Medical Provider: Sustaining Perpetual Growth and Innovation in Medicine

Lieutenant General
Eric. B. Schoonmaker, MD, PhD
The Surgeon General, Commander,
U.S. Army Medical Command

In 1970 he graduated from the University of Michigan in Ann Arbor, was commissioned a second lieutenant as a Distinguished Military Graduate, and was awarded a Bachelor of Science degree. He received his medical degree from the University of Michigan Medical School in 1975 and completed his Ph.D. in human genetics in 1979.

Schoomaker completed his internship and residency in internal medicine at Duke University Medical Center in Durham, N.C., from 1976 to 1978, followed by a fellowship in hematology at Duke University Medical Center in 1979. He is certified by the American Board of Internal Medicine in both internal medicine and hematology. His military education includes completion of the Combat Casualty Care Course, Medical Management of Chemical Casualty Care Course, AMEDD Officer Advanced Course, Command and General Staff College, and the U.S. Army War College.

Schoomaker has held a wide variety of assignments. From 1979 until 1982, he was a research hematologist at Walter Reed Army Institute of Research. He served as assistant chief and program director, Department of Medicine, Walter Reed Army Medical Center, 1982–1988; Medical Consultant to Headquarters, 7th Medical Command, Heidelberg, Germany, 1988–1990; deputy commander for clinical services, Landstuhl Army Regional Medical Center, Landstuhl, Germany, 1990–1992; chief and program director, Department of Medicine and director of primary care, Madigan Army Medical Center, Tacoma, Wash., 1992–1995; director of medical education for the Office of The Surgeon General/Headquarters USAMEDCOM conducting a split operation between Washington, D.C., and Fort Sam Houston, Texas, 1995–1997; and director of clinical operations at the HQ USAMEDCOM, February to July 1997. From July 1997 to July 1999, he commanded the USA MEDDAC (Evans Army Community Hospital) at Fort Carson, Colo. He attended the U.S. Army War College in Carlisle Barracks, Pa., from 1999 to 2000 followed by assignments as the command surgeon for the U.S. Army Forces Command (FORSCOM) from July 2000 to March 2001, and commander of the 30th Medical Brigade headquartered in Heidelberg, Germany, from April 2001 to June 2002.

Schoomaker was appointed chief of the Army Medical Corps when he assumed command of the Southeast Regional Medical Command/Dwight David Eisenhower Army Medical Center in June 2002. He served as corps chief until September 2006. Prior to commanding the North Atlantic Regional Medical Command, he was the commanding general of the U.S. Army Medical Research and Materiel Command and Fort Detrick, Md., from July 2005–March 2007.

His awards and decorations include the Distinguished Service Medal (with oak leaf cluster), the Legion of Merit (with four oak leaf clusters), the Meritorious Service Medal (with two oak leaf clusters), the Joint Service Commendation Medal, the Army Commendation Medal, the Army Achievement Medal and the Humanitarian Service Medal. He has been honored with the Order of Military Medical Merit and the “A” Proficiency Designator and holds the Expert Field Medical Badge.

Schoomaker was interviewed by MMT editor Jeff McKaughan.

Q: Looking back over the past year, how would you characterize the status of Army medicine, and what grade would you give the command overall?

A: I think Army medicine—and DoD medicine as a whole—is in a state of perpetual growth, adaptation and all the while advancing. Sometimes that growth is in quantum leaps and sometimes incrementally to improve care for our soldiers, sailors, airmen and Marines—our warriors on the battlefield as well as back in garrison. I think this has been an unprecedented time for us. It’s been a time of great challenge and demand but I think we are doing very well, and I would grade us excellent to superb despite some setbacks that we have worked through the past year.

I point to a number of things that we do and continue to do well. The first, perhaps, is that we are supporting without hesitation and without any major problems the wars in Iraq and Afghanistan. We in Army medicine are playing a key and essential role on the battlefield, in our combat support hospitals and other surgical capabilities in theater, and all other elements of battle operating systems that we field.

We are part of a joint medical team providing advanced care in that arena. This is one of the true examples of real successes in joint operations with Army medicine playing a key role in how we have created an almost seamless system of care—not unlike a single city in the United States would have for trauma management. But it’s being done across three continents—across thousands of miles by a team that includes all uniforms, DoD civilian health care providers and increasingly our coalition partners.

This has resulted in unprecedented survival from battlefield wounds and unprecedented pace of evacuations. We continue to be leaders both within the national arena and the international arena as well for trauma management.

The second thing we have done is that we have applied some of that same team focus and high energy to our warriors in transition. What we recognize is that soldiers who are wounded, injured or ill as a consequence of their service deserve to have the highest-quality care available to them—not just at the point of injury or enroute, but at any point of care. Our goal is for each of them to have the opportunity to return to uniform, which is an aspiration of many of those wounded. On average, we return about two-thirds of those ill or wounded back to uniform so they can fulfill their obligation and continue along their career path. We have been able to return 12 percent of amputees from this war back to uniform including some serving in combat roles.

We see the energy that the nation and the Department of Defense has for putting every resource and scientific advance available to not only ensure the survival of a warrior, but the rehabilitation of the soldier, and the fulfillment of their aspiration of returning to full duty or the civilian world. Or, when there is a need for long-term care and rehabilitation, to transition them into the VA systems for private care.

We have titled all of these soldiers as warriors in transition. These are transitional events regardless of where that soldier ends up, and we have internally transitioned much of Army medicine to attend to those needs.

Finally, the Army has adopted the ARFORGEN [Army force generation] model as an important lens to focus the energies of the entire Army on ensuring that we have well-trained, fully manned and battle-ready formations focusing around the brigade combat team. We in Army medicine play a key role in that on every level of the ARFORGEN.

By giving our soldiers the very best and newest equipment available and giving them evidence-based practices that they can take with them to deployment, we enhance the soldiers’ survivability. Once the deployment is over, we participate in resetting that unit, which is very important. We are looking at how we can reset our medical formations, how we can reset the human dimension—the soldier.

Remember, soldiers are the Army, and so our attention to the human dimension of those soldiers’ experiences in combat is critical. We have the ability to not only screen and treat them for physical injuries but to detect, in a very timely manner, psychological and other injuries they may have suffered.

All of this makes us key in the reset phase of a unit.

All of this has kept us very, very busy. I point to advances in each of these—fighting the war, transforming us around warrior care and participating in key phases of the ARFORGEN model—as great contributions of Army medicine over the past year.

Q: What does the Army do to attract health care professionals into Army medicine with the demand for those same people and skills so high in the civilian world? Has it been difficult to retain those people?

A: The second part of the question about retention is easier to answer so I will start there. Once in Army medicine, we find retention to be very, very high. Starting with enlisted retention, we are among the most successful commands within the Army in retaining high-quality soldiers with our retention efforts. The same holds true for our officers as well. I am a good example of a soldier who came into uniform in an earlier era, never expecting to be in uniform this long. Once we get people into Army medicine and once they see the quality of people they work with and see the mission focus of their fellow soldiers and the professionals that make up Army medicine, they easily assimilate. I’ve never seen such a uniform level of high quality and selflessness across the board as within Army medicine.

This has meant that I am not alone in recommitting myself to remain in uniform and be a part of Army medicine.

So for retention, I always say, I am less concerned about getting a lifetime commitment up front from someone who is interested in putting on a uniform, because I am confident that once they get into Army medicine and see what we are about, they will want to remain.

Recruitment is a different matter. We are in a highly competitive market for health care professionals—both in uniform and for our civilians. Army medicine is heavily civilianized, and we depend upon well-qualified individuals, both in uniform and out. We are competing in a marketplace that on a national scope has a shortage of nurses, certain physician specialties, keen competition for the types of people we are looking for—the best trained, highly qualified and most motivated. These folks embody Army values.

These same people are being aggressively sought after by others who want these same qualities in their work force. We have a number of initiatives that we have undertaken for our uniform providers. Congress has been extremely generous in helping us to provide accession bonuses and incentives to bring groups in, especially those where we have the highest need such as dental officers, pharmacy officers, nurses and so on.

We offer loan repayment programs that help professionals who have gone through long years of study for their professional degrees and certifications and find themselves burdened with debt. We are in a position to repay that debt, so they can practice the kind of medicine, nursing or administrative services that they want to without the money concerns looming over their heads.

We are also trying to do what I mentioned earlier in that we are trying to get some experience in the civilian community and who want to serve their nation but not necessarily for the long commitment that comes with a traditional recruit. We have started a new pilot program called the Army Officers Accession Pilot Program [OAPP] to get a select group of more senior physicians to come in a shorter period of time—perhaps just two years. As long as they meet certain accession criteria and have certain practices and certifications, we will bring them in and give them a great experience and let them contribute to serving their nation as an experienced physician.

Q: I understand that Army Recruiting Command has aligned itself in a way that is helping out AMEDD.

A: Yes, one thing that has happened within the United States Army Recruiting Command [USARC] that I think is very positive is their creation of a medical recruiting brigade. This brings together under a single command the recruiting battalions that recruit for AMEDD across the country. This has allowed us to partner with that medical recruiting brigade and the battalions that are subordinate with our hospitals and clinics. The best recruiter of a medical professional is another medical professional. We are working very closely with them.

In a world and society that has less and less experience with direct military service, it is great to have a one-on-one relationship through the recruiting process that allows someone to come into our hospitals, see what our practices are like, see the spectrum of patients—the great soldiers and their families—that we care for. This has proved very successful.

The other thing we have done is to establish our own civilian human resources and recruitment branch so we can target using the three Rs of recruitment, retention and relocation incentives. By doing so, we can target the kind of civilian professionals we need because we have no less a challenge on the civilian side to get the very best health care professional we can.

This is true for every element of this command. It’s often forgotten that to do good medicine you have to have good contracting officers and good veterinarian technicians and good dental technicians and a host of other providers other than the direct care giver. Our civilian colleagues are also leaning forward and doing great work.

Q: Turning to funding for a minute, how concerned are you with the rising costs—both in actual dollars and as a percentage of the DoD overall budget—of health care for both active and non-active servicemembers? How soon will the cost of veterans’ health care start to impact funding for research and development and then procurement of new systems?

A: I think all Americans are concerned about the rising health care costs so it’s not something just for the federal system and certainly not for just the uniformed force. It’s a concern that health care expenditures in general are on a continuous escalation well above the consumer price index and has been for a number of years.

That does affect us not only because we are reliant through the TRICARE program and others through a network of civilian providers but also because as a microcosm of the larger health care terrain, we are subject to some of the same inflationary costs for pharmaceuticals, equipment, building facilities and so on. I would emphasize that this is not, for us, a passive kind of event. We can play a very important role internal to Army and DoD medicine to help contain those costs. The way we in Army medicine have pursued this is by adopting the highest-quality practices for care, which comes under the rubric of evidencebased medicine where we apply practices to include diagnostic procedures and equipment, or therapeutic procedures that have some evidence for their use and have been shown to be effective with this group of patients for that set of clinical challenges.

It may surprise many to know that even in 2008 much of medical practice is performed without a clear demonstration that it adds value to the patient by ensuring that the clinical outcome from that encounter or treatment is going to be as good as possible. We are working hard, as is American medicine in general—especially the academic elements—to try and provide the best evidence-based practice we can. For example, a heart attack or cancer or a major injury is treated by the very best practices available.

That’s especially important as we deal with people who are developing and fielding devices that diagnose disease as well as therapeutic devices. We would like to see evidence that proves these devices add value for the patient, and at the end of the day they are better off for that encounter and application of that device.

I’m convinced that we can contribute a great deal to trimming the cost of care and help to bring down some of the cost escalations if we as practitioners of medicine, surgery and nursing can apply, whenever possible, those very best evidence-based practices and look at the ultimate outcome of the patient and consider that the goal.

Not surprisingly, the military has adopted a very similar approach when it comes to fighting war. It’s not just about how much ordnance you launch downrange; it’s about how many targets you have and how much you work or how successful you are in preventing collateral damage where you don’t want your kinetic weapons to hit or cause damage. We’re no different, but we’re in the healing world. We want to make sure that whatever we apply to our patients is done with the best effect. [We want] the best outcome on whatever that therapeutic investment is with the least damage.

Now, the other thing that people need to appreciate is that we are in an era in which Congress is extraordinarily generous to us in providing support for especially targeted research needs that we have—whether that’s post-traumatic stress disorder, traumatic brain injury, blast injury. I’m one who believes very firmly we don’t have a signature wound from this war, but we certainly have a signature weapon, and that signature weapon is blast.

Congress has been forthcoming with support through supplemental funding for research into prevention, mitigation, recognition in an ultimate treatment of blast injuries of all kinds—whether they are burns or amputations or blindness or hearing problems, or, in the case of head injuries, concussive or mild traumatic brain injury. We don’t compete for funding with the Veterans Administration. Our funding comes through either the military services acquisition funding line and research funding line, or it comes through defense health program budget.

So, I think the readers need not be concerned that veterans’ care and funding is going to rob from the DoD budget. I think that we’re in a very close partnership with the VA to ensure that the targets of our research are complementary of the targets of their research because we’re ultimately serving the same population of veterans.

Q: You mentioned post-traumatic stress disorder. The Army has instituted a training program designed to raise awareness and to reduce the stigma associated with mental health care for post-traumatic stress. Can you tell me more about that program?

A: Sure, I really credit the leadership of the Army—our secretary and our chief of staff and all the senior leadership right down to and especially including our junior officers and NCOs with taking a lead to educate the force and families about this human dimension of combat. We’ve long recognized that exposure to the trauma of combat—watching one’s friends get injured or killed, being in a life-threatening circumstance is not without cost to the individual.

As human beings, irrespective of how much we see ourselves as immune from those effects, we suffer from being in a stressful combat environment. Our studies have shown [the effects of a stressful combat environment] through a series of iterative surveys that have been conducted by what we call the mental health advisory teams, or MHATs, and Army medicine has been a leader in this. We have just completed the fifth annual MHAT, where we sent teams into battle to assess the impact on the psychological health of soldiers during their deployment and then following their deployment.

From that, we have learned that there is an almost predictable development of stress-related symptoms following exposure to combat and life-threatening circumstances. They frequently don’t arise at the moment of reintegration or return to home. The flurry of activities and the energy and the excitement about returning home often masquerades or disguises that. But, if we look back three or six months later, what we begin to see is an emergence of symptoms of hypervigilance, intrusive thoughts or sleep problems—things that might cause a soldier to seek relief with alcohol or drugs or to withdraw from the family.

Anger is a problem with post-traumatic stress symptoms, and we’ve recognized that and are very sensitive about families who are being caught up in the spasm of family violence because of this. The Army leadership, to go back to the role that the chief and secretary have played in this, recognized that this was a major dimension of combat, especially now in our seventh year.

They undertook a chain teaching and a message to the field that is embodied in Al Iraq 153-2007, directing all soldiers to receive training on post-traumatic stress symptoms. At the same time, because blast is such a prevalent part of our modern battlefield and is being used so extensively by this adaptive enemy, we recognize that concussive injury, mild traumatic brain injury, not unlike what a football player or a soccer player might receive on the sports field or what may happen in a vehicle accident, is not uncommon among soldiers, and so recognizing the delayed symptoms of having had a concussive injury—which, in many respects, overlaps with the symptoms of post-traumatic stress, is something that everybody should recognize, so that soldiers recognize in their fellow soldiers if their behavior begins to change, if they become withdrawn, if they begin turning to alcohol, that this might be a sign of either post-traumatic stress or a concussive brain injury.

The good news about both of these is, if recognized in a timely way and if put in the hands of a practitioner who is trained to treat them, we feel that the vast majority of these folks will fully recover and be able to return—not unlike the sports figure who might suffer a concussive injury on the sports field or someone who has experienced a traumatic event in their life in some other realm outside of combat.

Q: And other efforts?

A: The other thing that the Department of Defense has done, in attempting to remove the stigma associated with seeking care for these symptoms, is to remove or to modify the question on the security clearance questionnaire that is required by all of the DoD personnel seeking high-level security clearance. The requirement to report psychological or family counseling that they may have received as a consequence of deployment has been taken out so that soldiers don’t have to fear that if they seek care and counseling for these things, even anonymously, that they’re going to have to ultimately report that and threaten their security clearance. I think that the department as a whole and the Army as a service within the department have been very aggressive in getting the word out to try to lower the stigma associated with it.

Whether we are looking at deployment-based or battle-associated symptoms and problems at every turn, we are seeking the best evidence-based practices. With as many soldiers as we have now potentially affected by these symptoms returning from combat, there is a great interest out there in developing new devices and techniques to both diagnose and treat this. I’m very encouraged that so many people come forward with great ideas, and I think we’re on the cusp of some really revolutionary insights into the mechanisms by which stress and a direct blow to the head or a concussive event are two separate types of brain injuries, how these get translated into symptoms and how those symptoms may become, if not recognized and treated successfully, long-term disabilities for folks.

Q: Do I understand that at some point you think there will be either a device or a test that, even if a person doesn’t appear to have symptoms of post-traumatic stress, may be able to detect the onset of the symptoms?

A: I don’t have a crystal ball to know what science is going to provide for us. It would be ill-advised for me to predict what is going to happen. I suspect that through nanotechnology, through these emerging sciences of genomics and proteomics and the tabelonics, we’re going to see markers available to us that are going to allow us to target particularly susceptible groups and to identify those who are at the highest risk for this. That might be before even the emergence of symptoms; that would be terrific because we would relieve the suffering of people essentially before they have to go through the experience and risk of not being recognized and treated.

So, do I think that science is going to provide that for us? I think so. I don’t know how it’s going to come or how long it’s going to take, but I certainly think it’s important to remember, as I said before, while we’re moving toward this, that we’ve already applied some treatments for post-traumatic stress disorder, which is the more established diagnosis when those symptoms aren’t recognized and they become firmly entrenched on the individual.

We have practices that have been subjected to the right kind of rigorous science to ensure that they make a difference. Of our training that was developed within the Army—the best example is probably Battlemind training, which is a library of tools available for commanders, families and soldiers, to give them insight into what combat is about and into what interpersonal relationships are about as a consequence of deployment. Battlemind training has been subjected to studies [that] show that those who receive the training are less likely to experience symptoms when they come back [from deployment].

The last MHAT survey that was conducted has shown us that those soldiers in deployment right now in Afghanistan and Iraq who have gone through pre-deployment Battlemind training are less likely to develop symptoms while they’re on deployment. That’s the kind of effective practice and effective device we’re looking for.

Q: There has also been a well-documented rise in the suicide rate for soldiers. Can you address the Army’s course of action?

A: It’s true that over the last five to six years, we have seen a slow but steady increase in both suicide and attempted suicide of soldiers, and this does disturb us deeply. Five years ago, our rate of suicide for a demographically adjusted population in civilian life was probably half of what the civilian sector saw, and we were very proud of that. What we see is that disparity between being a uniformed soldier and being a civilian is beginning to disappear; in fact, we’re closing in fast on the civilian rates. We’re looking very carefully for the causes; some can be obvious—recurrent deployments, the length of deployments, separation from family, exposure to the risks of combat, and the like. But, we continue to see suicide and suicide attempts even by soldiers who haven’t been deployed. Sometimes some of our youngest soldiers are bringing with them experiences and problems.

One of the things that we’re working on very aggressively is a program called “Shoulder-to-Shoulder—No Soldier Stands Alone.” September was suicide prevention month for the nation. We designated a week, September 7–13, as Suicide Prevention Week for the active Army, and the Reserves kept the entire month of September as Suicide Prevention Month. The effort is to extend the warrior ethos, that element that talks about not leaving a fallen comrade to this area of suicide prevention. What we want is for our soldiers to recognize and reach out when necessary to their fellow soldiers’ changes in behavior or other signs that that soldier may be suffering and contemplating harming themselves. What we have done is to field a card called the ACE card, which is an acronym for “Ask a buddy, Care for that buddy and Escort that buddy” if there is reason to believe that there is a danger for that soldier.

The “Ask a buddy” [aspect] is probably the hardest of all. You are talking about an area that is very frightening for many people. It is deeply personal area when you are dealing with the stresses on an individual, particularly those that are your friends and colleagues. These issues are difficult to talk about and require someone to reach out to somebody when they become concerned about their behavior and ask a very simple question—are you in trouble, are you considering harming yourself?

Many folks think that by asking the question, you actually can do harm. But in fact the opposite is true. People who are contemplating suicide are frequently overwhelmed with thoughts of self-harm, so there’s no harm in asking the question. What you are doing is sending a clear message that you care and are concerned about them, and if you get some examples of what they are going through, you are extending to them a signal that you are there to help them—you are not going to leave them as a fellow soldier and that you are then going to help them by removing them from conditions that might make suicide easier. Suicide is an impulsive act, and if someone can be removed from the instrument they might use to do harm to themselves, you have already reduced the risk by some degree.

We are not asking that individual soldiers become psychologists; all we are asking is that they escort them to someone who is trained and skilled to help that soldier. ACE—Ask, Care, Escort.

Q: Are there prevention efforts as well?

A: Absolutely. On top of what I just mentioned, the Army is undertaking an effort to move from just putting out the fire of a suicide attempt, and moving back toward prevention earlier in the process. We want to prevent the most serious consequence, but we want to start examining all of the causes that we might be able to remove to reduce the risk from the outset. If someone was at risk for a heart attack, we might look back to earlier years and recommend eating better or getting more exercise.

We want to do the same thing for suicide prevention. What we are doing is looking at the positive of building resilience and psychological health among our force and working with the families and communities to do this.

This is a shared responsibility—not just medics. We are here to treat the consequences. What the chief of staff [of the Army] is working on is getting the Army leadership engaged. Our chaplains are involved, our community leaders are involved, all so that we take the approach of building strength and resilience within the force from earlier stages so that fewer and fewer of our soldiers reach a point of deep dismay.

Q: Reduction and elimination of paper patient records has long been a goal of the medical services. How is the Army doing regarding this?

A: Not only has it been a long-term goal of the military health system in general, but as an Army medical department we have taken a very strong lead in this. We are the first service to really push hard to field the outpatient electronic health record—called ALHTA—and to field the ACENTRIS for our inpatient records. We, along with the other services, very much recognize the need for an electronic health record. Medical care, whether we are talking about prevention or intervention—not unlike warfighting— is a knowledge struggle. It is a struggle for information about an individual patient that we aspire to use in such a way, with electronic enablers such as an electronic health record, that gives us the pertinent information about an individual at the right time to prevent an injury or illness, or if [an injury or illness] is emerging, to provide the right kind of therapy with the right kind of provider.

The precision of action is really dependent on the precision of information. This means having an expansive database of information about that individual that goes across time and space. This is what an electronic health record is all about. And by the way, this is related to one of your earlier questions about cost containment. It is obvious that with the precise information about people, we can precisely manage their care and as a consequence have more resources available to treat more people and extend our care to more people.

So, we’re really invested in a user-friendly, comprehensive electronic health record and one that communicates with our major partners, starting with Veterans Affairs. The VA has a different electronic health record than we do, but we’ve been working very hard on a bi-directional health information exchange that is maturing as we speak.

There is no question that we need improvements in ALTHA. The secretary of defense for Health Affairs has been very outspoken about this and very much a proponent that we accelerate improvements in this electronic health record. It is not as userfriendly for the clinician as we hoped it would be.

At the same time, our clinicians are not seeing the kind of return on their investment of time and energy that they have devoted to working with our patients that we are seeing. That is to say that the mining of information and data is not as readily available to the practitioner so they are giving us their time and energy and attention to using the system but are not seeing the full benefit of that. We are working very hard to make that happen, for example, using wireless networks, giving them tablets where they don’t have to fat-finger information onto a laptop or PC at their desk. We are increasingly using voice recognition software so they can go back to a model they are more familiar with using natural human language to populate the database.

Let there be no doubt that we are absolutely committed to this. The potential for us is to capture information about our patients, even in deployment at the point of injury or illness downrange, and to put that into a centralized data repository that allows us to track the patient, to glean from that record what care that they’ve been delivered. [That way] we don’t have to repeat or we don’t make errors in managing them later; we have a data repository of past clinical information that even on deployment or when they move from one hospital community to another we’re able to look back and see what’s been done for this individual or what problems that they encountered in the past so that we have instantaneous knowledge about who this patient is and what their needs are.

We are absolutely committed to this electronic health record, and I think that it’s going to be one of the most powerful enablers that we in federal medicine will have as we move into the next few decades of our practices.

Q: Recognizing the fact that everything is important, do you have a priority list of equipment items, technologies that you’d like to see? Do you focus more on combat medicine, initial treatment, preventive medicine?

A: I alluded to earlier the success we’ve had by looking at the whole trauma treatment and evacuation and post-evacuation management scheme. We do have a comprehensive list; we have a missionary materiel plan called “the Map.” It’s developed both by partnership between our materiel developers at the medical research and materiel command and the AMEDD center and school who develop our requirements. This prioritizes all of the devices and drugs that we think will have the most impact on the whole patient lest we place too much of our investment into a device or a drug or vaccine that is going to have a lesser impact on the force.

We do prioritize—I think we have a pretty good lash up between our materiel developers and events scientists with the requirements folks who have looked at the needs of the force in general. We’re basically looking at every phase of prevention and treatment of any potential major health threat to the force. These range from vaccines to preventive drugs to hemorrhage control, pain relief, devices that assist us in oxygen delivery, blood substitutes, and volume expanders for hemorrhaging patients, and many other examples are all being worked very actively and are prioritized.

Q: What’s your impression on the Stryker medical vehicle?

A: I think the Stryker vehicle has shown itself to be a value-added system in combat but within a prescribed kind of an environment. Stryker can’t go everywhere that our soldiers go and everywhere the force goes. But it is well-received by medics and the soldiers that use it. It has great capabilities for us. We are adapting it, as we do with all of our equipment, in real-time as we learn new things about it. As we expose new vulnerabilities we work to close those, and we make improvements as users provide feedback to the PMs about what experience has shown can be improved. Whether it’s the litter lift, internal cushioning, or whatever that might be, we make those improvements. I think this is something that everyone should be aware of, that this is a war that is unprecedented in the pace in which we are modifying our equipment and practices. As we learn new information we make adjustments. We have done this with the trauma system in general, and we are doing that with every bit of materiel.

While the Stryker is just one example; another example is what we are doing in body armor. We are mapping patterns of injuries both from surviving and non-surviving soldiers of combat wounds to see where the vulnerabilities of our Kevlar or our ballistic goggles and body armor are. This is how we adapt. I am also working on another armored ambulance vehicle to cover those areas where the Stryker is not as well-suited. There is no question that in the kind of urban combat that we are involved in that our soldiers, medics and wounded require protection from the enemy, and having a mine-resistant vehicle and an armored ambulance is essential. As the old M113s get taken out of inventory, we need to keep that gap in care closed.

Q: Is this the medical variant of the Bradley?

A: Yes, we are looking at and are impressed with the Bradley’s capabilities and could use some of the existing chassis and retrofit them. All of this is under advisement and is being investigated. One thing that the leaders need to understand is that we are absolutely committed to protecting and caring for our soldiers.

Q: Any final thoughts?

A: I do want to make sure that everyone understands that something of great significance recently occurred. November was Warrior Care Month and is an indicator of the importance that the Army and certainly Army Medicine place in caring for our warriors. Warrior Care Month is a three-phase month recognizing the entire continuum of care throughout the month beginning with the early phases of recovery from an injury to rehabilitation to ultimate reintegration— whether that reintegration is back into uniform or back into civilian life. Also earlier this month, Command Sergeant Major Dixon and I signed the Army Warrior Healthcare Covenant and expect all Army military treatment facilities to sign their individual covenants by February 2009. This covenant tells our wounded, ill or injured that we will get through it together, that we are grateful for the contributions they and their families have made, that we will provide them with the highest quality of care and services possible to honor their contributions to our nation. That we will provide the assistance needed by warriors and their families during the healing process; and that we will provide an environment that is conducive to healing by focusing on body, mind, heart and spirit.

The Warrior Month Website is www.warriorcare.mil. ♦