Simulation-Based Training Program
July – September 2006 43

but also for individuals to recognize that these roles

are only performed in conjunction with others of

differing training and levels of expertise. All team

members perform critical actions that are both

essential to and dependent upon the actions of the

other members. It is this time spent together working

towards shared goals that allows individuals to realize

what is truly meant by performing as a team.

CONCLUSION

Simulation appears to be a very useful tool for

improving patient care team performance in a wide

variety of settings, ranging from the mud floors of a

military aid station to the intensive care unit of a fixed

facility hospital. This modality should be available for

active duty and reserve military health care teams,

other agencies providing homeland defense, and

community hospitals and clinics.

Studies validating the impact of simulation based

training on outcome are urgently needed.12 Widespread adoption is likely to occur prior to definitive

proof. Careful documentation and consideration of the

optimization of training and the impact on outcomes

will require ongoing efforts.

REFERENCES

1. Institute of Medicine Committee on Quality of Health

Care in America. In: Kohn LT, Corrigan JM,

Donaldson MS, eds. To Err Is Human: Building a Safer

Health System. Washington, DC: The National

Academy Press; 2000.

2. Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD,

Berns SD. The potential for improved teamwork to

reduce medical errors in the emergency department.

The MedTeams Research Consortium. Ann Emerg Med.

1999;34;No. 3:373-383.

3. Reznek M, Smith-Coggins RS, Howard S, Kiran K,

Harter P, Sowab Y, Gaba D, Krummel T. Emergency

medicine crisis resource management (EMCRM): Pilot

study of a simulation-based crisis management course

for emergency medicine. Acad Emerg Med.

2003;10;No. 4:386-389.

4. Small SD, Wuerz RC, Simon R, Shapiro N, Conn A,

Setnik G. Demonstration of high-fidelity simulation

team training for emergency medicine. Acad Emerg

Med. 1999;6;No. 4:312-323.

5. Reznek M, Harter P, Krummel T. Virtual reality and

simulation: training the future emergency physician.

Acad Emerg Med. 2002;9;No. 1:78-87.

6. Sempowski IP, Brison RJ. Dealing with office

emergencies. Stepwise approach for family physicians.

Can Fam Physician. 2002;48:1464-1472.

7. Schwid HA, Rooke GA, Ross BK, Sivarajan M. Use of

a computerized advanced cardiac life support simulator

improves retention of advanced cardiac life support

guidelines better than a textbook review. Crit Care

Med. 1999;27;No. 4:821-824.

8. Willy C, Sterk J, Schwarz W, Gerngross H. Computerassisted training program for simulation of triage,

resuscitation, and evacuation of casualties. Mil Med.

1998;163;No. 4:234-238.

9. Holcomb JB, Dumire RD, Crommett JW, Stamateris

CE, Fagert MA. Cleveland JA, Dorlac GR, Dorlac WC,

Bonar JP, Hira K, Aoki N, Mattox KL. Evaluation of

trauma team performance using an advanced human

patient simulator for resuscitation training. J Trauma.

2002;52;No. 6:1078-1086.

10. Marshall RL, Smith JS, Gorman PJ, Krummel TM,

Haluck RS, Cooney RN. Use of a human patient

simulator in the development of resident trauma

management skills. J Trauma. 2001;51;No. 1:17-21.

11. Patel RM, Crombleholme WR. Using simulation to

train residents in managing critical events. Acad Med.

1998;73;No. 5:593.

12. Coonan K. Comparison of Computer Based and Patient

Simulator Based Crisis Management Programs. Anesth

Analg. 2003;96:1236.

AUTHORS

When this article was written, Dr Coonan was on the staff of

the Andersen Simulation Center, Madigan Army Medical

Center, Fort Lewis, Washington.

LTC Miller is Staff Anesthesiologist, Department of

Anesthesia and Operative Services, at the Madigan Army

Medical Center, Fort Lewis, Washington. When this article

was written, he was the Medical Director of the Andersen

Simulation Center.

Michelle Martinez is the Administrator of Simulation

Programs, Andersen Simulation Center, Madigan Army

Medical Center, Fort Lewis, Washington.

COL Kelly is a member of the Staff, Developmental

Pediatrics, Madigan Army Medical Center, Fort Lewis,

Washington. When this article was written, he was the

Chief, Department of Clinical Investigation.
44 Army Medical Department Journal

APPENDIX. Team Evaluation Form

Team Evaluation Tool

Scenario Time and date Total score (of 80

possible)

Team composition (circle leader, indicate level of training/specialty)

Score: 0=standard of care not met, 1=marginal, 2=optimal

Leadership Repeat vital signs

No delegation or instructions, multiple conflicting

instructions, several disjointed efforts, chaotic 0 None 0

Leader looses track or control of events but overall directs

care

1

One set, or incomplete (i.e. no temperature) omitted, or

deteriorating patient without repeat BP, HR measurements 1

Clearly defined leader maintained control of situation,

delegates and instructs throughout, organized 2

More than one complete set following initial vital signs, ongoing

with frequency as determined by patient stability 2

Exam findings and vital signs communicated to

team Use of information from other sources

No discussion of pertinent findings 0 Ignored 0

Some findings announced 1 Not sought 1

Clear announcement of significant findings with

acknowledgment by leader 2 Reviewed 2

Interventions clearly announced Abdominal examination

No announcement of completion of procedures or other

interventions 0 Not done 0

Some interventions announced 1 Done but incomplete 1

All interventions (IV started, bleeding controlled, etc.)

announced clearly 2 Done, including flanks 2

Communication Repeat chest examination

Yelling to be heard, arguments, or critical information not

communicated 0 Not done 0

Team leader misses any comments or doesn’t use checkback system 1 Done but incomplete 1

Calm, quite, professional with 2 way discussion of significant

events and findings 2 Done, including CXR 2

Workload distribution Neck examined

Members not used, or bogged down by serial tasks 0 Not done 0

1 Incomplete 1

All members involved, tasks coordinated, handled

distractions and redistributed personnel as needed 2

Inspection for JVD, tracheal deviation, c-spine tenderness,

bruits, hematomas, pulses 2

Team work Documentation

Members waiting on others for completion to initiate critical

tasks, unaware of what was needed

0 Not completed or not sent with patients 0

1 Incomplete, illegible 1

Members anticipated others needs and actions, worked in

parallel towards common goals

2 Complete and legible 2

Multidisciplinary Crisis Management Simulation-Based Training Program
July – September 2006 45

Assess risk to team Choice of transfer chosen

Failed to recognize hazard existed to team, failure to use

universal precautions, leaving sharps out

0 Dangerous 0

1 Wasteful or suboptimal 1

Recognized and managed hazards 2 Correct 2

Triage and prioritization of injuries Patient stabilized prior to movement

Failure to address life threats, futile resuscitations,

premature termination of efforts

0 Unstable or likely to loose airway en route, incorrect level of

provider accompanying

0

Address A-B-Cs serially and in order 1 Stable but with minimal additional intervention could be made

more stable

1

Simultaneous management of life threats, rapid initiation of

critical interventions

2 Stable and safe for transport, appropriate provider in

attendance

2

Assess airway patency Administration of analgesia

No assessment 0 None, or excessive 0

Noted patient is breathing or can talk 1 Inadequate dosing or use of IM/SQ/PO routes for severe pain 1

Look-listen-feel, talk to patient, assess for stridor and

pooling secretions

2 Titrated to effect 2

Oxygen applied Scenario Specific Critical action #1

>60 s before initiation 0 Not done or protracted, detrimental delay 0

30-60 s 1 Done with some delay or incomplete but adequate, technique

lacking but goal accomplished

1

<30s to initiation 2 Done promptly, efficiently and correctly 2

Auscultation Scenario Specific Critical action #2

>60s 0 Not done or protracted, detrimental delay 0

30-60s or not sufficient, missed findings 1 Done with some delay or incomplete but adequate, technique

lacking but goal accomplished

1

30s, bilateral, two locations each side 2 Done promptly, efficiently and correctly 2

Neurologic evaluation Scenario Specific Critical action #3

None 0 Not done or protracted, detrimental delay 0

Pupils, GCS, movement x 4 1 Done with some delay or incomplete but adequate, technique

lacking but goal accomplished

1

ROS and complete screening exam 2 Done promptly, efficiently and correctly 2

Assessed central pulses Scenario Specific Critical action #4

Not done 0 Not done or protracted, detrimental delay 0

1 Done with some delay or incomplete but adequate, technique

lacking but goal accomplished

1

Done 2 Done promptly, efficiently and correctly 2

Assessed peripheral pulses Scenario Specific Critical action #5

Not done 0 Not done or protracted, detrimental delay 0

Delayed or unilateral 1 Done with some delay or incomplete but adequate, technique

lacking but goal accomplished

1

Bilateral and determined in conjunction with central pulses 2 Done promptly, efficiently and correctly 2

APPENDIX. Team Evaluation Form (continued)
46 Army Medical Department Journal

Determined cardiac rhythm Scenario Specific Critical action #6

Not done 0 Not done or protracted, detrimental delay 0

Delay >60s in applying monitor or interpretation 1 Done with some delay or incomplete but adequate, technique

lacking but goal accomplished

1

Cardiac monitor applied and rhythm determined in <60 2 Done promptly, efficiently and correctly 2

Initial HR and BP Scenario Specific Critical action #7

Not done or >1 minute delay 0 Not done or protracted, detrimental delay 0

30-60s 1 Done with some delay or incomplete but adequate, technique

lacking but goal accomplished

1

<30s 2 Done promptly, efficiently and correctly 2

Full set of vitals obtained Scenario Specific Pitfall #1

Not obtained (including temperature) 0 Encountered or triggered and not managed 0

>5 minutes 1 Encountered or triggered but managed 1

<5 minutes 2 Not done 2

ECG obtained Scenario Specific Pitfall #2

Not obtained 0 Encountered or triggered and not managed 0

>5 minutes 1 Encountered or triggered but managed 1

<5 minutes 2 Not done 2

ECG interpretation Scenario Specific Pitfall #3

Not interpreted or missed significant diagnosis or erroneous

diagnosis with initiation of dangerous therapy

0 Encountered or triggered and not managed 0

Incomplete interpretation 1 Encountered or triggered but managed 1

Complete, full interpretation with recognition of pathologic

findings and initiation of therapy

2 Not done 2

Obtained AMPLE history Scenario Specific Pitfall #4

Not attempted or incomplete (e.g. forgetting to ask about

drug allergies)

0 Encountered or triggered and not managed 0

Unable to obtain and other sources not sought 1 Encountered or triggered but managed 1

Complete as possible 2 Not done 2

MADIGAN ARMY MEDICAL CENTER

APPENDIX. Team Evaluation Form (continued)

Multidisciplinary Crisis Management Simulation-Based Training Program
July – September 2006 47

Army Field Manual 22-100 defines leadership as “...

influencing people — by providing purpose, direction,

and motivation — while operating to accomplish the

mission and improving the organization.”1 My

leadership philosophy emphasizes six areas that are

critical to achieving success in any organization:

vision, communication, courage, developing

subordinates, knowing yourself, and passion. Leaders

who successfully tap these factors in their personal and

professional life are role models for their

organizations.

Vision is key to leadership. “Without vision, the

people perish.”2(p94) Vision is the leader’s roadmap of

the organization’s future. It provides the organization

with direction and a sense of purpose. An organization

needs to know the plan for its future and the

milestones that will be used to attain successful results.

People who work in an organization without a vision

have no sense of belonging and feel there is no higher

reason for their existence. Work is not meaningful

without a vision. Vision is thus the key ingredient that

stokes the fire of creativity and transforms an

organization. An intellectual image of the future is a

prerequisite for change and must precede any physical

change. Organizational change is undirected,

unfocused, and unproductive without a unifying

vision.

Communication is paramount to leadership. A wellformed vision for an organization is not enough. Goals

are useless if members of an organization do not

understand what they are. A leader’s vision must be

communicated to the organization in a clear and

succinct manner so that it is easily grasped by

organization members. Communicating the vision

involves persuading people to “buy into” it. To

achieve success, subordinates at every level of the

organization must be able to translate and apply the

leader’s vision to their daily jobs. Leaders must widely

articulate their vision in frequent interactions with

organization members. Communication can be verbal

or written and within formal or informal settings.

Newsletters, email communications, and small and

large group forums are effective and practical ways of

disseminating the vision. Every contact with a member

of the organization is an opportunity to reach out and

spread the vision.

Communicating the vision is only one of many

messages that must be conveyed throughout an

organization. Stressing the need for constant

improvement keeps the organization focused on

attaining future goals. Dissemination of results-based

learning about what is working and what needs

improvement within an organization is critical. Giving

praise, credit, and positive reinforcement for a job well

done is essential. By the same token, counseling and

constructive criticism is also important in the pursuit

of the vision.

A leader is a facilitator and moderator who influences

the behavior of individuals and teams within the

organization. Effective communication fosters group

problem solving and decision-making. It encourages a

climate of openness and truthfulness for free

interactions about commonly shared problems, errors,

and lessons. An open door policy and a willingness to

listen are integral components of effective

communication. Listening is just as critical as

speaking. Openness to new ideas capitalizes on an

organization’s creativity. Being accessible sends a

message that the leader cares and is approachable.

Nonverbal communication through behavior and

gestures sends a powerful message to organization

members. Leaders should not underestimate the extent

to which their followers observe them. A simple

gesture of integrity or compassion can be worth a

thousand words and can encourage role-modeling

behavior within the organization. Conversely, a leader

who sends inconsistent and contradictory messages by

not living up to the expectations that he sets for his

organization breeds mistrust and disrespect.

Courage is a third element of leadership. It is one of

the seven Army values forming the acronym

LDRSHIP that all Soldiers are expected to possess.

Elements of Leadership for the

Successful Organization

COL George W. Turiansky, MC, USA
48 Army Medical Department Journal

Courage can be summarized by the phrase, “When in

charge, be in charge.”2(p39) A leader must have courage

to follow his vision, take action, and initiate change.

He must translate his vision into reality. This involves

a willingness to take a public stand on his beliefs and

sometimes to challenge the status quo. A leader who

takes action does what he says and then more. He

speaks the truth and displays integrity, another of the

seven Army values. A courageous leader takes risks

and searches for solutions. He is tough enough to

ensure that the organization executes the actions

necessary to transform vision into reality and to

achieve the desired end result. He delegates

responsibility to empower his subordinates. He also

stands up for subordinates when necessary. Courage

also means taking responsibility for decisions and

acknowledging mistakes. Through personal reflection,

a leader uses mistakes as a learning tool in the lifelong

process of self-improvement. A leader with courage

embodies the values he cultivates in his organization

and lives by them. A leader consistently conducts his

personal and professional life in a manner that will

bring credit not only to himself, but also to his

organization. This encourages subordinates to follow

the path to success by emulating the leader’s behavior.

Developing and mentoring subordinates is essential to

effective leadership. “Leadership conceived as the lone

warrior is really heroic suicide.”3 A leader cannot

command in a vacuum disregarding his staff’s input. A

leader needs subordinates to advise and challenge him

and to help him identify his weak and blind spots. A

leader recognizes that developing and mentoring his

subordinates enhances his own effectiveness.

“Building leadership into the genetic code of an

organization is the ultimate competitive advantage.”4

According to Charan and Tichy, General Electric

attributes its abundance of chief executive officer

talent to its focus on “nurturing” and “growing”

leaders from within the organization.4 This means

making time for people issues such as encouraging,

mentoring, coaching, and advising. An effective leader

gives both positive and negative feedback to his

subordinates. A leader rewards, recognizes, and

celebrates the accomplishments and successes of their

subordinates. A leader provides guidance and suggests

pathways for problem solving. A leader also

encourages reflection as a tool for self-improvement

and emphasizes that people learn from mistakes.

An integral part of subordinate development is the

creation of a work environment in which people can

succeed. This is done by earmarking resources for

learning in areas such as training and education, pilot

projects, and developmental assignments and ensuring

the availability of basic resources such as financial

support, tools, materials, and facilities so subordinates

can excel. An environment for success encourages

teamwork and collaboration at each level of the

organization. A leader develops subordinates by

establishing and maintaining an ethical climate, which

emphasizes that racism, sexism, and prejudice are

unacceptable. Subordinate development also means

caring deeply about your people, both personally and

professionally. Respect and recognition are essential.

Providing resources to remedy social issues such as

marital discord and alcohol abuse is important for

harmonious and effective work performance. A fair

and caring command climate fosters role model

emulation and subordinate development.

Effective leadership means knowing yourself by

recognizing your limits, abilities, shortcomings, and

values. This also involves searching deeply within

yourself to understand your own assumptions, biases,

prejudices, and beliefs, as well as those of others. An

effective leader explores how he differs in these areas

from others and realizes the implications of these

differences on his behavior and interactions with

organization members. It is imperative that a leader

look inward and explore feelings toward race, gender,

rank, and sexual and religious orientation. The

implications of not recognizing differences between

your feelings and those of your organization members

can be immense. In addition, a leader must recognize

that others have varying decision-making, learning,

and interpersonal styles and that these styles may be

just as effective as any of his own. “Before you can

lead others, before you can help others, you have to

discover yourself... And nothing is more powerful than

someone who knows who they are... if you know who

you are, then people trust you.”5 A leader who knows

himself ultimately contributes to a command climate

of fairness and trust which can only spur role model

behavior in subordinates.

Effective leadership is passion. Passion is the inner fire

to inspire and motivate people. “Passion is born of

empathy, the ability to connect with people... With

passionate leadership, the pulse of an institution and its

Elements of Leadership for the Successful Organization
July – September 2006 49

people beats faster, it breathes harder, it runs

stronger.”6Passionate leadership involves instilling

optimism, high morale, enthusiasm, and an esprit de

corps in the work environment. According to the Blair

House Papers, one way to maximize people talent is to

“...raise the spirit of the workforce... Empowering

and energizing the front lines...”7 A leader must create

a work climate in which people feel good about their

jobs and their contributions to the organization. A

leader can instill enthusiasm for his vision by his mere

frequent presence and personal interactions with

organization members. This shows people that you

care enough to see how things are going, to make sure

that political red tape does not bog people down in

their jobs, and to make people feel that they really do

make a difference. An effective leader inspires people

to focus their energy on specific goals directed toward

the vision. However, a leader must be wise enough to

balance appropriate optimism with the realities that

face the organization members on a daily basis.

Inspiring subordinates to attain their goals generates

feelings of fulfillment, self-esteem, and job

satisfaction. By virtue of the role model status, a

passionate leader breeds enthusiasm in subordinates.

To achieve the end result an effective leader must

create a climate that stimulates positive change within

his organization. He must have a vision that is clear,

succinct, and understood by his subordinates. He must

have excellent communication skills as a speaker,

listener, facilitator, and moderator. He must have

courage to be a true leader. A smart leader nurtures

future leaders for his organization and becomes a

people’s leader by mentoring and developing his

subordinates and dealing with people issues. A leader

can be fair only when he knows deep inside who he

really is, how this compares with others, and how the

actions of his subordinates affect his own behavior.

Passionate leadership ignites the organization in

pursuit of the vision. All six of these elements are

critical to effective leadership and make a leader all

that he can be in today’s Army of One.

ACKNOWLEDGEMENT

The author gratefully acknowledges Lieutenant

Russell A. Baum, Jr., Supply Corps, United States

Naval Reserve, for his critical review and editorial

comments.

REFERENCES

1. FM 22-100 Army Leadership: Be, Know, Do.

Washington, DC: US Dept of the Army; 31 August

1999: 1-4.

2. Sullivan GR, Harper MV. Hope is Not A Method. New

York: Broadway Books; 1996.

3. Heifetz R. Quoted by: Gary L. The work of a modern

leader: an interview with Ron Heifetz. Harvard

Manage Update. April 1997:4-6.

4. Charan R, Tichy N. Need a CEO? Here’s how to grow

one. USA Today. October 20, 1997:21A.

5. Jaworski J. Quoted by: Webber AM. Destiny and the

job of the leader. Change Agent June/July 1996:40-42.

6. Rodin J. Quoted by: Trafford A. Leading medicine into

the future. Washington Post. November 4, 1997:Health

Section:6.

7. Clinton WJ, Gore A. Blair House Papers. January

1997: Part III, Section 1. Available at: http://

govinfo.library.unt.edu/npr/library/papers/bkgrd/

blair.html.

AUTHOR

COL Turiansky is the Program Director of the National

Capital Consortium Dermatology Residency at the Walter

Reed Army Medical Center, Washington, DC. He is also the

Dermatology Consultant for the DiLorenzo TRICARE

Health Clinic at the Pentagon.
50 Army Medical Department Journal

Mentors and Protégés: Simple Rules for

Success

COL Mark A. Melanson, MS, USA

Mentoring is a partnering relationship where a senior, more experienced officer provides guidance and advice to

a junior officer in order to foster professional growth in the subordinate. Speaking from personal experience,

mentoring has been and remains the single most important factor in my development and growth as an officer

and a leader. The following are some “kernels of wisdom” for the mentoring relationship that I have discovered

during my nearly quarter century of experience as both mentor and protégé. I have distilled this experience into

two sets of 10 common sense, yet remarkably often overlooked rules—one set each for the mentor and the

protégé respectively.

Ten Simple Rules for Mentors

When initiating any discussion on mentoring, a natural question to ask is where to begin? Do you start with the

mentor or the one being mentored (protégé)? While the contributions of both participants are important,

mentoring successes or failures most often depend upon the skills of the mentor. If the mentor is not prepared to

do his or her job, then the entire mentoring process may be ineffective and, consequently, discourage the protégé

from any future mentoring opportunities. It is hoped that by considering these 10 simple rules, mentors, present

and future, will be better prepared to assume this very important role.

MENTOR RULE #1

It’s Not About You!

Being chosen to be someone’s mentor is a powerful, potentially intoxicating

experience. Not surprising, it is easy to let it go to your head. However, if you simply

engage in mentoring to satisfy your own ego, you will ultimately fail. At best, your

protégé will recognize that you are just doing this for yourself and not for him or her.

At worst, you will model a self-centered behavior that your protégé may emulate and

then perpetuate when he or she becomes a mentor. While mentoring does offer

benefits to the mentor, such as self-validation and establishing a legacy, the primary

focus of mentoring is on the individual being mentored, the protégé. Since not all

attempts at a mentoring relationship will be successful and not all of your advice will

necessarily be followed, you should be humble while mentoring and check your ego

at the door. It is also essential that you do not use the mentoring relationship as a

vehicle to exploit the protégé for your own personal gain. For example, avoid giving

“busy work” that you do not want to do to a protégé under the guise of it “being good

for him or her”. Chances are your protégé will see right through this veiled attempt at

exploitation and understandably grow to resent it.
July – September 2006 51

MENTOR RULE #2

Always Maintain Confidences

Trust is critical in a healthy mentoring relationship. Hence, matters discussed

between a mentor and a protégé must remain confidential (as long as the issue does

not involve violations of Army regulations or the Uniform Code of Military

Justice). It is in this “safe” environment that a protégé can openly share mistakes or

any lack of self-confidence. It also allows the junior mentoring partner to take risks

without fearing negative consequences. Given that, the mentor should not share the

protégé’s mistakes and setbacks with others. Of course, maintaining confidences

goes both ways. This trusting environment allows the senior mentoring partner to

share lessons learned from personal mistakes and failures without the fear of these

“blunders” becoming common knowledge. Always remember, trust takes a long

time to become fully established, yet it can be destroyed in a matter of moments.

MENTOR RULE #3

Set and Enforce Boundaries

This rule deals with avoiding one of the darker aspects of a mentoring partnership—the

development of an inappropriate relationship. Throughout the course of mentoring a junior

officer, it is easy to develop a liking or affinity for your mentoring partner. But, it is

imperative that the mentor keep the relationship professional. As a mentor, you must always

insist on maintaining military courtesy with no exceptions. As a personal example, I called

my mentor of more than 20 years, “Sir” until the day he retired as a colonel. If you are a

supervisor to your protégé, you must never let your role as a mentor compromise your duties

and responsibilities as a rater. You must avoid letting any hint of cronyism or favoritism to

creep into your decision making. Of course, a romantic relationship with your protégé is

strictly forbidden and will probably adversely affect both of your careers. A final note: you

should never allow your mentoring relationship to circumvent the chain of command.

MENTOR RULE #4

Know Your Limitations

Once you have gained the trust and confidence of your protégé, you may find yourself

asked for guidance in areas about which you know very little, or, perhaps, nothing at

all. That is why it is so important that you acknowledge any such limitations when

providing advice. There may be the temptation to provide guidance, any guidance, just

so that you don’t lose face. Admitting a lack of knowledge on a subject may seem like

a weakness and threaten to undermine your standing with the protégé. But, in

actuality, acknowledging your own lack of expertise or experience will further

strengthen your mentoring relationship. Those being mentored do not expect their

mentors to know everything, but, rather to share their experiences and point them in

the right direction. So, if you are asked to provide advice on a subject about which

your knowledge is limited, you should guide the protégé in the proper direction and, if

possible, to the best person who can give them the necessary guidance.
52 Army Medical Department Journal

MENTOR RULE #5

Keep Your Promises

Mentoring takes time, your most valuable resource. Before entering into a mentoring

partnership, it is crucial that you determine whether or not you can make the time to

dedicate to such an endeavor (I strongly believe that if you truly think that mentoring is

important, you will make the time for it!). If you cannot dedicate the time, then I suggest

that you do not even attempt it. Once you have decided to commit to a mentoring

relationship, you must follow through with your promises. For example, if you agree to

weekly meetings with your protégé, you must keep these appointments. If you promise to

review a junior officer’s OER Support Form, then do it and provide your feedback in a

timely manner. A pattern of broken appointments and unfilled promises will send a clear

message to your mentoring partner that you are not really devoted to his or her

development. So, do what you say you are going to do, when you say you are going to do it.

MENTOR RULE #6

Listen and Ask Questions

A common misconception about mentoring is that the protégé simply brings

problems to the mentor and the mentor tells the protégé what to do. Although this

may be tempting for both mentoring partners, it should be done sparingly. First, do

not assume that you automatically know what your mentoring partner needs from

you. You need to truly listen to the questions that the protégé is asking. Practice

effective listening to be sure you are giving the actual help or advice that is required.

Interestingly enough, a highly effective way to impart wisdom is by asking questions

that lead the protégé to discover the right answer for him or herself. I know firsthand

that this can be very frustrating to the protégé who usually simply wants a quick

answer. However, in the long run it teaches the one being mentored how to think

through problems and independently develop sound solutions.

MENTOR RULE #7

Reach Out to Junior Officers

It is essential that, as a senior officer and potential mentor, one must remain

approachable. In the Army, rank can be very intimidating. Remember how you were

intimidated by senior officers when you first joined the Army. Given that fact, we as

senior leaders need to break the ice. A practice that I learned from another of my

mentors is to initiate conversations with junior officers whom I do not know. I

introduce myself and ask where they are from and try to learn a little about them.

This simple gesture pays big dividends in the long run. It greatly increases the

probability that these officers will seek me out for guidance in the future.

Mentors and Protégés: Simple Rules for Success
July – September 2006 53

MENTOR RULE #8

Don’t Sugarcoat Feedback

Honest feedback is very important in an effective mentoring partnership. However, there may be a

temptation to soften constructive feedback so as not to offend the protégé or ruin the mentoring

relationship. Typically, when handled correctly, such corrective feedback is usually some of the most

important mentoring that you can give a young officer. Now, I am not condoning degrading or

belittling the individual. Negative feedback needs to be specific, given judiciously and unemotionally.

Of course, it helps if such feedback is “sandwiched” between positive comments. As with all

counseling, it should be done immediately and in private to have the greatest impact. The feedback

should also provide recommendations on how to address shortcomings or areas that need improvement.

It is important to always separate the individual from the undesirable behavior. Finally, once the matter

is discussed, it should not be brought up again unless the behavior or mistake is repeated.

MENTOR RULE #9

Be Yourself

Since mentoring is a relationship between two unique individuals there is no single guaranteed

recipe for mentoring. The relationship will naturally reflect the distinct personalities of the pair

of individuals involved. So, it is important that, as a mentor, you are authentic. Your deeds

should match your actions or “your walk should match your talk.” If you are an introvert by

nature, trying to come across as an extrovert will seem phony. One thing that may help you in

developing your own style is to do some self-reflection. This can help you identify the key

elements of your leadership style and how you can use these traits to become a more effective

mentor. The good thing about mentoring is the more that you do it, the better you will become.

So take pride in being a mentor and do it your own way, with both passion and conviction.

MENTOR RULE #10

Commit to Continuous Learning

Whatever your military specialty, you should be dedicated to maintaining your technical competency and

staying abreast of advancements in your field. This is also true for the leadership and mentoring skills

required to be an effective officer. A way to do this is to set aside some quiet time for reading professional

journals, those relating to your military specialty and those related to officership. While you are probably

aware of professional references for your technical discipline, you may not be aware of journals for leader

development. Army journals that may be of help are Military Review, published by the US Army

Combined Arms Center at Fort Leavenworth, KS, and Parameters, from the US Army War College at

Carlisle Barracks, PA. Both institutions support websites from where their articles may be downloaded:

Military Review – http://usacac.leavenworth.army.mil/CAC/milreview/index.asp

Parameters – http://carlisle-www.army.mil/usawc/Parameters/

This publication, the AMEDD Journal, is another venue for staying current in developments with the

Army Medical Department. Finally, if you are serious about growing as a mentor, you should avidly read

all that you can on the subject of mentoring. For a list of suggested reading material, I have included a

bibliography of books and articles that I have found helpful in my personal growth as a mentor.
54 Army Medical Department Journal

SUMMARY

The key points of the above rules include remembering that mentoring is about the protégé, not the mentor.

Confidences must always be maintained to ensure trust. The mentor needs to set and enforce boundaries in the

relationship to ensure professionalism. A mentor must know his or her limitations when giving guidance or

advice. Promises made by the mentor need to be kept if the relationship is to last. During the mentoring, the

senior officer must use effective listening and should refrain from simply telling the protégé what to do in order

to develop problem-solving skills in the protégé. Potential mentors must be approachable if junior officers are to

feel comfortable in seeking them out as mentors. Feedback needs to be specific and, when necessary, include

constructive criticism. Mentors must understand themselves and develop a mentoring style that is authentic and

consistent with who they really are. Finally, mentors need to dedicate themselves to continuous learning,

technically, tactically, and as mentors.

It is my sincere hope that, by considering these key points, mentors will be better prepared to focus on the

individualized needs of their respective protégés, the real goal of any successful mentoring relationship.

Ten Simple Rules for Protégés

While the skills of the mentor are critical to mentoring, the protégé also shares responsibility for ensuring that

the relationship is successful. Unfortunately, some new protégés may not be aware of their responsibilities as a

mentoring partner. Hence, the following 10 rules for protégés are presented to help them realize the greatest

benefit from their mentoring relationships.

PROTÉGÉ RULE #1

Cherish your Mentor’s Time

It is important that as a protégé you truly value your mentor’s time. Your mentor is setting

aside time exclusively for your development and growth. Consequently, you owe it to your

mentoring partner to always be on time and fully prepared for meetings with him or her. If he

or she assigns you “homework” to do, such as reading assignments, then you must be sure to

complete your tasks before they are due. To not do so may be viewed by your mentor as a

cavalier attitude and will likely hurt the relationship. Your mentor may reasonably conclude

that, if you do not take your professional development seriously, why should he or she?

PROTÉGÉ RULE #2

Always Maintain Confidences

One of the cornerstones of a successful mentoring relationship is trust. It is within a safe

relationship that the protégé is able to freely ask questions, express concerns, and take risks

without the fear of negative consequences. One of the most effective ways for mentors to impart

wisdom is by sharing personal challenges and setbacks and what lessons the mentor has learned

from them. Since it is unlikely that anyone would want their mistakes widely advertised to

others, the same is probably true for those who mentor. Therefore, when your mentor tells you

things in confidence, you must honor that special trust and not share the information outside of

the mentoring relationship. Simply put, genuine trust only develops over time and can be

destroyed in an instant. Consequently, it is imperative that you always maintain confidences.

Mentors and Protégés: Simple Rules for Success
July – September 2006 55

PROTÉGÉ RULE #3

Learn from Your Mistakes

Good mentors do not expect perfection in those they mentor and fully expect their

protégés to make mistakes. Interestingly enough, it is usually from our mistakes and

failures that we learn our greatest lessons. So, be willing to take risks and try new

things; it is essential for your growth as an officer and a leader. Also, accept that you

will, from time to time, make mistakes. If and when you do fall short, reflect upon

those setbacks and glean whatever lesson that lies at the heart of your failure. Now,

while a mentor should be tolerant of mistakes, an effective mentor will not tolerate a

protégé repeating the same mistake. Such behavior does not show personal growth

and maturity. Be sure to learn from your mistakes and not repeat them.

PROTÉGÉ RULE #4

Be Receptive to Feedback

One of the most effective tools in successful mentoring is the use of feedback. Often

feedback is positive and encouraging. It can be just what a protégé needs during trying

or difficult times. But, sometimes the feedback is more critical. The key to being a

good protégé is to accept the good with the bad. If you expect your mentor to only

shower you with praise, you will be missing the full breath and depth of mentoring.

So, keep your ego in check and listen objectively to any constructive feedback from

your mentor. While it might not seem so at the time, such wisdom and insight can

often be some of the most important mentoring that you will receive.

PROTÉGÉ RULE #5

Keep Your Promises

Mentoring requires your most valuable resource, namely your time. Before entering into a

mentoring partnership, be sure that you can dedicate time to such an endeavor. If you

cannot set aside the time, then I suggest that you do not enter into a mentoring

partnership. That being said, if you do commit to a mentoring relationship, you must

follow through with your promises. For example, if you agree to weekly meetings with

your mentor, you must keep these appointments. If you promise to provide your OER

Support Form to your mentor, then do it promptly. Broken appointments and unfilled

promises will clearly demonstrate that you are not serious about being mentored. To avoid

this common pitfall, keep your promises to your mentor. By doing this, you will also be

keeping an important promise to yourself, namely to make the most of being mentored.
56 Army Medical Department Journal

PROTÉGÉ RULE #6

Genuinely Consider Advice Given

One of the most valuable benefits of mentoring is the opportunity to freely ask for advice. Guidance

can range from the technical aspects of getting the job done, to suggestions about choosing an

assignment, or whether or not to continue pursuing a military career. As a courtesy to your mentor,

you should thoughtfully consider any advice that is given. Now, this does not mean that you simply do

whatever the mentor suggests. Rather, it is best to listen to the suggestions given and then carefully

decide whether or not to follow the advice. A self-confident mentor does not expect the protégé to

follow every bit of advice. However, if you are constantly seeking advice from your mentor, but never

follow his or her guidance, then chances are that your mentor will stop giving you any advice. (This

happened to me with one junior officer I was mentoring. This recurring behavior ultimately ended the

mentoring relationship.) So, genuinely consider any guidance that is given and, if you choose not to

follow it, explain to your mentor why you elected not to follow the advice. This kind of open dialogue

will help to ensure that your mentor does not feel that he or she is wasting his or her time.

PROTÉGÉ RULE #7

Clarify Your Expectations

Since the focus of the mentoring is on the needs of the protégé, it is important that you clarify your

expectations to your mentor. For example, if you are only looking for someone to be a role model or a

sounding board, you should make that clear. If you are looking for a more in-depth relationship, you

should also spell this out. What you require from the mentoring relationship will determine the degree

of your mentor’s involvement. Therefore, open and honest communication is critical to ensure that

your actual needs are being met. Clarifying your expectations will make it easier for you to gauge

your progress and determine whether or not your mentoring goals are being fulfilled.

PROTÉGÉ RULE #8

Respect the Chain of Command

It is important to remember that mentoring is not a way to bypass or interfere with the chain of command.

For example, you should never use your mentor to “go over your boss’s head” in order to reverse a

decision with which you disagree. Also, refrain from asking your mentor to intervene in matters between

you and your rater. Now, that is not to say that you cannot ask your mentor for advice on how to talk with

your rater or resolve any disagreements. However, your mentor should not be inserting him or herself

between you and your rater. Any such interference would be highly inappropriate. So, always remember

to respect your chain of command and do not use your mentoring relationship as a short cut around it.

Mentors and Protégés: Simple Rules for Success
July – September 2006 57

PROTÉGÉ RULE #9

Bring More Than Just Your Problems

Over the years, I have had protégés come to me with problems and they wanted me to simply tell

them what to do (Much to their chagrin, rarely did I just give them the answer!). Since the

ultimate goal of mentoring is the development of a self-reliant officer that can independently

make timely and effective decisions, it is important for protégés to develop their own skills in

problem-solving. To help achieve this goal, it is desirable that, along with the given problem that

needs solving, you come armed with potential solutions. While this may seem like more work for

you and your proposed courses of action may ultimately prove to be inappropriate, this sort of

exercise will help you in the long run by improving your ability to solve your own problems.

PROTÉGÉ RULE #10

Commit to Continuous Learning

Whatever your military specialty, you should be dedicated to maintaining your technical competency and

staying abreast of advancements in your field. This is also true for the leadership and mentoring skills

required to be an effective officer. A way to do this is to set aside some quiet time for reading

professional journals, those relating to your military specialty and those related to officership. While you

are probably aware of professional references for your technical discipline, you may not be aware of

journals for leader development. Army journals that may be of help are Military Review, published by

the US Army Combined Arms Center at Fort Leavenworth, KS, and Parameters, from the US Army War

College at Carlisle Barracks, PA. Both institutions support websites from where their articles may be

downloaded:

Military Review – http://usacac.leavenworth.army.mil/CAC/milreview/index.asp

Parameters – http://carlisle-www.army.mil/usawc/Parameters/

This publication, the AMEDD Journal, is another venue for staying current in developments with the

Army Medical Department. Finally, if you are serious about growing as a protégé, you should avidly

read all that you can on the subject of mentoring. For a list of suggested reading material, I have included

a bibliography of books and articles that I have found helpful in my personal growth as a mentor.

SUMMARY

The key points of the protégé’s rules include remembering that the protégé must cherish the mentor’s time and

make the most of it. Mutual trust is dependent upon maintaining confidences. A protégé must learn from his or

her mistakes if he or she is to grow as an Army leader. Being receptive to feedback, both positive and negative,

is essential to maximize the mentoring experience. Promises made by the protégé must be kept if the relationship

is to last. While not all advice must be followed, the protégé should genuinely consider the guidance that is

received and, if the advice is rejected, explain to the mentor why it was not followed. Clarifying expectations

will ensure that the type of help wanted is provided and that the mentoring goals are achieved. Protégés must

never use their mentors to bypass the chain of command or ask the mentor to intervene in issues between the

protégé and his or her rating chain. When bringing problems to their mentors, protégés should also have possible

solutions in mind to foster the development of their own problem-solving skills. Finally, those being mentored

must dedicate themselves to continuous learning, technically, tactically, and as protégés.

I offer these key points in the hope that they will assist junior officers to better prepare for their roles as

successful mentoring partners in order to reap all of the lasting rewards of being mentored.
58 Army Medical Department Journal

Dalcort CJ. Mentoring: establishing a legacy,

shaping the future. Mil Rev. NovemberDecember 2002;82;No. 6:35-39.

Hendricks HG, Hendricks WD. As Iron Sharpens

Iron. Chicago, IL: Moody Press; 1995.

Hunsinger N. Mentorship: growing company

grade officers. Mil Rev. September-October

2004;84;No. 5:78-85.

Johnson W, Band Ridley CR. The Elements of

Mentoring. New York, NY: Palgrave

MacMillian; 2004.

Kem JD. Mentoring: building a legacy. Mil Rev.

May-June 2003;83;No. 3:62-64.

Kosper GJ, Mentoring in the military: not

everybody gets it. Mil Rev. NovemberDecember 2002;82;No. 6:40-44.

Lacey K. Making Mentoring Happen.

Warriewood, NSW, Australia: Business and

Professional Publishing; 2001.

Maxwell JC. Developing the Leaders Around You.

Nashville, TN: Nelson Business; 1995.

Melanson MA, Winstead AD. officer professional

development: a case study in officer mentorship.

AMEDD J. January-March 2003:7-10.

Murray M. Beyond the Myths and Magic of

Mentoring. San Francisco, CA: Jossey-Bass;

2001.

Peddy S. The Art of Mentoring. Houston, TX:

Bullion Books; 1998.

Pegg M. The Art of Mentoring. Gloucester, UK:

Forge House; 1999.

Portner H. Being Mentored: A Guide for Protégés.

Thousand Oaks, CA: Corwin Press; 2002.

Shea GF. Making the Most of Being Mentored.

Menlo Park, CA: Crisp Learning; 1999.

Stoddard DA. The Heart of Mentoring. Colorado

Springs, CO: Navpress; 2003.

Wicks RJ. Sharing Wisdom: The Practical Art of

Giving and Receiving Mentoring. New York,

NY: Crossroads Publishing; 2000.

Zachary LJ. Creating a Mentoring Culture. San

Francisco, CA: Jossey-Bass; 2005.

AUTHOR

COL Melanson is Chief of the Health Physics Office, Walter Reed Army Medical Center, Washington, DC.

SUGGESTED READING

Mentors and Protégés: Simple Rules for Success
July – September 2006 59

INTRODUCTION

Individual behavioral patterns affect every military

interaction and relationship. These patterns have been

examined empirically to predict success among

military leaders.1Some researchers have asserted that

an understanding of one’s own interactional patterns as

well as those of others can be a significant asset to the

US military in the training of command personnel.2

Consequently, several mental health and

organizational behavior measures have been used in

military training to assess personal traits and

interactional patterns.3-6 One such measure that is

currently being used by each branch of the Department

of Defense is the PersogenicsTM Personality Profile.7

Like many of the other measures mentioned above, the

Persogenics profile was an instrument originally

developed for use within civilian business

administration training which has subsequently been

incorporated as a training tool within the military. In

examining the use of personality and/or interactional

profiling systems in training military personnel, the

researchers of this study identified several instances

where the Persogenics profile is used. For instance,

according to Jim Batman, Senior Corporate Trainer for

the Persogenics Corporation who conducts workshops

within the Department of the Air Force, the

“Persogenics Personality Profile” is a valuable tool

that has been well received and utilized. Training

sessions have been held in various sections including

personnel, engineering, services, hospitals and clinics,

base command staff, and across all ranks. He believes

the program helps improve team relationships,

workplace skills, people skills in general, and conflict

resolution through an increased understanding of

individual strengths and weaknesses.

In conducting this research, the authors were able to

quickly identify two representative samples of military

clients who have utilized the Persogenics in their

training activities: COL David Bird, Randolph Air

Force Base, and COL Richard Mihalika, Wright

Patterson Air Force Base.

When interviewed, COL Bird stated that he has been

aware of the Persogenics system for 9 years and that

he has actively used the system for the past 5 years in

his capacities as squadron, group, and now wing

commander. He reports the Personal Profile and the

Persogenics system has taken him and his command

teams to a higher level of teamwork. He acknowledges

the past use of the Myers-Briggs Type Indicator as a

tool to identify how his personnel screened, processed,

and filtered information, but he reports the Persogenics

system is superior as it teaches “how” to communicate

and get a picture of the “output kind of behavior” each

individual demonstrates. He views the identification of

individual strengths and weaknesses as a “godsend,”

especially when dealing with pressure, stress and

A Validation Study of a Commonly Used

Military Assessment of Personality

Interactional Patterns

Susan J. Walley, MSW

COL (Ret) Kyle L. Pehrson, MS, USAR

Patrick T. Panos, PhD

ABSTRACT

Military leaders and trainers often use assessments developed within the civilian business sector in order to

determine interactional patterns and personality traits that may affect the operational effectiveness of their unit.

Unfortunately, validity and reliability studies with these instruments are rarely conducted to determine if they are

appropriate for use by the military. This study seeks to determine if the PersogenicsTM Personality Profile, an

assessment which is currently being used by many military commanders, is an effective method of enhancing

mission accomplishment. Recommendations for future studies are made.
60 Army Medical Department Journal

tension (PST). PST is a particular insight taught in the

training sessions and identified as “behavioral

shifting” or “backup behaviors.”7

COL Mihalika stated in interview that he utilizes the

Personal Profile and the “Nutshell Summary,” (a brief

printout that compares the interactional patterns

between two individuals) at each entry interview with

incoming officers and civilians who report directly to

him. He makes the profile available to them in order to

have it filter throughout the command. Although he

views the instrument as no better or worse than others,

he too views the Persogenics Personality Profile as a

step beyond the Myers-Briggs in that it allows better

articulation of interactional patterns. He views the

profile and implementation system as extremely useful

tools in establishing a more effective work

environment, as it permits increased understanding of

communication styles. He reports that the Persogenics

system has become a part of the daily lexicon of his

staff, increasing acceptance among differing

personality styles and enabling communication

without the level of offense previously seen in daily

interactions. For COL Mihalika, the Persogenics

Profile impacts mission accomplishment in two

specific areas. First, it establishes and reinforces

communication as a priority in management planning.

Second, it assists subordinates to adapt to the differing

communication styles of their commanders, an

especially valuable benefit in the hierarchal system of

leadership in the military where most personnel are in

direct supervision. COL Mihalika finds the personality

profile to be highly functional in these areas of

communication

It is clear, therefore, that because of the strong

anecdotal support for their use, civilian nonclinical

personality assessments are being used by military

leaders in an effort to increase their administrative

effectiveness. Further, there is an assumption on the

part of these military leaders that the tools developed

for use within the civilian sector provide equally valid

results when used within the military. Unfortunately,

this is an assumption that has never been tested with

many of these personality profiling tools, despite their

common use. Since military leaders are using

personality assessments developed outside the military

setting, the authors of this study sought to examine the

appropriateness of the use of these assessments. In

particular, the authors sought to study the validity of

the Persogenics Personality Profile, an assessment that

was identified as currently in vogue among many

military leaders. Specifically, this study examined the

Persogenics profile within the context of 4

fundamental questions that arise when using such

assessments for this population:

1. Is the test appropriate or suitable for the military

population?

2. What does the assessment measure or what purpose

will it serve?

3. Is it quickly administered and immediately scored?

4. Are the results easily interpreted and of benefit to

both the administrator and the subject?

In order to address the appropriateness of the profile

for the military population, the prevalence of 4

interpersonal behavioral patterns among military and

civilian personnel was compared with the profile

patterns among the general population and the

differences noted. An overview of the Persogenics

Personal Profile is given to assist the reader understand

the dimensions measured by the assessment and stated

purposes of the Profile. Fundamental questions

unanswered by the Persogenics Corporation regarding

the Personal Profile are also discussed. An overview of

4 nonpathological assessment instruments previously

used in military studies are also be examined for

comparative purposes.

LITERATURE REVIEW

In order to place the use of the Persogenics Personal

Profile within the military into context, a brief review

of relevant literature addressing various instruments

that have historically been used in military leadership

development is presented.

Myers-Briggs Type Indicator

According to CPP, Inc. (formerly Consulting

Psychologists Press), the most widely used personality

type assessment model in a nonclinical population is

the Myers-Briggs Type Indicator (MBTI).8 This 93

question instrument consists of 4 perception scales,

each represented by 2 opposite preferences. The

Extraversion/Introversion scale measures a person’s

preference for where attention is paid, either to the

inner world or the outer world. The Sensing/Intuition

scale describes the way a person acquires or perceives

A Validation Study of a Commonly Used Military Assessment of Personality Interactional Patterns
July – September 2006 61

information. The Thinking/Feeling scale defines the

way a person uses information to make judgments or

decisions. The Judgment/Perception scale indicates the

kind of method through which a person processes

information about his or her environment, with

judgmental (thinking or feeling) or perceptive (sensing

or intuition).9

The Myers-Briggs instrument is “primarily concerned

with the valuable differences in people that result from

where they like to focus their attention, the way they

like to take in information, the way they like to decide,

and the kind of lifestyle they adopt”9(p4) and is based

on the work of Carl Jung and his theory of

psychological types.10

Campbell studied personalities, vocational interests,

values, and raw intelligence scores of senior military

leaders in a search to describe their underlying

personality traits.3 He compared Army brigadier

generals, high-level corporate executives, and a control

group sample of managers and technical workers from

government, education, and public service

organizations. His findings, based on Myers-Briggs

and other assessments, led to the promotion of what he

called a “notable personality syndrome — the

aggressive-adventurer.”3(p167) This characterization of

military leaders discounted them as potential

warmongers unless an intervening emphasis on

education and democracy were available to mediate

the tendencies. Two findings of interest from this

study include the fact that none of the sample

populations were distributed evenly across the 16

preferences, and 2 types, Introversion/Sensing/

Thinking/Judging and Extraversion/Sensing/Thinking/

Judging, represented more than 56% of the brigadier

general sample. Additionally, in Campbell’s opinion,

“This lack of individual differentiation is one of the

features that is absent from the MBTI.”3(p157) In other

words, the characterization of top military leaders as

serious, orderly, matter-of-fact, logical and take-charge

realists who are steady in the face of protest or

distraction “tells something about the psychological

feel of the military environment.”3(p159)

Barber utilized the Myers-Briggs in his study of 270

students entering the US Army War College in order

to provide additional insights into the psychological

characteristics of senior military leaders.2 The military

population consisted primarily of Army lieutenant

colonels and colonels, although some students were

from other military services and foreign countries or

civilian government agencies. The study included a

control group from the general population. Based on

the results obtained using the Myers-Briggs, 53.5% of

senior military officers were distributed in just 2 of the

4 psychological types, Judging and Thinking. A

significant difference between the civilian and military

populations was found; leading Barber to interpret the

findings, as did Campbell,3to indicate that senior

military leaders are comparatively more Thinking and

Judging types than the general population.

Murray and Johnson, using the Myers-Briggs, studied

female Naval Academy midshipmen in an attempt to

determine if the instrument was a useful predictor of

subsequent student success.1 Although their study

found the Myers-Briggs “not especially useful as a tool

for predicting success among women at the Naval

Academy,”1(p893) other findings of the study helped to

identify which Myers-Briggs types were more likely to

submit voluntary resignations from the Naval

Academy. The study also revealed that women at the

Naval Academy have only slightly higher rates of

extroversion than women at other colleges. The use of

a different personality inventory was recommended for

future research.

Fundamental Interpersonal Relations

Orientation-Behavior

The 54 item Fundamental Interpersonal Relations

Orientation-Behavior (FIRO-B) instrument assesses

how personal needs affect a person’s behavior towards

others. Based on the interpersonal behavior theory of

William Schultz,11 this three-dimensional instrument

measures 3 basic needs: Inclusion, the degree to which

a person seeks contact from others; Control, the extent

of power or dominion that a person seeks and desires

from others; and Affection, the amount of closeness

sought or desired. The 3 basic needs are defined in 2

dimensions, expressed behavior and wanted

behavior.12

Shortridge used the FIRO-B in his study of 134

disabled Vietnam veterans attending postsecondary

education programs in order to determine differences

in the needs for inclusion, control, and affection

among combat and noncombat disabled veterans.6In

this study, disabled noncombat veterans were found to
62 Army Medical Department Journal

be better equipped to demonstrate inclusive behaviors

than disabled combat veterans and to express and want

affection from others more than those disabled in

combat. Although expressed or wanted control

behaviors did not differ between the two groups, it

became clear that soldiers who were disabled while

experiencing the horrors of combat retreated from

interpersonal involvement in society in greater

numbers than their noncombat comrades. The findings

of this study helped to identify interpersonal

adjustment difficulties experienced by combat

veterans.

Millon Index of Personality Styles

The Millon Index Personality Styles (MIPS) Revised

instrument, originally developed by Theodore Millon

in 1994 and revised in 2003, is described as “a brief,

well-rounded personality measure for adults presenting

as normal”13 which consists of 180 true/false

questions. It addresses 3 key dimensions of normal

personalities: Motivating Styles, which assess a

person's emotional style in dealing with the

environment, Thinking Styles, which examines a

person's mode of cognitive processing, and Behaving

Styles, which assesses how a person interrelates with

others.

Beckman et al used the MIPS to evaluate personality

characteristics of 72 US Navy divers, both enlisted

personnel (65) and officers (7).5 The top 5 personality

styles found in the divers were Enhancing, Modifying,

Individulating, Thinking, and Controlling. The study

authors found these traits very adaptive to the demands

of diving duty where the following qualities are often

present: independent decision making, easy adaptation

to changing operational needs, the ability to survive in

dangerous situations, and the tendency to put personal

safety first in order to fulfill mission requirements. The

findings appear to support a relationship between

personality style and occupational types. This finding

led the authors to propose “consideration of

psychometrically sound psychological tests in

screening personnel for specific types of military

service.”5(p35)

Eysenck Personality Questionnaire-Revised

The Eysenck Personality Questionnaire-Revised

(EPQ-R) measures 3 dimensions of personality and is

the most recent in the series of measures originally

developed by Hans Eysenck, who initially described 2

main dimensions of temperament: neuroticismstability and extraversion-introversion.14 Eysenck

added a third dimension, psychoticism/socialization,

after he determined a need for a third category of

temperament. The primary advance in the revision is

to include the name modification of ToughMindedness in the third major dimension. This revised

scale deals with normal behaviors which become

pathological only in extreme cases. The traits

measured are P (Psychoticism or Tough-Mindedness),

E (Extraversion), N (Neuroticism or Emotionality),

and L (Lie). The questionnaire contains 57 items.

The EPQ-R was used in a study conducted by Leach to

determine if any specific personality traits predispose

military personnel to be captured and imprisoned

during war.4 The questionnaire and other assessments

were administered to 75 Air Force crewmen prior to an

escape and evasion exercise. This procedure was

performed in order to assess whether personality

factors correlated with capture and consequent

internment as a prisoner of war. Although the variables

of age or length in military service showed no

correlation, significantly high levels in the EPQ L

scale were found in the captured crewmen. As was the

case in the proposal of a new personality syndrome by

Campbell3above, Leach identified a possible core

personality profile that exists prior to capture and

noted that this predisposition may be “masked by a

modified post experience profile.”4(p80)

PersogenicsTM Personal Profile

The Persogenics Personal Profile was originally

developed through collaboration by Dr Gordon Allport

and Dr Ford Cheney. It contains 24 questions and can

be completed in a short time period, usually less than

20 minutes. The profile for each individual participant

is scored in less than 5 minutes by a computer program

prior to training, in order to provide results for each

participant to use throughout the training sessions.

Allport, an early personality researcher, created the

“Most/Least” facets of the personality assessment

model through his original work classifying a wide

variety of personality traits.15 Allport's technique listed

multiple trait descriptive adjectives and then had

participants rate each adjective on the degree to which

the words applied “most” or “least” to them. Dr Ford

Cheney and 11 colleagues then formed Keystone

Research Labs in 1968 and began to study personality

profiling, building on Allport's pioneering personality

A Validation Study of a Commonly Used Military Assessment of Personality Interactional Patterns
July – September 2006 63

research. The group also determined that the validity

of the Allport technique could be increased by

including predictions of behavior on 2 scales. The first

of these, the Assertiveness Scale, measures the degree

to which an individual is willing to express his or her

needs, wants, and opinions. The second, the

Responsiveness Scale measures the degree to which an

individual is willing to share feelings or personal

information.16

The basis of the Persogenics system is 4 different

personality styles as illustrated in the figure. The first

style, “Dominants” exhibit high-assertive and lowresponsive behaviors. This means they possess a

primarily outspoken nature, but seek to maintain

control over the personal feelings and information that

they communicate to others. “Expressives” naturally

exhibit high-assertive and high responsive behaviors.

This means they communicate assertively, and are

more open in their gestures and expressions than the

other styles. “Analyticals” are by nature less assertive

and less responsive in their behaviors than the other

styles. This means they are reserved in the way they

express themselves and that they are controlled in their

outward gestures and actions. “Amiables” are naturally

low-assertive and high-responsive in their behaviors.

This means that they are not forceful in their

communication, but they do outwardly show concern

and understanding for others. Amiables are peopleoriented and team-oriented. They are concerned with

the happiness and satisfaction of all.17

Every person is a unique combination of the four

styles. The system measures for each person which

one of the styles is strongest; this is called their

“primary” style. The second strongest personality style

is called then “secondary” style. The 2 lowest scoring

styles are relevant to the scoring, but typically not

reported. Since every person has at least some

component of each style, the lowest scoring two

remain a valuable part of the assessment. The 2 highest

scoring styles make up a personality name, such as

Dominant-Expressive. The Persogenics Corporation

also claims that the 4 styles are consistently distributed

in the general population, regardless of nationality,

education, gender, or age: approximately 12%

Dominant, 19% Expressive, 37% Amiable, and 32%

Analytical.18(p8)

As mentioned previously, the Persogenics Profile is

currently being used with military populations. It is

useful to reexamine the aforementioned fundamental

questions regarding the utility of the Persogenics

Personal Profile. Namely, has it been shown to be as

relevant for the military population as the Persogenics

Corporation purports? To answer this question,

differences between the core users of the instrument,

the business community, and military populations

should be explored, as the Persogenics Corporation

promotes itself as impartial and “neutral with respect

to gender, race, culture, religious orientation, etc.”7

Will an assessment that measures interactional patterns

based on the dimensions of assertiveness and

responsiveness serve a useful function for military

leaders, mental health professionals, and personnel

completing the instrument? Further, will the time

invested in administering and scoring the instrument

provide benefits to the individual soldier,

administrator, and overall mission of the military? To

begin the search for answers to these 2 final questions,

the self-reported accuracy rates of military and

nonmilitary populations were compared and

differences between the accuracy rates purported by

the Persogenics Corporation were examined.

Increasing Levels of Responsiveness 

Increasing Levels of Assertiveness 

ANALYTICAL

DOMINANT EXPRESSIVE

AMIABLE

The Persogenics system classifies 4 personality

styles according to the individual’s level of

responsive and assertive behaviors.
64 Army Medical Department Journal

METHODOLOGY

The design of this study was a secondary analysis of a

database set that contains demographic information

and completed Personal Profiles for 114 military and

277 civilian subjects.

The median ages of subjects ranged from 36 to 45 and

included 167 males and 224 females. Race categories

included Caucasian, African American, Hispanic

Latino, Native American, Pacific Islander, and Other.

The subject populations included 114 military

personnel and 147 civilians from Randolph Air Force

Base, Texas, 69 school district employees from

Marysville, Washington, and 61 personnel from the

police department in Albany, Oregon.

DATA ANALYSIS

The Statistical Package for Social Sciences (SPSS

13.0) was used to analyze the data provided in the

database. The purpose of the analysis was to determine

the validity and reliability of standardized

interpretations of personality styles by examining if

there was a significant difference in the rate of

personality styles that occur in both military and

civilian participants within this study, with the

reported baseline rates within normative data provided

by Persogenics Corporation.7 Additional comparisons

were made to determine the stability of baseline rates

of reported personality styles of participants and the

normative data according to gender, race, and age.

Finally, a comparison was made between the reported

accuracy of the personality style findings by

participants in this study with the reported accuracy of

personality styles given within the normative data.

RESULTS

The Persogenics Corporation website7claims that the

occurrence of each of the 4 personality styles is

equally proportional (Dominant = 12%; Expressive =

19%; Amiable = 37%; Analytical = 32%) across the

general population regardless of demographic factors.

In order to determine if the military population also

reflects this distribution, a cross tabulation of general

style was performed using the Pearson Chi-Square

Goodness of Fit test.19 Tabulated data used in this

calculation are shown in Table 1. It was found that

there are statistically significant differences (Χ

2

=

A Validation Study of a Commonly Used Military Assessment of Personality Interactional Patterns

Table 1. Tabulated data used in the Pearson Chi-Square Goodness of Fit test18 to

determine if the military population reflects the normal distribution of personality styles7

Style Civilian

% Total

Count Military

% Total

Count Total

% Total

Count

Count 44 11.3 17 4.4 61 15.6

Dominant Expected

Count 43 18 61

Count 98 25.1 40 10.3 138 35.4

Expressive Expected

Count 97.3 40.7 138

Count 76 19.5 39 10.0 115 29.5

Amiable Expected

Count 81.1 33.9 115

Count 57 14.6 19 22.4 76 19.5

Analytical Expected

Count 53.6 22.4 76

Count 275 70.5 115 29.5 390 100

Total Expected

Count 275 115 390

Chi-square (χ

2

) = 1.913 ρ < 0.05
July – September 2006 65

1.913; p < 0.05) between the business population that

make up the Persogenics normative distributions and

the military/civilian subjects in our database.

Therefore, our sample appears to have a unique

distribution.

Military Sample Results

Persogenics Corporation reported no difference

between the distributions of personality styles between

the genders in their normative distribution.7 A

comparison of the genders within our military sample,

using the Chi-Square Test of Independence test, is

shown in Table 2. No statistical difference (X

2

= 3.980,

p = .264) was found between the expected Persogenics

distribution and our military sample based upon

gender.

Persogenics Corporation also reported no difference in

the normative distributions of styles due to race.7

Unfortunately, our military sample (Table 3) was too

small to make such a comparison based upon specific

racial differences. However, it was of sufficient size to

allow comparisons to be made between Caucasians

and non-Caucasians, in which we found a significant

difference within the military sample using the ChiSquare Test of Independence.

The final comparison within the military sample

relates to the Persogenics report that there are no

differences between age and personality style in their

normative population.7 A comparison of proportion of

styles reported by the Persogenics Corporation and age

within our military sample is shown in Table 4. No

statistical difference (X

2

(12, N=112) = 15.341,

p= .223) was found between the expected Persogenics

distribution and our military sample based upon age.

Civilian Sample Results

A comparison of the genders within our civilian

sample, using the Chi-Square Test of Independence

test, is shown in Table 5. Unlike the findings in our

military sample, a statistical difference (X

2

=14.793, p

< 0.05) was found between the expected Persogenics

distribution and our civilian sample based upon

gender, a finding that suggests that civilian population

in the study differs from the normative Persogenics

business population and our military

population.

A comparison between subjects based on race

was conducted on the civilian sample using

the Chi-Square Test of Independence and is

reported in Table 6. No statistical difference

(X

2

= 12.716, p = .624) was found between the

expected Persogenics distribution and our

civilian sample based upon race. In addition, a

comparison between civilian subjects and all

race categories found no significant

differences.

Table 2. Distribution of personality styles by gender

within the military sample

General Style Female Male Total

Dominant 9 7 16

Expressive 24 16 40

Amiable 15 24 39

Analytical 9 10 19

Total 57 57 114

Chi-square (χ

2

) (3, N = 114) = 3.980 ρ < 0.264

Table 3. Distribution of personality styles by race

within the military sample

General Style Caucasian Other Total

Dominant 0 3 3

Expressive 2 5 7

Amiable 7 4 11

Analytical 4 0 4

Total 13 12 25

Chi-square (χ

2

) (3, N = 25) = 9.078 ρ < 0.05

Table 4. Distribution of personality styles by age group within the

military sample

Age Range General Style

18-24 25-35 36-45 46-55 56-65 Total

Dominant 4 4 4 2 0 14

Expressive 8 20 12 0 0 40

Amiable 5 15 11 7 1 39

Analytical 4 5 9 1 0 19

Total 21 44 36 10 1 112

Chi-square (χ

2

) (12, N = 112) = 15.341078 ρ < 0.223
66 Army Medical Department Journal

A comparison between subjects based on age was

conducted on the civilian sample using the Chi-Square

Test of Independence within our civilian sample and is

shown in Table 7. No statistical difference (X

2

=

12.353, p = .418) was found between the expected

Persogenics distribution and our civilian sample based

upon age.

Accuracy Results

Client accuracy results are reported by the Persogenics

Corporation to fall between 87% and 93%.7 A Single

Sample t Test compared the mean accuracy of the

sample to the Persogenics average, 90%. A significant

difference was found (t(375) = -6.342, p< 0.05). The

sample mean of 86.8% was significantly smaller than

the Persogenics reported mean of 90%.

DISCUSSION

The study’s positive

correlated findings

regarding the gender

and ages in the

military subjects and

the normative business

population suggest that

many similarities do

exist between the two

populations and that

the profile would be

relevant for use within

military populations.

The statistical difference (X

2

= 1.336, p<

0.05) noted in the collapsed race

category and the Persogenics distribution

suggest that the instrument may not be

completely neutral regarding race.

However, it should be noted that in both

civilian categories (collapsed and with

all race variables), no significant

differences between the civilian sample

and the expected Persogenics

distribution was found. This finding

therefore suggests that the instrument

may not be valid within the more racially

mixed military setting. Unfortunately,

there is currently insufficient data upon

which to make this determination.

Therefore, further research is needed before

commanding officers can accept Persogenics profiles

as accurate, particularly among their troops belonging

to a racial minority. Research should continue focusing

A Validation Study of a Commonly Used Military Assessment of Personality Interactional Patterns

Table 7. Distribution of personality styles by age group within the

civilian sample

Age Range General Style

18-24 25-35 36-45 46-55 56-65 Total

Dominant 4 10 13 19 0 46

Expressive 9 26 29 21 2 87

Amiable 5 18 22 29 4 78

Analytical 4 10 24 21 1 60

Total 22 64 88 90 7 271

Chi-square (χ

2

) (12, N=271) = 12.353 ρ < 0.418

Table 6. Distribution of personality styles by race within the civilian sample

Race Classification

General Style

White

African

American

Hispanic

or Latino

Native

American

Pacific

Islander Other Total

Dominant 35 1 2 2 0 0 40

Expressive 64 5 7 3 1 1 81

Amiable 46 3 4 0 0 3 56

Analytical 32 1 5 0 0 2 40

Total 177 10 18 5 1 6 217

Chi-square (χ

2

) (15, N = 217) = 12.716 ρ < 0.624

Table 5. Distribution of personality styles by gender

within the civilian sample

General Style Female Male Total

Dominant 16 28 44

Expressive 61 35 96

Amiable 54 22 76

Analytical 32 24 56

Total 163 109 272

Chi-square (χ

2

) (3, N=272) = 14.793 ρ < 0.05
July – September 2006 67

on the validity and reliability of this instrument and

then on the replication and extension of the findings in

this study with larger samples of military and civilian

populations. Based on the ambiguous results of the

small military sample, further studies should be

conducted with a larger sample to determine if the

significant finding in the race category is substantiated.

Additionally, the finding of a significant difference

between gender in the civilian population and the

Persogenics distribution raises additional concerns

regarding the neutrality of the test.

Further studies comparing interactional patterns

between officer and enlisted ranks should be

considered and the potential to consider screening

personnel based on interactional patterns for

compatibility with specific military jobs may also be a

future consideration.

Studies to assess direct and tangible benefits to

military personnel will be necessary in the future to

assess the impact of the Personal Profile and the

Persogenics system in the areas of interactional

dynamics, productivity, communication, and mission

accomplishment. Based on the views of military

leaders already using the Persogenics system and

recommendations from cited studies, nonclinical

personality assessment is a desired tool that fulfills a

command need. Therefore, careful research must be

conducted to ensure that the military leaders who use

personality profiling receive accurate and reliable

information that is appropriate for use in the military.

REFERENCES

1. Murray KM, Johnson WB. Personality type and

success among female Naval Academy midshipmen.

Mil Med. 2001;166:889-893.

2. Barber HF. Some personality characteristics of senior

military officers. In: Clark KE, Clark MB, eds.

Measures of Leadership. West Orange, NJ:

Leadership Library of America; 1990:441-448.

3. Campbell DP. The psychological test profiles of

brigadier generals: warmongers or decisive warriors?

In: Lubinski DJ, Dawis RV, eds. Assessing Individual

Differences in Human Behavior: New Concepts,

Methods, and Findings. Palo Alto, CA: Consulting

Psychologists Press; 1995:145-175.

4. Leach J. Personality profiles of prisoners of war and

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5. Beckman TJ, Lall R, Johnson WB. Salient

personality characteristics among Navy divers. Mil

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6. Shortridge JL. The utilization of the FIRO-B for the

comparison of selected differences among disabled

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7. Persogenics Corp. The foundations of personality

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web/20041028114121/http://www.persogenics.com/

mainpage.jsp?page=site/About/Validity.htm.

Accessed October 10, 2003.

8. Briggs-Myers I, Briggs, KC. Myers-Briggs Type

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9. Myers IB. Introduction to type: A Description of the

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products/firo-b/index.asp. Accessed July 6, 2004.

13. Pearson Assessments. MIPS®revised (MillonTM

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16. Cheney MD. Learning Patterns of Interaction. Provo,

UT: Persogenics, LLC; 2003.

17. Cheney MD. Dealing With People. Provo, UT:

Persogenics, LLC; 2000.
68 Army Medical Department Journal

18. Cheney MD. Personal Profile. Provo, UT: Persogenics, LLC; 2000.

19. Bloom M, Fischer J, Orme JG. Evaluating Practice. Needham Heights, MA: Viacom; 1999.

AUTHORS

Susan Walley is currently a clinical social worker at the Utah State Psychiatric Hospital in Provo, Utah. When this article

was written, she was a graduate student in the School of Social Work, Brigham Young University, Provo, Utah.

COL (Ret) Pehrson is a professor at the School of Social Work, Brigham Young University, Provo, Utah.

Dr. Panos is an associate professor at the School of Social Work, Brigham Young University, Provo, Utah.

A Validation Study of a Commonly Used Military Assessment of Personality Interactional Patterns

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