Medical Provider: Supporting National Policy with Military and Humanitarian Health Care
Interview with
Vice Admiral Adam M. Robinson, Jr.
U.S. Navy Surgeon General Chief,
Bureau of Medicine and Surgery
Vice Admiral Adam Robinson, a native of Louisville, Ky., is the chief of the Navy Medical Corps. He entered the naval service in 1977 and holds a Doctor of Medicine from the Indiana University School of Medicine, Indianapolis, through the Armed Forces Health Professions Scholarship Program. Following completion of his surgical internship at Southern Illinois University School of Medicine, he was commissioned.
Robinson’s first assignment was as a general medical officer, Branch Medical Clinic, Fort Allen, Puerto Rico, before reporting to the National Naval Medical Center, Bethesda, Md., in 1978 to complete a residency in general surgery. His subsequent duty assignments included: staff surgeon, U.S. Naval Hospital, Yokosuka, Japan, and ship’s surgeon, USS Midway.
After completing a fellowship in colon and rectal surgery at Carle Foundation Hospital, University of Illinois School of Medicine (1984-85), Robinson reported to the National Naval Medical Center, Bethesda, as the head of the Colon and Rectal Surgery Division. While there, he was called to temporary duty in 1987 as ship’s surgeon in USS John F. Kennedy and in 1988 as ship’s surgeon in USS Coral Sea. Robinson reported to Naval Medical Center, Portsmouth, Va., in 1990 as the head of the General Surgery Department and director of General Surgery Residency Program. He was appointed acting medical director for the facility in 1994. While at Naval Medical Center Portsmouth, Robinson earned a Masters in Business Administration from the University of South Florida. In 1995, he reported to the commander, Naval Surface Force, U.S. Atlantic Fleet, as the force medical officer serving in that capacity for two years. Following that assignment, he reported to Naval Hospital Jacksonville in 1997 as the executive officer. In January 1999, as Fleet Hospital Jacksonville commanding officer, he commanded a detachment of the fleet hospital as a medical contingent to Joint Task Force Haiti (Operation New Horizon/Uphold Democracy).
In August 1999, Robinson reported to the Bureau of Medicine and Surgery (BUMED) as the director of readiness and was selected as the principle director, Clinical and Program Policy in the Office of the Assistant Secretary of Defense for Health Affairs in September 2000, where he also served as the acting deputy
assistant secretary of defense for health affairs, Clinical and Program Policy. he was assigned as commanding officer, U.S. Naval Hospital Yokosuka from September 2001 to January 2004, after which he received assignment back to BUMED as deputy chief of BUMED for medical support operations with additional duty as acting Chief of the Medical Corps. In July 2004, Robinson reported as commander, National Naval Medical Center, Bethesda, Md. He assumed the duties as commander, Navy Medicine National Capital Area Region in October 2005.
The author of numerous presentations and publications, Robinson holds fellowships in the American College of Surgeons and the American Society of Colon and Rectal Surgery. He is a member of the Le Societe Internationale de Chirurgie, the Society of Black Academic Surgeons, and the National Business School Scholastic Society, Beta Gamma Sigma. He holds certification as a Certified Physician Executive from the American College of Physician Executives.
His personal decorations include the Distinguished Service Medal, Legion of Merit (two awards), Defense Meritorious Service Medal (two awards), Meritorious Service Medal (three awards), Navy Commendation Medal, Joint Service Achievement Medal, Navy Achievement Medal and various service and campaign awards.
Interviewed by MMT Editor Jeff McKaughan
Q: You recently returned from the CENTCOM AOR? What was the purpose of the trip?
A: Last month I went on a trip to Iraq with the ASD-HA, Dr. [S. Ward] Casscells. Among many stops, we attended a conference held in Baghdad organized by the Iraqi minister of health. It was the first national health care conference in Iraq in over 25 years.
This meeting was significant. I hope that it portends a real and lasting change in health care delivery in Iraq. Our primary goal was to support the Iraqi people and their medical providers in order to make basic medical and dental care available to the millions of Iraqi people in need.
The 200-plus Iraqi physicians and health care providers who attended the conference were energized and committed to bring about the changes necessary to promote quality health care in Iraq. I am delighted in the fact that I and scores of other international health partners will have a supportive part in this new Iraqi health care system. This is expeditionary medicine operationalized—expeditionary medicine at work.
This was my first trip to Iraq but my second trip to the CENTCOM AOR in the last month.
Q: What were your observations on the role of Navy Medicine during this trip?
A: In December, I traveled to Bahrain, Kuwait and Landstuhl to see how Navy medicine is partnering with our Army and Air Force colleagues in providing medical and surgical care to our troops and to thank our men and women for their service, their sacrifice and their commitment to force health protection.
What I found in Bahrain is that Navy medicine is playing a significant role in support of maritime security operations [MSO] for U.S. and coalition forces in the NAVCENT area of operation—which includes the Arabian Gulf, parts of the Indian Ocean, the Red Sea and the Sea of Aden. From providing expanded medical care afloat during maritime interdiction operations in support of anti-piracy operations in the Horn of Africa to providing comprehensive medical care in an isolated and arduous environment onboard Iraq oil platforms [OPLATS], Navy Medicine is deeply embedded in all operations supporting NAVCENT’s role in preserving the free and secure use of the world’s oceans by legitimate mariners and in defeating transnational terrorists.
While in Kuwait, I saw first hand the service and sacrifice of our medical professionals in theater. EMF Kuwait [EMF-K] is a Level III medical facility comprised of 370 Navy personnel from 30 different MTFs. They have a productivity output which [more than] meets our medical/dental requirements. They are true professionals doing a superb job!
For the last three years, over 75 percent of the troops who were admitted to EMF-K were able to remain in theater. The quality of care provided by EMF-K is outstanding and the Army has been overwhelmingly complimentary of Navy Medicine’s service in providing comprehensive, state-of-the-art medical and dental care for USARCENT, the Army component command for CENTCOM.
In mid-February, approximately 300 personnel from EMF-K returned home after serving their six- to 12-month tour. We thank these dedicated men and women for a highly successful deployment and wish them well as they return back to their respective regions.
My tour of Navy Medicine in the field followed a similar path to the one taken by the wounded. On December 7th, we flew to Landstuhl, Germany to visit the Navy Expeditionary Medical Unit [NEMU] and the Deployed Warrior Medical Management Center [DWMMC] to see how Navy Medicine continues to accommodate the seriously wounded service members who are airlifted regularly from the battlefields of Iraq and Afghanistan.
Similar in size to EMF-K, the Deployed Warrior Medical Management Center is staffed by 360 Navy personnel, mostly Reservists—demonstrating that we are in fact one Navy medical team.
My naval medical professionals at DWMMC are doing a superb job serving our wounded, and I’m happy to note that approximately 40 percent of those admitted to Landstuhl return to duty shortly after their stay.
Q: At the recent TRICARE conference you asked, “With the service’s medical departments being in a resource
constrained environment and being called on to always do more with less, can the health care system afford to take on more responsibilities such as humanitarian assistance and disaster relief [HA/DR]?”
A: The United States Navy simply cannot afford not to conduct humanitarian assistance/disaster relief. This component of the new maritime strategy has been elevated as a core mission and is critical to protect our vital national interests while promoting greater collective security, stability, trust and prosperity.
During USNS Comfort’s 2007 Partnership for the America’s deployment, the crew conducted more than 1,200 surgeries and treated more than 98,000 patients—a patient throughput similar to one of my Navy hospitals.
Likewise, the USS Peleliu modeled her deployment on USNS Mercy’s highly successful 2006 Southeast Asia and Westpac deployment, delivering substantial medical and dental support to a significant number of people in remote locations onboard a large-deck amphibious ship—demonstrating that beyond the kinetic energy of a mighty warship lies the equally compelling compassionate non-kinetic force power projection of HA/DR.
I can tell you first hand that there is nothing more impactful in people’s lives than providing them with comprehensive and compassionate medical and dental care. This is also true for the providers who deliver the care. Truly these missions are uplifting and life changing.
Medical and dental care was not the only service we provided. Our medical personnel worked hand-in-hand with the Seabees who built schools, repaired clinics and delivered fresh water. Comfort conducted nearly 30 infrastructure projects at a total value of $400,000.
The Comfort, Peleliu and Mercy deployment paid off, not just with providing compelling compassionate care, but public-opinion surveys conducted in Southeast Asia and South America found that our humanitarian assistance/disaster relief missions have directly caused a rise in favorable public opinion of the United States.
Our response to the devastating 2004 tsunami in Indonesia—led by the USNS Mercy—resulted in favorable attitudes toward the U.S. by the broader Muslim world.
The consensus approval of the Mercy mission by the people of both Indonesia and Bangladesh bridged political views. These nationwide polls of Indonesia and Bangladesh conducted in August 2006, following the Mercy’s visit, suggest that a remarkable 85 percent of Indonesians and 95 percent of the people of Bangladesh held favorable impressions of the Mercy’s mission.
Humanitarian assistance missions by the U.S. military continue to reap demonstrable and measurable gains in U.S. approval worldwide. The near-universal approval of the Mercy is a striking testament that tangible humanitarian aid from the U.S. military can continue to improve public opinion of the U.S. in Muslim countries.
Expenditure, cost and price cannot define our concept of care. By demonstrating our common humanity and the benevolent side to American power, these missions have proved to be a highly successful weapon against extremism in the global war on terror.
Q: Can you give me some examples of how Navy Medicine has worked with NGOs and foreign local governments to mutual benefit? Are such efforts worthwhile?
A: NGOs were integral to the success of the Partnership for the Americas mission—providing critical surgeries, training and donations.
USNS Comfort embarked 17-20 Project Hope personnel including four general surgeons for a total of 83 volunteers during the four-month deployment. This successful partnership enabled 80 additional surgeries and provided 52 percent of the training ashore—amplifying the impact each organization can provide.
Another example of a successful Comfort—NGO partnership is Operation Smile. The doctors with Operation Smile performed 100 cleft lip/palate surgeries and Project Handclasp who facilitated the delivery of 21,000 pounds of donation worth nearly $125,000.
During the Comfort’s mission, each NGO brought unique capabilities and assets and the assessment of their lasting effects will require long-term review. We will continue to study the second and third order effects and incorporate lessons learned in our follow-on planning efforts. Overall, our interoperability with the NGOs and foreign governments was extremely successful and the skills that we honed during the deployment will continue to benefit us down the road.
In mid-November 2007 when Cyclone Sidr struck Bangladesh, members of the United States Agency for International Development as well as senior members from the Bangladeshi government flew out to the USS Kearsarge to discuss how they could best support ongoing disaster relief efforts.
Over the next few weeks, the Kearsarge and the 22nd MEU [Marine Expeditionary Unit] delivered more than 160,000 pounds of relief supplies which included food, blankets, clothing, water purification tablets and medical supplies to 30 locations identified by the government of Bangladesh. This is expeditionary medical care working today.
During the TRICARE Conference the MHS hosted a panel that included: Dr. James Howe, president and CEO of Project Hope, Dr. Harvey Fineberg, president and CEO of the Institute of Medicine and Dr Kent Hill, assistant administrator for global health at the U.S. Agency for International Development, Captain Al Shimkus NC, USN [Ret], associate professor and director, Policy Making and Process Division, National Security Decision Making Department, Naval War College, and commander Dan Beck, PHS representing the surgeon general of the United States.
During the panel we discussed the benefits and lessons learned from these missions as well as the roles of the NGOs and other international organizations in medical diplomacy, outreach and humanitarian missions around the world. The panel highlighted to the conference attendees how we can maximize the effect of these collective efforts.
We must look at the next steps to continue the momentum with the USNS Mercy’s western Pacific Ocean and Southeast Asia deployment this summer—the vessel’s third humanitarian mission in four years.
Q: What are the most prominent technological developments in recent years that have impacted combat casualty care from the Navy perspective?
A: Medical research is a vital component and necessary pillar to Navy Medicine and force health protection. Through research, we are making significant advances in combat casualty care.
Navy Medicine has taken a concept from bench to field culminating in the following advances: one-handed field tourniquet; vacuum-assisted wound closure devices; advanced material for abdominal wounds; advanced prosthetics; hemostatic agents to stop bleeding[QuikClot, Hemcon]; interventional radiology to do angioplasty for cerebral vascular for traumatic vasospam; and high-definition computerized tomography [CT] scanners for 3-D skull reconstruction [cranioplasties].
Many combat casualties from OIF/OEF sustain serious injuries to the head and neck resulting in traumatic brain injury. Previously, reconstruction of these injuries, based only on post-injury 3-dimensional CT scans required multiple visits to the operating room to fabricate and fit. Current advances in imaging have produced systems that can provide information pertaining to both hard and soft tissue at a fraction of the radiation exposure and cost of conventional CT scans. This makes them ideal for use in local dental or medical facilities to establish pre-existing images of hard and soft tissues of deploying warfighters. These images can later be used with post-traumatic injury images to produce information for complex treatment planning that would otherwise be unavailable. The end result would be a more predictable outcome of greater aesthetic quality, accomplished in less time, and with fewer operative procedures.
Using high definition CT scanners for 3-D skull reconstruction is but one example of the technical innovation that our health providers have used to provide world-class treatment to our injured warfighters.
Other technical innovations have contributed to improved survival, to a more rapid return to duty, and to an improved quality of life. The deployment of the hemostatic agent QuikClot, for example, was facilitated by Navy medical research over several years and was part of a process of evaluation that continues today. Navy Medicine researchers are currently testing new formulations of hemostatic agents, to include next generations of the QuikClot agent. The process of continual improvement to find the most efficacious technologies for the warfighter knows no end.
Similarly, our research community is working hand and glove with clinicians in the hospital to advance medical science and treatment. An excellent example is a current study by surgeons at the National Naval Medical Center who wondered if the ooze [effluent] that is sucked off the wounds from the now commonly used wound vacuum devices could inform the clinical provider—the surgeon—about the potential fate of the wound and more specifically, when to surgically close the wound. The results indicate that the wound effluent can indeed provide the surgeon this valuable information to guide care of the patient.
Under the leadership of neuropsychologist, Dr. Maria Mouratidis, the National Naval Medical Center’s [NNMC] traumatic brain injury (TBI) care program is one of the best in the military. The program’s mission is to provide an integrated and coordinated continuum of assessment and treatment for returning service men and women suffering from brain injury and traumatic stress throughout the entire continuum of care.
This program has been a leader in establishing clinical standards of care for patients suffering from the effects of traumatic brain injury and traumatic stress, with a special emphasis on blast brain injury. For the past three years, during their acute inpatient admission, NNMC has been conducting neuropsychological testing and mental health evaluations on all patients with a history of blast exposure. This rigorous screening approach has identified patients as early as possible to ensure that they receive their necessary care.
The assessments conducted through this program assist with numerous administrative processes such as disposition from the inpatient medical units, fitness for duty, medical boards and decisions regarding redeployment. Inpatient and outpatient treatment services include a range of brain injury treatment services, including cognitive remediation, psychotherapy, pain management, behavioral management, adjustment to physical injuries and family therapy. In conjunction with physical, speech and occupational therapies, the brain injury treatment services available at NNMC through the traumatic stress and brain injury program have produced a cutting-edge, comprehensive, integrated and multidisciplinary approach to brain injury detection and treatment. The concept of care and the services through this program are fundamentally integrated into NNMC’s casualty care mission and service.
In addition to clinical services, the traumatic stress and brain injury program provides patient, family, and staff education and resources regarding brain injury, traumatic stress, and behavioral health casualty care. They also provide resources and support to minimize compassion fatigue in our staff.
Research is at the backbone of Navy Medicine. There are countless examples of innovation from our Navy clinicians and from our scientists at Navy medicine’s research laboratories to advance Navy Medicine so that we deliver the absolute best care possible.
Without a doubt, graduate health education combined with progress in research and development of evidence-based medicine is essential to the advancement and enhancement of Navy Medicine. This is critical to continue training the future generations of health care providers and to continue our success in delivering world-class health care. Its value can not be understated, and my ambition is that it will continue to be as strong, or stronger, as we proceed with the many transitions and challenges ahead.
Q: Can you describe the progress to date at the Comprehensive Combat and Complex Casualty Care facility?
A: Last year we opened the Comprehensive Combat and Complex Casualty Care [C5] facility in San Diego that manages the care of a severely injured or ill patient from medical evacuation through inpatient care, outpatient rehabilitation, and eventual return to active duty or transition from the military. The program provides patients and families with an all-encompassing treatment and services for physical injuries, mental health and rehab.
C5 is strategically important in the Navy’s concept of family-centered care because approximately 25 percent of all combat casualties call the West Coast home—many being stationed in Camp Pendleton just 40 miles north of San Diego. Patients can be brought directly to San Diego from Landstuhl or shortly after initial treatment at the National Naval Medical Center in Bethesda or Walter Reed Army Medical Center, allowing families to be together and obtain access to essential support services which improves the total healing process. These warriors deserve our best, and it is our calling and duty to give them the best medical care and rehabilitation support possible.
This newly renovated facility features a multi-terrain obstacle course which contains ramps, stairs and beams that allows a patient to work on ambulation and balance; a 30-foot climbing wall that enables work on agility, problem solving and muscle strengthening and an advanced training apartment with a full kitchen, living room and bedroom which gives patients the opportunity to practice tasks in an environment that they will encounter upon discharge.
Similar to the Military Amputee Training Center that just opened in September 2007 at Walter Reed Army Medical Center, both share the same case management model that facilitates healing for our wounded Marines, soldiers, sailors, airmen and Coastguardsmen.
I pledge to you that we will never stop striving for a care model that restores the health of our wounded warriors and brings them and their families back into the mainstream of our great nation. They deserve no less and we must be honorable and true to our commitments.
Q: Navy Medicine has described its concept of care as patient- and family-centered. What are the basic elements of the concept?
A: When wounded warriors are admitted to our MTFs, they are assigned to a multi-disciplinary care team that is comprised of physicians, nurses, case managers, social workers, chaplains, physical and occupational therapists as well as all of the ancillary personnel. The entire team meets three times a week and goes over each and every patient providing them and their families with all of the administrative, clinical, spiritual and social avenues at their fingertips.
The highest quality care is not reserved only for those who are active duty, or war-wounded heroes; but all beneficiaries and those closest to them. Our concept of care can be summed up in the word care. We recognize that caring for the patient reaches far beyond the practice of medicine. Navy Medicine goes not only heart to heart; but heart to hearts in its approach. The philosophy of Navy Medicine is treat the patient; care for the entire family.
I learned a long time ago that establishing a strong culture that incorporates values that permeate the organization and empowers individuals throughout the organization to do the right thing is the most effective way to ensure the highest levels of patient and staff satisfaction
In Navy Medicine, we empower our staff to do whatever it takes to deliver the highest quality, compassionate and responsive health care centered around the patients’ and families’ needs and well being. By listening to and understanding the unique and individual needs of all concerned, Navy Medicine creates a personalized and family-oriented plan. This patient-family centered approach coupled with the insight gained from the providers ensures the highest quality of health care.
Q: What is Navy Medicine doing to the logistical and administrative barriers for active duty service members transitioning from military to VA-centered care at Navy MTFs?
A: In Navy Medicine, we empower our staff to do whatever it takes to deliver the highest quality health care that is centered around the patients’ and families’ needs and well being. The patients’ medical needs and the families’ well being must drive everything and not the other way around
When wounded warriors are admitted to our MTFs, they are assigned to a multi-disciplinary care team providing them and their families with all of the administrative, clinical, spiritual and social avenues at their fingertips. We never allow patients to find the administrative and process remedy; we bring those solutions directly to the patient.
Our staff ensures a close and coordinated physician-to-physician hand-off of our wounded warriors ensuring that their care needs are always met. We also ensure a full electronic transfer of the entire medical record and radiological images as well as ensuring the families are both informed and involved—a demonstration of patient- and family-centered care in action.Last September, I visited Great Lakes, Ill., for the naming ceremony for the Captain James A. Lovell Federal Health Care Center, the nation’s first joint Veterans Affairs (VA)-Navy hospital when it opens in 2010. The Lovell Center will serve an estimated 100,000 veterans, active duty personnel, and family members and has already established collaborative processes, which can be exported to other locations and in turn shape the future of federal health care.
Prompt and comprehensive medical treatment is a priority for servicemembers suffering an illness or injury. As a result, the lessons learned at NNMC—the facility that has treated most returning casualties—have been exported to other facilities, both in and out of the military, involved in casualty care. The development of these lessons was a collaborative effort to improve processes and outcomes.
Currently, weekly tele-conferences between the MTF and the VA polytrauma rehabilitation centers are 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. Before a transfer is imminent, direct communication occurs between the medical staff, including the caseworker, the patient and/or family members and the treatment team at the VA polytrauma rehabilitation center. Also, electronic copies of medical records are transferred to the receiving facilities. 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.
Q: Can you tell me a little more about the Marine Corps aspect here?
A: The Navy SG office and the Medical Officer of the Marine Corps office shares common goals and we can shape our future by setting the gold standard for force health protection, resuscitative care and enroute care in austere expeditionary environments.
The Marine Corps has always maintained a presence at our MTFs in the form of a Marine Corps liaison office staffed with Marine Corps personnel and administration experts.
At the onset of OIF, the Marine Corps quadrupled the size of their Marine Corps liaison offices at key casualty receipt locations anticipating the increased volume and unique needs of this patient population and their families. Since the beginning of OEF/OIF, the Navy and Marine Corps team embraced the similarities and differences in their cultures.
Working side by side with Navy Medicine providers, the recently established Wounded Warrior Regiment [April 2007] provided Marine liaisons immediately available to the patient, their family, and the clinical care teams from the moment of admission to an MTF through discharge. Navy Medicine takes care of the patient’s clinical needs, and the Wounded Warrior Regiment becomes an optimizing adjunct to the patient care plan.
The Wounded Warrior Regiment facilitates the development of a family readiness plan ensuring smooth transitions for the servicemembers and those dedicated to their long-term care. 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 that will endure over a lifetime.
Like the Wounded Warrior Regiment, Navy established the 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 where improvements are still needed.
Concurrent with the establishment of the Wounded Warrior Regiment, the Wounded Warrior Barracks, Marine for Life and other initiatives, we continue to coordinate with the Marine Corps to evaluate and expand where necessary USMC liaison offices at our major medical centers for the purpose of coordinating and supporting the needs of the Marines and Sailors, and their families.
We have 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 MTFs for the purpose of coordinating follow-on care requirements and providing education on VA benefits and the newly created federal recovery coordinators are also located at the NNMC and the Naval Medical Center San Diego.
Q: Any final comments?
A: As I have seen firsthand during my forward-deployed travels, Navy Medicine is supporting the war in every aspect: sustaining the war effort, supporting the warfighter, taking care of their psychological ne trauma center LRMC and finally at home, to the National eds and caring for the wounded at every level: from the mobile and immediate forward resuscitative surgical system on the battlefield to the Level IV Naval Medical Center in Bethesda or Naval Medical Center in San Diego.
As the surgeon general of the Navy, I have the ultimate responsibility for ensuring medical readiness with the right force with the right balance.
I have to ensure Navy Medicine forces are prepared, trained and deployed with the right capabilities so we can fully support our warriors, no matter who they are, no matter what the mission might be. ♦