Dawn of a New Medical Era
Written by Walter Reed Army Medical Center public affairs team
MMT 2009 Volume: 13 Issue: 7 (October)
EVOLUTIONARY MEDICINE
THE FOUNDING CONCEPT
BY SHERMAN L. FLEEK
As the 20th century dawned, the medical community, especially in the United States, was in the midst of a dynamic revolution of research and professional education. The concept of combining medical treatment, research and education together was a new and exciting concept often termed as “teaching hospitals” at that time.
Though other medical institutions may have pioneered the teaching hospital concept, the Army developed a more advanced vision of medical treatment, education and research by the early 1900s with the “medical center” concept.
One medical officer who clamored for a new idea of reform and medical advancement was Major William C. Borden (1858-1934), who later became a lieutenant colonel. In 1904, Borden, the Washington Barracks (later Fort Leslie McNair) hospital commander, envisioned a concept, now called “Borden’s Dream” that was the framework for the future Walter Reed Army Medical Center. His vision combined separate medical institutions together at one location and under the authority of one Army medical officer.
These institutions conceived by Borden comprised four parts: the Army Medical Museum, established in 1862; the Army Medical School, in 1893; a general hospital; and the Army surgeon general’s medical library—all located together and part of one institution. All of these components eventually did in fact come to Walter Reed (except the surgeon general’s library).
Borden took his proposal to Congress in 1905 to lobby and gain financial support. One of the congressmen labeled his vision a “dream,” which was not a positive remark. The title “Borden’s Dream” stuck and is now part of the legacy of Walter Reed.
THE GREAT EXPANSION
BY SHERMAN L. FLEEK
During Walter Reed’s 100 years of service, medical care, staff, organization and grounds have all experienced change and advanced steadily on. The greatest and most expeditious change here has always been spurred by war, and there was perhaps no greater universal transformation at Walter Reed than during World War I. It was called the “War to End all Wars,” the “War to Preserve Democracy,” and also the “Great War,” until we learned how to number wars.
The Army was already in the midst of a transformation from decades of frontier service as a constabulary force into a modern “combined-arms” force. The war, however, pushed this transition more quickly, with the small regular Army of some 60,000 men expanding with draftees and National Guardsmen to some 4 million in just one year.
Walter Reed General Hospital, too, expanded and conformed as a result of modern warfare and more lethal technologies. The original hospital had 80 beds when it opened May 1, 1909. During 1914 and 1915, two small “ward” annexes were added to each end of the original Walter Reed hospital (Building 1), increasing the hospital’s capacity to some 150 beds. Almost overnight, buildings, roads and tents sprung up on the garrison. Walter Reed soon had more than 2,500 personnel. Dozens and dozens of mostly one-story wood, frame buildings were built, each taking just a few weeks to throw together.
Sadly, the severely wounded of modern warfare began to arrive—first dozens, then hundreds, and finally more than 2,000 wounded and sick were treated at Walter Reed from 1918 to 1919. During the last full year of peace, 1916, Walter Reed admitted 1,350 patients. In 1918, the only full year of war for America, there were 13,362 admissions. The war also brought the grievous wounds of increasing severity and number, especially the loss of limbs.
Walter Reed soon staked out a reputation as a pioneer in physical and occupational therapy and became world renowned in helping soldiers recover from serious wounds.
Another result of the Great War was poison gas. The terrible effects of mustard, chlorine and phosgene compounds caused the staff and healers at Walter Reed alarm as they faced a sphere of treatment that was new, horrifying and the cures unknown.
A NEW ERA AT WALTER REED
BY CATHY SORGE
By the mid-1960s, the original hospital at Walter Reed was showing its age. It had served the Army well through World Wars I and II, Korea and Vietnam. But while patients were receiving treatment in overcrowded, outdated wards scattered around the post, it became apparent that a larger, centralized, technologically advanced medical center was necessary.
In the summer of 1972, Army officials broke ground on Building 2, a state-of-the-art health care facility that would better serve the military medical community.
The new hospital was dedicated September 26, 1977. The 1,280-bed facility was designed with the needs of the patient in mind.
In 1994, Building 2 was named in honor of Lieutenant General Leonard D. Heaton, the former Army surgeon general and commander of Walter Reed who spoke before the Senate during the 1960s on behalf of constructing the new hospital, and who was largely responsible for making it a reality.
PRACTICAL R&D
NEW SURGICAL CARE UNIT
BY SHARON RENEE TAYLOR
The new surgical intensive care unit (SICU) at Walter Reed Army Medical Center opened its doors to six patients September 21.
Located on the fourth floor in the northwest corner of the hospital, the new SICU occupies Ward 46. The design of the 12-bed unit incorporates a patient- and family-centered focus that maximizes staff space and time, officials said.
WRAMC admits between 60 to 80 patients to the SICU each month, according to Owen Curran, the unit’s head nurse. He explained patients are treated on the ward because they’ve experienced high-risk surgery, trauma or an acute life-threatening illness and need life-sustaining equipment, or must receive medications to regulate their heart rate or blood pressure.
“The construction lends itself to decrease cross contamination and hospital-acquired infection,” said Curran, who also explained that the design helps to disperse staff throughout the unit, placing nurses at the patient’s bedside.
Windowed kiosks situated between every two rooms allow the attending nurse to keep an eye on their patients while entering notes at the nursing station. The unit’s new technology also enables the nurse to view the status of one patient on a split screen in another patient’s room without compromising patient privacy information. The split screen shows alerts and patient emergency situations throughout the ward.
The new SICU design also includes nine rooms for all patients and three rooms for patients needing more space to accommodate dialysis machines, vents, balloon pumps, traction devices or specialty beds. In addition, the rooms have Internet connection capability.
“It’s for our more complicated critical care patients,” explained Terri Tatum, a nurse on Ward 46 involved in the unit’s transition. Every SICU patient room contains its own mobile supply cart to store medical supplies such as IV starts and wound dressings. Medicine specific to each patient can be securely stored at their bedside.
A nourishment room for family and patient food storage inside the SICU and a large family waiting room with internet access and a big flat screen TV round out the new family-focused amenities.
Tatum explained the unit’s L-shaped design increases workflow with two nursing stations on each end of the SICU and helps traffic visitors who enter through a single main entrance. The unit contains a separate entrance for staff.
Physicians enter notes from their own workstation, “allowing for increased efficiency and comfort in the work environment,” Curran said.
Physicians rest in a sleep room located on the unit, providing quick access for SICU nursing staff and patients.
After the SICU transition, Tatum said plans include moving the medical intensive care and step down units next door to the SICU.
“This configuration helps the physician and makes it easier to do patient care,” Tatum said. “Communication will be easier, and if there’s an emergency, they’re just two doors away.”
CREATING AN EYE
BY CRAIG COLEMAN
Eyes don’t normally bring a dental office to mind, but soldiers and retirees who have lost an eye go there to find Louis Gilbert, a dental technician with a very specialized skill—he creates lifelike prosthetic eyes by hand.
Gilbert, a retired Navy dental technician, received training in maxillofacial prosthetics, the craft of creating replacements for missing eyes, ears, noses and other parts of the face missing through wounds, defects or cancer, while serving in the military.
Gilbert began making ocular prosthetics nine years ago, when he chose to attend the Navy’s advanced Dental Laboratory Maxillofacial advanced “C-School,” on the campus of the National Naval Medical Center in Bethesda. He had served 13 years at that time, and he said the decision to change specialties had a negative impact on his Naval career, but it was worth it.
“In the end, it was the best decision for me and my family,” Gilbert said. “I’m able to really do what I love doing, and it’s just a great job. I think it’s the best job in the dental field—the most rewarding job.”
The job entails a two-day, multi-step process. An impression of the socket missing the eye is made, then a mold is created from the impression. Next, the remaining eye is measured for iris and pupil size. Then an iris is attached to the mold and inserted into the socket to check the alignment of the iris in the socket.
After ensuring proper size and alignment, a mold is made in white acrylic that resembles the sclera, or white part of an eye. Fitting and adjustments are completed, then the iris is painted. Red strands of thread are used to create veins in the eye matching the remaining eye, then a clear coat is added.
“The materials we use to make eyes— acrylics—are the same materials we use to make dentures,” Gilbert explained. “It’s just an eye instead of a tooth.”
The maxillofacial “C” School prerequisites include “a high level of manual dexterity and artistic ability.” They come into play when the dental tech paints the ocular prosthetic iris, not with computer imaging equipment, but by hand, requiring what Gilbert calls an “artistic eye.”
“With the irises, it can sometimes be hard to match up with the patient’s eye,” he said. “The hardest part is the color, because if it isn’t right the patient’s not going to like it. And if he doesn’t like it, he’s not going to wear it. If it doesn’t fit right, the patient’s not going to wear it, either. He’ll let you know.”
Gilbert first sees patients eight to 10 weeks after surgery. After the initial swelling in the socket recedes, he makes their first pair of eyes, one for indoors and another for outdoors, since pupil size will vary with the amount of light available. Six months later, the patients are recalled for another fitting and a new pair, since the swelling will continue to recede and the originals will no longer fit well. Finally, six to nine months later, another measurement and a final set is created. Gilbert follows up with each patient annually after that to check the eye socket and to clean and polish the ocular prosthetics.
Since coming to Walter Reed more than two years ago, Gilbert has created ocular prosthetics for 114 patients. Ninety percent were wounded warriors. Gibbons said the feeling of giving back to soldiers who have sacrificed is important: “A lot of the time the soldiers may not feel appreciated for what they’ve done, so for me to give back to them and the feeling it gives them—it’s priceless. Priceless.”
REAL-LIFE BIONIC MAN
BY CRAIG COLEMAN
Lieutenant Colonel Greg Gadson, a bilateral above-the-knee amputee, stood in bright sunlight on the patio of Walter Reed’s Building 88 on April 17. A pack of reporters pointed mini-audio recorders, and a clutch of television cameramen rolled tape. The wounded warrior’s prosthetic legs looked, with their composite construction and gray-on-silver design, like futuristic sci-fi movie props.
Gadson is the first person to use the completed version of the Power Knee2, a nextgeneration powered prosthetic knee featuring new artificial intelligence and sensor technology that makes it possible for above-the-knee amputees to walk with increased confidence, safety and a more natural gait.
Earlier, Gadson walked on his new bionic legs from the Military Advanced Training Center (MATC) to Building 88 flanked by his doctor, Lieutenant Colonel Paul F. Pasquina, chief of integrated orthopedics and rehabilitation at Walter Reed Army Medical Center and the National Naval Medical Center, and his prosthetist, Michael Corcoran. The trip across the street went smoothly, with Gadson using two canes for balance.
But one week earlier, on April 9, his first training session with his new knees was more challenging.
Gadson walked gingerly around the MATC indoor track that morning. The powerfully built former West Point football star marched step after step, connected by a long cable to the overhead oval support system, a pulley and rail that keeps patients from falling to the ground while they practice walking. He took one, two, three steps—then one of the knees buckled, and he was left swinging by the tether cable. Corcoran, the prosthetist, helped him stand again. Gadson lost his balance often, but each step was a small victory. With each stumble, engineers from Ossur, the prosthesis’ designer, tapped furiously at a laptop keyboard connected to the prosthetics by Bluetooth, making adjustments based on Gadson’s gait.
Corcoran said that Gadson’s willingness to fall was key to his ability to help the design team. He said people learning to walk on prosthesis who are afraid to fall won’t push themselves.
“Basically, he’s perched up on these prosthesis, and that’s a long way off the ground,” Corcoran said. “Imagine you’re standing on a table and lose your balance. It’s a similar feeling. For him to be able to pick himself up and carry on has got us to this point. It’s a testament to [Lieutenant] Colonel Gadson that we’re here.”
Pasquina said the medical team tries to challenge the available technology in order to give the patient as much mobility and independence as possible. They simulate movements ordinarily made in the home, like climbing and descending stairs. Pasquina noted the new knee is not a military application. “The intent is not to have better prosthetic knees for soldiers; the intent is to have better prosthetic knees for the world’s population,” he said.
Gadson trained with the new knees four times in the seven days between his first experience with the final product and the news conference. In that time the improvement in his stability was evident. He was able to walk unaided.
Corcoran explained that when an amputee steps and lands on the leg, the knee locks, and when they roll over the knee during the stride, it releases. This is done through sensors in the prosthesis.
“These legs really mimic your walk,” Gadson said. “I’m trying to think back to what it used to be like to walk ... the feeling of natural motion. When you are wearing a passive [unpowered] prosthetic, you have to kick that leg out and you’re listening or feeling for a secure lockout before you put that foot down. This is much more natural. You know that whatever position the leg’s in, whether it’s in or locked out, it’s going to be stable. That really gives you a more natural motion.”
Gadson’s next goal is to learn to walk on his new knees with one cane, then progress to wearing them full time, rather than the two to four hours he uses them today. He knows he will improve with experience.
“It’s going to come,” he said. “But I’m really confident I’m going to get there and I’m really optimistic about what these legs can offer.”
THE PATH TO AHLTA SUCCESS
BY CRAIG COLEMAN
For health care professionals, time is a precious commodity. After every appointment, meticulous patient instructions, common symptoms and screening notes must be entered into the patient’s medical record, and doctors, nurses and medics spend hours entering the information into the Armed Forces Health Longitudinal Technology Application (AHLTA), the military’s electronic health records system.
A civilian program like AHLTA is a key provision of a possible overhaul of the nation’s civilian health care system due to efficiency and cost-saving benefits. But practitioners will not save time—or money—until they’ve learned to use the system effectively. Enter the Army Medical Command AHLTA Provider Satisfaction (MAPS) initiative.
MAPS is a collection of computer hardware and software combined with efficient and effective means of documenting health care.
Eight Medcom MAPS trainers will instruct local trainers at 16 military treatment facilities in the initial round of visits. The first Walter Reed clinic trained was the Warrior Clinic, where wounded warriors receive care.
MAPS consists of five tools: a wireless tablet PC, voice recognition software, a macro note typing program and a digital consent form program. Used together, they make it possible for practitioners to significantly reduce the time required to record medical notes in AHLTA.
The tablet PC is a portable touch screen, wireless-capable computer that providers can use in the treatment room or in their office to document patient treatment in AHLTA. Voice recognition software allows the practitioner to dictate notes into the computer and have it typed automatically. Macros, also called shortcuts, allow the provider to use a simple word or phrase and have the program automatically type out complex notes.
The note-typing software works the same way as voice recognition software, only its macros allow the user to type a code or word and have the program fill in a pre-arranged set of notes.
The digital consent form software allows the patient to sign consent forms digitally using a stylus on the tablet PC, making paper copies unnecessary.
TOOLS TO COMBAT DEPRESSION
BY KRISTIN ELLIS
Depression affects 15 million American adults each year, and finding a treatment that works may not always be easy.
“What may work for one person may not work for another; that’s why we need different tools to be able to treat depression,” said Lieutenant Colonel Geoffrey Grammer, chief of inpatient psychiatry.
One such treatment, Transcranial Magnetic Stimulation (TMS), was approved for use by the Food and Drug Administration last October. Walter Reed Army Medical Center became the first Department of Defense hospital to use TMS to treat depression in patients. WRAMC is the only area hospital with this technology and joins the ranks of a dozen other treatment facilities in the country that offer this new device, including Yale, Columbia University and the Mayo- Rochester.
The therapy is used for patients who are not responding to at least one anti-depressant trial of an adequate length and dose, according to Grammer.
“We want to take these people not responding and offer them a relatively painless way of seeking treatment,” he said.
TMS activates certain parts of the brain by generating a magnetic field through a coil device and applying it to the front part of the brain where mood is regulated. Quick pulses are sent to a small, precisely measured section of the patient’s scalp. It does not require medication or sedation during the nearly 40-minute session, with the whole process lasting about four to six weeks, five times a week.
One in two patients experiences significant improvements, and one in three have complete symptom resolution. Because of the powerful magnetic field being generated, patients with pacemakers or metal in their head cannot receive the TMS treatment.
“We are stimulating the prefrontal cortex. There are millions and millions of nerves in this area, and we are targeting a part the size of a quarter that gives you the sense of positive mood,” Grammer said. “We’re causing the nerve to activate, to fire, like it normally would. Then what happens over time is that you begin to change some of the nerve transmitters within deeper sections of the brain that have been known to be associated with depression.”
As WRAMC moves ahead with this new technology, other programs will be set up to study how magnetic stimulation may be harnessed to treat traumatic brain injuries, post-traumatic stress disorder and chronic pain.
Since the machine is a modular system, the manufacturer can send new devices that can change the coil behavior and move to different areas of the brain to stimulate in a different way for a different illness.
“Now that we actually have the technology and funding to start the program, I think we’ll be in a unique position to ride that wave forward rather than chase it,” he said. “We really are forging ahead and trying to be one of the pivotal first players for this.”
THE SIM MAN
BY KRISTIN ELLIS
Four interns were in the Pediatrics Ward when the red light above ‘Lieutenant Colonel Jones’ door turned on. They rushed to his room to find him coughing and gurgling. During the next 15 to 20 minutes they worked diligently to stabilize him as part of a difficulty breathing scenario replicated by Walter Reed’s simulation center.
The patient, a high-tech dummy also known as “sim man,” imitates breathing, noises and other vitals and is controlled by the center’s administrator hidden in another part of the room.
“By replicating scenarios like this, you’re making the learners more proficient in patient care. They could end up saving someone’s life from this type of training,” said Mark Wyn, the center’s administrator.
The medical simulation center aims to enhance graduate medical education, assist in refresher training and improve patient safety by offering realistic simulations and task trainers. Paracentesis, thoracentesis, suture and IV models are among some of the center’s trainers along with a sim baby. The center, which had its official grand opening in July, has served about 1,000 interns, fellows, graduate medical education students and other medical personnel since its inception in the summer of 2008.
“Patient safety is the driving force for all of this,” said Major Jeffrey Mikita, medical director for the center.
Simulation scenarios like Jones’ can be tailored to meet the learning points that instructors want for their students. Like the “Wizard of Oz” behind the curtain, Wyn speaks for the sim man, changes his breathing sounds, pulse, monitors and EKG rhythms, and can even make his tongue swell all through his laptop computer.
“Every action the learner makes has a reaction with the patient, which adds to the reality,” Mikita said.
The sim man records the reaction of the learners, down to how shallow or deep CPR compressions were. An event sheet is printed out for the instructor and is used during the after action review.
“It lets the grader see if they learned the lifesaving protocol they learned in school and rounds,” Wyn said. “The scenario is like a lump of clay, it takes shape as the interns are being introduced to the situation. It will last about 15 to 20 minutes so they stay alert and engaged. Any longer and you run the risk of them saying: ‘Ah this is fake. I want to get out of here.’”
Although the simulation center is most often used by GME students, doctors and nurses have taken advantage of the services to freshen up on certain skill sets. As simulation training expands in the next few years, framework for curriculum will be developed for the GME programs. In addition, a new center will be built post-BRAC moving the operation from its current 500 square-foot space to 5,000 square feet at its new location.
FUTURE FACILITIES
THE NEW WALTER REED
Defense Department officials broke ground on the Walter Reed National Military Medical Center July 3, 2009, at 10 a.m. on the campus of the National Naval Medical Center in Bethesda. Officials said construction of the 345-bed facility represents a new era of joint health care for the country’s servicemembers and their families.
The 2005 Base Closure and Realignment Commission recommended the relocation of certain Walter Reed Army Medical Center activities from D.C. to Bethesda, establishing the Walter Reed National Military Medical Center. The medical center will provide tertiary, sub-specialty and complex medical services. The $970 million project will add or renovate 2.5 million square feet and represent the largest single capital investment ever made in the Military Health System.
The Walter Reed National Military Medical Center will be complimented by a new 120-bed community hospital at Fort Belvoir, Va., which will provide non-tertiary care services to the Northern Virginia area. The Base Realignment and Closure law requires construction of the two facilities to be completed by September 15, 2011. More information on the integration of NNMC and WRAMC may be found at www.jtfcapmed.mil.
THE NEW BELVOIR HOSPITAL
BY HOLLY MEYER
The patient- and family-focused design of a new community hospital at Fort Belvoir is taking physical shape after a year of construction.
Under the Base Realignment and Closure Act of 2005, the new hospital will replace DeWitt Army Community Hospital and take over some of the services now offered at Walter Reed Army Medical Center. The current Walter Reed facility is scheduled to close September 15, 2011, as a new hospital expansion opens in Bethesda.
Belvoir’s 1.3-million-square-foot joint military hospital will have 120 singlepatient rooms and a number of amenities designed to give control and comfort to the patients and their families.
“Everything that has gone into the hospital has been designed with the intent of improving patient outcomes,” said Colonel Charles Callahan, commander of DeWitt Army Community Hospital and Health Care Network.
Callahan said the new hospital will follow the national movement of patient family-centered care. At Fort Belvoir, the patients and families will control the environment of the room and can adjust temperature, light and other amenities from the patient’s bedside.
The seven-level hospital will feature an intensive care unit, a behavioral health inpatient unit, a cancer center, an emergency center, operating rooms and diagnostics centers.
The hospital will use evidence-based health care design to create a therapeutic, family-centered and efficient space. It will also integrate research-based architectural design that improves patient outcomes, Callahan said.
“One of the researches that’s been done has shown that in the presence of scenes of nature you actually require less pain medication after surgery,” Callahan said.
The hospital will be divided into five nature-themed sections—river, eagle, sunrise, oak and meadow—that spread out like fingers to admit natural sunlight into each patient room, according to Callahan. Half of the rooms face east and the other half face west, ensuring either morning or afternoon sunlight shines through the patient windows, Callahan said.
In addition to the different color schemes, the hospital will also have kiosks placed throughout the hospital and parking garages with maps for directions and intercoms that allow patients to notify doctors of their arrival, according to Lieutenant Colonel Troy Walker, National Capitol Region and North Atlantic program manager for the U.S. Army Health Facility Planning Agency’s Project Management Division.
“It’s laid out in a way that is supposed to be very simple in allowing patients to almost navigate the building with very little assistance from the staff,” Walker said.
The hospital was also engineered to minimize impact on the outside environment and will receive silver status through the international green building rating system, Leadership in Energy and Environmental Design, better known as LEED, according to Walker.
The swooped roofs of the hospital collect rain water into an irrigation system for the healing garden that patients can sit in or view from all waiting rooms.
The community hospital is scheduled to start accepting patients by April 2011. As the first joint military hospital stateside, the facility will serve active-duty service members, retirees and their families, Callahan said. ♦