Q&A: Major General James K. Gilman
Written by Ted McKenna
Commander
U.S. Army Medical Research &
Materiel Command and Fort Detrick
Major General James K. Gilman hails from Hymera, Ind. He is a 1974 graduate of Rose-Hulman Institute of Technology with a degree in biological engineering and received his M.D. degree from Indiana University School of Medicine in 1978.
Following a categorical medicine internship and residency in internal medicine at the Brooke Army Medical Center (BAMC) at Fort Sam Houston, Texas, Gilman served as the chief resident in medicine at BAMC and then as staff internist and chief of the internal medicine service at the U.S. Army Medical Department Activity in Nurnberg, Germany. He then returned to BAMC, where he completed a fellowship in cardiovascular diseases and served as a staff cardiologist. In 1991, Gilman completed a fellowship in clinical cardiac electrophysiology at the University of Texas Health Science Center at Houston. He then served as chief of cardiac electrophysiology and assistant chief of the cardiology service at BAMC. From 1994 until 1997, he served as chief of cardiology and director of the Cardiology Fellowship Program at BAMC. In 1995, he deployed to Haiti with the 2nd Armored Calvary Regiment in support of Operation Uphold Democracy.
Subsequent assignments include deputy commander for clinical services at Darnall Army Community Hospital, Fort Hood, Texas; deputy commander for clinical services at Madigan Army Medical Center at Fort Lewis, Wash.; commander of the Bassett Army Community Hospital, Fort Wainwright, Alaska; acting assistant surgeon general for force projection at the Office of the Surgeon General (OTSG); director of health policy and services at the OTSG; and commander of the Walter Reed Health Care System. Before coming to the U.S. Army Medical Research and Materiel Command, Gilman served as commander of the Brooke Army Medical Center and Great Plains Regional Medical Command in San Antonio, Texas.
Gilman is a graduate of Command and General Staff College and the Army War College. He is board-certified in both internal medicine and cardiovascular diseases. He is a fellow of the American College of Cardiology. Military awards and decorations include the Distinguished Service Medal, Legion of Merit (three Oak Leaf Clusters), Meritorious Service Medal (two Oak Leaf Clusters), the Army Staff Badge and the Expert Field Medical Badge. He also is the recipient of the surgeon general’s “A” proficiency designator and a member of the Order of Military Medical Merit.
Gilman was interviewed by MMT Editor Ted McKenna.
Q: Given your medical background, is there any of the work here that you’d note as being of particular interest to you personally?
A: I’ve spent all of my career to this point taking care of patients in military treatment facilities. The last five years in particular, a year at Walter Reed and then four years in San Antonio, a large portion of what I’ve done has been taking care of soldiers, sailors, airmen and Marines who get injured in Iraq and Afghanistan and evacuated back. There are lots of individual things that I’ve grown interested in, including amputee care and rehabilitation medicine in general. Because I just came from DoD’s only burn center, the care of the burn patients is [also] something that I’m interested in.
But if you pull back from that a bit, one of the things I find very interesting is the complexity of the injuries on the battlefield today. Nobody just has an amputation, or very few people do. These warriors get blown up. When you get blown up, there are lots of things that happen. Some of it may be an amputation, some of it may be a burn, some of it may be functional loss—that is, you’re left with digits or extremities that are still present, but they don’t work very well. Then there are the psychological health aspects of what’s happened to them and the social and familial issues. So one of the things that I’ve gotten very interested in is how big this therapeutic team and treatment and rehabilitation team has to be to cover all that.
Q: Because it’s not just, as you say, one aspect to an injury, it’s all these different pieces of the medical care system that have to come together to look after someone.
A: Yes, and certainly there has to be some direction. There has to be somebody who’s the captain of the ship, as the Navy would say. But I don’t know that it’s just the world-famous doctor, or the world-famous surgeon who knows all and can do all. I’m more and more impressed that the person who assumes the management role in all this is the person who actually is able to listen to all these different disciplines, and then integrate that information into a very holistic plan that takes into account all these different things that are wrong with a patient, and all the things that have to be worked on.
That’s the only way to achieve the best outcome. If you take a severe cranial facial injured patient, on that team may be a neurosurgeon, a plastic surgeon, an oral and maxillofacial surgeon, an ophthalmology surgeon and an [ear, nose and throat] ENT surgeon. Quite honestly, you can have world-class experts, and if somebody isn’t integrating and pulling information together and deconflicting information, you can still not get the best result for the patient.
Q: Do you think DoD has gotten better at putting all that care together? Is it basically a human resource or personnel management issue?
A: It all starts with being sound clinically. But, also, I think the physician manager or integrator is often one of the best listeners that you’ll ever find. Because they have to take information from all these different disciplines and incorporate them somehow into a plan, rather than imposing some external plan that will work for some aspects of the care but not for all of them.
Q: There are a lot of efforts related to electronic health records, but good management of patients requires more than that, right? There needs to be a human element to the management.
A: Electronic health records do facilitate what we’re talking about very much because, again, it’s very hard and time-consuming to put all these people in the same meeting rooms all the time. Some of that has to happen, too—care team meetings and multidisciplinary team meetings. We do a lot of that now, and didn’t used to do so much of that. But having all this information in a health record that can’t get lost is a pretty important part of that.
Q: Here at Fort Detrick, there’s an amazing variety of work going on. I imagine it’s like Bill Gates at Microsoft: He understands the work that everyone’s doing, but doesn’t follow every detail of all the software developers there. In your role, are you essentially a manager of the various research going on, but not typically closely involved in it? How do get up to speed on all these activities?
A: There are different layers. At the level that’s just below my level, I have two principle assistants, one for acquisition and one for research and development. Colonel [Jeffrey] Davies is the chief of staff and has very deep roots in this command and knows how it works very well. And the command sergeant major, who knows the soldiers. Then I have the six laboratories that have very senior military officers in charge of them, and we have a way of communicating, occasionally meeting in person, more regularly by teleconference, and then we have a regular exchange on e-mail that helps me keep abreast of what’s going on in those areas. That pretty much covers a lot of the intramural business. The extramural business is something that I’m still getting my arms around.
Q: What does that mean, “extramural”?
A: That would be the areas where we partner with universities or private industry. I’m still learning that part of the business and how to make sure I stay abreast. But each one of those has a product, project or program manager whose job is to monitor that and let me know if there are any issues.
Q: Medicine and academia always seems to involve a lot of collaboration among universities and other groups. I would think that’s been the case with DoD, but is that true now even more than ever?
A: I think there’s more emphasis on the collaboration. I think there’s collaboration among the different military services within the Department of Defense, because we all face some similar challenges in terms of medical research and development. There’s also collaboration in the interagency environment. Good examples of that would be the National Interagency Biodefense Campus located here on Ft. Detrick. DoD, Homeland Security, the National Institute of Allergy and Infectious Diseases, and CDC are working to collaborate more closely on projects, especially biodefense threats and ways to defend against them.
Q: Is that a particular emphasis right now? All the things here would be important, but is there a particular research area that’s seeing a lot of emphasis right now?
A: The Interagency Biodefense Campus is of interest to lots of people and a big focus area. That’s not to say that stuff that goes on in combat casualty care research, or infectious disease research, or chemical defense, isn’t just as important. But I do think that in the wake of the anthrax attacks of 2001, that type of defense has gotten a great deal of focus.
Q: The biomedical research groups here, working on fatigue, environmental conditions, metabolism—that seems like a really interesting area as well.
A: The U.S. Army Research Institute for Environmental Medicine in Natick, Mass., is one of the six core laboratories. Obviously we go to parts of the world where there are environmental extremes and knowing how to deal with those as well as we can, knowing how to train to be able to deal with those sorts of issues, knowing how to take care of ourselves when we reach a point in terms of environmental stress where we’re not as effective as we ought to be or we need to pull back and take a little time to regroup before we launch our next initiative— that’s all very, very important. And not just for the Army, but for all the services.
Q: There again, it seems like something that’s not just a piece of technology that lets you do that; it’s psychological factors as well. So it’d be a very multidisciplinary area of research.
A: Absolutely. It does require a whole group of people who are involved in the evaluation of stress.
Q: Going back to what we were talking about at the beginning, are there successes for treatments related to injuries suffered in Iraq or Afghanistan that you’d point out in particular?
A: Soldiers who die on the battlefield that you can do something about die of a pretty small number of things. They die of hemorrhage, they die of airway problems, and they die of pneumothorax. [That’s] when you have a hole in the lung that lets air out and it accumulates around the lung, presses on the lung, and keeps your lung from being able to expand.
Of those [things], the cause of the greatest number of deaths and severe casualties on the battlefield is hemorrhage. We have made a lot of effort and a significant amount of progress in the way we resuscitate those patients in terms of trying to balance all the different things they get—they get fluid, they get plasma, they get blood products, they get platelets, they get things to try to help the blood clot. Trying to do that in a way that makes sense scientifically based on research in our laboratories and what we observe in patients on the battlefield would be one big area, in addition to employment of hemostatic agents. Things that we can put directly on something to try to stop the bleeding.
Q: Like the QuickClot?
A: That didn’t come directly from us. That was at the start of the war. Our latest is something called Combat Gauze—that’s the latest project that we’ve had some role in the development of. So [there’s] hemorrhage control and the use of the tourniquet that every soldier now has in their Improved First Aid Kit—the Combat Application Tourniquet that [we] tested and were in involved in the development of.
Q: That seems like a simple technology.
A: Yes, there are no microchips in there. The injury has to be in the right place for us to be able to apply a tourniquet, but we can in many of the extremities, and many of the injuries in this war are to the extremities. And the way we replace the loss of blood with appropriate blood components and fluids, I think those are the things in Iraq and Afghanistan on the battlefield that have the most direct connection to MRMC.
Q: Any other sorts of trends or technologies here that you would highlight? The viruses have been in the news for civilians, and I know the military does work related to the swine flu, for example.
A: We obviously are concerned about potential exposure and illness due to infectious diseases in parts of the world where we may be called, and things for which may not be in the United States, and therefore commercial firms in the United States are not especially interested in the work always, because they’re not as much civilian threats as they are threats to our military. Like malaria. We’ve had a role in the development of almost every anti-malarial vaccine.
Q: Is there not a vaccine for malaria? Or just not for the different strains of it?
A: Malaria is an organism that seems to change over time. It’s kind of hard, but we are involved and have been involved for a long time in the development of malarial vaccines and trying to test their effects and efficacy in populations to see if there’s one that not only would help us but also would help any indigenous populations, too. WRAIR has been extremely successful in developing and field testing antimalarial drugs, such as mefloquine, halofantrine and tafenoquine, which provide treatment alternatives for drug-resistant strains.
Q: You’re also working on a needle-less DNA vaccine that seemed interesting as well. So it seems like you run the gamut from super high-tech research and development to simple but effective solutions like the one-handed tourniquet.
A: One of the newest DNA vaccine delivery methods is being studied at USAMRIID and relies on technology that delivers the vaccine directly into cells. The needle-free vaccination method is more cost-effective and less painful for the recipient. When you know somebody’s going to be exposed, there’s no limit to the amount of science and technology that can be in that solution. But you’re going to have somebody [using it] that doesn’t have lots and lots of medical training, and must do so within 60 to 120 seconds, in a very chaotic battlefield situation. That requires a low-tech solution. You can put all the technology into the device, but at the end of the day, it’s got to be simple and easy to use, and it has to be something you can train a soldier to do in a very short period of time. So we’re involved all along that whole spectrum, from a low-tech but fully tested and validated battlefield tourniquet to some pretty exotic vaccines and novel delivery systems.
Q: What’s your medical background?
A: I’m a cardiologist. My special interest was in cardiac rhythm problems. Cardiologists come in different flavors; there are plumbers and there are electricians, and I’m a cardiac electrician.
Q: Do you miss doing that kind of work? I imagine it’s like a really good teacher at a school who gets promoted to principal and then misses teaching.
A: I do a little bit. I don’t miss the procedural cardiology that I used to do very much; I do miss seeing the patients in clinic. A patient comes to see you, you diagnose a problem and you implement a solution. If everything works out fine, then there’s a pretty direct source of gratification in that for a health care provider. Something I did really helped that patient. Here the view is a little more strategic. What can we do to protect the soldier on the battlefield? What can we do to better prepare them mentally, psychologically and physically for what they’re going to do? What information products help their families deal with issues that soldiers experience? What do we put in the hand of soldiers that ensures that if something happens to them, their chances of survival and recovery are as high as they can possibly be? Then what do we look to develop and put in the hands of our fixed facilities, our military treatment facilities back here that will help those soldiers, sailors, airmen, Marines have the best chance of a full recovery?
Again, over the course of these wars in Iraq and Afghanistan, that has included a big investment in rehabilitation medicine, which is the newest research area directorate that’s been stood up here at MRMC.
Q: Our magazine has always been interested in prosthetics. People talk about how the commercial world doesn’t have much incentive to invest in that kind of development, because the consumer market is relatively small, but that the military has much more interest and incentive in that kind of research and development.
A: We have a different population than the commercial sector has. Many civilian amputees are older; many have vascular disease—problems with the arteries or diabetes.
Q: And that makes it more difficult to develop prosthetics for them?
A: Even when optimally rehabilitated, they’re not going to be back doing things that are very physically vigorous—what we call our tactical, athletic endeavors. So we have these younger patients that have amputations, and they don’t have the other things that the older patients have—the vascular disease.
Q: They maybe want to play basketball or tennis?
A: They want to do everything, even if they didn’t do it before they had an amputation. They are not going to be content in most instances to sit in a chair. They want to walk, and then they want to run and then they want to go up and down stairs. They want to do as much as they possibly can. Before they were injured, that was their life. They were active. That’s something they learned being in the military, and they want to be active. Thankfully, we’ve had the resources to try to help them do as much as they can do.
Q: Any final thoughts on other things NRMC is working on?
A: All of our research efforts are closely examined by external reviewers that are subject matter experts in their own right. They evaluate our projects and programs to ensure we have high-quality science that’s relevant to the military. But they also help us find areas where there’s overlap or even potential duplication of efforts outside DoD. We’re not intent on doing it all ourselves. If somebody else can do it and give us what we need that is militarily relevant, we’re generally pretty happy with that.
In addition to collaboration with our other uniformed services and our agency partners, we also involve outside subject matter experts, from national and international committees in helping us to design and oversee our research efforts. Folks like the National Academy of Sciences’ Institute of Medicine, the National Institute of Health’s AIDS Research Advisory Committee, and the International Society of Travel Medicine. Many great Americans from groups like that help us to determine our research priorities, and also, in some instances, partner with us as we go forward. The Bill and Melinda Gates Foundation and many senior scientists who edit journals are also involved.
Q: A lot of the benefits of what you develop may be different than weapons systems that are classified or proprietary. A lot of these things can benefit humankind in general.
A: I just visited the Museum for Civil War Medicine, which is right here in downtown Frederick. We have a partnership with them, and one of the exhibits there notes that every significant advance that occurred in wartime in military medicine was very soon exported to the commercial sector and civilian medicine as well. Everything from medical evacuation to trauma resuscitation, burn care and the like. Almost everything we do in that regard can be translated if there is a commercial model that makes a profit.
Q: So just about everything you do can become common knowledge and things that everyone can use.
A: Our first responsibility is to the servicemember, but a lot of what we do can translate into the civilian population. We move forward and reap the greatest benefit by working in partnership with a lot of people, not just in the United States but around the world. ♦