Conference Recap: Partnership for Military Medicine Syposium

Written by Ted McKenna

MMT 2009 Volume: 13 Issue: 8 (December)

As speakers at the Partnership for Military Medicine Symposium, held November 6, 2009, in Washington, D.C., repeatedly noted, advances in these treatments, while in many cases driven by the military medical community, depend hugely on civilian medical experts. This military/civilian marriage of efforts is only expected to grow, speakers said, as the U.S. military responds to everything from natural disasters in the United States and abroad to treatment of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD), and infectious diseases, including that current strain of influenza so often mentioned these days, H1N1.

Sponsored by the Henry M. Jackson Foundation for the Advancement of Military Medicine and the Tug McGraw Foundation, the symposium began with some introductory remarks from U.S. Army Surgeon General Lieutenant General Eric Schoomaker and a keynote speech by U.S. Marine Corps Assistant Commander General James Amos, who noted a number of technological advances achieved through joint civilian/military research efforts, including in the area of prosthetics.

In the opening panel discussion of the symposium, on military and civilian efforts in humanitarian aid and disaster response, several panelists noted that humanitarian missions today are now a core mission of the U.S. military not only for the obvious reason of aiding humanity but also for the more selfinterested motive of national security.

“There is a changing strategic imperative to the uniformed services,” said Dr. Craig Vanderwagen, a former assistant secretary for preparedness and response at the U.S. Department of Health and Human Services (HHS). “Those strategic objectives relate both to homeland security and in international environments and go beyond our war fighting ability to the security needs of our people.”

In terms of practical response to disasters, several panelists noted that proper responses to both domestic and international disasters inevitably require strong, pre-existing ties between local authorities, military responders and non-governmental agencies that donate food, medical and other supplies and their expertise. But while the hands-on treatment by and medical supplies of military medical personnel are important, often the greatest contributions from the military lie in the provision itself of services or supplies provided by a multitude of civilian partners, noted Dr. John Howe, president and CEO of a non-governmental organization, Project Hope, that works frequently with the military in responding to natural disasters and other humanitarian emergencies, including the tsunami that hit Southeast Asia a few years ago.

“This capability lets us go forward in a disaster quickly, but also to stay if needed,” Howe said. “When the USS Kearsage went into Haiti, it turned out the most important capability it had was not the medical, but the logistics ... to carry the large helicopters used to ferry supplies inland.”

TBI/PTSD DETECTION

Certainly, the military medical community has historically been a leader in advancing medicine—including developing solutions for yellow fever and small pox, for instance—but it has always also sought to benefit from and collaborate with academic and commercial researchers. Such remains the case with current efforts under way to use technology to better understand and detect TBI and PTSD, as also discussed during the symposium by a panel of military and academic researchers.

Common symptoms of mild TBI may be easily observed or determined by clinicians: headaches, memory loss, sleep disturbances, depression, mood changes, slowness of thinking and more. Symptoms of more severe cases of TBI are along the same lines but far more obvious. But advances in magnetic resonance imaging (MRI) technologies now allow medical personnel to actually see the effects of TBI, both mild and severe.

First commercialized in the early 1980s by General Electric, MRI has long been used for cognitive research, noted panelist Dr. Allen Song, a professor of radiology, psychiatry, neurobiology and biomechanical engineering and the director of the Brain Imaging and Analysis Center at Duke University.

Structural MRI, the most common type of MRI, measures the shape, volume and composition of the brain. But functional MRI (fMRI), around since the 1990s, now permits researchers to understand how brains are damaged and if and how they are recovering by mapping out the brain components, including neurons, axons and fluid, and how they are connected and work together. “We can assess anatomy as well as the brain at work to detect abnormality and the outcome of treatment, to find the most effective solutions,” Song said, in summing up the usefulness of fMRI for understanding conditions like TBI and how patients may be responding to clinical treatments.

Of the four signature injuries of the wars in Iraq and Afghanistan, two are physically observable: severe burns and amputations, noted Dr. Jasmeet Pannu Hayes, an assistant professor of psychology at Boston University and a staff psychologist at the National Center for Post-Traumatic Stress Disorder. Two are not: TBI and PTSD. But that doesn’t mean they can’t be detected through technology as well as by clinical diagnosis. Hayes noted that her lab not only uses fMRI to track the “biomarkers” of TBI, but PTSD as well.

In describing one patient she worked with, identified as “Sgt. N.,” who had worked with explosive ordnance disposal teams in Iraq and been close enough to blasts to “feel something go through his body” some 50 or 60 times, Hayes said fMRI was used to discover that the patient’s brain had highly compromised connective tissue.

“The traditional MRI doesn’t show this,” Hayes said. “Neuroimaging technology can help to quantify treatments in the brain. We’re looking to understand what regions of the brain are affected when blasts occur, and from that possibly develop [countermeasures],” perhaps in the form of pills or something else that might protect [those] particular areas.

Interestingly, researchers see a convergence between military and sports medicine, with victims of improvised explosive devices in Iraq and Afghanistan suffering traumatic brain injuries—essentially concussions— that are the same in effect as those suffered on, among other places, professional football fields, where some players who participate in blocking and tackling are developing or have developed what’s called chronic traumatic encephalopathy (CTE), a condition known in the professional boxing world since the 1940s.

Dr. James Kelly, director of the National Intrepid Center of Excellence, noted that in both these worlds—the military and sports— technology for detection is advancing rapidly, bringing close to market new means of quickly evaluating brain damage.

“The more sensitive our instruments and technologies become, the finer the detail,” Kelly said. “There are technologies that are right now on the verge of becoming clinically useful.”

The ability to determine recovery from concussion could become a particularly important need for the military given the continued occurrence of IED attacks in Iraq and Afghanistan. The closer in time between concussions, the worse it is for the victims, Kelly noted, partly because they have less time to recover.

“The nearer in time that these events are spaced, the less recovery time,” Kelly said. “The worst case scenario is the ‘second impact syndrome’—massive brain swelling that occurs when there is not enough time for recovery between the first and second event. If someone goes back prematurely, they are much more likely to have a serious concussion [in the event of another head trauma of some type]. There are protocols being written now to take care of the first blast victim so we know better” when or if they can return to the battlefield.

COOPERATING IN DISEASE TREATMENT

Finally, the symposium featured panelists discussing the joint civilian/military response to infectious diseases. Captain Kevin Russell, director of the Department of Defense Global Emerging Infections Surveillance and Response System and deputy director of the Armed Forces Health Surveillance Center, noted that the DoD Surveillance Network first identified and presented to the Centers for Disease Control and Prevention the apparently first case of H1N1, a boy in Mexico.

As with the military response to natural or other disasters around the world, the provision by the U.S. military of treatment for infectious diseases even in countries where the United States has no military presence has strategic benefits, as well as being morally proper. “We have an ethical obligation to extend our resources as far forward to the [resident] nationals where we have our labs as we can,” Russell said. “It’s not just plague or small pox anymore that the World Health Organization wants us to work on, but public health emergencies.”

Speakers at the symposium repeatedly underscored the need for broad collaboration among the federal, commercial, academic and military medical communities—on everything from PTSD and TBI to infectious diseases to the multiple injuries servicemembers are sustaining simultaneously while in battle.

Sometimes the collaboration isn’t as close or productive as many would like, noted Vanderwagen, the former HHS official, who acknowledged during the question-andanswer period following the panel on civilian/ military efforts in humanitarian aid and disaster response that research by the military in various technological areas often lacks private investment to create commercially viable products of benefit to people in general and not just the military.

“It is tough, particularly in this tough economic environment, where they have young biotechs that understand this [technology] but don’t have that much financial backing or manufacturing capability,” Vanderwagen said. “There has to be an ongoing analysis of how we use federal funds. That’s a public-private partnership.”

But he and others noted that military research efforts have historically made and continue to make their way into the private world as viable products and treatments. In a keynote address during the symposium, U.S. Lieutenant Colonel Gregory Gadson, who is currently a fellow at the Institute of World Politics, noted that he survived an attack in Iraq that caused him to lose both his legs but would have killed him in the previous Gulf War.

“I lost 129 pints of blood the night I was hit by a roadside bomb,” Gadson said. “In 1989, if the same incident had happened, I would not be here today. So I had a chance to see how far the military community has come in my 25 years in the military. In the area of prosthetics, I’ve had the chance to wear advanced prosthetics and push the envelope for not only people in the military but all of mankind. We must never forget that medicine is a human endeavor.” ♦

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