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i

43–249 2008

[H.A.S.C. No. 110–116]

THE STATUS OF THE IMPLEMENTATION

OF THE ARMY’S MEDICAL ACTION PLAN

AND OTHER SERVICES’ SUPPORT FOR

WOUNDED SERVICE MEMBERS

HEARING

BEFORE THE

MILITARY PERSONNEL SUBCOMMITTEE

OF THE

COMMITTEE ON ARMED SERVICES

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

SECOND SESSION

HEARING HELD

FEBRUARY 15, 2008

(II)

MILITARY PERSONNEL SUBCOMMITTEE

SUSAN A. DAVIS, California, Chairwoman

VIC SNYDER, Arkansas

LORETTA SANCHEZ, California

NANCY BOYDA, Kansas

PATRICK J. MURPHY, Pennsylvania

CAROL SHEA-PORTER, New Hampshire

NIKI TSONGAS, Massachusetts

JOHN M. MCHUGH, New York

JOHN KLINE, Minnesota

THELMA DRAKE, Virginia

WALTER B. JONES, North Carolina

JOE WILSON, South Carolina

DAVE E. KILDEE, Professional Staff Member

JEANETTE S. JAMES, Professional Staff Member

ROSELLEN KIM, Staff Assistant

(III)

C O N T E N T S

CHRONOLOGICAL LIST OF HEARINGS

2008

Page

HEARING:

Friday, February 15, 2008, The Status of the Implementation of the Army’s

Medical Action Plan and Other Services’ Support for Wounded Service

Members ............................................................................................................... 1

APPENDIX:

Friday, February 15, 2008 ...................................................................................... 41

FRIDAY, FEBRUARY 15, 2008

THE STATUS OF THE IMPLEMENTATION OF THE ARMY’S MEDICAL

ACTION PLAN AND OTHER SERVICES’ SUPPORT FOR WOUNDED

SERVICE MEMBERS

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, Chairwoman, Military Personnel Subcommittee ............................................................................. 1

McHugh, Hon. John M., a Representative from New York, Ranking Member,

Military Personnel Subcommittee ...................................................................... 2

WITNESSES

Schoomaker, Lt. Gen. Eric B., the Surgeon General of the United States

Army, and Commander, U.S. Army Medical Command, U.S. Army; Brig.

Gen. Michael Tucker, Assistant Surgeon General for Warrior Care and

Transition, U.S. Army; Vice Adm. Adam M. Robinson, Surgeon General,

U.S. Navy; Lt. Gen. (Dr.) James G. Roudebush, Surgeon General, U.S.

Air Force beginning on ........................................................................................ 3

APPENDIX

PREPARED STATEMENTS:

Davis, Hon. Susan A. ....................................................................................... 45

McHugh, Hon. John M. .................................................................................... 48

Robinson, Vice Adm. Adam M. ........................................................................ 57

Roudebush, Lt. Gen. (Dr.) James G. ............................................................... 65

Schoomaker, Lt. Gen. Eric B. joint with Brig. Gen. Mike Tucker ................ 50

DOCUMENTS SUBMITTED FOR THE RECORD:

Army Medical Action Plan Update ................................................................. 84

Statement of Mutual Support submitted by James B. Peake, Secretary

of Veterans Affairs and Pete Geren, Secretary of the Army ..................... 83

QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD:

[There were no Questions submitted.]

(1)

THE STATUS OF THE IMPLEMENTATION OF THE ARMY’S

MEDICAL ACTION PLAN AND OTHER SERVICES’ SUPPORT FOR WOUNDED SERVICE MEMBERS

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, MILITARY PERSONNEL SUBCOMMITTEE, Washington, DC, Friday, February 15, 2008.

The subcommittee met, pursuant to call, at 10 a.m., in room

2212, Rayburn House Office Building, Hon. Susan Davis (chairwoman of the subcommittee) presiding.

OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM CALIFORNIA, CHAIRWOMAN, MILITARY

PERSONNEL SUBCOMMITTEE

Mrs. DAVIS. Good morning everyone. Thank you for being here

with us today. The purpose of the hearing today is for members to

get an update on the implementation of the Army Medical Action

Plan (AMAP) for—are we calling that AMAP?—and hear how the

Navy, Marine Corps, and Air Force are caring for their wounded

warriors.

At our last hearing on this subject, back in June of last year, the

Army’s Vice Chief of Staff, General Cody, suggested that we have

him back in October and January to testify on the progress of

AMAP toward full operational capability. Unfortunately, he is not

able to join us this morning. I believe he is just on his way back

from Iraq. But we are going to push forward and learn how far the

AMAP has come and how far it still has to go.

I want to also be clear that while we have spent a great deal of

time focusing on the Army, we also are concerned about the Navy,

the Marine Corps and the Air Force and how they are insuring

that their wounded warriors and their families receive the appropriate care and the support needed.

The subcommittee started to raise concerns about the quality

and completeness of care provided to wounded warriors back in

2005 and we will certainly continue to focus on this issue.

This hearing marks the first time that Vice Admiral Adam Robinson, Surgeon General of the Navy, has come before our panel.

Welcome, sir. I am very happy to have you here.

I also wanted to mention that while we have had these Army

leaders testify about Walter Reed Army Medical Center before this

subcommittee previously, today they are here in new roles.

Lieutenant General Eric Schoomaker, formerly the Commander

of the North Atlantic Regional Medical Command in Walter Reed

Army Medical Center, became the Army’s new Surgeon General in

December.

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And Brigadier General Michael Tucker, formerly the Deputy

Commander of the North Atlantic Regional Medical Command in

Walter Reed Army Medical Center, is now the Army’s Assistant

Surgeon General for Warrior Care and Transition.

In his opening statement last year, at the last hearing on this

subject, Dr. Snyder remarked on the power of focus and about how

true the revelations at Walter Reed and its aftermath almost all

involved parties, including our wounded soldiers, family members,

commissioners and advocates, and nothing but good things to say

about the quality of inpatient care wounded soldiers have received

at military hospitals.

The Army Medical Action Plan has strived to set up new focus,

a new structure to focus on the unmet needs of wounded warriors

so that hospitals could continue their focus on patient care.

Our challenge and our responsibility is to make certain that the

military as a whole, and not just the military health care system,

remains focused on the recovery and the rehabilitation of our

wounded soldiers and their families, and that is what we are really

here to do today and to see how that progress has occurred.

I want to turn the meeting over to Mr. McHugh, also, for an

opening statement.

[The prepared statement of Mrs. Davis can be found in the Appendix on page 45.]

STATEMENT OF HON. JOHN M. MCHUGH, A REPRESENTATIVE

FROM NEW YORK, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

Mr. MCHUGH. Thank you very much, Madam Chairman.

I would ask that my prepared statement be entered in its entirety in the record and in the interest of time, let me just make

a couple of comments.

First of all, I want to add my words of welcome to our distinguished panelists this morning. As you noted, Madam Chair, we

both appreciate and look forward to their participation here today,

but more importantly, for the leadership and the concern they

bring on behalf of all of us toward those who have worn the uniform and who have given so much in service to their country.

I think we have come a long way. I think, as the chair noted,

with respect to the Army, the AMAP plan has begun to address,

with some good efficacy, the challenges and problems we saw arising out of Walter Reed.

I think as you look at the other services, as well, notably the Air

Force and the Navy, their programs are striving in directions that

portend a lot of progress and a lot of help for those who need it.

I do think there are challenges that remain, some disturbing developments through the warrior transition units, that we look forward to General Schoomaker’s comments upon, from a parochial

perspective, some recent press reports with respect to the

transitioning and the working of the veterans’ benefits administrators and assistance providers and the Army at Fort Drum.

So we have tried to address those, but I am looking forward to

General Schoomaker talking on a bit broader basis about those, as

well.

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So our interest, our concerns are all similar here and that is to

do everything that is necessary, everything that certainly is appropriate and more to pay back in some small way those who find

themselves in medical need after serving so proudly in the uniform

of this Nation.

So thank you again, gentlemen, not just for being here, but for

what you do, and we look forward to your testimony.

With that, Madam Chair, I would yield back.

[The prepared statement of Mr. McHugh can be found in the Appendix on page 48.]

Mrs. DAVIS. Thank you, Mr. McHugh.

General Schoomaker, if you want to begin and we will go down

the line, and then we will have plenty of time for questions.

Thank you, gentlemen, once again for being here.

STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, THE SURGEON GENERAL OF THE UNITED STATES ARMY, AND COMMANDER, U.S. ARMY MEDICAL COMMAND, U.S. ARMY; BRIG.

GEN. MICHAEL TUCKER, ASSISTANT SURGEON GENERAL

FOR WARRIOR CARE AND TRANSITION, U.S. ARMY; VICE

ADM. ADAM M. ROBINSON, SURGEON GENERAL, U.S. NAVY;

LT. GEN. (DR.) JAMES G. ROUDEBUSH, SURGEON GENERAL,

U.S. AIR FORCE

STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER

General SCHOOMAKER. General Tucker and I have a single statement for the Army.

Chairwoman Davis, Congressman McHugh and distinguished

members of the subcommittee, thank you for providing the joint

medical service Surgeon General and my Assistant Surgeon General and colleague, Brigadier General Mike Tucker, and me the opportunity to discuss warrior care and for us to discuss the total

transformation that the Army is undergoing in the way we care for

soldiers and families.

And, ma’am, I noted in your introductory comments that your

focus is on our services and how we as an entire service are focused

on that, and I would like to talk about that here today.

We as an Army are committed to getting this right and to providing a level of care and support to our warriors and families that

is equal to the quality of their service.

February 18, 2007, almost a year ago to the day, is the day that

a series of ‘‘Washington Post’’ stories began about problems in the

care that were provided soldiers and their families at one of our

premier medical centers.

It was a day that the Army will not soon forget. It was a painful

day for us, as a proud institution, Army medicine, which truly

prides itself in looking out for each other and for our brothers and

sisters in arms.

But because of those revelations and the strong response of Army

leaders by our Secretary of the Army, Pete Geren, our Chief of

Staff, General George Casey, and our Vice Chief of Staff, General

Cody, we truly are a better Army today with respect to how we

care for our soldiers.

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The Army remains committed to continuing to improve our care

and support for those who have borne the battle and for their loved

ones. We have instituted a comprehensive Army Medical Action

Plan that you alluded to earlier, with which I believe all of you are

familiar.

While we are continuing to move forward, I would like to highlight a few of our accomplishments as part of this truly unprecedented effort.

We now have more than 2,400 soldier leaders, 2,400 soldier leaders assigned as cadre to 35 warrior——

Mrs. DAVIS. Excuse me, General, if you could just bring the mike

a little bit further. I think they were having a little trouble hearing

you.

General SCHOOMAKER. Yes, ma’am. Is that better?

Mrs. DAVIS. Thank you.

General SCHOOMAKER. That is about as close as I can get it.

Mrs. DAVIS. We can hear you just fine here, but I think they

were having trouble in the back.

General SCHOOMAKER. We now have more than 2,400 soldier

leaders assigned as cadre to 35 warrior transition units, small

units that exist throughout the Army today, collocated with our

medical treatment facilities, that did not exist last February.

This is 2,400 small unit leaders in jobs where last year at this

time we had fewer than 400 cadre for about the same number of

patients, many with very complex injuries and illnesses.

The most significant feature of these warrior transition units is

a triad, which consists of a primary care physician, a nurse case

manager and the squad leader, where they work together to attend

to the needs of each individual and the family.

The regular meetings and coordination between every leg of this

triad really creates a web of overlapping responsibility and accountability that embraces every warrior for the duration of their

treatment, their recovery and their rehabilitation, and then transition back into uniform and service or fully recover back into a productive civilian life or into continued care and rehabilitation in the

Veterans Administration (VA) or into our network of private health

care.

Our squad leaders, many of them are combat arms soldiers and

former patients themselves, are trained and responsible for the

well being of a small group of warriors in transition in their squad,

just like any other Army unit.

In the room today, if I might, ma’am, I would like to introduce

four of the warrior transition brigade small unit leaders at Walter

Reed today. Colonel Terran McKendrick is a career infantryman

who has the distinction of having stood up the first warrior transition unit in the Army. He and his Command Sergeant Major, Jeff

Hartless, who is with him here today; Major Steve Gventer, one of

our company commanders and First Company Commander in the

Walter Reed warrior transition brigade; and, his First Sergeant,

Matthew Dewsberry, are here with us today and I would just like

to acknowledge them and the terrific work that all of them have

demonstrated here.

5

These are the soldiers who really wrote the doctrine, wrote the

training courses and taught us how to do this right, and I would

like to thank them for being here today.

Thank you, gentlemen.

Mrs. DAVIS. Thank you.

General SCHOOMAKER. All four are combat tested leaders. They

spend their busy day looking out for the best interests of their

wounded, ill and injured soldiers. Two, in fact, have been wounded

themselves in combat and were patients at Walter Reed. So they

have tremendous insight into what could make that place work better and what they felt worked well for them and their families.

In less than one year, and this is noteworthy, in less than one

year, the Army has funded, staffed and written the doctrine to establish these new organizations.

It is a significant change and it is the backbone of our Army

Medical Action Plan.

Another improvement in the care of the soldiers is that a year

ago, our wounded, ill and injured believed that their complaints

were falling on deaf ears within the Army. Now, we have established a medical command-wide ombudsman program, with ombudsmen at 26 of our installations across the Army and we are hiring more every day.

Everyone at our treatment facilities knows who the ombudsmen

are, they know how to find him or her. Many are retired NCOs,

non-commissioned officers, or officers themselves with medical experience. They work outside of our chain of command, but they

have direct access to the hospital commander, to the garrison commander, to the installation senior mission commander, to get problems fixed.

We have also established a 1–800 wounded soldier and family

hotline, and I would draw your attention to a card that you have

here. I encourage you to take it back with you.

In fact, we hand them out as often as we can to people who are

interested in this, and Congressman McHugh may be interested,

but when we worked with the VA recently in putting together our

memorandum of understanding, we actually gave them these and

they are setting up a similar hotline for the VA to solve problems

for soldiers and families on the fly.

They can share concerns through this 1–800 line 24 hours a day

about any aspect of their care or administrative concerns. We have

fielded in excess of 7,000 calls to date and we answer that call and

find a solution for them and get the process going to get it ultimately fixed within 24 hours.

Over the last year, we have developed multiple feedback mechanisms so that we can see ourselves from a variety of perspectives.

This is one of the things that the ‘‘Washington Post’’ stories taught

us, that we weren’t seeing the full picture.

To accomplish this, we monitor and evaluate our performance

through 18 internal and external means, including the ombudsmen

and the hotline that I mentioned earlier.

We also use a contracted industry leader in patient surveys to

provide us a very granular view of how our patients and families

feel we are doing for them.

6

We host numerous visits from Members of Congress and your

staff. In January alone, we opened our warrior transition unit

doors to more than a dozen congressional visits.

These visits give us a valued external perspective and allow us

the opportunity to be as open and as transparent in our operations

as possible, and, quite frankly, your feedback on these visits and

your staff’s feedback has been instrumental in our success, and we

extend our appreciation for that.

As you well know, despite these successes there is much progress

still to be made. We still need more research into psychological

health and traumatic brain injury.

Congress jumpstarted us last year with supplemental funding for

both research and care, for which we are truly grateful, but research needs to be our continuing priority effort.

We must continue to look into the physical disability evaluation

system and the ways to make it less antagonistic, more understandable and more equitable for soldiers and their families, and

more user-friendly.

I can tell you that one of the most difficult aspects of being the

commander at Walter Reed and going through this troubled period

was as a physician who spent his career trying to help patients,

standing in front of town hall meetings with patients and families

and feeling that I was the enemy, that I wasn’t there to help them,

that I was hurting them in some aspect, and I would submit that

that is a direct outgrowth of our divisive and antagonistic physical

disability evaluation system between the Department of Defense

(DOD) and the VA.

I believe that the pilot program that we have started in the National Capitol region is a good start, but I want to continue to pursue changes in the disability evaluation system as aggressively as

possible and to get legislative relief for a single disability adjudication.

We need your continued support so that we can move forward together in 2008 as we have in 2007. This year’s National Defense

Authorization Act was very consistent with how the Army is approaching wounded warrior matters.

I truly appreciate the flexibility you provided us to develop policies and to achieve solutions and not to micromanage details of

how we do that and how we develop and grow our warrior transition units.

Your bill not only helps our warriors, it helps our families, it

helps health care providers in caring for them, and we truly thank

you for the time you took to listen to us and to work with us.

The Army’s unwavering commitment and a key element of our

warrior ethos is that we never leave a soldier behind on the battlefield or lost in a bureaucracy. We are doing a better job of honoring

that commitment today than we were at this date last year.

In February of 2009, I want to come back to you and report that

we have achieved a similar level of progress as we have over this

last year. I am proud of Army medicine’s efforts over the last 232

years and especially over the last 12 months to help our warriors

and their families.

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I am convinced that, in coordination with the Department of Defense, my colleagues here at the panel today, the Department of

Veterans Affairs, and the Congress, we have turned the corner.

Thank you for holding this hearing. Thank you for your continued support of our warriors and their families. We are truly honored to serve them.

I look forward to your questions.

[The joint prepared statement of General Schoomaker and General Tucker can be found in the Appendix on page 50.]

Mrs. DAVIS. Thank you.

Admiral Robinson.

STATEMENT OF VICE ADM. ADAM M. ROBINSON

Admiral ROBINSON. Good morning. Thank you, Chairwoman

Davis, Ranking Member McHugh, and distinguished members of

the committee.

Your unwavering support of our service members, especially

those who have been wounded during Operations Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), is deeply appreciated.

In the last year or so, the interest and concern about the care

and support being provided to our service members when they return from combat has increased dramatically.

From those with severe injuries to those whose significant injuries may not be visible to the naked eye, our Nation is providing

care to a generation of veterans unlike those from previous conflicts.

For Navy medicine, the progress a patient makes from definitive

care to rehabilitation and in the support of lifelong medical requirement is the driver of where a patient is clinically located in the

continuum of care.

Medical and administrative processes are tailored to meet the

needs of the individual patient and their family, whatever that may

be. For the overwhelming majority of our patients, their priority is

to locate their care as close to home as possible.

We learned early on that families displaced from their normal

environment in dealing with a multitude of stressors are not as effective in supporting the patient in his or her recovery.

Our focus is to get the family back to normal or as close as we

can possibly get it as soon as possible, which means returning the

patient and their family home to continue the healing process.

Navy medicine takes into consideration family dynamics from the

beginning and they are looked on as part of the care team. Their

needs are also integrated into the care plan. They are provided

with emotional support by encouraging the sharing of experiences

among other families, that is, family-to-family support, and access

to mental health services.

Also, families receive assistance dealing with administrative

issues when necessary through the Marine Casualty Services

Branch. I may say that we also have Army and Air Force liaisons

that do the same thing.

One of the cornerstones of Navy medicine’s concept of care is to

capitalize on our longstanding and effective partnership with the

Marine Corps in caring for injured and ill Marines. The Marine

8

Corps has always maintained a presence in our medical treatment

facilities in the form of a Marine Corps liaison office staffed with

Marine Corps personnel and Administration experts.

At the outset of OEF/OIF, the Marine Corps quadrupled the size

of their liaison offices at key casualty receipt locations, anticipating

the increased volume and the unique needs of this patient population and their families.

Working side by side with Navy medicine providers, the recently

established wounded warrior regiment, in April of 2007, made Marine liaisons available immediately to the patient, their family and

the clinical care team.

Navy medicine takes care of the patient’s clinical needs and the

wounded warrior regiment becomes an optimizing adjunct to the

patient care plan.

Based on a concept of care of Marines taking care of Marines, the

Wounded Warrior Regiment has ensured that the care provided to

our wounded, ill and injured is not just a process, but a relationship with lifelong care.

Like the Wounded Warrior Regiment, Navy established a safe

harbor program in 2005 to meet the needs of severely injured sailors from OEF/OIF. It is expected that approximately 250 sailors

each year will need the services provided by this program, which

will include non-clinical case management for the sailors and their

families.

Safe harbor case managers are actively collecting feedback from

program participants to closely monitor the program’s successes

and to make improvements where needed.

In Navy medicine, we have established a dedicated trauma team,

as well as a comprehensive multidisciplinary care team, which

works to maximize the interface with all of the partners involved

in the continuum of care.

To move patients closer to home requires a great deal of planning, interaction and coordination with providers, case workers,

and other health care professionals to ensure smooth movement

across the continuum of care.

Our single trauma service admits all OEF/OIF patients with one

physician serving as the point of contact for the patient and for

their family.

Other providers serve as consultants, all of whom work on a single communication plan. In addition to providers, other key members of the multidisciplinary team include the service liaisons at

the MTFs, the medical treatment facilities, the VA health care advisors, and the military service coordinators.

We also expanded our nurse case management capabilities, increasing the number of case managers from 85 in 2006 to 148 funded positions today. In addition, VA has established liaison offices

at Navy hospitals and at Navy clinics for the purposes of coordinating follow-on care requirements and providing education on VA

benefits.

Also, the newly created Federal recovery coordinators are located

at National Naval Medical Center (NNMC) and Naval Medical

Center San Diego.

9

The lessons learned at Bethesda, NNMC, the Navy facility that

has treated most returning casualties, have been exported to other

facilities, both in and out of the Navy, involved in casualty care.

The development of these lessons was a collaborative effort to improve processes and outcomes. Currently, weekly teleconferences

between our hospitals, between NNMC and Balboa and others and

the VA polytrauma rehabilitation centers is ongoing to ensure continuity of care.

One key issue for patients requiring care at another facility is

the physical transition of leaving the protective environment of an

acute care facility and moving to a rehabilitative environment.

When a patient is headed to a VA facility, there is significant coordination between the military, the VA liaison and the transferring Navy medicine MTF, medical treatment facility, and the electronic copies of medical records are transferred to the receiving facility.

We continue to make significant strides toward meeting the

needs of military personnel with psychological health needs and

traumatic brain injury related diagnoses, their families and their

caregivers.

Service members who return from deployment and have suffered

such injuries may later manifest symptoms that do not have a

readily identifiable cause, with potential negative effects on their

military careers and, of course, on their quality of life and most directly on their families.

Our goal is to establish comprehensive and effective psychological health and traumatic brain injury services throughout Navy

and Marine Corps. This effort requires seamless programmatic coordination across the existing line functions, while working numerous fiscal, contracting and hiring issues.

Your patience and your persistence are deeply appreciated as we

work to achieve long-term solutions to provide the necessary care.

Chairwoman Davis, Ranking Member McHugh, distinguished

members of the committee, I again want to thank you for holding

this hearing and continuing to shed light on these important

issues.

Also, it is my pleasure to testify before you today and I look forward to answering any of your questions.

Thank you very much.

[The prepared statement of Admiral Robinson can be found in

the Appendix on page 57.]

Mrs. DAVIS. Thank you.

STATEMENT OF LT. GEN. (DR.) JAMES G. ROUDEBUSH

General ROUDEBUSH. Good morning. Madam Chairwoman, Ranking Member McHugh, distinguished members, it certainly is an

honor and privilege for me to be here with this distinguished panel,

my partners in providing individual and collective joint capabilities

to our wounded warriors.

This is indeed important business and it is a pleasure to be here

before you today to be able to discuss that with you.

Your Air Force is America’s force of first and last resort to guard

and protect our Nation. To that end, we Air Force medics—and

when I use medics, I use that term broadly—our officers, enlisted,

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all professionals within the Air Force Medical Service, we Air Force

medics work directly for our line leadership in addressing our Air

Force’s top priorities—winning our Nation’s fight today, taking care

of our people and preparing for tomorrow’s challenges.

No modern war has been won without air superiority and no future war will be won without airspace and cyberspace superiority.

The future strategic environment is complex and uncertain. Be assured that your Air Force and Air Force Medical Service are ready

for today’s challenges and are preparing for tomorrow’s.

It is important to understand that every Air Force base, at home

station and deployed, is an operational platform and Air Force

medicine supports war fighting capabilities at each of our bases.

Our home station military treatment facilities are the foundation

from which the Air Force provides combatant commanders a fit and

healthy force capable of withstanding the rigors and physical challenges associated with combat and other military missions today.

Our emphasis on fitness and prevention has led to the lowest disease and non-battle injury rate in history. Deployed forward, the

Air Force Medical Service is central to the most effective joint casualty care system in military history.

Forward stabilization followed by rapid air evacuation has been

repeatedly proven to be the gold standard in saving lives.

We have safely and rapidly moved more than 48,000 patients

from overseas theaters to stateside care during Operation Enduring

Freedom and Operation Iraqi Freedom. Today, the average patient

arrives from the battlefield to stateside care within three days and,

if required, within 18 to 20 hours.

This is remarkable given the severity and complexity of the

wounds that our forces are sustaining and has directly contributed

to the lowest died-of-wounds rate in history.

The daily delivery of health care at our medical treatment facilities is also critical to maintaining those critical skills that guarantee our readiness capability and success.

We care for our families at home. We respond to our Nation’s call

supporting our warriors and we also provide humanitarian assistance to countries around the world.

To execute these broad missions, all of our services, Air Force,

Navy and Army, must work interoperatively and interdependently.

Every day, together, those that you see before you here today,

every day, together, we earn the trust of America’s all volunteer

force, airmen, soldiers, sailors and Marines and their families, and

we hold that trust very dear.

Today we are here to address the health needs of our returning

warriors. The Air Force is in lockstep with our sister services and

Federal agencies to implement the recommendations from the

President’s commission on the care for America’s returning wounded warriors. We will deliver on all those provisions, as well as

those set forth in the 2008 National Defense Authorization Act

(NDAA) and provide our war fighters and their families the help

they need and deserve.

The Air Force Medical Service is focused on the psychological

needs of our airmen and reducing the effects of operational stress.

The incidence of post-traumatic stress disorder (PTSD) is low in

the Air Force, diagnosed at less than one percent of our deployers.

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For every airman affected, we provide the most current effective

and empirically validated treatment for post-traumatic stress disorder. We have trained more than 200 psychiatrists, psychologists

and social workers to recognize and treat PTSD in accordance with

the VA/DOD PTSD clinical practice guidelines.

We hired an additional 32 mental health professionals for those

locations with the highest operational tempo to enhance the care

for our airmen and their families.

The Air Force is also an active partner with the Defense Center

of Excellence for Psychological Health and Traumatic Brain Injury,

the VA, the Centers for Disease Control (CDC), industry and academia in collaborating on research in traumatic brain injury prevention, assessment and treatment.

We thank Congress for fiscal year 2007 supplemental funding,

which strengthened our psychological health and traumatic brain

injury program research, surveillance and treatment. It has improved access, coordination of care and the transition of our patients.

The Air Force wounded warrior program, formerly known as Palace Heart, continues to maintain contact and provide assistance to

wounded airmen both on active duty and following separation from

the Air Force for a minimum of five years.

We are committed to meeting the health needs for our airmen

and their families and will continue to execute and refine those

programs.

In closing, Madam Chairwoman, I am humbled by and intensely

proud of the daily accomplishments of the men and women of the

United States Air Force Medical Service. The superior care routinely delivered by Air Force medics is a product of preeminent

medical training programs, groundbreaking research, and a culture

of personal and professional accountability fostered by the Air

Force’s core values.

With your help and the help of this committee, the Air Force and

partnering with our Navy and Army counterparts and comrades in

arms will continue our focus on the health of our war fighters and

their families.

Thank you for your enduring support and I look forward to your

questions.

[The prepared statement of General Roudebush can be found in

the Appendix on page 65.]

Mrs. DAVIS. Thank you very much. Thank you for all of your

presentations. And you certainly stayed within a good time frame,

as well.

What we are going to do, I am going to keep to my five minutes,

and I think we can have at least two rounds and all questions from

members that are here.

Let me start, General Schoomaker, with you, if I may. And I

think that we are impressed by the changes, the response that you

all have made and we would hope, certainly, that our men and

women who are serving us today are feeling the impacts of the

changes that have been made and in a very positive way.

Could you then speak to the sustainability of this effort, both as

it relates to our budget and personnel, as well, because we seem

to have very high caliber of those who are serving in the capacities

12

that you have outlined today, and, yet, how can we sustain that effort, as well?

But, first, on budget. Where is this in the budget, in the 2009

budget, and is that, do you think, where it should be?

General SCHOOMAKER. Yes, ma’am, and thank you for that question. I think that is one of the issues that the Army and the Department as a whole is very focused on right now, the sustainability, and many ask what evidence we can present that shows

that this is going to be a long-term, sustainable process.

I would answer that in three forms. First of all, we respond in

three ways to sustainability. First, through our organizations, do

we have tangible evidence in our organizations that we have

changed the way we do business.

And I would point to the assistant surgeon general for warrior

care and transition who oversees a cell now that is codified in our

organization, in the medical command, in the Office of the Surgeon

General, as well as the warrior transition units that are embedded

within each one of my regional medical commands and medical

treatment facilities.

This is——

Mrs. DAVIS. I think, General, does that lie in the base or in the

supplemental?

General SCHOOMAKER. Currently, most of the funding to support

administratively and the barracks that would be built to support

those warrior transition units are in supplemental.

They have been programmed—they have been placed in the Program Objective Memorandums (POMS) of our submissions and proposed supplemental adjuncts for both fiscal year—they went into

the fiscal year 2008 budget and I am told they are in fiscal year

2009.

And we have some substantial requests for funding for barracks

and the like. That is the second way that we are showing sustainability. And, third, of course, our policies, we are writing formal

Army policy and doctrine that will be out there and will drive the

way that these organizations and these soldiers are cared for.

Mrs. DAVIS. I think, though, in many ways, if we are thinking

of this in an institutional way, we are looking to ask whether or

not it should be in the base budget as opposed to the supplemental

budget.

General SCHOOMAKER. And, ma’am, I think——

Mrs. DAVIS. Why does that work for you?

General SCHOOMAKER. I think you are echoing the Chief of Staff

of the Army, whose challenge it is to migrate more of our funding

in the supplemental into the base.

Mrs. DAVIS. More of the supplemental?

General SCHOOMAKER. Into the base.

Mrs. DAVIS. Into the base.

General SCHOOMAKER. Into the Army’s base.

Mrs. DAVIS. And the Army has forecasted that it would need about $1.4 billion in fiscal years 2008, 2009 and 2010 to build the

warrior transition complexes.

Is this the funding coming, again, out of other medical projects

or is it new funding? You mention in the supplemental, but——

General SCHOOMAKER. It is new funding.

13

Mrs. DAVIS. It is all new funding.

General SCHOOMAKER. It is all new funding, and it is largely

being carried not by the medical command, it is carried by the installation management command as a part of the building of our

installations.

It provides barrack space, administrative space and all of those

areas necessary to house the soldiers and the cadre that are going

to be caring for them.

Mrs. DAVIS. Thank you. And if I could quickly just move to personnel and how we can expect the Army to fill the warrior transition unit positions, given the challenges that you face in Iraq and

Afghanistan, and grow the Army.

How do we do that?

General SCHOOMAKER. The Army has been very forthcoming. We

stood up the warrior transition units in June, and we had full operational capability in early January. We currently stand at in excess

of 90 percent of the cadre necessary to run all of our warrior transition units on the documents that were provided, and we are at the

projected ratios that we require for squad leaders, for nurse case

managers and primary care managers for each one of those warrior

transition units right now.

Mrs. DAVIS. In visualizing this and the large number of men and

women that are required to fill these positions, I understand it is

more than in a brigade combat team. Is that correct? As you look

at the E–5s and E–6s or, I guess, the bulk of the 2,500 Warrior

Transition Unit (WTU) cadre that are mid-grade and non-commissioned officers.

General SCHOOMAKER. Can you speak to that?

General TUCKER. No, ma’am. Although these are units that are

representative of companies, battalions and brigades that we have

in the Army, the amount of leadership, comparatively speaking,

leader for leader, there are not as many leaders.

I will give you an example. At the lowest level, the squad, the

squad leader is a staff sergeant. The 1-to-12 ratio on which we

based it was based on FM–7–8, the infantry platoon, a longstanding document in our Army to which we have always based command and control.

In an infantry platoon, however—an infantry squad—excuse

me—you have a staff sergeant commanding the squad, as we have

in a WTU, but that squad leader also has two team leaders who

are sergeant E–5s, and we don’t have those sergeant E–5s, because

you don’t need those sergeant E–5s because it is not a tactically deployed unit.

They break off into rifle teams and deploy, so to speak, tactically.

But we have the staff sergeant there where we didn’t have the staff

sergeant before. Before, we had a platoon sergeant, who, in most

cases, was a staff sergeant, but it was 1-to-50. Now we have a staff

sergeant 1-to-12.

And so the number of leaders, per se, to soldier in a WTU is not

exactly the same numbers you would see in a brigade combat team,

ma’am.

Mrs. DAVIS. Will we be able to look at those numbers soon as we

would other readiness units, so we can determine the extent to

which we have the people that are necessary to fill these positions?

14

General TUCKER. Yes, ma’am. And just to back up, if I could expound a little bit on it, the squad leader in this case is not standing

alone. He has got a nurse case manager, a primary care manager

alongside of him, a platoon sergeant to help, as well, and an entire

arsenal of other medical care providers that work with the squad

leader every day to take care of the social workers, occupational

therapists, vocational education specialists, just to add a few that

are part of the whole team.

General SCHOOMAKER. But to answer directly, we are currently

doing exactly what you say, ma’am, and we will be holding quarterly training reviews of exactly these questions to make sure that

we are sufficient for staffing.

The Vice Chief of Staff of the Army has, throughout the standup

of these units, done that personally with all of the warrior transition teams.

Mrs. DAVIS. Thank you.

General TUCKER. And every 90 days, we review the table of distribution allowances (TDA), that has authorized our numbers per

unit. We review that every 90 days and determine whether or not

it is the right mix, at the right pay grade, at the right numbers

for our population, to keep ourselves abreast of what is changing

as we continue to progress.

Mrs. DAVIS. Thank you.

Mr. McHugh, beg my indulgence, I went over.

Mr. MCHUGH. Thank you, Madam Chairman.

Just another question on that point. General Schoomaker, you

mentioned the vice chief. The vice chief had a directive that these

units be fully manned up by January 2.

Your testimony and your comments, you are a little over 90 percent. When are we going to hit 100?

General SCHOOMAKER. In some cases, for particular roles within

the cadre, we are over 100 percent. Across the board, I gave you

the rollup. And by the way, when we gave the fully operational and

capable briefing to the vice chief on or about that date, we were

agreeing, that is, that we had achieved a 90 percent or above goal

by that date.

And I say that is a grand rollup of all of those roles, squad leaders, company commanders, nurse case managers, physicians.

Mr. MCHUGH. So you are full up now.

General SCHOOMAKER. Yes, sir. For all intents and purposes, we

are entirely staffed at the point we need to be staffed.

Mr. MCHUGH. Okay, because I know the directive said 100 percent. It didn’t distinguish. But if you are full up, that was the question.

I thank you for bringing those soldiers that are heading up these

transition units. They are the face of this program and its success

is going to rise, as you know, General, from their dedication and

I have every confidence they are going to do a great job.

But there have been some challenges lately, three deaths in warrior transition units just in the last three weeks, another apparent

unintentional suicide from an overdose in Kentucky.

Can you give us any insight as to what you have done to look

at the deaths and what, if anything, you have or hope to be able

to do to respond to those?

15

General SCHOOMAKER. Yes, sir. Thank you for that question.

You are right, now that we are concentrating all of our wounded,

ill and injured soldiers in our warrior transition units, we are beginning to have the visibility that we didn’t have heretofore. All of

us have experiences of soldiers within units, patients or non-patients, formerly within our hospitals, who may have inadvertently

overdosed with either near lethal or lethal consequences.

But now what we are seeing is, having concentrated all of our

soldiers within the units, we are seeing a pattern emerging, a

trend. We have now had 11 deaths since June in our warrior transition units, three from accidental death from overdoses, four suicides, frank suicide, and I contrast the accidental overdoses with

suicide.

I truly think these are unintentional. These are accidental, not

unlike what the CDC, the Centers for Disease Control and Preventive Medicine has reported recently has become an almost epidemic

problem in the United States with prescription drugs.

And we have had deaths from motor vehicle accidents and we

still have several under investigation.

We have recently brought together a team of experts, epidemiologists, pharmacy specialists, some of our warrior transition unit

leaders, physicians, nurse case managers, specialists from the

Army’s Combat Readiness Center or formerly our safety center to

look at how—what are the root causes of these and near misses

that we have had, because we have been able to find, again,

through a better tabulation of clinical events in our electronic

health record, that there are other near events that could have

very easily resulted in death, as well.

The combination of multiple prescription drugs in patients who

have chronic pain, and not always chronic pain from severe battle

injuries, most of these, in fact, were training accidents or degenerative problems of a kind.

Compound that with behavior health or mental health challenges

and then you add alcohol to that combination, especially on a weekend, if it is unsupervised, and you get a toxic combination that can

result in death, and that is exactly what has happened in several

of those accidental deaths.

We are now instituting some policies that are going to mitigate

those risks from sole provider programs. So that as you begin to

amass greater needs for prescription drugs that may obscure the

sensorium or may be potentially lethal, that we have a single provider, a single physician or nurse practitioner prescribing those

drugs so that they can monitor them effectively.

We have better accountability through our triad in the warrior

transition units and that we create alcohol-free zones around the

barracks and around the treatment areas that our patients are in.

Understand, sir, that these are not inpatient. These are outpatients. They are living, some of them, with families in guest

homes and the like, and we have recognized that that is a problem.

Does that answer your question, sir?

Mr. MCHUGH. Yes, for the most part. Obviously, tighter control

on the allocation of prescriptions and where you might have

counter indications there, it would be important.

16

But it is something we want to follow and I just want to, I guess,

add, for the record, that we are, as a committee as a whole, and

I know you are, as well, I didn’t mean to suggest you are not, are

deeply concerned about this. So we will be watching you progress.

Thank you. Thank you, Madam Chair.

Mrs. DAVIS. Thank you, Mr. McHugh.

Mrs. Boyda.

Mrs. BOYDA. Thank you.

Thank you all for coming and for the soldiers that have come and

joined us today.

I was out at Walter Reed a little while ago and what a difference

a year makes. So thank you very much for how the Army has addressed this issue and moved forward.

I am going to have a couple rounds of questions, so I will just

come back to what we were just talking about to get some additional information.

When you have a prescription drug that has the potential for

abuse, is the soldier given a 30-day supply of that or a 15-day supply at a time or how is that actually administered?

General SCHOOMAKER. I think that is very dependent on the

case, ma’am. Our soldiers are like any other patients that America

has and they are treated by physicians, nurse practitioners and

physician’s assistants in accordance with clinical indication.

I think you may know that there has been a great deal of attention over the last few years to ensure that our patients aren’t in

pain. There isn’t a patient who goes into any clinic or emergency

room in America today that isn’t asked by the staff, ‘‘Are you in

pain? Is there anything we can do to mitigate pain?’’ And I think

that has contributed to probably our being very aggressive about

prescribing drugs.

That is not coordinated sufficiently, and especially if the patient

isn’t aware of the potential lethality of these combinations, you run

into problems.

And as I said before, if you also are suffering from an emotional

or psychological problem, that further drives you to take more than

you might have. If you add alcohol in combination, then we have

a problem.

Mrs. BOYDA. With the 1-to-12 ratio in that unit, is it possible

then to just not give overdose quantities at a time?

General SCHOOMAKER. That is going to be part—that is part of

our policy case.

The last thing I think that any of us wants to do is to take a

patient who is on a stable course of medication for, say, pain relief

and make them suffer because of draconian policies that we establish. But I think having the command and control that we now

have, we can do a case by case assessment of what the risks are

and do exactly what you are talking about.

Mrs. BOYDA. The 1-to-12, I mean, that is pretty close care.

General SCHOOMAKER. Yes, ma’am.

Mrs. BOYDA. And then the 1-to-18 on the nurse. The soldier that

I had gone to visit at Walter Reed is doing well, saw him recently,

and a good guy, a specialist, and I asked him how are things going

and he couldn’t say enough good about so many things.

17

He was getting better. The doctors were good. He went on about

how well things are going.

There is a ‘‘but’’ coming.

General SCHOOMAKER. Yes, ma’am.

Mrs. BOYDA. And that ‘‘but’’ was he said, ‘‘The only problem is

it takes me forever to see the doctor.’’ So I said, ‘‘Is it 1-to-200?’’

He goes, ‘‘Well, I don’t know about that. I just know that it takes

me about a month and a half to see a doctor.’’

Now, I would like to just—at some point, we will follow up on

his case specifically, and that was just an off the—with a 1-to-200

ratio of doctors, how often would you expect them to—how many

times a day or how many patients a day does a doctor see? How

many patients a day and how often would you expect to see a doctor at 1-to-200?

This is a man who is really so committed to his country, he is

like so many of the other veterans, ready to get back just as soon

as possible.

General SCHOOMAKER. Yes, ma’am.

Mrs. BOYDA. So he just said, ‘‘I don’t need’’—it didn’t seem to

bother him too much. It is just that he wants to get back.

General SCHOOMAKER. Yes, ma’am. And I don’t want you to walk

away from this, the committee to walk away thinking that we have

a structure now that allows us to have one physician for every 200

patients throughout Army medicine.

We have——

Mrs. BOYDA. And he is part of the wounded transition. He is part

of the wounded warrior transition.

General SCHOOMAKER. This program alone, we have set a very

generous ratio of physicians and nurse case managers for our patients, 1-to-200. That is not typically the ratios that we have. They

are more on the order of 1-to-1,000, 1-to-1,500 in most primary care

models for, say, a family medicine doctor or general internist or pediatrician.

But for this group, we have given them an additional population

of physicians.

We actually give patients within the warrior transition units accelerated access for care for routine, as well as specialty care. In

fact, I am sure that the cadre who are in the room here today are

cringing as you describe that patient and that he can’t see his doctor very often.

I suspect, ma’am, that what you are hearing is from those that

are anxious to get back, anxious to get as much attention as possible to his or her wounds and then anxious not to have to sit there

and heal during the time and probably resisting what they have

told them, ‘‘Listen, be patient, the time will come.’’

But if you will give us details after we——

Mrs. BOYDA. We will follow up, absolutely. I just feel it would be

remiss to—again, this is a good guy that I have kind of been following and he can’t say enough good about what is going on.

So we will follow up with that and just see where—but I wanted

to make sure the 1-to-200 ratio would mean that we are—that

there still is—you know, these are people who clearly need a fair

amount of—they are wounded. So they are going to need care pretty often.

18

General SCHOOMAKER. And, ma’am, if I could add, just real

quickly. It is a very important point.

We are returning most of two-thirds or three-quarters of our soldiers back into uniform after injuries and illnesses, combat-related

or not. That is a very important part of this.

We are saving the equivalent of two combat brigades a year

through our process of recovering and rehabilitating.

Mrs. BOYDA. We will go over the details and follow up again on

it later.

General SCHOOMAKER. Yes, ma’am.

Mrs. DAVIS. Thank you.

Mr. Kline.

Mr. KLINE. Thank you, Madam Chair.

Thank you, gentlemen, for being with us today.

Admiral Robinson, could you tell us what your working relationship is, not your personal relationship, but your working relationship is with Colonel Boyle? How does that work?

Admiral ROBINSON. With Colonel Boyle, who is the Marine Corps

liaison at Bethesda?

Mr. KLINE. No, sir, I am sorry. He is the Chief Officer (CO) of

the Wounded Warrior Regiment, and we have been talking about

how the Army does that. I am just trying to see how the Navy and

the Marine Corps does that.

Admiral ROBINSON. Okay. The Wounded Warrior Regiment at

Camp Lejeune or at Pendleton?

Mr. KLINE. Admiral, there is one wounded warrior regiment and

it has battalions on each coast. I guess what I am hearing here is

there is not—we are not very well plugged in there between the

Navy Surgeon General and the Marines Wounded Warrior Regiment.

The Army, you seem to be under one hat here. General

Schoomaker talked about the installations providing the funding, it

comes under installations command for the barracks and so forth,

but it looks like your wounded warrior program in the Army falls

under you.

Is that right, General Schoomaker?

General SCHOOMAKER. Yes, sir.

Mr. KLINE. And with the Navy, you have a safe harbor program

that treats 250 or so sailors a year. That falls under you, Admiral?

Admiral ROBINSON. No. That falls under the Chief of Naval Personnel.

Mr. KLINE. So for neither the wounded sailors nor Marines, you

don’t have any direct connection with that follow-on program, that

outpatient program, that mentoring and caring for program that

we are hearing about in the Army.

Is that what I am hearing from you?

Admiral ROBINSON. Well, other than doing the initial health care

in the institution, then doing the medical case management and

the non-medical case management, going through the continuum of

care and transitioning them to the appropriate facility, such as the

polytrauma or wherever they need to be, and then, when ready,

getting them back as close as they can to their home unit, Lejeune

or Pendleton, or wherever that may be, and we do that through the

wounded warrior program.

19

I think that we have a very good hookup. The fact that Colonel

Boyle, who I do know, and who does have the regiment and the fact

that we have one at Lejeune and at Pendleton that I don’t have

daily cognizance over, doesn’t mean that Chris Hunter at Balboa,

who is the Commander at medical center at Balboa, and that Marl

Olsen, who is the Commander, my Commander of the naval hospital at Camp Lejeune, aren’t talking with them.

And for my three years at Bethesda as the Commander, the Assistant Commandant of the Marine Corps (ACMC) and the Commandant of the Marine Corps (CMC) and the Sergeant Major of the

Marine Corps and the wounded warrior Marine liaison that was

there were a daily occurrence, are hooked into the multidisciplinary

team that I spoke about.

So those people are people that I have lived with on a day to day

basis for the last few years.

Mr. KLINE. Thank you. I am a little bit concerned. Maybe it is

time, and I would suggest, Madam Chair, that if we are going to

look at this wounded warrior continuing care issue, that it would

probably be helpful to have the Marines wounded warrior regiment, since that is an up and running organization that is connected.

And the Admiral is explaining some of what is connected, but I

would like to explore that a little deeper and I could do it on my

own. Perhaps, as a subcommittee, we ought to do that. We ought

to take a look at that.

Admiral ROBINSON. Well, the deputy medical officer Marine

Corps, Mike Anderson, who is sitting behind me, is here. The medical officer Marine Corps is Admiral Bill Roberts, who couldn’t be

here today, but that connection exists and it exists on a daily basis,

and it has for a long time and it will in the future.

Mr. KLINE. It is not the same relationship, though, as what they

have in the Army and I was just wondering——

Admiral ROBINSON. No. It isn’t the same relationship for a number of reasons, not the least of which is we don’t have quite as

many people involved in terms of wounded.

But the relationship is a little different in terms of philosophy of

how we manage the care.

Mr. KLINE. Exactly, and this is not meant as a criticism. I am

trying to understand how it works. So I would like to explore that

a little bit separately, because we have a different model here.

There are a lot of similarities. The Marines are assigning officers

and staff non-commissioned officers and barracks in a model very

much like what the Army is doing, I think, and the cadre members

are back here in the audience, but I am—in the Army’s case, it

falls under the Surgeon General of the Army, I understand, all one

uniform, and in the Navy and Marine Corps case, it is a little bit

different, and I would just like to understand how that works. That

is all I am suggesting.

I have got some other questions, Madam Chair, having to do

with sort of an unrelated matter and I will wait for the second

round.

I yield back.

Mrs. DAVIS. All right, thank you.

Mr. Wilson.

20

Mr. WILSON. Thank you, Madam Chairwoman.

And, Generals, Admirals, thank you for being here today.

I have a perspective that I am very grateful to share with Congressman Kline.

He is a distinguished veteran. As you can tell by his label pin,

he is still a Marine, and I am really grateful that he has had a son

serve in the Middle East. I have had two of my sons serve in Iraq.

I have had three sons in the Army National Guard. I am also

very proud that one of my sons is a doctor in the Navy.

So, Admiral, thank you for being here.

I can also cover the Air Force. I have a nephew who is in the

Air Force. My dad was in the Air Force.

I visited my nephew in Baghdad while he was serving there, and

they are all very proud and grateful for their service overseas.

Additionally, I have had the extraordinary opportunity of visiting

with the military medical personnel and patients in Baghdad, at

Landstuhl, at Bethesda, at Walter Reed, at Fort Jackson, the naval

hospital at Buford.

Everywhere I go, I am impressed by the quality of personnel.

There is no question that, to me, American military medicine is the

best in the world and is the best it has ever been in the world.

I also want to thank the persons here today with the warrior

transition units, because we were all so disappointed in some of our

troopers falling through the cracks, that we need one-on-one attention and persons who I see here today, I just have faith in their

competence and ability to follow through.

I have also had the opportunity to meet a person I consider an

American hero, Major David Rosell, who has lost a leg. He was able

to go back on duty. Then he has come back to encourage other persons to go back on duty, and it is so awesome to me.

I have also seen the experience of Lieutenant Andrew Kinard, a

Naval Academy graduate, who lost both legs, but, my goodness,

when you are with him, his spirit is tremendous.

And so I can see firsthand the success. With this, with the warrior transition units, some concern has been that some of the persons who are placed in these units are somewhat offloaded problem

soldiers. But, again, by working one by one, General Schoomaker,

General Tucker, how is it determined what care is given and what

is needed for each person?

General SCHOOMAKER. A very good question, Congressman, and,

by the way, we thank you for your contributions to our force.

Mr. WILSON. I think all of us sitting up here are thankful. All

the credit goes to my wife.

General SCHOOMAKER. Yes, sir. I think we can all relate to that,

as well.

You are exactly right. We now have approximately 9,500 warriors in transition within warrior transition units. The directive of

the Vice Chief of Staff and the Chief of Staff of the Army was go

out into the Army at large, find those soldiers that are in long-term

care or facing medical evaluation boards, and have the hospital

commander, warrior transition unit commander, and line commander sit down and have a discussion.

And based upon a risk matrix that we have developed for whether they are safer to stay within the unit, the line unit, and have

21

a high probability of returning and being an active soldier with

that unit or probability that they are going to have problems that

they need to come into the unit, we do that.

There has always been, sir, a prospect of a line unit turning to

the medical community to solve the problems of a problem soldier.

But the fact now that it is a negotiation, that we have some objective criteria that center around their health and behavioral health

problems I think helps with that discussion.

Mr. WILSON. Another interest I have, my National Guard unit,

the 218th Brigade, 1,600 troops, are located in Afghanistan, training the Afghan police and army, they will be coming back this summer.

I am delighted at the services provided on base. What will be

provided for Guard and Reserve persons who maybe live in rural

communities?

General SCHOOMAKER. Sir, I think that is a challenge to all the

services and it is a major focus of Secretary Peake, the new Secretary of the Veterans Administration. He talks often about the

fact that especially those that aren’t recognized at reintegration

and demobilization, but may later turn up with problems in remote

areas, are soldiers that we are focused upon within the direct care

system, through our TRICARE network, and through the VA, as

well, and I think that is part of the importance of this coordination

with the VA.

Mr. WILSON. One thing that I saw, Madam Chairman, that was

actually helpful, my sons, we still get their mail at home, and I was

really impressed by the quarterly mailings that I just inadvertently

see about—that service members receive who have been deployed

overseas, with questions as to their care and suggestions.

So thank you for what you do.

General SCHOOMAKER. Thank you, sir.

Mrs. DAVIS. Thank you, Mr. Wilson.

General Tucker, one of the things we know about you is you are

a bureaucracy buster. Is that correct?

General TUCKER. Yes, ma’am.

Mrs. DAVIS. Could you tell us, give us an example of some of

those bureaucratic roadblocks that you overcame to make all these

work?

General TUCKER. Ma’am, that is a great question.

First of all, I would ask myself—we came to a lot of impasses as

we worked our way through the problems as we saw them and

began to conduct mission analysis.

And when it came to a decision, we always basically erred on the

side of healing. If this decision is going to result in allowing this

soldier to heal, and his family, then unless it is illegal, immoral,

unethical, we are going to take on the policy or regulation that is

preventing that, and we have been able to create a book, it is about

an inch thick, and I think that is testimony to how much bureaucracy was actually there that would prevent soldiers from—you

know, these are—this is a population of people whose worlds have

been taken off kilter by means out of their control.

We should probably do everything we can to get it right side up

and not continue to allow it to list. A couple examples.

22

We authorize you a non-medical attendant if your activities of

daily living are limited such to where you can’t do some things on

your own and you need an assistant.

The policy said that the non-medical attendant had to be a family member. Well, what if your mom works and your sister is in college and your dad can’t do this, and why can’t your best friend do

it, why can’t your fiance do it, why can’t a father-like figure in your

life do this for you?

So we got policy changed to allow that.

Some of the soldiers, in the initial stages of standing up the transition units, some soldiers were reluctant about coming to the warrior transition units because they were afraid they would never get

to go back to their unit.

So here is a soldier in an infantry platoon who doesn’t want to

leave his platoon or his company because if he goes to the warrior

transition unit, thoughts are ‘‘I will never come back.’’

And so we have published policy that says you will come back to

the unit that you came from, regardless of even if it is an overstrength status, you are going to come back to the unit you came

from.

We established permanent change of station policies so that a

family can leave their children at home, say, at Fort Bragg and

come to Walter Reed and still draw per diem payments there, regardless of the status that the soldier is in at Walter Reed.

We allow soldiers—soldiers do not want to wear this patch, the

medical command (MEDCOM) patch in a warrior transition unit,

even though they are assigned to the medical command under the

Surgeon General, because their patch made them feel good. Feeling

good is kind of what you could call healing, and so we authorize

them to wear their patch, as well.

And I could go on and on and on, but it is about an inch thick,

ma’am, and if we continue to find—as we move in concentric circles

out from ground zero, so to speak, we continue to find other bureaucracies out there that we haven’t seen.

I will give you another example. Our soldiers see drug counselors. The drug counselors and what they discover in counseling

with soldiers, their information databases, so to speak, doesn’t

cross over to the physician that is also treating the soldier for their

medical and their clinical condition.

These two professionals should be able to talk about this soldier

and their family and try to help them. So we tripped into that last

week as we were doing a tiger team on some unexplained deaths

in our WTUs.

So we continue to protract this, ma’am.

Mrs. DAVIS. Is there anything that Congress can do to be supportive of that? Is there anything legislatively that you discovered

that needs to be changed?

General TUCKER. Well, we are going to go back to the physical

disability evaluation system, obviously, and I think NDAA is moving in that direction, ma’am.

The biggest challenge, ma’am, is culture. It is a cultural change.

We have been having warrior transition units in the Army since

1778, when the first inspector general, von Steuben, said that we

will stand up a regiment for the sick and the lame who cannot keep

23

up in the regiment and they would be cared for by our non-commissioned officers.

And so this is not new work. It is just work that we have got

to get better at, and I think we are moving in the right direction.

Mrs. DAVIS. Thank you.

Admiral Robinson, perhaps along the lines of Mr. Kline’s question earlier, has the Navy also had to break a few bureaucratic

roadblocks in order to have their program work?

I think part of our question really is whether the nature of Safe

Harbor and I think multiple programs, in many ways, that you all

have put together really are like what is happening over on the

Army side.

I mean, how will the comparisons work out and, in fact, if you

had to create some of those opportunities, as well to change the

way people look at this system?

Admiral ROBINSON. Yes, ma’am, and I think I understand your

question. The Navy medical department is different from the Army

medical department in one fundamental way, and that is we are

the medical department to both the blue Navy and, also, to the Marine Corps.

So we have two services with distinctly different missions, but

we provide care to both.

So the safe harbor program, one of the things that we have

done—and we need programs for both groups of people, because

they are completely different in terms of who they are, where they

are and the cultures, et cetera.

One of the similarities, though, is to make sure that we take—

I guess the phrase would be best of breed, because there are lots

of parts of the wounded warrior program for the Marines that we

have instituted in our safe harbor program to make sure that we

are giving an equivalent level of care and concern for everyone.

Again, the numbers are vastly different, because the numbers on

the Navy side are much, much lower and the Marines have much

higher and, of course, the Marines are still lower than the Army.

In terms of rule sets, the Navy functions in a little different way.

Our 232-year history is to get underway and to leave and for a long

period of time, when communication was poor, we had to make decisions about how we were going to conduct affairs based upon the

best circumstances that we found ourselves, very similar to what

General Tucker was already talking about.

So our history and our tradition has been to make sure that we

get to the crux of what the problem is. In this instance, the concept

of care for Navy medicine has long been patient and family centered, and I think that one of the things that Navy medicine does

well, one of the things that MHS, military health service, has to

do better is to help patients integrate their care.

Integration of care is going to be a huge help in terms of people

who are, in fact, injured, who are under tremendous stress, and I

think we do that and we usually put patients and family concerns

first when we have that.

Mrs. DAVIS. Thank you, Admiral.

Mr. McHugh.

Mr. MCHUGH. Thank you, Madam Chair.

24

General Schoomaker, you and I have had the opportunity to talk

several times during the past few weeks regarding the circumstances current in the national media, where apparently there

was—well, for the moment, we will call them a misunderstanding

between the veterans administrative personnel at Fort Drum and

the Army as to the propriety of the VA, and the Vietnam Veterans

of America (VVA) in providing guidance and assistance in the preparation of soldiers’ medical evaluations board papers.

Since that time, you and Secretary Peake have—I guess it was

Secretary Geren and Secretary Peake have executed an agreement

that provides a way by which to approach that, those jurisdictional

issues.

There has been some confusion, based on calls I have gotten, as

to what this agreement allows the veterans, VVAs to provide to the

soldiers. If I read from the agreement itself, it says ‘‘VA service

representatives will assist and advise service members, but will not

prepare documentation for other than VA benefit claims.’’

A lot of media representatives calling me were somehow interpreting that to mean that the VVAs were not allowed to provide

any assistance.

What my interpretation of this is, and I would like you to state

for the record what your understanding is, is that the VA representatives could continue to advise, provide oral suggestions and

guidance, but, just in the vernacular, couldn’t sit down at the typewriter and actually fill out the paperwork.

Can you help us understand exactly what your understanding is?

Is VA assistance available now? And it is not just at Fort Drum,

by the way. It will be anywhere where you have this nexus between the medical evaluation process and VA. True?

General SCHOOMAKER. Yes, sir. And my understanding is exactly

yours, sir. Let me just go back real quickly and reconstruct what

happened here.

As we stood up the first warrior transition units and General

Tucker began to bust bureaucracies and formulate the Army Medical Action Plan, a team was sent out from the Surgeon General’s

office, under the Acting Surgeon General, Gail Pollock, to rapidly

get as much information as possible out in those camps, posts and

stations where this was occurring every day.

Where was it working well, where was it not? All facets of the

care and transition into the VA system, to include the disability

process. And Fort Drum happened to be the 11th place they visited

and one of the last ones and they found really some of the best

practices that they saw, very well embedded veterans benefits advisory group that there were giving good counsel to our families and

soldiers.

But I think that there was confusion across all of these sites as

to exactly what the interface should be.

When the stories surfaced about the exchange between the Army

team and the VVA counselors at Fort Drum, Secretary Peake, with

whom we were in pretty constant contact, said, ‘‘You know, it is

very clear here that we have got some heterogeneity of how the

process operates and if we have got that kind of a patchwork going

on, we need to establish from the top how this should happen so

there is no question out there in the field that VVA counselors and

25

the soldiers and their families should be working closely together,’’

and that is exactly what that policy was intended to do.

My understanding is it spoke to the strengths that the VVA

counselors had, which was understanding of veterans’ benefits. Yes,

sir.

Mr. MCHUGH. Absolutely. Thank you, General.

Admiral, before your presence in the subcommittee, the subcommittee staff had visited your mobilization processing site in San

Diego and Norfolk and, at that time, we heard some complaints

from ill and injured sailors in the units regarding demobilization.

And the complaints specifically were that they were being ordered to demobilize while still undergoing medical treatment and

being told to go to VA or to TRICARE for transitional assistance

management program for follow-on care.

We brought those concerns to the attention of your predecessor.

We were assured by the Navy leadership that that practice would

end.

Just this past week, the committee staff again has obtained information that suggests that soldiers, at least in some regard, are

still being processed in that way and we have illustrations of sailors being demobilized a few days prior to scheduled surgery and

told to obtain the surgery and recover while they are on training

and leave and such.

And I would like to get your comments on that for the record.

Admiral ROBINSON. Sir, I have no information and no comments

on any of the specific cases. I will tell you that from a physician

and from a surgeon’s perspective, and as the Surgeon General, I

would like to make sure that all injured, ill personnel who are on

active duty and who—and the folks that you are talking about are

in the reserve capacity generally, but that they, in fact, have complete medical care before they leave the service or if the care isn’t

given to them before they leave the service, the condition that they

have is something that can be cared for and that we know exactly

how we are going to transition them to what provider for the proper treatment and for the proper care.

From the surgeon in me, I am telling you that most of the time,

I don’t think that anyone should leave the service until their medical condition has been eliminated or treated, but the specifics here

I don’t know.

Mr. MCHUGH. If I may, Madam Chair, I know the light is on, I

will be very brief.

But clearly I don’t expect that you can possibly respond to the

specific cases. I don’t know if it is appropriate, we could probably

get those to you for resolution, if nothing else.

Admiral ROBINSON. I would like to have that, sir.

Mr. MCHUGH. I appreciate that.

But you have been clear, in general terms, it would not be the

Navy policy to discharge a sailor who, a few days later, had surgery

scheduled. Am I correct in that assumption?

Admiral ROBINSON. That is correct. If a sailor had surgery that

is needed and who has been on active duty, particularly if that injury or whatever has occurred because of the—it has occurred during the period of duty, then I would expect that we would care for

26

them and, again, pending the particulars, I would say that that is

what should occur.

Mr. MCHUGH. Thank you, Admiral.

Thank you, Madam Chair.

We will get that information to you.

Admiral ROBINSON. Fine, thank you.

Mrs. DAVIS. Thank you.

Mr. Kline.

Mr. KLINE. Thank you, Madam Chair.

Admiral, I got us kind of twisted around there with the Marine

Wounded Warrior Regiment. I didn’t mean to get us that twisted

around. Let me just hasten to assure you that I have been, over

many years of service in the Marine Corps, extremely pleased with

naval medicine.

My son was born in a naval hospital. Of course, he is now an

Army officer. I am not sure where I am going with that, except that

every time I am with Mr. Wilson, I am thinking about if our families weren’t as engaged as they were, the Department of Defense

would have to increase its recruiting budget substantially.

I have three nieces in the Army, one of whom is an Army nurse,

serving in Baghdad, and all of them very proudly. But, again, I

didn’t mean to imply, and I was talking to Mr. McHugh for a

minute, come across that I had some criticism of naval medicine

and, certainly, from my family’s perspective, that is not so.

But I do want to get at the relationship between the Surgeon

General’s office and the Wounded Warrior Regiment, not here

today, because we need to explore that when we have somebody

from the Marine Corps who can talk about this.

I want to go back and pick up—I guess I am back in your lane

again now, General—what Mr. Wilson was talking about, these

members of the Guard and Reserve who are coming back and you

expressed that that is a problem that all the services were having

to face.

Mr. McHugh was just talking about it sometimes with sailors

who are discharged. We put in statute now and we have been seeing for the last couple of years a pretty aggressive reintegration

program by the National Guard, expanding to the reserves.

So we bring these soldiers back, we don’t just demobilize them

and sort of say good luck to them, we will see you in a few months.

We are bringing them back after 30 days, 60 days, and 90 days to

see how they are doing in a wide range of areas, are they getting

their jobs back, house, family, life going, but part of it is medical,

as well, and particularly in view of PTSD and perhaps some traumatic brain injury, where symptoms are a little bit slower coming.

How do you see your office, the Surgeon General’s office relating

to that? Do you have a direct input into that, direct relation, or is

that sort of the guard comes back and then those reintegration efforts connect them with the VA? What is the relationship? Can you

tell me that?

General SCHOOMAKER. Well, I have a good relationship with the

leadership of the Guard and Reserve and with their surgeon, with

whom we work very closely in trying to attend to exactly the point

that you made here, sir.

27

And you have raised some very, very important points about the

Guard and Reserves challenges once they finish their mobilization

and are reintegrating.

The two areas that we see the biggest problems right now, first

is dental. We have a real problem with dental readiness and dental

health within the reserve component.

This is one of our biggest challenges for bringing reserve component soldiers into a state in which they can be medically deployed.

And so especially as we turn the reserves from being a strategic

reserve into an operational reserve, we see their service as, in a

sense, the preparation, the beginning of the preparation for the

Army’s force generation model of the next time that we mobilize

and deploy.

And so it is very important for us to maintain their dental health

and their dental readiness through programs that we are developing.

The second is, that you alluded to already, our studies now have

shown, for the last five years of careful cohort studies, that the

emergence of symptoms of post-traumatic stress of a reintegrating

soldier don’t appear at the moment of demobilization or at the moment of redeployment.

And so we have learned that 30, 90, 60, 180 days out, we should

be re-interfacing, we should be reexamining, re-interviewing that

soldier to see how they are doing.

We now have a standing policy across the entire military medical

system that my colleagues in here and I, we all attend to and that

is to 90 to 180 days out, perform a post-deployment reassessment

of health that is focused on those symptoms.

The National Guard, Reserve and the Army have been very, very

responsive to that.

Mr. KLINE. Thank you very much, General.

Madam Chair, I have got another line of questioning having to

do with what we are doing in terms of research and treatment for

extremity injuries. But if we don’t have another round, I will just

submit those for the record. If we do, I will raise it then.

Thank you very much. I yield back.

Mrs. DAVIS. Thank you.

Mr. Wilson, you are actually up by when you came in the room.

So if you would like to ask a question now.

Mr. WILSON. I would be happy to. Thank you.

A concern that a lot of people have had, as the National Capitol

regional medical command is being transformed, a concern would

be for the ongoing program. What is planned and being done to

make sure that indeed there is no one left behind?

General TUCKER. Sir, if I could take it. I know that the Warrior

Transition Brigade at Walter Reed, they are transforming to what

we see as a joint warrior transition unit at Bethesda.

It will also take on units in the National Capitol region. There

will be a battalion—population size at Fort Belvoir, at Fort Meade,

at Fort Myer, and at the eight medical treatment facilities around

the National Capitol region will all have smaller, obviously, subunits of the joint warrior transition unit.

28

And within that, we would see the Wounded Warrior Regiment,

the Air Force program and the Army program for this population,

sir.

Mr. WILSON. So a concern that occurred last year was that as

there was a movement of facilities, personnel, organizations from

Walter Reed to Bethesda, that there, indeed, could be a problem.

But you feel like this will be addressed.

General TUCKER. In terms of BRAC, yes, sir. Yes, sir. Our funding lines have come back up to keep us at full operational capability through the entire BRAC process, to the last day that we stay

open, and we have got hiring authorizations to keep our people

hired through the process, as well, sir.

Mr. WILSON. I wish you well, all of your coordinating.

General SCHOOMAKER. Yes, sir. I will point out that Admiral

Robinson and I, he at National Naval Medical Center, Bethesda,

and I at Walter Reed, actually were a part of that process before

they stood up the joint task force capitol medicine under Rear Admiral John Madison and we have already begun pretty full integration of clinical services and training program, even though we are

not collocated yet as a single campus.

And Admiral Madison has had full visibility of our efforts to integrate. It is deceptive to many people that even when the Secretary

of Defense recently broke his shoulder, he may have been seen at

Bethesda, but he was seen by an orthopedics and rehabilitation

service that is actually shared between the two institutions.

We have had great success.

Admiral ROBINSON. I think that we have, and I just want to emphasize that the difference in the area, and I think the reason that

there won’t be anyone left behind, is that as Admiral Madison and

as the joint task force capitol medicine becomes more mature, and

it just began a few months ago, but as it gets more mature, I think

we are making inroads to make sure that we have the right services not only at Bethesda, but also in the whole capitol area, including Belvoir, so that we end up in the National Capitol area, the

National Capitol region, with a joint run military health system,

which would be Air Force, Navy and Army.

And I think that we are, in fact, getting there.

General ROUDEBUSH. Yes, sir. I would add, from the Air Force

perspective, certainly, with the very focused attention of the deputy

secretary of defense, Mr. England, and the service Secretaries and

Vice Chiefs, this has been a very focused and collaborative affair,

both in BRAC integration and assuring that the care that is being

provided to these wounded individuals coming back, there is not a

decrement anywhere in that.

From the Air Force perspective, of course, a lot of focus, rightfully so, on Walter Reed, Bethesda and DeWitt, but Andrews plays

a critically important part in that at Malcolm Grow, both in terms

of a strategic asset located within the National Capitol area, but

also as a focal point for ensuring that Air Force medical manpower

is, in fact, committed and placed throughout the region to the best

effect of the overall outcome of health care.

So I think this has been a very productive relationship and Rear

Admiral Madison, I think, has done a very good job of assuring

29

that equities are addressed and met in all regards in a very demanding situation.

Mr. WILSON. Well, I wish you well and I know you have a success

story with the Uniformed Services University being a joint facility.

It truly came to mind when I attended graduation of my son and

to see persons from every service. It was just such a positive experience and the recent movie about the Uniformed Services University is just such an inspiration.

And, again, thank you again for what you have done and thank

you for what you do for our troops.

Mrs. DAVIS. Thank you, Mr. Wilson.

Mrs. Boyda.

Mrs. BOYDA. Thank you, Madam Chair.

Last year we had a hearing with Surgeon Generals. It was after

the Walter Reed had kind of settled into a plan. We just generally

asked about how things were going and one of the main messages

that we heard at that point was about the military-to-civilian conversions.

And basically their recommendation at that time was that those

needed to be slowed down or even halted and in the NDAA last

year, we said that we are going to put a halt to those.

And, yet, in your 2009 proposed budget, the military-to-civilian

conversions are still in there and budgeted for. If you could help

me understand what is going on with that. Are they going to be

planned to be taken out? Do you still feel the same way? What impact does military-to-civilian conversion have?

I would like to hear actually from each one of you, if I could, each

one of the branches.

General ROUDEBUSH. I will begin. The Air Force has been very

focused on the military-to-civilian conversions and this has been

going on for some time, really started laying them in back in 2004.

As far as the Air Force is concerned, we have done what we are

confident in, is very good analysis, where it makes sense to do that,

where it doesn’t make sense, where the capabilities are, in fact,

available to be hired.

So that was a part of our analysis and that allowed us to go

through the subsequent years, four, five, six, seven and eight, and

certify, according to the direction of this committee, in terms of

those that we felt were suitable for conversion and would not decrement either access or quality of care.

So we, in fact, complied with that. When the Fiscal Year 2008

NDAA was signed in late January, that did, of course, cause us to

move into a very concerted effort to be sure that we do comply with

that law. And working with our Air Force A–1, our personnel, as

well as our planners and programmers, the Air Force is fully committed to complying with the Fiscal Year 2008 NDAA, as it is written and as it is intended.

Mrs. BOYDA. So you see those budget items being deleted then?

General ROUDEBUSH. What you will see is those positions will be

converted back to military in 2009. Those positions not filled will

be converted back to military and we are working with our planners, programmers, and resourcers to assure that that, in fact, occurs.

30

Now, I will tell you, there is difficulty in that, because as early

as 2004, when we began laying those in, our recruiting and training pipeline was adjusted accordingly to do that. So as we move

these back to military positions, it is going to take some time to

reconfigure both that recruiting and training pipeline to deliver

those military personnel to fill those positions.

So this is not without challenge and we are looking at strategies

to address that, as well.

But the bottom line is the same as the top line—we fully intend

to comply with the Fiscal Year 2008 NDAA as it has been published.

Mrs. BOYDA. I will speak on my behalf and not the entire committee perhaps, but that was certainly done—that was what came

out of the hearing, too.

So we need to make sure that that is meeting your needs and

this is not the needs of the committee. We want to make sure that

we are meeting your needs.

So, again, I will speak personally, not on behalf of the committee,

but if there is—if we need to continue to look at that, I would be

happy to do that.

General ROUDEBUSH. Yes, ma’am. And please rest assured, as we

have worked very carefully with your staff members, they have

been very helpful and very forthcoming in working through the

challenges and working to assure that we understand on both sides

precisely what the implications of that are.

Mrs. BOYDA. And speaking for myself, the objective is to give you

the leverage to make the best decisions that you think need to be

done for our military personnel.

General ROUDEBUSH. Yes, ma’am.

Mrs. BOYDA. General Schoomaker.

General SCHOOMAKER. Yes, ma’am. We will fully comply, as well,

with law. There is no question that we will do that.

We have several challenges. One is to allow us to internally restructure our force for the kind of wounds, the kind of care, the

kind of demands that we see now and we see over the horizon.

So, for example, in the mental health arena, we need the latitude

to be able to restructure even the uniformed force to acquire more

mental health support.

That the Army is allowing us to do and has been allowing us to

do. We were using the military-to-civilian conversions actually to

work within that conversion process or that remixing process.

The second is as the Army grows, we need a medical supplement,

if you will, within our force to meet the Army’s needs as it grows

new modular brigades, as it pushes more trainees through its

training pipeline and the like and grows more families, we need a

greater medical force.

The Army, again, has been very generous in providing us a

‘‘Grow-the-Army’’ slice of the medical.

So we are complying with the law now. We are also getting the

force mix conversions that we need to structure our medical force

for the kind of needs that we have now and that we see on the horizon, and we are growing the medical force to respond to the

growth of the Army.

Mrs. BOYDA. Thank you.

31

Admiral, is there anything that we need to add? My time has expired.

Admiral ROBINSON. Just that both parts of the Air Force and the

Army are very similar and that we are going to comply with the

same thing and at Chief of Naval Operations (CNO) and Configuration Management Program (CMP), we are fully engaged. We are

going to do what the law says.

Mrs. BOYDA. All right. Thank you.

Mrs. DAVIS. Thank you, Mrs. Boyda.

I would say, as well, I appreciate the fact Mrs. Boyda raised the

question, because there was concern that there is a disconnect here

between what we were seeing coming forward in the budget and,

in fact, what had been designated in the NDAA.

So I think we want to obviously work with you. We know that

there are some needs and some challenges, but the overwhelming

needs seem to be to have those billets available really to our military and to not do anything that would take away the need to have

the kind of pipeline within the services that is going to be so critical to the future. And so I appreciate your concern.

Any additional thoughts on what the problem was, whether there

was a miscommunication somewhere on whether the needs were

just so different from what you were seeing?

General SCHOOMAKER. I think in the case of the Army, what we

had done is negotiate with the Army to allow them to restructure

military and civilian workforces, but to give us an additional workforce that we could rebalance the way we needed, and I think the

legislation, ironically, has somewhat forced us to go back to the

table with the Army and renegotiate how we are going to do that.

That may be what you saw from the Army, that was a part of

it.

Mrs. DAVIS. Okay, thank you.

General Tucker, for just a second, if you could just talk to us a

little bit more about how you bring together the Warrior Transition

Unit cadre.

I know we have some outstanding men with us today, individuals, and women I think I see in the audience. Where are they

really drawn from? And while I don’t think we would have any

question of their military leadership, I would want to know a little

bit more about the training or what might be called the bedside

manner.

We are dealing with some very vulnerable men and women who

need that kind of service, and that is not always a natural ability

that people have.

General TUCKER. Yes, ma’am, and that is a terrific question.

They do come from all the ranks, all ranks in the Army, and they

are assessed by human resources command.

They are two-year stabilized assignment, and we are looking for

remarkable people, obviously. I often say, when I speak with them,

that the skills that made you successful as a sergeant in an infantry platoon may not be the same skills that are going to make you

successful in this organization, because these people are all individuals with individual needs and they are all on a different emotional

plane.

32

And so we are looking for the sergeant who is probably the

world’s best father, a steady, but firm hand, but compassionate and

has enormous depth for feeling and understanding and, also, to understand that standing behind that wounded soldier is probably a

parent or a spouse who is going to tell you what they are thinking,

as we would if someone—if we thought our loved one was not being

cared for.

And so they have to absorb that, as well, while still maintaining

their military bounds. And so we put them through a 40-hour

course currently, we are moving it to a 3-week course, a resident

course at Fort Sam Houston, the home of the Army Medical Center

and School. They begin that course in Lewiston in October of 2008.

But right now, they are taking a 40-hour course and it takes

them through the bedside manner, like you have spoken of, ma’am,

but there are some things about Army medicine, about pharmacology, how to read a profile, how to read a pill bottle that says, ‘‘Hey,

Jones, you got 30 Percocet on Monday, you take two a day or two

every two hours and it is Thursday and you have one left, what is

going on here.’’

So they also understand the effects of medications and what you

can’t have with certain medications and they have to understand

the physical disability evaluation system, the entire world of what

a warrior in transition is going through and, also, the world of the

family and the finances, the special hazardous duty pays that they

draw, Traumatic Service Members’ Group Life Insurance (TSGLI),

all the things, the benefits, so that they become a portal through

which to guide these soldiers to.

And because we are looking for these special people and we expect them to offer an enormous amount of compassion, they spend

a lot of hours on duty. And so we have also—another piece of busted bureaucracy is we have gotten authorization for them to have

special duty pay.

Mrs. DAVIS. What role do you think that plays? I mean, if you

didn’t have the special duty pay——

General TUCKER. It does two things, ma’am. Number one, it tells

them they are special. We give drill instructors special duty pay.

We give recruiters special duty pay. These people are doing special

duties, as well. They are unlike their peers.

There are no other units like this in the Army and they are doing

the Lord’s work, so to speak, with people who we should be paying

pretty close attention to. So we are asking something more of them

than we would a normal sergeant and they have to be trained in

special skills. And so we give them $225 extra a month for the first six months, six months to a year, it is $300, and then $375 after the first year.

And the second thing that it does is it tells the Army that these

people are enormously special and we are only looking for the best

you have and that sends a strong message and then coupled with

that, the Secretary of the Army has instructed the Department of

Army Secretariat to place special emphasis on selection boards and

promotion boards to identify these cadre members as key and essential to the Army’s mission to sustain itself.

General SCHOOMAKER. And if I could just say real quickly, Mike

himself represents what we are looking for. When I was asked to

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look at candidates by the Vice Chief of Staff of the Army for this

role, I selected Mike.

He is a former non-commissioned officer himself. He has been a

former drill instructor. And I needed someone who could look at a

process like training soldiers and see a process that had regimentation and regularity and standardization, but, at the same time,

could see human beings inside of that and knew that some needed

a different kind of motivation than others, and you obviously see

that in him today.

Mrs. DAVIS. Thank you. Are you able to keep the diversity in

that cadre, as well, that represents the military, men, women, minorities, et cetera?

General TUCKER. Yes, ma’am, and also the diversity expands into

the component.

They are our National Guard cadre. Half of the cadre are active

component, one-fourth is National Guard and one-fourth is Army

Reserve, because the warriors in transition themselves are kind of

that mix of the population, as well.

Mrs. DAVIS. Thank you.

Mr. McHugh. We ought to be able to get around quickly for everybody.

Mr. MCHUGH. Thank you, Madam Chairman.

Just to the point that you and Mrs. Boyda were pursuing a couple weeks ago at full committee, we had Secretary DeSantis and

the Chairman of the Joint Chiefs and the Comptroller General,

Tina Jones, and we explored that very issue.

It is obviously a critical one. One of the problems I think the

services face is, frankly, we didn’t do a bill until January and they

prepared their budgets, as you know, long before.

So they have got a big ship to turn around. I was pleased, in my

conversations with the Comptroller General, that as a lady who

kind of keeps her eye on the purse strings, which is going to be an

important part of the rehiring that is required under this provision,

if you haven’t filled vacancies by, I believe, October 1st, that the

dollars are going to be there, but I just wanted to underscore the

concerns this panel has, and, Madam Chair, I know you will.

We are going to have to keep an eye on two balls here, both these

good folks’ efforts to comply with that, but also the Department of

Defense trying to do some things that help them financially, because this has significant monetary impact, as well, even though it

is absolutely the right thing to do for our men and women in uniform.

So I just want to get that on the record.

The other thing, General Schoomaker, the NDAA for this year

gave to the Secretary of Defense the authority to do pilot programs

to try to explore better ways for the functioning and the nexus of

the VA and DOD and, in your case, the Army disability systems.

That comment that you made about how you stood as primarily

a physician in front of people that you were there to help and felt

as though you were the enemy was a very poignant one and I think

one of the things that frustrates us all is that you have got two

good systems manned by the military disability folks, who care

very deeply about those who have come to them and are

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transitioning through their process, and, of course, the VA that is

modeled upon helping those who have done so much for us.

And, yet, when you put them together and you try to work, the

soldier, sailor, Marine or airman or woman, through them, it becomes frustrating. All of a sudden, the two systems are the enemy.

So this pilot program I think can hold a lot of promise as to how

can this system become more user friendly and, therefore, in the

eyes of those who are using it, become more of a solution than a

problem.

As I understand, you are the ball carrier, if you will, for the pilot

program. Can you give us any insight on how far along you are in

working out a plan with the VA or is that just too early?

General SCHOOMAKER. No, sir. Actually, the pilot began in November. I understand there are 100 soldiers or service members in

it right now. I think two or three of them have cleared the process

and have completed their adjudication and are into the VA system.

But I will also say, candidly, sir, that the Congress has not fully

executed the Dole-Shalala recommendations. I think the DoleShalala commission and the independent review group both very

thoroughly looked at the disability adjudication process and concluded, I think, what many of us in uniform have known for our

entire careers.

We have a system that is over 50 years old that was devised for

a World War II generation of soldiers, sailors, airmen, Marine,

Coast Guardsmen, that when we had an all—not an all volunteer

force, but a conscripted force, when we did not have a TRICARE

health care benefit, when most of our soldiers, sailors, airmen were

not married.

Now, in the Army, we have a largely married force, with an extraordinary health benefit called TRICARE that every soldier and

his or her family is looking to get if they have a medical disability.

And we have a complexity of especially mental health challenges

that are not well codified within the disability process.

So what we are doing right now through the pilot is essentially

to speed up a process and reduce bureaucratic hurdles in a process

which is fundamentally flawed, and the fundamental flaw is that

the military, under Title 10, has got to determine the fitness for

duty of the soldier, sailor, airman, Marine, Coast Guardsman and

should, and it should retain that, but then adjudicates on a table

very similar, in fact, it is an identical table to the VA, what the

disability for that one disabling condition is.

And then we turn to the VA, using the same tables and the same

physical exam, if we get a single exam to do that, and allow the

VA to then use the whole person concept to determine how well

will they be able to be employed, what is their quality of life.

And so the typical soldier sees the constellation of problems they

have, arthritis, sleep apnea, an injury residue, determined by the

Army, Navy, Air Force or Marines to have a disabling condition

with a single set point for that disability and then go to the VA

system, see the same constellation of systems, but then looked at

from the standpoint of a whole person and being given more and

ask themselves, ‘‘Why does the Army value me less than the VA

system does?’’

35

And especially when a threshold for receiving health care benefits is 30 percent, that can be a major difference. I can give you

cases. A 10-year veteran military policeman trashes his ankle

through duty while in Korea. He comes back. We can’t fix his ankle

above one that can’t run long distances and certainly can’t ruck 80

pounds for 12 miles.

And so he is determined to be unfit to serve as a combat Military

Personnel (MP). He has got three children under the age of seven

and a non-working wife and he will be separated from the Army

with an unfitting condition for that ankle.

He also has shoulder arthritis and sleep apnea, 10 percent, 10

percent and 20 percent for the ankle. The Army separates him at

20 percent disability, no TRICARE benefits.

He goes to the VA. They say total person concept, 40 percent disability, but you have already been through the military assessment

and you don’t get TRICARE benefits. You get a separation bonus

from the Army for $28,000.

He comes to my office and he says, ‘‘I have got three children

under the age of seven. I have served ten years. I am not going to

have a retirement from the Army. I can’t do an Army job. But what

am I going to do with the $28,000 and no health benefits?’’

Sir, that is the centerpiece of our problem and that is the seam

in the seamless system between the DOD and the VA.

Mr. MCHUGH. And I appreciate your saying that and it is important to say it, and I was heartened by the President’s comments

during his ‘‘State of the Union,’’ a rededication of Dole-Shalala.

And I know everyone on this committee, both sides of the aisle,

feel the same way as the timing came with respect to the militaryto-civilian move within the medical health corps. The Dole-Shalala

commission report didn’t give us a lot of time to look at it.

But I know we are going to continue to do that. It is absolutely

critical. The basis by which you are retired out of the Army is, as

you have noted, far different than out of the VA. One is a lack of

the ability to serve in a uniform. The other is a lack to survive in

life.

But we have got to bring continuity to those two and this pilot

program, as much as you have pointed out, absolutely correctly, the

structural challenges that Congress needs to change, but the pilot

program and the bureaucracy piece of that, I would argue, is important, too.

General SCHOOMAKER. Absolutely.

Mr. MCHUGH. We are looking forward to your development on

that and we have just got to do better. I mean, that is the bottom

line. And turn our images, if you will, all of our images into what

we want it to be, and that is collectively individuals and organizations that are deeply appreciative for the sacrifices these people

make and need to share that in very real ways.

General SCHOOMAKER. Yes, sir. My only concern here, I will be

very straightforward, is when you speed up a bad process, all you

have is a fast bad process.

Mr. MCHUGH. I agree.

Mrs. DAVIS. I think we all agree we need to solve this one and

there isn’t a consensus within the communities that are affected by

it either.

36

General SCHOOMAKER. Yes, ma’am.

Mrs. DAVIS. We need to work toward that.

Mr. Kline.

Mr. KLINE. Thank you, Madam Chair.

I am going to switch directions quite a bit here.

We as a Nation, you as the Surgeon General have been placing

a lot of emphasis on traumatic brain injury and PTSD and some

of the stresses that have been associated with the combat in Iraq

and Afghanistan, the nature of the weapons, all of those things,

and I think that is very appropriate.

I know that members of this committee have also spent a lot of

time looking at those issues. But, still, we have over 80 percent of

our injuries are extremity injuries. I think 82 percent was the last

number I saw. A lot of cases of legs, particularly, but legs and

arms.

And we are putting some resources into that. I was talking to

General Roudebush beforehand. I know there is some peer reviewed sort of joint effort going on between civilian orthopedic efforts and military to make sure that we are doing the best that we

can for these wounded warriors, where so many of them have these

wounds, and we have seen tremendous examples of—in fact, we

had in this hearing, I think, a couple of years ago, we had a Marine

and an airman who had artificial legs and they were in uniform

and looking great and proud and the Marine had just come back

from his second tour in Iraq and after he served with that artificial

leg.

But my question is, have we let that emphasis on Traumatic

Brain Injury (TBI) and PTSD pull us away from this orthopedic effort and should we look at putting some more emphasis and resources into that effort? I will just throw it out for any of you who

have a comment.

General SCHOOMAKER. Let me just—and I certainly would welcome my colleagues’ observations or thoughts about this, but let me

just say something quickly, sir.

You often hear people talk about one wound or another wound

being the signature injury of this war. I am here to tell you there

is no single signature injury, in my view. There is a signature

weapon. The signature weapon is blast. The signature weapon is

blast.

It is very effectively used by an adaptive enemy and that blast

takes off limbs. It blinds. It deafens. It burns. It causes traumatic

brain injury from the mildest concussive form to the most severe

penetrating form that, frankly, our Navy colleagues at Bethesda

are leaders in the world in a combined team and getting better.

And the context of all of those physical injuries leads to posttraumatic stress later.

We have in the Department of Defense now, through the help of

Congress, focused all of the work in blast injury in the series of research programs that are being administered through the United

States Army Medical and Research and Materiel Command, under

the Assistant Secretary of Defense for Health Affairs, the Principal

Deputy Assistant Secretary of Defense for Force Health Protection,

Ms. Ellen Embrey.

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And that program of blast injury I think is answering the question that you just asked, and that is are we keeping balance, are

we looking at all the gaps where research and where care needs

to be administered and are we doing the appropriate things for all

of the elements of the signature weapon, which is blast.

Mr. KLINE. Anybody else?

General ROUDEBUSH. Yes, sir. Congressman, I think you very

rightly make a case for being sure that we keep track of all elements of the constellation of injuries that we are seeing.

In terms of the orthopedic extremity trauma research, the Army

Institute of Surgical Research, with work with Air Force surgeons,

Navy surgeons, Army surgeons, working collaboratively on the joint

trauma system which exists today in Iraq and Afghanistan, have

been instrumental in identifying both the wounding patterns, but

also the treatment modalities that begin to allow us to salvage, if

you will, at the first opportunity to resuscitate, to look at these injured men and women in a way that we begin thinking about recovery at the very first opportunity to resuscitate.

That kind of collaboration has been key. Dr. Andrew Pollock, a

leading trauma surgeon at Baltimore Shock Trauma and a leader

within the American Academy of Orthopedics, with a particular eye

toward trauma, has, in fact, gone downrange to our Air Force theater hospital at Balad and participated with us in both providing

that care, but also helping teach us, learning from our experience,

collaborating with those folks forward.

It has been a very productive relationship. Now, research becomes the crux of this, because if we are, in fact, to take that experience and begin to translate that into opportunities to help us all

do better in taking care of trauma, both in the military sense and

in the civilian sense, the research is critical to that.

So I think to the extent that we can foster and encourage the research activities that are already present and put those forward, I

think that would serve us all very well.

Thank you for your interest in that, sir.

Admiral ROBINSON. Thank you very much, also, for the question.

I agree with both colleagues, General Schoomaker and General

Roudebush.

I would only point out this one thing. Amputations are—and research needs to be done and the research needs to be done also in

terms of the limbs and the biomechanics and the future is really

abounding with opportunities.

So I think that, in the future, people are going to have even better modalities of extremity care and prosthetic care and both from

the impact and both from the surgical research and tissue regeneration, these are all things that have to be done.

The emphasis I want to put is I think that, traumatic brain injury, and post-traumatic stress disorder is something that is unseen and we don’t know what we don’t know. With a limb, you do

know there is an amputation. You don’t necessarily know how far

you can take that individual in recovery, but you still are starting

with a little bit better understanding of what you have.

With post-traumatic stress disorder and with TBI, you don’t

know, and that compounded with the stressors of combat make for

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mental health and mental conditions that we haven’t really fathomed yet.

So I would only suggest that—and I would agree with General

Schoomaker. I think blast is the signature weapon, but that is the

emphasis and I think we can go back to Vietnam, because the

PTSD that developed in the veterans who were not treated, because we didn’t even look at that, and now we are seeing 25 and

30 years later, now 35 years later that that was a very important

thing.

So I would only point that out.

Mr. KLINE. Thank you very much.

And thanks for your indulgence, Madam Chair.

Mrs. DAVIS. Thanks.

Mr. Wilson.

Mr. WILSON. Thank you, Madam Chairwoman.

Again, I want to thank you and I want to thank you and I want

to thank your colleagues for your obvious genuine care and concern

for our soldiers who have made—sailors and Marines who have

made such a difference and they are heroes for all of us.

Also, Madam Chairwoman, this has just been a terrific meeting.

I appreciate your leadership.

And I want to conclude my part with an invitation and that is

for our colleagues, for you, for staff people, and that is that there

is a movie that has been made about uniformed services called

‘‘Fighting for Life’’ and we have had a screening here on Capitol

Hill. I was very honored with Congressman Chris Van Hollen to

have this screening.

We are going to be doing it again, because it was such a wonderful movie and it is going to be released across the country. But in

the promo, Madam Chairwoman, sometimes it is a bit exaggerated.

This is understated, and I want to read it. It is a new film by

two-time Academy Award winner Terry Sanders, ‘‘a powerful, emotional and dramatic film about the fight that begins when the battle ends. It is today’s story of young wounded soldiers, American

military doctors and nurses in a time of war, and the West Point

of military medicine, USU, the best medical school no one has ever

heard of.’’

And so it is an extraordinary movie. I am very grateful here in

the capitol area, at Bethesda, on March the 14th, Bethesda Road

Theater, in Washington at the E Street Theater, and it will be

shown across the country.

But it is an extraordinary, moving film of the success of military

medicine.

Thank you very much.

Mrs. DAVIS. Thank you.

And thank you, gentlemen. We certainly want to acknowledge

the great strides made in medicine, of course, but also in the last

year in trying to make certain that the men and women who serve

and who are injured get the kind of support and care that they

need, and we greatly appreciate that.

I can assure you that this committee will provide continuing

oversight on this issue and I am wondering when you feel it is an

appropriate time to come back and look at some of the ongoing

challenges, some of the gaps perhaps that you think still need to

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be filled as we continue to move forward, and when we might be

able to evaluate some of that continuing progress.

Is it six months, a year?

Admiral ROBINSON. From the Navy’s perspective, I think a year

is too long. I think a six-month timeframe would be very good.

General SCHOOMAKER. I would concur. I think one of the concerns we all have is about the transition that may take place in

the enduring programs that have been established here. I think six

months is a very good time. Yes, ma’am.

Mrs. DAVIS. Okay, we will certainly do that. And continue,

please, to ask the questions, questions that we don’t know yet, but

we don’t we don’t, what we haven’t asked, and particularly, as we

move forward with research, that we are tapping really all the

tools that we have to answer some of the questions that are out

there.

Thank you very much. Thank you all for being here.

[Whereupon, at 12:02 p.m., the subcommittee was adjourned.]

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