A Legacy of Lessons Learned:

LANDSTUHL REGIONAL MEDICAL CENTER 

DURING WARTIME

2001–2014

A Legacy of Lessons Learned:

LANDSTUHL REGIONAL MEDICAL CENTER 

DURING WARTIME

2001–2014

. ,

KAREN HENNESSY, RN, MS, CPNP

BORDEN INSTITUTE

US ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

HEALTH READINESS CENTER OF EXCELLENCE

FORT SAM HOUSTON, TEXAS
JOHN H. GARR, MD, MSE, FACEP | COLONEL, MC, US ARMY

Director and Editor in Chief, Borden Institute

JOAN REDDING

Senior Production Editor

CHRISTINE GAMBOA, MS, MBA

Creative Director & Production Manager, Fineline Graphics, LLC

The opinions or assertions contained herein are the personal views of the author and 

are not to be construed as doctrine of the Department of the Army or the 

Department of Defense. Use of trade or brand names in this publication does not 

imply endorsement by the Department of Defense.

CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT RESTRICTIONS. 

ALL RIGHTS RESERVED. NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE 

REPRODUCED OR TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC 

OR MECHANICAL (INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION 

STORAGE AND RETRIEVAL SYSTEM), WITHOUT PERMISSION IN WRITING FROM THE 

PUBLISHER OR COPYRIGHT OWNER.

Published by the

OFFICE OF THE SURGEON GENERAL

BORDEN INSTITUTE

US ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

HEALTH READINESS CENTER OF EXCELLENCE

Fort Sam Houston, Texas

2016

Library of Congress Cataloging-in-Publication Data

Names: Hennessy, Karen, 1962- author. | Borden Institute (U.S.), issuing body.

Title: Legacy of lessons learned : Landstuhl Regional Medical Center during

 wartime, 2001-2014 / Karen Hennessy.

Description: Fort Sam Houston, Texas : Borden Institute, US Army Medical

 Department Center and School Health Readiness Center of Excellence, 2016.

 | Includes bibliographical references and index.

Identifiers: LCCN 2016039282

Subjects: | MESH: Landstuhl Regional Medical Center. | Hospitals,

 Military--history | Trauma Centers--history | Military Medicine--history |

 Afghan Campaign 2001- | Iraq War, 2003-2011 | Germany | United States

Classification: LCC RA989.G3 | NLM WX 28 GG4 | DDC 362.110943/43--dc23 LC record available at 

https://lccn.loc.gov/2016039282

PRINTED IN THE UNITED STATES OF AMERICA

23, 22, 21, 20, 19, 18, 17, 16 5 4 3 2 1
Dedication

We dedicate this book 

to the remarkable individuals who worked at 

Landstuhl Regional Medical Center

 and epitomized the hospital’s motto of 

“Selfless Service” 

during this challenging wartime period; 

and to the thousands of 

Wounded Warriors 

who were treated at 

Landstuhl Regional Medical Center. 

Your strength, courage, resiliency, and service 

to your country have been an 

inspiration to a generation of Americans.

Contents

Contributors ix

Foreword by The Surgeon General xi

Acknowledgments xiii

Introduction xv

CHAPTER ONE A Soldier’s Story 1

CHAPTER TWO Patient Administration Division and Deployed 

 Warrior Medical Management Center 9

CHAPTER THREE Liaisons 25

CHAPTER FOUR Medical Transient Detachment 41

CHAPTER FIVE Traumatic Brain Injury 55

CHAPTER SIX Wounded Warrior Finance Office 75

CHAPTER SEVEN Trauma 95

CHAPTER EIGHT Nursing 123

CHAPTER NINE Chaplain Services 145

CHAPTER TEN General Laboratory Services 163

CHAPTER ELEVEN Critical Care Air Transport Team 173 

Acronyms and Abbreviations 187

Index 191

Contributors

Executive Editors

Daniel E. Banks, MD, MS, MACP, LTC (Retired), MC, US Army

Timothy K. Jones, DDS, COL (Retired), DC, US Army

Greg Beilman, MD, COL, US Army Reserve, Trauma/Critical Care Surgeon

William Branch, Lt Col, US Marine Corps, Detachment Officer in Charge, 

Wounded Warrior Battalion East

Weyman Cannington, LTC, US Army, Chief, Patient Administration Division

Brenda Corrunker, Lt Col, US Air Force, Liaison Officer

Jane Darigo, RN, Outpatient Nurse Case Manager 

Warren Dorlac, MD, COL, US Air Force, Medical Director, Trauma/

Critical Care Unit; Director, C-STARS

Ray Fang, MD, Lt Col, US Air Force, Trauma/Critical Care Surgeon; 

Director, C-STARS

Joshua Forbess, SSG, US Army, Wounded Warrior Resiliency Program

Jeffrey B. Frazier, Deputy Chief, Patient Administration Division 

Charles Frizzell, CMSgt, US Air Force, Liaison Officer

Philip Gilbert, MSgt, US Air Force, Liaison Officer 

Kathryn Gillespie, RN, Chief Inpatient Nurse Case Manager

Robert Hinkel, Director, Laboratory Services

Darren Kasai, LT, US Army, Senior Noncommissioned 

Officer in Charge, DWMMC

Kevin Kirkpatrick, SSG, US Army, HMF (FMF) Liaison Officer 

Kevin Kumlien, CDR, US Navy Reserve, Intensive Care Unit Nurse

Jeffrey Lawrence, SFC, US Army, Medical Transient Detachment
Martha K. Lenhart, MD, PhD, FAAOS, COL, MC, US Army

Lisa Lewis, CDR, US Navy Reserve, Outpatient Nurse Case Manager

David Livesay, HMF (FMF) Officer in Charge, 

Navy/Marine Corps Fleet Liaison Detachment

Phillip Madrigal, 1SG, US Army, Medical Transient Detachment

Kathleen Martin, RN, MSN, Nurse Director, Trauma Program

Marcus McGee, CPT, US Army, Commander, Medical Transient Detachment 

Larry McGowan, SGM, US Army, Medical Transient Detachment

M. Josef Mikeska, MAJ, US Army, Director, CCATT

Mary Norgaard, CAPT, US Navy Reserve, Medical-Surgical Nurse 

John Oh, MD, LTC, US Army, Surgeon, Director, Trauma Program

Shelley Ohlendorf, Supervisor, Wounded Warrior Finance Office 

Pamela Patnode, CDR, US Navy Reserve, Medical-Surgical Nurse

Ronald Pettigrew, LCDR, US Navy Reserve, Chaplain

Gloria Portillo-Leanos, SMSgt, US Air Force, Liaison Officer

Dee Dee Price, RN, Intensive Care Unit 

Paul W. Pruden, CDR, US Navy, Assistant Officer in Charge, DWMMC 

Charles D. Roberts, Deputy Public Affairs Officer

Luis Sanchez, MSgt, US Army, Senior Liaison Officer 

Marie L. Shaw, Chief, Public Affairs Office

Donald D. Trunkey, MD, FACS, Trauma Surgeon 

Megumi Vogt, Lt Col, US Air Force, Traumatic Brain Injury Program

Rachel Watson, HMCS (SW), Senior Noncommissioned 

Officer in Charge, DWMMC 

Carol “Toussie” Weingarten, RN, PhD, ANEF, Civilian Volunteer

Michael S. Weingarten, MD, MBA, FACS, Vascular Surgeon, Civilian Volunteer

Laurie Wesely, CAPT, US Navy 

David Williams, Manager, Traumatic Brain Injury Program 

Tracey Wilson, LTC, US Army, Laboratory Services 

Daniel Yourk, CPT, US Army, Medical Transient Detachment 

David Zonies, MD, Lt Col, US Air Force, Surgeon, Director, Trauma Program 
Foreword

For over 25 years, Landstuhl Regional Medical Center (LRMC) has served as a 

model of “selfless service,” stepping up to the demands of a suddenly increased 

rate of traumatically injured service members arriving from the battlefield. From 

Operations Desert Storm/Desert Shield; through the attacks in Somalia, the 

Khobar Towers, and USS Cole; to the recent conflicts in Afghanistan and Iraq, 

LRMC has stood at the forefront of military healthcare, receiving our Nation’s and 

our partners’ wounded and ill from battlefields and contingencies across multiple 

theaters. From a community hospital providing routine healthcare delivery to 

personnel stationed in Europe and their families before 9/11, LRMC transitioned 

into a Level 1, triservice, integrated trauma center, providing lifesaving care to 

tens of thousands of evacuated service members, in addition to handling all the 

associated needs of these patients, from payroll assistance to chaplain services, 

service and unit liaison support, and veteran service organization support, as well 

as delivering ongoing healthcare to beneficiaries across Europe, Africa, and Asia. 

The goal of this text is to share the lessons learned by LRMC staff in converting 

from a peacetime to wartime footing, serving as a guide for US military hospitals 

in similar situations in the future. The innovations and solutions planned and 

implemented so successfully by LRMC staff will assist future military medical 

and line leaders in maintaining the highest quality of healthcare services for future 

generations of our service men and women in combat, improving upon the 

historically high survival rates seen in these conflicts.

BRIAN C LEIN

MAJOR GENERAL

Staff Surgeon, 2nd General Hospital and LRMC, 1993–1996

Commander, Landstuhl Regional Medical Center, 2007–2009

Fort Detrick, Maryland

July 2016

Acknowledgments

A special thank you to Commander Lisa Lewis, US Navy Reserve, Outpatient 

Nurse Case Manager, our point of contact at Landstuhl Regional Medical Center 

(LRMC). Her efficiency, dedication, and commitment to this project made this 

book possible. We also thank her commanding officer, Captain Laurie Wesely, US 

Navy, who supported this book both at LRMC and upon her return home. 

We thank Charles Roberts and Marie Shaw of LRMC’s Public Affairs Office for 

reviewing the manuscript and providing photos, resources, and contributors. The 

legacy of lessons learned addressed in this book spanned a period of more than a 

dozen years, and their long service at LRMC proved invaluable to understanding 

the progression and growth of this unique medical facility. 

We are grateful to all of the individuals from designated units at LRMC who 

contributed to each chapter’s content by sharing their knowledge and experience 

from various periods of service. We also thank those individuals we interviewed 

who gave us hours of their time, providing valuable information and perspective 

through their personal stories and experiences: Warren Dorlac, Joshua Forbess, 

Robert Hinkel, Kevin Kirkpatrick, Kevin Kumlien, Kathleen Martin, Mary 

Norgaard, Shelley Ohlendorf, Pam Patnode, Ronald Pettigrew, Carol Weingarten, 

Michael Weingarten, and David Zonies. We are indebted to Colonel Martha K. 

Lenhart for her vision, persistence, and enthusiasm for this project. We thank 

Lieutenant Colonel (Retired) Daniel Banks and Colonel (Retired) Timothy Jones 

of Borden Institute for their assistance in reviewing and editing the manuscript. 

Introduction

The quiet, quaint village of Landstuhl, Germany, is located in the 

Rheinland-Pfalz province, about 90 miles southwest of Frankfurt, close to the 

French border. Tucked comfortably in a small valley, the village is surrounded 

on three sides by notably sized hills. Locals and visitors enjoy the walk to the 

restaurants and shops that reflect the flavors of this community, as well as the 

view of Burg Nanstein, a 15th century castle overlooking the entire village. 

At the bottom of one of these hills is a long, steep driveway that has earned the 

nickname “Cardiac Hill.” No one would know that beyond the thick forest 

of trees on either side of that driveway is an American military base with a 

compelling story and a hospital that has saved thousands of lives.

History of Landstuhl Regional Medical Center

The Landstuhl area has a rich history tracing to Celtic and Roman times. In 

1796, the area was taken over by the French and later became part of the French 

Empire under Napoleon Bonaparte. After Waterloo, Landstuhl became part of 

the Kingdom of Bavaria. After Germany was formed in the late 19th century, 

breweries and factories brought wealth to the area. Landstuhl also became known 

as a spa resort, attracting patients suffering from arthritis and other diseases. 

German soldiers who died in World War I were buried in a small cemetery near 

the 13th century chapel in downtown Landstuhl. In early 1938, construction of 

the Hitlerjugend Schule (Hitler Youth School) began on one of the hilltops, the 

site that later became home to Landstuhl Regional Medical Center. Some of the 

buildings from the Youth School are still on the military post today. On March 

19, 1945, US troops entered Landstuhl. The US Army has maintained a hospital 

presence in the town of Landstuhl since November 28, 1951, when the 320th 

General Hospital took over operational control from an existing German military 

hospital. Construction soon began on a new facility, which admitted the first 375 

patients on March 9, 1953. 
xvi A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

The following year, the facility was renamed the 2nd General Hospital. Its facilities 

expanded throughout the Cold War era. The hospital not only provided healthcare 

within the European theater, but also played an integral role in patient care during 

high profile terrorist incidents and disasters: for example, caring for US Marines 

injured during the aborted 1980 rescue attempt of American hostages in Iran and 

caring for those injured in the 1983 bombing of the US Marine Corps barracks in 

Beirut, Lebanon. Soldiers injured during the 1986 LaBelle Discothèque bombing 

in Berlin and the 500 casualties of the 1988 Ramstein Air Show disaster were also 

treated at the hospital in Landstuhl. From August 1990 through March 1991, more 

than 4,000 service members injured during Operation Desert Shield and Operation 

Desert Storm and more than 800 military personnel deployed to Somalia between 

1992 and 1994 were evacuated and treated at the 2nd General Hospital. 

In 1994, the hospital was renamed the Landstuhl Army Medical Center, and it 

continued to serve as the primary medical center for casualties of US operations 

within Europe, southwest Asia, and the Middle East. In August 1998, the hospital 

treated American and Kenyan victims of the US Embassy bombing in Nairobi, 

supported the repatriation of three American prisoners of war in 1999, and treated 

the sailors injured in the USS Cole bombing. In November 2003, the hospital was 

renamed Landstuhl Regional Medical Center (LRMC), and subsequently included 

personnel from all branches of the military. In addition to providing specialty care 

to patients in the Kaiserslautern area, LRMC became the evacuation platform for 

casualties of US overseas contingency operations in the European, African, and 

Central commands. 

LRMC is the only US Role 4 medical treatment facility outside the United 

States and, from 2011 to 2014, it was the military’s only Level I trauma center 

overseas. Since 2003, every wounded warrior from Afghanistan and Iraq has 

come to LRMC to receive care. More than 90,000 sick and injured patients from 

Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New 

Dawn have been treated at LRMC to date.

The Evolution of a World-Class Medical Facility

The events of September 11, 2001 forever changed our nation. They also changed 

the operational landscape of LRMC. As the largest US military healthcare facility 

in Europe, LRMC found itself in a unique position as the common link between 

Central Command and continental US medical facilities. Because of its location, 

LRMC became a pivotal strategic evacuation center across a spectrum of conflict 

stretching over thousands of miles and three continents. LRMC could no longer 

be seen as a community hospital delivering routine medical care to European 
INTRODUCTION xvii

service members and their families; the Global War on Terrorism transformed it 

into a world-class trauma center addressing the needs of seriously ill and injured 

wounded warriors and saving thousands of lives. 

The first post-9/11 casualty arrived at LRMC in October 2001. Over the next 

year, approximately 25,000 troops were sent to Afghanistan, and by December 

2002, the hospital was feeling the impact of increased patient volume. It became 

clear that additional administrative and clinical assistance was needed to support 

this effort. Tracking patients and medical management were not feasible with its 

previous resources. Some of the units and programs described in this book—such 

as the Deployed Warrior Medical Management Center, the Medical Transient 

Detachment, and the Wounded Warrior Finance Office—did not previously exist. 

In 2003, LRMC requested and received 400 Army and 200 Air Force reserve 

personnel to augment the existing Table of Distribution and Allowances staff. 

Additional staff came from the Navy in 2006.

Challenges continued to arise at LRMC despite the additional staffing. The 

survival rate of soldiers injured in combat had significantly increased due to 

improvements in protective body armor, advances in trauma care, and knowledge 

gained by medical personnel in the prehospital far-forward environment. However, 

the type of warfare engaged in by combatants, the types of injuries sustained, the 

duration of deployments, the number of redeployments, and the short down 

time between deployments made these wars fundamentally different. New and 

additional medical and surgical specialists were required to adequately evaluate and 

treat the arriving wounded warriors. Innovations born of these challenges became 

part of the valuable lessons learned at LRMC. The synergistic relationship between 

military and civilian trauma care proved to be an essential asset. Fellowship-trained 

trauma surgeons advocated for tools such as trauma registries, performance 

improvement processes, and clinical practice guidelines. The growing awareness of 

the significant impact of traumatic brain injuries (TBIs) led to the development of 

mandatory TBI screening for all patients evacuated to LRMC. The development 

of a TBI program at LRMC benefited all patients who presented at LRMC with 

head injuries and cognitive symptoms. The initiation of the Critical Care Air 

Transport Team was instrumental in significantly reducing patient morbidities and 

mortalities. The success of this “flying hospital” program continues to have farreaching impact for both military and peacetime missions. 

The medical staff at LRMC performed just about every surgery possible from head 

to foot, from sports injuries to injuries from improvised explosive devices. LRMC 

staff treated soldiers with burns, tumors, diabetes, depression, and posttraumatic 
xviii A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

stress disorder. Before 2001, LRMC would have considered admitting 30 to 40 

patients in a day as a mass casualty event. Instead, this pace became the new norm, 

and staff adapted accordingly. This was accomplished while LRMC remained 

committed to the mission of treating retirees, local service members, and their 

families stationed in Europe. Since January 2004, 21% of patients evacuated to 

LRMC have suffered from battle injuries, whereas the remainder was disease- or 

nonbattle injury-related. Remarkably, more than 20% of wounded warriors 

who were treated at LRMC returned to duty. This rate equates to more than 19 

battalions that LRMC was instrumental in keeping in the fight. 

People are the lifeline of any organization, and this fact was never exemplified more 

clearly than at “Larmcy,” the affectionate nickname given to LRMC. The factors 

that remained consistent throughout this period of war were the unwavering 

dedication, commitment to excellence, and humanitarian effort represented in the 

hospital’s motto of “selfless service.” These values were seen in every corner and 

in every hallway of LRMC, from administrative staff, to the Wounded Warrior 

Finance Office, to liaison officers, chaplains, laboratory services, clinicians, and 

volunteers. Although a sick and wounded soldier may only have spent 24 to 

72 hours at LRMC, these patients humbled, inspired, and motivated an entire 

hospital community whose relentless purpose centered on doing whatever it took 

to save lives, diminish suffering, and offer comfort in any way possible. 

LRMC continued to evolve to meet the needs of wounded warriors. For more 

than a decade of war, the lessons learned at LRMC were invaluable and ongoing. 

Capturing these lessons became a priority, and this book was written with the 

purpose of identifying and understanding the integral role of LRMC as a strategic 

evacuation center across the spectrum of conflict. These lessons not only contribute 

to the history of military medicine, but also serve as an essential resource should 

another military medical facility need to replicate LRMC’s evolution. 

The battlefield did not stop at the borders of Iraq and Afghanistan. C-17 cargo 

planes landing at Ramstein Air Base brought the war to Landstuhl, Germany, at all 

hours of the day and night. The extraordinary endeavor that went on daily in the 

last 13-plus years of conflict have validated and proven the vital role of LRMC as a 

world-class military medical center. 
What is Success?

To laugh often and much;

to win the respect of intelligent people

and the affection of children.

To earn the appreciation of honest critics

and the betrayal of false friends;

To appreciate beauty,

To find the best in others;

To leave the world a bit better,

whether by a healthy child,

a garden patch, or a redeemed social condition;

To know even one life has breathed easier

because you have lived. 

This is to have succeeded.*

*According to the Ralph Waldo Emerson Society and the English department of Texas A&M University (http://emerson-legacy.tamu.edu/Ephemera/Success.html), this poem, although often attributed 

to Emerson, was published as “What is Success?” by Bessie A. Stanley, in: Chapple JM, ed. Heart 

Throbs, Vol 2. Boston, MA: Chapple Publishing Company; 1911.
A nurse holds a patient’s hand while being transferred to the 

hospital, July 9, 2013, at Landstuhl Regional Medical Center, 

Germany. An active-duty Air Force crew made history while flying 

specialized medical teams, and their patient required medical 

equipment never before used on board a Transatlantic mission.

US Air Force photograph by Senior Airman Hailey Haux. 

Reproduced from: http://www.ramstein.af.mil/shared/media/photodb/

photos/2013/07/130709-F-IQ718-144.JPG.
CHAPTER ONE

A Soldier’s Story

Sometimes you are lucky enough in life to meet a person who profoundly 

impacts you, someone who makes you want to be a better person, someone 

who changes your life simply by the way that he has lived his. And when you 

are privileged enough to hear his story, you recognize the extraordinary in his 

ordinary; his day-to-day living, humbly going about his business with intent 

and purpose despite the overwhelming obstacles he’s faced.

The mission statement for Fort Campbell, Kentucky, flows along the top 

of its website: I will always place the mission first. I will never accept defeat. 

I will never quit. I will never leave a fallen comrade. That is exactly the 

commitment Private Josh Forbess engrained in his soul when he joined the Army 

2 days after his 18th birthday, a mere moment after he officially went from boy 

to man. This was a decision made to broaden his experiences from the small town 

in Illinois he had known all his life. The military career aptitude test targeted his 

innate mathematical and mechanical abilities, which were a perfect skill match 

for a Field Artilleryman: a soldier trained to fight on foot and attack the enemy in 

face-to-face combat. Athletic, with strong muscles, quick feet, and a sharp, keen 

mind, Josh Forbess was a natural for this position in the Army. 

Two years later, at age 20, he was deployed for the first time. Both Bosnia 

and Kosovo were considered peacekeeping missions, but to a small-town young 

man, neither place looked anything but peaceful. This was his first exposure to 

a developing country: refugees in broken down half-way houses, skeletal limbs 

starving for food, listless eyes starving for hope, fear peering from the eyes of the 

young and old with no certainty for a safe day, much less a safe future. It was 

poverty and devastation to a degree he never knew possible. Forbess will tell you 

that there is a certain point in every man’s life when he finds out who he really is. 

This was that experience. It “set him, grounded him,” catalyzing his philosophy, 

his mind-set, his commitment to be the best he could be. That turning point to 
2 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

a new level of self-growth and self-awareness might have been one of the most 

important events in his life, an eerie foreshadowing to prepare the 20-year-old for 

an even greater challenge to come. 

Fast forward to 2003. Life was good for 26-year-old Josh, now Sergeant (SGT) 

Forbess, who seemingly was on the fast track in his career. He loved the military, was 

engaged to be married, and his life had both personal and professional meaning. 

Josh deployed out of Fort Campbell to Iraq on March 8, 2003. Dates become 

particularly relevant to a person when one day or one timeframe separates your life 

from everything you know as normal to nothing ever being the same again. 

The date he will never forget was November 15, 2003. Josh was conducting 

“Eyes Over Mosul,” an aerial quick-reaction force mission providing surveillance 

support from the air to where ground disruption was stirring. One instant to 

the next became transforming that day: flying overhead in a UH60 Black Hawk 

utility helicopter, then the sound of an explosion, black smoke circling the air, 

and a life about to change forever. His memory of exact details is somewhat 

sketchy, and most of what he knows was told to him. An RPG (rocket-propelled 

grenade) hit another Black Hawk helicopter that was close by, but not part of 

their mission. That aircraft was transporting troops between bases. The second 

Black Hawk hit them midair, taking off their tail rotor (back wing). Both planes 

were spinning wildly out of control when another RPG exploded into their 

helicopter, slamming them onto the roof of a house. The second Black Hawk also 

crashed, hitting the side of a school. For Josh, it then went black.

That unforeseen, gut-wrenching ending to “Eyes Over Mosul” took the lives 

of 17 soldiers. All ten passengers in the second Black Hawk were killed, as were 

seven of the twelve 101st Airborne Division soldiers in Josh’s aircraft. SGT Forbess 

was the most severely injured of the remaining survivors and the only one who 

could be pulled out from inside the wreckage. He was taken to a combat hospital in 

Mosul, then Baghdad, and from there flown to Landstuhl Regional Medical Center 

(LRMC) in Germany. After a CT (computed tomography) scan and emergency 

hand surgery, SGT Forbess was whisked back to the United States to Brooke 

Army Medical Center (BAMC) in San Antonio, Texas. From the moment of crash 

landing in Mosul to being wheeled into BAMC was a period of just 36 hours. He 

was still covered in soot. Josh Forbess has no memory of any of this. 

There was nothing minor about any of his injuries. SGT Forbess had severe 

burns to his face, head, right shoulder, and right arm. Bones were broken in both 

of his hands. His lungs, drenched in black, looked like the inside of a coal mine. 

Josh developed pneumonia from severe smoke inhalation and had extensive lung 

damage. He was on a ventilator for 2 weeks and spent 2 months in the intensive 

care unit where he was placed in a medically induced coma. The burns took his 

ear and half of his nose.
A SOLDIER’S STORY 3

January 11, 2004: another significant date. It was the first one Josh 

remembers after coming out of his coma. He recalls looking on a computer to 

actually see the date and then looking at the NFL schedule (the Packers played 

the Eagles that day). His life from November 15, 2003 up to this very point was 

a complete blank. The details of his life for those 8 weeks and the details of that 

fateful November day were then told to him. He remembers asking how many 

soldiers were lost and where his fiancée was. 

And so began a long, painful, and heroic return to a life now drastically 

different from anything he had ever anticipated. Josh suffered extensive 3rd 

and 4th degree burns to 11% of his body, 7% to his face and head, and 4% 

to his right arm. His life became a series of reconstructive surgeries and skin 

engraftments, from eyelids to nose to ear to right arm. He recounts his complex 

medical history matter-of-factly, as if he had recovered from a minor car accident 

rather than a helicopter explosion. He has told his story so many times and will 

tell you he has mastered separating the facts from the emotion. He has, however, 

never lost his dry sense of humor. “They took my latissimus dorsi (broadest back 

muscle) and a skin flap from my right butt cheek to engraft my skull,” Forbess 

states. “That makes me a REAL genuine butthead!” 

Josh also states that he is not sure if it was the pain itself he remembers or 

the pain from the depression. “Mental pain is way harder than the physical,” he 

states, once envisioning himself looking like the elephant man. Josh attributes 

his first step to acceptance to J. R. Martinez, a fellow infantryman from Fort 

Campbell who had been deployed to Iraq in February 2003. Two months 

later, Martinez was driving a High Mobility Multipurpose Wheeled Vehicle (or 

HMMWV—pronounced “Humvee”) when its front tire hit an IED (improvised 

explosive device). He suffered smoke inhalation and severe burns and, like Josh, 

was evacuated to LRMC and then transferred to the Burn Center at BAMC. Josh 

recalls his first visit, when 20-year-old Martinez walked into his room, completely 

unfazed by scars, skin grafts, or disfigurement, his own included. Martinez 

announced, “I am who I am and the hell with everybody else.” How cool was that? 

thought Forbess, who was awed by this strength, courage, and determination. 

Later that night, Josh picked up a mirror to look at his face for the first time. The 

journey to healing and self-acceptance, however, was long and painful, and Forbess 

admits that there were many dark hours. He was given a 30-day convalescence 

before officially being discharged from the Burn Center. He returned home to 

Illinois at that time. His demons followed. Anger, guilt, and sadness raged an ugly 

war within as he struggled daily with the fact that he lived and his comrades had 

died. He blamed himself for crawling out and leaving his men behind. It was not 

until months later that he learned the whole story of how he survived: that in fact 

he did not crawl out, but had to be pulled out from the wreckage. 
4 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Forbess spent $5,000 on alcohol during those 30 days trying desperately to 

numb the pain in any way possible. He was very clear on his purpose during that 

time. Alcohol gave him a means to drink himself into a dream world of being 

an uninjured soldier in the greatest division in the greatest Army in the world. 

In that dream, he is firing a Howitzer. It’s fun, he’s a natural; this is what he was 

trained to do. Josh awakened instead to a nightmare called reality. He continued 

drinking as a way to return to that dream. 

He returned to BAMC and underwent a series of surgeries to rebuild his 

nose and ear. At some point in 2004, Josh had an epiphany. His group of guys 

would never want him living like this. He loved the military, and he refused to 

believe his career was over. His honesty is painstakingly real, as he also admitted 

to being afraid to leave the Army. It was the life he knew and where he felt most 

comfortable in his own skin. 

SGT Forbess got his drinking under control and in 2004 returned to 

Fort Campbell, where he was assigned to administrative duty. Even though 

he was not firing a Howitzer as in his dreams, he was with his unit. It was like 

returning home to be with his family. In December 2004, he was promoted to 

Staff Sergeant (SSG) Forbess. He stayed at Fort Campbell until 2007, when the 

command team had an idea about how to better utilize his experiences. He was 

given an opportunity to work in the hospital at Fort Campbell, where they were 

setting up an Ombudsman program, an organization established by the Army 

in 2007 as a support service and resource augmentation for soldiers and their 

families. SSG Forbess would serve as a Wounded Warrior Advocate. Josh had 

been visiting soldiers in the hospital on his own time; he now had a formal title 

and position. This job turned out to be the stepping stone for his future position 

at LRMC. After 6 months, he became the Noncommissioned Officer in Charge 

at Fort Campbell’s Soldier and Family Assistance Center (SFAC), where he 

supported warriors in transition and their families. In 2006, the Fort Campbell 

Fisher House opened, the home built on post for military families to reside in 

while a loved one was receiving medical treatment. Josh was a regular volunteer, 

leading wounded warrior meetings and sharing his story.

In August 2011, SSG Forbess was assigned to LRMC to continue his 

mission at the Wounded Warrior Resiliency Program. The title of this program 

was particularly relevant to Forbess, who sees resiliency as the master key in 

unlocking the healing process. His credibility is his Midas touch. Forbess feels 

it is important to talk about his own black days, which were every bit a part of 

his story as the work he does now. Nothing was more real than living that raw 

emotional pain. It gave him a unique and genuine launching pad to relate to 

other soldiers facing similar struggles. “No one can tell you what it feels like to be 

blown up except someone who has been blown up.” No argument there, soldier! 
A SOLDIER’S STORY 5

He often relies on a Native American philosophy that helped him in his 

darkest hours: a belief that there is a 1-year grieving period that is necessary, and 

then it is time to let go and move forward. We cannot stay stuck in the past forever. 

There is no formal protocol to his approach when he meets each wounded 

soldier. He knows that as soon as he walks in the room, they know “he has been 

there and back.” His goal is to gain their trust. That is most important. He breaks 

the ice by just hanging out, telling jokes, and getting them to laugh. He will help 

transport them to various tests if needed. Josh might tell parts of his story, but more 

importantly, he wants them to tell theirs. SSG Forbess relies on instinct, experience, 

and “just being real” to assess whether soldiers are really spilling their pain or 

repressing it. “You have to talk about it,” he tells them, “really talk about it, and not 

the kind of talking you do when you are out drinking with your buddies.” It might 

take a while for someone to start opening up; once that happens, you never want to 

lose that emotional momentum, that moment of opportunity. SSG Forbess might 

be in a room for an hour, sometimes 5 or 6 hours, or sometimes a soldier wakes up 

and he is still there. Forbess stays until his work is done. The clear message he wants 

them to know is “My brother’s got my back.” 

Josh reflects on his own experience, those first weeks and months when he 

came out of the coma. He is honest with his assessment. This was a new war. No 

one was really prepared to deal with the volume of patients, the complexity of 

injuries, or the degree of psychological ramifications for these wounded warriors. 

During the Vietnam conflict, most soldiers with the types of injuries he sustained 

would have died. This was 30 years later and an entirely different battlefield. 

Josh himself was the first surviving soldier with life-threatening burns who had 

experienced the loss of fellow soldiers. At the time, the psychology team did not 

really know how to help him. Josh does not blame anyone, nor is he angry. There 

was no instruction manual for this type of devastation. What he does painfully 

remember, however, is how alone and lost he felt digging himself inch by inch 

out of the grave of emotional hell. That is what he tries to prevent for every 

wounded warrior who comes his way. He does not want to see a new generation 

of disgruntled veterans. “These are my brothers and sisters,” Josh states. “It is us 

taking care of us. No one is alone.” 

Healing is hard work. Healing takes time. There is no shortcut or bypass or 

escape. Josh lives with daily reminders of that fateful November day. He has TBI 

(traumatic brain injury), which has resulted in challenges with word associations 

and short-term memory loss. He has been told that he has PTSD (posttraumatic 

stress disorder). Scars, grafts, and broken bones have restricted the full range of 

mobility in his arm and hands. These are not the problems, however, Forbess 

chooses to focus on. Eight and a half years after the accident, Josh awoke one 

morning and felt totally at peace. He is grateful for what is good in his life: a job 
6 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

with purpose and a spouse who understood “in good times and in bad” long 

before those official wedding vows were spoken. Back in 2003, his 20-year-old 

fiancée never left his side. A nursing student at the time, she flew to be with him 

in the intensive care unit in San Antonio. An extraordinary young woman, she 

stood by him during those 30 dark days when he bathed his pain in alcohol, 

through dozens of surgeries, and through every twist and turn of his remarkable 

journey. Josh Forbess was married on September 3, 2005, and his wife works as a 

nurse at LRMC. 

SSG Forbess feels it is essential to pass on lessons he has learned to future 

facilities and caretakers that may face a similar challenge, including the following: 

• A caring hospital staff is essential.

• Be honest; truth is critical.

• Never assume that a patient “hears” what you are telling him or her the 

first time. Keep repeating and re-telling the information as if it is the 

first time the patient is hearing it. It may take multiple efforts before it 

all sinks in.

• The impact of sharing experiences cannot be underestimated. It is so 

valuable to both the patients and their families. 

• The first step to healing others is to first start with healing yourself. 

Not a day goes by that SSG Forbess does not think about his fallen 

comrades—those men that were his family. They are his lessons learned, his 

“raison d’être.” It is in their memory that he had the courage to put one foot in 

front of the other and continue to live. Forbess recommits to his purpose daily:

• Never let their memories fade. As soon as they fade, they truly die.

• Always keep them smiling down on me.

• Keep their families proud.

On any given day at any given hour, soldiers, patients, and caregivers will be 

seen along the 3 miles of hallways at LRMC. SSG Josh Forbess has lived each one 

of these roles. He is the soldier who understands commitment to the mission, the 

patient who has lived the word “suffering,” and the caregiver who practices putting 

patients first. It is what makes his perspective so valuable, his story so unique. 

What is it about the resiliency of a human spirit that can reach down to 

the depths of unbearable despair, and somehow surface to face the world with 

unfathomable courage, integrity, and resolve? Josh Forbess faced unspeakable loss 

at every corner he took a breath: the death of men he called brothers, a dream 

career shattered in the debris of a helicopter wreckage, and a stranger staring 

back in the mirror. Diligent surgeons carefully worked to restructure and realign 
A SOLDIER’S STORY 7

the face of SSG Josh Forbess, who was then tasked to diligently restructure and 

realign the architecture of his own life. 

The following chapters in this book depict the development and implementation of various units and programs that grew out of sheer necessity to both 

save and rebuild lives. SSG Josh Forbess represents the epitome of what made 

LRMC one of the greatest lessons learned during this war. 

 
These unique two-story modular trailer units were adjacent to 

the hospital and home to the Deployed Warrior Medical 

Management Center. 

Courtesy of the Public Affairs Office, Landstuhl Regional Medical Center.
CHAPTER TWO

Patient Administration

Division and Deployed Warrior 

Medical Management Center

It is one thing to admit and discharge sick patients who live locally; 

it is quite another when that same process now involves admitting 

and discharging evacuated patients from thousands of miles away, 

communicating with families thousands of miles away, and safeguarding 

and accounting for funds and valuables of patients from all over the world. 

Before any wounded warrior arrived at Landstuhl Regional Medical Center 

(LRMC), many wheels of the patient support system were already set in 

motion. Behind the scenes of direct patient care are hospital administrative 

services that address a multitude of necessary functions integral to the delivery of 

quality care. These essential services are particularly complex in the military during 

wartime as administrative responsibilities become more global. It is one thing to 

admit and discharge sick patients who live locally; it is quite another when that 

same process now involves admitting and discharging evacuated patients from 

thousands of miles away, communicating with families thousands of miles away, 

and safeguarding and accounting for funds and valuables of patients from all over 

the world. This complexity does not eliminate the other routine responsibilities 

of administrative services such as: ensuring HIPPA (Health Insurance Portability 

and Accountability Act) compliance and training, reporting medical data, 

documenting appropriated medical coding, and maintaining medical records for 

wounded warriors and local civilians needing medical care from birth to death and 

everything in between.1

The Patient Administration Division (PAD) at LRMC has always been a 

patient-centric service organization that carried out varied responsibilities on a 
10 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

daily basis. Through teamwork and collaboration, PAD’s goal was to consistently 

provide professional, administrative support to clinical staff; ensure patient 

satisfaction; and sustain quality medical documentation. The PAD mission 

statement at LRMC is as follows: 

A collaborative, well trained, and ready team that enables our clinical staff to 

provide safe, world-class healthcare for our patients to maximize their health 

and well-being through accurate medical documentation and quality patient 

administrative services.1

The Deployed Warrior Medical Management Center (DWMMC) was 

a unique organization at LRMC that also played an integral role in providing 

medical and administrative management to US military service members 

evacuated from supported theaters. The DWMMC originally grew from 

the PAD Aeromedical Evacuation (PADAE) office. The center evolved from 

an internally LRMC-staffed entity into a triservice and civilian organization 

staffed through the global force management process and funded by the 

Overseas Contingency Operations (OCO) budget. The development of this 

comprehensive systems approach to casualty management facilitated patient 

evacuation and accountability during Operation Enduring Freedom (OEF) and 

Operation Iraqi Freedom (OIF). The DWMMC was responsible for tracking 

all patients being evacuated from the combatant commands and served as the 

permanent link between the combat theater and continental US (CONUS) 

medical facilities. This integral unit coordinated services across eight functional 

areas: (1) clinical management, (2) patient administration and logistical support 

for incoming patients, (3) healthcare delivery, (4) redeployment processing, (5) 

billeting and lodging, (6) case management, (7) financial and logistical support, 

and (8) outbound movement.2

The mission of the DWMMC is as follows: 

To coordinate and facilitate triage, reception, medical management, and 

onward movement of wounded warriors from overseas contingency operations 

(OCO) in the US Central Command (CENTCOM), US Africa Command 

(AFRICOM), and US European Command (EUCOM) areas of responsibility 

(AORs).2 
PAD AND DWMMC 11

BACKGROUND

The Evolution of Service: Patient Administration Division to the 

Deployed Warrior Medical Management Center 

After the events of September 11, 2001, LRMC became the logical 

evacuation platform for personnel coming from the CENTCOM AOR (US 

Central Command area of responsibility) who needed sophisticated medical 

testing, specialty care appointments, short-term treatment, and inpatient care, 

due to its strategic location and medical capabilities. At that time, LRMC was 

not structured to handle such an increase in patient volume, which resulted in 

prolonged delays of outpatient treatment. 

With the announcement that the United States would be sending 25,000 

troops to Afghanistan (OEF) in 2001, LRMC began a series of meetings with 

personnel who were at LRMC during Operation Desert Shield/Operation Desert 

Storm (ODS/ODS). One of the lessons learned during that war was the importance of LRMC continuing its peacetime mission (ie, caring for local beneficiaries 

and other eligible patients), while also receiving and caring for wounded warriors 

from downrange. During ODS/ODS, LRMC had put its peacetime mission on 

hold and admitted 100% of patients arriving from theater. While admitting that 

all contingency patients solved problems in patient tracking and command and 

control, it turned out to be a huge problem for local beneficiaries who then had to 

rely solely on German hospitals for inpatient and specialty care. This proved to be 

a catastrophic financial issue for retirees over 65 years of age because, at that time, 

military insurance (CHAMPUS or Civilian Health and Medical Program of the 

Uniformed Services) paid for medical care at civilian facilities for all beneficiaries 

until they turned 65, after which they were no longer eligible for civilian care reimbursement. Free medical care could then only be obtained at a military medical 

facility. Many of those affected lost their life savings to pay for necessary medical 

treatment. LRMC did not want this situation to occur again during this war. 

The chief and deputy chief of PAD discussed the needs of patients coming 

from theater. Based on experiences during ODS/ODS, as well as patients from 

the Balkans, Somalia, and the USS Cole, it was determined that the best approach would be to establish a separate unit specifically responsible for managing 

wounded warriors. The logical foundation for this new entity was the PADAE, 

with augmentation from other PAD personnel and hospital clinical staff. 

PAD was divided into several sections, each with a different AOR. The 

PADAE was specifically responsible for processing requests for air evacuation to 

CONUS for patients needing more complex care elsewhere, or those needing continuous care at another medical facility. Prior to OEF the PADAE consisted of two 

junior enlisted personnel. Their mission was to enter patients into the TRANSCOM Regulating and Command & Control Evacuation System (TRAC2ES) 
12 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

who were referred by providers at LRMC to CONUS medical treatment facilities. 

Additionally, they produced travel orders for all patients departing LRMC for 

medical care in CONUS. They also tracked and provided support to patients from 

Kosovo and Bosnia. Patient tracking once consisted of a Microsoft Excel spreadsheet, which eventually developed into the Department of Defense (DoD) patient 

tracking system now known as the Theater Medical Data Store (TMDS).

In response to the new logistical and operational challenges that arose with 

OEF and OIF, various units or “cells” were developed in PAD. Each cell had its 

own unique set of tasks, but all tasks were interrelated. The need to streamline and 

improve patient movement prompted PAD to make a proposal to LRMC to establish a new unit that would provide logistic support to patients coming from the 

CENTCOM theater, including billeting, meals, clothing, and transportation. This 

new organization would also work closely with clinical staff on early notification 

and planning for receiving inbound patients. The traditional medical holding company was used as the model for the initial development of this organization. The 

new unit was approved in October 2001, coincident with the beginning of OEF. 

Daily meetings were held with PAD, nursing, and clinical staff members to review 

the inbound patient movement requests (PMRs) and make ward assignments.

A NEW UNIT EMERGES

From October 2001, when the unit was approved, until early 2003, the 

unit that was initially named the Deployed Warrior Medical Care Center was then 

changed to its current name and consisted of 10 personnel. With the buildup of 

troops for OIF and the arrival of 400 US Army reservists and 200 US Air Force 

reservists at LRMC, the DWMMC expanded to more than 100 personnel and 

came under the leadership of an Army Medical Corps lieutenant colonel and a 

Medical Service Corps captain.1

With the new command at the DWMMC, PAD then stepped back and 

provided a supporting role, while still continuing on with its original mission. 

The only exception was that the PADAE remained a part of the DWMMC, and 

continued to process orders and input TRAC2ES information for all patients 

(contingency and noncontingency) departing LRMC for further care elsewhere.1

The DWMMC then assumed the following responsibilities: 

• administrative: reporting and recording medical information in the 

computer before a patient arrives; 

• air evacuation: monitoring departures from downrange to arrival at 

LRMC;

• case management: nursing coordination of outpatient care;

• mission teams; 

• logistics: addressing essential patient needs from luggage handling to 

clothing to medical appointments;
PAD AND DWMMC 13

• triage: assessing severity of the patient’s condition from downrange 

to arrival;

• billeting; 

• maintaining movement sections: tracking patient evacuation movement 

worldwide; and

• coordination: collaborating with other LRMC personnel, such as liaisons 

and chaplain services, for nonmedical needs. 

By 2006, sourcing LRMC augmentation was becoming increasingly difficult 

because Army active and reserve medical forces were supporting protracted operations in both OIF and OEF. On behalf of LRMC, US Army Europe submitted a 

request for forces, asking for joint augmentation to staff the DWMMC and other 

areas within LRMC. In November 2006, the US Navy was tasked with fulfilling 

the request and responded with a reserve component Navy fleet hospital from 

Great Lakes, Illinois, with more than 300 assigned personnel. Since then, the Navy 

component at LRMC evolved into a Navy Expeditionary Medical Unit (NEMU). 

In 2007, other units evolved to support the wounded warriors: 

• the Medical Transient Detachment: responsible for accountability of all 

outpatients and billeting (see Chapter 4, Medical Transient Detachment); and 

• the Chaplain’s Closet: provided clothing and personal items for soldiers, such as food, DVDs, CDs, and books (later realigned under the 

responsibility of LRMC chaplains; see the “Chaplain’s Closet” vignette in 

Chapter 9, Chaplain Services). 

IMPLEMENTATION METHODS

Organization and Responsibilities of the 

Deployed Warrior Medical Management Center

The DWMMC was composed of a command and control section and four 

departments (Operations, Nursing, Logistics, and Clinic). The LRMC deputy 

commander for clinical services had operational control of the DWMMC, 

while administrative control of Navy personnel within DWMMC remained 

with the NEMU. In command and control roles, DWMMC had a total of five 

personnel: (1) the officer in charge, (2) the assistant officer in charge, (3) the staff 

noncommissioned officer in charge, (4) a civilian administrative assistant, and 

(5) a civilian data analyst. The officer in charge and the assistant officer in charge 

positions were filled by both Navy Medical Corps and Navy Medical Service 

Corps officers. Key command and control tasks included the following: 

• manpower management, 

• data analysis, 

• process improvement, 
14 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

• interagency communication, 

• briefings and tours (as requested), 

• personnel evaluations and awards, and 

• subordinate and peer career development.

OPERATIONS DEPARTMENT

This department consisted of 21 personnel, including a senior enlisted 

department head, and was divided into two branches: (1) Missions and (2) Air 

Evacuation. The Missions branch was the only office within DWMMC opened 

24 hours a day, 7 days a week. It consisted of twelve military enlisted and one 

civilian personnel. This branch was responsible for the following:

• maintaining visibility and informing LRMC of inbound patients,

• registering and updating patients in medical information systems,

• coordinating patient reception, 

• ensuring accountability, and 

• providing orientation at reception.

The Air Evacuation branch was responsible for overseeing medical regulation 

of US military OCO patients designated for transfer to continued care (TCC) 

to CONUS in accordance with DoD and service-specific policies. The Air 

Evacuation branch had six military enlisted and one civilian personnel. 

Command and Control

Operations

Department

Nursing

Department

Logistics

Department

Clinic

Department

Missions

Air 

Evacuation

Clinical Flight

Coodination

Case

Management

Movement

and Orders

Supply, 

Material Handler

and CAC ID

Organization of the Deployed Warrior Medical Management Center

CAC ID: Common Access Card Identification

Courtesy of the Deployed Warrior Medical Management Center, Landstuhl Regional Medical Center.
PAD AND DWMMC 15

NURSING DEPARTMENT 

This department consisted of nine military registered nurses (RNs), one of 

whom also served as department head, and five civilian RNs. This department 

also had two branches: (1) Clinical Flight Coordination (CFC) and (2) Case 

Management (CM). All of the military RNs worked in the CFC branch. They 

triaged all inbound OCO inpatients in consultation with on-call physicians 

prior to patients’ arrival at LRMC, coordinated bed management of inpatients 

with LRMC Nursing Services, and entered consults for outpatients. CFC nurses 

also facilitated onward TCC movement through clinical review of medical 

information systems and outpatient interviews, entering necessary clinical 

information into PMRs. 

The CM branch maintained continuity of information in medical 

information systems for both outpatients and inpatients and ensured that each 

US Army and Air Force wounded warrior outpatient completed his or her 

physician-developed treatment plan. CM referred patients for further evaluation if 

any concerns were identified during encounters. The Liaison Noncommissioned 

Officer (LNO) detachment at LRMC provided similar care coordination services 

for all Navy and Marine Corps patients. PAD provided CM for US government 

civilians, contractors, and coalition OCO patients.

LOGISTICS DEPARTMENT

This department consisted of 15 personnel, including a senior enlisted 

department head, and was divided into two sections: (1) Movement and Orders 

(M&O) and (2) Supply, Material Handler, and CAC ID. Staffed with seven 

enlisted military personnel, M&O prepared travel orders and coordinated 

commercial air transportation for Army wounded warriors designated for TCC 

or return to duty. It also coordinated ground transportation to the appropriate air 

terminal, military or commercial, for all departing patients or attendants. Its Navy, 

Marine Corps, and Air Force LNOs provided travel orders and commercial air 

coordination services for their respective patients (PAD provided similar services to 

US government civilians, contractors, and coalition OCO patients). 

The Supply, Material Handler, and CAC ID section received, stored, issued, 

and disposed of inpatient and outpatient baggage and equipment. Additionally, 

this section operated a DEERS (Defense Enrollment and Eligibility Reporting 

System)/RAPIDS (Real-Time Automated Personnel Identification System) system 

to reissue lost or damaged military ID cards to patients supporting OCO and 

unlocked ID cards and verified certificates for LRMC staff. This section had two 

military enlisted personnel, four civilians, and one contractor.
16 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

CLINIC DEPARTMENT

This department served the primary care needs of all wounded warrior 

outpatients, performed medication reconciliation, ensured that traumatic brain 

injury screening was recorded, if appropriate, and provided sick call for NEMU 

personnel. The clinic consisted of four personnel, including one military physician 

(who also served as department head), one military physician assistant, one civilian 

physician assistant, and one military enlisted medic. 

DEPLOYED WARRIOR MEDICAL MANAGEMENT 

CENTER CAPACITY 

At the height of the war, 60 DWMMC triservice and civilian staff sustained 

a throughput (reception plus onward movement) of approximately 1,700 patients 

per month through the consolidation of critical clinical and administrative 

functions, as described below. This ensured efficient and effective coordination of 

the needs of the wounded warriors. 

Prearrival

Patients from downrange arrived on evacuation flights at Ramstein Air Base. 

The Missions branch was responsible for monitoring TRAC2ES every hour 

to identify all evacuation flights destined for LRMC within the next 24 hours. 

Depending on the number of casualties, DWMMC usually received one to two 

flights per day, except for during the height of the war when there may have been 

three or four. Once an inbound flight became visible, the following sequence of 

events occurred:

• The Missions branch began registering patients on the flight in the 

Composite Health Care System and notified CFC. 

• CFC nurses reviewed the PMRs and TMDS to begin prearrival triage. 

CFC nurses consulted either the internal medicine or general surgery 

on-call physician, depending on the patient’s diagnosis. 

• The on-call internal medicine or general surgery physician determined to 

which specialty service each inpatient would be admitted. 

• CFC nurses then notified the designated specialty service and the wards 

to ensure that they were prepared to receive the patient. 

• The DWMMC Clinic department head reviewed the PMRs to ensure 

that each outpatient had enough medication to last until his or her first 

appointment with a specialty provider. 

• Once admitting service designation and ward assignment of inpatients 

were completed, CFC nurses notified the Missions branch, which 

finalized the inbound patient manifest. 
PAD AND DWMMC 17

Patient Flow Through the Deployed Warrior Medical Management Center 

DFAC: Dining Facilities Administration Center

DWMMC: Deployed Warrior Medical Management Center

LRMC: Landstuhl Regional Medical Center

Mgmt: Management

RTD: return to duty

TCC: transfer to continued care

Courtesy of the Deployed Warrior Medical Management Center, Landstuhl Regional Medical Center.

Missions/Triage

Contingency Aeromedical Staging Facility

Movement and Orders

Departing Accountability and Travel

Inpatient

Inpatient Ward

Treatment

Case Mgmt/Liaisons

Outpatient

DFAC/Brief/

Clinic/Billeting

Treatment

Case Mgmt/Liaisons

DWMMC/LRMC

RTD or TCC

Theater Medical

Data Store

Prearrival Reception Management Departure

• The Missions branch electronically posted the inbound patient manifest 

on both the DWMMC network drive and on the STARTC (Soldier 

Transfer and Regulating Tracking Center) Army Knowledge Online 
18 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

page. The Missions branch then notified the appropriate personnel 

teams who were responsible for meeting the ambulance buses arriving 

from the Contingency Aeromedical Staging Facility at Ramstein Air Base 

to offload inpatients.

Reception

The condition and number of patients on each inbound flight determined 

the need for the number of medical ambulance buses. A Missions branch 

representative, a CFC nurse, and LRMC teams met each evacuation flight on 

arrival, and the patients were transported by ambulance bus to LRMC. The job of 

the Missions branch was to ensure accountability, whereas the CFC nurse received 

clinical updates from Contingency Aeromedical Staging Facility personnel. If 

significant changes in a patient’s status had occurred, the CFC nurse retriaged the 

patient to make a final decision on the appropriate medical plan. Each inpatient 

was offloaded by the team and taken by the appropriate personnel to his or her 

respective wards. Outpatients met with their respective LNOs and were assigned to 

the Medical Transient Detachment. 

Management

The primary care needs of US military OCO outpatients and their escorts 

were met by the DWMMC clinic, which provided primary care services, medication refills, and sick call, also ensuring that traumatic brain injury screening was 

complete.2 Each outpatient was required to report to CM following every specialty 

appointment. The DWMMC CM was then responsible for the following:

• ensuring that consults were completed;

• generating a weekly report intended to maintain visibility of patient flow 

in accordance with theater evacuation policy; 

• entering outpatient encounters in the Armed Forces Health Longitudinal Technology Application (AHLTA); 

• collaborating with the physicians, command liaisons, the service member’s command, and the DWMMC clinic for coordinating every aspect 

of wounded warrior care; and

• entering inpatient information from Essentris (the inpatient electronic 

medical record system) into TMDS, which provided visibility to deployed unit leadership and augmented information continuity (access to 

this medical information was helpful to the providers who cared for these 

soldiers after LRMC, when they are treated in US hospitals or by the 

Veterans Administration). 
PAD AND DWMMC 19

Departure

There were two possible dispositions for each OCO patient who was received 

at LRMC: (1) TCC or (2) return to duty. The average length of stay at LRMC 

was 3 to 5 days for inpatients and 10 days for outpatients.2 For TCC patients, the 

following steps were performed:

• The attending specialist at Landstuhl initiated Form AF IMT 3899 

PMR and submitted it to the DWMMC Air Evacuation branch. 

• The Air Evacuation branch created a PMR in TRAC2ES, completed the 

administrative sections, and forwarded it to the CFC nurses. 

• CFC nurses then accessed inpatient and outpatient electronic medical 

records to enter the necessary clinical information onto the PMR. 

• CFC nurses also conducted interviews with outpatients designated 

for TCC. The CFC nurses compiled patient medical data, including 

transcribing data from Essentris and AHLTA, the Composite Health 

Care System, TMDS, and previous PMRs. The CFC nurses also 

coordinated with the validating flight surgeon at the Theater Patient 

Movement Requirements Center, Europe, regarding onward movement 

via commercial or military air travel. 

• M&O issued temporary change of station orders for Army patients who 

were either TCC or return to duty, and then created and distributed bus 

manifests and TCC reports. 

• M&O also coordinated with the DoD-contracted travel company for 

commercial air travel of wounded warriors. 

 

Deployed Warrior Medical Management Center Equipment

DWMMC required no specialized equipment beyond standard office spaces 

and workstations. The following is a list of recommended information systems that 

required access and proficiency in use: 

• TRAC2ES,

• TMDS, 

• AHLTA, 

• Composite Health Care System, 

• Essentris, 

• Medical Protection System, 

• Single Mobility System, 

• DEERS,

• Defense Medical Logistics Standard Support, 

• Army Knowledge Online, and 

• Automated Orders and Resource System. 
20 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Deployed Warrior Medical Management Center Reports

The DWMMC prepared and distributed a number of regular and ad hoc 

reports. Recurring LRMC internal reports included a daily morning report; 

weekly, monthly, quarterly, and fiscal year LRMC patient movement summaries; 

and inbound patient manifests (as required). Recurring external reports included 

outbound patient manifests, bus manifests, TCC reports, and Office of The Army 

Surgeon General reports. The DWMMC officer in charge and Clinic department 

head met weekly to review all outpatients who were at LRMC for 10 days or more 

to ensure compliance with theater evacuation policy.

LESSONS LEARNED

Since 2004, LRMC has received and treated more than 70,000 patients 

evacuated from OCO.3 LRMC achieved an approximate 20% return-to-duty rate, 

which is significantly higher than in any previous conflicts.3 More than 14,000 of 

these patients were treated as a result of battle injuries, and 85% of these patients 

spent less than 96 hours at LRMC prior to TCC to CONUS.3 Both the PAD and 

the DWMMC significantly contributed to the efficient reception and movement 

of patients. This led to reduced loss of personnel to deployed units, cost avoidance 

from reduction of necessary TCC to CONUS, and improved outcomes through 

case managed and coordinated care. These benefits were seen at the unit level, the 

service component level, and the DoD level. 

Successes and Challenges for the Patient Administration Division

• An early lack of compliance oversight and coding training for providers 

and coders was resolved through the development of the Training, 

Auditing, and Compliance branch, which provided coding training for 

providers and certification for new coders.

• Locating housing for foreign military and US civilian employees and 

contractors requiring outpatient treatment, who did not qualify for 

lodging and support at the hospital, was often problematic. PAD’s 

solution was to acquire rooms in local billeting on an ongoing basis.

• Foreign patients who required a visa to enter Germany encountered 

immigration problems, which were resolved by developing a mechanism 

through the German Interior Ministry for pre-approval delivery of 

passports to the German federal police. 

• Communication with foreign patients and their home governments was 

challenging. This situation was improved by establishing and supporting 

a foreign medical liaison program whereby liaisons were translators 

and conduits for communication with their home nations and military 

organizations. 
PAD AND DWMMC 21

Deployed Warrior Medical Management Center Successes 

• The DWMMC has a proven outcome of decreasing the length of 

stay for wounded warriors from deployed units, limiting time spent 

at LRMC to 14 days or less for outpatients. The DWMMC directly 

contributed to the approximate 20% return-to-duty rate for those 

evacuated from theater.3

• A DWMMC could be set up at any medium-to-large medical treatment 

facility, provided extra required staff and equipment are available to deal 

with a recurring influx of patients during a conflict. It is also conflictadaptable and can be altered, depending on the needs of the patients 

being evacuated from theater. The records of this process and skill sets 

must be maintained to ensure efficiency of medical care and evacuation 

channels in any future conflicts.

• DWMCC processes were replicated and perfected to the point that 

most were second nature within the hospital. The number of inbound 

and outbound OCO patients were included as part of the morning 

command report. This innovative idea was generated specifically 

for LRMC and to date has not been replicated at any other post. 

It has proved successful for LRMC and is clearly a best practice for 

contingency missions. 

• A summary of DWMCC successes include the following: 

— worldwide availability of patient movement information; 

— patient reception and accountability; 

— coordinated cooperative reception with multiple teams, including 

LNOs, chaplains, DWMMC personnel (Missions and CFC 

branches), and LRMC personnel teams; 

— seamless patient handoff from LRMC to the Contingency 

Aeromedical Staging Facility; 

— CM services that ensured continuity of care; and

— continuous information flow and in-transit visibility for both 

the receiving medical treatment facilities and the deployed unit 

leadership. 

Deployed Warrior Medical Management Center Challenges 

• Lack of training. There was no DWMMC-specific predeployment 

training for assigned Navy, Army, or Air Force personnel. Additionally, 

DoD patient movement and service-specific medical regulating policies 

and related information systems were generally not well known, except 

in particular specialties or communities. As a result, the staff experienced 
22 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

a steep learning curve. The curve may be reduced by implementing 

sufficient turnover periods between rotations. 

• Regulations and policy updates. Because medical regulation policy 

updates were not always contiguous, DWMMC and clinical staff often 

questioned whether pre-existing policies were still to be used even when 

they were expired. Regulations and changes in such policies also needed 

to be explained to patients and families to help manage expectations. 

• Frequency of staff turnover. Staff turnover within both the DWMMC 

and LRMC generated a particular challenge. The officer-in-charge 

position rotated more frequently than the rest of the DWMMC staff 

(usually every 6 or 9 months vs 12 months), and there were no civilians 

in leadership positions who could provide significant continuity across 

rotations. Because of the unpredictability of the number of casualties, 

DWMMC civilian positions were term, not permanent. Hiring was 

dependent on the limited local civilian talent pool. Furthermore, when 

LRMC staff experienced turnover, DWMMC had to engage in repeated 

education and expectation management for new providers and support 

staff who were unfamiliar with medical regulation policies, CENTCOM 

guidance, and the DWMMC scope of responsibility and authority. 

Each time new DWMMC personnel reported, there was friction for 

a period of time until rapport with the LRMC staff, the Contingency 

Aeromedical Staging Facility, the Theater Patient Movement 

Requirements Center–Europe, and STARTC were developed. 

• Ongoing change. The DWMMC constantly evolved with ongoing 

improve-ment initiatives, changing service and combatant command 

policies, and changes in requests for feedback support. Although change 

was good, it needed to be carefully managed to reduce potential friction.

• Funding multiple operations. Funding of temporary change-of-station 

orders for soldiers from other than OEF and OIF was problematic. 

Specifically, DWMMC only had authorization to use budgetary funding 

associated with the aforementioned operations. However, there were 

other OCOs supported by LRMC and DWMMC, such as Operation 

Joint Guardian and Operation Joint Forge in EUCOM, and Combined 

Joint Task Force–Horn of Africa in AFRICOM. 

• Medical support of multiple operations. LRMC supported OCO in three 

geographic combatant commander’s AORs, but also supported non–

OCO-eligible beneficiaries from those same AORs. DWMMC was 

created entirely for the support of OCO patients and was funded 

accordingly. LRMC PAD supported all non-OCO patients arriving at 

LRMC for care. It was not always clear whether an inbound flight or 
PAD AND DWMMC 23

a patient was OCO or not. For example, LRMC received US military 

patients from embassies in CENTCOM or AFRICOM who at first 

glance were recognized as OCO, but in reality were not personnel on 

OCO deployment orders. DWMMC’s practice was to treat all inbound 

flights and patients as OCO until definitively determined otherwise. 

When patients were determined to be other than OCO, DWMMC 

contacted the appropriate responsible party. 

ACKNOWLEDGMENTS

Thanks to Commander Paul Pruden, DWMMC Assistant Officer in Charge; 

Lieutenant Darren Kasai, DWMMC Senior Noncommissioned Officer in 

Charge; HMCS (SW) Rachel Watson, DWMMC SNCOIC; LTC Weyman 

Cannington, Chief, Patient Administration Division; and Jeffrey Frazier, Deputy 

Chief, Patient Administration Division.

REFERENCES

1. Landstuhl Regional Medical Center Patient Administration Division. How to 

be a Strategic Level IV MEDCEN Across the Spectrum of Conflict. Landstuhl, 

Germany: LRMC; undated. 

2. Landstuhl Regional Medical Center Public Affairs Office. Fact Sheet: 

Deployed Warrior Medical Management Center. Landstuhl, Germany: LRMC; 

October 2013.

3. Landstuhl Regional Medical Center Public Affairs Office. Medical Transient 

Detachment Sidebar [news release no. 11]. Landstuhl, Germany: LRMC; 

April 22, 2008. 
Liaison officer (right) escorts patient to the intensive care unit. 

Photograph courtesy of the Public Affairs Office, Landstuhl Regional 

Medical Center.
CHAPTER THREE

Liaisons 

“The best way to find yourself is to lose yourself in the service of others.” 

— MAHATMA GANDHI

At any given moment at any location on the campus of Landstuhl Regional 

Medical Center (LRMC), a wounded warrior may hear these words: “if 

you have any questions or problems, ask your unit LNO (liaison officer).” 

An Army military article best described this position as follows: “Soldiers 

have their battle buddies. Airmen have their wingmen. Sailors have their 

shipmates. At LRMC, wounded warriors have their unit LNOs.’’ 1

The term “liaison” at its essence, refers to communication and cooperation 

maintained between elements of military forces or other agencies to 

ensure mutual understanding and unity of purpose and action. The 

liaison officer at Landstuhl Regional Medical Center (LRMC) is the official 

“go-between” serving as a critical point of contact for the patient, the patient’s 

downrange unit and home station, and the patient’s family. More than 30 Liaison 

Noncommissioned Officers (LNOs) from each service work with individual 

wounded warriors and play a critical role in their care. Liaisons escort wounded 

warriors to appointments, answer questions, and address a variety of their needs. 

Liaisons serve as a single point of contact and interface between LRMC and the 

medical department representatives of operational forces. This position is not a 

0730 to 1630 job, but a way of life 24 hours a day, 7 days a week, 365 days a year.

The mission of Army liaisons is as follows: To ensure that all wounded warriors 

receive the best care available and that they are returned to their home of record or placed 

in the closest medical treatment facility that has the capability to treat their injuries.

2

IMPLEMENTATION METHODS

What does it mean to be available 24 hours a day, 7days a week? The role of 

theliaison begins before the patient arrives at LRMC and does not end until after 
26 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

the patient leaves. LNOs are the “master coordinators”; nothing is out of their 

job description. A liaison’s duties can range from patient advocate and patient 

administrator, to counselor, finance clerk, driver, tour guide, first sergeant, and 

friend. The LNO is the one consistent person who wounded warriors can rely on. 

Reassurance is essential; while some soldiers are independent, others need handholding every step of the way. One LNO made the following remark: 

In one hour, I may be picking up baggage, taking soldiers to appointments, picking 

up families at the airport, communicating with downrange units, tracking down 

a missing meal card, and running to Subway to get a sandwich for an inpatient 

soldier.

The LNO offices are located in the multilevel trailer units that were built to 

accommodate the multiple administrative roles needed during the wars. LNOs, 

however, are rarely in those offices. They are constantly talking, moving, and 

multitasking. While the job entails a great deal of unpredictability, what every 

LNO does know for sure is that no moment can ever be wasted. 

Liaison Force Structure

LNOs are assigned to LRMC by their respective units. During the height 

of the war, there were more than 40 LNOs responding to the three to five flights 

coming in per day from Iraq and Afghanistan. Some countries had their own 

LNO for coalition patients. If this was not the case, PAD (Patient Administration 

Division) assigned an LNO for those patients as well. Although the numbers of 

LNO personnel needed to staff the various branches has fluctuated over the years 

in response to war needs and demands (from 7 to 40), the liaison force structure 

for all military branches, on average, has included the following: 

• Army Liaison Force Structure. Army liaisons have 26 members paired up 

to cover their respective post assignments. Army LNOs are deployed to 

LRMC from 6 months to 1 year. Army liaisons include two National 

Guard LNOs and four Reserve LNOs; 18 of them are active duty, 

including a senior Army LNO, for a total of 24 LNOs.

• Air Force Liaison Force Structure. The Air Force has two liaisons deployed 

to LRMC. Both are enlisted positions filled by either reservists or active 

duty service members. These service members are deployed to LRMC 

for 150 to 179 days. One of the Air Force liaisons also serves as the 

noncommissioned officer in charge (NCOIC) of the 86th Medical 

Squadron’s Deployer Flight.

• Navy Liaison Force Structure. The Navy Liaison Office is a detachment 

from other naval hospitals across Europe who have been reassigned to 
LIAISONS 27

represent the Navy as LNO officers at LRMC. All four LNO sailors are 

on 3-year permanent change-of-station orders. The four Navy LNO 

personnel are: (1) chief hospital corpsman (FMF [Fleet Marine Forces]), 

officer in charge, Navy Liaison Detachment; (2) hospital corpsman 

first class (FMF), lead petty officer; (3) hospital corpsman second class 

(FMF), Navy liaison; and (4) hospital corpsman second class, Navy 

liaison. All Navy liaisons are active duty. All sailors in the Navy Liaison 

Office are trained in the same manner from top to bottom. This ensures 

that the care provided to wounded sailors and Marines is the same across 

the board. 

• Marine Liaison Force Structure. The Landstuhl Marines are a detachment 

of Wounded Warrior Battalion–East, based out of Camp Lejeune, 

North Carolina. The nine Marine liaisons, all reservists, are deployed on 

2-year, permanent change-of-station orders. The religious ministry team 

attached to the Marine liaison team has one Navy chaplain and one 

chaplain’s assistant (an E-5; religious program specialist second class).

Liaison Duties

Duties of the liaison include the following:

• tracking inbound patients,

• meeting new patients, 

• monitoring patients by keeping daily track of their whereabouts and 

medical progress, 

• assisting patients,

• assisting families of patients,

• assisting discharged patients,

• assisting other liaisons and agencies, and 

• providing communication.

TRACKING INBOUND PATIENTS 

Continual monitoring of all inbound and outbound aeromedical evacuation 

traffic occurs through the TRANSCOM Regulating and Command & Control 

Evacuation System (TRAC2ES). Liaisons meet every flight to receive the patients.

Planning and preparing for patient arrivals and departures are challenges that 

demand extensive flexibility for the LNO because of the dynamic nature of flight 

schedules and changing patient conditions. The liaison must sort out who is here 

for what reason, and correctly identify arriving patients by service branch, as well 

as any attendants who are accompanying them. The LNO is responsible for the 

whereabouts of all medical patients and non-medical escorts on the flight manifest 

in TRAC2ES. Liaisons must also make special arrangements and notifications 
28 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

for distinguished visitors (DVs) who come to LRMC to meet with the patients 

and tour the facility. Every DV has an LNO assigned to them, paired by military 

branch of service. 

The Deployed Warrior Medical Management Center (DWMMC) mission 

team provides a finalized manifest via e-mail and contacts liaisons approximately 

2 hours in advance of flight arrival. Flights are scheduled from several downrange 

bases and do not arrive on a particular schedule. Liaisons meet flights at various 

times throughout the day and night, depending on aeromedical evacuation patient 

requirements, aircraft availability, and weather conditions. 

The liaison enters information on every identified inbound patient into the 

database and prepares an arrival information package. This requires researching 

the aeromedical evacuation mission’s information in TRAC2ES and researching 

the TRAC2ES patient medical record. The purpose of this initial data collection 

is to understand the patient’s condition and needs, to prepare for any special 

requirements, to establish downrange and home station communication, and 

to amend the daily status of patient reports for several chains of command 

throughout the Department of Defense.

 LRMC also receives “ghost” patients on an unpredictable basis. Ghost 

patients refer to those soldiers, contractors, etc, stationed in other areas of the 

world (ie, other parts of Europe, Africa, and Egypt) who are in need of medical 

care or evaluation, and their location of deployment lacks this capability. They are 

therefore sent to LRMC for care, but they are not patients normally tracked by 

local patient administration or who are within the aeromedical evacuation system. 

Ghost patients arrive unexpectedly and require “work on the fly” to address their 

needs because they are not tracked in TRAC2ES. They typically arrive via normal 

military air rotations from downrange or, in some cases, via commercial air. 

LNOs must then ensure that transportation is provided to and from the Ramstein 

Passenger Terminal and Frankfurt Airport. 

MEETING NEW PATIENTS 

Regardless of time of day or any weather condition, each liaison is present 

to meet the AMBUS (ambulance bus) on arrival in front of the hospital. The 

liaison meets individually with each patient (and escort, if required), provides a 

personal briefing, collects all required information, identifies any initial needs, and 

establishes rapport. This initial meeting often sets patients at ease and provides a 

sense of comfort knowing that another soldier, airman, sailor, or Marine is there 

for them at all times. 

Initial needs vary by patient, but may include some of the following:

• provision of a CAC (Common Access Card),

• reception,

• post exchange vouchers,
LIAISONS 29

• finance support, 

• uniforms and physical training gear,

• baggage,

• clothing,

• toiletries and other items,

• lodging,

• tours,

• contacting next of kin,

• escorting to an initial appointment, and

• addressing emergent care requirements.

Once initial needs are addressed, the liaison advises the patient to stay 

in contact with his or her family, deployed unit leadership, and home station 

leadership. It is vitally important that the patient do so because liaisons are heavily 

restricted by HIPAA (Health Insurance Portability and Accountability Act) 

privacy laws. 

In the event that a ghost patient arrives, the liaison must escort this person 

through the entire DWMMC process, including all in-processing. The liaison 

must also escort the patient to the Medical Transient Detachment (MTD) or, in 

the case of a DV, to the Fisher House or Ramstein Inn to establish billeting. The 

liaison must also coordinate initial appointments for these patients. When LRMC 

receives a DV, the liaison must make lodging and transportation arrangements, 

and contact appropriate personnel (including LRMC Public Affairs) to ensure that 

hospital leadership is aware and available, as necessary. The liaison also escorts the 

patient to and from appointments and addresses all other needs.

MONITORING PATIENTS

Patients are tracked daily by liaisons. The liaisons are responsible for knowing 

where each patient is housed, monitoring the attendance of all scheduled visits, 

and following their progression of care. To track patient care and keep it moving 

forward, liaisons are responsible for the following:

• contacting the patient directly;

• accessing the Theater Medical Data Store (TMDS) to view 

appointments (when updated), working with DWMMC Case 

Management to access the Armed Forces Health Longitudinal 

Technology Application (AHLTA) to determine the medical status of 

the patient; and

• contacting a particular inpatient ward for updates (neither liaisons nor 

Case Management have access to Essentris, the inpatient electronic 

medical record system).
30 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Liaisons visit every inpatient daily. Patients are often housed in rooms alone 

with limited access to the outside world. Liaisons help bridge this gap by checking 

on the patient’s care and providing a listening ear. This is especially valuable for 

those patients undergoing specialty care not available at LRMC, but at other 

German civilian hospitals (ie, Saarland University Medical Center, Homberg, or 

University Hospital Regensburg) because a liaison is often the only American face 

they will see during their stay.

Liaisons also keep track of the whereabouts of all nonmedical patient 

attendants (escorts) and provide nearly the same services for them as well. They 

serve in an oversight role to make sure that patients and escorts meet their 

obligations, such as attending all required appointments (including physically 

escorting patients to their appointments, as needed) and complying with all 

LRMC and MTD rules. Liaisons ensure patient and escort accountability, and 

coordinate administrative action with downrange leadership and home station 

leadership. This often requires liaisons to physically track down patients to get 

them to wherever they are required to be at any given point in time. 

ASSISTING PATIENTS

The liaison assists patients for specific reasons, such as the following: 

• Escorting them to and from scheduled appointments, which is 

especially critical for patients undergoing sedation. The liaisons 

must remain with patients for the extent of the appointment. This 

responsibility also includes appointments at Ramstein Air Base 

(typically dental) and at civilian hospitals in the area for specialty care 

not available at LRMC. 

• Escorting patients requiring additional medical attention (those with 

limited movement or who are wheelchair bound, etc).

• Obtaining prescribed medications. 

• Acquiring necessities, such as toiletries, clothing, snacks, books, etc, 

from the Chaplain’s Closet (see Chapter 9, Chaplain Services), the 

hospital shopette, or Ramstein Base Exchange.

• Locating patients’ baggage from storage or following up on missing 

baggage with local baggage handlers, local and downrange contingency 

aeromedical staging facilities, and airlines.

• Transporting patients to and from Ramstein Air Base, local community 

services, and Frankfurt Airport.

• Helping patients replace a CAC.

• Helping patients address Government Travel Card loss.

• Working with Personnel Support for Contingency Operations 

(PERSCO) and downrange units to obtain patients’ military orders. 
LIAISONS 31

This is particularly difficult when dealing with classified orders, because 

the liaison must coordinate Secret Internet Protocol Router Network 

(SIPRNET) communication and printing with Ramstein Medical 

Readiness.

ASSISTING FAMILIES OF PATIENTS 

Sometimes a patient’s medical condition necessitates bringing his or her 

family to visit for a given amount of time. The liaison coordinates emergency 

family medical travel via points of contact in Washington, DC. The liaison is 

then assigned to those family members for the entire duration they are at LRMC 

and provides one-on-one support. They ensure that family members have 

transportation, lodging, food, compassionate care, and assistance from appropriate 

caregivers. The liaison is responsible for the following: 

• making billeting arrangements (a room is reserved at the Fisher House 

prior to their arrival for families visiting a seriously injured recovering 

warrior) so that families are close to their loved ones and are provided 

with a comfortable environment where they can share a common bond 

with others experiencing similar challenges; 

• transporting the family to and from Frankfurt Airport;

• escorting the family to the patient;

• transporting the family to other services (for food, personal needs, etc.);

• helping with arrangements in the event of the patient’s death;

• ensuring that the recovering warriors have contacted family members by 

phone, e-mail, or both; and 

• arranging both pastoral care and holistic recovery services.

The patient and his or her family are the highest priority for the liaison, who 

establishes a unique rapport with both. The liaison is the face of the US military 

and is there to help families cope with a variety of circumstances. 

ASSISTING DISCHARGED PATIENTS

Once LRMC discharges a patient, the liaison helps that patient with outprocessing. This includes the following:

• outprocessing at the MTD;

• acquiring additional baggage, if necessary;

• coordinating baggage storage and pickup;

• assisting with ground transportation; 

• coordinating aeromedical evacuation with home station patient 

administration;
32 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

• coordinating individual body armor shipment (about a third of the 

outpatient soldiers arrive with their body armor)—this is an important 

part of the discharge processing because the armor is very expensive and 

both the soldier and LNO are responsible for keeping track of it; 

• coordinating stateside aeromedical evacuation changes to meet patient 

or family needs; and

• providing the patient’s downrange units with a patient release letter.

ASSISTING OTHER LIAISONS AND AGENCIES

Liaisons work daily with active duty, Army National Guard, and Army 

Reserve counterparts to improve patient understanding and navigation of medical 

and nonmedical processes associated with their care and benefits. When working 

with seriously injured patients and their families, especially those requiring indepth support, liaisons often work across service lines to assist liaisons from other 

branches to meet mission requirements. 

PROVIDING COMMUNICATION

“My phone never stops ringing.” This is a statement that is likely to be made 

by every LNO at LRMC. The liaison serves as the central point of contact for all 

wounded warriors at LRMC in fielding calls and e-mails around the clock from 

downrange units, home stations, various commands, and patient families. Both 

units and families require real-time information and sometimes direct patient 

communication regarding the patient’s care or status. Calls come in at all hours 

of the day and night for updates. The day starts in Afghanistan at 0700, which 

is 0500 in Germany. Families of wounded warriors often contact the Family 

Readiness Group, who in turn contacts the LNO to get information about their 

loved ones. 

To help streamline this process, each liaison has a work cell phone, enabling 

contact 24 hours a day, 7 days a week, 365 days a year. Home Internet access 

is also needed to review both TRAC2ES and the daily status of patient reports. 

In the event that more thorough information is required to assist information 

requests, the liaison readily returns to the office, regardless of the time of day or 

night, to access available resources and immediately answer information requests.

Most importantly, liaisons meet with both inpatients and outpatients at 

LRMC and at civilian hospitals in the area to address their needs. Based on 

appointment and procedure scheduling, the liaison is often with patients any time 

during the day and night. As a courtesy, the liaison attempts to contact patient 

units to provide them with an LRMC point of contact. The assigned liaisons 

are responsible for contacting the units of every active duty, Guard, and reserve 

wounded warrior, including those in classified locations. Liaisons must rely on 
LIAISONS 33

each patient to provide accurate point-of-contact information because it is all but 

impossible to know deployed points of contact for every unit. In the vast majority 

of patient encounters, however, the liaison is often researching point-of-contact 

information based on just a last name (often misspelled) for each patient, and 

utilizing Air Force and Army global directories to locate a telephone number or 

e-mail address. 

Unfortunately, in some instances, the contact information is simply not 

available, and liaisons must stand by for the unit to reach out to them. Liaisons do 

attempt to reach out to the deployed unit base operator to attempt to find a phone 

number for the patient’s unit. The liaisons then attempt to establish an appropriate 

point of contact (typically a commander, first sergeant, or supervisor). Liaisons do 

their best to keep everyone informed about patient status in a timely manner, via 

telephone and e-mail. The immediate needs of patients and families always take 

priority. Because of HIPPA communication limitations, liaisons also rely on the 

patients themselves, the vast majority of whom are ambulatory and cognizant, to 

communicate with their respective units and keep them apprised of their status.

Service-Specific Duties of Liaisons

• Army Liaisons. The Army line-of-duty letter for soldiers in the reserve 

and National Guard states that the injured soldier was seen and treated 

at LRMC. The soldier then has this letter to verify that he or she was 

seen for a specific ailment or injury. The line-of-duty letter ensures that 

any necessary follow-up care needed as a result of injury or ailment 

sustained during deployment is covered by the military if soldiers are redeployed or visit their own primary care physician through TRICARE. 

• Air Force Liaisons. Air Force liaisons maintain an ongoing relationship 

with the Ramstein recovery assistance coordinator, who is responsible 

for providing training, attending face-to-face meetings, and ensuring 

that communication flows back to patient home stations via recovery 

assistance channels. Liaisons also work with the Ramstein Airman and 

Family Readiness Center to help patients and families with other needs. 

Upon learning of the transfer of an injured airman, the Air Force liaison 

enters the new patient’s name into the Air Force Wounded Warrior 

(AFW2) database and prepares an AFW2 arrival information package.

• Navy Liaisons. All wounded warriors who are returning on a military 

air MEDEVAC (medical evacuation) flight are required to have funded 

orders with a line of accounting. Outpatient travel for Navy and Coast 

Guard personnel are funded by the individual’s command. Inpatient 

travel is chargeable to the US Navy Bureau of Medicine and Surgery. 

The Navy liaisons are provided a line of accounting at the beginning of 
34 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

each fiscal year for the purpose of writing inpatient MEDEVAC orders 

for all Navy, Marine Corps, and Coast Guard personnel receiving care 

in Landstuhl. The Navy liaisons also act as medical case managers, 

providing daily medical updates to commands downrange via TMDS, 

e-mail, and telephone. Liaisons also work with LRMC providers to 

identify the receiving physicians in CONUS (continental United States), 

including the occasional civilian facility for Coast Guard patients, and to 

provide continuity of care. 

• Marine Liaisons. Marine liaisons have a flight line escort specifically 

dedicated to arriving and departing Marine patients. The Marine 

LNO goes directly to Ramstein to receive the injured patients, rather 

than waiting for the AMBUS to arrive at LRMC. While the other 

service branch LNOs say good-bye to their patients at LRMC, the 

Marine LNO escorts them back to Ramstein to either return to their 

deployed units or transfer to CONUS. They also provide congressional 

notification forms to notify the injured Marine’s congressperson and 

invitational travel order requests to the US Marine Corps Casualty 

Branch. In addition, they provide outpatient transfer orders for the 

patients. The US Marine Corps culture dictates that Marines care for 

each other as much as possible. The flight line liaison provides direct 

accountability at the earliest possible moment and provides a final 

handoff at the last possible moment. 

ADDITIONAL TRACKING TOOLS

Liaisons frequently communicate with each other and rely on peer feedback 

to share ideas of “what works and what does not” in terms of the multiple demands 

and multitasking that is a part of their daily routine. LNOs also have access to a 

variety of different reports to track information on patients, including the following: 

• patient air evacuation report,

• daily patient tracking report,

• host nation liaison report,

• daily departure report, and

• TRAC2ES.

LESSONS LEARNED 

What is it that keeps pushing a person to keep going, to answer that 200th 

phone call, to coordinate just one more appointment, or to meet another AMBUS 

at 0500? Staff Sergeant Kevin Kirkpatrick, an LNO at LRMC, reflected a moment 

before answering that question: 
LIAISONS 35

On those really hard days when you are truly ready to collapse because you are just 

that dog tired; when you begin having mirage images of your own bed because 

you have put in so many hours and addressed so many needs, you do wonder what 

keeps you going. I thought I knew what “service” was. Then I came to Landstuhl, 

assigned as a liaison officer, and the word “service” took on a whole new 

dimension. This is real life and the real stuff of people’s lives; nothing superficial. It 

is humbling and life-changing to hear so many stories from wounded warriors who 

never complain or question, “why me?” They will simply tell you they were serving 

their country and this is what happened. What keeps you going is the strength of 

the human spirit, the exchange of human connection, the humbling experience of 

seeing untold suffering and wondering why it is them and not you. It is a complete 

giving of self—service felt at a visceral level. And on those really hard days, that is 

what drives you to continue to do more. 

It is impossible to overstate the liaison’s importance to wounded warriors and 

their families. This role is a vital contribution to the success of the seamless flow at 

LRMC, and demands a wide range of professional and personal skills. The LNO 

is a person who needs to be highly organized and efficient, with navigational savvy, 

because he or she is required to access multiple systems and facilities throughout 

the Kaiserslautern Military Community and local area. Flexibility is essential 

because job responsibilities can vary from minute to minute, and schedules can 

dictate meeting patient and family needs at all hours of the day or night. The 

role of the LNO takes a great deal of maturity and personal strength to deal with 

unpredictable and sometimes difficult situations. Although all such skills are 

essential, empathy is perhaps the most important, because LNOs are people with 

the ability to continually offer that friendly smile even when they cannot recall the 

last time they closed their eyes. 

Successes

• Patient reception. Depending on wind, weather, and international 

airspace permission, it can take anywhere from 7 to 10 hours to fly 

from Afghanistan to Germany. Ambulatory wounded warriors step off 

the AMBUS tired, hungry, and often sick or in pain. Seriously injured 

patients are on stretchers, some intubated and unable to communicate. 

The LNO is one of the first to greet the patients on arrival to LRMC 

and sets the tone for the duration of their stay until departure. This 

initial interaction provides a great deal of comfort and stability for 

wounded warriors. During the reception, the LNO explains the general 
36 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

process and what to expect while at LRMC. This time also allows the 

patients to ask any questions or share any concerns that they may have. 

• Efficient communication with parent and operational command. In the 

past, LRMC was called the “land of the lost” because patients arrived 

there and were not heard from for days or weeks on end. Status updates 

were not provided, and downrange units were uncertain what was 

happening to their soldiers: if they were returning to their units or being 

transferred for continuous care. The liaison has changed all of that. 

Notification e-mails are now sent by the liaison to both the patient’s 

downrange and home stations within 8 hours of the patient’s arrival. 

Leadership is informed every step of the way as they are updated with 

the patient’s medical and logistical status while at LRMC. If a decision 

is made to transfer a soldier to CONUS, both the unit and receiving 

hospital are frequently updated with medical status, flight itineraries, 

and when “wheels up” occurs. This reciprocal dialogue has been greatly 

appreciated by the patients and their units, and has alleviated much 

stress. Direct contact information is also given to the unit to be passed on 

to the patient’s family. The patient is given access to call the home station 

or deployed units.

The Air Force LNO notifies the Casualty Affairs Office of the 

patient’s arrival and the names of family members requested to be 

at bedside, if applicable. Bringing family members to the patient’s 

bedside in a timely manner is a team effort. There is a strong working 

relationship with the Casualty Affairs Office, which provides the orders 

enabling families to come to LRMC and ensures that expenses are 

covered. 

Challenges 

• Patient attendants/escorts. Certain circumstances require the need for an 

escort to accompany wounded warriors to LRMC. In the majority of 

situations, the escort is another soldier from the same downrange unit. 

The escort is usually told at the last minute that he or she is escorting a 

patient to LRMC and to come right back. The escorts and their units 

are often under the impression that they will be released immediately 

to return downrange once they have arrived with the wounded warrior 

at LRMC. It usually comes as a shock when they arrive at LRMC 

and are then told that they are not immediately returning, and are 

given other duties and responsibilities. There are situations in which 

patients need someone with them at all times because of a concern 

they could potentially harm themselves or other personnel. Even if 
LIAISONS 37

the soldier is being treated as an outpatient, the escort needs to be 

with the soldier at all times. Other patients may need to be wheeled 

around to appointments or need help with getting or eating food, etc. 

Although the liaison is an extraordinary support to wounded warriors, 

the workload and the volume of patients do not realistically enable 

the liaison to address patient needs on a one-to-one basis. Downrange 

leadership needs to inform the escort of what will be expected of him or 

her prior to arrival at LRMC. Often, the liaison must deal with both the 

injured or sick soldier and a disgruntled escort. 

• External interference with the patient movement process. In certain 

situations, unique arrangements are made by the patients themselves, 

which deviates from the LRMC standard operating procedures, thus 

making their accountability more difficult for the LNOs. For example, 

some patients do not adhere to standard procedures, such as taking bus 

transportation from the MTD to the passenger terminal; instead, they 

take it upon themselves to make their own travel arrangements. Other 

times, patients have their commander’s permission to deviate from the 

process, such as flying out of Frankfurt Airport instead of Ramstein. This 

causes time away from the mission because the LNO is asked to make 

these special arrangements, accompany the patient to the specific airport, 

maintain accountability of that separate flight status, and track when 

that individual arrives at his or her destination. 

• Resiliency and compassion fatigue. The liaison mission is maintained 24 

hours a day, 7 days a week. At the height of the wars, or when attending 

to unusual circumstances or complications with wounded warriors, 

liaisons sometimes work 19 hours daily. There is very little to no “down 

time.” This is both physically and emotionally stressful and exhausting. 

It is therefore imperative that LNOs work as a solid team, with seamless 

debriefings when duties are taken over to maintain mission continuity. 

Flexibility is key. A good working relationship leads to a good working 

schedule.

It is imperative for the LNOs to take the time to meet with 

the Combat and Operational Stress Reaction/Staff Resiliency Team. 

Although this is not a mandatory requirement, it is extremely beneficial 

given the constant stress and demands of the LNO and the LRMC staff 

in general. This team’s mission is to promote resiliency and to identify 

and treat operational stress and compassion fatigue via prevention 

and intervention efforts. The important aspect for anyone seeking 

intervention is that the counseling is done on a one-to-one basis 

and remains confidential. This policy is particularly essential and has 
38 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

alleviated some of the reluctance of staff to meet and talk with the team 

for fear it would not remain private information. The Resiliency Team 

also arranges weekly game and pizza nights as a fun and relaxing event. 

This has been very popular.

• High staff turnover/no current overlap time in place for training. The 

LNOs are comprised of Army, Navy, Marine, and Air Force deployed 

personnel. All LNOs are deployed for 1 year, except the Air Force LNOs 

who are deployed for 6 months. It is crucial to ensure that overlap 

training is built into the deployment orders for the LNOs. With no 

overlap training, it could lead to degradation in the mission. 

• Lack of representation from all stateside units. LNOs are deployed to 

LRMC from their stateside military bases to represent and serve those 

soldiers from their units who have been injured in the war and sent to 

LRMC for treatment. Some of the large US military units with many 

soldiers deployed to Iraq and Afghanistan have not, however, sent 

an LNO to serve at LRMC. This has been a challenge because every 

wounded warrior at LRMC is required to have an assigned LNO. 

The accountability and needs of these soldiers are then divided up 

among the LNOs from other units, which adds additional stress and 

time commitment. It is not as much of a problem for the smaller units 

without an LNO representative because the numbers of injured soldiers 

are proportionately less and therefore manageable. It is a much bigger 

challenge for the larger units sending hundreds of soldiers into theater, 

with a much higher percentage likely to arrive at LRMC for treatment 

of various sorts. The support of the LNO cannot be underestimated, 

and is particularly paramount when the injured solider comes off of the 

AMBUS and is greeted and reassured by an LNO from his or her home 

unit. It is like being greeted by an old friend, and immediately reduces 

stress and anxiety. Although soldiers from other units are given equal time 

and assistance, they feel disappointed that someone from their home unit 

is not there to support them. The importance of every US military unit 

sending representation is essential in terms of both workload and soldier 

morale. 
LIAISONS 39

ACKNOWLEDGMENTS

The authors would like to thank Lieutenant Colonel William Branch, Detachment 

Officer in Charge, US Marine Corps Wounded Warrior Battalion–East; Chief 

Master Sergeant Charles Frizzell, Senior Master Sergeant Gloria Portillo-Leanos, 

and Master Sergeant Philip Gilbert, US Air Force Liaisons; Lieutenant Colonel 

Brenda Corrunker, US Air Force; Master Sergeant Luis Sanchez, Senior Army 

Liaison; Staff Sergeant Kevin Kirkpatrick, US Army; and HMF (FMF) David 

Livesay, Officer in Charge, Navy/Marine Corps Fleet Liaison Detachment.

REFERENCES

1. Melancon D. Liaisons ‘watch over’ Landstuhl’s wounded. May 25, 2007. 

US Army news website. http://www.army.mil/article/3343/Liaisons___039_

watch_over__039__Landstuhl__039_s_wounded/. Accessed January 28, 

2015. 

2. Mission statement provided by Lieutenant Colonel Brenda Corrunker, US 

Air Force, Liaison, Landstuhl Regional Medical Center. 
Medical Transient Detachment facility at Landstuhl Regional 

Medical Center.

Photograph courtesy of Captain Marcus McGee, US Army.
CHAPTER FOUR

Medical Transient Detachment

“Servients Nostri Vulnerati” (Serving Our Wounded)

I grew up in a family of 12 siblings, and all that I do is based on my 

upbringing and family morals and traditions. If anyone needed assistance, 

my family always made an effort to lend a helping hand because others 

helped us when we were in need. That will always be instilled in me. 

I treat everyone as I would like to be treated. I was hand-picked as 

First Sergeant at the MTD [Medical Transient Detachment], and my 

responsibility was to take care of those soldiers the best way I could. 

I believed that all warriors deserved the best during their transition. 

Every day, I personally asked every wounded warrior if they had an 

anniversary or a birthday, and, if so, I recognized them in the formation. 

This could have been embarrassing for some because we did sing 

Happy Birthday. I also bought lunch or dinner out of my own pocket for 

every wounded warrior who had a birthday while at the MTD. This was 

my way of giving back to all who served in harm’s way, for what they have 

done, and for what they will continue to do. 

FIRST SERGEANT LARRY McGOWAN

LANDSTUHL REGIONAL MEDICAL CENTER, GERMANY

DECEMBER 2007–JUNE 2009

Driving along the campus at Landstuhl Regional Medical Center 

(LRMC), one may not take particular notice of the two white stucco 

buildings that blend in with the rest of the architecture. Yet these 

buildings now represent an essential unit at Landstuhl, as well as one of the 

most essential lessons learned during this war. Walking into the buildings is 

like walking into a hotel: there is a warm and cozy sitting area with a television 

adjacent to the reception desk, there is a smiling soldier extending a greeting, and 

there is a glass jar filled with candy. It is not unusual to smell fresh coffee brewing 
42 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

or freshly baked cookies coming out of the oven. One soldier commented that 

“this feels like the Taj Mahal compared to sleeping in a tent in the desert.” 

This renovated former Air Force hotel on the hospital premises is more like 

home, or at least pretty close to it. It is actually home to the Medical Transient 

Detachment (MTD), an organization responsible for overseeing the needs of 

those men and women who are in transient status while receiving outpatient 

care at LRMC. Although the actual physical structure was not renovated until 

2007, the organization itself was established in 2003 with the responsibility of 

providing local mission command functions for soldiers, airmen, sailors, and 

Marines evacuated from Operation Iraqi Freedom (OIF), Operation Enduring 

Freedom (OEF), and Operation New Dawn. Although the MTD and Deployed 

Warrior Medical Management Center (DWMMC) are tightly linked and work 

in close coordination with each other, they are two separate organizations with 

separate leadership structures. Although the DWMMC tracks patient movement 

in the aeromedical evacuation system from downrange to Landstuhl and then 

coordinates the patient’s medical and logistical needs, the DWMMC is not 

involved in overseeing each soldier on a daily basis. 

While duty, honor, and responsibility encompass the backbone code of 

ethics of every infrastructure unit entrusted to care for the thousands of wounded 

warriors at LRMC, the MTD goes to a level of accountability even deeper than 

that. Each MTD cadre is responsible for tracking the whereabouts of all of their 

patients, all day and every day, regardless of rank or service affiliation. This daily 

proximity, constant interaction, and ongoing support lend themselves to a level 

of commitment and reciprocal personal impact that cannot be underestimated. 

Sergeant Major Larry McGowan states, “I wanted to provide the best care that I 

could based on my position and responsibility. I was able to listen to their stories 

of what they had gone through during their deployment and the reasons they 

were sent to Landstuhl. I participated in the group discussion of those soldiers 

with posttraumatic stress disorder (PTSD) and reassured them that things would 

get better. When soldiers didn’t want to open up, I coached them as a senior 

leader, always reassuring them that what was said at the MTD would stay at the 

MTD.”

The mission of the MTD is as follows: To provide company-level mission 

command, administrative and logistical support, and quality of life needs to the 

evacuated wounded, ill, and injured service members, and all we are privileged to serve.1

BACKGROUND

After creation of the DWMMC in 2002, it became apparent that a formal 

system of mission command was necessary for service members transferred to 

LRMC for outpatient care. In the summer of 2003, LRMC was inundated 
MEDICAL TRANSIENT DETACHMENT 43

with sick and injured service members from OIF who needed the next role of 

medical treatment care. Not every soldier required inpatient care, and those who 

did not needed a place to stay. Initially, all outpatient wounded warriors were 

housed at Kleber Kaserne, the primary inprocessing/outprocessing center for 

the Kaiserslautern Military Community, and the location of the 21st Theater 

Sustainment Command (TSC). Kleber Kaserne had the capacity to house 300 

patients in barracks. An entire building was designated to provide lodging for 

transient wounded warriors receiving outpatient care at LRMC. Although this 

facility provided the much-needed housing, the solution came at a logistical 

cost. Kleber Kaserne was 25 miles away from LRMC. This distance made both 

scheduling and attending appointments difficult for patients. It also limited the 

overall scope of command control. Staff members at LRMC were tasked with 

attending to the nightly charge of quarters on the billets housing these wounded 

warriors. This placed a heavy responsibility on staff lacking any true authority 

over these individuals. 

Over time, LRMC was no longer able to maintain control and 

accountability of the continual large influx of evacuated patients from wars in 

Afghanistan and Iraq. Although the DWMMC was efficiently managing the 

process of bringing patients in and out of Landstuhl, it did not have the staff or 

command authority to deal with the increasingly problematic administrative and 

personnel issues. The DWMMC’s authority was limited to patient care only. 

After several legal incidents, it became evident that a separate system for mission 

command specifically addressing the needs of these outpatients was necessary. 

Tasking soldiers to merely keep an eye on the patients did not work, and written 

policies were needed. Therefore, it was determined that some type of oversight 

was essential, and a formal system of mission command was required.

 The MTD was then created in 2003 for this purpose. It was initially staffed 

with a commander, a first sergeant, five platoon sergeants, and three soldiers to 

perform administrative functions. During this time, the MTD was averaging 

a total of 180 to 200 outpatients, with daily in- and outprocessing of 20 to 

40 personnel. In April 2004, during the First Battle of Fallujah in Iraq, Kleber 

Kaserne nearly reached its maximum occupancy of more than 280 soldiers, 

sailors, airmen, and Marines staying in the barracks while receiving care at 

LRMC. This was a daunting task for the MTD, which was staffed with only 10 

personnel now overseeing nearly 300 patients. 

Mission command of the MTD remained the responsibility of LRMC from 

2003 to 2005. When it became increasingly problematic to provide available 

personnel for this level of patient support, the 21st TSC agreed to take on the role 

and provide mission command for patients evacuated to LRMC. Unfortunately, 

there was a lack of medical management and coordination between the 21st TSC 
44 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

and LRMC. Poor communication between personnel at LRMC and Kleber 

Kaserne resulted in patients missing appointments because they were either 

uninformed or simply did not show up. The MTD staffing at Kleber Kaserne was 

limited, and it was impossible for this small cadre to keep track of hundreds of 

patients effectively and make sure that they were following orders. Patients were 

assigned case managers, but the distance in location and poor communication 

also made it difficult for them to effectively and efficiently provide quality care. 

The culmination of these problems had further-reaching effects beyond the 

boundaries of LRMC and Kleber Kaserne. Downrange units were negatively 

impacted because there was no established timeline for returning these wounded 

warriors to duty. Outpatient stays were delayed at LRMC because of the lack of 

sufficient numbers of local mission command staffing and overall disorganization. 

As time went on, it also became increasingly apparent that the lodging 

facilities were inadequate and contributed to the multiple problems. The 

10-person, open-bay rooms at Kleber Kaserne were noisy and lacked privacy 

and comfort. The 30-minute bus commute to LRMC for appointments with 

doctors, therapists, liaisons, and case managers was inconvenient.2

 Morale and 

quality of life were adversely impacted by the limited amenities and suboptimal 

accommodations. It was clear that a new facility was needed to better serve 

patients and give them the dignity and care they deserved. 

The current facility was renovated in 2007 on the grounds of LRMC, and the 

overall responsibility for the MTD unit was placed back under LRMC command. 

Outpatient soldiers were moved on post, now closer to their appointments. At 

this time, the Table of Distribution and Allowances—used for the Army Warrior 

Transition Units (WTUs)—was applied to the MTD to improve the cadre-topatient ratios. It remains the current staffing structure used today. 

IMPLEMENTATION OF MEDICAL TRANSIENT DETACHMENT 

Leadership and Staffing

There is no other organization exactly like the MTD, although the Soldier Family 

Readiness Center at Walter Reed National Military Medical Center does replicate 

some functions handled at LRMC. WTUs replicate the MTD’s local mission 

command function with a more long-term focus, whereas the MTD focuses on 

short-term support to all branches of the US military. 

MTD leadership is comprised of a commander and a first sergeant. Their 

key tasks are to maintain the following:

• mission command of all assigned personnel; 

• daily management of all MTD operations; 

• continuous process improvement (a strategic approach to develop a 

culture of continuous improvement);
MEDICAL TRANSIENT DETACHMENT 45

• joint coordination with DWMMC leadership, LRMC leadership, the 

Patient Administration Division, and various outpatient programs 

(eg, Traumatic Brain Injury, Intensive Outpatient Program for Posttraumatic Stress, Addiction Treatment Facility); 

• personnel evaluations and awards; and 

• subordinate and peer career development. 

The MTD is aligned with the LRMC command structure, with direct 

reporting to the LRMC troop commander and the LRMC medical treatment 

facility commander. The remainder of the MTD staff includes the following: 

• squad leader, 

• platoon sergeants, 

• civilian personnel, and 

• liaison. 

Medical Transient Detachment Structure

The MTD structure is much like the current WTU structure, but functions 

in a different manner. The MTD mission assists service members with either 

returning to duty or transferring to CONUS (continental United States) for 

continued care. Upon arrival at LRMC, the service member is assigned a 

liaison and an MTD squad leader, escorted to the outpatient facility for room 

assignment, and given an initial in-briefing regarding policies and procedures. 

The squad leader is responsible for coordinating efforts between the liaisons, 

DWMMC case managers, LRMC clinics, and MTD leadership to ensure that 

patients are well cared for and move through the system in an efficient and safe 

manner. 

The platoon sergeants are, in turn, responsible for ensuring the 

accountability of all service members. This includes the patients evacuated to 

LRMC, the escorts who accompanied them, and the MTD cadre who provide 

support to the soldiers and carry out typical administrative duties. In addition, 

the MTD platoon sergeant and squad leaders are responsible for ensuring that all 

soldiers adhere to the MTD policies, such as the following: 

• no drinking alcohol while assigned to the MTD;

• no overnight passes (exceptions made on case-by-case basis);

• day passes granted on a case-by-case basis; 

• uniform adherence; 

• computer adherence; 

• daily morning and evening accountability; 

• established curfew of 2300 hours (aligns with closing of USO 

[United Service Organization]);
46 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

• all service members restricted to MTD barracks between 2300 

and 0600 hours;

• escorts must remain with appointed service member at all times;

• no outprocessing from the MTD without appropriate 

confirmation; and 

• possession of contraband, drugs, ammunition, or illegal items is 

prohibited.3

The MTD has civilian personnel who issue vouchers and maintain the 

MTD’s supply of clothing and personal care items. All US Army personnel 

receive a uniform issue if returning from downrange with missing items or 

unserviceable uniforms. They are often evacuated with very few belongings. The 

MTD is authorized to issue to all patients a one-time $250 Army and Air Force 

Exchange Service (AAFES) voucher that can be used to purchase personal care 

and clothing items from the local AAFES stores.3

Another civilian provides S-1 paperwork and administrative functions 

for both cadre and patients receiving care at LRMC. The first sergeant and 

commander provide overall mission command and also have the Uniform Code 

of Military Justice authority for all assigned and attached personnel. 

The “gold standard” goal for anyone returning to CONUS is to provide 

necessary support and to complete an efficient and effective evacuation within 

14 days. This is not an official policy, but rather a goal to strive for, especially 

during the height of the wars when bed space was at capacity. It is not always 

possible to attain because the length of hospital stay varies from patient to patient. 

Some patients have stayed as long as 8 weeks and were then ready to return to 

their units. Although every effort is made to return patients to active duty, some 

patients have to be returned to CONUS, where they have a support structure of 

family, friends, and the local command.

Medical Transient Detachment Capacity

The MTD has had anywhere from 27 to 34 Army and civilian personnel 

overseeing a facility that accommodates a maximum of 218 patients. It provides 

billeting and support services at any given time. When it was needed, additional 

overflow billeting was available at Landstuhl through coordination with the 21st 

TSC installation management office. Coordination with the DWMMC and 

patient liaisons enables the MTD to accommodate the DWMMC throughput, 

including processing patients from the time they arrive at Ramstein Air Base 

(Germany) to the time they leave LRMC and return to their unit or CONUS.
MEDICAL TRANSIENT DETACHMENT 47

Medical Transient Detachment Equipment and Buildings

The MTD outpatient facility is a two-building, four-story structure transformed from a former Air Force hotel. The US Army Garrison Kaiserslautern 

Installation Management Command spent more than $2.9 million renovating 

the two buildings, which are located on the Landstuhl hospital grounds.2 There 

are private rooms designated for senior personnel, and the remainder are twoperson accommodations for a total capacity of 218 patients. Each room is 

generously equipped with one or two private beds, individual locking closets, a 

desk, microwave, mini-refrigerator, cable TV with a DVD player, telephone, and 

computer with free Wi-Fi Internet access and webcam capacity. There are also 

phones in the common area where patients can call anywhere in the world for 

free. Residents can prepare popcorn in their microwave and enjoy a cold soda 

from their mini-refrigerator while watching TV or e-mailing loved ones. They can 

also play video games in the community room, cook a meal in the fully furnished 

kitchen, or use the full-service laundry. It is not unusual for fresh-baked goods 

or donated food to appear in the refrigerator, compliments of many generous 

volunteers, all wanting to help soldiers feel at home.

ADDITIONAL RESOURCES AND SERVICES

• The MTD is responsible for overseeing transportation services 

between Landstuhl, Ramstein Air Base (location of base exchange/post 

exchange), and Kleber Kaserne (location of the Army clothing and sales 

store). There are scheduled bus trips every day to ensure that service 

members have opportunities to use clothing vouchers and have some 

downtime away from the medical center. 

• The MTD coordinates efforts with the Chaplain Service, USO, 

Veterans of Foreign Wars, Soldiers’ Angels, Red Cross, and other 

nonprofit organizations to organize scheduled bus trips to various 

cities and provide morale and welfare services dedicated to the service 

members staying in the MTD. 

• The MTD also coordinates efforts with the LRMC command to 

provide mission command and lodging to the LRMC Addiction 

Treatment Facility, Evolution Posttraumatic Stress Disorder Treatment 

Program, Synapse Traumatic Brain Injury Program, and the Integrated 

Pain Management Center Program personnel. 

• The MTD does not provide command and control or lodging services 

for foreign military personnel, civilians, or dependents. 
48 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Views of the Medical Transient Detachment facility at Landstuhl Regional Medical Center: 

(A) building sign, (B) reception desk, (C) kitchen, and (D) lobby. 

Photographs courtesy of Captain Marcus McGee, US Army.

LESSONS LEARNED

The MTD is an excellent example of a command structure that supports 

all branches of the services. The hospital has treated 61,155 patients evacuated 

from Iraq or Afghanistan, and 21% (12,691) of patients have returned to duty.4

More than 12,000 patients have sustained battle injuries, and 85% of those 

patients are spending less than 96 hours at LRMC.4 From 2007, when the 

building renovations were completed, to the end of 2013, more than 42,000 

outpatients had gone through the MTD.1 The fact that doctors, case managers, 

liaisons, Chaplain Services, and a wide circle of supporters are now just steps 

away has exponentially changed the dynamics of morale and overall quality of 

life for outpatient soldiers. Someone cares and is there to escort, listen, or lighten 

a burden at any corner they turn. This system of 24-hour accountability and 

proximal mission command dramatically increased the safety, security, stability, 

A B

C D
MEDICAL TRANSIENT DETACHMENT 49

and success of patient care. The MTD has done an outstanding job, significantly 

contributing to the impressive mission at LRMC. 

As the US military becomes smaller and military facilities are combined (eg, 

Walter Reed Army Medical Center with the National Naval Medical Center and 

the San Antonio Military Medical Center with the Wilford Hall Ambulatory 

Surgical Center), it is important that future leaders use the MTD command 

structure as an example of how to provide mission command support to patients 

from all service branches of the military. 

Successes

• The MTD has a proven record of helping to decrease lost time from 

downrange units by limiting time spent at LRMC to 14 days or less 

and has directly contributed to the 21% return-to-duty rate for those 

evacuated from theater.4

Life inside the Medical Transient Detachment offers some of the comforts of home: 

(A) bedroom, (B) exercise room, (C) common area and TV room, and (D) the Internet cafe.

Photographs courtesy of Captain Marcus McGee, US Army.

A B

C D
50 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

• Outpatient lodging facilities on the Landstuhl grounds significantly 

cut costs (approximately $5–$6 million dollars/year from paying for 

accommodations for soldiers at the Ramstein Inn).1

• The MTD can be set up at any medium-to-large military medical 

treatment facility provided there are extra required staff and equipment 

to deal with the reoccurring influx of patients from a conflict. 

• The MTD is a great example of how people come together to help 

those who are hurt and in need. There is a unified seamless flow of 

teamwork between all branches interacting and working together. 

Everyone benefits from the reciprocal understanding of each service 

branch and what they do. 

• The MTD is conflict-adaptable and can be altered depending on the 

needs of the patients being evacuated from the theater of operations or 

in a garrison environment. This is perhaps its greatest strength.

• The MTD processes that serve its patient population have been 

institutionalized to the point that most processes are self-regulated 

within the hospital. It has been proven successful for LRMC, and is 

clearly a best practice for contingency missions and may be applicable to 

noncontingency missions in a garrison environment for future utilization.

• The mission command of the MTD ensures safety and security to 

soldiers receiving care, and is essential to maintaining good order and 

discipline. These benefits are seen at the unit, service component, and 

Department of Defense levels.

Challenges

• Justifying the existence of the MTD in a conflict-free military is a 

significant obstacle in maintaining the current operating structure and 

staffing levels. 

• Although the MTD has focused primarily on the deployed soldiers, 

airmen, sailors, and Marines from Afghanistan, it may be necessary to 

use this same structure (and perhaps the same unit) to provide mission 

command and lodging for wounded military in the European area who 

currently travel to LRMC for outpatient specialty services unavailable 

in areas of Bavaria, Italy, and Belgium. If this is the future of the MTD, 

it is imperative that wounded warriors report for orders to the MTD 

(to maintain mission command) and are unaccompanied by family 

members when using the MTD services on a short-term basis (eg, 

specialty provider appointments, outpatient procedures, and MRIs 

[magnetic resonance imaging]). 
MEDICAL TRANSIENT DETACHMENT 51

• Some military hospitals may have barracks and buildings available, but 

are they logistically located? Do they provide optimal accommodations? 

It may be necessary to finance renovations of existing structures or build 

a new facility. This would pose a challenge, especially with fiscally tight 

budgets. Over the long term, however, it would save the government a 

lot of money with lodging costs. 

• Keeping track of every wounded warrior for medical care, especially 

when they were not in transit, is a daunting task. Many still found ways 

to disobey orders and sneak away from the MTD and Landstuhl to go 

downtown and consume alcohol.

• Better training is needed to prepare those assigned to the MTD. Most 

of the soldiers come from an infantry unit and are used to being in 

the field. They are not familiar with medical knowledge or what it 

means for someone to be sick, scared, in pain, or in need of medical 

care. Many of these younger soldiers, both patient and personnel, have 

never been in a hospital. It can be an overwhelming process. The MTD 

would likely benefit from the 2-week WTU Cadre Training. 

When Sergeant Larry McGowan was asked what he would remember the 

most about his time at Landstuhl working for the MTD, he responded with the 

following:

Patients Transitioned Through the Medical Transient Detachment Since FY2007

YEAR NUMBER OF PATIENTS

FY07 5,442

FY08 6,370

FY09 6,351

FY10 8,055

FY11 6,827

FY12 5,002

FY13 3,549

FY14 1,775

TOTAL 43,371

FY: fiscal year

Reproduced from: McGee M, Bond J. Medical Transient Detachment, Landstuhl Regional Medical Center, 

command brief. PowerPoint presentation; April 2014; LRMC, Germany.
52 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

I will always remember October 31, 2008. I invited all those who supported 

the wounded warriors from LRMC and Ramstein to participate in the 

Costume Run. It was a moment that was frightening to the soldiers because the 

announcement over the public affairs system said for all of them to get out of their 

rooms. They were expecting me to bring drug dogs in the barracks. Instead, I had 

my staff, who were all dressed in costumes, turn out the lights and run through 

the barracks yelling “Trick or Treat” and passing out candy. We then invited those 

who were able to go for a run/walk. We actually pushed a wounded warrior 

in a wheelchair along the 2-mile route we ran. What I will remember is how 

important it was to find ways to make those wounded warriors laugh. It really 

was a place to heal at a home away from home.

ACKNOWLEDGMENTS

The author thanks Captain Daniel Yourk, First Sergeant Phillip Madrigal, 

Sergeant First Class Jeffrey Lawrence, and Captain Marcus McGee for their 

invaluable assistance with this chapter.

REFERENCES

1. McGee M, Bond J. Medical Transient Detachment, Landstuhl Regional 

Medical Center, command brief. PowerPoint presentation; April 2014; 

LRMC, Germany.

2. Miles D. Landstuhl Outpatient Facility Makes Good on Promise to 

Wounded Warriors [news release]. American Forces Press Service; 

November 1, 2007. 

3. Medical Transient Detachment, Landstuhl Regional Medical Center. 

MTD Patient Policy Letters. December 18, 2013. 

4. Probus MC. Analyzing the Requirement for a Deployed Warrior Medical 

Management Center Table of Distribution and Allowances at Landstuhl 

Regional Medical Center [thesis]. Waco, TX: Baylor University; 2004.
MEDICAL TRANSIENT DETACHMENT 53

BIBLIOGRAPHY

Cooper RA, Pasquina PF, Drach R, eds. Warrior Transition Leader Medical 

Rehabilitation Handbook. Fort Detrick, MD: Borden Institute; 2011.

Deployed Warrior Medical Management Center [news release]. Landstuhl, 

Germany: Landstuhl Regional Medical Center Public Affairs Office; 

July 2009.

Europe Regional Medical Command (ERMC). Fact Sheet—LRMC history: 

Landstuhl Regional Medical Center. Public Affairs Office. http://ermc.

amedd.army.mil/landstuhl/factsheets/LRMCHistory.pdf. Accessed 

March 13, 2013.

Medical Transient Detachment Sidebar [news release no. 11]. Landstuhl, 

Germany: Landstuhl Regional Medical Center Public Affairs Office; 

April 22, 2008.
Members of the Camp Eggars Force Protection team assess the damage 

of an explosion near the gate on January 17, 2009. A vehicle-borne 

improvised explosive device (VBIED) exploded near the German 

Embassy and a US base in Kabul City, Afghanistan. The VBIED killed and 

wounded multinational personnel and damaged vehicles and nearby 

buildings. 

Photographer: Technical Sergeant Brenda Nipper. Reproduced from: https://www.

dvidshub.net/image/145118/vehicle-born-improvised-explosive-devide-explosionkabul-city-afghanistan#.VuwVgzZf2pq.
CHAPTER FIVE

Traumatic Brain Injury “

It takes only seconds for an explosion to occur. It takes only those same 

seconds for a life to be changed forever. This intersection of an instant in 

time and a relentlessly chronic effect epitomizes the signature wound of the 

Iraq and Afghanistan wars—traumatic brain injury. 

S

ince the United States went to war in Afghanistan in 2001, and Iraq in 

2003, approximately 2 million US military personnel from every branch 

have been deployed to the Middle East.1 The lives of many of these service 

members (SMs) and their families have been drastically impacted due to multiple 

deployments, injuries, and death. Statistics and realities of this magnitude 

have taken a grave toll on both the physical and psychological well-being of 

our fighting soldiers. Traumatic brain injury (TBI) remains the most prevalent 

injury among those who fought during Operation Enduring Freedom (OEF), 

Operation Iraqi Freedom (OIF), and Operation New Dawn (OND).2

Improvised explosive devices (IEDs) are a lethal primary weapon of choice 

used extensively against coalition forces in current warfare. This has significantly 

changed the frontline milieu; death and injury are now measured more by 

“cleverness of bombs rather than the accuracy of bullets.”3

 The deleterious impact 

of this type of warfare is further complicated by multiple deployments in which 

soldiers are repeatedly exposed to ambushes by roadside bombs, IEDs, and the 

effects from blast exposure. 

Iraq is one of the most mine-infested nations in the world. Landmines have 

been uncovered that date back as far as World War II, and since the early 1980s 

this country has been involved in three wars. This ongoing strife meant that Iraqis 

were learning continuously and extensively about explosives. The threat to US 

military came from both the bomb and the bomb maker. By September 2003, 

the design, construction, and technology of IEDs became more complex, and the 

strategies behind using them became more organized and sophisticated.4 
56 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Exposure to a blast, and more significantly repetitive exposure, leaves a 

devastating neurological malady with a range of symptoms, such as memory 

problems, dizziness, sleeplessness, cognition problems, and mood changes. TBI 

occurs when a blow or jolt to the head or a penetrating head injury disrupts brain 

function and damages brain tissue.5 When a blast such as that from an IED occurs, 

there are sudden changes in air pressure resulting in intense winds caused by 

the heat of the explosion and rapid movement of air molecules. Blast waves and 

powerful winds from explosions are strong enough to throw fragments, bodies, 

and even vehicles with tremendous force. These forces damage the brain, resulting 

in different levels of injury from mild (concussion) to severe and even penetrating 

injuries.6

Casualties treated for brain injuries were minimal during prior conflicts. In 

the Vietnam War, for example, mortality rates were greater than 75% for this type 

of injury, and survivors therefore comprised a small fraction of casualties treated 

in hospitals.2 Improvements in helmets and Kevlar (DuPont, Wilmington, DE) 

body armor significantly decreased morbidities and mortalities in the current 

war because they better protect soldiers from bullets and fragments. However, 

even these improved helmets do not offer full protection because they do not 

completely cover the face, head, and neck. They cannot prevent closed-head 

trauma that occurs from blasts.2

TBI has been described as “one of the most complicated injuries to one of 

the most complicated parts of the body.”7 Symptoms range from mild to severe 

and may not necessarily correlate with the level of injury sustained. Physical and 

psychological impacts can be devastating and life altering at both personal and 

military levels. Therefore, development of the TBI program at Landstuhl Regional 

Medical Center (LRMC) was profoundly significant. Its mission is as follows: 

The creation of a network of medical facilities working together to provide 

the required capability to screen, assess, treat, educate, follow-up, and conduct 

surveillance on all military mild and moderate TBI patients residing in the 

European theater.8

BACKGROUND

The “community hospital” atmosphere of LRMC changed in 2001 when 

critical care needs escalated in conjunction with the beginning of the global war on 

terrorism. In 2005, the Trauma Team became aware of TBI as a commonly missed 

injury. This was not altogether surprising because the focus of care was placed on 

more obvious and acute injuries. Casualties were often passed through LRMC, 

and the initial diagnosis of TBI did not occur until patients were seen by medical 

providers in the continental United States (CONUS). The Trauma program at 
TRAUMATIC BRAIN INJURY 57

LRMC then began collaborating with the Neurology Department and Behavioral 

Health Medicine to discuss why this diagnosis was being missed and to identify 

specific resource constraints at LRMC. 

In March 2006, the Defense and Veterans Brain Injury Center (DVBIC) 

provided a Grand Rounds presentation to LRMC on TBI. The Trauma 

program and the Deployed Warrior Medical Management Center (DWMMC) 

subsequently collaborated on the development of a TBI tracking tool. In May 

2006, the DWMMC staff began the initial identification of TBI through a formal, 

but limited, screening of combat casualties. They began collecting data from 

these screenings as well. In August 2006, the DWMMC issued a TBI screening 

policy statement that outlined formal roles and responsibilities for executing the 

TBI screening mission. A clinical management algorithm was implemented in 

November 2006 for those patients identified with mild TBI (also referred to 

as concussion). The Department of Defense (DoD) then modified evacuation 

protocols to route more severely affected patients to other centers with resources 

capable of providing sophisticated TBI rehabilitation. On March 23, 2007, the 

Assistant Secretary of Defense issued a memorandum outlining the consolidation 

of TBI initiatives in the DoD under the Deputy Assistant Secretary of Defense 

for Force Health Protection and Readiness.9 The US Army Medical Research and 

Materiel Command would coordinate all DoD research related to TBI. This was 

important because Congress wanted the US Army to take on the role of Executive 

Agent for TBI. DVBIC was designated as the single office responsible for the 

consolidation of all TBI-related incidence and prevalence information collected 

by all services. DVBIC had existed for many years and consisted of subject matter 

experts on TBI. 

In October 2007, the Office of The Surgeon General (OTSG) distributed a 

memorandum outlining requirements for TBI certification for all Army military 

medical treatment facilities (MTFs) and a gap analysis to compare the present 

performance with future desired outcomes.10,11 Information gained from these 

documents would be the Army’s first attempt to develop and then provide a standardized approach to creating an organizational structure to build TBI programs.

In April 2008, the US Army Medical Command Headquarters issued 

Operations Order 08-39, The Army Medical Command Traumatic Brain Injury 

(TBI) Action Plan, which outlined additional requirements needed for the 

establishment of TBI treatment capabilities at all Army MTFs.12 In mid-2008, the 

DWMMC passed complete responsibility for all TBI screenings of inpatient and 

outpatient OIF/OEF SMs to the Trauma program.

The OTSG memorandum and the gap analysis identified a lack of 

equipment, space, financial resources, and personnel to staff a TBI program at 

LRMC. Clinicians from Sterling Medical Corporation, Inc (a healthcare staffing 
58 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014 Negative screen Document findings to TBI database, AHLTA and Essentris No further intervention OIF/OEF patients mTBI screening Vented and sedated Plan for WRAMC, BAMC or NNMC Head CT with significant findings Increase severity to moderate or severe Document findings to TBI database and Essentris No head CT or head CT with no significant findings Nonscreenable Document findings to TBI database and Essentris No further intervention Positive screen MACE Current symptoms and/or MACE < 25 Refer to TBI Specialty Center Head CT scans Yes No Notify MD with recommendation for head CT and document Document findings to TBI database, AHLTA and Essentris Discuss with RN or provider No significant findings CONUS MTF Document findings to TBI database, AHLTA and Essentris Increase severity to moderate or severe

Document 

findings to TBI 

database, AHLTA 

and Essentris

No further 

intervention

No current 

symptoms 

and/or 

MACE = 25

Plan for CONUS

If head CT

available discuss

with RN or

provider

No significant

findings

Significant

findings

Document 

findings to TBI 

database, AHLTA 

and Essentris

Increase 

severity to 

moderate or 

severe

Document 

findings to TBI 

database, AHLTA 

and Essentris

Significant

findings

CONUS TBI

Specialty Center

Plan for return to

duty (RTD)

Exertion

testing

Negative signs

and symptoms

Positive signs

and symptoms

Cleared for RTD Escort to

neurology clinic

Refer to

DWMMC to

clear RTD

No further 

intervention

Landstuhl Regional Medical Center clinical management algorithm for patients with mild traumatic brain injury AHLTA: Armed Forces Health Longitudinal Technology Application; BAMC: Brooke Army Medical Center; CONUS: continental United States; CT: computed tomography; DWMMC: Deployed Warrior Medical Management Center; MACE: Military Acute Concussion Evaluation; MD: medical doctor; mTBI: mild traumatic brain injury; MTF: medical treatment facility; OIF: Operation Iraqi Freedom; OEF: Operation Enduring Freedom; NNMC: National Naval Medical Center; RN: registered nurse; TBI: traumatic brain injury; WRAMC: Walter Reed Army Medical Center
TRAUMATIC BRAIN INJURY 59

organization in Cincinnati, OH), were then contracted and arrived in Germany 

in December 2008. It was believed that using contract clinicians would reduce risk 

and provide the greatest flexibility to the Army as it developed TBI programs across 

the nation and overseas. Unfortunately, the timing and order of arrival of resources 

were not optimal. In ideal circumstances, resources such as space and equipment 

are obtained prior to the arrival of clinical staff. Unfortunately, the exact opposite 

occurred. Personnel showed up first, which created a tremendous challenge in 

finding a workspace for them within the existing hospital structure. In a few cases, 

such as speech and language pathology, the existing clinic had an extra room and 

desks to accommodate the two new clinicians. However, this was not the norm. 

The TBI program was given some limited space in a newly renovated wing of the 

hospital; however, this appointed space came without equipment or furniture.

Developing the infrastructure, understanding resource and budget processes, 

and navigating through layers of bureaucracy were essential skills needed to meet 

the OTSG requirements. These are skills that are not known to most clinicians. 

The critical need for a program manager was, therefore, quite apparent. The 

position was finally filled in March 2009 and proved vital to the success of meeting 

the OTSG requirements for establishing a TBI program.

In May 2009, the TBI Screening Team was officially transferred from the 

Trauma program to the TBI program under the Department of Neurology. The 

Intensive Rehabilitation Program piloted its first cohort in August 2009 with 

a dedicated TBI Rehabilitation Center building opening in November 2010. 

Beginning that month, the LRMC TBI program utilized a variety of specialists to 

responsibly serve the European TBI patient population. This continues to be the 

current practice. Although the drawdown in Iraq and Afghanistan has resulted in 

decreased patient encounters it has not diminished the requirement to provide key 

program elements nor the goal of addressing the complex and multidisciplinary 

needs of TBI patients. 

IMPLEMENTATION METHODS

Leadership Staffing

Leadership staffing consists of the following personnel:

• medical director (physiatrist),

• program manager, 

• noncommissioned officer in charge (NCOIC), and

• team leaders.

Each of the TBI program elements has an assigned team leader who reports 

to the medical director on clinical matters and to the program manager for 

nonclinical issues. 
60 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Program Elements

The TBI program is composed of nine program elements:

1. TBI Screening,

2. Initial Evaluation/Treatment Planning,

3. Case Management,

4. TBI Rehabilitation,

5. Research, 

6. Data/ANAM (Automated Neuropsychological Assessment 

Metrics) Management, 

7. Education,

8. Telehealth, and

9. Clinical/Business Operations.

Traumatic Brain Injury Screening

The TBI Screening Team consists of the following:

• one registered nurse (RN) team leader,

• two RN nurse screeners, 

• two licensed practical nurse (LPN) screeners, and 

• one social services assistant.

The Screening Team’s mission is to ensure that all military personnel, civilians 

(DoD and contractors), and coalition military personnel medevaced from the 

theater of operation for OND/OEF undergo TBI screening before returning 

to CONUS or return to duty (RTD). OND/OEF refers to those patients who 

are medevaced from Iraq, Afghanistan, the Horn of Africa (Djibouti), Kuwait, 

Qatar, and Dubai. In addition, Kosovo and Bosnia fall under the Joint Program 

Management Guardian and are included under the OND/OEF umbrella. 

The initial screening tool is a self-reporting survey administered to all OND/

OEF patients medevaced to LRMC. The three key components of this screening 

questionnaire include (1) type of TBI exposure (eg, blast, vehicle collision, fall), 

(2) immediate symptoms following the event (eg, loss of consciousness, confusion, 

no recollection), and (3) symptoms experienced since the event (eg, headache, 

dizziness, memory loss).13 All patients are given an individual appointment with 

a TBI Screening Team member that lasts between 5 and 45 minutes, depending 

on whether there are indicators of a possible TBI event. Any patient who screens 

positive (with or without symptoms) is subsequently assessed using the DVBIC’s 

Military Acute Concussion Evaluation (MACE).13 This document is used to gauge 

the severity of symptoms and cognitive deficits. The questionnaire consists of three 

components:
TRAUMATIC BRAIN INJURY 61

Landstuhl Regional Medical Center patient screening questionnaire for 

traumatic brain injury

Courtesy of the Landstuhl Regional Medical Center Traumatic Brain Injury Program.

1. history of injury and symptoms, 

2. cognitive screen with score, and 

3. screening neurological examination. 

All patients with an abnormal MACE score (symptomatic and asymptomatic) 

are referred to a neurologist for a more comprehensive evaluation and possible 
62 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

radiographic imaging with either computed tomography (CT) or magnetic 

resonance imaging (MRI) scans.13

The screening at LRMC is only an initial assessment; 85% of the patients 

medevaced from downrange continue to CONUS within 72 hours of arriving at 

LRMC. 

Initial Evaluation/Treatment Planning

The Initial Evaluation/Treatment Planning Team consists of a neurologist 

and a nurse practitioner. Both are under the supervision of the program medical 

director. 

SMs who have had a potential TBI event and who are currently having 

symptoms associated with that event (termed positive symptomatic) are referred 

to the neurology clinic to receive clinical confirmation of the TBI diagnosis. A 

comprehensive neurological examination may reveal abnormalities of the cranial 

nerves, postural stability/vestibular system, and visual function.

SMs who had a potential TBI event, who are not currently having symptoms 

associated with that event (termed positive asymptomatic), and who are requesting 

an RTD are referred to the neurology clinic to confirm the diagnosis and undergo 

an exertion test prior to clearance for RTD. An exertion test raises the heart rate of 

a patient for a set period of time to determine if TBI-related symptoms return. No 

patient screened positive asymptomatic can RTD unless he or she undergoes the 

exertion test and has a MACE score greater than or equal to 25.13

SMs who had a potential TBI event, who are not currently having 

symptoms associated with that event (positive asymptomatic), and who are 

not requesting RTD are free to continue with all other appointments and 

processing. No further TBI action is required for these SMs at LRMC, except 

for documentation and education.

The initial TBI screening, exertional testing results, and TBI evaluations 

are documented in the inpatient and outpatient medical records of all patients 

evacuated through LRMC. Data are entered into the TBI database, and this 

information is subsequently available to healthcare providers in CONUS. 

Case Management 

The Case Management (CM) Team consists of three RN case managers. 

Nurse CM is a collaborative process of assessment, planning, facilitation, care 

coordination, evaluation, and advocacy to meet the comprehensive healthcare 

needs of an individual or family. 

Nurse case managers act as liaisons between the patient, healthcare providers, 

commanders, and community resources to achieve high-quality, patient-centered, 

cost-effective outcomes with an emphasis on health promotion, maintenance, 

education, and risk prevention. 
TRAUMATIC BRAIN INJURY 63

The TBI nurse case manager coordinates TBI referrals, ensures that all SMs 

receive individualized treatment plans, and provides for comprehensive continuity 

of care for all SMs identified as potential TBI patients. Case managers work in 

three areas: 

1. screening-intake and referral, 

2. intensive rehabilitation, and 

3. follow-up.

Traumatic Brain Injury Rehabilitation 

The TBI Rehabilitation Team consists of a strong interdisciplinary team of 

providers from the following disciplines: neurology, primary care, physiatry, physical therapy, occupational therapy, speech language pathology, behavioral health, 

optometry, audiology, pain management, vocational rehabilitation counseling, and 

the Chaplain’s Office. Additional specialists are consulted as needed.

The Intensive Rehabilitation Program at LRMC, known as “Synapse,” 

is currently for USAREUR (US Army Europe) soldiers and their dependents 

whose needs cannot be met at their home station TBI centers for reasons such as 

increasing symptoms, unavailability of specialists, and recommendations of local 

TBI treatment teams. The purpose of the program is to coordinate the care and 

integration of medical services and therapeutic resources that are critical to the SMs 

receiving rehabilitation for concussion care. The program eliminates the need for 

TBI Evaluation: A sample of the assessment used to screen for traumatic brain injury 

known as MACE (Military Acute Concussion Evaluation). The test has a possible 30 

points. Patients without concussions average a score of 28. Scores below 25 indicate a 

possible diagnosis of TBI.

IMMEDIATE MEMORY: 15 points (1 point for each correct answer over three trials) 

A test giver will say five random words and ask a patient to repeat them in any order. 

Test giver and patient repeat this two more times for a total of three trials.

ORIENTATION: 5 points (1 point for each)

Patients are given five time and date questions.

CONCENTRATION: 5 points (1 point for each)

Patients are told a string of numbers and asked to recall the numbers in reverse order. 

The number strings range from three to six digits in length. Then patients are asked to 

recite the months of the year in reverse order.

DELAYED RECALL: 5 points (1 point for each)

Without the test giver repeating the same five words from the immediate memory 

portion, patients are asked to recall the five words from the first portion of the test.

Source: Defense and Veterans Brain Injury Center, Silver Spring, MD.

For the complete version of the MACE screening, see http://www.pdhealth.mil/downloads/MACE.pdf.

.
64 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

local SMs and those from downrange who require short-term outpatient care for 

TBI-related symptoms (eg, headaches, balance problems) from having to navigate 

multiple clinics at LRMC. Local patients needing care beyond the scope of their 

stationed health clinic can travel to LRMC for more intensive treatment, including 

the Synapse program. This intensive intervention at LRMC meets the individual 

needs of each SM, and can be for a few weeks or as long as 8 weeks based on the 

unique symptom presentation. 

Synapse Group Therapies: An example of the types of programs, interventions, and 

specialists involved in the Synapse Intensive Rehabilitation Program. Each patient has 

an individual treatment plan based on his or her particular needs as determined by the 

evaluation and clinical team. The Synapse Treatment Team is happy to involve family 

members or significant others in the program, with consent. Team members can help 

educate family members regarding relevant symptoms, therapy, progress, and outcomes. This can be done in-person or by telephone. 

MORNING GROUP: The day begins with a review of the daily schedule and participation 

in short activities to get focused. Patients meet briefly with their case manager and the 

occupational therapist to organize their scheduled treatments.

COGNITIVE GAME GROUP: The Cognitive Gaming group is designed to provide an 

opportunity to practice cognitive skills in a fun and interactive environment. The group 

is facilitated by a speech-language pathologist and an occupational therapist. A variety 

of group, solo, and two-player games are provided that specifically challenge skills, such 

as: working memory, problem-solving, planning, creative thinking, visual spatial skills, and 

fast-paced attention. Participation will be part of a therapy plan and tracked as therapy 

goals. Group members who are not being seen for cognitive skills development are 

welcome to participate as space permits. 

CONDITIONING & STRENGTH TRAINING: Patients participate in a physical therapydirected approach to improving circulation, flexibility, and neuromuscular function. This 

enhances other aspects of treatment by providing opportunities to improve sleep and 

concentration, and decrease stress and tension headaches. 

VOCATIONAL EDUCATION GROUP: This group focuses on goal setting, and establishing 

objectives for either successful reintegration into work and education or preparation for 

transition. This group is co-facilitated by individuals who have experienced traumatic 

brain injury and the group is focused on cognitive reframing to support recovery, quality 

of life, and personal goals. 

MINDFULNESS/RELAXATION: A variety of activities will be utilized to increase mental 

and emotional focus, a sense of relaxation, and regulation of the nervous system.

PSYCHOEDUCATIONAL/OCCUPATIONAL GROUP: A variety of educational resources 

and small group options are available to the patient to address specific vocational 

aspects of his or her rehabilitation as well as provide the patient with educational 

opportunities to increase awareness and understanding of recovery from concussion.

Source: Landstuhl Regional Medical Center Traumatic Brain Injury Program. 
TRAUMATIC BRAIN INJURY 65

The interdisciplinary team first evaluates TBI patients using a multidiscipline 

assessment process to determine if they meet the appropriate criteria for intensive 

rehabilitation. If their needs require this level of intervention, they are accepted 

into the Synapse program and an interdisciplinary treatment plan is developed 

and reviewed with the patient. Based on individual needs, daily intensive therapy 

is scheduled that includes a combination of one-on-one and group treatment sessions. For those individuals who do not require the level of intense rehabilitation 

offered through Synapse, appropriate recommendations are made.

The primary mission of the Rehabilitation Team is to maximize the quality of 

life and recovery of function for all TBI patients referred to LRMC. The assessment for comorbidities is especially critical given the circumstances under which 

the injuries have occurred. The Synapse program works closely with the LRMC 

Evolutions program, a comprehensive day treatment approach to treating posttraumatic stress disorder (PTSD). If a patient experiences complex symptoms related 

to PTSD, the team may recommend that the individual attend the Evolutions 

program. For problematic but less intense trauma-based treatment needs, patients 

may receive individual or group psychotherapy with behavioral health providers 

within the Synapse program.

It is also incumbent upon the team to determine the ability of the patient 

to RTD and to then facilitate that goal. The team meets weekly to ensure that 

all patients are receiving appropriate treatment plans, monitor progress, review 

goals, and formulate a comprehensive discharge plan. They also work closely with 

command to communicate patient progress. If it seems likely the SM will RTD, 

the team also works with command to review job function and performance, and 

tailors treatment toward addressing specific job capacities needed for that SM to 

function within his or her military occupational specialty. Educating SMs and 

their families about their recovery, and how to cope with all the factors related to 

TBI, is a vital part of the program. Treatment plans are developed at discharge, and 

follow-up services can often be implemented via telemedicine and home therapy 

programs, or with local providers at the patient’s home base of record. 

Research

The Research Team consists of a research coordinator who is a licensed 

rehabilitative psychologist. 

The TBI research coordinator works with the entire research community at 

LRMC to facilitate research activities, provides subject matter expertise on TBIrelated research, and manages the programmatic coordination of all TBI research 

trials. Examples of proposed projects include the following: 
66 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Project 1: Secondary Data Analysis Trial

Purpose: To review 2010 TBI screening database for trajectory of recovery and 

care models.

Project 2: Banyan Biomarkers Trial

Purpose: Pilot study (N = 30) on acute, subacute, and chronic serum 

biomarkers for TBI.

Project 3: Visual-Ocular Motor Trial

Purpose: To review visual-ocular motor vision therapy provided to 500 soldiers 

in 2008 to model care recovery and benefit from therapy.

Project 4: TBI Outcome Measures

Purpose: To explore common outcome measures for mild TBI assessment, 

evaluation, and treatment.

Project 5: TBI Trial: ANAM vs ImPACT (Immediate Post-Concussion 

Assessment and Cognitive Testing)

Purpose: To evaluate efficacy of various automated neuropsychological 

assessment metrics.

Project 6: RU486 Trial

Purpose: To assess the efficacy of RU486 (mifepristone) in the treatment of 

combat-related PTSD.

Project 7: Clinical Trials Enterprise

Purpose: To evaluate clinical trial enterprise markers in military members.

Project 8: ADVAB/WTAR (Armed Services Vocational Aptitude Battery/

Wechsler Test of Adult Reading) Trial 

Purpose: To demonstrate the association between ADVAB general technical 

scores and WTAR. 

Project 9: TBI Education Trial

Purpose: To examine the efficacy of TBI education on improving recovery and 

rehabilitation outcomes in military patients.

Project 10: Natural History Trial

Purpose: To examine the trajectory of recovery from mild TBI in military 

soldiers.
TRAUMATIC BRAIN INJURY 67

Data/Automated Neuropsychological Assessment 

Metrics Management

The Data/ANAM Team consists of a data management specialist (who is in 

charge of the team), two trained ANAM testing facilitators at each military MTF, 

and five ANAM psychology technicians strategically placed across the Europe 

Regional Medical Command (ERMC) area of responsibility. 

In May 2008, the Assistant Secretary of Defense (Health Affairs Office) issued 

a memorandum mandating that all SMs receive a predeployment computerized 

neurocognitive assessment using the ANAM.14 The purpose of the test was to 

establish baseline information of brain function. In the event that the SM sustained a TBI, the test could then be retaken and the results compared with the 

original to monitor any changes in cognitive function. The ANAM is a computer 

program that detects speed and accuracy of attention, memory, and reaction time. 

Performance is measured through responses provided on a computer, and the test 

takes about 20 minutes to complete.15 The DVBIC has been designated as the 

office of responsibility for this DoD program, referred to as the Neurocognitive 

Assessment Tool Program.

The primary mission is to ensure that the ANAM program is fully coordinated 

across ERMC. Prior to deployment, ERMC incorporates baseline ANAM testing 

results for all deploying soldiers into either soldier readiness processing, periodic 

health assessment, or predeployment processing, and then supports postinjury 

ANAM testing when clinically indicated and ordered by a medical provider.

The data management specialist is responsible for administrative control of 

the TBI Screening Access Database and development of a TBI Clinical Outcomes 

Database.

Education

The framework of the rehabilitative program is the belief that a positive 

course of recovery from any degree of a TBI begins and ends with education, 

which is therefore mandatory for SMs, beneficiaries, and retirees. In addition, TBI 

education is given to TBI providers and staff, other nonspecific hospital and clinic 

providers and staff, regular line units, and other community organizations. 

In-service educational briefings on the screening process used for TBI 

patients are given on a monthly basis for both new employee orientation and 

the Department of Nursing orientation. A member of the TBI Screening Team 

provides an overview of TBI at both briefings and also quarterly to the hospital 

wards, outpatient clinics, and outlying Army health clinics. In addition, the TBI 

screeners give DVBIC-approved verbal and written TBI educational information 

to patients who have a positive result for concussion on their screen. Providers 

caring for the TBI-identified patient will continue the education process by 

affirming the expected recovery and providing an individualized plan of care. 
68 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

A full-time RN education coordinator is available to facilitate and coordinate 

educational activities for local TBI patients, family members, commands, 

providers, and the community. A midlevel provider (eg, a nurse practitioner), with 

experience in treating patients who have sustained a TBI, coordinates educational 

activities targeted specifically to providers across the ERMC. This training and 

education include face-to-face and videoteleconference briefings, proctorships, 

conference lectures, and electronic information dissemination. 

Telehealth 

All military personnel, civilians (DoD and contractors), and coalition military 

personnel who are evaluated by the interdisciplinary team for the TBI Intensive 

Rehabilitation Program are eligible to receive follow-up rehabilitative care through 

the use of telehealth resources and videoteleconferencing. This telehealth capability 

has been instrumental in reducing travel costs for patients spread across the 

European region and also in reducing time away from the workplace.

Clinical/Business Operations 

Clinical/business operations for the TBI program is led by the TBI NCOIC. 

The NCOIC serves as the supervisor for three medical support assistants (a GS-04 

position) and one administrative assistant (a GS-06 position). 

Clinical operations encompass all of the duties and responsibilities that 

facilitate day-to-day patient care and facility management. These include, but are 

not limited to, the following:

• front desk management; 

• safety and hazardous material training; 

• infectious control; 

• information management, performance management, and 

representative management; 

• medical equipment and supply chain management; 

• property and inventory management; and

• facilities and equipment maintenance management.

Business operations encompass the following duties and responsibilities:

• financial management, 

• personnel status management, 

• timekeeping, 

• key control management, 

• patient/visitor control, and

• reports and data analysis.
TRAUMATIC BRAIN INJURY 69

ADDITIONAL TRACKING TOOLS

• TBI Screening Database. This is a Microsoft Access-based database that 

stores all TBI screening data collected by the TBI Screening Team. 

Because of HIPPA (Health Insurance Portability and Accountability Act) 

regulations, this database is restricted, and information is not available to 

the public. 

• Intensive Rehabilitation One-Note CM Files. This is an interdisciplinary, 

HIPAA-secure, collaborative, shared database that assists case managers 

and providers in managing intensive rehabilitation planning and 

treatment progress.

LESSONS LEARNED

Military hospitals experience the stark reality of increased patient volume and 

more serious injuries during any sort of armed conflict. The high rate of TBI and 

blast-related concussion events resulting from current combat operations directly 

impacts the health and safety of individual SMs, and subsequently the level of unit 

readiness and troop retention. The impact of TBI has been felt within each branch 

of the service and throughout both the DoD and the Department of Veterans 

Affairs healthcare systems.

The creation of the TBI program at LRMC was a paramount contribution to 

the overall care of wounded warriors impacted by this diagnosis. The importance 

of early identification and assessment of TBI symptoms facilitated patient care, 

provider communication, and appropriate rehabilitative intervention. Although 

creating the clinical structure to address patient needs was an integral piece of the 

program, building and operating an environment to effectively work in was the 

far greater challenge. This fully integrated interdisciplinary team approach to TBI 

treatment and management continues to be an important mission of LRMC.

Successes

• Traumatic brain injury screening. Since the initiation of the TBI database 

in March 2006, more than 43,000 TBI screenings have been conducted 

at LRMC and more than 8,500 positive screens have been identified, 

which likely would have gone undetected without this program. The 

creation of a dedicated TBI Screening Team paid great dividends toward 

workload allocation and early identification of TBI in those patients 

with obvious head injuries, and even more so in those patients with no 

external indications.

• Traumatic brain injury encounters. TBI encounters are documented 

with an ICD-10-CM (International Classification of Diseases, 10th 

Revision, Clinical Modification) diagnosis code of V15.52, “Personal 
70 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

History of TBI.” From October 2009 to September 2012, LRMC staff 

documented more than 30,000 TBI specific encounters.

• Traumatic brain injury rehabilitation. Since the start of the TBI Intensive 

Rehabilitation Program in August 2009, LRMC has managed more 

than 500 SMs for symptoms associated with a TBI event. By fiscal year 

2011, the program had attained a 65% RTD rate. At an estimated 

$250,000 invested training cost per SM, this program resulted in cost 

avoidance to the US Army in excess of $79.9 million.16

• Research. Since the initiation of the TBI database in March 2006, a 

number of research trials and projects were conducted that provided 

pertinent information affecting clinical outcomes. The role of the TBI 

research coordinator was especially valuable to LRMC participation 

in national protocols because a tremendous amount of time is needed 

to ensure that trial development, approval, and execution occur. TBI 

research must continue to move forward, and the local military hospital 

needs to be a vital partner in the process.

• Education. Educating SMs and their support systems on engaging in 

their own recovery and considering factors in their lives that influence 

a positive course of rehabilitation has been a vital component to the 

success of the TBI program, and for discharge and follow-up planning. 

A positive course of recovery from brain injury begins and ends with 

education. Every component of LRMC’s intensive program emphasizes 

the importance of a holistic and dynamic recovery process. Awareness 

and understanding of the expected course of recovery from brain injury 

creates empowerment, which is how patients rebuild a sense of normalcy 

and develop self-efficacy. 

• Award. The Surgeon General and the chief of the Army Medical 

Department Civilian Corps created the Wolf Pack Award to recognize 

exceptional teamwork by an integrated group of military and civilian 

team members focused on excellence in support of Army Medicine. 

In the first quarter of fiscal year 2012, the TBI team at LRMC was the 

recipient of the Wolf Pack Award.

Challenges

• Maintaining the mission. Assessing and treating TBI-related symptoms 

is a core mission of the Army. Maintaining this focus will require 

continued vigilance in the areas of TBI care, research, education, and 

outreach. Although recent attention has been intensively focused on 

combat-related TBI, it should be noted that the majority of TBI-related 

injuries are non–combat-related. Many routine operational and training 
TRAUMATIC BRAIN INJURY 71

activities in the military are physically demanding and even potentially 

dangerous. TBI incidents also occur in garrison during daily activities. 

SMs enjoy exciting leisure activities: they ride motorcycles, climb 

mountains, and parachute from planes for recreation. Although both the 

training and recreational activities are expected for SMs and contribute 

to a positive quality of life, they also can increase the risk for TBI.

• Reintegration. The challenges faced by TBI patients and their families 

are enormous. Brain injuries can affect motor, sensory, cognitive, and 

behavioral functioning. SMs who have sustained a TBI may have 

difficulty returning to work, school, and family life, or engaging in 

activities enjoyed prior to injury. The high number of wounded warriors 

with TBI has highlighted and reinforced the need for various types of 

support as they attempt to reintegrate. Both garrison leaders and the 

general community need to reach out and help soldiers reintegrate with 

families, friends, work, and activities. It is not uncommon for SMs with 

TBI to also experience PTSD. Encouraging those SMs to ask for help 

when they are struggling so that appropriate interventions can be made 

is paramount to their recovery and family cohesiveness. Community 

support plays a vital role in the rehabilitative continuum of care. 

• Model of care. For the majority of wounded SMs, TBI (typically mild) 

was only one diagnosis of many. Identifying and treating comorbidities 

in a coordinated fashion has been crucial for this population. Future 

programs would benefit by focusing on combat rehabilitation, as 

opposed to a single diagnosis-driven rehabilitation. By emphasizing 

function and identifying all diagnoses that are impacting it, the patient’s 

quality of life becomes the central coordinating influence around 

which care is provided. This patient-centered and patient-directed care 

model helps patients reestablish a quality of life that is meaningful and 

personally relevant.
72 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

ACKNOWLEDGMENTS

The authors thank David Williams and LTC Megumi Vogt, US Army.

REFERENCES

1. Hosek J. How Is Deployment to Iraq and Afghanistan Affecting U.S. Service 

Members and Their Families? An Overview of Early RAND Research on the 

Topic. Santa Monica, CA: RAND Corporation; 2011. http://www.rand.org/

pubs/occasional_papers/OP316. Accessed July 29, 2015.

2. Okie S. Traumatic brain injury in the war zone. N Engl J Med. 2005;352: 

2043–2047.

3. Dao J. Afghan war’s buried bombs put risk in every step. New York Times. July 

15, 2009.

4. McFate M. Iraq: the social context of IEDS. Mil Rev. 2005;May–June: 

37–40. 

5. National Institute of Neurologic Disorders and Stroke. NINDS traumatic 

brain injury information page. http://www.ninds.nih.gov/disorders/tbi/tbi.

htm Accessed June 22, 2015.

6. Hicks R, Fertig S, Desrocher R, Koroshetz W, Pancrazio J. Neurologic effects 

of blast injury. J Trauma. 2010;68(5):1257–1263. 

7. Alvarez L. War veterans’ concussions are often overlooked. New York Times. 

August 25, 2008. 

8. Landstuhl Regional Medical Center Public Affairs Office. Fact Sheet: 

Traumatic Brain Injury. Landstuhl, Germany: LRMC PAO; 2013.

9. Winkenwerder W. Consolidation of Traumatic Brain Injury Initiatives in the 

Department of Defense. Washington, DC: Assistant Secretary of Defense, 

Health Affairs. Memorandum to the Assistant Secretary of the Army, 

Assistant Secretary of the Navy, Assistant Secretary of the Air Force, Surgeon 

General of the Army, Surgeon General of the Navy, and Surgeon General of 

the Air Force; March 23, 2007.

10. Casscells SW. Traumatic Brain Injury: Definition and Reporting. Washington, 

DC: Assistant Secretary of Defense, Health Affairs. Memorandum to the 

Assistant Secretary of the Army, Assistant Secretary of the Navy, and Assistant 

Secretary of the Air Force; October 1, 2007.

11. US Army Combined Arms Center. Army Operational Knowledge 

Management: KM Gap Analysis. Fort Leavenworth, KS: USACAC; 2013.

12. Army Medical Command Headquarters. The Army Medical Command 

Traumatic Brain Injury (TBI) Action Plan (AP). Fort Sam Houston, TX: 

MEDCOM; 2008. Operations Order 08-39.
TRAUMATIC BRAIN INJURY 73

13. Dempsey KE, Dorlac WC, Martin K, et al. Landstuhl Regional Medical 

Center: traumatic brain injury screening program. J Trauma Nurs. 

2009;16(1):6–12. 

14. Casscells SW. Baseline Pre-deployment Neurocognitive Functional Assessment—

Interim Guidance. Washington, DC: Memorandum to the Assistant Secretary 

of the Army, Assistant Secretary of the Navy, and Assistant Secretary of the Air 

Force; May 28, 2008.

15. Defense Centers of Excellence for Psychological Health and Brain Injury. Fact 

Sheet: Automated Neuropsychological Assessment Metrics Management (ANAM). 

Silver Spring, MD: DCoE; Summer 2012. 

16. Statistics provided by Williams D, Vogt M, Landstuhl Regional Medical 

Center Traumatic Brain Injury Program, February 2013. 
Another busy day on the job for Shelley Ohlendorf, 

Supervisor, Wounded Warrior Finance Office. 

Photograph courtesy of the Public Affairs Office, 

Landstuhl Regional Medical Center.
CHAPTER SIX

Wounded Warrior Finance Office 

“Success is the sum of small efforts, repeated day in and day out.” 

— ROBERT COLLIER

From point of arrival at LRMC, to point of designated departure, 

the Wounded Warrior Pay Office supports each soldier through every step 

of this process. The combination of professional financial support, vigilant 

monitoring, and premier customer service has eliminated untold financial 

stress for these wounded warriors and their families. 

This office is the quintessential example of “mission accomplished!” 

All team members see this unique job opportunity as a life-changing, 

rewarding honor serving our nation’s heroes. 

First Sergeant Shelley Ohlendorf worked in the finance office during her 

deploy-ment to Iraq. Unbeknownst to her at the time, this experience was 

the segue to her future position at Landstuhl Regional Medical Center 

(LRMC). She retired from the military after 26 years of service and remained in 

Germany with her husband and sons. It was the first time in her life she stayed 

at home and did not work. Eventually, Shelley became restless; she needed a new 

purpose. By August 2007, the Wounded Warrior Pay Management Team at 

LRMC needed a supervisor, and they hired her for the position. The team had 

been established to prevent debts for combat zone entitlements for injured or sick 

soldiers evacuated from downrange. 

Battle-injured soldiers face daunting challenges physically, emotionally, and 

financially. Many of them undergo multiple surgeries followed by months of 

physical rehabilitation. Some soldiers are unable to return to duty or, worse yet, to 

their military careers. Such injuries can be life-altering, calling for a reassessment 

of goals and an adjustment to physical limitations. 

The mission of the Wounded Warrior Pay Management Team is as follows: 

To improve the accuracy and the timeliness of pay to Wounded Warriors and their 
76 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

families and to ensure the critical human dimension of pay support (face-to-face 

contact to educate the customer) occurs at all critical patient flow locations.1

BACKGROUND

When soldiers are injured and medically evacuated, they are quickly whisked 

off for appropriate care, thus leaving their units before their mobilization period 

officially ends. A soldier’s pay status is dependent on his or her status or location. 

Prior to 2005, the lack of a centralized automated data system meant that a 

soldier’s duty status was not automatically updated when he or she was medically 

evacuated. Without the proper input of changes in wounded warrior status, 

finance battalions were not receiving the necessary substantiating documents, 

and appropriate pay changes were therefore not made. This led to pay-related 

problems, including in some cases substantial debt, which caused undue stress for 

the soldiers and their families. 

Finding New Purpose 

She was known as “Mama O” to her battalion in Balad, Iraq. Deployed in 2003, 

First Sergeant Shelley Ohlendorf was no stranger to hard work, hard conditions, 

danger, or commitment to the mission. She remembers no running water, no 

electricity, and washing her laundry in a trash bag. She was the protective, but 

tough, First Sergeant yelling to her unit at any hour of the night “to get to the 

bunkers” with the first sounds of exploding mortars, watching the night air 

enveloped in suffocating clouds of black smoke. To this day, Shelley cringes at 

the sound of fireworks and avoids claustrophobic places. Mama O earned her 

nickname because she was also a caring mother figure—nurturing, listening, and 

looking to keep sagging spirits high. Undaunted by limited resources, she used 

a one-burner Coleman stove to make Mickey Mouse pancakes for her soldiers 

on Christmas morning in Balad. Shelley was a mother of two boys herself. She 

understood that the simplest things can make a difference. 

Wanting to learn more, Shelley remembers her first visit to LRMC. She was 

observing the team she would soon lead, and watched as the AMBUS (ambulance 

bus) pulled to the front of the hospital to offload sick and injured soldiers. She 

watched the stretchers come down off the bus, intensive care patients the first 

priority. All Shelley could see was tubing and equipment; not the patient nor 

the person with him who had helped keep him alive. She remembers being glad 

it was raining because no one could see the tears in her eyes. Shelley Ohlendorf 

knew she wanted to be part of this team; she wanted to ease this suffering in some 

capacity. This was the right thing to do. “Mama O” had found her new purpose.
WOUNDED WARRIOR FINANCE OFFICE 77

In tracing the problem backward, it became apparent that the lack of a 

centralized patient tracking system was the pivotal underlying issue responsible 

for these erroneous overpayments. This essential realization then led to the 

establishment of a Senior Non-Commissioned Officer (NCO) Patient Tracking 

Team by the US Army Europe (USAREUR) G1 (personnel office) at LRMC 

because it was the prime location for medevaced (medical evacuation) missions. 

The team was responsible for 100% accountability of all warriors medevaced to

LRMC and for providing updates on those that departed from LRMC either for 

return to their units or for transfer to CONUS (continental United States) for 

continued care. The team generated daily Casualty Information Center reports to 

account for these Army MEDEVAC soldiers. Shortly after, a decision was made 

to also involve finance soldiers; trained military personnel with specialization 

in military pay, travel pay, resource management, accounting, etc. This was an 

essential support supplement because Europe-based finance units were already 

on rotational deployments to theater to support deployed units and the needs at 

LRMC demanded consistency. The finance soldiers in turn coordinated with the 

Patient Tracking Team and LRMC medical staff to provide the necessary support 

needed for the medevaced soldiers. 

In October 2005, a wounded warrior pay mission was implemented as 

a preventive measure to minimize overpayment of combat zone entitlements 

by the US government to wounded warriors. At this point, there was growing 

realization of soldiers incurring debt from overpayments of continuing combat 

zone entitlements if they were not accounted for. The two to three Army finance 

soldiers assigned from the battalions under the 266th Finance Command were 

now the first official finance team at LRMC, and they were assigned to meet with 

each wounded warrior. The goal was to prevent debt by ensuring accountability 

for those warriors being medevaced from theater, verifying inpatient or outpatient 

status, and reporting who was being transferred to CONUS for further medical 

care. The Defense Finance and Accounting Services (DFAS) developed the 

Wounded in Action (WIA) database in June 2005, and LRMC became the “hub 

of the wheel” for the Army-wide program.2 

Challenges arose, however, as the initial Wounded Warrior Finance Team 

worked with minimal resources. Standard operating procedures had yet to be 

created to handle this unique organization. Efforts were aimed at accounting for 

medevaced soldiers, providing needed finance support, answering pay-related 

inquiries, and working an expedited debt remission process if overpayments 

occurred. Young warriors in particular needed help in navigating through the system 

because many had never been in a hospital and were overwhelmed by the entire 

experience. These soldiers were unsure if they were financially responsible for their 

medical bills and if they had to pay for their equipment that was lost or damaged 
78 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

during the attack that injured them. To further complicate the issues at hand, the 

wounded warrior finance team was not yet a full-time mission. In fact, it was more 

of an intermittent mission as the team juggled supporting other finance missions 

throughout Europe and training for their own deployments. Minimal staff working 

with minimal office equipment found it increasingly difficult to keep up with the 

volume of warriors who were medevaced to Landstuhl. This ultimately hampered 

any real consistency in accountability, which then affected proper pay status. 

By November 2005, finance battalions throughout Europe were each staffed 

with two to three soldiers to assist with reviewing wounded warrior pay accounts 

in their respective community or country. However, most of the work was done 

remotely, with small operations as far away as Belgium and Italy, all of which made 

this mission additionally challenging. 

In May 2006, a US news article was published about injured warriors 

medically evacuated from combat zone areas owing money to the government due 

to the continuation of receiving combat zone entitlements.3

 Just a few weeks prior, 

on April 27, 2006, nine people had testified about this issue before the House 

Government Reform Committee. The hearing reported nearly 900 wounded 

soldiers owing more than $1.2 million in government debt.3 Further reviews found 

that between 2002 and 2005, nearly 1,300 soldiers who were wounded and left 

the Army, or who were killed in action, had debts totaling $1.5 million.3

 Because of this initial lack of a centralized tracking system, combat pay 

entitlements were not immediately adjusted when soldiers were medevaced from 

theater. Sometimes it was weeks or even months before the system caught up with 

this change in status. At that point, military pay entitlements were then stopped 

after their true effective date, and the pay system automatically calculated a debt 

for this time period of “overpayment” of combat pay entitlements when the 

soldier was no longer in combat.

The pay system also generated a Leave and Earnings Statement that reflected 

amounts owed to the US government as advanced debt. Warriors were receiving 

a letter in the mail notifying them of this debt that they now owed to the US 

government. Options were provided on how to repay the debt, such as:

• making one lump sum payment, 

• having the debt prorated for the same amount of time the erroneous 

pay continued, or

• applying for a remission or cancellation of debt.4

Debt of this magnitude was financially devastating for soldiers and their 

families. The effects were far-reaching because bills could not be paid, and credit 

ratings were damaged. It was particularly difficult for those warriors who had 

sustained permanent injuries precluding them from returning to duty. Changes 
WOUNDED WARRIOR FINANCE OFFICE 79

were put in motion to address this problem and prevent future recurrences of 

soldier debt. 

The 266th Finance Command provided full-spectrum finance and 

accounting services in USAREUR. The command oversaw the numerous finance 

battalions sent into Kuwait, Afghanistan, and Iraq to provide financial support to 

joint and combined theaters, establish banking processes, and oversee contractor 

support for rebuilding and refurbishing these countries. Because of the 266th 

Finance Command’s vast number of deployment missions, and the overwhelming 

volume of soldiers medevaced to LRMC, the DFAS Europe team assumed 

the wounded warrior pay mission at LRMC in July 2006. Originally hired as 

temporary employees to replace the military finance staff at LRMC, DFAS Europe 

staff also worked with minimal resources. Their office was located on the second 

floor of the Deployed Warrior Medical Management Center (DWMMC) trailer, 

complete with recycled furniture and tight office space. Warriors on crutches or in 

wheelchairs were instructed to ring a bell for service, which alerted a technician to 

come and provide assistance. 

An onsite visit by the director of DFAS Europe initiated positive changes. 

Plans were developed for a designated office area within the hospital itself, better 

accommodating wounded warriors and families. The DFAS Program Manager for 

Wounded Warrior Pay strongly reiterated the need for a fully staffed operation in a 

more suitable work environment and insisted on better financial support for these 

soldiers. The goal was to create a team of civilians who would focus on assisting 

wounded warriors at LRMC. 

By May 2007, the current Wounded Warrior Pay Office at LRMC was 

established. Renovations of a former day care center included providing easy 

access for soldiers in wheelchairs and adequate space to maintain customer privacy. 

The mission developed into a complete proactive measure across the Army. The 

permanent staff consisted of a supervisor with four technicians. The 266th Finance 

Command continued to provide military support with an officer in charge, and 

the noncommissioned officer in charge was staffed through the DFAS Indianapolis 

Mobilization Support Office.

In August 2007, the decision was made to expand the finance team’s customer 

service office and enhance its technical knowledge and proficiency. Although the 

primary mission remained proper pay of combat zone entitlements, this expansion 

of services resulted in nearly $400,000 in back pay for various entitlements 

in soldiers’ accounts.5

 This addition was also a source of great satisfaction and 

employee morale. This office eventually became a recognized model by DFAS for 

all wounded warrior finance teams. 

In September 2007, the LRMC operations coordinated with the 266th 

Finance Command’s Wounded Warrior Pay Office to ensure a seamless transition 
80 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

for those warriors departing LRMC for various locations throughout Europe. 

Soldiers with less severe injuries received appropriate care at LRMC and then 

either transferred back to their garrison communities throughout Europe for 

additional medical care, or returned to their deployment location. The two teams 

still continue to work together to provide thorough support to Europe-based 

wounded warriors.

In May 2008, pay and allowance continuation (PAC) was approved for up to 

one year from the date of injury for those soldiers assigned to Warrior Transition 

Units (WTUs). These units had been established by the Army at major military 

medical facilities around the world to provide both logistical and personnel 

support for those ill and injured warriors needing at least 6 months of further 

medical or rehabilitative care. The new PAC regulations brought significant 

financial changes for wounded warriors, including the following1

: 

• Pay includes incentive payments and combat zone entitlements that 

soldiers are receiving at the time of the WTU assignment. 

• Pay is tax free for inpatient status and for the month if the warrior is 

admitted as an inpatient for reasons related to MEDEVAC. Tax-free 

status can apply for rehospitalization up to 2 years after the end of the 

conflict. 

• Pay is taxable for outpatient status for the duration of assignment 

to WTU. Outpatients also receive a PAC per diem ($3.50/day) for 

incidental expenses paid in a travel settlement when the warrior is 

released from the WTU. 

• Combat zone entitlements stop at the end of the month when warriors 

are released from the WTU.

 In May 2009, DFAS Indianapolis established the Debit Card Travel Advance 

Program to support families using Travel and Transportation Orders issued by the 

Department of the Army’s Casualty Affairs Office. This was another advantageous 

change that greatly benefited families. Orders were issued for families traveling to 

LRMC and returning home; or traveling to LRMC and then traveling with the 

soldier for further medical care to either Walter Reed National Military Medical 

Center in Bethesda, Maryland, or Brooke Army Medical Center in San Antonio, 

Texas. Orders were also issued for families if a soldier was not expected to survive, 

allowing them to come to LRMC and be with their dying family member. The 

family was also given the option of returning home directly after the death of their 

loved one or traveling first to Dover Air Force Base, Delaware, for the Dignified 

Transfer of Remains. To date, the LRMC Wounded Warrior Finance Office 

has provided 242 family members with debit card advances totaling more than 

$131,000. The process is completed within an hour and includes preparation of the 
WOUNDED WARRIOR FINANCE OFFICE 81

final travel claim, ensuring that the family does not have to struggle with unfamiliar 

forms (DD 1351-2 Travel Voucher or Subvoucher). Advances are collected with 

the payment processing. This is upfront cash that is loaded onto the debit card for 

per diem expenses, such as meals and incidentals. In many cases, these advances 

significantly reduce financial stress at a very difficult time for families. 

Shelley Ohlendorf recalls one story in particular as a poignant reason why 

this mission is so important. A mother of a dying warrior wanted to be with her 

son in his last hours. He was kept on life support in the intensive care unit (ICU) 

at LRMC until she arrived. With Shelley’s help, travel orders were issued, and the 

complicated process expedited to unite this mother and son in his last moments 

of life. Traveling alone, and several flight delays later, she arrived to be with him. 

Shelley remembers the place in the ICU where this mother sat holding her dying 

son in her arms. As nurses removed the mechanical support keeping him alive, this 

mother read to her son from his favorite childhood book, Clifford the Big Red Dog. 

With the sound of a familiar soothing voice echoing a beloved memory from his 

past, this valiant warrior drew his last breath in the loving arms of the woman who 

had given him life. 

IMPLEMENTATION METHODS

When any service member becomes ill or sustains injury in a hostile fire 

pay area, or as a result of a hostile fire act, they are medevaced to LRMC. Like 

many units, the work of the wounded warrior finance office begins long before 

the C17 arrives at Ramstein with a new group of sick and injured soldiers. The 

preparation process is tedious, and the attention to detail is meticulous. The team 

reviews each flight manifest and the supporting Patient Movement Records to 

obtain the social security number (SSN) of each arriving patient. Each SSN is then 

run through both the active duty and reserve component pay systems to verify 

all Army patients. This review ensures that each injured warrior is receiving the 

proper combat zone entitlements and family separation allowances as applicable. 

If discrepancies are noted, they are addressed with the warrior and, if necessary, his 

or her deployed unit leader is contacted to assist with proper documentation to 

ensure that appropriate pay adjustments are made. 

The Wounded Warrior Finance Office works closely with the Mission Team 

at Ramstein to ensure that they meet each arriving flight to account for and brief 

the arriving warriors. Regardless of patient status, this is the initial finance team 

that wounded warriors meet. All outpatients from every branch of service are 

briefed upon arrival to LRMC. The finance team explains that their direct support 

is to the Army and that other branches have wounded warrior pay support in 

CONUS. It is a bit more complicated for inpatients because their medical status 

determines whether a finance team member is able to meet with them on the 
82 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

day of arrival. If initial contact cannot be made, the team makes daily attempts to 

meet with inpatients to provide updates and answer questions as long as they are 

at LRMC. In medically critical cases, family members are brought to the bedside 

and briefed on financial matters. The main mission is to ensure the prevention of 

combat zone entitlement debts, and alleviate this stress and worry for wounded 

warriors. 

Once the finance team verifies the arrival of all Army warriors, they establish 

an account for each soldier in the Army-wide WIA database, and provide a status 

of his or her combat zone entitlements and incentive pay. This database then serves 

as an audit trail of the warrior’s arrival and departure from LRMC. It is updated 

by LRMC Wounded Warrior Pay Office staff with confirmation of departure. 

Accounts are then transferred to the soldier’s prospective Wounded Warrior Pay 

Office or annotated as a return to deployment location. 

Assistance is also provided with transfer of funds on the Eagle Cash card, a 

debit card associated with service members’ direct deposit accounts. This card can 

be used to load or unload funds from a US Treasury Department kiosk at LRMC. 

The finance team is available to assist with pay inquiries or review Leave and 

Earnings Statements because they have found that many warriors do not 

really understand their pay structure. Soldiers and escorts often arrive with no 

money or any way to access cash. The finance team provides a casual payment of 

up to $200 per week to enable service members to purchase necessary items and 

enjoy the various opportunities at LRMC and the surrounding area. The finance 

team keeps track of this cash advance that is later recouped from their regular 

paycheck. 

All wounded warriors discharged from LRMC will outprocess. At that time, 

the finance team meets with each soldier to answer any pay-related questions, 

provides updates on their combat zone entitlements, and ensures continued 

monitoring of their pay accounts for proper payment. All wounded warriors 

transferring to a medical facility for continued care are informed that another 

Wounded Warrior Pay Office will now pick up and provide this continued 

support, and will assist with travel pay for deployment and MEDEVAC processes. 

The LRMC finance team will continue to monitor proper pay for those soldiers 

returning to their deployment location. 

From point of arrival at LRMC, to point of designated departure, the 

Wounded Warrior Pay Office supports each soldier through every step of this 

process. The combination of professional financial support, vigilant monitoring, 

and premier customer service has eliminated untold financial stress for these 

wounded warriors and their families. This office is the quintessential example of 

“mission accomplished!” All team members see this unique job opportunity as a 

life-changing, rewarding honor serving our nation’s heroes. 
WOUNDED WARRIOR FINANCE OFFICE 83

Leadership Staff

• One GS 9 military pay supervisor. Because the Wounded Warrior Finance 

Office does not take any holidays, the person in charge ensures that 

the operation is covered 365 days a year. Organization, flexibility, 

and multitasking with efficiency and ease are certainly important job 

requirements for the supervisor. What is even more essential, however, 

is a genuine understanding of what the wounded warrior’s journey from 

combat to hospital bed has entailed, as well as a relentless commitment 

to the mission based on that understanding. This is the catalyst driving 

the team to provide the highest quality of service and attention. Strong 

communication skills are also important for this role. At any given 

moment, the supervisor interacts with the finance team, wounded 

warriors, families, personnel at LRMC, finance teams at other deployed 

locations, and DFAS Indianapolis. Responsibilities for this position 

include the following: 

Dedicated staff 

of the Wounded 

Warrior Finance 

Office, Landstuhl

Regional Medical 

Center, 2014.

Photograph 

courtesy of the 

Public Affairs Office, 

Landstuhl Regional 

Medical Center.
84 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

— hire staff;

— ensure that training is complete for both staff and wounded 

warriors regarding pay adjustments and transactions;

— establish the weekly schedule and on-call roster for around-theclock coverage;

— establish strong rapport with other Landstuhl offices and other 

deployed finance teams to facilitate the MEDEVAC process for all 

warriors, and expedite problem-solving if there are complications 

with pay;

— help staff with travel claims and advances for families;

— liaise with DFAS to report if system problems, reports, or pay issues 

are interrupting the daily mission;

— prepare monthly reports; and 

— brief all VIPs who visit LRMC—coordinate as needed with the 

266th Financial Management Support Center (FMSC), which 

provides additional personnel support. 

• Four GS 5/6/7 military pay technicians. Each technician is cross-trained 

on all operational processes within the office. This has created a work 

environment that is flexible, challenging, and growth oriented. Each 

team member operates with a great deal of care and compassion when 

providing patient briefings, which is the strength of the foundation for 

the team’s high-quality service. Responsibilities for this position include 

the following:

— prepare the pay analysis for each arriving warrior, making necessary 

pay adjustments based on patient status; 

— update accounts in the WIA database;

— process the casual pay recoupments for Army customers, preventing 

loss of funds from these payments; and 

— assist Europe-based warriors with their travel claims if their 

deployment has ended. 

• Two finance soldiers from the 266th (FMSC). The additional support from 

the FMSC has been mutually rewarding. FMSC has been the primary 

pay agent providing casual pay for wounded warriors and escorts. These 

two positions, usually an officer in charge and a soldier, assist with pay 

analysis for arriving flights, patient briefings, and in- and outprocessing 

of all warriors coming through the office. 

Equipment and Technical Support

Equipment and technical support consist of the following:

• furniture and office supplies; 
WOUNDED WARRIOR FINANCE OFFICE 85

• wounded warrior entitlement handbooks and business cards; 

• computer, duty cell phones, and safes; 

• information management office support from LRMC and the 

266th FMSC—the LRMC team assists with all interior computer 

complications, and the 266th FMSC team assists with all complications 

related to the finance system (often, both offices interact to ensure 

minimal interruption of operations since it is understood by both ends 

that the finance office works under time-sensitive requirements). 

LESSONS LEARNED

“Look for Barry.” These are the words soldiers will hear when they ask 

someone for the location of the Wounded Warrior Finance Office. The cheery, 

big-faced, St. Bernard stuffed animal is the first smile they will see when they 

make several rights and lefts, and finally wind down multiple hallways to find the 

office. It is definitely not the last. Barry is the office’s official mascot and represents 

the friendliness, hospitality, quality service, and commitment to mission of the 

entire staff. The operational goal of this office is to successfully track all pay-related 

adjustments and alleviate financial stress. Wounded warriors need to focus on 

healing. The success of this office lies not only in the hard work that accomplishes 

this goal, but also in the hearts that are behind it. 

Successes

• Accountability. This team has maintained 100% accountability 

of all Army wounded warriors arriving to and departing from 

LRMC, including soldiers readmitted to German hospitals. This has 

tremendously decreased the likelihood of combat zone entitlement debts 

from occurring.

Mascot Barry, a pup in 

camouflage ready for a 

day in the trenches at the 

Wounded Warrior 

Finance Office.

Photograph courtesy 

of the Public Affairs Office, 

Landstuhl Regional Medical 

Center.
86 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

• Financial audits. There were no combat zone-related debts that occurred 

in more than 40,000 accounts since 2007. Additional audits have been 

conducted in the months following the arrival of soldiers at LRMC 

to ensure that the combat zone entitlements are accurate (according to 

patient status).

• Follow-up. DFAS Indianapolis is notified of any discrepancies caused by 

system processes or delayed or possible erroneous action by the receiving 

Wounded Warrior Pay Office (many of the warriors are transferred 

to CONUS) to ensure that the necessary pay inputs are made. The 

continuation of combat zone entitlements are verified if the wounded 

warriors return to theater to complete their mission.

• Communication. To ensure accurate communication and thorough 

follow-up, each incoming flight to Ramstein that transports sick and 

injured warriors to LRMC is met by a member of the finance team to 

make certain that incoming patients are aware of the Wounded Warrior 

Pay Program. Each patient is provided with a Wounded Warrior Pay and 

Entitlements Handbook to guide them throughout their medical care. 

The pay status of each incoming soldier is researched by a technician 

prior to arrival at LRMC. Soldiers are immediately notified of any pay 

discrepancies. The resolution process then begins as soon as the soldier 

is able to complete the necessary DWMMC in-processing and come to 

the finance office for assistance. 

• Inpatient soldiers. Inpatient soldiers are offered the same services with 

the understanding that patient acuity and medical care are the first 

priorities. The goal is to try to meet and brief every inpatient within 

72 hours of arrival to LRMC. Patient visit logs are prepared on a daily 

basis to ensure that those capable of receiving a finance briefing are 

assisted with any pay inquiries and entitlement discrepancies. They are 

also reassured that their pay is not affected for the duration of inpatient 

status, even if transferred to CONUS for further care. 

• Morale. The impact of these finance briefings is far-reaching. They 

allow many warriors to concentrate on getting better rather than focus 

on financial stress or concerns. Warriors are surprised and appreciative 

of the friendly, professional, and thorough customer service this team 

provides. In addition, they gain a new respect for finance operations. It 

is often difficult and upsetting to see the level of injuries of wounded 

warriors. The supervisor ensures that every team member first be 

informed of the medical acuity and types of injury before meeting with 

each inpatient warrior. This prepares them ahead of time for what to 

expect and has enabled the team to meet each soldier with compassion 
WOUNDED WARRIOR FINANCE OFFICE 87

and professionalism. It is often these simple details that make all the 

difference. 

• Leave and Earnings Statement. An in-depth explanation of the Leave 

and Earnings Statement and current pay entitlements status is provided. 

Many soldiers really do not understand the entire process, nor do they 

have the time to ensure that they are actually being paid correctly. The 

finance office spends a lot of time resolving pay discrepancies, and 99% 

of their investigations have resulted in back pay. 

• Family assistance. The Wounded Warrior Finance Team has played a 

significant role in helping families of wounded warriors. When critical 

situations arise, Department of the Army Casualty Operations staff 

expedite the passport process so that families can be at LRMC within 

a day. Debit card advances of more than $131,000 have been given 

to 242 family members. Travel entitlements for the LRMC portion 

of the trip are processed for families, and include a daily allowance for 

meals and incidentals. Prior to this assistance by the finance office, 

families had to pay for personal expenses up front. Although they were 

eventually reimbursed, this put a stressful burden on many families who 

simply did not have available cash to travel and be with their injured 

family member. This assistance has made all the difference in the world. 

Families are also provided with pertinent information, such as finance 

briefing, medical status, and programs that are specific for various 

types of injuries. The office also provides cash payments to wounded 

warriors and escorts from all branches of the service. Normally, these are 

cash advances of $200 per week maximum and are later processed for 

collection from the next paycheck. To date, the finance office has issued 

$725,000 with no loss of government funds because of strict internal 

controls and thorough review of overall office procedures. 

Challenges

• Staff and budget constraints. Variations in flight arrivals and an ever-changing 

OPTEMPO (operational tempo) require a 24/7/365 operation. There is a 

24-hour on-call technician and an office duty roster covering weekends and 

holidays to ensure that all medevaced soldiers are met upon arrival at LRMC. 

Budget constraints now restrict the availability of finance technicians to meet 

flights arriving after 1600 hours on weekdays or at any time on Sundays, if 

there are less than five Army outpatients. To ensure that these patients are 

provided with the same excellent customer service, a list of outpatients is sent 

to the Medical Transient Detachment staff to send the soldiers to the office 

the next business day. 
88 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Welcome to Germany 

Anticipation mounts as the CASF (Contingency Aeromedical Staging Facility) 

team waiting at Ramstein Air Base watches the C-17 loom closer. Things move 

quickly and efficiently from the moment the wheels touch the ground, and the 

mammoth slate gray plane comes to a stop. Like the jaws of a shark, the rear of the 

C-17 opens wide and deep. At first glance, onlookers can only visualize massive 

amounts of cargo that a group of soldiers are unfastening and moving out for 

transport back to Landstuhl Regional Medical Center (LRMC). Walking up the 

ramp of the plane and behind the cargo, the scene tells another story, one that is 

actually quite astonishing. For the 10-, 12-, or 17-hour flight that it took to fly 

to Germany from Afghanistan, the C-17 was a fully equipped flying hospital, 

complete with an airborne intensive care unit. 

The eyes take in what the mind is trying to quickly process. Nurses and 

doctors are hovering around stretchers where wounded warriors lie, some attached 

to ventilators, oxygen, monitors, and tubing of every sort and life-sustaining 

purpose. Limbs and heads are swathed in bandages, and sometimes it is hard 

to even see the person amidst all of this intervention. The walls of the C-17 are 

gigantic outlets for the electrical support needed for intricate machinery, generators 

for back-up support, and computers to track necessary information. It is clear that 

a complex and organized system is in place to quickly and safely transport these 

seriously injured patients from the hospital in the air to the hospital on land. 

At the same time, an array of camouflage is moving about on the plane, 

soldiers glad to be stretching their legs and walking after so many hours sitting and 

strapped into a jump seat. They are also patients, primarily ambulatory, needing 

medical care at LRMC for a variety of reasons. Some of the soldiers are nonmedical escorts coming from their downrange units to accompany a particular 

individual. What they all generally share in common is that they are tired, hungry, 

and glad to have landed. 

The CASF team that waited with anticipation quickly moves into action, 

each person knowing their designated role. Seriously injured patients are the first 

priority to be transferred off the C-17 and onto the blue-converted ambulance 

bus (AMBUS). All seats have been removed to make room for as many gurneys 

as possible, secured into place with straps stretching from ceiling to floor. Patients 

continue to be monitored by the Critical Care Air Transport Team (CCATT) that 

escorted them from downrange on the C-17. The driver is given the thumbs-up 

to proceed, and the AMBUS then begins its 20-minute trek from Ramstein to 

LRMC along bumpy, curvy roads. 
WOUNDED WARRIOR FINANCE OFFICE 89

Chaplain Ronald Pettigrew (left) welcomes a patient as he is being transferred from 

the ambulance bus to Landstuhl Regional Medical Center.

Photograph courtesy of the Public Affairs Office, Landstuhl Regional Medical Center.

Simultaneously, another team has also been preparing for the C-17 arrival. 

At 0600 hours, the sun is still resting at LRMC, and the morning frost on the 

grass glistens in the light shining from the awning outside the emergency room 

doors. Shoe style and camouflage color reveal that every branch of the military 

is represented in this group: Army, Navy, Air Force, and Marines. Some carry 

clipboards with notes they review, while others cradle a warm cup to help offset 

their shivers from the cold morning air. They are a combination of medical staff, 

liaisons (or Liaison Noncommissioned Officers), administrative staff, volunteers, 

and chaplains. They also have their designated role once the wounded warriors 

arrive. Neither time of day nor rain, snow, or sleet ever interfere with what has 

become a daily routine in a decade of war. 

The AMBUS pulls in front and stops, the back doors swing open, and an 

immediate protocol of movement begins. Lines are formed on either side of the doors, 

four staff to a side, arranged from the tallest to the shortest. Great care, respect, and 

precision are in evidence as each stretcher is gently passed from the AMBUS, down 

the line to each person, and onto a wheeled gurney. Instructions can be heard, such as 

“move left,” “be careful of the IV [intravenous line],” or “got it!” 
90 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

When the stretcher is secured to the gurney on the ground, the chaplain is the 

first to greet each wounded warrior. Some patients are conscious, whereas others 

are not. The chaplain reaches for a hand, or even just a finger, amid the dizzying 

array of tubing, machinery, and bandages. Regardless of their level of awareness, 

religious denomination, or military rank, each wounded warrior hears the words, 

“Welcome to Landstuhl [first name of soldier], you are safe.” A short prayer is then 

offered. In those few seconds, a human connection is made, and the whisper of a 

comforting voice reminds them of home.

Army Captain Karla Clarke, an Intensive Care Unit nurse at Landstuhl Regional Medical 

Center, assists in transporting her patient to a bus for air transport. August 2007.

Photograph courtesy of Soldiers’ Angels Germany.
WOUNDED WARRIOR FINANCE OFFICE 91

Inpatients are incorporated into the daily visit log preparation for 

the team to conduct bedside briefings. This then requires additional 

follow-up to ensure that all needs are met. 

• Communication delay. When discrepancies are identified, all efforts are 

made to resolve them with the soldier within 2 days. In most cases, 

this is possible. If warriors arrive with no combat zone entitlements on 

their pay accounts, verification of deployment date from the soldier’s 

unit is needed. There are many soldiers who do not have contact 

information with them, so extensive measures are undertaken to obtain 

a good point of contact to assist with the necessary confirmation of 

deployment date. Unfortunately, not all units are able to respond to the 

request for assistance. When no documentation is received to resolve the 

discrepancy, combat zone entitlements are started and are effective from 

the day soldiers are medevaced. Back pay is processed for the soldier. 

A note of explanation about the issue is made in the WIA database to 

ensure that all back pay is processed with the assistance of the forwarding 

Wounded Warrior Pay Office. Each wounded warrior has an account 

that transfers to each assigned location. 

• Europe Warrior Transition Unit assignment process. When soldiers are 

transferred to CONUS for continuous care, they report to a WTU. 

Determination is later made to release soldiers to their units or keep 

them in the WTU while their care continues. For Europe-based 

soldiers, the process is in reverse; they first return to their units and then

must apply for WTU status. Approval of these applications averages 

3 to 5 months. This affects the PAC entitlement, often causing PAC 

entitlement inquiries to then be made through Human Resources 

Command (HRC). This office is responsible for the Army’s management 

of assignments and personnel. The HRC is the determining authority 

on PAC issues. For those warriors not receiving PAC, all inquiries are 

made through the HRC in conjunction with the DFAS Indianapolis 

Wounded Warrior Pay Management Office. If full PAC status is 

approved for these warriors, back pay of entitlements is processed. But 

this presents an accountability and pay issue for warriors in Europe that 

can take months to resolve. There is no current solution other than the 

PAC inquiry process, but a suggestion to have the WTU assignment 

process reevaluated for Europe-based soldiers is being considered. 

Because this mission has so many moving parts in caring for 

wounded warriors, there are often destination diversions in CONUS 

of which LRMC is not informed. A soldier may be set for transfer to 

a certain facility, but health complications can arise that result in the 
92 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

transfer of that soldier to another location. The Wounded Warrior 

Finance Office has access to the manifest listing names of all service 

members transferred from LRMC to the next medical facility. This 

manifest, however, is not updated once they leave LRMC. Eventually, 

the LRMC finance office is contacted by a CONUS Wounded Warrior 

Pay Office because amended travel orders are required if diversion 

occurred from the original orders issued. This delays the travel settlement 

process for these warriors. Thus, upon request from the CONUS 

Wounded Warrior Pay Office, a request for amended orders is sent 

to the LRMC Movement and Orders Team. The affected soldiers are 

paid as soon as the amendments are issued. The location of warriors 

is what drives their entitlements. Accuracy is therefore imperative. If 

these destination diversions occur with little or delayed follow-up by the 

accepting medical facility, Wounded Warrior Pay Office entitlements can 

be affected. 

Sometimes soldiers are given bad news regarding their health and 

whether they will ever be able to return to duty. Some have suffered 

terribly from their injuries. Sometimes soldiers are simply worn down 

from the reality of war. Every member of the finance team is only too 

happy to serve as an interim family member or friend to warriors far 

away from their unit and from their own families. A candy dish on every 

desk, sweets from the local bakery or a staff member’s oven, an endless 

supply of hugs, and always, sincere words of thanks and encouragement; 

this is the atmosphere that soldiers walk into after “meeting” Barry at the 

door. The LRMC Wounded Warrior Finance Team deeply believes that 

wounded warriors and their families deserve the best support possible. 

They pride themselves on delivering the whole package: financial 

support, professional expertise, and attention to every necessary detail, 

all wrapped in the human essence of kindness and compassion. Staff 

is not afraid of long hours and hard work—whatever it takes to serve 

our warriors who have served our country. This is the mindset instilled 

in this team. The Wounded Warrior Pay Office is an integral part of 

the Landstuhl story. Since its development in 2006, countless soldiers 

and their families have benefited from this mission and the outstanding 

people who have carried it through. 

For the most up-to-date content, visit the Wounded Warrior Finance 

Office website at www.dfas.mil/militarymembers/woundedwarrior/

woundedwarriorpay.html.
WOUNDED WARRIOR FINANCE OFFICE 93

ACKNOWLEDGMENT

We wish to thank Shelley Ohlendorf for her assistance with this chapter.

REFERENCES

1. Wounded Warrior Pay Management Team, Defense Finance and Accounting 

Service. Wounded Warrior Pay and Entitlements Handbook, January 2013. 

2. Christensen J, Hanrahan M, Burghardt S. One can only imagine: easing 

the burden of financial strain on Wounded Warriors and their families is 

a commitment that DFAS personnel take most seriously. Armed Forces 

Comptroller. Fall 2010; Vol 55, No 4. 

3. Government Accountability Office. Military Pay: Military Debts Present 

Significant Hardships for Hundreds of Sick and Injured GWOT Soldiers.

Washington, DC: GAO; April 27, 2006. GAO report number 

GAO-06-657T. http://www.gao.gov/assets/120/113657.html. 

Accessed December 15, 2014.

4. Department of the Army. Remission or Cancellation of Indebtedness. 

Washington, DC: DA; April 29, 2009. Army Regulation 600-4.

5. Wounded Warrior Finance Office. Monthly reports. Landstuhl Regional 

Medical Center, Germany,
Trauma patient from “downrange” arriving from Ramstein Air 

Base via “AMBUS” (ambulance bus).

Photograph courtesy of the US Army.
CHAPTER SEVEN

Trauma 

World-class health care routinely envisions what could be . . . so that the 

 extraordinary becomes ordinary and the exceptional routine. 

— KENNETH K. WIZER, MD, MPH

The early trauma program encompassed all surgical disciplines, 

including general surgery, orthopedics, and the other surgical subspecialties, 

as well as the medicine subspecialties of pulmonology, critical care, infectious 

disease, and gastroenterology. The goal of the trauma program was to 

establish timely multidisciplinary care. This was initially accomplished 

informally without an explicit organizational structure. There was no 

organized performance improvement or patient safety program specific to the 

care of the trauma patient, despite the exponentially increasing numbers of 

severely wounded casualties arriving at Landstuhl Regional Medical Center. 

Throughout the history of modern warfare, the military medical response 

has had to continuously adapt to both the increasing lethality of weapons 

used and geographic constraints. Despite these challenges, the military 

has mobilized robust medical assets to austere and hostile locations throughout the 

world.1 As a result, combat casualty care has significantly improved, and mortality 

rates are historically lower. 

The development of sophisticated critical care air transport capability has 

further enhanced patient outcomes through the transcontinental evacuation of 

critically ill patients out of combat theaters to hospitals within the United States 

at unprecedented speed. To manage large numbers of severely injured patients 

across three continents, a sophisticated trauma system spanning multiple roles of 

care had to be developed. Understanding how Landstuhl Regional Medical Center 

(LRMC) developed as a key military medical treatment facility (MTF) within this 

global continuum of casualty evacuation is an integral lesson learned for future 

facilities. 
96 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

BACKGROUND 

Development of the Trauma Program at Landstuhl 

Regional Medical Center

The trauma program at LRMC was developed to provide optimal care for 

combat casualties. Prior to the wars in Iraq and Afghanistan, LRMC rarely cared 

for traumatically injured patients. Clinicians with varying levels of experience 

provided care in their own independent manner, and communication between 

the different roles of care was nonexistent. The events of September 11, 2001, and 

then combat operations in Afghanistan and Iraq brought about an abrupt need for 

change. These events subsequently led to the development of the world’s largest 

and most complex inclusive trauma system, stretching over thousands of miles and 

three continents. 

As the largest US military healthcare facility in Europe, LRMC found 

itself in a unique position as the common link between US Central Command 

(CENTCOM), whose areas of responsibility included Iraq and Afghanistan, and 

the continental US (CONUS) medical facilities. Although the primary source 

of casualties came from CENTCOM, LRMC was also strategically located as 

an evacuation facility for the US Africa Command (AFRICOM) and the US 

European Command (EUCOM). The intent of Landstuhl’s trauma program 

was to streamline the process of care between the turbulence of deployed facilities 

to the safe haven of an MTF in Germany. LRMC also served as the evacuation 

hospital for CONUS medical centers. 

The early trauma program encompassed all surgical disciplines, including 

general surgery, orthopedics, and the other surgical subspecialties, as well as 

the medicine subspecialties of pulmonology, critical care, infectious disease, 

and gastroenterology. The goal of the trauma program was to establish timely 

multidisciplinary care. This was initially accomplished informally without 

an explicit organizational structure. There was no organized performance 

improvement (PI) or patient safety program specific to the care of the trauma 

patient, despite the exponentially increasing numbers of severely wounded 

casualties arriving at LRMC. Although some measures of PI and patient safety 

were accomplished through the surgical and professional diligence of individual 

providers, the overall lack of structure, organization, and objective standards 

resulted in inconsistent practices and variable outcomes. 

It was therefore determined that the trauma program required the expertise 

of an experienced trauma program manager (a nurse), as well as the leadership of 

a fellowship-trained surgeon in critical care who could successfully develop and 

implement the goals of the trauma program. Implementation of evidence-based 

trauma practice, strong management, recruitment of experienced trauma staff, and 
TRAUMA 97

establishment of a model trauma plan aligned with the criteria set by the American 

College of Surgeons (ACS) eventually led to the verification of LRMC as an 

ACS Role 2 trauma center in 2007. This received full support from the LRMC 

command and approval of the Europe Regional Medical Command. The mission 

and vision of the LRMC trauma program were to decrease patient morbidity and 

mortality, which mirrored the mission and vision statements of LRMC: 

To provide world class comprehensive and compassionate care to our Nation’s 

injured Warriors and families, through a maintained and ready healthcare force 

that seeks, thrives on, and embraces change while accomplishing the mission.2 

Optimum patient care could only be accomplished through a 

multidisciplinary team approach using the collaborative efforts of all services. 

Civilian leadership and military nurse leadership were particularly instrumental in 

providing and maintaining this continuity of care because of the severe nature of 

combat injuries, the immediacy of care required, and the high physician turnover 

related to deployments and short reservist rotations. 

Catchment area for Landstuhl Regional Medical Center. This area includes CENTCOM, 

AFRICOM, and EUCOM—three of the nine combatant commands.
98 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

American College of Surgeons Committee on Trauma Verification 

Process at Landstuhl Regional Medical Center

The ACS trauma verification program at LRMC was established through 

collaboration with military and civilian trauma system experts using the ACS 

Committee on Trauma (COT) manual, Resources for Optimal Care of the Injured 

Patient, 2006. This manual outlined more than 240 criteria for optimal resources 

needed to provide consistent and contemporary trauma care, and served as a guide 

for the ACS COT trauma center verification process by outlining trauma center 

requirements.3 Trauma care in general crosses multiple medical disciplines. Trauma 

care within the military structure also had to cross interservice barriers between the 

Navy, Army, and Air Force to provide care and transportation of trauma patients 

across three continents. 

Early in the conflicts in Afghanistan and Iraq, military services did not have 

an integrated trauma system. Each service had its own version of predeployment 

training and trauma experience. There was also a lack of effective communication 

between roles of care. Each service had a different emphasis on trauma, as 

evidenced by a disproportionate number of trauma and critical care-trained 

surgeons and nurses. In addition, not all services had a dedicated trauma 

consultant under their respective surgeons general. Furthermore, there were no 

senior nursing positions dedicated to trauma program systems. 

In addition, there was a general lack of institutional knowledge regarding 

trauma programs and trauma systems organization. Therefore, hiring an 

experienced civilian trauma program manager was vital to the success of LRMC 

achieving ACS verification. The trauma program manager hired at LRMC 

had a master’s degree in nursing and decades of experience in the clinical and 

management aspects of major civilian trauma centers, as well as extensive 

experience in the ACS verification process. This individual also provided the 

necessary expertise to perform systematic and comprehensive gaps and barriers 

analyses, and could implement appropriate changes and interventions as assessed. 

In addition, a number of senior civilian trauma surgeons played a significant 

role in supporting the growth of LRMC as a trauma center.4

 The Senior Visiting 

Surgeon Program, co-sponsored by the American Association for the Surgery of 

Trauma and the ACS COT, provided the ability for recognized senior civilian 

leaders in trauma and surgical critical care to visit LRMC. This program also 

provided for an active interaction and flow of information between the civilian and 

military communities. More than 60 senior visiting surgeons volunteered time and 

expertise in caring for the wounded and in mentoring military surgeons and staff.

When it was verified as a Role 2 center in 2007, LRMC became the first 

medical facility outside of the United States to be verified by the ACS as a trauma 

center. The hospital was reverified in 2010. Both research and graduate medical 
TRAUMA 99

education were enhanced, and LRMC achieved verification as a Level I trauma 

center in 2011 with multiple accolades and no deficiencies. 

Implementation of the Trauma Program—Part I:

Trauma Program Organization

The Department of Trauma and Critical Care was composed of the Trauma 

Critical Care Service and trauma program staff. The Trauma Critical Care 

Service had up to five trauma critical care surgeons and three critical care medical 

physicians. The trauma program staff included two trauma registrars, five trauma 

PI staff members, four research coordinators, and three support staff. 

Trauma programs include the following components: 

• combat casualty care, 

• a trauma registry, 

• PI and patient safety safeguards,

• education, 

• injury prevention efforts,

• rehabilitation, 

• research, and 

• graduate medical education. 

 Three of these components are described in detail below because they 

specifically apply to the military and LRMC.

COMBAT CASUALTY CARE

Management of casualties coming directly from the combat theater required a 

special diligence and specific understanding of combat trauma because the injuries 

encountered differed in both mechanism and severity compared with those seen in 

civilian trauma centers. Causes of such injuries included the following: 

• improvised explosive devices (IEDs) encountered on foot patrol with 

blast injury (combined primary blast injury, thermal injury, blunt trauma 

from being thrown, and penetrating fragment wounds),

• gunshot wounds sustained on roofs or hilltops with subsequent falls and 

concomitant blunt trauma, 

• gunshot wounds sustained by vehicle drivers traveling at high speeds 

followed by collision or rollover, and 

• IED blasts encountered in armored vehicles with subsequent rollover 

into canals resulting in near drowning. 
100 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014 Admin Coordinator PIPS Coordinator Data Informatics Coordinator Research Compliance Coordinator Admin Assistant NCOIC Trauma Coordinator Trauma Coordinator Trauma Registrar Trauma Registrar

Trauma

Coordinator

Trauma

Coordinator

Research

Coordinator

Research 

Coordinator

Research

Coordinator

Support

Staff

Performance

Improvement Cell

Combat Casualty

Trauma Registry

Cell

Combat Casualty

Research Cell

Trauma Program

Nurse Director

Trauma

Medical Director

Chief, Trauma/

Critical Care

Medical Intensivist

GME Director

Trauma 

Critical/Care

Education Director

Trauma and Critical Care Service

Trauma Critical/Care 

Trauma Ward 

Director

Trauma 

Critical/Care

PIPS Director

Research Director 

ICU

Surgical Director

Medical Intensivist 

ICU

Medical Director

Department of Trauma and Critical Care Staffing at Landstuhl Regional Medical Center, 2012Admin: administrativeGME: graduate medical 

education

ICU: intensive care unitNCOIC: noncommissioned 

officer in charge

PIPS: performance improvement and patient safety 
TRAUMA 101

The mechanisms and weaponry used during the conflicts in Iraq and 

Afghanistan also changed over time. For example, IED blasts in vehicles were a 

significant injury mechanism seen in casualties during Operation Iraqi Freedom 

(OIF) from 2003 to 2009. Vehicles utilized early in this theater were less heavily 

armored, resulting in frequent penetrating wounds and burns. Later in the 

conflict, the vehicles became more heavily armored. In response, the IEDs then 

became more powerful. This resulted in the creation of a blunt injury pattern with 

calcaneal fractures, pelvic fractures, vertebral fractures, and traumatic brain injuries 

resulting from vehicles being violently thrown into the air and then landing.5 

When the drawdown in OIF occurred, there was a shift and the majority of 

casualties began coming from the Afghanistan theater. Because of terrain challenges 

and changes in military tactics in Afghanistan, foot patrols became more common. 

More IEDs were encountered on foot than had been seen in OIF, and the effects 

of primary, secondary, and tertiary blast effects became commonplace, resulting in 

spinal cord injuries and multiple limb amputations with severe penetrating perineal 

and pelvic injuries. An increase in the incidence of invasive fungal infections was 

also seen at the same time.6 The severity and multisystem nature of these injuries 

presented constant challenges to military physicians. These continuously changing 

patterns of injury and their resulting complications required a comprehensive PI 

process to develop and maintain best practice guidelines and standard operating 

procedures (SOPs). 

 As in any military installation, there was a frequent turnover of provider 

staff at LRMC. This situation created an ongoing need to reteach best treatment 

practices with each incoming medical team. The development of clinical practice 

guidelines and SOPs improved patient outcomes and minimized variations in 

practice. The trauma program was responsible for monitoring provider adherence 

and compliance with best clinical practice guidelines and SOPs. Deviations from 

these practices had to be documented and investigated immediately. This ensured 

greater consistency in practice and improved clinical outcomes compared to earlier 

in the conflict. 

TRAUMA REGISTRY

Initially, there was no method to adequately capture and utilize trauma data 

to improve outcomes and develop lessons learned. In an effort to improve care 

throughout the trauma care continuum, the Joint Theater Trauma System (JTTS) 

was developed under the Center for Army Strategic Studies and Army Institute 

of Surgical Research. The JTTS then implemented the Joint Theater Trauma 

Registry (JTTR), which was approved by the Army surgeon general in 2002. 

Initially, collection of combat casualty data was independently completed via 

spreadsheets or homegrown databases at multiple military MTFs in theater, as well 
102 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

as in CONUS. Over time, the JTTR matured into a single, web-based data entry 

system that could be accessed from military MTFs in theater, as well as at LRMC 

and CONUS facilities. The trauma registry was used to code and sort information 

for analysis and reports through the use of either system/process checks (audit 

filters), or review of universally defined morbidities (eg, pneumonia or infections), 

in order to drive evidence-based PI and quality assurance. This registry resulted 

in a standardized data collection system for all roles of combat casualty care and 

allowed for well-defined data elements, automatic calculation of the number and 

percentage of those with specific diagnoses, categorization and scoring of injury 

severity, and the use of standardized coding procedures. 

PERFORMANCE IMPROVEMENT AND PATIENT SAFETY SAFEGUARDS

The trauma PI and patient safety processes required the continuous gathering 

of data. Any part of the trauma care system at LRMC that did not perform well 

was identified through a network of communications that included trauma service 

morning reports, intensive care unit (ICU) and ward rounds, self-reporting, 

concurrent chart reviews, and trended registry reports. 

Assessment of the PI process transcended several continents and actually began 

prior to the patient’s arrival at LRMC. Acute resuscitation and damage control 

procedures were initiated and frequently completed in theater. Patient care then 

continued across Europe and back to facilities in the United States. Communication 

across continents with different time zones further exacerbated the challenge of 

this widespread geographic distribution of patient care delivery. Once the patient 

left LRMC, PI issues were also identified in CONUS. The creation of a forum for 

communication across the continuum of care was vital to the PI process. 

In 2005, the LRMC trauma program initiated a unique PI process through 

the worldwide Trauma Clinical Video Teleconference (VTC). The VTC was held 

on a weekly basis, and included video and audio participation from the point of 

injury to the CONUS facilities. It also included leaders of the Tactical Combat 

Casualty Care system and members of the JTTS. During this teleconference, issues 

of communication, operative and critical care, transport and equipment, PI, and 

opportunities to enhance care were presented openly. All members of the LRMC 

trauma team participated in the VTC, and the PI issues identified were forwarded 

to the LRMC trauma program director, the JTTS medical director, or the trauma 

medical directors in CONUS. 

POSITION DESCRIPTIONS

• Trauma Medical Director

The specific duties and responsibilities of the trauma medical director are 

outlined in detail in the ACS’s Resources for Optimal Care of the Injured 
TRAUMA 103

Patient, 2006.3

 Specific to the military, the trauma medical director 

was an active duty trauma critical care surgeon who also served as the 

chief of the Department of Trauma and Critical Care. The general 

responsibilities included establishing the operational management of the 

day-to-day clinical care of trauma patients. The overarching goal was to 

support the integration of the LRMC trauma program across the JTTS, 

while simultaneously maintaining trauma center standards established 

by ACS. Leadership duties and responsibilities of the trauma medical 

director also included development of the strategic vision for trauma 

operations at LRMC, as well as integration of the trauma program across 

the continuum of care. 

Participation in PI and peer review activities coordinated between 

LRMC and the JTTS and CONUS trauma programs was essential. 

LRMC was in a unique position to identify trends in outcomes and 

process changes from within theater. LRMC provided the necessary 

continuity in reporting these trends because the trauma surgeons 

changed every 3 to 6 months in theater, and every 3 years at LRMC. 

From this vantage point, the LRMC trauma director was able to identify 

and communicate variations from clinical practice guidelines, SOPs, or 

unanticipated complications present on arrival. LRMC has benefited 

from the efforts of several trauma medical directors over the 11 years of 

combat operations. 

• Trauma Program Nurse Director (Trauma Program Manager)

The specific duties and responsibilities of the trauma program manager 

(TPM) are outlined in detail in the ACS’s Resources for Optimal Care 

of the Injured Patient, 2006.3 Specific to LRMC, the trauma program 

nurse director (TPM equivalent) was a civilian employee and a registered 

nurse. An extensive background in trauma program management at a 

civilian ACS or state-verified Role 1 or 2 trauma center was a prerequisite 

for this position. Interestingly, the Department of Defense (DoD) did 

not have a trauma program nurse director or other trauma program 

position available to active duty nurses. 

This position required strong communication skills because the 

trauma program nurse director collaborated with the trauma medical 

director while also interfacing with LRMC military leadership, medical 

staff, nursing staff, and the regulatory agency of the ACS Committee on 

Trauma Verification.3

 

The TPM was responsible for strategic trauma center planning, 

supervision of the operational budget, management of all departmental 
104 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

nonprovider staff, leadership of the ACS verification preparation process, 

and the educational and skill development of the professional staff in 

matters related to trauma care. Both the trauma program director and 

the trauma program nurse director interfaced with key departmental 

directors, and were representatives of the trauma program to hospital 

leadership. The TPM also had the essential role of integrating with JTTS 

program managers in other unified commands, primarily CENTCOM 

and NORTHCOM (US Northern Command). As the trauma program 

matured, the manager’s responsibilities extended throughout EUCOM 

and, in conjunction with the director, the TPM developed the EUCOM 

component of the worldwide JTTS. 

Implementation of the Trauma Program—Part II:

Characteristics of the Patient Population and 

Flow of Patient Care

The military trauma system was visualized as one hospital across three 

continents. After point-of-injury care occurred in the combat theater, patients had 

the majority of their acute injuries stabilized at Role 2 or Role 3 military MTFs. 

A typical Army Role 2 MFT was composed primarily of a forward surgical team 

that could resuscitate and surgically stabilize patients for transfer to the next level 

of care. Army Role 3 MTFs were stationary hospitals located at major airfield hubs 

in the combat zone with enhanced capabilities, such as computerized tomography 

(CT) scanning, angiography, magnetic resonance imaging (MRI), and a multitude 

of specialty surgeons. As soon as they were stabilized for transportation, patients 

were transferred to a Role 3 staging facility. Throughout combat operations during 

OIF and Operation Enduring Freedom (OEF), key in-theater facilities at Balad, 

Iraq, and Bagram, Afghanistan, prepared patients for transfer from the combat 

hospital to Landstuhl. 

Patient flow differed at LRMC compared to a traditional trauma center 

within the United States, where injured patients typically arrive from the point 

of injury and are taken directly to the emergency department (ED). Once the 

LRMC trauma team received notification of incoming patients, the on-call trauma 

surgeon triaged the patients pre-arrival based on the patients’ movement medical 

records (a short synopsis of the patient’s injuries and care) received from the Role 

3 MTF. This information enabled patients to be transported directly from the 

aircraft to the appropriate location within the hospital. A trauma activation was 

initiated for any patient who became unstable or met certain neurological or 

hemodynamic instability criteria. This alerted LRMC medical staff to prepare 

appropriate, high-level resources to best care for that patient. Medically unstable 

patients were transported directly to the ICU. Patients not undergoing activation 
TRAUMA 105

were admitted either directly to the ICU or to the general medical/surgical inpatient unit based on the clinical information relayed. Patients admitted to the 

ICU usually required ongoing resuscitation and further operative procedures. 

This intermediate stop at LRMC after a 6- to 10-hour transport mission from the 

combat theater was both mandatory and clinically essential because many critical 

patients could not tolerate the long flight directly from the combat theater back to 

the United States (at least 16 hours).

LANDSTUHL REGIONAL MEDICAL CENTER 

TRAUMA PATIENT POPULATION

Although the majority of trauma patients cared for at LRMC arrived by 

air transport from Iraq or Afghanistan, patients were also occasionally injured 

on the base at Landstuhl (Army) or Ramstein (Air Force). These patients were 

transported to LRMC by the Ramstein Air Base ambulance service. Occasionally, 

Timeline of transport and roles of care after combat injury—Role 1: field care. 

Role 2: limited in-theater resuscitative capabilities. Role 3: highest level of in-theater 

care, includes many surgical and medical specialties. Role 4: hospital near area of 

operations, but outside theater. 

ARDS: acute respiratory distress syndrome 

CCATT: Critical Care Air Transport Team

CONUS: continental United States

Dx: diagnosis

eval: evaluation 

GSW: gunshot wound

ID: identification

IDF: indirect fire 

IED: improvised explosive device 

PE: pulmonary embolism 

Rx: treatment 

stab: stabilization

TX: transport 

<1 hour

• Field care

• TX to Role 

2 or Role 3 

facility 

•En route 

care

• Hemorrhage 

control

Role 1

2–3 days

• 10 resuscitation

• 10 surgical 

stab

• In-theater 

TX to Role 3

• 20 surgical 

eval, care

Role 2, Role 3

12 hours

• CCATT 

TX to 

LRMC

1–4 days

• Ongoing 

surgical stab

• Initial Dx 

and Rx of 

complications (ARDS, 

renal failure, 

PE, others)

• 10 eval of 

blast injury

Role 4

12 hours

• CCATT 

TX to 

CONUS

3 months

• Definitive

surgical Rx

• ID and 

Rx of

complications

• Rehabilitation

Combat-related Trauma

IED, IDF, GSW
106 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

patients transported themselves to the ED, and sometimes locally stationed 

injured service members were transported directly to the LRMC ED by German 

civilian ambulance crews. All injured patients were evaluated in the LRMC ED 

for hemodynamic stability (a tiered trauma response), and a trauma activation was 

called, if appropriate. Patients who required admission were admitted to a surgical 

service or had a trauma consultation. 

More commonly, aeromedical transportation of trauma patients from OIF or 

OEF (3,000 miles) or to CONUS (4,000 miles) was provided by a combination 

of aeromedical evacuation (AE) and Critical Care Air Transport Teams (CCATTs). 

The CCATT operated as an ICU in the cabin of a fixed-wing aircraft during flight, 

adding critical care capability to the US Air Force AE system that did not exist in 

the first Gulf War (see Chapter 8, Nursing, for a detailed discussion of the history 

and utilization of CCATTs).7

The typical patient transported by the CCATT had undergone initial 

evaluation and operative management in one or two hospitals in the combat zone. 

These patients were often still in their early postresuscitative stage after injury at 

the time of their transport to Germany. Less severely injured patients who did 

not require critical care en route were transported by AE teams. These teams were 

composed of nurses and technicians with specialized training in AE. All in-flight 

patient concerns were immediately relayed to LRMC. The AE and CCATT teams 

had activation criteria for both trauma and critical incidents. Part of the halo effect 

of being a trauma center was that 50% of the activations that did occur were not 

for trauma patients, yet these patients benefited from this well-organized system. 

This enabled a more robust medical response immediately on arrival of the patient 

into the ICU.

Aeromedical transportation of patients in the local German area was provided 

by civilian assets. The German Red Cross (Deutsches Rotes Kreuz or DRK) also 

provided rotary wing transportation of trauma patients in the local area. If patients 

required critical care during these transportations, the DRK platforms (helicopter 

or ambulance) could be staffed by local critical care physicians. Of note, LRMC 

did not serve as a base station for local emergency medical services operations. 

Implementation of the Trauma Program—Part III:

Trauma Service—Clinical Care

The structure was in place for the trauma service to care for injured patients 

as soon as they arrived at LRMC. Multiple disciplines were involved, including 

general surgery, orthopedics, neurosurgery, emergency medicine, critical care, 

pulmonology, infectious diseases, radiology, and surgical subspecialties. 

Patients with multisystem injuries were admitted to either the ward or 

the ICU, but were always under the direct management of a general or trauma 
TRAUMA 107

surgeon. Patients who suffered single-system injuries were admitted to the appropriate specialty service with mandatory consultation to the trauma service for 

certain indications. All trauma patients, regardless of location in the hospital or 

the admitting service, were monitored and tracked by trauma coordinators.

In the ICU, assessments were performed on all patients by the ICU team, 

composed of one trauma surgeon, one general surgeon, one intensivist (medicine 

or pulmonary critical care), rotating residents (from US-based military residencies, 

typically two on service most months), and a physician assistant or acute care nurse 

provider. The ICU team leader was a trauma surgeon, and the individual daily 

assessment and plans were communicated to the ICU team leader during morning 

rounds. 

The trauma ward service was composed of a single attending general or 

trauma surgeon and two physician assistants. All aspects of the patient’s care were 

managed by the attending surgeon. Each morning, the trauma service made 

rounds on the ward, and ICU physicians, trauma nurse coordinators, physician 

assistants, perioperative nurse director, ICU nurse director, case managers, and 

chief of surgery attended as well. All systems issues and complications in the 

trauma service were discussed to capture significant PI events. 

The trauma medical director oversaw all aspects of multidisciplinary care 

provided to trauma patients at LRMC through several parallel channels. The 

trauma service morning report and reports by the trauma coordinators were key 

forums for day-to-day operations. The trauma coordinators acted as the functional 

eyes and ears of the trauma medical director by visiting patient care areas daily, 

observing care plans, and identifying key issues that needed the attention of the 

trauma medical director. Trauma coordinators had access to the trauma medical 

director at any time to convey concerns. 

Other channels of information to enhance management and patient care 

included the trauma morbidity and mortality conference, the weekly patient 

feedback VTC (encompassing providers from Iraq/Afghanistan to CONUS), and 

multidisciplinary peer review conferences. 

SUBSPECIALTY SURGEONS

Because of the significant specialization and increasing sophistication of 

catheter-based therapeutics, a fellowship-trained vascular surgeon was required 

at LRMC to provide optimal care to patients suffering from vascular injury. At 

the beginning of operations in Iraq, vascular surgery care at LRMC was provided 

by rotating reservists. This was not sustainable because of the small numbers of 

vascular cases at LRMC. Beginning in 2007, members of the Society for Vascular 

Surgery (SVS) volunteered to provide needed expertise during 2-week rotations 

at LRMC in which they were credentialed to supply services as civilian Red Cross 
108 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

volunteers. Since that time, more than 80 SVS members have rotated through 

LRMC, serving as consultants in this increasingly specialized area.

Neurosurgery was another vital specialty required for all trauma centers. At 

LRMC, neurosurgical services had been provided through a variety of means. 

During the initial phase of the conflict (2001–2004), neurosurgical patients were 

transferred to a local German facility for their care. Patients who required acute 

neurosurgical services arrived at Ramstein Air Base and were transported directly 

to either the German military hospital in Koblenz (200 km) or the civilian trauma 

center in Homburg (22 km). Neurosurgeons at both of those facilities also had 

privileges at LRMC and could attend to patients onsite (although this occurred 

rarely). Beginning in 2004, members of the American Association of Neurological 

Surgeons offered their services as Red Cross volunteers and provided much of the 

needed care to injured patients. Starting in 2006, neurosurgeons from the Navy 

and Army Reserves provided continuous, 24-hour-a-day care in conjunction 

with a contracted civilian neurosurgeon. Availability and standardization of 

neurosurgical trauma care have been the greatest challenges of the trauma program.

INTENSIVE CARE UNIT 

The trauma ICU system is based on a closed model, wherein the patient 

was admitted to the trauma service that directed the patient’s care.8

 Patients who 

underwent resuscitation and surgical stabilization in theater arrived daily, and were 

admitted directly from the flight line to the ICU. Multidisciplinary rounds were 

conducted daily with multiple specialists, including infectious disease, pulmonary/

critical care, pharmacy, respiratory therapy, nutrition, and trauma coordinators. A 

critically important role of the trauma service was to determine when the patient 

was stable enough to be evacuated to a Role 4 MTF in CONUS, such as Walter 

Reed National Military Medical Center in Bethesda, Maryland, or San Antonio 

Military Medical Center in Texas. This decision was challenging because the 

physician had to balance the benefits of being in a definitive care setting close to 

home in the United States, while also considering the potential dangers of an 8- 

to 10-hour transcontinental flight. However, as the trauma program and trauma 

services at LRMC evolved, almost all the necessary ICU supportive care was 

available, making it possible to hold patients until they were stable for transport 

by CCATT to CONUS. Most patients spent 2 to 3 days hospitalized at LRMC. 

Despite changes in the two conflicts in the Middle East, both ICU and hospital 

admissions to the trauma service remained relatively stable with approximately 

40 ICU admissions per month, though there was a steady rise in the Injury 

Severity Score. 
TRAUMA 109

Medical Records

Maintaining accurate and timely medical records from downrange through 

CONUS was essential for the continuity of care. During the early phases of OIF 

and OEF, medical records were kept on paper charts that followed the patient 

through multiple roles of care. These records were sometimes scant, unintelligible, 

or frequently misplaced during the chaos of intertheater transport. During busy 

combat periods, many surgeons wrote the operative procedures performed 

on the patient directly onto the patient’s dressings with permanent markers. 

Communication regarding the condition of incoming patients was challenging, so 

LRMC staff developed and implemented the Joint Patient Tracking Application 

(JPTA). This was a secure, military, web-based application that allowed providers 

from combat theaters to communicate critical information regarding resuscitation 

and operative interventions. It also allowed the upload of operative notes, photographs, discharge summaries, and supporting documentation in theater, at LRMC, 

and in CONUS. JPTA was touted by the providers as an excellent and userfriendly method to maintain a consecutive record and move critical information 

Trauma admissions to the intensive care unit by month correlated with the Injury 

Severity Score from January 2007 through June 2012

350

300

250

200

150

100

50

0

Jan 07

Mar 07

May 07

Jul 07

Sep 07

Nov 07

Jan 08

Mar 08

May 08

Jul 08

Sep 08

Nov 08

Jan 09

Mar 09

May 09

Jul 09

Sep 09

Nov 09

Jan 10

Mar 10

May 10

Jul 10

Sep 10

Nov 10

Jan 11

Mar 11

May 11

Jul 11

Sep 11

Nov 11

Jan 12

Mar 12

May 12

blue line: Operation Enduring Freedom

red line: Operation Iraqi Freedom/Operation New Dawn

green line: average intensive care unit Injury Severity Score

thin black line: linear (average intensive care unit Injury Severity Score) 
110 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Combat documentation. Pertinent information about site and findings is included on 

dressing to facilitate communication between roles of care.
TRAUMA 111

through the various roles of care. JPTA was reliable, allowed for quick transfer of 

information between sites, and was modifiable to meet the changing needs of the 

combat theater. 

The JPTA system morphed into a vital tool used by all roles of care. With 

great effort, that system was then integrated with Medical Communications for 

Combat Casualty Care (MC4) in 2009 and became the Theater Medical Data 

Store (TMDS). TMDS was a secure, web-based patient tracking and management 

tool used to collect, manage, analyze, and report data on patients arriving at all 

MTFs from their deployed locations. It provided administrators and medical 

personnel with the ability to view the current status of patients as they moved 

through all roles of care. Providers used the TMDS to transmit key medical 

information to the next caregivers along the continuum. This improved the 

medical staff’s ability to anticipate and plan for the needs of incoming patients, as 

opposed to waiting until they arrived. 

The original JPTA program was developed at LRMC for a minimal cost, but 

the current TMDS is now operated and managed by DoD. All hard copies of intratheater and LRMC paper medical records (including downrange documentation) 

and follow-up information were scanned to a HIPAA (Health Insurance Portability 

and Accountability Act)-compliant, web-based site at LRMC to facilitate the 

collection of data into the trauma registry, support research efforts, and develop 

improved methods of care. Laboratory and radiology results were also included.

Radiology

At the beginning of the wars, there were no diagnostic images forwarded from 

the combat theater, and official radiology reports were scant. Out of necessity, 

most injured patients arriving from downrange were reimaged. Eventually CT 

scan images were loaded onto compact discs that were sent along with the patient’s 

hard-copy medical records. In 2006, a digital radiology system called PACS 

(Picture Archiving and Communication System) was installed to store and retrieve 

images, and an interface between the combat theaters and LRMC was established. 

This required a manual “push” of the films over the Internet to LRMC, as well 

as a manual “pull” from LRMC. Radiology technologists came into the hospital 

at night to have films available by the time the wounded warriors arrived the 

next day. However, sagittal and coronal reconstructions could not be transferred 

because of large bandwidth requirements; thus, the LRMC radiologist completed 

the reconstructions on studies performed in theater. The culmination of efficient 

and reliable data transmission significantly decreased the need to perform repeat 

radiological studies or procedures between roles of care.
112 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

LESSONS LEARNED

During times of military conflict, experiences gained by military physicians 

have contributed to the advancement of civilian trauma care. There has been a 

significant effort to promote dissemination of lessons learned from pivotal clinical 

experiences over the last decade at LRMC. Over the last few years, more than 50 

peer-reviewed publications related to patient care at LRMC have been published 

in the medical literature. Many of the successes of the trauma program at LRMC 

were born from the challenges encountered in the earlier years of conflict and the 

interventions that were created to address them. 

End-of-Life Care

In 2004, DoD issued a directive that all military personnel receive organ 

donation-related information and that the names of those personnel interested in 

participating be documented. The directive also stated that all military hospitals 

should affiliate with a local organ procurement organization for education and 

procurement purposes. LRMC developed an affiliation with the Deutsche Stiftung 

Organtransplantation (DSO), the national organ procurement organization in 

Germany. Standards for determining brain death and patient donor eligibility 

according to the DSO mirrored DoD policy. In addition, the DSO did not 

participate in donation after cardiac death, which is acceptable practice in the 

United States. Patients were declared brain dead at LRMC in accordance with 

local policy. 

Families were often present during the brain death determination at LRMC. 

This rapid response occurred with the assistance of the service member’s deployed 

unit, who notified the family in cases of catastrophic injuries, and also with the 

assistance of the Departments of the Army, Navy, and Air Force, which expedited 

the issuance of passports, if necessary. Once the family was reunited, confirmation 

was documented regarding the patient’s preference for organ donation. The 

family was approached by a trained physician or registered nurse who was not 

participating in the care of the patient. These individuals underwent 4 hours 

of training conducted by the DSO on how to approach families for organ 

donation. Once the patient’s organ donation status was confirmed, the German 

organ procurement team conducted the organ harvest at LRMC, with vigilant 

attendance of an Armed Forces Medical Examiner. Between 2001 and 2010, there 

were 93 combat casualty deaths at LRMC primarily from severe head injuries. The 

organ donation conversion rate for that period of time was 85% for those who 

were eligible for donation, with 105 organs recovered.9 As a comparison, the US 

Organ Procurement and Transplantation Network reported a national conversion 

rate of 73% for 2012.10
TRAUMA 113

Acute Lung Rescue Team

The Acute Lung Rescue Team (ALRT) was the only team in the DoD 

with the capability to transport combat casualties with severe lung injury.11 

The development of acute lung injury and acute respiratory distress syndrome 

significantly complicated evacuation of critically ill and injured casualties. In 

the past, patients with acute lung injury remained in theater until either their 

condition improved or they died. The ALRT, which was housed at LRMC, 

performed missions to transport seriously ill patients from the EUCOM, 

CENTCOM, and AFRICOM theaters of operations. Members of the team 

included both surgical and medical intensivists, ICU nurses, and respiratory 

therapists, all trained in CCATT. Additional therapeutic options available to the 

ALRT included advanced modes of ventilator support using specialized transport 

ventilators (eg, volumetric diffusive respirator percussive ventilation), inhaled 

prostacyclin, and extracorporeal membrane oxygenation (ECMO) capability. 

The ALRT transported patients more critically ill than those transported via 

CCATT. Patients transported by ALRT had a predicted mortality of more than 

70% and an average oxygen need of 93% FiO2 (fraction of inspired oxygen), 

compared with a CCATT patient who typically had a predicted mortality of 

35% and an average oxygen need of 53% FiO2. The ALRT was activated for 

both trauma (60%) and nontrauma diagnoses (40%). Trauma-related diagnoses 

Veno-venous extracorporeal membrane oxygenation at Landstuhl Regional 

Medical Center.
114 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

0

5

10

15

20

2005 2006 2007 2008 2009 2010 2011 2012

Launches

Cx: improve

Cx: died

5 1

2

10

6

10

4

16

Number of activations of the Acute Lung Rescue Team from 2005 to 2012

Cx: cancelled (if cancelled because patient died, death occurred prior to arrival of 

the team)

0

5

10

15

20

2005 2006 2007 2008 2009 2010 2011 2012

ECLS

PCV

HFPV

CONV

Pulmonary support used by the Acute Lung Rescue Team

CONV: conventional ventilation

ECLS: extracorporeal life support

HFPV: high-frequency percussive ventilation 

PCV: pressure control ventilation
TRAUMA 115

included blunt pulmonary contusion, blast and thermal inhalation injuries, near 

drowning, and penetrating chest injuries. Nontrauma patients with diagnoses 

of eosinophilic pneumonitis, sepsis, pneumonia, multiple organ failure, and 

postcardiac arrest were also transported.11,12 Between 2005 and 2012, the team was 

activated more than 60 times. 

Extracorporeal Membrane Oxygenation 

ECMO was an infrequently needed, but potentially life-saving, mode of 

support for patients with severe pulmonary failure.11,12 Patients suffering from lung 

injury due to combat were potentially excellent candidates for ECMO because 

most were young and sustained a form of lung injury (blast injury) that was 

typically reversible over a relatively short period of time. In concert with colleagues 

from the University Hospital Regensburg, the ALRT initiated ECMO multiple 

times between 2005 and 2012. After evaluation by members of the ALRT, patients 

who met eligibility criteria for ECMO were typically cannulated by the ALRT 

surgical intensivist at Role 3 facilities in theater (or at other medical facilities in 

EUCOM or AFRICOM). After cannulation and stabilization, patients were then 

transported to LRMC. Once stabilized at LRMC, patients were transferred to the 

University Hospital Regensburg for respiratory care until they could be weaned off 

ECMO. The survival rates were excellent, with 100% of patients surviving until 

ECMO was removed and 85% of patients surviving 30 days from that point. 

Deep Vein Thrombus Screening and Prophylaxis

A systemic prevention program for deep vein thrombus (DVT) was one of the 

first JTTS clinical practice guidelines enacted because of a perceived high DVT/

pulmonary embolism rate. In conjunction with the JTTS director’s in-theater 

program, LRMC began an aggressive DVT prevention protocol that included early 

chemical prophylaxis, sequential compression stocking use, and DVT screening on 

all ICU patients and other high-risk groups. In a PI analysis (postinitiation of the 

DVT screening program), the rate of DVT was 14.1% (80 patients with DVT), 

and the rate of pulmonary embolism was 4.42% (25 patients with pulmonary 

embolism). The newly identified rates of thromboembolic events were significantly 

higher than those identified prior to this aggressive screening program.9

 Further 

analysis identified that femoral venous catheters, in common use at this time, were 

a significant risk factor for the development of DVT. Efforts were then enacted 

to remove them as early as possible. Furthermore, all patients with DVT and pulmonary embolism were treated with therapeutic anticoagulation or inferior vena 

cava filters if contraindications to anticoagulation existed. 
116 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Invasive Fungal Infections After Combat Injury

Infections had been a problem in the combat injured since the beginning of 

the conflicts. An increase in invasive fungal infections in the immune competent 

service member has been noted.13 These infections included the unusual pathogens 

(unusual for the immunocompetent host) Mucor and Aspergillus. The occurrence 

of these infections in patients after injury was associated with significant morbidity. 

The clinical picture of progressive ongoing tissue necrosis in the wounds of a 

critically injured patient who demonstrated signs of systemic inflammatory 

response was a common presenting scenario. An aggressive approach of early 

diagnosis and initiation of appropriate local and systemic therapies to treat 

infection improved outcomes. A number of risk factors were identified for invasive 

fungal infections in the combat injured, including dismounted (patrolling on 

foot rather than in a vehicle) blast injury, above-the-knee traumatic amputations, 

extensive perineal/pelvic injury with the need for massive transfusion, and injury 

location in the Afghanistan Sangin River Valley. 

Recognition of this problem at LRMC led to the development of a blast 

injury protocol that was initiated in those patients at particular risk for an 

invasive fungal infection. This protocol included histological evaluation and 

microbiological culture of tissue during the first debridement after arrival from 

theater. Histological evaluation included fungal staining and evaluation for plant 

material and foreign material in debrided tissue. This early histological evaluation 

significantly facilitated identifying patients with fungal infection. 

Incomplete Fasciotomy

Because of the increased incidence of missed and incomplete fasciotomies, 

a retrospective review of 336 combat casualties undergoing 643 fasciotomies in 

Iraq, Afghanistan, and LRMC was performed. Patients requiring a fasciotomy 

revision at LRMC had a fourfold increase in mortality. Additionally, patients had 

increased rates of amputation (31% vs 15%) when they required a fasciotomy 

revision. The most commonly unopened compartments were the anterior and 

deep compartments of the lower leg.14

This led to an ALARACT (or All Army Activities) specifying that Role 

2 and 3 military MTFs should liberally perform complete fasciotomies when 

indicated.15 Prophylactic fasciotomies should be performed prior to transport for 

at-risk extremities. Delaying transport for 24-hour observation was recommended 

for those casualties at high risk for developing compartment syndrome and in 

cases where the surgeon decided against immediate fasciotomy. This also led to 

significant changes in emergency war surgery courses and other predeployment 

training programs that now emphasized the two-incision, four-compartment 

release method of relieving the lower leg compartments.15 Thus, there was a major 
TRAUMA 117

decrease in overall missed compartment syndromes and adequate compartment 

releases. 

Revision of Brooke Army Medical Center 

Burn Resuscitation Algorithm

Complications such as overresuscitation and abdominal compartment 

syndrome were seen in seriously burned patients transported through the various 

roles of care. Identification of this problem led to a multidisciplinary development 

of a resuscitation algorithm and Burn Flow Sheet. The algorithm was later 

modified by the US Army Institute of Surgical Research ICU team. This was 

promulgated throughout the system with the publication of a burn resuscitation 

clinical practice guideline by the JTTS. Weekly utilization of the algorithm and 

flow sheet, with appropriate feedback to deployed providers at Role 2 and 3 

facilities at the theater-wide VTC, led to a significant reduction of complications 

from overresuscitation.16,17 

THE FUTURE: MAINTAINING TRAUMA CENTER 

VIABILITY AND CAPABILITY

Returning to prewar conditions raises major concern both for Landstuhl 

and, by implication, other DoD facilities that may serve as Role 4 hospitals. 

Our wounded warriors deserve world-class care. Such excellence in care was a 

significant challenge for Landstuhl at the beginning of the current conflicts. It 

required nearly 6 years to establish a mature trauma program and trauma system 

at LRMC. In retrospect, it would be faster and more efficient to expand an existing

trauma program that remained in continuous readiness to handle a large influx 

of severely injured patients during outbreaks in hostilities within the combatant 

commands. This type of approach would also provide the agility to support shorter 

conflicts (the expected norm) without the need to expand over the years of the 

conflict. Such an approach allows many of the processes and services that would 

already be engaged in a trauma system—such as operating room readiness, critical 

care service, the massive transfusion protocol, PI, and the trauma registry—to 

immediately expand because many of those processes would already be in place. 

Building on the lessons learned at LRMC, the institutional knowledge and process 

of trauma care, as well as the engagement of necessary services (eg, blood bank and 

neurosurgery), would be present and active in this situation. 

How would such a facility, operating at a lower level, be kept active? The area 

serviced by Landstuhl includes Africa, Europe, and the Middle East. It is certain 

that there will continue to be low-level conflicts in these areas that will contribute 

to the need for trauma services and a trauma system, such as the attack on the 

American diplomatic compound in Benghazi, Libya, on September 11, 2012. In 
118 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

addition, there are significant numbers of service members and dependents within 

the catchment area. A significant portion of beneficiaries injured in EUCOM 

could be sent to LRMC once their acute injuries were stabilized. It is likely that 

this level of activity would support activities at Landstuhl commensurate with 

an ACS Role 3 trauma facility and support involvement of the multidisciplinary 

medical and ancillary care critical to its function. This approach should also be 

applicable to other regions of the globe where the US military has a presence. 

These opportunities would serve to maintain a Role 4 military MTF viability 

as a trauma center. To achieve that goal, the trauma program staffing should 

be incorporated into the Table of Distribution and Allowances (TDA) of all 

Role 4 military MTFs. Many of the roles of the trauma program staff could be 

accomplished by active duty military personnel. To maintain the manpower 

necessary to provide trauma center and trauma systems expertise, each branch of 

military service will need to make this type of professional development a priority.

There are two technology/capability fixes that would aid in the functioning 

of a Role 4 facility during times of lower operational tempo. The first capability is 

telemedicine, which is increasingly being used for patient care in rural areas and for 

complex conditions. Telemedicine has significant potential benefit in the military 

setting, especially in the areas of critical and subspecialty care. The department 

of surgery at LRMC has pioneered a novel telemedicine clinic in otolaryngology 

with remote clinics in Germany. The specialty providers are able to perform, 

via video, examinations of the ear, nose, and mouth performed by a surrogate 

provider (primary care physician or nurse practitioner). There is also a plan to test 

this technology in the combat theater with burn patients. The ability to project 

specialty expertise to austere locations could help fill gaps during mobilization to 

contingency operations. Similarly, ICUs at LRMC can be equipped with monitors 

to provide remote intensive care consultation and monitoring. This practice has 

been shown in studies to reduce mortality, reduce ICU lengths of stay, and increase 

adherence to best care practices.18 

The second capability is aeromedical transport. There is currently significant 

capability to transport critically ill patients through the CCATT program. This 

program allows evacuation of patients across long distances to the Role 4 facility. 

The high volume of patient transfer (more than 8,000 patient movements) and 

associated low morbidity are testaments to a finely tuned training program. 

Therefore, the CCATT concept must continue to be used because it will become 

an asset for peacetime initiatives. The advanced experience of the LRMC-based 

ALRT serves as both a model for the DoD and the civilian sector. 

The input and efforts of multiple groups have significantly improved the 

current US military trauma system compared to previous conflicts. If remaining 

challenges were addressed and improved upon, care for injured service members 
TRAUMA 119

would be significantly improved in the future. These challenges include the 

following:

• Electronic health record. Communication between roles of care has 

significantly improved. However, the military medical system, like 

many health systems, struggles with integrating multiple electronic 

record systems to provide a longitudinal medical record across the entire 

continuum of care. This is a significant challenge to overcome across 

continents. The consolidation of one unified record, which includes all 

radiological images, is critical to improving communication and care. 

• Performance improvement. The DoD JTTS has made significant strides 

in PI efforts across the continuum of care. However, there continues to 

be difficulty in identifying and tracking complications across the system. 

An example of this is the patient who develops a pulmonary embolus at 

a Role 4 facility in CONUS after receiving suboptimal anticoagulation 

at another Role 4 facility prior to arrival. Current tracking mechanisms 

do not allow for routine reporting of this type of complication back to 

LRMC, which then hinders subsequent PI efforts up and down the care 

continuum. 

• Trauma program. Further definition of the role and importance of the 

trauma program within the military hierarchy and across the various 

military services would significantly facilitate function. The DoD 

readiness organizations have always emphasized individual unit training 

and equipment, but have been very slow to recognize the importance of 

trauma systems and trauma programs. This was evidenced by the need to 

hire civilian personnel to manage the trauma program at LRMC. Training 

and maintaining active duty nurses in the skills necessary to manage a 

trauma program and a trauma PI program within the institution would 

provide continuity and bridge gaps within the military system. 

• Turnover rate. Turnover continues to limit the development of 

institutional memory at most military facilities. The estimated annual 

turnover at LRMC is 40%.9 A cap of only 25% turnover of personnel 

(to include reservists) every 6 months should be implemented in order to 

maintain optimal clinical performance and growth. 

ONE HOSPITAL ACROSS THREE CONTINENTS

LRMC is in a unique and vital position as the Role 4 facility providing 

combat casualty care to all patients injured during combat operations in the 

current conflicts. Over time, LRMC has matured into a robust and active trauma 

center and is perhaps the most critical example of the global care model for US 

combat casualty care. Nearly 100% of surviving patients injured in two theaters 
120 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

of operation (Iraq and Afghanistan) have passed through LRMC for additional 

care. The pace of modern warfare and the increasing lethality of weapons used will 

require the Role 4 military MTFs of the future to respond quickly and efficiently. 

To capitalize on lessons learned, facilities such as LRMC should maintain trauma 

center viability in perpetuity. 

ACKNOWLEDGMENTS

Greg Beilman, MD, COL, US Army Reserve, Trauma/Critical Care Surgeon; 

John Oh, MD, LTC, US Army, Surgeon and Director, Trauma Program; Kathleen 

Martin, RN, MSN, Nurse Director, Trauma Program; David Zonies, MD, Lt Col, 

US Air Force, Surgeon and Director, Trauma Program; Ray Fang, MD, Lt Col, 

US Air Force, Trauma/Critical Care Surgeon and Director, C-STARS; Donald 

D. Trunkey, MD, FACS, Trauma Surgeon; Warren Dorlac, MD, COL, US Air 

Force, Medical Director, Trauma/Critical Care Unit and Director, C-STARS. 

REFERENCES 

1. Hetz SP. Introduction to military medicine: a brief overview. Surg Clin North 

Am. 2006;86:675–688.

2. Trauma program mission statement as provided by Oh J, Martin K, Beilman, 

G, Zonies D, Fang R, Trunkey D, Dorlac W. Landstuhl Regional Medical 

Center, January 2013.

3. American College of Surgeons Committee on Trauma. Resources for Optimal 

Care of the Injured Patient, 2006. Chicago, IL: COT-ACS; 2007.

4. Martin MJ, Dubose JJ, Rodriguez C, et al. “One front and one battle” : 

civilian processional medical support of military surgeons. J Am Coll Surg.

2012;215:432–437.

5. Possley DR, Blair JA, Freedman BA, et al. Skeletal Trauma Research 

Consortium (STReC). The effect of vehicle protection on spine injuries in 

military conflict. Spine J. 2012;12:843–848.

6. Warkentien T, Rodriguez C, Lloyd B, et al. Invasive mild infections following 

combat-related injuries. Clin Infect Dis. 2012;55:1441–1449. 

7. Cannon JW, Zonies DH, Benfield RJ, et al. Advanced en-route critical care 

during combat operations. Bull Am Coll Surg. 2011;96(5):21–29.

8. Fang R, Pruitt VM, Dorlac GR, et al. Critical care at Landstuhl Regional 

Medical Center. Crit Care Med. 2008;36(7 suppl):S383–S387.

9. Statistics provided by Oh J, Martin K, Beilman, G, Zonies D, Fang R, 

Trunkey D, Dorlac W. Landstuhl Regional Medical Center, January 2013.
TRAUMA 121

10. US Department of Health & Human Services, Health Resources and Services 

Administration. OPTN/SRTR 2012 Annual Data Report: Deceased Organ 

Donation. Washington, DC: HHS; 2012. http://srtr.transplant.hrsa.gov/

annual_reports/2012/pdf/07_dod_13.pdf. Accessed August 2, 2015.

11. Fang R, Allan PF, Womble SG, et al. Closing the “care in the air” capability 

gap for severe lung injury: the Landstuhl Acute Lung Rescue Team and 

extracorporeal lung support. J Trauma. 2011;71(1 suppl):S91–S97.

12. Dorlac GR, Fang R, Pruitt VM, et al. Air transport of patients with severe 

lung injury: development and utilization of the Acute Lung Rescue Team. J 

Trauma. 2009;66(4 suppl):S164–S171.

13. Paolino KM, Henry JA, Hospenthal DR, et al. Invasive fungal infections 

following combat-related injury. Mil Med. 2012;177:681–685.

14. Ritenour AE, Dorlac WC, Fang R, et al. Complications after fasciotomy 

revision and delayed compartment release in combat patients. J Trauma. 

2008;64(2 suppl):S153–S161.

15. US Department of the Army. Management of OIF/OEF Casualties Requiring 

Extremity Fasciotomy. Washington, DC: HQDA; May 2007. ALARACT 

Memorandum 106/2007. 

16. Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned 

military casualties: fluid begets more fluid. J Trauma. 2009;67:231–237.

17. Ennis JL, Chung KK, Renz EM, et al. Joint Theater Trauma System 

implementation of burn resuscitation guidelines improves outcomes in 

severely burned military casualties. J Trauma. 2008;64(2 suppl):S146–S151.

18. Lilly CM, Cody S, Zhao H, et al. Hospital mortality, length of stay, and 

preventable complications among critically ill patients before and after teleICU reengineering of critical care processes. JAMA. 2011;305:2175–2183.
Work station for medical staff at Landstuhl Regional 

Medical Center. 

Photograph courtesy of CDR Kevin Kumlien, Navy reservist, 

Intensive Care Unit nurse.
CHAPTER EIGHT

Nursing

Heroes are never perfect, but they’re brave, they’re authentic, they’re 

courageous, determined, discreet, and they’ve got grit.

WADE DAVIS, PhD

ANTHROPOLOGIST AND ETHNOBOTANIST 

UNIVERSITY OF BRITISH COLUMBIA 

I

ntensive care units (ICUs) in civilian hospitals are stressful environments. 

Patients are in critical condition, the workload is demanding, and noise 

is constant from beeping machines, monitors, and ongoing conversation 

between various caregivers on the clinical team. Flexibility is mandatory because 

a seemingly stable moment can change in an instant. A phone call from the 

emergency room usually means there is a new admission, maybe more than one. 

This brings a heightened level of activity as bed status is reviewed, changes made, 

and assignments added to a nurse’s already stressful patient load. 

Medical-surgical (med/surg) floors at civilian hospitals are also notoriously 

busy. Although patients are not as seriously ill as in an ICU, the volume of 

patients in those units can be triple. Depending on the shift, nurses can care for 

anywhere between five and ten patients at a time, many postoperative, and most 

with complex comorbidities. 

Across the ocean in Germany, nurses at an American-based military hospital 

experience stress, critical patients, change, the need for flexibility, and tragedy 

at a level far beyond what is seen in any civilian hospital. After the onset of 

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), 

Landstuhl Regional Medical Center (LRMC) was transformed from a quiet, 

“sleepy” community hospital caring for routine medical problems to a Level I 

trauma center caring for thousands of combat casualties evacuated from war 

zones. Every administrative and clinical unit within this facility underwent rapid 

evaluation and change to meet the enormous and complex needs of wounded 
124 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Remembering Landstuhl

Without a doubt, the hardest part of being a nurse at Landstuhl Regional Medical 

Center was the emotional piece. I had worked in the neurotrauma intensive care 

unit at a large civilian hospital before I was deployed, and thought I was “42 and 

bulletproof.” But this was something altogether different; these were young kids, 

so many of them, and with so many devastating injuries. Their lives would never 

be the same again, and you just wondered how they could survive all of this. It was 

crisis after crisis in that intensive care unit, and you were so busy that you did not 

have time to wrap your brain around all of the devastation, or rationalize any of it. 

One story I will never forget happened early in my deployment. My patient 

was a young lady evacuated from Afghanistan, the only survivor in her unit after 

an explosion where both of her legs were blown off. In a morphine haze, she was 

unaware of her surroundings, and I repeated to her that she was safe in Germany. 

As the accident was recalled in her mind, she asked about the others in her unit, 

name by name. I had to deliver the news that they had died. She repeatedly asked, 

“Why did I make it?”I remember standing next to her bed and telling her, “I don’t 

know why you are here, but I believe you will have the rest of your life to figure 

that out.” It was a statement I repeated many times to other soldiers in similar 

circumstances who asked the same question. I don’t know what made me say this 

to that patient, but I could only hope that she and others like her found a sense of 

peace and the realization that there was still purpose in their lives.

CDR KEVIN KUMLIEN, NAVY RESERVIST

 INTENSIVE CARE UNIT NURSE

soldiers. Nursing responsibilities changed drastically as well. While improvements 

in Kevlar (DuPont, Wilmington, DE) body armor protected soldiers better than 

in earlier conflicts, current weaponry brought devastating injuries. Casualties 

rarely arrived at LRMC with just a single injury. Polytrauma, such as traumatic 

brain injury (TBI), multilimb amputations, blindness, burns, and penetrating 

wounds produced a cascading series of needs that required an intricate level of 

care. Four major kinds of nurses played integral roles in the lifesaving efforts of 

caring for wounded warriors: ICU and med/surg clinical nurses and inpatient and 

outpatient nurse case managers (NCMs). 

BACKGROUND

Demographics became quite different for LRMC with the onset of the 

global war on terrorism (GWOT). Prior to 2001, the hospital primarily provided 

primary and tertiary care to military personnel and their families in the European 
NURSING 125

A team of nurses and doctors from Landstuhl Regional Medical Center.

Photograph courtesy of US Air Force.

theater. Hospital staffing was a combination of Army (50%), Air Force (15%), 

and civilian (35%) personnel.1 The nursing department at LRMC was under the 

direction of the Army command. Caring for wounded warriors was certainly not 

a new phenomenon for military nurses. As far back as 1943, Army nurses were 

trained in air evacuation procedures, caring for patients from secret missions in 

North Africa, New Guinea, and India. The concept of transporting wounded soldiers by helicopter ambulances to frontline mobile surgical hospitals began during 

the Korean War, and nurses helped transport more than 17,000 of those soldiers. 

The helicopter system was further refined during the Vietnam War.2 

The nurses at LRMC rose to the occasion in this military conflict. The 

wars in Iraq and Afghanistan, however, were straining the medical center, which 

remained committed to its primary purpose of treating US service members and 

families, in addition to caring for the deluge of injured soldiers evacuated from 

downrange. The workload at LRMC was most intense when the fighting was 
126 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

most intense. During the first attack on Fallujah, in April 2004, there were more 

than 400 war-related inpatient admissions, and this increased to more than 500 

with the second Fallujah attack in November.3 On average, casualties from the 

war accounted for 60% of the hospital census.4 The constant flow of soldiers with 

devastating injuries was taking a toll on caregivers, and additional support was 

needed. 

A plan was initiated to acquire resources from all military branches and augment the clinical staff at LRMC. This plan also freed up Army personnel, who 

could now be sent forward to combat hospitals where additional medical support 

was also needed. In October 2006, a group of 350 Navy reservists from the Great 

Lakes region were deployed and arrived at LRMC. This was now a true triservice 

initiative. There were some initial adjustments for both sides as the existing staff 

at Landstuhl saw the high clinical skill level of incoming reservists (corpsmen, 

nurses, etc) and reorganized to utilize these capabilities most efficiently. New staff 

had to learn various computer systems, paper charting, and the rules of the Army 

command. Although the challenges were great, the plan was quite successful as 

this dedicated, skilled, and hard-working group significantly contributed to the 

excellent quality of care given to wounded warriors at LRMC. The first group of 

Navy reservists completed their tour in November 2007 and was succeeded by 

another equally large reservist group who continued providing necessary medical support to LRMC. As the intensity of the war diminished, the numbers of 

The ten heaviest casualty months at Landstuhl Regional Medical Center: Operation 

Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn inpatients, 

January 2003 to July 2013.

450

400

350

300

250

200

150

100

50

0

Jan 03

Apr 03

Jul 03

Oct 03

Jan 04

Apr 04

Jul 04

Oct 04

Jan 05

Apr 05

Jul 05

Oct 05

Jan 06

Apr 06

Jul 06

Oct 06

Jan 07

Apr 07

Jul 07

Oct 07

Jan 08

Apr 08

Jul 08

Oct 08

Jan 09

Apr 09

Jul 09

Oct 09

Jan 10

Apr 10

Jul 10

Oct 10

Jan 11

Apr 11

Jul 11

Oct 11

Jan 12

Apr 12

Jul 12

Oct 12

Jan 13

Apr 13

Jul 13

233 241

286

391

260

231

235

235

219

230

Fallujah Baghdad

Iraq Surge Afghanistan

Surge
NURSING 127

deployed Navy reservists decreased. In 2014, the last group of Navy reservists was 

deployed to LRMC. 

 

IMPLEMENTATION: HOSPITAL CLINICAL NURSING

Preparing for Arrival

Morning report in the ICU and the med/surg floors is suddenly interrupted 

by each unit clerk’s voice on the intercom announcing “wheels down.” There is 

immediate reaction to these words, a palpable change in the room demeanor 

as faces turn solemn, bodies tense, and heart rates increase. These two seemingly 

simple words impart great impact: an incoming flight from downrange has just 

arrived at Ramstein Air Base with wounded warriors from combat and other 

patients with various illnesses. They will soon be transported to LRMC. The 

initial silence is quickly broken by a rush of adrenaline, and the realization of all 

that needs to be done in preparation for this arrival.5

Althugh wounded warriors arrived at any time of the day or night, this 

was a typical scenario for nurses who prepared for each new group of patients 

evacuated from theater to LRMC. During different points in the war, they heard 

the words “wheels down” more than once a day. Nursing teams are usually able to 

review the patient medical records (PMRs) 1 to 6 hours before the flight arrives 

at Ramstein. These records contain the patient’s history, diagnosis, event of the 

injury/illness, and any treatment that has been given from time of injury to time 

of evacuation from the combat support hospital.5 The PMR also documents the 

medical condition of the patient during flight, medications given, and medical 

equipment used. This is vital information that helps the medical team at LRMC 

determine which patients will be assigned to the ICU and the med/surg floor. 

Nurses try to anticipate what equipment they will need: additional wound care 

supplies and devices, patient-controlled anesthesia pumps, ventilators, chest tubes, 

and intravenous pumps. No pause button can be hit, no downtime can be found. 

There is constant movement, conversation, planning, and decision-making in 

anticipation of patient arrival and all that it entails. In the midst of all of this, 

nurses are still caring for their other critically ill ICU patients. 

All trauma patients and nontrauma patients requiring mechanical ventilation, invasive monitoring, or vasoactive medications are admitted to the ICU. 

Beds must be made available and patient assignments shifted to accommodate 

new arrivals. It is not unusual for the ICU to admit six new patients from one 

flight, while also preparing a group of three to five critically ill patients for 

transport to the continental United States (CONUS) by the Critical Care Air 

Transport Team (CCATT).5
128 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Nurses on the med/surg floors react in a similar manner upon hearing 

the news. They know how hectic and stressful the day is going to get. Each of 

the three med/surg floors may receive five or six sick and injured patients per 

flight.5 These nurses are also reviewing PMRs, finding beds for new patients, 

obtaining proper equipment, and balancing nursing assignments. Nurses 

became used to making initial assessments about patient needs from the PMRs, 

planning how to address these needs, and then implementing and re-evaluating 

the assessments when they could see and touch the wounded soldier or civilian 

in front of them. 

Arrival of Patients at Ramstein and Transport to Landstuhl

There is heightened activity at Ramstein Air Base as another group is also 

preparing for this arrival of wounded soldiers. Members of the Contingency 

Aeromedical Staging Facility (CASF) teams are there to assist with patient 

transport from the aircraft to the ambulance bus (AMBUS) to LRMC. CASF 

personnel strategically position themselves at the rear of the plane, and wait for 

it to open to move things along as quickly and as seamlessly as possible. First 

priority is given to assisting the CCATT with transferring critical patients to 

one AMBUS, and then less critical patients are assisted to another. During the 

flight, the CCATT—consisting of a critical care nurse, physician, and respiratory 

technician—members have cared for the complex and seriously ill patients. 

CCATT’s role is to stay with these patients until they are received by the ICU 

team at LRMC. Each patient is carefully lifted onto a litter by the CASF team 

and taken to the AMBUS, which has been constructed to accommodate patient 

litters and a variety of medical equipment. Once on board, each litter is secured 

to a Special Medical Emergency Evacuation Device (SMEED), which is a metal 

platform created to hold and stabilize medical equipment, such as intravenous 

pumps, oxygen tanks, ventilators, suction canisters, and cardiac monitors. Before 

the AMBUS driver starts the vehicle, there is a round of assessments to prepare 

patients for the bumpy, 20-minute trip to LRMC. The CCATT nurse or doctor 

may bolus narcotics to lessen pain or sedate a patient to reduce intracranial 

pressure or decrease anxiety. It is not uncommon for monitors to alarm en route, 

and each situation is addressed accordingly.5

 Although this is the last stage of the 

journey, the AMBUS moves slowly because bumpy ground transportation is 

uncomfortable and difficult for patients. Finally, after multiple transports from 

combat field to combat hospital to a C-17, in which patients travel thousands 

of miles, the AMBUS makes one last turn onto “cardiac hill,” the aptly named 

steep, forested driveway that runs straight up to the hospital from Landstuhl 

village. After passing through the gates, the familiar blue bus with the Red Cross 
NURSING 129

sign pulls in front of the emergency department at LRMC, where another group 

anxiously waits to welcome the wounded warriors. 

Arrival of Patients at Landstuhl 

An overhead page delivers a message directing all available or designated 

nursing staff to the emergency department. ICU nurses and respiratory therapists 

wear yellow isolation gowns and protective gloves and stand ready to receive 

new critically ill patients. Other hospital nursing staff and NCMs are there to 

welcome soldiers and assist in directing them to the appropriate pre-assigned 

unit. The LRMC team hoists each litter from the AMBUS onto a gurney. The 

chaplain then welcomes all soldiers by name, whether they are awake and alert or 

in a coma. Critically ill patients are taken to the ICU, where CCATT members 

give an updated report for each patient they monitored during the flight to the 

respective LRMC ICU nurse now caring for those patients. Hospital equipment 

replaces that used on the plane, and the nurses remove the SMEED.5

The LRMC critical care team of nurse, physician, and respiratory therapist 

do their own initial assessment, and baseline laboratory tests are sent off. Critically 

ill patients are often unstable, in varying stages of sepsis, respiratory failure, and 

multi-organ failure.5 Multitasking is essential, as orders are coming quickly and 

urgently from various medical disciplines. At any given moment, portable chest 

x-rays are being done on all intubated patients, changes are made to ventilator 

settings, a computerized tomography (CT) scan is needed for a patient with 

increased intracranial pressure, vasopressor dosages are adjusted, antibiotics are 

added, patients are prepped for surgery, dialysis is initiated, and fluid resuscitation 

is intensified.5 Experienced nurses guide novice nurses and those who are new 

to the unit. All records and reports from combat facilities need to be retrieved 

and organized to ensure continuity of care because most patients are stabilized 

at LRMC and transported to CONUS within 24 to 72 hours of arrival. Those 

patients who are medically unstable to withstand the long air travel remain at 

LRMC until they are able to do so.5

The situation is also hectic on the med/surg units, where staff are settling 

patients in their rooms and retriaging them. Every effort is made to keep 

wounded warriors together for support and camaraderie. Sometimes a patient’s 

medical status has altered during the flight and changes need to be made from 

the pre-assigned unit. At any time, the med/surg charge nurse may need to accept 

additional patients originally sent to the ICU who are now medically stable, or 

send patients who are now medically unstable to the ICU from the floor. 

The med/surg patient rooms are initially crowded with medical personnel 

from multidisciplinary teams (nursing, respiratory, infection control, various 

physician specialists, pharmacy, nutrition, etc) who are assessing each new patient 
130 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

and recommending a plan of care. Trained personnel come to screen each new 

patient for any sign of TBI. Conversation is constant, clinical decisions are being 

made, and changes are taking place. Pain management is a primary concern 

for patients who have traveled long hours on an uncomfortable litter and are 

experiencing increased discomfort. Nurses juggle multiple priorities at one time. 

They are quickly trying to obtain orders for pain medication, swab wounds 

to rule out multidrug-resistant organisms, complete the enormous volume of 

required documentation, answer patient questions, and offer continual support. 

Although addressing patient health is the nurses’ first priority issue, personal 

hygiene is the top concern for many soldiers who have just arrived from the 

desert. They want to feel clean and refreshed, and wash away the gritty feeling 

from sand and stale blood from their injuries.5

Nurses with various clinical backgrounds have deployed to LRMC. Some 

arrived having worked in labor and delivery, pediatrics, and outpatient clinics. 

Seasoned med/surg nurses were invaluable mentors in teaching skills essential to 

treating casualties of war, such as tracheotomy care, irrigation, dressing changes, 

and wound care. Patients typically had already undergone at least one surgery in 

the combat hospital. Wound assessment began on arrival at LRMC, and nurses 

moved quickly in preparing patients for washout surgery, and then stabilizing 

them for evacuation to CONUS for further evaluation and treatment. In any 

given 24-hour period during the height of the war, nursing staff on a med/surg 

floor might discharge ten patients and admit eleven new ones. This was the 

typical high-paced, operational tempo that went on day after day at LRMC. 

Meeting Additional Needs

Nurses at LRMC have a deep understanding that there are important 

emotional needs for these wounded warriors, in addition to their physical needs. 

Once initial medical priorities have been addressed, nurses facilitate calls to family 

and friends at home. This is the best “support medicine” soldiers can receive. The 

transfer of patients from combat zone to LRMC happens quickly and efficiently, 

before many soldiers can ask questions or come to terms with what has happened 

to them. They are often worried about their units and want to return to duty 

as soon as possible. Communication with the appropriate chain of command 

is part of the LRMC protocol, and this is reinforced to soldiers. Amid all of the 

orders and necessary medical care, nurses do their best to offer as much emotional 

support to their patients as possible. Many patients are young and have never 

been hospitalized before. They are often scared and overwhelmed by the entire 

process. Others need someone to listen and answer questions. 

Nurses utilize the supportive resources at LRMC to bolster morale and help 

meet patient needs, such as obtaining items from the Chaplain’s Closet (DVDs, 
NURSING 131

clothes, candy, snacks, books, etc) and making sure each patient returns home 

with a Quilt of Valor (see Chapter 9, Chaplain Services). Patients also receive a 

money voucher to purchase clothes, shoes, and other essential items. 

IMPLEMENTATION: NURSE CASE MANAGERS

Outpatient Nurse Case Managers

In the early morning, outpatient NCMs pass through the main entrance of the 

Deployed Warrior Medical Management Center (DWMMC) and stop to scan 

the mounted flat-screen television that lists the number of expected flights for the 

day and their anticipated arrival times.This mode of communication is a few 

notches up the technology ladder compared to the dry erase board used prior to 

2010 that had to be updated every evening. Although clinic hours don’t begin 

until 0800, NCMs arrive by 0700, frequently grab whatever coffee they can 

find, and use this administrative hour to check on details of arriving flights and 

incoming manifests to learn what patients to expect and their various injuries or 

illnesses. Patients en route have already been assigned to a particular inpatient or 

outpatient service by the on-call provider the night before arrival. NCMs glean 

additional information from the PMRs and electronic outpatient notes (AHLTA 

[Armed Forces Health Longitudinal Technology Application]) so they know as 

much as possible before the patient is sitting in front of them in the outpatient 

NCM office.

The arrival of wounded warriors impacts another group of essential nursing 

personnel at LRMC. Outpatient NCMs fall under the administrative umbrella 

of the DWMCC, an integral unit created in 2001 to provide administrative 

and medical management to US service members evacuated from theater. The 

DWMMC is located in four bi-level trailers adjacent to the outside entrance of 

the hospital’s emergency department. One of those trailers is home to the NCMs 

and consists of several small offices where patients are seen. There is also a patient 

waiting area nicknamed the “fish tank room” because it houses two large freshwater fish tanks. This room is also used for staff to discuss incoming patient briefs. 

When the AMBUS pulls up in front of the emergency department, NCMs 

are often among the group to welcome new patients and assist as needed. After 

the critically ill soldiers are transported off the AMBUS and immediately taken 

to the ICU or the med/surg floor, attention turns to the outpatient soldiers. They 

initially meet with their respective Liaison Noncommissioned Officer (LNO), who 

provides a personal briefing, identifies any initial needs, and offers support. Every 

outpatient must be seen by the NCM within 48 hours of arrival time at LRMC. 

Patients sometimes come directly to see the NCM after their meeting with the 

LNO, though some may not be seen for a day or two after arrival; that decision 
132 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

typically depends on the severity of their illness/injury and how much instructional 

information they are able to retain. Often, soldiers miss some of the information 

given to them because of hearing loss from improvised explosive device blasts. 

Others are in pain or just not feeling well. All of these soldiers have just traveled 

on a long flight on a C-17, and are often exhausted, hungry, and uncomfortable. 

Some have been waiting days for a flight in stopover places like Bagram, Kuwait, 

or Qatar. Should a patient not report within the specified time, NCMs know 

which LNO to contact. They are also given the patient’s room number at the 

Medical Transient Detachment and can check on them there. 

DWMMC case managers are registered nurses who coordinate outpatient 

care for wounded warriors and civilians. They work closely with physicians, command liaisons, the service member’s command unit, and the DWMMC. Located 

adjacent to the emergency department, the DWMMC outpatient clinic is the 

patient’s source for primary care, sick visits, medication refills, and TBI screening. 

NCMs ensure that patients see the correct medical specialist and complete the 

blood work and medical tests listed on the provider treatment plan. All service 

members arriving at LRMC from downrange must have a TBI screen completed 

prior to returning to duty or transferring for continued care. This helps identify 

those patients who need further neurological services. NCMs also refer patients 

for additional evaluation if any new concerns are identified during encounters. 

Although there are multiple specialty outpatient services, the busiest are general 

surgery and orthopedics. If LRMC does not have the capability to perform 

certain procedures, patients are sent to a German hospital, usually the Saarland 

University Medical Center in Homburg, about 30 km west of Landstuhl. Each 

outpatient must report back to the NCM following every specialty appointment 

to ensure that all consults are complete. Many soldiers come with sports injuries 

unrelated to combat injuries.

The NCM is responsible for:

• generating a weekly report to maintain patient flow visibility in 

accordance with theater evacuation policy; 

• entering outpatient encounters in AHLTA (outpatient electronic 

medical records); and 

• entering patient information into the Theater Medical Data Store 

(TMDS) system to facilitate a seamless and paperless flow of medical 

information to the next level of care.

Each military branch manages and coordinates outpatient medical care, and 

patients are followed accordingly: 

• Army and Air Force patients are managed by DWMMC NCMs and 

Army/Air Force LNOs;
NURSING 133

• Navy and Marine Corps patients do not visit DWMMC NCMs—the 

Navy LNO coordinates and manages all patient care-related issues; and 

• other (Department of Defense civilian, contractor, and foreign national) 

patients are not managed by DWMMC NCMs (they are managed by 

the Patient Administrative Division)—inpatient NCMs sometimes 

become heavily involved with civilians and contractors because of their 

varying needs and medical insurance.

The average outpatient length of stay at LRMC is 10 days.6 For that time 

period, wounded warriors can rely on their NCM as their healthcare advocate. In 

addition to the responsibilities of managing and coordinating care, NCMs are an 

invaluable resource and source of support for many soldiers who need someone 

who cares to listen to what they have seen and been through. As the intensity of 

the war decreased, staffing needs across the hospital were reduced accordingly. 

Between 2010 and 2012, there were six outpatient NCMs, which was decreased 

to four by the fall of 2012, and three in August 2013. 

Inpatient Nurse Case Managers

The role of the inpatient NCM at LRMC was initiated in mid-2010 in direct 

response to the need for improved management of patient care. Trauma to multiple organs and sensory systems necessitated immense coordination of a multitude 

of specialty services. The continuous flow of critically ill patients evacuated from 

downrange, and the quick turn-around of patients transferred to CONUS medical 

treatment facilities (MTFs), required an additional layer of strategic care planning. 

Lack of coordination during transitions often caused delays and complications 

for both the patients and the medical staff. Case management therefore became a 

Nurses move quickly 

while transporting 

patients from the 

ambulance bus into 

Landstuhl Regional 

Medical Center. 

Photograph courtesy 

of Landstuhl Regional 

Medical Center.
134 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

pivotal role in ensuring continuity of care and keeping track of the whole treatment picture. The goal of inpatient NCMs at LRMC is to optimize patient 

outcomes, optimize quality of care, and manage costs. Inpatient NCMs report 

to LRMC’s deputy chief of nursing. At the time the role was initiated, the NCM 

group was comprised of the chief of medical management and five NCMs assigned to specific departments throughout the hospital. 

The day begins early for the inpatient NCM who participates in morning 

multidisciplinary rounds, both in the ICU and on the med/surg floors. When 

a new patient is admitted to LRMC, NCMs immediately initiate a treatment 

care plan. Inpatient NCMs are responsible for other patients in their designated 

area, in addition to wounded warriors, such as those in active duty within 

the European theater, retirees, and beneficiaries. Goals are initially established 

based on a thorough patient assessment by various members of the medical team, 

which helps to identify additional necessary resources. Coordination with various specialists—such as occupational therapy, physical therapy, speech therapy, 

pharmacy, nutrition, and other medical specialists—begins immediately to ensure 

early referral to the appropriate teams. 

NCMs communicate directly with patients, families (when possible), 

clinical providers, TRICARE, and other health insurance companies. They are 

proactive and utilize the nursing process to continually assess the needs of patients 

and their support systems, facilitate implementation, and evaluate progress. 

Flexibility is essential because adjustments are often necessary throughout the 

duration of hospitalization, illness, disability, or need for service. The initial care 

plan and goals are often readjusted based on clinical and logistical changes and 

needs. Achieving the best possible patient outcomes and maintaining quality 

care are balanced with ensuring that available resources are used in a timely and 

cost-effective manner. NCMs help relieve administrative burdens placed on the 

providers and patients that could result in delays in patient treatment, recovery, 

transition to another level of care, or discharge. 

Given the extensive and complex injuries sustained by many of the casualties admitted to LRMC, it is paramount to anticipate and plan for the multiple 

layers of specialty needs. It would not be unusual for any one patient to need the 

services of seven different specialists as part of his or her treatment and rehabilitation.7

 Discharge planning is therefore initiated at the time of admission to foster 

the continuation of care. For patients being transferred to CONUS, the NCM 

ensures that all necessary paperwork is in order and disseminated to the proper 

departments. Planning for successful transitional care is another important element of case management. Transition of care takes place when patients move 

between care settings, return home, go to a rehabilitation facility, or experience a 

change in medical status or personal situation. Lack of coordination during these 
NURSING 135

transitions can cause delays and complications for everyone involved. Successful transitions involve extensive coordination between the patients, clinical and 

administrative staff at LRMC, the receiving MTF, the Theater Patient Movement 

Requirement Center, and the Global Patient Movement Requirement Center. 

NCMs also ensure that the families of wounded soldiers have been contacted and 

that updates are routinely communicated to the appropriate chain of command. 

This level of care and detail for a caseload of wounded soldiers requires a high 

degree of organization and a strong clinical skill set. 

Inpatient NCMs also participate in weekly multidisciplinary patient care 

conferences to collaborate and coordinate services and plan discharges. Nurse and 

physician representatives from each unit and various specialty services attend these 

weekly meetings, and provide input on the specific needs of each patient. Each 

inpatient is reviewed, and those with a significant change in status, or needing 

additional care or services beyond what they are currently receiving, are discussed. 

Adjustments to care plans are made according to how the patient is progressing 

and whether the established goals can be attained by discharge. When possible, 

patients and family members may attend these conferences. Bi-monthly guest 

speakers give presentations at the conferences on a variety of relevant topics to 

educate staff, promote professional growth, and decrease fragmentation of care. 

All patient care conferences and related decisions are summarized in the patient’s 

inpatient medical records. 

Each NCM at LRMC is knowledgeable about the hospital’s clinical guidelines, standard operating procedures, and protocols. NCMs often are responsible 

for briefing the continually rotating staff, which is particularly essential at LRMC 

due to the constant turnover from multiple deployments and reassignments. 

LESSONS LEARNED

It is almost inconceivable when one thinks about the multiple levels of care 

that occur for a casualty who is first treated with a tourniquet to stop the bleeding 

in the combat field and later arrives at LRMC. Yet this complex care happened, 

day after day, hour after hour, and with a great deal of success. More than 90,000 

wounded warriors from Afghanistan and Iraq have been treated at LRMC as they 

made their way through the medical evacuation system and back home.8

 Severely 

ill or injured critical care patients typically arrive in Germany after one or more 

operations in the last 24 to 36 hours, and will likely require another operation 

within 3 to 12 hours after arrival. This surgery will be done by a surgeon different 

from the one who performed the primary surgery and different from the 

surgeon who will perform any necessary future surgeries in CONUS. Patients 

have survived the initial procedures, and have just traveled 5 to 10 hours at an 

altitude greater than 30,000 feet, at an ambient pressure of half an atmosphere, 
136 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

strapped to a stretcher, and receiving continuous high-level critical care en route.9 

Most clinicians would agree that these same critically ill patients would not 

be considered stable enough to move from a civilian ICU to have a CT scan, 

yet they have just been moved from a combat hospital to a plane and traveled 

multiple hours, and are moved again. 

Electronic medical records from downrange have preceded approximately 

80% of the patients that arrive. The rest of the time, information is written on 

surgical wound dressings, passed on by the CCATT team, or both. In either 

case, clinicians would agree this is more information than what they get from 

patients who arrive off the street in US trauma centers. The critical care team at 

LRMC interviews the CCATT team about the patient’s condition during the 

flight to verify the accuracy and completeness of all information. Once settled in 

the hospital, each patient is then reassessed with a complete history and detailed 

physical examination as if the patient had not been seen before.9 All of this takes 

place at LRMC at the same time hospital staff are continuing quality primary 

care and inpatient care to the 450,000 military personnel stationed in Europe, 

southwest Asia, and Africa.5 

People are the lifeline in any organization, mission, or goal. The extraordinary measures described herein could only have occurred because of the 

extraordinary individuals making them happen. Nurses were a vital part of this 

Patient care area in the intensive care unit at Landstuhl Regional Medical Center. 

Photograph courtesy of CDR Kevin Kumlien, Navy reservist, Intensive Care Unit nurse.
NURSING 137

remarkable team who worked relentlessly to care for wounded warriors for those 

few days that they were patients at LRMC, and then sent home or returned to 

duty. Although most people would agree that the rewards were beyond words 

and the experience would be a part of them forever, there was a price that came 

with that commitment. Care for the caregiver was a vital lesson learned and a 

necessary part of this human endeavor that took place at LRMC. The invaluable 

contribution of nursing to the GWOT cannot be forgotten. 

Successes

• Dedication to quality care. The nurses who served their country at 

LRMC during the GWOT left an impeccable trail of dedication, hard 

work, and the highest quality of care. They pushed aside their own 

exhaustion, stress, homesickness, and grief to do what was needed. 

Despite the despair they themselves felt from the devastating injuries 

they witnessed day after day, they put a smile on their faces for their 

patients. Every measure was taken to provide an optimal level of care 

for these brave men and women who were now wounded warriors. 

Nurses were compelled by their own desire to do their best, push their 

limits in the face of extremely challenging circumstances, and provide 

exceptional care for their patients who sacrificed so much in the name 

of freedom. They helped train each other, advocated for patient needs, 

and worked together for the common mission. The nurses at LRMC 

set a high standard of care for the modern hospital battlefield. A 

deployed trauma surgeon and a visiting civilian vascular surgeon both 

remarked that “great nursing care kept these patients alive” (telephone 

interviews with Colonel Warren Dorlac, former medical director, 

Trauma and Critical Care, LRMC; September 2014, and Dr. Michael 

S. Weingarten, civilian vascular surgeon; December 2014). To these 

clinicians, who had both witnessed and treated the repercussions of the 

war, it was atrocity at its worst and humanity at its best. 

• Internal support. During work hours, nurses took care of their patients. 

When the shift was over, they did the best they could to support and 

take care of each other as friends and substitute families. They laughed 

and cried together. No one other than coworkers could understand 

the enormity of what they experienced on a daily basis. People coped 

in various ways just to survive the sadness. There was no judgment, 

only understanding from those who were doing their best to cope. 

Hospital chaplains also provided an important support system as they 

encouraged staff to recognize and accept all of their feelings, good and 

bad. They listened, advised, validated, and grieved with caretakers, 
138 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

recognizing the toll their jobs were taking on their emotional and 

physical health. All medical staff was encouraged to volunteer on the 

chaplain day trips, which took ambulatory soldiers sightseeing to local 

areas and for meals in German restaurants. These trips were supported 

by private donations and brought a great deal of benefit to both patient 

and professional. It was therapeutic for staff to see patients out of 

uniform, relaxing, having fun, and enjoying life. This renewed their 

sense of hope and reinforced the value of the work they did so tirelessly. 

• Collaboration of nurse teams. The military trauma transport system had 

its own unique challenges based on the rapid movement of critically 

ill patients from several MTFs, evaluation and treatment by multiple 

providers, and travel across three continents and multiple time zones. 

The likelihood for some degree of miscommunication was inevitable 

given the complexities of this large, multitiered system. The ongoing 

collaboration among trauma nurse coordinators and all unit-specific 

nurses within the Joint Theater Trauma System (JTTS) facilitated 

communication and provided the much needed consistency to ensure 

continuum of care.5

• Performance improvement. Performance improvement (PI) and evaluation 

of critical care were among the greatest successes in the treatment of 

wounded warriors. Before a patient even arrived at LRMC, all members 

of the healthcare team could monitor and track medical records and 

trauma activation and compliance with clinical guidelines by viewing 

the Joint Patient Tracking Application. One of the greatest successful 

examples of this was the JTTS Burn Clinical Management Guideline.10

A burn flow sheet was developed to efficiently communicate ongoing 

fluid resuscitation as the patient moved across the evacuation continuum 

of care from several providers and hospitals, spanning three continents 

and several time zones.10 This continuous means of communication 

significantly improved patient outcomes, with decreased abdominal 

compartment syndrome and decreased mortality.11 The trauma nurse 

coordinator was also responsible for monitoring the trauma registry 

database that tracked all PI issues. Any complication identified was 

conveyed to the clinical nurses and providers, and appropriate changes 

were made to the patient’s plan of care.

Nurses also participated in a unique PI process through a weekly 

video teleconference (VTC), including members of the trauma team 

across the entire evacuation spectrum of care, from field hospitals in the 

combat zone, to LRMC, to four stateside MTFs that received patients 

during OEF/OIF. During the VTCs, discussions were held on transport 
NURSING 139

and equipment, clinical care, complications, improving outcomes, and 

communication. A monthly JTTS VTC was held specifically to focus 

on optimizing nursing care. Teleconferencing proved invaluable in 

addressing problematic issues, ensuring standards of care, improving 

communication, and improving patient care across the board.5

Challenges

• Patient population. The demographics of the LRMC patient population 

changed drastically with the onset of the GWOT. During peacetime, 

the average age of patients was over 50 years, and typical diagnoses 

included heart and lung disease, stroke, complications from diabetes, 

gastrointestinal bleeding, and the need for general surgery. After the 

beginning of OEF/OIF, the patient landscape looked very different: 

the average age dropped from 18 to 24 years, and primary diagnoses 

now included polytrauma, burns, amputations, penetrating wounds, 

and open and closed-head injuries. This sudden shift in demographics 

caused a roller coaster of emotions for nurses, who saw these young 

men and women as someone’s spouse, parent, son or daughter, and 

friend. The realization that these young lives were changed forever by 

disfigurement, TBI, and deep emotional scars was extremely painful. 

There was also the realization that many of these service members 

had young families at home whose lives were now changed forever. 

It was emotional listening to wounded warriors tell their families, “I 

am coming home, but just different than when I left.”5 Patients came 

and went quickly, and nurses often worried and wondered how they 

adjusted and coped once they were back home and the realities of their 

injuries and the implications for their lives set in. 

One of my biggest challenges is not having closure with the patients I cared 

for after they left Landstuhl. We always hear if the patients did not make it, 

but not always the stories about their recovery progress. You cannot help but 

think about what happened to the patients, how the families are doing, etc. 

I have to find peace for myself, knowing that we got them “home,” knowing 

that the excellent medical care and medical personnel commitment will see 

them through at the other military hospitals. Still, I would like to know how 

they are doing.

 — DEE DEE PRICE, CIVILIAN ICU NURSE, LRMC

• Compassion fatigue. The hospital nursing care and inpatient/outpatient 

nurse case management at LRMC were of the highest caliber. The level 
140 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

of commitment and dedication to quality care never wavered. Yet the 

critical injuries, demanding workload, young patients, staff turnover, 

and distance from family and friend support brought significant stress 

to caretakers and took a toll. This increased stress level was characterized 

as secondary traumatization or compassion fatigue.

12 Symptoms are similar 

to those of posttraumatic stress disorder (PTSD) and can range from 

difficulty sleeping, anxiety, depression, anger, fear, and grief to lack of 

motivation, feeling overwhelmed, cognitive problems, and physical 

fatigue. Nurses look at their patients and see young lives just beginning 

and now changed forever. They heard about pregnant wives at home 

giving birth while their husbands were diagnosed with severe TBI.12

Nurses were also dealing with problems and stress in their personal lives 

because many left spouses and children at home when they deployed. 

As work pressures accumulated, there was less ability to cope and a 

higher incidence of symptoms. Those nurses with grief or stress prior to 

deployment were at highest risk for developing PTSD-type problems. 

 • High turnover and diversity in nursing staff. The unique nursing 

environment of LRMC itself added another dimension to the various 

challenges and stress of caring for critically ill and injured soldiers. 

This diverse group consists of active duty and reserve nurses from the 

Army, Navy, and Air Force, as well as civilian nurses hired through the 

Department of Defense. In most instances, these nurses were given 

little notice before deployment to a foreign country a continent away. 

Despite the differences across military branches, the nurses joined 

forces as dedicated professionals caring for wounded warriors. However, 

challenges arose in the constant turnover of staff. Typically, active duty 

nurses are assigned for 2 to 3 years, whereas reservists are assigned to 

LRMC for 1 year. Sometimes, these reservists were at LRMC for only 

2 to 3 weeks and then were reassigned. In addition, some active duty 

nurses were assigned to other external military units in addition to 

LRMC. This meant they might leave the hospital for days to weeks at a 

time for specialized training in the field, leaving gaps in nursing support 

that increased the workload for those who remained behind. Some Air 

Force nurses were also part of the medical evacuation team and could be 

called upon at any time to transport patients out of the country. They, 

too, might be gone for days at a time. This constant flux in staff numbers 

and turnover caused a level of chaos, stress, and heavy workload that was 

a perpetual challenge.5 

 • Training. Nurses come to LRMC with a variety of clinical backgrounds. 

The nature of complex injuries due to the destructive forms of combat 
NURSING 141

in Iraq and Afghanistan required a high level of medical and trauma 

care. Nurses in civilian hospitals were used to practicing in a certain 

specialty area; however, nurses at LRMC needed to know how to 

care for a multitrauma patient who needed a multitude of specialists, 

such as orthopedics, neurology, pulmonary, and burn care. Although 

military nursing has always maintained high standards of care reflecting 

evidence-based practice, the constant turnover of nursing staff with 

different types of training made the consistent implementation of this 

practice a constant challenge. 

 • Burn care. When nurses arrived at LRMC, they were typically assigned 

to units that matched their skill level, experience, education, and 

competency. Most ICU nurses at LRMC worked in other ICU settings 

in either other military or civilian hospitals. Most had some trauma 

experience, albeit nothing to the extent of what they experienced at 

LRMC. However, most did not have burn care experience, which is 

typically its own specialty unit or hospital in the US medical system. 

Many wounded soldiers arrived in the ICU and the med/surg units 

with various degrees of burns. Wound care was essential, as well as 

identifying the clinical risks of burn patients. Most nurses wished that 

they had more experience and training in this specialty. They relied on 

their strong clinical instincts, and for a period of time, on the expertise 

of a civilian nurse with burn care experience. 

During my first three years in the ICU at LRMC, the war in Iraq brought 

a higher percentage of burn patients. My preceptor was previously stationed 

at the BAMC [Brooke Army Medical Center, Fort Sam Houston] burn 

unit; thus burn care became my specialty. Our burn patients were always 

60% to 95% TBSA [total body surface area] burns. Multi-trauma patients 

arrived with opened abdomens, fractures with ex-fixes, head injuries, and/

or burns. From 2004 to 2007, we would have up to 20 to 24 vented multitrauma patients, and at one point eight burn patients arrived on one flight.

 — DEE DEE PRICE, CIVILIAN ICU NURSE, LRMC

 • Reintegration. Caregivers, like soldiers, find it difficult to reintegrate 

after deployment. There is a feeling of “not fitting in” once they reenter 

the civilian world. Although reuniting with family is wonderful, it 

often brings stress and uncertainty. Some deployed caregivers find it 

difficult to talk about what their experience was like and how they were 

impacted. They are not sure anyone could understand what they went 

through unless they were there to see and live it firsthand. Others learn 
142 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

that family and friends do not want to hear about their experiences 

and find it hard to relate to a world thousands of miles away. Spouses 

often felt alone and resented handling all the responsibilities of home 

and children while the other partner was away. Divorce and separation 

rates after deployments are relatively high. Deployed personnel have 

to learn to reacclimate and figure out where they fit in. Those who 

return to work in their civilian jobs learn that their positions were held 

by other individuals in their absence. This transition is often awkward 

for coworkers as more changes are then made. Additional support and 

attention are essential for these exceptional caregivers in helping them 

to reintegrate and return to civilian life. They have made great sacrifices 

and contributed a valuable service to their country. They are often in a 

vulnerable state, and it is paramount to recognize and respond to their 

unique needs. 

My first burn patient who passed away in 2006 was a young soldier, 95% 

burn patient, who starting coding within 15 minutes after he was in my 

room. There were only a few people in the room—the anesthesiologist, the 

respiratory therapist, myself, two trauma attending physicians, and one other 

nurse with the medications. We did everything we could to try to save him; 

his injuries were just too significant. 

When I returned to LRMC in 2008, I had two patients pass away 

within 2 days of each other. The first patient was a young marine with a 

high amputation. Most people do not know that not too many families are 

at LRMC, due to the high turnaround of our patients to the states, yet the 

parents of both of these patients were at their bedsides. The marine’s family 

was at his bedside when he passed, and I found some comfort knowing his 

mom and dad were able to be there with him. The second patient was a 90% 

burn patient. My coworker and I came to work about 0300 to receive a flight 

with two burn patients. I had a second nurse helping me because I did the 

burn care with the physician. We stayed for over 17 hours that day. He passed 

within 2 hours of my arrival at work the next day. His mother was at his 

bedside that day. She kept telling me thank you, thank you for trying to save 

him. She hugged me. I remember feeling numb, and I sat on the floor of the 

next patient’s room and just cried. The service members I have taken care of 

still affect me to this day and always bring tears that I/we could not fix or save 

them all. I always thought, if I can just get them home to their families, they 

will be okay. It was when we could not that affected me the most. 

 — DEE DEE PRICE, CIVILIAN ICU NURSE, LRMC
CHAPLAIN SERVICES 143

ACKNOWLEDGMENTS

The authors thank CDR Lisa Lewis, Navy Reservist, outpatient NCM; CDR

Kevin Kumlien, Navy Reservist, ICU nurse; CDR Pamela Patnode, Navy 

Reservist, Medical/Surgical nurse; Dee Dee Price, civilian ICU nurse; CAPT 

Mary Norgaard, Navy Reservist, Medical/Surgical nurse; Jane Darigo, civilian 

outpatient NCM; and Kathryn Gillespie, civilian, Chief Inpatient NCM. 

REFERENCES

1. US Army. Army Medicine: Landstuhl Regional Medical Center website. 

http://www.goarmy.com/amedd/health-care/facilities/landstuhl-regionalmedical-center.html. Accessed November 23, 2015.

2. Dorland P, Nanney J. Dust Off: Army Aeromedical Evacuation in Vietnam. 

Washington, DC: Center of Military History; 2008: 4.

3. Robbins S. Landstuhl staff busy as Afghan fight intensifies. Stars and Stripes. 

November 13, 2009. 

4. Grills M. Out of harm’s way. The American Legion Magazine. March 1, 2008. 

5. Steele N, Katz A, Martin K, Garcia D, Womble S, Wright H. Rewards and 

challenges of nursing wounded warriors at Landstuhl Regional Medical 

Center, Germany. Nurs Clin North Am. 2010;45(2):205–218.

6. Fact Sheet–Deployed Warrior Medical Management Center, Landstuhl Regional 

Medical Center. Landstuhl, Germany: LRMC Public Affairs Office; July 

2009.

7. Cobbs A, Pidgen N. Polytrauma care: a delicate balance for the military 

nurse case manager. J Trauma Nurs. 2008;15(4):192–196.

8. Fact Sheet–Landstuhl Regional Medical Center. Landstuhl, Germany: LRMC 

Public Affairs Office; September 2015.

9. McSwain N. Musings from Landstuhl Regional Medical Center. After 

Action Report, July 8–30, 2007. http://www.aast.org/Assets/b94716d3-

8178-4a69-bb1c-147fb9bd3530/633870595881200000/after-actionreport-final-v9-16-pdf. Accessed November 15, 2015. 

10. Chung LL, Blackbourne LH, Wolf SE. Evolution of burn resuscitation in 

Operation Iraqi Freedom. J Burn Care Res. 2006;27(5):606–611. 

11. Holcomb JB, McMulin NR, Pearse L. Causes of death in U.S. Special 

Operations Forces in the global war on terrorism: 2001–2004. Ann Surg. 

2007;245(6):986–991; Abstract. 

12. Kenny D. Critical care nurses’ experiences caring for the casualties of war 

evacuated from the front lines: lessons learned and needs identified. Crit 

Care Nurs Clin North Am. 2008;20(1):41–49. 
Chaplain at bedside visiting with a wounded warrior.

Photograph courtesy of the Public Affairs Office, 

Landstuhl Regional Medical Center.
CHAPTER NINE

Chaplain Services 

“Pro Deo et Patria” (For God and Country)

Where does one ever find the right words to comfort a soldier who has lost 

two limbs, a soldier who is the only remaining survivor from his mission, or a 

nurse cradling a 19-year old in her arms while he draws his last breath? 

What do you say to a family who has flown 10 hours across oceans to say 

good-bye to their son or daughter, child before soldier, who once romped in 

overalls before camouflage? Is there enough faith to offer a surgeon, on his feet in 

an operating room for 48 hours, called upon to exercise his mastered craft, 

while making decisions that change the lives of the human beings entrusted 

to his care? There are no “right words,” cards, platitudes, or phrases to fill the 

vacant hole occupied by a sadness and despair chronically lingering in the 

shadows of such realities. This was daily life at Landstuhl Regional 

Medical Center starting in 2001.

S

oldiers come into the military with diverse religious backgrounds, some 

with none at all. Faith is personal, individual, and predictably changeable 

with the natural ebb and flow of life events. Like nature’s seasons, faith 

experiences dreary winters, hearts barren as naked trees, and glorious springs, 

hearts bursting with blooming color and radiant hope. Faith can be tumultuous, 

snapping with emotions as vivid as an autumn day strewn with fiery red and burnt 

orange leaves swirling the air on their descent to the ground. Like a lazy breeze 

on a summer day, faith can also be lackadaisical, paying little attention to time or 

commitment. There are likely few life events that could shake the foundation of 

one’s faith more than war. It takes great inner strength to cope with the magnitude 

of loss that barrels forward in every direction. In a split second, a life can be lost 

or changed forever. What can really prepare the human psyche to cope with the 

depth and breadth of the physical and emotional suffering that war brings . . . to a 

soldier, a caretaker, a family, or an entire nation?
146 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Military chaplains have always been a source of comfort and strength for 

men and women in the armed services, especially during war.1 They help soldiers 

cope with the overwhelming circumstances they encounter, such as: combat stress, 

environmental challenges, separation from family and friends, and physical and 

emotional loss. The chaplains at Landstuhl Regional Medical Center (LRMC)

are an integral part of the war effort and have greatly impacted the lives of 

soldiers, staff, and family members. Their mission is as follows: The Clinical 

Pastoral Division at LRMC provides religious and counseling support to the military 

community, staff, and patients. The staff of Air Force, Army, and Navy personnel 

consists of active duty, Guard and Reserve chaplains and chaplain assistants, as well as 

full-time civilians and volunteers.2

BACKGROUND

Prior to the onset of Operation Iraqi Freedom and Operation Enduring 

Freedom, LRMC functioned primarily as an American-based community hospital. 

Until September 2001, it was staffed with two chaplains and two chaplain 

assistants. Fast forward to 2004, when time unfolded to a completely different 

story: a community hospital turned trauma center, now staffed with thirteen 

chaplains and seven chaplain assistants. The changes in wartime intensity brought 

changes to the chaplain role as well. No longer was it a matter of only visiting 

patients and making notes as needed. Chaplains rotated shifts because they were 

required to be on-call 24 hours a day. Documentation on every patient seen 

was now mandatory. Chaplains were required to meet all incoming flights from 

Ramstein upon arrival at LRMC, regardless of time of day or night. Uncertainty 

was the only “certainty” they could truly count on because there was no consistent 

schedule for flight arrivals, suffering, or death. 

Military chaplains require a high level of training and experience prior 

to entering the military. They must have a graduate degree in theology, have a 

minimum of 2 years of professional experience, and be considered a qualified 

leader in their particular religious denomination. At the time of application, they 

undergo a physical examination and security clearance. Although they are noncombatants, they still undergo a type of military training. For example, the Army 

requires chaplains to attend the Chaplain Basic Officer Leadership Course, which 

provides an introduction to noncombatant core skills.3

In addition, hospitals then require military chaplains to complete a 1-year 

Clinical Pastoral Education (CPE) course. The military CPE program is one of 

the most effective chaplain training environments for battlefield ministry.4 Topics 

during the training include crisis counseling, death and dying, grief counseling, 

family systems, and spirituality. There are also a variety of seminars that focus on 

reflection, worship, and interpersonal relationships. Throughout the year, there 
CHAPLAIN SERVICES 147

is supervisory one-on-one training and consultation for pastoral education, and 

regular annual and monthly training provided for most chaplains. 

IMPLEMENTATION

The chaplain is the first person who meets wounded warriors right off the 

ambulance bus when they arrive at LRMC. From that point on, there are multiple 

duties and responsibilities throughout the day. Chaplains provide religious services 

for a variety of faiths, make daily bedside visits to all sick and injured inpatients, 

including both wounded warriors and local civilian patients, and spend time with 

outpatient soldiers. Wounded warriors, civilian contractors, and coalition troops 

come from a total of 44 different countries treated at LRMC.2

 

One of the most integral roles for the chaplain is that of counselor. There is 

a great deal of physical and emotional suffering in wartime. Loss is a continual 

theme. Chaplains help wounded warriors come to terms with and make sense 

of their traumatic experiences. The pastoral staff also monitor the emotional 

thermometer of the caretakers at LRMC, who deal with trauma and high stress on 

a continual basis. 

Chaplain Ronald Pettigrew is a soft-spoken man. His smile is warm and wide 

and engages you immediately; his words, even more so. The soft-spoken voice 

speaks with conviction, passion, and truth about the devastation wounded warriors 

have faced, the impact on their families, the toll on caretakers, and what it means 

to experience this on a daily basis at LRMC. Humanity and compassion mingle 

with his honesty. Ronald Pettigrew has an unwavering belief in the goodness of 

his God, which likely explains his aura of tranquility and an acceptance of what is. 

Although suffering often lures people into an emotional tug-of-war between what 

is fair and what is not, Pettigrew has somehow moved past the point of questioning 

“why” and focuses instead on “what more can we do?” 

Chaplain Pettigrew, a Navy Reservist, has been deployed twice to LRMC; 

the first time in 2006–2007 and again in 2012. The second time, his wife and 

daughters came to Germany with him. Although this was an initial adjustment for 

them with new work, school, and friends, keeping the family together was worth 

the changes. There was an additional intention with this decision as well. Although 

both parents felt it was enriching for their children to live in another county and 

experience another culture, the decision was deeper than even that. It was a way for 

Pettigrew’s children to see and feel the value and meaning of daily life at LRMC, 

the reason for their father’s role, and a way to understand commitment to one’s 

country. On a personal level, he and his family felt blessed. 

On a professional level, the chaplain is continually humbled. His patients 

are his best teachers on what is important in life. He considers each moment 

and conversation he shares with a soldier to be a privilege. Chaplain Pettigrew is 
148 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

continually amazed by the selfless attitude of each wounded warrior who arrives 

at LRMC. No matter the extent of their injuries, they are more concerned with 

others rather than themselves. He is amazed by these young men and women, 

some of them still teenagers, who understand that they are part of something 

bigger than themselves. He gives an example of this when he talks about his initial 

visits with soldiers and repeatedly hears the same questions from all of them: 

• “Where’s my Sergeant?”

• “When can I return to my unit?”

• “Did [name of comrade] make it?” 

• If someone did not make it, they ask, “How can I take care of 

his or her family?”

There is also consistency in the painful issues faced by wounded warriors:

• survivor’s guilt,

• separation anxiety (from their unit),

• grief, and

• denial.

The nature of recent wars has resulted in insidious injuries, and often soldiers 

arrive at LRMC having lost one or more limbs. The chaplain sees that many are 

initially in denial when hearing of their injuries. Often, they will instead focus on 

getting back to their respective units. It takes a while to absorb the enormity of the 

news and the impact this new reality will have on their lives. 

Chaplain Pettigrew recalls a story of a solider in the intensive care unit who was 

a quadriplegic as a result of his injuries. It was initially difficult for him to speak, 

and he did not want to talk to a chaplain. Pettigrew used a message board and 

moved letters up and down to communicate with the soldier, who eventually, over 

time, opened up with his feelings. The soldier’s wife had made several attempts to 

call and talk to him, but he was afraid to talk to her. He expressed his fears and 

worries about providing for his family due to his injuries. Never once did he ever 

really worry about himself. Chaplain Pettigrew contacted the soldier’s wife and put 

the soldier on the phone. Over and over again, she reiterated to him how much 

she loved him and that she was not going anywhere. She cried and told him she 

was just so happy he was alive and could come home to their family. After the 

conversation, the soldier spelled out the word “R-I-N-G” on the message board. 

He wanted to wear his wedding ring. 

Stories and experiences such as this were the victories that kept him going, but 

Ronald Pettigrew is honest to also say that there were many hard days as well. He 
CHAPLAIN SERVICES 149

admits to feeling helpless at times. Was he doing enough? What would happen to 

these soldiers when they left LRMC? Was there enough available support for them 

in their process of grieving and adjusting? 

Chaplain Pettigrew has experienced firsthand the power of human connection. As simple as that sounds, it may be the most significant ingredient in 

a soldier’s recovery. Both big and small efforts work concomitantly in making a 

difference. What he also saw firsthand was the generosity of the human heart, 

especially the American heart. Programs such as the Chaplain’s Closet (see Saying 

Thank You . . . One Box at a Time: The Chaplain’s Closet) and the Quilts of Valor 

(see Saying Thank You . . . One Stitch at a Time: The Quilts of Valor Foundation) 

were born out of the sheer effort and determination of two American military 

spouses/mothers who saw a need and wanted to help. Their impact has been farreaching, as volunteers around the country have been inspired by their spirit and 

have joined in supporting their mission. Chaplain Pettigrew has seen how this 

trickle-down effect, from a small American town to the bedside at LRMC, has 

touched the hearts of wounded warriors. Some have been moved to tears by the 

generosity of strangers who want them to know how much their sacrifice for their 

country means. Someone cares; a stranger no less. That fact alone is a powerful tool 

in the healing process.

Many locals have been bitten by the “need to volunteer bug” and have come 

forth to help in any way. This includes both American citizens living in Germany, 

as well as German locals themselves. Hot meals, soda, snacks, and deserts are 

delivered on a regular basis to the United Service Organization. The chaplain 

day trips for outpatient wounded warriors are run by the chaplain ministry and 

supported by volunteers. The bus driver for these trips, who is retired from the 

Army and living in Germany, is devoted to the ministry. He speaks fluent German 

and helps pick the best restaurants and interprets as needed. Week after week, he 

goes out of his way to make sure everyone is comfortable on the bus trips. A grin 

crosses Chaplain Pettigrew’s face when he refers to Marcos, a once perfect stranger, 

and now a genuine friend. 

Taking care of these soldiers is as natural for him as breathing. He does not just 

drive the bus to get us where we want to go. He takes the time to get to know these 

men and women on a deep and personal level. He likes to chat, and share a soda 

and a few jokes with them. Marcos believes this is his chance to help take care of 

their hearts and souls. 

The chaplain day trips are staffed by hospital medical volunteers. Pettigrew 

sees this as equally beneficial to soldiers and staff. Participating in the trips gives 

caretakers an opportunity to interact and get to know wounded warriors outside 
150 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Saying Thank You . . . One Box at a Time

The Chaplain’s Closet

The dictionary defines the word “closet” as a small room or space used for storing 

things.1

 That is likely not the first impression one gets opening the door to the 

“Chaplain’s Closet” at Landstuhl Regional Medical Center (LRMC). The “closet” 

is more like the size of a convenience store and supplied with enough stock for a 

satellite PX (Post Exchange). 

The history of this effort dates to October 2001, with the onset of Operation 

Enduring Freedom. Injured soldiers certainly did not have time to pack their 

belongings before being flown from the Middle East to Germany for medical 

care. Many arrived with only the bloody and torn clothing they were wearing at 

the time of their injuries. If they were lucky, their belongings might have been 

thrown into a bag, arriving on a different flight. By late 2002, as combat casualties 

continued to flow into Germany, Landstuhl nurses decided more needed to be 

done for their patients. It was now winter and wounded warriors were arriving 

straight from the battlefield without coats, sufficient warm clothing, or personal 

care items. Provisions were needed until their bags caught up with them from 

downrange.2

The Wounded Warrior Ministry Center began as boxes lined in a hallway 

with donations from staff, local churches, and charities. The boxes were then 

stored in an actual closet in the chaplain’s office, thus giving origin to the nickname 

“Chaplain’s Closet.” Today, there is a large designated room adjacent to the 

A Christmas stocking and shelves of donated items bring a smile to this soldier. 

Photograph courtesy of the Public Affairs Office, Landstuhl Regional Medical Center. 
CHAPLAIN SERVICES 151

Pastoral Division that holds these supplies. Overflow boxes are stored in other 

buildings. Rows and rows of shelves line one part of the Chaplain’s Closet, 

organized by clothing type, color, and size for both men and women. Toiletry 

items, such as toothbrushes, toothpaste, shampoo, soap, etc, are in a separate 

section. Ambulatory soldiers come and “shop” for items they need, ranging from 

sweatpants, T-shirts, underwear, and socks, to athletic shoes, duffel bags, favorite 

candy, CDs, DVDs, towels, quilts, sheets, phone cards, handheld games, and 

books. Liaison officers and chaplain staff fill the requested needs of those patients 

unable to leave their rooms.3

As the war progressed, the needs of the Chaplain’s Closet quickly surpassed 

the local donations. In 2004, a very kind and caring American named Karen 

Grimord came to Germany. She was there visiting her daughter and son-in-law 

stationed at Ramstein Air Force Base. During that visit, Karen learned from her 

daughter that LRMC had a very small collection of movies (DVD/VHS) for the 

wounded soldiers to watch while recuperating from their injuries. Karen returned 

to the States and got busy putting the word out to her family and friends of this 

need. They joined efforts with a Boy Scouts group from Huntsville, Alabama, and 

collected 485 DVDs and VHS tapes to send to the Chaplain’s Closet at LRMC.4

This donation was met with great enthusiasm and appreciation, so much 

so that the Landstuhl chaplain asked 

Karen if she could now collect sweatpants 

because they were greatly in need. That 

was all Karen needed to hear, and again 

she got busy. She turned to family and 

friends and between all of them came up 

with 108 donated pairs. The chaplain was 

again greatly appreciative, but Karen was 

shocked to learn this number was a “drop 

in the bucket” to meet the hospital’s needs. 

At the time, as many as 1,000 soldiers were 

arriving at the hospital every month, and 

their first stop was the Chaplain’s Closet. 

Supplies were dwindling daily. 

Such a reality might have daunted 

most, but not Karen Grimord. If anyone 

understood military mission and the needs 

of soldiers, it was this woman. She entered 

the world as a military brat, born in a 

There is something for everyone in 

the Chaplain’s Closet, including a 

box of single shoes for amputees. 

No needs go unattended. 

Photograph courtesy of the Public Affairs 

Office, Landstuhl Regional Medical Center.
152 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

military hospital, and surrounded by supportive military families her entire life. 

Both her husband and father served in the Air Force and, at one point, five family 

members served in the Middle East at the same time. Although it had never been 

a goal to start a nonprofit organization, Karen moved forward and began the 

Landstuhl Hospital Care Project. Initially, she used her own money and savings to 

meet the requests of the perpetual wish list. In the first year, her organization sent 

out 33 boxes of supplies. But the seesaw of supply and demand continued, and 

Karen quickly learned that the more supplies she mailed to Landstuhl, the greater 

the requests for donations. She then reached out to churches, charities, and veterans groups, such as the American Legion, and soon donations came pouring in. 

Karen also knew she needed help with the legal and financial realities of running 

a charitable organization. Today, the organization is supported by a small group of 

volunteers, many with strong military ties, who handle accounting, communications, and other vital support services.4

Karen Grimord became known as the “woman from Stafford, Virginia, who 

could not said no” when it came to a need of a soldier. The two-car garage in the 

Stafford home is full of boxes, both flat and full. On any given day and at any hour, 

Karen Grimord is seen sorting through supplies, filling boxes, or taping them shut 

ready to be sent to those in need. Sometimes there are volunteers, but mostly it is 

just Karen. She even traded in her beloved Jeep for a Chevy Suburban, better able to 

handle the volume of her loads and her trips to the post office 4 to 5 days a week.4

So what actually goes into these boxes? What are the most popular “hot ticket 

requests”? Dark clothes are preferred—blacks, grays, and blues. The plainer the better, although one year a large donation of flannel pants with the “Sarge” character 

from the Pixar/Disney animated film “Cars” was a huge hit. Although soldiers do 

not like a lot of corporate logos all over their clothes, they do have a sense of humor 

and Sarge was very popular! Quality is a must. As Karen sifts through the endless 

piles of stock, she asks herself, “Would I want to wear or use this? A “yes” makes 

it into the box, and a “no” gets put aside. Smaller, rather than full-size, toiletries 

are preferred because soldiers may be at LRMC for only a few days. Water bottles, 

underwear, socks, Crocs, and sneakers of every size are universal needs. Soldiers need 

diversion and fun, so magazines, books, games, CDs, and DVDs are entertainment 

essentials. Snacks, candy, and nonperishable food take up valuable space and are 

greatly appreciated. Everyone needs a treat and a reminder of home.4 

This extraordinary mission is responsible for shipping more than 200,000 

pounds of donated clothes and supplies to wounded warriors. What started as 

33 boxes a month is now up to almost 2,000 boxes a month.4 There is no greater 

labor of love. Although the majority of donated items are sent to LRMC, Karen 
CHAPLAIN SERVICES 153

also sends supplies to medics, nurses, and chaplains at more than 150 military 

units throughout Afghanistan, Iraq, and other Middle East countries with US 

military operations.3

Perhaps what drives this “Virginia angel” to pack just one more box is her 

own annual, self-funded trip to Germany, where she volunteers for a month in 

the Chaplain’s Closet at LRMC. Karen Grimord sees firsthand the reactions of 

soldiers as they receive items of need. She sees a smile of appreciation and a flash of 

hope simply because these soldiers know that people care about them. Karen also 

sees firsthand what they have been through. That is enough to get her back on the 

plane to the States and into her garage to get busy once again. 

Americans are known for their generosity and patriotic spirit. This extraordinary humanitarian effort reflects just that. Karen Grimord represents that 

unified effort to combat the war on terrorism . . . one box at a time. 

REFERENCES 

1. Merriam-Webster online dictionary. http://www.merriam-webster.com. 

Accessed April 28, 2015.

2. Landstuhl Regional Medical Center Public Affairs Office. Fact Sheet–Pastoral 

Division, Landstuhl Regional Medical Center. Landstuhl, Germany: LRMC; 

June 2009. 

3. Greenhill J. Chaplains’ closet helps Landstuhl’s wounded warriors. American 

Forces Press Service. June 26, 2009. http://www.defense.gov/news/

newsarticle.aspx?id=54926. Accessed April 28, 2015. 

4. Evans JA. American angel. Saturday Evening Post. November/Dececember 

2012. http://www.saturdayeveningpost.com/2012/11/27/in-the-magazine/

people-and-places/american-angel.html. Accessed April 28, 2015.

A volunteer at 

the Chaplain’s 

Closet assists a 

soldier with 

making a 

selection.

Photograph courtesy 

of the Public Affairs 

Office, Landstuhl 

Regional Medical 

Center. 
154 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

of the acute setting where intensity and stress are high. It is therapeutic for 

them to talk and get to know soldiers as themselves, not just as patients who are 

recovering or facing life-threatening injuries. Soldiers get to know their caretakers 

as individuals with interests, humor, and personal lives, something that gets 

forgotten in the business of a hospital setting. The line separating patient from 

professional erases just a bit on chaplain day trips, where staff dress casually in jeans 

rather than scrubs and white lab coats. Volunteer hours are supported by hospital 

administration; staff members are not required to take personal leave. The majority 

of them return to volunteer again, and they tell the chaplain staff how much these 

experiences renew their sense of hope and meaning in the work they do at LRMC. 

LESSONS LEARNED

The chaplain ministry has played an essential role in supporting wounded 

warriors, families, and caretakers at LRMC. Soldiers want and need to tell their 

stories. They need a supportive environment and the right person who responds to 

a cue to hold a hand, offer a prayer, sit and listen, or simply just sit in silence. They 

need that person who can absorb and respond to the enormity of their individual 

suffering, pain, and grief. Whether they choose to connect it to their faith is 

personal. What is universal, however, is the feeling that their story and experiences 

are valued. Even in the short amount of time some of the patients are at LRMC, 

chaplains can quickly identify the various stages of grief as described by Elizabeth 

Kübler-Ross.5

 Healing is painful. Healing takes time. There are no shortcuts or 

abbreviated versions to the process. 

Chaplains agree that amputees should be given the chance to continue serving 

in some capacity in the military after their recoveries. Those in the ministry who 

have been deployed more than once have seen the benefits of such decisions. They 

believe that a very important message is sent to wounded warriors when they are 

allowed to continue military service: they are valued, their family is valued, and 

their story is valued. Prior to such decisions being made, a different message was 

heard. Soldiers felt that anyone was expendable and their stories were demoralizing, 

regardless of the sacrifices made for serving one’s country. This only intensified the 

flames of anger and resentment. Humans derive meaning in the commitments 

made to self and others. That thread of connection is simple, but powerful. 

 

Successes

• Pastoral support. Additional staff support provided the necessary 

environment for chaplains to spend more quality and quantity time 

with wounded warriors at LRMC. It takes time to gain trust. Getting 

soldiers to talk about what they have been through is the first essential 

step in the healing process. Some find comfort in their respective faith, 
CHAPLAIN SERVICES 155

whereas others benefit just by having a caring person nearby who is 

willing to listen. Pastoral support extends beyond the bedside. Families 

also greatly benefit from counseling and comfort offered by chaplains, 

particularly if they have come to LRMC to say goodbye to their beloved 

solider. The medical staff also draws strength from pastoral support, and 

many look to chaplains for help when stress is particularly high. It is 

extremely difficult to watch patients die, especially after caring for them 

and watching them suffer. Chaplains play a vital role in addressing the 

emotional needs of care providers, as well as patients. 

• Chaplain day trips. Fun is not usually the first word that comes to mind 

when one thinks of war or time spent at a military hospital. But fun is 

exactly the word that is used over and over every Tuesday, Thursday, and 

Saturday, when chaplains take outpatient wounded warriors on trips in 

the local area to help them relax and sightsee. Private donations fund these 

outings, and transportation and meals are covered. Soldiers must sign up 

for the trips and alert their LNO (Liaison Noncommissioned Officer) 

as to where they will be. They generally work the trips in between their 

medical appointments. The chaplain organizes visits to historical sites, 

scenic views, and tasty restaurants with plenty of ambience. Soldiers are 

permitted to dress out of uniform, and jeans, sweats, and sneakers are the 

clothes of choice. Volunteers supply cold drinks and snacks on the bus. It 

does not take long to hear conversation and laughter coming from behind 

the bus driver. Soldiers are able to experience the beauty of German 

architecture and the countryside. Trips during the month of December 

make stops at some of the festive Christmas markets, a German tradition. 

It is not uncommon to see American soldiers tasting bratwurst links 

cooked over the open pits or picking out a special Christmas gift for a 

spouse. Limb injuries, even casts, do not preclude chaplain day trips; 

wheelchairs get loaded on the bus and soldiers get wheeled around by a 

willing comrade with two empty hands. The value of these trips cannot 

be underestimated, for they repeatedly have helped soldiers restore a sense 

of normalcy and life balance. Chaplains have found that many are more 

willing to open up and talk after such excursions. Soldiers have said these 

trips give them a renewed feeling of hope and reconnection to the world 

outside of a battlefield. It is a day where wounded warriors feel valued 

and appreciated for the selfless service they have given their country. 

The trips are opportunities for soldiers to be with fellow comrades and 

“tell their stories.” It helps break up their time. The positive impact had 

been enormous, and chaplains agree that it is one of the most effective 

components of their ministry at LRMC. 
156 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

• Care of the caregivers. Although stress and burnout are common 

challenges during war, the implementation of certain routines helped to 

offset that reality. Universally, the chaplain staff will state that caregivers 

(including themselves), like wounded warriors, consistently need a safe 

and supportive place to tell their stories. They need to be reminded 

of the good they do all day, every day, and of the personal meaning 

derived from their work. For some, these types of conversations are most 

beneficial as a one-to-one conversation. Others have greatly benefited 

from the weekly Bible study groups started by the chaplain ministry. 

Hearing and seeing that each of them as caregivers are not alone with 

their feelings of grief, fatigue, anger, and frustration has helped with 

both healing and coping. Chaplains see that such support has attenuated 

a jaded and cynical outlook that is often prevalent in high stress work 

areas. Instead, most caretakers leave LRMC tired, but proud of their 

commitment and the outstanding care they provided. Other successful 

strategies have included family outings and marriage retreats. Addressing 

the needs of both couples and family is essential in maintaining the 

wholeness of couples and family units.

• Volunteer programs. See the “Chaplain’s Closet” and the “Quilts of Valor 

Foundation.”

Challenges 

• Reintegration. More resources and attention need to be invested to help 

soldiers and caretakers reintegrate after their time of service when they 

return home. Family life is particularly vulnerable because this is an 

adjustment period for everyone. Spouses at the home front have been 

alone and working to keep the family unit going during deployment. 

They are looking to have their husband/wife return and resume their role 

as a shared partner. They often do not understand what their deployed 

spouse has seen or been through, many of whom return suffering from 

posttraumatic stress disorder. Soldiers and caretakers often find it difficult 

to talk about their feelings, or what they experienced during deployment. 

In a matter of days, a frontline Marine, for example, goes from looking 

at people and deciding whether to shoot them, to being with his fellow 

Americans in the general public. Each spouse has his or her own needs 

that get shortchanged and misunderstood at a time when each needs the 

other more than ever. 

Counseling is often necessary to help the family readjust to each 

other and to new roles. Both spouses have lived independently like 

a single person. They have each gotten into a routine that had not 
CHAPLAIN SERVICES 157

included the other. Although they love their spouse, it is hard to all 

of a sudden be a couple again. What is necessary for the day-to-day 

functioning in a military unit does not necessarily translate to family life. 

Soldiers are use to a set regime, doing what needs to be done to get the 

job done. For example, a deployed soldier might have been use to giving 

orders all day. This obviously would not make for a peaceful and happy 

marriage or parenting style. Simple tasks—such as driving, sharing 

meals, and scheduling their life with their spouse—are all part of the 

transition and require patience for all involved.

The divorce rate is particularly problematic, especially if there have 

been multiple deployments. An informal study conducted by the Army 

in 2005 showed that soldiers and their significant others rated the loss 

of their relationship as the number one concern regarding deployment, 

even more so than death of injury.6

 Family solidarity remains the most 

essential support for each soldier and the military as a whole. It is 

therefore paramount to recognize and respond to the unique needs of 

the military couple and family unit. 

• Burnout and stress. With great meaning often comes great intensity. 

The level of devastation and trauma seen by the staff at LRMC would 

overwhelm the strongest of characters. Joy and sadness continuously 

exchange turns as the palpable emotion of the moment. Chaplains, 

medical professionals, and administrative staff work long hours, 

sometimes round the clock, caring for the various needs of their fellow 

American soldiers. What they would all tell you is that they wish they 

could do more. They are greatly humbled by the strength and selflessness 

of those soldiers they meet and who have been entrusted in their care. 

Eventually though, the physical and emotional exhaustion takes a toll, 

particularly for those on repeat deployment. Posttraumatic stress disorder 

is common among caretakers and chaplains as well. Strong support is 

essential for all caretakers and staff—while they are at LRMC and when 

they return stateside. 

On his first mobilization at LRMC, Chaplain Pettigrew worked with almost 

3,000 patients; during his second, it was close to 4,000. He can recall many 

stories, multiple faces, and poignant moments. He can recall resounding 

themes of pain, bravery, and heroism. But what will resonate most deeply in 

his heart and in his memory are the gratitude and humility of the American 

soldiers, even in the midst of their own pain and separation from their unit 

and loved ones. He remembers a level of energy that could only be explained 

by experiencing such overwhelming humanity, and that inspired Chaplain 
158 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Pettigrew and all of the staff to keep going until they dropped. They did not 

know how to do it any other way, and this was based on what wounded 

warriors had already done.

Chaplain Pettigrew returned to his position as an academic advisor at 

Western Illinois University. Like the returning wounded warriors, he, too, 

found challenges in reintegrating. He had to readjust his mind frame to 

a world that did not understand or know the bravery, selfless service, and 

sacrifices of wounded warriors or the medical staff at LRMC. He had to 

acclimate back to a college campus with the everyday problems and priorities 

of a college environment. 

It was all so normal, all so appropriate, but so relative. He was primarily 

working with 18- to 22-year-old students, naïve still to the realities of work 

and world. Most of the 18- to 22-year-olds he had counseled at LRMC had 

already experienced several lifetimes of reality. Although he greatly enjoys his 

work at Western, a piece of his heart still lingers in the 3 miles of hallways at 

LRMC, a place that forever changed Chaplain Ronald Pettigrew.

ACKNOWLEDGMENT

We wish to thank Chaplain Ronald Pettigrew for his assistance with this chapter.

REFERENCES

1. Defense Centers of Excellence for Psychological Health and Traumatic 

Brain Injury. No Ordinary Warrior: Your Chaplain is a Frontline Resource. 

http://www.realwarriors.net/active/treatment/chaplains.php. Accessed 

April 27, 2015.

2. Landstuhl Regional Medical Center Public Affairs Office. Fact Sheet–Pastoral 

Division, Landstuhl Regional Medical Center. Landstuhl, Germany: LRMC; 

June 2009.

3. US Army. Chaplain Basic Leadership Course. http://www.goarmy.com/

chaplain/about/basic-officer-leader-course.html. Accessed April 27, 2015.

4. US Army Medical Department. Clinical Pastoral Education Program. 

http://www.ddeamc.amedd.army.mil/GME/InterResPrograms/

ClinicalPastoralEducationResidency.aspx. Accessed April 27, 2015.

5. Kübler-Ross E, Byock I. On Death and Dying: What the Dying Have to 

Teach Doctors, Nurses, Clergy and Their Own Families. New York, NY: 

Macmillan; 1969.

6. Miles D. Army divorce rates drop as marriage programs gain momentum. 

American Forces Press Service. January 27, 2006. http://www.defense.gov/

news/newsarticle.aspx?id=14501. Accessed April 27, 2015.
CHAPLAIN SERVICES 159

Saying Thank You . . . One Stitch at a Time

The Quilts of Valor Foundation

It is a known fact that a mother’s love can go a long way. A mother with a mission 

can go even farther. The Quilts of Valor Foundation (QOVF) started in a sewing 

room in Seaford, Delaware, home to Catherine Roberts. She believed that all 

returning soldiers should be welcomed home with warmth and appreciation for 

their service and sacrifices made for their country. After her own son’s deployment 

to Iraq, she felt a need to reach out and give back to these soldiers. Catherine’s 

sewing skills and the needle in her hand provided the answer. This desire grew into 

a national grassroots movement. Since November, 2003, the unique and heartfelt 

QOVF program has connected similar-minded quilters to wounded warriors and 

veterans.1

To date, QOVF chapters continue to pop up all over the country. Each week, 

groups meet at recreational centers, individual homes, churches, or any available 

donated space. Talented quilting volunteers are seen transporting their supplies 

to get the job done. The groups are often a mixture of every walk of life, age, and 

ethnicity: military wives, military mothers and grandmothers, their friends and 

families, and others with no connections at all to the military. The common thread 

is a love of quilting and a desire to volunteer and serve others who serve. One 

volunteer reports that quilt giving is a long-time American tradition dating back 

A Red Cross volunteer covers a patient with his new and very patriotic Quilt of Valor. 

Photograph courtesy of the Public Affairs Office, Landstuhl Regional Medical Center. 
160 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

to the Civil War, when men going off to fight took a quilt from home, likely made 

with scraps from family members’ clothing.2 The American volunteer spirit has 

spread across the globe. Coalition members of the QOVF in the United Kingdom, 

Canada, and Australia are sewing patriotic patches for their own soldiers. The 

foundation has an impressive list of staff comparable to any business organization: 

a board of directors, regional and state coordinators, IT (information technology)

manager, and coordinators for the newsletter, special events, distribution, 

membership, and many more. What is even more amazing is that all staff members 

are volunteers. 

The communities of quilters stay connected through the very detailed and 

continuously updated website www.qovf.org. There is a link to the QOVF blog 

and Facebook page. The website provides instructions and very specific “do’s” and 

“don’ts.” Quilts range in size from a minimum of 55 ̋ x 65 ̋ to no larger than 

72 ̋ x 90 ̋. Only high-quality 100% cotton quilting can be used. Softness is a must! 

In fact, quilters are told if they are unsure of any fabric, to close their eyes and rub 

it against their faces. If a fabric feels course, scratchy, or hard, it cannot be used.1 

Each quilt is bound, washed, labeled, and wrapped in a presentation case. Quilts of 

Valor are made to comfort and heal. The majority of quilters prefer using patriotic 

red, white, and blue colors. Stripes, stars, and every geometric shape and design 

imaginable are woven into unique and creative artistic blankets. Quilts are awarded 

at many different levels: individually, to military hospitals, to entire service units 

returning from deployment, and to the Department of Veterans Affairs.

Across the ocean, the impact of this effort is enormous. The majority of 

seriously injured wounded warriors arrive at Landstuhl Regional Medical Center 

(LRMC) with little more than the torn and blood-stained clothing they were 

wearing at the time of injury. Their stay may be only hours or days before they 

are stabilized for transport to a US military hospital for further care. The quilt is 

something personal and meaningful that is theirs alone. With so much loss that 

has often transpired in just a flash of time, this is something that stays with them. 

Boxes of quilts arrive at LRMC from all parts of the country. Chaplains 

primarily distribute these blankets crafted with love. They are given to soldiers 

with wounds ranging from concussions, to blast injuries, to amputations. Nurses 

use them to cover their patients whenever possible. If the patient is hot or has a 

fever, they are placed over the footrest or at the bottom of the bed. Their beauty 

and brightness help offset the difficult moments when families see their loved one 

so injured or in pain. That splash of patriotic color goes a long way in humanizing 

the antiseptic smell of a hospital, endless walls of white, and a hospital bed. 
CHAPLAIN SERVICES 161

Soldiers display some Quilts of Valor. 

Photograph courtesy of the Public Affairs Office, Landstuhl Regional Medical Center.

Quilts are given to soldiers who are awake and able to see and feel this gift, and to 

soldiers who are unconscious, intubated, and seemingly unaware. It is not unusual 

to see soldiers wrapped in their quilts while transported around the hospital in 

wheelchairs. Quilts of Valor have covered soldiers as they were being awarded 

with Purple Hearts, and they have covered soldiers while they were dying. No 

matter rank or circumstance, they were stitched with love and gratitude to convey 

a universal thank you from groups of quilters wishing to honor those who serve. 

Americans care about the comfort and well-being of US soldiers; their service, 

sacrifices, and valor are valued. Each quilt turns an ordinary moment of giving a 

gift into one that conveys a simple but powerful message. 

To date, more than 110,000 quilts have been awarded to our soldiers and veterans.

REFERENCES 

1. Quilts of Valor Foundation website. www.qovf.org. Accessed April 15, 2015.

2. NBC Nightly News. Quilts of Valor offer warmth to wounded soldiers 

[video]. October 21, 2013. http://www.nbcnews.com/video/nightlynews/53338284/#53338284. Accessed April 15, 2015. 
Laboratory personnel entering specimen information into 

the computer at the counter designated as the “downrange 

processing bench” at Landstuhl Regional Medical Center. 

Photograph courtesy of the Public Affairs Office, 

Landstuhl Regional Medical Center.
CHAPTER TEN

General Laboratory Services 

As the war progressed, clinical challenges at Landstuhl Regional Medical 

Center brought about constant reassessment to improve patient care 

outcomes and find optimum solutions through evidence-based best practice. 

Landstuhl Regional Medical Center (LRMC) played a pivotal role in 

stabilizing and treating combat casualties for return to duty or for 

evacuation to the continental United States for further medical evaluation 

and care. Quality patient-focused care continued to be the highest priority amid 

the constant changes and challenges brought to the hospital as a result of the global 

war on terrorism. Each administrative and clinical arena continuously reevaluated 

their respective services to meet the ongoing needs of sick and injured soldiers, 

as well as the health needs of patients residing in the community. The primary 

mission of the Department of Pathology and Area Laboratory Services at LRMC 

is as follows: To provide responsive, reliable, and high-quality laboratory testing in 

support of patient care.

BACKGROUND

Prior to 2003, the sole mission of laboratory services at LRMC was to 

support daily hospital inpatient and outpatient laboratory needs. At that time, 

there was no designated area to process samples from downrange because there 

was clearly no need for it. This reality changed with the onset of the war in Iraq 

in 2003, and then significantly again in 2007, when a troop surge of more than 

20,000 soldiers was deployed in support of Operation Iraqi Freedom.1

 This 

military strategy changed the patient care landscape thousands of miles away at 

LRMC. Comparative hospital data from 2001 to 2007 showed that the average 

daily census in the intensive care unit had tripled, and the level of acute care had 

doubled. By November 2007, LRMC had treated more than 45,000 combat 

patients with varying degrees of trauma from battle-related injuries.2

 
164 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

There was a significant trickle-down effect across continents as the complexity 

of medical and surgical care intensified for injured soldiers, and the impact at 

LRMC was felt hospital-wide. For example, laboratory services at downrange 

medical treatment facilities (MTFs) were historically limited to providing basic 

testing only. However, as downrange Role 3 hospitals increased their treatment 

capabilities, a greater variety of clinical laboratory tests were added to the 

standard menu to support routine healthcare, as well as the intense trauma care 

requirements. Versatility was mandatory in combat laboratories because the 

mission could change at a moment’s notice. Downrange laboratory technicians 

could go from processing a basic chemistry panel, to typing and cross-matching 

blood samples from injured soldiers requiring immediate surgery, triaging the 

downrange hospital supply for available units of whole blood and platelets, or 

thawing units of fresh frozen plasma or cryoprecipitate.3

 Although the level of 

care had certainly increased, and downrange laboratories were handling several 

hundred samples per month, some of the necessary and more sophisticated testing 

could still not be supported. Deployed physician specialists were likely to order 

more varied and specialized blood tests that could not be done in combat facilities. 

Therefore, it became necessary for LRMC to become the referral laboratory 

for both Iraq and Afghanistan MTFs. By 2007, the laboratory at LMRC was 

experiencing a 25% workload increase; by 2009, it was at its highest workload 

capacity. Personnel were responsible for processing and testing incoming samples 

from downrange, as well as those from the inpatients and outpatients, who had 

also greatly increased in both volume and complexity of injuries. 

Physical space was a precious commodity at LRMC, and there was not a lot 

of “extra” to meet the needs of various clinical departments and specialty services, 

all working at maximum capacity. The laboratory was no exception. Space had 

to be found in the crowded 10 by 25 square-foot processing area for the 30 to 40 

boxes containing laboratory samples that arrived almost daily. All boxes had to 

be recycled and sent back downrange because they were difficult to come by in 

combat hospitals. Whereas the existing laboratory space did not permit any further 

expansion, a countertop was designated specifically as the downrange processing 

bench in 2009 because of the sharp increase of samples being received. At its 

peak, the bench was receiving and processing approximately 2,500 specimens a 

month from the Afghanistan and Iraqi theaters. Staffing adjustments were made 

to accommodate the operational requirements of the downrange bench, and 

two laboratory staff members were trained in CHCS (Composite Health Care 

System, a medical informatics system) and CoPath (laboratory software) computer 

programs. Every downrange sample (about 80–100/day) was hand-annotated that 

it was received, and then orders were manually entered into the computer for every 

requested laboratory test. Laboratory staff also adjusted to a variety of needs and 
GENERAL LABORATORY SERVICES 165

tasks outside of the usual realm of duty. For example, large yellow buckets were 

used to hold surgical samples, such as fragments, any type of foreign body, heavy 

metals, and miscellaneous fragments for pathology analysis. 

In 1994, the Armed Services Blood Bank Center, Europe, had been 

reorganized and moved to a facility on the LRMC campus. The chief of Blood 

Services was overseeing both the donor center operations and the hospital 

transfusion service. Blood Bank services became a more daunting challenge 

after 2003, when more and more critically ill trauma patients required multiple 

transfusions of various blood products as lifesaving treatment. 

IMPLEMENTATION METHODS

After the surge, the laboratory department reorganized and consolidated 

all sections that handled any aspect of initial specimen collection or receipt. This 

included blood samples (phlebotomy services) and human tissue (department 

of pathology). The purpose of this new umbrella unit, now called Central 

Operations, was to ensure that only one section received, processed, and distributed all specimens coming into the laboratory from inpatient wards, outpatient 

services, and downrange theaters. Staff from Central Operations attended ward 

rounds daily during the week to assess the anticipated inpatient needs. 

Funding was provided to hire additional personnel and to purchase 

necessary supplies and equipment needed to handle the extra workload. This 

was essential due to the high volume of patients within the hospital itself and to 

support downrange theater laboratory needs. Phlebotomy services also fell under 

the Department of Laboratory Services. Prior to 2003, there were four trained 

phlebotomists who collected blood for the outpatients at LRMC. Two more 

technicians were added to meet the increased needs. 

The process for transferring laboratory samples from downrange to LRMC 

involved a great deal of organization and communication. This service gave 

downrange medical providers access to laboratory services and results not typically 

available in a combat zone. It also minimized unnecessary evacuations of medically 

stable soldiers who previously would have been sent to LRMC for laboratory tests; 

specimens could now be sent to LRMC rather than patients. The 5-step process was 

as follows:

1. Samples were collected at outlying theater clinics with laboratory 

facilities, logged in, and properly stored. 

2. These samples were then transported to the nearest Role 3 hospital 

within theater. If that facility did not have the necessary laboratory 

equipment to handle the required testing, they were stored for shipment 

to LRMC.
166 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

3. The downrange Role 3 laboratory officer in charge then coordinated 

with the nearest Air Force transportation office, which determined 

the next available flight to Ramstein Air Base. Central Operations at 

LRMC’s laboratory was also notified regarding the upcoming shipment. 

4. Samples were then properly packaged and transferred to a CASF 

(Contingency Aeromedical Staging Facility) team for a MEDEVAC

flight to Ramstein Air Base. These samples accompanied patients from 

theater transferring to LRMC for further medical care.

5. After arriving at LRMC, the CASF team delivered the samples to 

the hospital’s noncommissioned officer-in-charge, who notified the 

laboratory for pick-up. 

LESSONS LEARNED

The dedication and tireless effort of both the administrative and clinical 

personnel in the Department of Laboratory Services contributed greatly to the 

quality care provided to patients at LRMC. Successful changes occurred from 

valuable lessons learned as the war progressed, and the patient volume and needs 

intensified. Successes and challenges arose in every section of the laboratory. 

Successes

• Central operations: customer satisfaction. All patients had an opportunity 

to submit customer comments either through an online computer 

program or a written card. The patient advocate office entered the results 

from received cards into the computer. Information obtained from 

submitted comments was reported at the laboratory’s quality assurance/

performance improvement committee meetings and evaluated for 

any adverse patterns or trends. All dissatisfactory patient comments 

or complaints were thoroughly investigated and assessed for systemic 

problems and solutions. When requested, the laboratory also personally 

contacted the patient to discuss and address their concerns. The 

laboratory measured customer satisfaction monthly by percentage and 

posted these results in the patient waiting area. Staff wanted patients 

to know that quality customer service and patient satisfaction were 

taken seriously. The laboratory at LRMC served an average of 45,000 

outpatients annually, and Central Operations consistently received a 

customer satisfaction score of 98%. The front desk staff, phlebotomists, 

and technicians who all interact directly with patients were consistently 

complimented on their attitude, professionalism, and expertise. 

• Downrange processing: transport of laboratory samples. Between 2003 and 

2009, laboratory samples were transported to LRMC from downrange 
GENERAL LABORATORY SERVICES 167

Blood Bank Services

New Initiative Brings Lesson Learned

As the war progressed, clinical challenges at Landstuhl Regional Medical Center 

brought about constant reassessment to improve patient care outcomes and to 

find optimum solutions through evidence-based practice. Anemia is common in 

critically ill patients, particularly those admitted to the intensive care unit (ICU). 

The nature of injuries in combat casualties—such as amputations, internal organ 

trauma, and burns—often necessitated multiple blood product transfusions. The 

greater the length of stay in the ICU, the greater the likelihood the patient required 

additional red blood cell (RBC) transfusions.1 Research has shown that the storage 

of RBCs over time leads to progressive degradation (known as “storage lesion”) 

that affects RBC structure and function. Biochemical changes occur that decrease 

oxygen delivery to cells, and changes in the RBC shape increases the likelihood 

of occluding the microcirculation.2 Adverse clinical outcomes in critically ill and 

trauma patients have been associated with these RBC changes, such as a decrease 

in tissue oxygenation and an increased risk for infection, multisystem organ failure, 

lengthened hospital and ICU stay, and mortality.2

US Army Specialist Lauren O’Neal, 153rd Blood Support Detachment, medical laboratory 

technician, prepares to receive platelets from Army Specialist Samantha Criscio at Craig 

Joint Theater Hospital, Bagram Airfield, Afghanistan, December 31, 2015. 

Photograph courtesy of the US Air Force. Photographer: Technical Sergeant Robert Cloys.
168 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

The complexity of transfusing life-sustaining blood products was augmented 

by having to send samples from freshly donated blood for testing to the United 

States, where regulations are much stricter than those in Europe. No blood product could be released for use until test results were received. As a result of this 

requirement, there was an average lag time of 6 days from the time of blood 

donation to the time blood products were released to the shelf for use.3 In 2011, 

the LRMC Department of Pathology (under Laboratory Services) and the Blood 

Services department identified an increase in the age of transfused RBCs used in 

ICU patients. Between May 2010 and February 2011, there were 941 units of 

RBCs transfused to 1,809 trauma patients admitted to the ICU, with a mean age 

of 28.5 days.3

Collaborative efforts then began with a multidisciplinary team comprised of 

trauma researchers, nurse educators, and pathology, blood service, and blood bank 

personnel. Several initiatives were implemented with the goal of reducing the age 

of blood in units used to transfuse ICU trauma patients. These included improving 

communication among providers, streamlining requests for blood products, and 

optimizing the blood bank inventory. One of the first policy changes required 

that trauma ICU patients receive packed RBCs less than 30 days from the time 

of collection. To further ensure that this requirement was met, a “newest blood” 

stamp was created for use on all blood product request forms (Form SF 518).3

The LRMC blood bank collaborated with the Blood Donor Center to 

improve response to blood product needs by scheduling and organizing area blood 

drives to maintain appropriate inventory. A designated “trauma shelf” was created 

specifically for storage of all blood products less than 30 days old. This improved 

identifying stock of the freshest blood units available and decreased storing older 

units of blood.3

Hospital leadership and the education department combined forces to 

incorporate training on blood product use and policies in general employee 

orientation. New clinical nurses attended hands-on training of the entire 

transfusion process, from collecting and labeling to documenting and 

administering blood products. A poster mock-up of the blood product request 

form highlighting the “newest blood” stamp was placed on all nursing units as 

both a guide and a reminder of the initiative.3

A blood utilization committee was formed to oversee and optimize blood 

product use at LRMC. This committee collaborated with the blood bank, the 

Pathology and Blood Services Department, the Blood Donor Center, and the 

LRMC education department to maintain all initiatives geared toward reducing 

the age of blood products administered to trauma patients.3
GENERAL LABORATORY SERVICES 169

Finally, the Pathology and Blood Services Department worked with local 

and international shipping agencies to improve blood sample delivery and 

identification of the shipment to alert agencies of their priority status. This resulted 

in expedited delivery and a decrease in the turnaround time of laboratory results.3

A formal policy change was created at LRMC to reduce the maximum age of 

blood administered to trauma patients in the ICU from 30 days to 25 days. After 

implementing these various initiatives, data showed that the age of blood used 

in transfusions between March 2011 and December 2013 was 19.6 days, a 45% 

decrease. Additionally, the collaborative efforts of the Pathology and Blood Services 

Department and the shipping agencies reduced the lag time of blood product 

donation to the “trauma shelf” from 6 days to 3 days.3

Hard work, strong leadership, and collaborative efforts brought effective 

change. This evidence-based best practice was a valuable lesson learned that can be 

replicated in other facilities to improve patient outcomes when caring for critically 

ill and trauma patients in the ICU. 

REFERENCES

1. Corwin H, Surgenor S, Gettinger A. Transfusion practice in the critically ill. 

Crit Care Med. 2003;31(12):668-671.

2. Vandromme M, McGwin G, Weinberg J. Blood transfusion in the critically 

ill: does storage age matter? Scand J Trauma Resusc Emerg Med. 2009;17(35).

3. Chappell W. Age of blood: reducing the age of red blood cells and transfusion 

in critically ill and trauma patients. Best Practice Submission, Landstuhl 

Regional Medical Center. www.baylor.edu/graduate/mha/doc.php/228325.

docx. Accessed August 16, 2015.
170 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

by means of commercial air carriers. This process proved to be highly 

unreliable because samples were not maintained in appropriate 

temperatures en route and arrived too late, no longer viable or stable for 

testing. It therefore became necessary to identify an alternative transport 

method. Successful coordination with the downrange processing staff 

at LRMC, medical personnel in the Afghanistan and Iraqi theaters, 

and the CASF team enabled specimens to be expeditiously shipped via 

MEDEVAC aircraft to Ramstein Air Base. This process was a success 

and reduced the average turnaround time for laboratory results from 

12 days to less than 48 hours, and maintained specimen viability and 

stability. Once implemented, this important change allowed patients 

who were not seriously injured to be treated within the theaters of 

operation instead of having to be medically evacuated to LRMC. 

• Phlebotomy services: wait-time and quality of work. The US Army Medical 

Command standard for patient waiting time requires no more than 15 

minutes to elapse from the time the patient presents to the laboratory 

until served. At LRMC, the average patient waiting time in the 

laboratory was 5 minutes. The number of patient sample recollections 

was always consistently below the national average because very few 

errors were made by the labora-tory’s well-trained and experienced staff. 

This was especially significant given the high volume of patients seen and 

the constant turnover of military staff. 

Challenges

• Staff turnover. Personnel turnover continued to be the biggest challenge 

in the laboratory department. New staff had to be trained and brought 

up to speed in each of the various sections of the laboratory. This was 

particularly difficult when the hospital census was full, and sick and 

injured patients were arriving daily from downrange. In addition, the 

hospital remained 100% committed to continuing to serve the patients 

in the European community, so there was very little “downtime” in 

providing patient care. 

Turnover of providers in the combat hospitals was also a challenge 

for the lab at LRMC. The laboratory staff at LRMC entered the 

requested tests and provider information under the name of the person 

who sent and ordered the sample. However, that provider may have left 

by the time the sample was received at LRMC, and now staff had to 

spend time getting necessary information on the replacement provider 

to enter into the system. It was time-consuming for staff, and sometimes 
GENERAL LABORATORY SERVICES 171

delayed running samples and reporting laboratory results to the care 

providers. 

• Communication. Coordination was always a challenge with theater 

transportation units to ensure that the “right box of laboratory samples 

got on the right plane.” Communication and organization were vital 

in this process, but errors did sometimes occur. As the war continued, 

lessons learned brought about changes and improvements to eliminate 

this from happening as much as possible.

ACKNOWLEDGMENTS

The authors thank Robert Hinkel and LTC Tracey Wilson.

REFERENCES

1. Abramowitz M, Wright R. Bush to add 21,500 troops in an effort to 

stabilize Iraq. Washington Post. January 11, 2007.

2. Fang R, Pruit V, Dorlac G, et al. Critical care at Landstuhl Regional 

Medical Center. Crit Care Med. 2008;36(7):S383–S387.

3. Sapasap S. Laboratory practices in a combat zone. 

Lab Med. 2008;39(8):453–457.
Captain Mario Ramirez and Captain Suzanne Morris, members of the 

455th Expeditionary Aeromedical Evacuation Squadron Critical Care 

Air Transport Team (CCATT), confirm a patient’s identity and prepare 

to administer a blood transfusion during a flight out of Bagram 

Airfield, Afghanistan, March 21, 2013. A CCATT crew consists of a 

physician, intensive care nurse, and a respiratory therapist, making it 

possible to move severely injured or gravely ill service members by air. 

US Air Force photograph by Senior Airman Chris Willis. Reproduced from: http://

media.defense.gov/2013/Mar/28/2000063341/-1/-1/0/130323-F-LR266-126.JPG.

 
CHAPTER ELEVEN

Critical Care Air Transport Team 

The Critical Care Air Transport Team is a highly specialized medical team that 

functions as a supplement to the primary aeromedical evacuation system. 

The intensive care unit (ICU) in any hospital is a complicated, and often 

unpredictable, environment. This is the nature of caring for critically 

ill and injured patients. Now add factors such as noise from a roaring 

engine, vibration, dim lighting, fluctuating altitude, temperature extremes, and 

barometric changes of flight patterns. This is the reality of caring for critically ill 

and injured patients in the air, one of the most challenging care environments 

conceivable.

The Critical Care Air Transport Team (CCATT) is a highly specialized 

medical team that functions as a supplement to the primary aeromedical evacuation (AE) system. The concept behind its inception, in 1994, is to manage 

critically ill but stable patients who have undergone initial resuscitation in 

downrange medical facilities. Under the most challenging of physiological, 

psychological, and logistical circumstances, the CCATT has provided the highest 

level of care to complex patients with severe trauma, burns, respiratory failure, 

multiorgan failure, and other life-threatening complications. Across thousands of 

miles from Iraq or Afghanistan to Landstuhl Regional Medical Center (LRMC), 

highly trained medical professionals have monitored patients who are in a state of 

dynamic physiological flux and require continuous observation and intervention 

during transport to the next level of care. 

BACKGROUND

Evacuating military casualties by air began during World War I, but it was 

during World War II that the US Army Air Corps organized an integrated AE 

system (AES). Nurses with specialized training in AE traveled with patients on 

cargo aircraft returning from downrange.1 In 1942, the US Army Medical Service 
174 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

formed the 38th Medical Air Ambulance Squadron at Fort Benning, Georgia, 

and more than 1 million patients were evacuated during the last 3 years of the war 

using AE.2 During World Wars I and II, however, it took weeks to months to move 

a patient from a combat hospital back to the United States. The average evacuation 

during the Vietnam War was 45 days.3 Fast forward to the 1990s, when the AES 

had grown significantly and now included command and control functions, 

trained personnel, facilities for staging patients, and logistic support. Although this 

system was capable and successful in evacuating large numbers of stable patients, it 

lacked the capabilities to medically manage critically ill casualties.3

It became apparent that a reevaluation of the AES was crucial after Operation 

Desert Storm in 1991 and during United Nations peacemaking operations in 

Somalia in 1993, when the AES was unable to provide care for critically ill and 

injured patients.4 The existing system relied on the transferring combat facility 

to provide supplies, equipment, and critical care specialists for AE, which then 

depleted their own capabilities to care for such patients at their field location.1 The 

operational requirement identified a need to close the “care in the air” capability 

gap with a new program that would address the needs of caring for critically ill 

patients.4 This need gave birth to the US CCATT program. 

During the 1980s and early 1990s, Dr. Paul Carlton Jr (Air Force Surgeon 

General, 1999–2002) developed the capability to quickly and effectively stabilize 

critically ill patients for transport. He based his intervention on his experiences 

receiving casualties from the embassy bombing in Beirut, Lebanon, in 1983. 

In May 1994, Carlton and Dr. Joseph Farmer, a medical intensivist, launched 

the CCATT program, and a 2-year test phase was implemented at the US Air 

Force (USAF) medical centers in San Antonio, Texas, and Biloxi, Mississippi. 

CCATT’s manning consisted of a three-person team, including a critical care 

physician, critical care nurse, and a respiratory therapist. A simulated critical care 

environment was developed, and each team was provided with the necessary 

supplies and equipment to care for patients during an evacuation flight. The 

physician on the flight was responsible for medical decisions if a patient’s condition 

changed and warranted new interventions. The goal of the CCATT was to 

monitor critical patients and keep their condition stable without interrupting 

transport. After 2 years of pilot testing, the CCATT was formally approved and 

adopted into the USAF AES in June 1996.1,4 

The initiation of the CCATT program occurred in parallel to changes made 

in military doctrine after the end of the Cold War. During the Cold War, large 

hospitals had been established in predictable locations in anticipation of large 

battles. These medical facilities were intended to hold numerous casualties who, 

if they could recover within 1 to 2 weeks, would remain there until their recovery 

was complete and they were ready to return to duty. Post-Cold War military 
CRITICAL CARE AIR TRANSPORT TEAM 175

operations, when the United States became involved in missions that were often 

unpredictable in timing and location, necessitated a different strategy. It was no 

longer feasible or efficient to set up large-capacity hospitals because locations of 

military operations could rapidly change. The goal then focused on deploying 

small but high-capability medical treatment facilities that would stabilize and then 

evacuate casualties as needed. Military leaders needed assurance that this strategy 

could safely evacuate critically ill and injured patients; the CCATT now ensured 

this commitment.1

IMPLEMENTATION METHODS

Organization

AE teams are composed of two to three nurses and four to seven technicians 

who provide care to noncritically injured patients and act as the liaison between 

the CCATT and the aircraft crew members. The CCATT augments the AE 

team through the capability of highly trained medical specialists who care for 

critically complex patients.5,6 Each CCATT is comprised of a physician intensivist 

(anesthesiologist, emergency medicine specialist, surgeon, pulmonologist, or 

cardiologist), a critical care registered nurse, and a respiratory therapist.1,4,5 Within 

USAF active duty, reserve, and National Guard units, there are approximately 250 

CCATTs. Per guidelines, these highly trained professionals can transport three 

critically ill ventilated patients (eg, with extensive trauma or burns), six less acutely 

ill nonventilated patients, or a combination thereof.7 The operational definition of 

a patient stable enough for AE includes a secured airway, controlled hemorrhage, 

and immobilized extremity fractures.6 During Operation Enduring Freedom and 

Operation Iraqi Freedom, all critically ill and injured patients were flown out 

of theater to Germany by the CCATT.5,8 The 10th Expeditionary Aeromedical 

Evacuation Flight, a deployed unit stationed at Ramstein Air Base, may fly several 

missions to Afghanistan and Iraq in 1 week to pick up critically ill wounded 

soldiers. They also then transport patients back to CONUS (continental United 

States).Often. theseflights will be filled with different categories of wounded 

soldiers, the medical teams treating them en route, other passengers, and cargo. 

These CCATTs are primarily deployed from CONUS bases, though one team is 

part of the 86th Medical Squadron (MDS), also at Ramstein Air Base. The 86th 

MDS primarily provides AE capabilities for the European Command theater. The 

CCATT mission is only part of these teams’ responsibilities; their primary duty is 

to provide patient care at LRMC.9

Training

The training for a CCATT is intense and highly specialized. Commanders 

nominate those USAF members with the skills and critical care experience to fill 
176 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

the positions needed to meet their unit’s manning requirements. Each candidate 

must pass a flight physical. Candidates then undergo a process called clinical 

validation, whereby their training and experience are evaluated by a committee of 

CCATT crew members who serve in the same roles the candidates are applying 

for. If they pass this point, candidates attend a 2-week initial CCATT basic 

training course at the USAF School of Aerospace Medicine in San Antonio. This 

course covers everything from altitude and patient flight physiology to flight 

stresses, flight safety, surviving deployed environments, and equipment and supply 

allowances. Candidates are taught how to apply their critical care knowledge of 

caring for patients “in air” versus patients “on land.” The AE crew also provides 

training to candidates in simulated aircraft cargo interiors.1,4

Teamwork is a vital component of the CCATT. The next step in training a 

new member involves participating in collaborative exercises that develop the vital 

teamwork required to interact and implement the multiple components of a fully 

deployed tactile AES. This training occurs during the Aeromedical Evacuation 

Air Force Staff Sergeant Napolean Gifford, left, respiratory technician for a critical care air 

transport team deployed to Ramstein Air Base, Germany, and Air Force 1st Lieutenant Brad 

Tiefel, the team’s intensive care nurse, are part of an aeromedical evacuation capability 

that turns a C-17 Globemaster III into a flying intensive care unit as they transport patients 

to increasingly advanced levels of care. 

Department of Defense photograph by Donna Miles. Reproduced from: http://archive.defense.gov/

DODCMSShare/NewsStoryPhoto/2011-05/hrs_110505-D-5555M-005.JPG.
CRITICAL CARE AIR TRANSPORT TEAM 177

Contingency Operations Training exercise at Sheppard Air Force Base, Texas. 

Here, candidates interact with other AE crew members, including those from 

command and control and ground staging facilities.1,4 

Selected CCATT candidates then enter a sustainment phase in which they 

continually practice their clinical skills in their respective critical care area of 

expertise. When tasked for deployment, candidates begin CCATT Advanced, 

a 2-week course at the Center for Sustainment of Trauma and Readiness Skills 

(C-STARS) at the University of Cincinnati Medical Center, taught by both USAF 

and civilian faculty who provide intense training for military medical personnel in 

the areas of trauma and critical care. The University of Cincinnati was chosen as 

a C-STARS location due to its excellent reputation as a teaching hospital and its 

high volume of trauma and critical care patients. The C-STARS program provides 

the opportunity for CCATT members to refresh and enhance clinical skills and 

knowledge by working closely with expert civilian colleagues.4

 This course has 

three major goals for trainees:

1. review basic training from the initial CCATT basic course,

2. participate in 60 to 80 hours of critical care rotations in a busy Level I 

trauma center under the supervision of civilian and military faculty, and

3. incorporate lessons learned from ongoing operations at the civilian 

hospital into the training experience.4 

Lieutenant Colonel Ed Galvez, trauma nurse specialist, reviews HAL’s medical chart during a Critical Care Air Transport Team exercise on board a C-130 Hercules. HAL is a male 

manikin-simulator used for training purposes. 

US Air Force photograph by Technical Sergeant Bob Sommer. Reproduced from: http://www.minneapolis.afrc.af.mil/shared/media/photodb/photos/120205-F-TQ906-092.jpg.
178 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

This is the final validation process class for members, and evaluation consists 

of didactics, multiple real-life simulations, and a training flight using actual 

CCATT equipment, medications, and supplies. If the C-STARS faculty feels any 

candidate is not adequately prepared for mission success, that indivisual will not be 

deployed on a CCATT mission until he or she completes remediation training.4 

Ongoing training is required to maintain current and updated CCATT skills. 

All CCATT members must reattend C-STARS every 24 months and maintain 

their respective readiness skills. In addition, all members must successfully 

complete a valid operational support flying class physical examination and possess 

a valid altitude chamber card.

Equipment

A combination of capability and practicality are the compromising factors 

used to determine the medications, supplies, and equipment carried by the 

CCATT.4 Although the goal is to replicate the critical care capabilities of a hospital 

intensive care unit, there is also the reality of logistical limitations in an aircraft 

environment. All CCATT equipment is tested and must meet strict safety criteria. 

Standard critical care equipment—such as mechanical ventilators, physiological 

monitors, suction canisters, intravenous pumps, and blood analyzers—must be 

compact, portable, battery-operated, and flight-use certified.1,4 The equipment 

must also interface with the aircraft oxygen and electrical systems, and be able 

to function amid constant vibration and temperature variability. A standardsized canvas or nylon litter is mounted inside the aircraft, and metal brackets are 

strapped to poles that secure the patient to all the equipment.1,4 All CCATTs are 

issued the same complete allowance standard weight of 790 pounds, which is 

packed in customized backpacks, specifically designated for CCATT. Between 

missions, the backpacks are designed to hang alongside the aircraft fuselage.1,4

The majority of CCATT missions are flown on the C-17 Globemaster and 

the C-130 Hercules aircrafts. The C-17 can support 36 litter patients and 54 

ambulatory patients, whereas the C-130 carries a maximum of 74 litters. Only the 

C-17 has the capacity for on-board oxygen; portable oxygen tanks must be used 

on the C-130.1,10

CRITICAL CARE AIR TRANSPORT TEAM UTILIZATION 

REQUEST AND FLIGHT PREPARATION

When the downrange critical care team identifies the need for CCATT 

transport, an AE liaison officer is contacted who then notifies a local flight surgeon 

to evaluate the patient and identify any special needs the patient may have in 

flight. The request is then forwarded to a Theater Patient Movement Requirement 

Center (TPMRC), which contacts the CCATT point of contact to discuss the 
CRITICAL CARE AIR TRANSPORT TEAM 179

need for CCATT movement and to relay basic patient information. Once the 

request is cleared, an effort is coordinated with the Tanker Airlift Control Center 

(TACC) to locate an available aircraft for patient movement. An AE team, a 

CCATT, and the patient are then assigned to that aircraft and preparations are 

made for the flight.5

 The medical team from the sending facility turns over the 

care of the patient to the CCATT, who must be ready to accept the patient (often 

directly from the operating room) and assist in ground transport of that patient to 

the evacuation aircraft. 

Careful and prudent measures are taken to prepare for this departure to 

ensure that necessary supplies are available and all equipment is functional. Prior to 

takeoff, preventive interventions—such as securing airway and endotracheal tubes, 

ensuring intravenous access, checking recent blood work and radiology reports, 

and reinforcing wound dressings—are taken to prevent in-flight crises. During 

this tenuous and critical period, the CCATT must be prepared to continue all 

interventions and resuscitation measures initiated by the forward facility. These 

include administration of blood products (packed red cells, fresh frozen plasma, 

US airmen assigned to the 455th Expeditionary Aeromedical Evacuation Squadron (EAES)

repack aeromedical evacuation (AE) equipment and supplies after an AE mission aboard 

a C-17 Globemaster III aircraft at Ramstein Air Base, Germany, August 9, 2015. The 455th 

EAES airmen are charged with the responsibility of evacuating the sick and wounded from 

Central Command to higher levels of medical care. 

US Air Force photograph by Major Tony Wickman. Reproduced from: http://media.defense.gov/2015/

Aug/20/2001274036/-1/-1/0/150809-F-LH521-154.JPG.
180 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Members of the Contingency Aeromedical Staging Facility (CASF) and the 455th Expeditionary Aeromedical Evacuation Squadron Critical Care Air Transport Team assist patients 

onto the C-17 Globemaster III at Bagram Airfield, Afghanistan, March 21, 2013. The CASF is 

the relay between the Craig Joint Theater Hospital and aeromedical evacuation missions 

throughout Afghanistan. 

US Air Force photograph by Senior Airman Chris Willis. Reproduced from: http://media.defense.gov/2013/

Mar/28/2000063344/-1/-1/0/130323-F-LR266-081.JPG.

Senior Airman Delton McClary, 455th Expeditionary Aeromedical Evacuation Squadron 

Critical Care Air Transport Team respiratory therapist, performs an arterial blood-gas 

sampling during a flight out of Bagram Airfield, Afghanistan, March 21, 2013. The results 

will be used to monitor the patient’s hemoglobin and electrolyte levels and guide further 

resuscitation during the flight. 

US Air Force photograph by Senior Airman Chris Willis. Reproduced from: http://media.defense.gov/2013/

Mar/28/2000063338/-1/-1/0/130323-F-LR266-136.JPG.
CRITICAL CARE AIR TRANSPORT TEAM 181

Members of the 455th Expeditionary Aeromedical Evacuation Squadron assist patients on 

a C-17 Globemaster III medical transport flight out of Bagram Airfield, Afghanistan, March 

21, 2013. With help from the Critical Care Air Transport Team, the crew can turn a regular 

medical transport aircraft into a flying intensive care unit, making it possible to move 

severely injured or gravely ill service members by air. 

US Air Force photograph by Senior Airman Chris Willis. Reproduced from: http://media.defense.gov/2013/

Mar/28/2000063328/-1/-1/0/130323-F-LR266-222.JPG.

Members of the 455th Expeditionary Aeromedical Evacuation Squadron and the 

Contingency Aeromedical Staging Facility at Ramstein Air Base assist patients on a bus 

bound for Landstuhl Regional Medical Center (LRMC), Germany, March 22, 2013. LRMC 

provides state-of-the-art care using sophisticated invasive/noninvasive medical equipment 

and is the only tertiary intensive care unit within the European theater. 

US Air Force photograph by Senior Airman Chris Willis. Reproduced from: http://media.defense.gov/2013/

Mar/28/2000063325/-1/-1/0/130323-F-LR266-228.JPG.
182 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

platelets, etc); observation of amputation complications; and monitoring of 

ventilatory and cardiac support, intracranial pressure, chest tubes, sutures, wound 

drains, and external fixators.6 Medical complications that are manageable in a 

controlled hospital setting can become quite a different and lethal challenge at 

cruising altitudes.11 

CRITICAL CARE AIR TRANSPORT TEAM COMMAND AND 

CONTROL (AT LANDSTUHL REGIONAL MEDICAL CENTER)

When the CCATT crew arrives at Ramstein Air Base, they remain with their 

patient while the litter is taken off the aircraft, assist with getting the litter onto the 

AMBUS (ambulance bus), and continue to monitor the patient on the 20-minute 

ride to LRMC, where they report to the receiving critical care team that will then 

take over. There have been many occasions when CCATTs have delivered critically 

burned patients from Iraq to LRMC, where they are met by another CCATT who 

has flown to Ramstein Air Base from the burn center in San Antonio to transport 

burn patients immediately to this facility.7

When a critically ill patient at LRMC needs transport to CONUS, the 

CCATT point of contact is notified, and the decision is then made on whether 

a mission can be launched with 86th CCATT assets. This decision is dependent 

on the condition of the patient, length of mission, and availability of aircraft and 

aircraft crew. Because all the 86th CCATT members are fulfilling their regular 

duties, the minimum time for an alert and launch of a CCATT is 4 hours. This 

allows for CCATT members to be relieved of their patient duties and prepare for 

the mission. If, for any reason, a CCATT mission cannot be launched, the patient 

will usually be transported by commercial air ambulance. 

LESSONS LEARNED

In the 12 years of conflict in Iraq and Afghanistan, the military medical 

system has effectively evolved to meet the needs of wounded warriors. The CCATT 

mission has significantly contributed to this effort. The nature of current military 

warfare and the use of explosives have intensified the need for exceptional trauma 

skills, both “on ground” and “en route.” Developments in both the immediate 

critical care attention in theater, and AE transport across thousands of miles to 

LRMC, have resulted in improvements in patient morbidity and mortality. Even in 

the most austere settings, the highest level of critical care was delivered in some of 

the most defining lessons learned in these wars. They are described below. 

Successes

• Patient outcomes. Between 2001 and 2012, the USAF CCATT 

program transported more than 8,000 critically injured patients, with 
CRITICAL CARE AIR TRANSPORT TEAM 183

an associated mortality rate of less than 1%. This is a testament to the 

caliber and commitment set forth by every team member. Under the 

most extreme circumstances, this unique mission delivered advanced 

critical care never seen in prior conflicts.12 

• Implications for civilian practice. The CCATT serves as a useful and 

successful model for hospitals to utilize to augment care during natural 

and manmade disasters, or to transport critically ill patients to facilities 

hundreds of miles away. Retrospectively, the CCATT would have 

been effective during Hurricane Katrina in 2005 or the 2011 tsunami. 

The CCATTs were utilized during the 2010 Haiti earthquake and 

successfully transported patients from Port-au-Prince to south Florida.12 

• Other settings. The CCATT program is flexible enough to respond 

across a wide spectrum of operations and has been successful in a variety 

of situations, including humanitarian and relief assistance, homeland 

defense, military missions other than war, peacetime missions, special 

missions, and nation building.13 

Challenges

• Aircraft environment. Even the most experienced critical care specialists 

would find en route patient care extremely challenging when compared 

to a hospital ICU setting. Although most clinicians are use to a certain 

level of noise, distraction, and fast pace in a civilian ICU, the austere 

conditions in an aircraft add a whole new dimension of challenge to 

delivering patient care.

• Light. The majority of CCATT missions occur at night, and light 

restrictions are enforced to avoid alerting the enemy. Clinicians must 

adjust to patient care under dim and minimal lighting, far different from 

a brightly lit US hospital setting. Routine clinical assessment of patient 

status—such as skin color (circulation), intravenous line patency, and 

interpretation of the color of fluid and wound drainage—is much more 

difficult and can be compromised in a darker setting.6

• Noise. Auditory cues (eg, as monitor and machine alerts and alarms), 

as well as normal conversation, compete against an average ambient 

noise level of about 85 dB inside the aircraft. Hearing protection is 

mandatory for all crew members, making questions and communication 

about patients’ conditions or needed changes challenging and limited at 

all times.6 

• Vibration. Both the crew members and patients are exposed to the 

turbulent and rapid ascent and descent of the aircraft (a tactical maneuver 

that is necessary for safety). The noise and sensation are additional factors 
184 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

that contribute to the challenging environment. Acceleration changes 

associated with steep combat takeoffs and landings may lead to increased 

intracranial pressure in patients with traumatic brain injury.6 

• Altitude. The average aircraft altitude during AE is 8,000 feet and can 

sometimes reach as high as 10,000 feet. The impact of a hypobaric 

environment on critically ill patients, and especially those with softtissue trauma from explosive injuries, cannot be underestimated. The 

lower oxygen content in the air, as well as the tendency for gas within an 

enclosed space to expand, is problematic. The CCATT must constantly 

assess for complications involving the presence of air or gas in the lungs, 

cranial cavity, or eye sockets. The altitude must also be considered and 

appropriate adjustments made when air is used to inflate endotracheal 

tube cuffs, Foley catheter balloons, and other medical devices. The 

effect of a hypobaric environment on life-sustaining equipment, such as 

portable ventilators, is also a constant consideration.6 

• Duration. A typical AE flight to transport patients in the United States 

averages between 45 minutes and 3 hours. An average CCATT mission 

from Afghanistan to Germany is 10 hours and can take longer if other 

circumstances arise. The team must think ahead in preparation for 

extenuating time and circumstances for up to 72 hours.6 

• Emotional stress. The extraordinary physical and logistical circumstances 

of a CCATT mission take an emotional toll on caregivers. They must 

draw on deep personal strength, courage, and resiliency as they face 

constant stress and responsibility when caring for critically ill patients 

under conditions of limited resources, sleep deprivation, and separation 

from family and friends. The mission is immensely rewarding but often 

isolating, especially in the face of limited options or resources when 

confronted with an unpredicted situation. A high level of clinical skill 

and knowledge is required to be a part of this unique team, as well as a 

strong physical and psychological readiness.11

• Staff. Because of its highly specialized nature, it is a constant challenge 

to find and maintain a sufficient pool of service members throughout 

the USAF who are qualified for the CCATT mission. There is an 

even smaller pool of members to draw from at LRMC. The challenge 

there is that members must commit to volunteering additional work 

hours beyond their regular duty assignments at the hospital. It is also 

challenging to keep members current and updated on the knowledge 

base. Fortunately, there have always been some CCATT members 

who have multiple deployment experiences to help instruct the less 

experienced members.
CRITICAL CARE AIR TRANSPORT TEAM 185

ACKNOWLEDGMENTS

We thank Colonel Warren Dorlac, MD, former Medical Director, Trauma and 

Critical Care, Landstuhl Regional Medical Center, and Major M. Josef Mikeska, 

former Director of the Critical Care Air Transport Team. 

REFERENCES

1. Beninati W, Meyer M, Carter T. The critical care air transport program. 

Crit Care Med. 2008;36(7):S370–S376.

2. Martin T. Aeromedical Transportation: A Clinical Guide. Burlington, VT: 

Ashgate Publishing Co; 2006.

3. Zonies D, Pamplin J, Fang R. U.S. military advanced critical care air transport. 

Soc Crit Care Med. April 2, 2015; Clinical Controversies. 

4. Fang R, Allan P, Womble S, et al. Closing the “care in the air” capability gap 

for severe lung injury: the Landstuhl acute lung rescue team and extracorporeal 

lung support. J Trauma. 2011;71(1):S91–S97.

5. Norton D, Mason P, Johannigman J. Critical care. In: Savitsky E, Eastridge B, 

eds. Combat Casualty Care: Lessons Learned from OEF and OIF. Washington, 

DC: Office of The Surgeon General, Borden Institute; 2011: 639–715. 

Chap 13.

6. Johannigman J. Maintaining the continuum of en route care. Crit Care Med. 

2008;36(7):S377–S382.

7. McNeil D, Pratt J. Combat casualty care in an Air Force theater hospital: 

perspectives of recently deployed cardiothoracic surgeons. Sem Thorac 

Cardiovasc Surg. 2008;20(1):78–84. 

8. Johannigman JA. Critical care aeromedical teams (CCATT): then, now, and 

what’s next. J Trauma. 2007;62(6 suppl):S35. 

9. US Air Force. Medical Operations. Washington, DC: Office of the Secretary of 

the Air Force; June 21, 2012. Air Force Doctrine Document 4-02. 

10. Guerdan B. United States Air Force Aeromedical Evacuation—a critical 

disaster response resource. Am J Clin Med. 2011;8(3):153–156.

11. Brewer T, Ryan-Wagner N. Critical care air transport team (CCATT) nurses’ 

deployed experience. Mil Med. 2009;174(5):508–514.

12. Zonies D. Long-range critical care evacuation and reoperative surgery. Surg 

Clin North Am. 2012;92(4):925–937.

13. US Air Force, Wilford Hall Ambulatory Surgical Center, Office of Public 

Affairs. Fact Sheet: Critical Care Air Transport Team. Lackland AFB, TX: 

January 2012. http://mldc.whs.mil/public/docs/report/hb/USAF_CCATTFactSheet_WilfordHallAmbulatorySurgicalCenter.pdf. Accessed September 3, 

2015. 

Acronyms and Abbreviations

A

AAFES: Army and Air Force Exchange Service

ACS: American College of Surgeons

admin: administrative

ADVAB: Armed Services Vocational 

Aptitude Battery

AE: aeromedical evacuation

AES: aeromedical evacuation system

AFRICOM: US Africa Command

AFW2: Air Force Wounded Warrior

AHLTA: Armed Forces Health Longitudinal 

Technology Application

ALARACT: All Army Activities

ALRT: Acute Lung Rescue Team

AMBUS: ambulance bus

ANAM: Automated Neuropsychological 

Assessment Metrics

ANEF: Academy of Nursing Education Fellow

AOIC: Assistant Officer in Charge

AOR: area of responsibility

ARDS: acute respiratory distress syndrome

B

BAMC: Brooke Army Medical Center

C

CAC: Common Access Card

CAC ID: Common Access Card identification

CAPT: Captain

CASF: Contingency Aeromedical Staging Facility

CCATT: Critical Care Air Transport Team

CDR: Commander

CENTCOM: US Central Command

CFC: Clinical Flight Coordination

CHAMPUS: Civilian Health and Medical 

Program of the Uniformed Services

CHCS: Composite Health Care System

CM: Case Management

CMSgt: Chief Master Sergeant

COL: Colonel

CONUS: continental United States

CONV: conventional ventilation

COT: Committee on Trauma

CPE: Clinical Pastoral Education

CPT: Captain

CT: computed tomography/computerized 

tomography

C-STARS: Center for the Sustainment of 

Trauma and Readiness Skills

Cx: cancelled

D

DEERS: Defense Enrollment and Eligibility 

Reporting System

DFAS: Defense Finance and Accounting Services

DoD: Department of Defense

DRK: Deutsches Rotes Kreuz (or German 

Red Cross)

DSO: Deutsche Stiftung Organtransplantation

DV: distinguished visitor

DVBIC: Defense and Veterans Brain 

Injury Center

DVT: deep vein thrombus

DWMMC: Deployed Warrior Medical 

Management Center

Dx: diagnosis
188 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

E

EAES: Expeditionary Aeromedical Evacuation 

Squadron

ECLS: extracorporeal life support

ECMO: extracorporeal membrane oxygenation

ED: emergency department

ERMC: Europe Regional Medical Command

EUCOM: US European Command

eval: evaluation

F

FiO2

: fraction of inspired oxygen

1SG: First Sergeant

FMF: Fleet Marine Forces

FY: Fiscal Year

G

GME: graduate medical education

GSW: gunshot wound

GWOT: global war on terrorism

H

HFPV: high-frequency percussive ventilation

HIPAA: Health Insurance Portability and 

Accountability Act 

HMC: Chief Hospital Corpsman

HMCS (SW): Senior Chief Hospital Corpsman 

(Surface Warfare Specialist)

HMF (FMF): Hospital Corpsman (Fleet Marine 

Forces)

HML: Helicopter Marine, Light

HMMWV: High Mobility Multipurpose 

Wheeled Vehicle (or “Humvee”)

I

ICD-9-CM: International Classification of 

Diseases, 9th Revision, Clinical Modification

ICD-10-CM: International Classification of 

Diseases, 10th Revision, Clinical Modification

ICU: intensive care unit

ID: identification 

IDF: indirect fire

IED: improvised explosive device

ImPACT: Immediate Post-Concussion 

Assessment and Cognitive Testing

ISS: Injury Severity Score

J

JPTA: Joint Patient Tracking Application

JTTR: Joint Theater Trauma Registry

JTTS: Joint Theater Trauma System

L

LNO: Liaison Noncommissioned Officer; 

Liaison Officer

LPN: Licensed Practical Nurse

LRMC: Landstuhl Regional Medical Center

LT: Lieutenant

LTC/Lt Col: Lieutenant Colonel

M

M&O: Movement and Orders

MACE: Military Acute Concussion Evaluation

MAJ: Major

MC: Medical Corps

MC4: Medical Communications for Combat 

Casualty Care program

MDS: Medical Squadron (US Air Force)

MEDEVAC: medical evacuation

med/surg: medical/surgical

MGMT: management

MRI: magnetic resonance imaging

MSgt: Master Sergeant

mTBI: mild traumatic brain injury

MTD: Medical Transient Detachment

MTF: medical treatment facility

N

NCM: nurse case manager

NCO: noncommissioned officer

NCOIC: noncommissioned officer in charge

NEMU: Navy Expeditionary Medical Unit

NFL: National Football League

NNMC: National Naval Medical Center

NORTHCOM: US Northern Command

O

OCO: Overseas Contingency Operations

ODS/ODS: Operation Desert Shield/

Operation Desert Storm

OEF: Operation Enduring Freedom

OIF: Operation Iraqi Freedom

OND: Operation New Dawn
ACRONYMS AND ABBREVIATIONS 189

OPTEMPO: operational tempo

OTSG: Office of The Surgeon General

P

PAC: pay and allowance continuation

PACS: Picture Archiving and Communication 

System

PAD: Patient Administration Division

PADAE: Patient Administration Division 

Aeromedical Evacuation

PCV: pressure control ventilation

PE: pulmonary embolism

PERSCO: Personnel Support for Contingency 

Operations

PFC: Private First Class

PI: performance improvement

PIPS: performance improvement and patient 

safety

PMR: patient movement request/patient 

medical record

PTSD: posttraumatic stress disorder

PX: Post Exchange

Q

QOVF: Quilts of Valor Foundation

R

RAPIDS: Real-Time Automated Personnel 

Identification System

RBC: red blood cell

RN: registered nurse

RPG: rocket-propelled grenade

RTD: return to duty

Rx: prescription

S

1SG: First Sergeant

SF: standard form

SFAC: Soldier and Family Assistance Center

SFC: Sergeant First Class

SGT: Sergeant

SIPRNET: Secret Internet Protocol Router 

Network

SM: service member

SMEED: Special Medical Emergency 

Evacuation Device

SMSgt: Senior Master Sergeant

SNOIC: Senior Noncommissioned Officer in 

Charge

SOP: standard operating procedure

SSG: Staff Sergeant

SSN: social security number

stab: stabilization

STARTC: Soldier Transfer and Regulating 

Tracking Center

SVS: Society for Vascular Surgery

T

TACC: Tanker Airlift Control Center

TBI: traumatic brain injury

TBSA: total body surface area

TCC: transfer to continued care

TDA: Table of Distribution and Allowances

TMDS: Theater Medical Data Store

TPM: trauma program manager

TPMRC: Theater Patient Movement 

Requirement Center

TRAC2ES: TRANSCOM Regulating and 

Command & Control Evacuation System

TRANSCOM: Transportation Command

TSC: Theater Sustainment Command

TX: transport

U

USAREUR: United States Army Europe

USN: United States Navy

USO: United Service Organization

V

VBIED: vehicle-borne improvised 

explosive device

VIP: very important person

VTC: video teleconference

W

WIA: Wounded in Action

WTAR: Wechsler Test of Adult Reading

WTU: Warrior Transition Unit

WW: Wounded Warrior

Index

A

AAFES. See Army and Air Force 

Exchange Service

Acronyms and abbreviations, 187–189

ACS. See American College of Surgeons

Acute Lung Rescue Team, 113–115

Aeromedical Evacuation Contingency 

Operations Training, 176–177

Africa Command, 96–97

AFRICOM. See Africa Command

AHLTA. See Armed Forces Health Longitudinal 

Technology Application

Air evacuation. See also Critical Care Air 

Transport Teams

 ambulance bus, 88–89, 128

 PAD Aeromedical Evacuation, 10, 11, 12

 trauma patients, 106, 118, 128

Air Force liaisons, 26, 33

ALARACT. See All Army Activities

All Army Activities, 116

ALRT. See Acute Lung Rescue Team

Ambulance bus, 88–89, 128. See also Critical 

Care Air Transport Teams

AMBUS. See Ambulance bus

American Association for the 

Surgery of Trauma, 98

American College of Surgeons, 97–99

ANAM. See Automated Neuropsychological 

Assessment Metrics

Area Laboratory Services. See Laboratory services

Armed Forces Health Longitudinal Technology 

Application, 18, 19, 29, 131, 132

Army and Air Force Exchange Service, 46

Army Institute of Surgical Research, 101

Army Knowledge Online, 17–18

Army liaisons, 26, 33

The Army Medical Command Traumatic Brain 

Injury (TBI) Action Plan, 57

Army Medical Service, 173–174

Army Warrior Transition Units, 44

Automated Neuropsychological Assessment 

Metrics, 67

B

Blood Bank services, 165, 167–169

Brain injury. See Traumatic brain injury

Brooke Army Medical Center, 80, 117

Burn Clinical Management Guideline, 138

Burns

Burn Clinical Management Guideline, 138

care challenges, 141

resuscitation algorithm, 117

C

C-STARS. See Center for Sustainment of 

Trauma and Readiness Skills

Carlton, Paul, Jr., 174

Case Management, 15

CASF. See Contingency Aeromedical 

Staging Facility

Casualty Information Center, 77

CCATTs. see Critical Care Air Transport Teams

CENTCOM. See Central Command

Center for Army Strategic Studies, 101

Center for Sustainment of Trauma and 

Readiness Skills, 177–178

Central Command, 96–97

CFC. See Clinical Flight Coordination
192 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Chaplain services

 background of, 146–147

 burnout, 157

 challenges for, 156–158

 chaplain day trips, 149, 154–155

 Chaplain’s Closet, 13, 150–153

 duties of, 145–146

 implementation of, 147–149, 154

 pastoral support, 154–155

 Quilts of Valor Foundation, 159–161

 reintegration challenges, 156–157

 successes of, 154–156

 support for caregivers, 156

 volunteer programs, 149–153, 156, 

 159–161

Chaplain’s Closet, 13, 150–153

CHCS. See Composite Health Care System

Clinic department, 16

Clinical Flight Coordination, 15–16, 19

Clinical Pastoral Education, 146–147

CM. See Case Management

Combat casualty care, 99–101

Committee on Trauma, 98–99

Compassion fatigue, 139–140

Composite Health Care System, 16, 164

Computed tomography, 111

Continental US medical facilities, 96

Contingency Aeromedical Staging Facility, 18, 

88–90, 128

CONUS. See Continental US medical facilities

CoPath, 164

COT. See Committee on Trauma

CPE. See Clinical Pastoral Education

Critical Care Air Transport Teams

 aircraft environment, 183–184

 background of, 173–175

 command and control, 182

 equipment, 178

 flight preparation, 178–182

 implications for civilian practice, 183

 organization of, 175

 patient outcomes, 182–183

 role of, 128

 staff members, 184

 training of, 175–178

 utilization of, 106

 utilization request, 178–182

CT. See Computed tomography

D

DATA/Automated Neuropsychological 

Assessment Metrics, 67

Debit Card Travel Advance Program, 80–81

Deep vein thrombus, 115

DEERS. See Defense Enrollment and Eligibility 

Reporting System

Defense and Veterans Brain Injury Center, 57

Defense Enrollment and Eligibility Reporting 

System, 15

Defense Finance and Accounting Services, 77, 79

Department of Defense

TBI evacuation protocols, 57

Department of Pathology. See Laboratory services

Deployed Warrior Medical Care Center, 12

Deployed Warrior Medical Management Center

 capacity of, 16

 challenges for, 21–23

 clinic department, 16

 departure, 19

 equipment, 19

 evolution of, 10, 12–13

 funding, 22

 logistics department, 15

 management, 18

 mission of, 10

 nursing department, 15, 131–133

 operations department, 14

 organization of, 13–16

 Patient Administration Division, 9–12

 prearrival, 16–18

 reception, 18

 reports, 20

 responsibilities of, 12–16

 staff turnover, 22

 successes of, 20–21

 TBI screening, 57

Deutsche Stiftung Organtransplantation, 112

Deutsches Rotes Kreuz, 106

DFAS. See Defense Finance and 

Accounting Services

Dignified Transfer of Remains, 80

Distinguished visitor, 28, 29

DoD. See Department of Defense

Dover Air Force Base, 80
INDEX 193

DRK. See Deutsches Rotes Kreuz

DSO. See Deutsche Stiftung 

Organtransplantation

DV. See Distinguished visitor

DVBIC. See Defense and Veterans Brain 

Injury Center

DVT. See Deep vein thrombus

DWMMC. See Deployed Warrior Medical 

Management Center

E

Eagle Cash card, 82

ECMO. See Extracorporeal membrane 

oxygenation

Electronic health records, 119

End-of-life care, 112

ERMC. See Europe Regional Medical Command

Essentris, 29

EUCOM. See European Command

Europe Regional Medical Command, 67, 97

European Command, 96–97

Evolutions program, 65

Extracorporeal membrane oxygenation, 115

F

Family Readiness Group, 32

Farmer, Joseph, 174

Fasciotomies, 116–117

Finance Command, 266th, 79

Forbess, Staff Sergeant Josh

 burn injuries, 2–3

 Iraq deployment, 2

 peacekeeping mission, 1–2

 work with Wounded Warrior 

 Resiliency Program, 4–7

Force Health Protection and Readiness, 57

Fort Campbell Fisher House, 4

Fungal infections, 116

G

German Red Cross, 106

Ghost patients, 28

Global Patient Movement Requirement 

Center, 135

Global war on terrorism, 124, 139

Grimord, Karen, 151–153

Gunshot wounds, 99

GWOT. See Global war on terrorism

H

Health Insurance Portability and Accountability 

Act, 9, 29, 69, 111

Health records, 109–111, 119

HIPAA. See Health Insurance Portability and 

Accountability Act

Hospital clinical nursing, 127–131

House Government Reform Committee, 78

HRC. See Human Resources Command

Human Resources Command, 91

I

ICU. See Intensive Care Unit

IEDs. See Improvised explosive devices

Improvised explosive devices

 combat casualty care for, 99, 101

 impact on traumatic brain injuries, 55–56

Indianapolis Mobilization Support Office, 79

Inpatient nurse case managers, 133–135

Intensive care units

 medical records, 109–111

 radiology, 111

 role of, 108

 trauma service, 106–108

Intensive Rehabilitation One-Note CM Files, 69

Intensive Rehabilitation Program, 63–65, 70

J

Joint Patient Tracking Application, 109, 111, 138

Joint Program Management Guardian, 60

Joint Theater Trauma Registry, 101–102

Joint Theater Trauma System, 101, 138

JPTA. See Joint Patient Tracking Application

JTTR. See Joint Theater Trauma Registry

JTTS. See Joint Theater Trauma System

K

Kirkpatrick, Staff Sergeant Kevin, 34–35

Kleber Kaserne, 43–44

L

Laboratory services

 background of, 163–165

 Blood Bank services, 165, 167–169

 challenges for, 170–171

 communication challenges, 171

 customer satisfaction and, 166

 implementation methods, 165–166
194 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

 staff turnover, 170–171

 success of, 166, 170

 transport of laboratory samples, 166, 170

 waiting time, 170

Landstuhl Hospital Care Project, 152

Landstuhl Regional Medical Center

 chaplain services, 145–161

 Contingency Aeromedical 

 Staging Facility, 88–90

 Deployed Warrior Medical Management 

 Center, 9–23

 evolution as world-class medical 

 facility, xvi–xviii

 heaviest casualty months, 126

 history of, xv–xvi

 laboratory services, 163–171

 liaisons, 25–39

 Medical Transient Detachment, 41–52

 nursing department, 123–142

 trauma program, 95–120

 traumatic brain injury program, 56–71

 Wounded Warrior Finance Office, 75–92

Leave and Earnings Statements, 78, 82, 87

Liaison Noncommissioned Officers

 assisting discharged patients, 31–32

 assisting families of patients, 31

 assisting other liaisons and agencies, 32

 assisting patients, 30–31

 challenges, 36–38

 duties of, 15, 27–34

 liaison force structure, 26–27

 meeting new patients, 28–29, 131

 mission of, 25

 monitoring patients, 29–30

 providing communication, 32–33

 role of, 25–26

 service-specific duties, 33–34

 successes, 34–36

 tracking inbound patients, 27–28

 tracking tools, 34

LNOs. See Liaison Noncommissioned Officers

Logistics department, 15

LRMC. See Landstuhl Regional Medical Center

M

MACE. See Military Acute Concussion 

Evaluation

Marine liaisons, 27, 34

Martinez, J.R., 3

MC4. See Medical Communications for 

Combat Casualty Care

McGowan, Sergeant Larry, 51–52

MEDEVAC. See Medical evacuations

Medical Air Ambulance Squadron, 174

Medical Communications for Combat 

Casualty Care, 111

Medical evacuations, 77–78, 80

Medical records, 109–111, 119

Medical Transient Detachment

 buildings, 47

 capacity, 46

 challenges, 50–52

 creation of, 42–44

 equipment, 47

 facility, 41–42

 implementation of, 44–47

 leadership of, 44–45

 liaison responsibilities, 29

 mission of, 42

 responsibilities of, 13

 services, 47

 staffing of, 44–45

 structure of, 45–46

 successes, 48–50

Medical treatment facilities

TBI certification, 57

Military Acute Concussion 

Evaluation, 60–61, 63

M&O. See Movement and Orders

Movement and Orders, 15

MTD. See Medical Transient Detachment

MTFs. See Medical treatment facilities

N

Navy Expeditionary Medical Unit, 13

Navy liaisons, 26–27, 33–34

NCMs. See Nurse case managers

NCOIC. See Noncommissioned officer in charge

NEMU. See Navy Expeditionary Medical Unit
INDEX 195

Neurocognitive Assessment Tool Program, 67

Noncommissioned officer in charge, 59, 68

Nurse case managers, 131–135

Nurses

 background of nursing 

 department, 124–127

 burn care challenges, 141

 Case Management, 15

 Clinical Flight Coordination, 15–16, 19

 collaboration of nurse teams, 138

 compassion fatigue, 139–140

 dedication to quality care, 137

 diversity of staff, 140

 hospital clinical nursing, 127–131

 inpatient nurse case managers, 133–135

 internal support for, 137–138

 nurse case managers, 131–135

 patient population challenges, 139

 performance improvement, 138–139

 registered nurses, 15

 reintegration of, 141–142

 responsibilities of, 123–124, 135–137

 training for, 140–141

 turnover, 140

O

OCO. See Overseas Contingency Operations

ODS/ODS. See Operation Desert Shield/ 

Operation Desert Storm

OEF. See Operation Enduring Freedom

Office of The Surgeon General, 57

Ohlendorf, First Sergeant Shelley, 75–76, 81

OIF. See Operation Iraqi Freedom

OND. See Operation New Dawn

Operation Desert Shield/Operation 

Desert Storm, 11

Operation Enduring Freedom, 11, 12, 60

Operation Iraqi Freedom, 12, 101

Operation New Dawn, 60

Operational tempo, 87

Operations department, 14

OPTEMPO. See Operational tempo

Organ donation, 112

Organ Procurement and Transplantation 

Network, 112

OTSG. See Office of The Surgeon General

Overseas Contingency Operations, 10, 18–19

P

PAC. See Pay and allowance continuation

PACS. See Picture Archiving and 

Communication System

PAD. See Patient Administration Division

PAD Aeromedical Evacuation, 10, 11, 12

Pastoral support, 154–155

Pathology department. See Laboratory services

Patient Administration Division, 9–12

Patient medical records, 127–128, 131

Patient Movement Records, 81

Patient movement requests, 12, 19

Patient safety safeguards, 102

Patient tracking system. See Theater Medical 

Data Store

Patient Tracking Team, 77

Pay and allowance continuation, 80, 91

Performance improvement, 96, 101, 102, 119, 

138–139

PERSCO. See Personnel Support for 

Contingency Operations

Personnel Support for Contingency 

Operations, 30

Pettigrew, Chaplain Ronald, 147–149, 158

Phlebotomy services, 165, 170

PI. See Performance improvement

Picture Archiving and Communication 

System, 111

PMRs. See Patient medical records; 

Patient movement requests

Posttraumatic stress disorder

 nurses and, 140

 treatment of, 65

PTSD. See Posttraumatic stress disorder

Q

QOVF. See Quilts of Valor Foundation

Quilts of Valor Foundation, 159–161

R

Radiology reports, 111

Ramstein Air Base, 128–129, 182

RAPIDS. See Real-Time Automated Personnel 

Identification System

RBC transfusions. See Red blood cell transfusions

Real-Time Automated Personnel Identification 

System, 15
196 A LEGACY OF LESSONS LEARNED: LRMC, 2001–2014

Red blood cell transfusions, 167–168

Registered nurses, 15

Resources for Optimal Care of the Injured Patient, 

2006, 98, 102–103

Return to duty, 60, 62, 65

RNs. See Registered nurses

Roberts, Catherine, 159

RTD. See Return to duty

S

School of Aerospace Medicine, 176

Secret Internet Protocol Router Network, 31

Senior Visiting Surgeon Program, 98

SFAC. See Soldier and Family Assistance Center

SIPRNET. See Secret Internet Protocol 

Router Network

SMEED. See Special Medical Emergency 

Evacuation Device

Social security numbers, 81

Society for Vascular Surgery, 107–108

Soldier and Family Assistance Center, 4

Soldier Transfer and Regulating Tracking 

Center, 17–18

SOP. See Standard operating procedures

Special Medical Emergency Evacuation 

Device, 128–129

Standard operating procedures, 101

STARTC. See Soldier Transfer and 

Regulating Tracking Center

Sterling Medical Corporation, Inc., 57, 59

Subspecialty surgeons, 107–108

Supply, Material Handler, and CAC ID, 15

Surgeons, subspecialty, 107–108

SVS. See Society for Vascular Surgery

Synapse Intensive Rehabilitation Program, 63–65

T

Table of Distribution and Allowances, 118

TACC. See Tanker Airlift Control Center

Tanker Airlift Control Center, 179

TBI. See Traumatic brain injury

TBI Screening Database, 69

TCC. See Transfer to continued care

TDA. See Table of Distribution and Allowances

Telehealth, 68

Telemedicine, 118

Theater Medical Data Store, 12, 29, 111, 132

Theater Patient Movement Requirement 

Center, 135, 178

TMDS. See Theater Medical Data Store

TPM. See Trauma program manager

TPMRC. See Theater Patient Movement 

Requirement Center

TRAC2ES. See TRANSCOM Regulating and 

Command & Control Evacuation System

TRANSCOM Regulating and Command &

Control Evacuation System, 11–12, 16, 

27–28

Transfer to continued care, 14, 19

Trauma Critical Care Service, 99

Trauma program

 ACS Committee on Trauma verification 

 process, 98–99

 Acute Lung Rescue Team, 113–115

 background of, 95–108

 burn resuscitation algorithm, 117

 clinical care, 106–107

 combat casualty care, 99–101

 deep vein thrombus, 115

 Department of Trauma and Critical 

 Care, 99

 development of, 96–97

 electronic health records, 119

 end-of-life care, 112

 extracorporeal membrane oxygenation, 115

 implementation of, 99–108

 incomplete fasciotomies, 116–117

 intensive care unit, 108–111

 invasive fungal infections after 

 combat injury, 116

 maintaining viability and capability, 

 117–120

 medical records, 109–111

 mission of, 97

 organization of, 99

 patient care flow, 104–105

 patient population characteristics, 105–106

 patient safety safeguards, 102

 performance improvement, 102, 119

 position descriptions, 102–104

 radiology, 111

 staffing, 100

 subspecialty surgeons, 107–108

 timeline of transport and roles of care, 105
INDEX 197

 Trauma Critical Care Service, 99

 trauma medical director, 102–103

 trauma program manager, 103–104

 trauma registry, 101–102

 turnover rate, 119

Trauma program manager, 103–104

Trauma registry, 101–102

Traumatic brain injury program

 background of, 56–59

 business operations, 68

 case management, 62–63

 challenges for, 70–71

 clinical management algorithm 

 for patients, 58

 clinical operations, 68

 DATA/Automated Neuropsychological 

 Assessment Metrics Management, 67

 education program, 67–68, 70

 impact of improvised explosive devices 

 on injuries, 55–56

 implementation methods, 59–68

 initial evaluation, 62

 Intensive Rehabilitation Program, 59

 leadership staffing, 59

 mission of, 56

 program elements, 60

 rehabilitation, 63–65, 69, 70

 research, 65–66, 70

 screening, 60–62, 69

 successes of, 69–70

 TBI encounters, 69–70

 TBI Screening Team, 59, 60, 69

 telehealth, 68

 tracking tools, 69

 treatment planning, 62

 Wolf Pack Award, 70

Travel and Transportation Orders, 80

266th Finance Command, 79

U

University of Cincinnati Medical Center, 177

US Army Europe, 77, 79

US Army Medical Command Headquarters

 The Army Medical Command Traumatic 

 Brain Injury (TBI) Action Plan, 57

US Army Medical Research and Materiel 

Command, 57

US Army Medical Service, 173–174

USAF School of Aerospace Medicine, 176

USAREUR. See US Army Europe

V

Video teleconferences, 138–139

Volunteer programs, 149–153, 156, 159–161

VTCs. See Video teleconferences

W

Walter Reed National Military Medical 

Center, 80

Warrior Transition Units, 44, 80, 91–92

WIA. See Wounded in Action database

Wolf Pack Award, 70

Wounded in Action database, 77, 82

Wounded Warrior Finance Office

 accountability of, 85

 background of, 76–81

 budget constraints, 87

 challenges for, 87, 91–92

 communication delays, 91

 equipment, 84–85

 establishment of, 79

 Europe Warrior Transition Unit 

 assignment process, 91–92

 family assistance, 87

 financial audits, 86

 follow-up, 86

 implementation methods, 81–85

 leadership staff, 83–84

 staff constraints, 87

 successes of, 85–87

 technical support, 84–85

 website, 92

Wounded Warrior Finance Team, 77

Wounded Warrior Ministry Center, 150

Wounded Warrior Pay and Entitlements 

Handbook, 86

Wounded Warrior Pay Management 

Team, 75–76

Wounded Warrior Pay Office, 79, 82, 86

Wounded Warrior Resiliency Program, 4–7

WTUs. See Warrior Transition Units