Q&A: Rear Admiral Richard R. Jeffries
Written by Marty Kauchak
MMT 2010 Volume: 14 Issue: 5 (August)
Rear Admiral Jeffries began his naval career in 1976 through the Armed Forces Health Professionals Scholarship Program and earned his B.A. from Coe College in Cedar Rapids, Iowa. He completed graduate studies at the University of Colorado in secondary education, earning a state of Colorado teaching certificate. He graduated from the College of Osteopathic Medicine and Surgery in Des Moines, Iowa, in 1979.
Jeffries completed an internship and Family Medicine residency at Naval Hospital Pensacola, Fla., in 1982 and immediately attained board certification from the American Board of Family Practice. His first staff assignment was to Branch Naval Hospital Twentynine Palms, Calif., where he received appointments as head, Family Practice Department, acting director, Clinical Services, and chief, Medical Staff.
In August 1984, Jeffries was transferred to the Department of Family Medicine at Naval Hospital Camp Pendleton, serving as staff Family Physician, Residency Faculty and Clinic director. In 1986 he was promoted to director, Residency Training, where he attained board certification in Family Practice from the American Osteopathic Board of General Practice and Fellow, American Academy of Family Physicians. Jeffries is a member of the American Academy of Family Physicians, Association of Military Osteopathic Physicians and Surgeons (Past President), Uniformed Services Academy of Family Physicians, American Osteopathic Association and the Association of Military Surgeons of the United States.
In August of 1990 he served in Operation Desert Shield as Artillery Regimental surgeon, 11th Marines. While in theater he was deputy, then acting division surgeon. A year later he was assigned to the 1st Marine Division as division surgeon. In December 1992 he was appointed Marine Forces Central Command and I Marine Expeditionary Force (Forward) force surgeon for Operation Restore Hope, Somalia.
In the summer of 1993 Jeffries was re-assigned to Naval Hospital Camp Pendleton as Family Practice Department head and Residency Program director. In 1996 he was appointed chairman, Executive Committee of the Medical Staff and completed his tour as director, Medical Services. In October 1998 he reported to Marine Forces Pacific, Camp Smith, Hawaii, as the force surgeon. In April 2000 he assumed duties as the deputy commander for Clinical Services at Tripler Army Medical Center until April 2003, when he assumed command at Naval Hospital Camp Pendleton. In August 2005 Jeffries reported to the Bureau of Medicine and Surgery as the deputy chief for Future Plans and Strategies. Soon after his arrival, Jeffries was deployed as the JFMCC surgeon in support of Hurricane Katrina relief efforts. From November 2005 to July 2007, Jeffries was medical officer to the Marine Corps. He then assumed command of National Naval Medical Center and Regional Commander Navy Medicine National Capitol Area in Bethesda, Md. In August 2008 he returned to Headquarters U.S. Marine Corps where he is currently assigned.
Jeffries’ personal decorations include the Legion of Merit with four Gold Stars, Bronze Star, Joint Meritorious Service Medal, Meritorious Service Medal with one Gold Star, Combat Action Award, Joint Meritorious Unit Award, Navy Unit Commendation, Meritorious Unit Commendation, Bronze Star, Army Order of Military Medical Merit, and Artillery Order of Saint Barbara.
Rear Admiral Jeffries was interviewed by Marty Kauchak, MMT editor, on May 28, 2010.
Q: Admiral, good morning and thanks for taking time to speak with us again. Provide an overview of the state of Marine Corps medicine.
A: A lot has happened since appearing in the MMT cover Q&A [October 2006]. I’d like to lay a foundation about things that we were doing. As we found issues, problems, concerns, we marched forward to try to correct those. A lot of those are technological—equipment and new research findings. In our programs the key ones have to do with the far forward casualty care. It started with OSCAR [Operational Stress Control and Readiness] and the mental health embedding that started in 2003 and recently became a program of record. It was extended with OSCAR Extender [in 2009] by the Marine Corps, because in reality, primary care takes care of the majority of the mental health issues. We have a great togetherness in the Marine Corps, from boot camp on, of how we work and manage as a Navy Medicine and Marine Corps organization.
We have now extended the whole concept called OSCAR Extender through all the leadership and down to the non-commissioned officers. We just had the first Executive Safety Preservation Board. The assistant commandant of the Marine Corps, General [James] Amos, just changed the safety board to a preservation board to address: How do we keep the total force healthy, prepared and ready, etc. in the future? Before, it was mainly focused on injuries on the job, during recreation, on motorcycles and from other causes. They did look at suicides and a few other issues, but now they have added in all aspects affecting the health of the force, with a large focus on OSCAR Extender, the mental health issues and also TBI [traumatic brain injury]—what is happening in the field of injuries to our frontline Marines.
So those are the kind of changes, and with that comes the tools and techniques to do it. I would say one of the foremost is OSCAR Extender. We trained most of 1 MEF in the last two months, done quickly and before deployment. We have some metrics and measures being followed by Naval Health Research Center, Navy Medicine, to see how things will go with those programs. In six months, when they return, we’ll see how we have done in the field, far forward, not only with OSCAR of the past but with the “whole” new program concept for the Marine Corps.
Q: You mentioned TBI. Please update us any developments within your service on this issue.
A: The memorandum from the Secretary of Defense’s office [a new TBI Memorandum] has been signed and we [the Marines] have already implemented by FRAGO that on our frontlines. They have now changed the dynamics—a paradigm shift in medicine—going away from when the patient declares himself as having a problem to an event-based situation. For example, when an IED detonates, or a blast, or a head knock injury that involves the brain, there is a new requirement to report and evaluate that will be joint and across the theater. The Marine Corps has already started it—to immediately identify that event and the people tied to it. This is going to be implemented as joint policy shortly.
The key to this policy is going to be immediate health evaluation and follow-on health evaluations all the way through the system of continuing care. This will create an increased focus on electronic medical records and the ways to combine the event, which is actually on the SIPR side, with the personnel and medical care on the NIPR side, and still keep the personal protection aspects. There will be a lot of movement in getting that right. Then, not everyone may have access to get it [SIPR and HIPAA]—we worry about our MARSOC personnel who are in small groups and isolated in some areas. How do they fit into it? Telehealth will probably have a role. There are some studies being done with this right now and what’s capable in that realm of medicine is still unknown.
Q: Highlight some of the recent changes in training for hospital corpsmen [FMF] and other battlefield health care providers that were generated by lessons learned from Afghanistan and Iraq.
A: It’s an ongoing continuum for us. Both NOMI [Navy Operational Medicine Institute] and the Marine Corps’ lessons learned system are now tied very much together. We’re looking through different time frames, so we can see the evolutions and what has changed.
For corpsmen, as you know, the first ones everybody knows about: QuickClot [blood clotting material from Combat Medical Systems] and now Combat Gauze. Some of the research now is why can’t we do better, especially with major injuries that are bleeding internally—is there something we can do there? Especially ones that are hard to get at with gauze or QuickClot. That’s a key research area.
That is because our corpsmen, having this capability along with tourniquets, has allowed us to advance to the next evolution—what else can we do better.
Q: It appears tourniquets have again proven their value in battlefield health care.
A: Yes, and that comes from looking at the whole picture. We were using tourniquets in the operating rooms with orthopedic surgeons and general surgeons to stop the blood flow, so they can do surgery better and without abnormal problems and complications that were identified years ago from tourniquet use. The ways they used them, the timeframes they used, were not identified for far forward care. Having that knowledge base, putting it with the far forward teams and knowing at what level you need to respond and how, counts.
And continuing our discussion about lessons learned, the Mobile Trauma Bay we just came out with is another one of those stories. Most of our far forward resuscitation was based on an FMF corpsman stopping the bleeding, putting the tourniquet on or the gauze or whatever to stabilize the patient and getting him to what turned out, in Operation Iraqi Freedom I, to be a forward surgical team to make follow-up decisions. However, not all of them needed surgery. Those teams are very small with highly skilled people for surgery. The Battalion Aid Stations [BAS] with our general medical officers have not changed much in decades and is now just doing routine type care. The way it is going with fast casualty evacuation, if from the corpsman in the first five or 10 minutes to save a life and ship them to the surgical or Level III. What we had was a Shock Trauma Platoon [STP] that was being used for pre- and post-care, and yet it had an emergency capability (with emergency physician) sitting with the forward surgical team. As teams had to jump forward with an assault, the STP could keep the patients so that the surgical team would stay with the line.
Now what we have done is expand [the concept] where the ER physician with the Mobile Trauma Bay, which is kind of a miniemergency room for resuscitations, moves forward and can make better choices of who goes to surgeons, who goes to level III, who stays—just like you do at the ER in your local hospital.
When the 2nd Battalion, 7th Marines deployed to Afghanistan, we were still under tents with the equipment. The worst place to be now is in a fixed forward operating base, which used to be protected area, because you had lines of battle way out front. Now there are no lines—the engagements are all over the place. Within the first few days 2/7 medical lost most of their tents and some of their equipment to enemy rocket propelled grenades, mortars and artillery. So they built a Mobile Trauma Bay that is more hardened and gives them some protection plus it is movable. It’s starting to save lives that we used to lose. That battalion took some of the biggest hits the Marine Corps has had in this war. There were over 300 trauma cases. The emergency physician took the lessons learned and presented to Navy Medicine and the Marine Medical Operational Advisory Group. Then I took lead and asked if we could present it to the commandant and the senior leadership at Headquarters Marine Corps, and all of this in a very short period of time. The commandant said, “I want this.” And it happened with the Marine Corps Systems Command, the Warfighting Lab, Marine Corps Combat Development Command and Training and Education Command. They started building prototypes. We just sent the last one of the first prototypes out for training, the ninth one just left. The first one was out in four or five months and tested at Camp Lejeune before going to Afghanistan. We’re getting the lessons learned back from the battlefield on where it’s used, how it’s used, the concept of operations, and they say we are saving some lives there—that’s what we are hearing back from the commanders. They now have several over there. We also have them at Mohave Viper with the I Marine Expeditionary Force training area and the II MEF area at Camp Lejeune. We’re sending the third one to Okinawa [III MEF]. So we have three training prototypes and six in theater. This is a new evolution—we don’t know yet all the ins and outs, but this shows what can happen when a good new solution is presented. It’s like the MRAP and the fast, accelerated pace of development.
Q: Any other thoughts about corpsmen?
A: Back to corpsmen, how do they communicate and how do we monitor the casualties they have? Some of the latest work is in the new MOVES, the new stretcher-type capability they may put at the BAS and other far forward sites, that would have the entire patient monitoring and support capability and allow them to transfer through the total evacuation system on one stretcher. In the past you used to get monitoring at the surgical company or higher only. The patients would come in and have surgery. The nurses would put on all the equipment and monitor them through post-recovery. Now, we want to do it out front with the smaller teams. You have to move critical patients that were just resuscitated or had damage surgery, not complete surgery, done. The MOVES has all that you need—light, flexible and easily movable.
There is also the new concept in oxygenation with longer lasting batteries, small monitors and other capabilities to do all the work on one stretcher. Theoretically and here’s where I think we are going— USTRANSCOM wants to use it all the way through the aeromedevac system. So I need better supported corpsmen; if we can move monitoring capabilities to the front we need to make their job easier in selecting who gets triaged where, who they are taking care of and what information they are getting. And communications capability to put their inputs in electronic medical reports, so the helos, the ground transport or whatever platform is taking those casualties can receive them.
The problem is you must have advanced, secure communications. You don’t want to give away their location. It’s like convoys jamming for IEDs—that affects everyone else’s communications too. So you have to work all those pieces. That’s the complexity and intricacy of military versus civilian medicine that is so critical in making these decisions. It’s nothing simple, like saying, “They have one in the civilian world. They’re using it on helos for emergencies.” You can’t transfer that to the field and say it works. You have other things to take into consideration.
Q: Discuss the budgeted, ongoing programs and planned efforts to increase the efficiency and effectiveness of your service’s medical IT infrastructure and supporting systems.
A: The key is this new medical health care record requirement with open architecture. We have AHLTA [Armed Forces Health Longitudinal Technology Application]. This is the next generation to CHCS and it has to take place. For us on the battlefield, it is the TMIP [Theater Medical Information Program]. We have started doing it now. We had a test of Block 2 and they just fielded with I MEF before they deployed. We have contactors in theater to help I MEF understand how it works, along with the “S-6s” [communicators] and others training to support. We are now doing it on the frontlines—putting these latest capabilities in all of our forward operating bases and a few of our outposts. The bottom line is to get continuous care reporting by electronic means far forward.
The TBI DTM [Directive Type Memorandum] is the best [example] on this. You will have someone who has just been hit, has a brain injury. We need to do the brain evaluation with the MACE [the assessment] and other processes, and we are going to get that right into an electronic record so that each station he goes to [has it]. Right now we are also putting in a restoration clinic pilot with I MEF. Lieutenant General [James] Dunford, [commander], is very excited about it. He’s asked for a sports medicine doctor, a PT [physical therapist] and OT [occupational therapist], and along with our combat stress teams at our Level IIs at the forward operating bases, we will be set up to care for casualties over time and can decide who needs to really be medevac-ed out of theater or to Level III and who can stay for a short period and return to duty. In that is: what are the capabilities to do that monitoring, that checking, that evaluation and care. So, these capabilities will now be in this new platform. You need that information. If you don’t have it, you don’t have the value of what really happened. There is the tendency to medevac them all out now and few are returned to duty. Some pilot projects have been done in theater. The Army completed a good one at Task Force Shank. They found that knowing that kind of information and then caring for and monitoring these casualties, they can send more back to duty, instead of having to send them all the way back [to the U.S.] to figure it all out. We are moving newer knowledge, technology and equipment to do this.
All of this will be tied to the VA in the end. The information architecture, the joint capabilities and what are the different parts that get the information back to that department. The Defense Health Information Management System is the key to working these things out between DoD and the VA. The theater data system is going to interface with the data system in garrison here in the U.S. so that you will have the information flowing to everyone. And the new HAIMS [Healthcare Artifact and Image Repository] capability is going on right now. This has to do with digital imaging and the capabilities of sending the digital findings with the electronic medical record. You can do pre- and post-kinds of studies and we can make comparison decisions. All that is in the ballpark being worked by OSD.
Q: Your help wanted list: highlight the top technology challenges across your broad medical portfolio that you need industry’s assistance to solve.
A: One of the key things identified at a conference this past year was encouraging everyone in industry to bring out what research or proposal they have to monitor the brain after an injury at the very front to tell us yes, something happened and what’s happened to it, what we need to do. You can’t have CAT scanners and MRI machines everywhere to evaluate casualties.
When you get to the amputees you get to the AFIRM research programs. We have a Marine with a transplanted hand and forearm. He wants to come back on active duty. The arm is functioning and grips fairly well. We have people that are growing new bladders and we are on the cutting edge of regenerative medicine. What used to force you out of the service is not true anymore—we even have a double amputee back on active duty. We have a lot of prosthetic amputees who have gone back to the theater to fight. So, we’re having new capabilities all the way through the system that are allowing us to preserve the force, to get them as “whole” as they can be and back to duty if they can adequately perform. They may choose to stay in the military or they might want to get out. Now, they have choices. Before, they were all sent home.
Q: Do you have any concluding thoughts?
A: The one thing I want to stress is that there are a lot of media stories and other perceptions out there focused on some of the more negative developments or the latest crisis. If you take a look since 2001, or really 2003—the start of the wars—and see the changes, see what is happening with our people—for example, amputees going back to duty and the war fully functional or entering society more capable then ever. This has never happened before. The new focus on mental health and brain injury care and the additional focus on ways to stop bleeding and save lives. The advances are happening so rapidly and in a positive way.
No, it’s not always perfect and we don’t always get it right the first time. But those advances are coming fast and furious and are making a huge difference. It totally changes what health care means. We are in a new dynamic situation—how it looks and how it works as a whole system. I don’t think people are evaluating this remarkable change as well as they should. I don’t think they consider from where we’ve come and where we’re going. It’s a miracle; it’s amazing. They are now seeing that it will continue and that is the good news story. ♦