The primary mission of the military physician assigned to a combat-arms unit is to sustain the un... more The primary mission of the military physician assigned to a combat-arms unit is to sustain the unit's fighting strength through prevention, primary medical care, and trauma resuscitation. Technical and organizational details of civic action assistance are not emphasized routinely during training. Real-world deployment, however, presents challenges approachable only with flexibility and improvisation. Historically, combatant commanders have recognized the health of civilians in their operational area as a target through which local acceptance of United States (US) intervention may be achieved. The medium-unit (battalion and brigade) physician may be charged with providing care to the host-nation populace. Because the mission's emphasis is one of public relations and not sustainable development, lasting medical benefits are not attained. This article addresses the challenge of on-the-spot military civic assistance. The experience of the 173d Airborne Brigade (Bde) Medical Sect...
The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and res... more The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and resource capacity. A regionally located United States Military Mobile Surgical Team was deployed and operational within 48 hours. However, a post-mission analysis confirmed a low yield from the military surgical resource. The experience of the team suggests that non-surgical medical, transportation, and logistical resources filled essential gaps in health assessment, evacuation, and essential primary care in an otherwise resource-poor surge response capability. Due to an absence of outcomes data, the true effect of the mission on population health remains unknown. Militaries should focus their disaster response efforts on employment of logistics, primary medical care, and transportation/evacuation. Future response strategies should be evidence-based and incorporate a means of quantifying outcomes.
The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and res... more The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and resource capacity. A regionally located United States Military Mobile Surgical Team was deployed and operational within 48 hours. However, a post-mission analysis confirmed a low yield from the military surgical resource. The experience of the team suggests that non-surgical medical, transportation, and logistical resources filled essential gaps in health assessment, evacuation, and essential primary care in an otherwise resource-poor surge response capability. Due to an absence of outcomes data, the true effect of the mission on population health remains unknown. Militaries should focus their disaster response efforts on employment of logistics, primary medical care, and transportation/evacuation. Future response strategies should be evidence-based and incorporate a means of quantifying outcomes.
The primary mission of the military physician assigned to a combat-arms unit is to sustain the un... more The primary mission of the military physician assigned to a combat-arms unit is to sustain the unit's fighting strength through prevention, primary medical care, and trauma resuscitation. Technical and organizational details of civic action assistance are not emphasized routinely during training. Real-world deployment, however, presents challenges approachable only with flexibility and improvisation. Historically, combatant commanders have recognized the health of civilians in their operational area as a target through which local acceptance of United States (US) intervention may be achieved. The medium-unit (battalion and brigade) physician may be charged with providing care to the host-nation populace. Because the mission's emphasis is one of public relations and not sustainable development, lasting medical benefits are not attained. This article addresses the challenge of on-the-spot military civic assistance. The experience of the 173d Airborne Brigade (Bde) Medical Sect...
Flying directly from its home station in Vicenza, Italy, the 173rd Airborne Brigade committed its... more Flying directly from its home station in Vicenza, Italy, the 173rd Airborne Brigade committed itself to the invasion of Iraq on the night of March 26, 2003. Representing the establishment of a northern front, ϳ1,000 paratroopers jumped into an isolated valley on a mission to secure and to hold the Bashur airstrip. This article describes the unique challenges of medical preparation for the mission, injuries sustained on the jump, and lessons learned. Emphasis is placed on the use of a policy of delayed evacuation until clarification of diagnosis.
The population of Soldiers not medically fit for deployment has created readiness problems for th... more The population of Soldiers not medically fit for deployment has created readiness problems for the U.S. Army in recent years. To address this issue, the 3rd Infantry Division created councils of experts to address the size of its medically nondeployable population. Our results demonstrate success in effectively reducing the subpopulation of Soldiers who have been medically nondeployable for long periods of time by enforcing their return to duty or medical retirement. This study also demonstrates that council-based management affects the composition of the medically-not-ready population. Traditional approaches allow a minority subpopulation of Soldiers with poor prognoses to dwell within the nondeployable population for long periods of time (6-18+ months), whereas the healthier majority recovers within the first 6 months. This creates a dynamic in which remaining in the population for longer time periods increases the probability of being medically retired. Our study demonstrates that councils consistently and actively shape the character of the group such that those remaining in the medically-not-ready population for longer periods of time do not have an increased risk of medical retirement. Soldier Medical Readiness Councils have already been adopted by the Army. This article provides evidence to support their efficacy.
Background: In 2009, suicide accounted for 36 897 deaths in the United States. Purpose: To review... more Background: In 2009, suicide accounted for 36 897 deaths in the United States. Purpose: To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care. Data Sources: Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012). Study Selection: Fair-or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings. Data Extraction: One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality. Data Synthesis: Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths. Limitation: Treatment evidence was derived from high-risk rather than screening-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited. Conclusion: Primary care-feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven.
: An 18-year-old male recruit underwent a physical examination to assess fitness for enrollment i... more : An 18-year-old male recruit underwent a physical examination to assess fitness for enrollment into the Naval Academy. There was no health complaint. His medical history was significant for a pectus excavatum. His surgical history was notable only for a cosmetic repair of the pectus at age 14. Review of systems included an ability to participate in athletics without limitation. His admission physical exam documented only ?a left chest wall 6 cm scar consistent with surgical history.? The screening chest x-ray is presented below (Fig 1A). Technical limitations impeded a thorough echocardiographic evaluation and a cardiac magnetic resonance imaging (MRI) study was performed to determine whether the condition represented dextroposition, true mirror-image dextrocardia, or a more sinister culprit such as corrected transposition of the great arteries (Fig. 1B, coronal; Figs. 1C, 1D and 1E, axial cranial to caudal).
Introduction Since 2009, the Military Health System (MHS) has represented its mission as that of ... more Introduction Since 2009, the Military Health System (MHS) has represented its mission as that of attaining the Quadruple Aim (QUAD AIM): increased readiness, better health, better care, and low per capita costs. The journey to reach the four goals is challenging and ongoing. Leaders in the MHS’s Central Texas Market (CTM) sought to understand and overcome the root-cause obstacles that interfered with achieving the QUAD AIM. This process required a self-critical and thoroughly objective review of the behavioral economics of the system. We hypothesized that two corporate behaviors fed upon each other to create a vicious downward spiral. First, as a socialized (salary-based) system, the enterprise has a built-in incentive that covertly competes with the attainment of the QUAD AIM. Because additional work does not result in any material gain for its workers, the system regulates to a comfortable flow. Second, centralized leaders defer important management controls to tactical teammates ...
: Perhaps the greatest modern medical policymaker was Major General (MG) Spurgeon Neel. Serving f... more : Perhaps the greatest modern medical policymaker was Major General (MG) Spurgeon Neel. Serving from 1943 to 1977, Neel is best known as the Father of DUST OFF or the Father of Aviation Medicine for his pioneering role in the creation of the doctrine of helicopter medical evacuation. One of Neel's greatest strengths was his power of evidenced-based persuasion. He published more than 33 articles in the fields of flight, operational, and military medicine. He was passionate about his causes to be sure. Nonetheless, his support for them was based on rational analysis. Diverging from common mental models, the ideas contained in his writings included a supported set of instructions for an improved future. Most importantly, as a champion of change, MG Neel possessed the leadership skills to convince the establishment that his visions were incontrovertible. Almost all of Neel's policies have withstood the test of time. One has become distorted. In 1973, Neel described the concept o...
INTRODUCTION For the past 16 years, Military Health System primary care providers have been incen... more INTRODUCTION For the past 16 years, Military Health System primary care providers have been incentivized to pursue work in a fee-for-service (FFS) model. The system values documentation of productivity to earn as many relative value units as possible. The result is densely packed clinic schedules that often lack the space or flexibility to accommodate patients when sick. Leakage ensues. Furthermore, prevention and patient experience are not directly incentivized. METHODS The Central Texas Market's Accountable Care Organization reformed incentives in its #5 FFS-designed community-based medical homes to value outcomes over productivity. The resulting quality, urgent, internet, and phone care (QUiC) clinics are value-based and, therefore, better structured to achieve the Quad aim (better care, better health/readiness, and low cost). Forsaking deeply ingrained FFS practices, QUiC clinics funnel all routine (information-sharing) appointments into efficient internet or phone appointme...
An 18-year-old male recruit underwent a physical examination to assess fitness for enrollment int... more An 18-year-old male recruit underwent a physical examination to assess fitness for enrollment into the Naval Academy. There was no health complaint. His medical history was significant for a pectus excavatum. His surgical history was notable only for a cosmetic repair of the pectus at age 14. Review of systems included an ability to participate in athletics without limitation. His admission physical exam documented only "a left chest wall 6 cm scar consistent with surgical history." The screening chest x-ray is presented below (Fig 1A). Technical limitations impeded a thorough echocardiographic evaluation and a cardiac magnetic resonance imaging (MRI) study was performed to determine whether the condition represented dextroposition, true mirror-image dextrocardia, or a more sinister culprit such as corrected transposition of the great arteries (Fig. 1B, coronal; Figs. 1C, 1D and 1E, axial cranial to caudal). Imaging Findings The PA radiograph (Fig. 1A) demonstrates a right-sided heart. Cardiac MRI images further define the internal cardiac anatomy. On a coronal bright blood MRI image (Fig. 1B; LA = left atrium; LPA = left pulmonary artery; Ao = aorta), the pulmonary veins (arrow) are seen entering into the leftsided atrial chamber (i.e. left atrium). This confirms the usual atrial position. On axial black blood MRI images (Figs. 1C thru 1E, cranial to caudal), the moderator band (arrow, Figs. 1D and 1E; RV = right ventricle; LV = left ventricle), a structure unique to the right ventricle, is visualized in the right-most ventricle in Fig. 1C, confirming a normal d-loop ventricular development and orientation. On a more cranial axial cardiac MRI image (Fig. 1C), the aorta
BACKGROUND The COVID-19 pandemic creates unique challenges for healthcare systems. While mass cas... more BACKGROUND The COVID-19 pandemic creates unique challenges for healthcare systems. While mass casualty protocols and plans exist for trauma-induced large-scale resource utilization events, contagious infectious disease mass casualty events do not have such rigorous procedures established. COVID-19 forces Emergency Departments (EDs) to simultaneously treat seriously ill patients and evaluate large influxes of 'worried well'-while maintaining both staff and patient safety. METHODS The objectives of this project are to create an avenue to evaluate large surges of patients while minimizing hospital-acquired infections. After identifying areas for improvement and anticipating potential failures, we devised eight healthcare delivery innovations to address those areas and meet our objectives: (1) Parallel ED Lanes (2) Universal Respiratory Precautions (3) Respiratory Drive Through (RDT) (4) Medical Company (5) Provider Triage (6) ED Quarterback Patient Liaison (EDQB) (7) Virtual Re...
[ILLUSTRATION OMITTED] Leader development is achieved through the lifelong synthesis of knowledge... more [ILLUSTRATION OMITTED] Leader development is achieved through the lifelong synthesis of knowledge, skills, and experiences gained through institutional training and education, organizational training, operational experience, and self-development. --FM 6-22, Army Leadership, October 2006 (1) THE ARMY POSSESSES a corps of noncommissioned officers (NCOs) unparalleled among the world's militaries. Noncomissioned officers assigned to maneuver units deserve praise for their ability to adapt, with agility, to the roles of Soldier, leader, and trainer. Because of the wars in Iraq and Afghanistan, NCOs have become master communicators, diplomats, strategists, and mediators; however, NCO growth and mastery in technical areas may be overlooked. In specialties such as communications, engineering, and computer science, NCOs have transformed the U.S. land force into an entity for which the word "army" seems simple and antiquated. Due to their dedication and ability to learn, the men and women who deploy in support of U.S. national security represent a team of multidimensional experts. A good example is combat casualty management. The case fatality rates for the wars in Iraq and Afghanistan are the lowest on record. Experts credit two items for this development: body armor and battlefield first aid. Arguably, the more dynamic and ethereal component of this two-armed success is medical care. Unfortunately, reducing its actions to the term "first aid" depersonalizes heroic deeds performed by Soldiers within a frightening kinetic environment. The "medic," or Military Occupational Specialty (MOS) 91W, is one of many unsung heroes of the wars in Iraq and Afghanistan. Using the combat medic as a case study, I will evaluate technical professionalism in the Army as a micro-revolution in military affairs. To describe the transformation of the combat medic during the first decade of the new millennium, one must trace the roots of change to decades past. In the 1980s, careful analysis of the lessons of the Vietnam War set in motion a chain of events that led to the creation of the modern U.S. medic. During the 1990s, the lessons learned from Vietnam gradually became part of reformed medical training. When war broke out in Afghanistan in 2001 and Iraq in 2003, the U.S. military found itself at a crossroads of medical doctrine. Without hesitation, the Army attacked the challenge and instituted a fundamentally new model of battlefield first aid. [ILLUSTRATION OMITTED] The medical NCO was influential in every chapter of this growth in medical professionalism. Medical NCOs first provided proof of concept. Thereafter, the Army entrusted them with the vital task of teaching, training, and mentoring a new breed of combat medic. The Army Medical Department Center and School in San Antonio, Texas, delegated the details of institutional change to the medical NCO. When the luxury of time dissipated with the onset of combat operations in 2001, the medical NCO provided a "hip-pocket" training bridge from old doctrine to innovative practice on the battlefield. The stakes were high, and there was no guarantee of success. At each step, the Army placed more expectations upon the medical NCO. The lower case fatality rates in Iraq and Afghanistan are a testament to the degree in which NCOs have met these expectations. The achievement of this standard reflects a model of organizational leader development. NCOs continually supported, reinforced, and expanded good ideas with professional and technical competency. Understanding Soldier Combat Medical Needs Today's combat medic owes much of his success to the pioneering work of Dr. (Colonel) Ronald F. Bellamy. Using theoretical models and data on wounds and munitions effectiveness in Vietnam, Dr. Bellamy sought to understand how Soldiers died on the modern battlefield. (2) In his 1984 article, "The Causes of Death in Conventional Land Warfare: Implications for Combat Casualty Care Research," Bellamy reached two important conclusions: first, that 90 percent of Soldiers killed in action suffered unsurvivable, catastrophic deaths while only 10 percent had injuries that were potentially survivable; and second, that 98 percent of patients who reached medical aid stations while still alive, ultimately survived. …
The primary mission of the military physician assigned to a combat-arms unit is to sustain the un... more The primary mission of the military physician assigned to a combat-arms unit is to sustain the unit's fighting strength through prevention, primary medical care, and trauma resuscitation. Technical and organizational details of civic action assistance are not emphasized routinely during training. Real-world deployment, however, presents challenges approachable only with flexibility and improvisation. Historically, combatant commanders have recognized the health of civilians in their operational area as a target through which local acceptance of United States (US) intervention may be achieved. The medium-unit (battalion and brigade) physician may be charged with providing care to the host-nation populace. Because the mission's emphasis is one of public relations and not sustainable development, lasting medical benefits are not attained. This article addresses the challenge of on-the-spot military civic assistance. The experience of the 173d Airborne Brigade (Bde) Medical Sect...
The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and res... more The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and resource capacity. A regionally located United States Military Mobile Surgical Team was deployed and operational within 48 hours. However, a post-mission analysis confirmed a low yield from the military surgical resource. The experience of the team suggests that non-surgical medical, transportation, and logistical resources filled essential gaps in health assessment, evacuation, and essential primary care in an otherwise resource-poor surge response capability. Due to an absence of outcomes data, the true effect of the mission on population health remains unknown. Militaries should focus their disaster response efforts on employment of logistics, primary medical care, and transportation/evacuation. Future response strategies should be evidence-based and incorporate a means of quantifying outcomes.
The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and res... more The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and resource capacity. A regionally located United States Military Mobile Surgical Team was deployed and operational within 48 hours. However, a post-mission analysis confirmed a low yield from the military surgical resource. The experience of the team suggests that non-surgical medical, transportation, and logistical resources filled essential gaps in health assessment, evacuation, and essential primary care in an otherwise resource-poor surge response capability. Due to an absence of outcomes data, the true effect of the mission on population health remains unknown. Militaries should focus their disaster response efforts on employment of logistics, primary medical care, and transportation/evacuation. Future response strategies should be evidence-based and incorporate a means of quantifying outcomes.
The primary mission of the military physician assigned to a combat-arms unit is to sustain the un... more The primary mission of the military physician assigned to a combat-arms unit is to sustain the unit's fighting strength through prevention, primary medical care, and trauma resuscitation. Technical and organizational details of civic action assistance are not emphasized routinely during training. Real-world deployment, however, presents challenges approachable only with flexibility and improvisation. Historically, combatant commanders have recognized the health of civilians in their operational area as a target through which local acceptance of United States (US) intervention may be achieved. The medium-unit (battalion and brigade) physician may be charged with providing care to the host-nation populace. Because the mission's emphasis is one of public relations and not sustainable development, lasting medical benefits are not attained. This article addresses the challenge of on-the-spot military civic assistance. The experience of the 173d Airborne Brigade (Bde) Medical Sect...
Flying directly from its home station in Vicenza, Italy, the 173rd Airborne Brigade committed its... more Flying directly from its home station in Vicenza, Italy, the 173rd Airborne Brigade committed itself to the invasion of Iraq on the night of March 26, 2003. Representing the establishment of a northern front, ϳ1,000 paratroopers jumped into an isolated valley on a mission to secure and to hold the Bashur airstrip. This article describes the unique challenges of medical preparation for the mission, injuries sustained on the jump, and lessons learned. Emphasis is placed on the use of a policy of delayed evacuation until clarification of diagnosis.
The population of Soldiers not medically fit for deployment has created readiness problems for th... more The population of Soldiers not medically fit for deployment has created readiness problems for the U.S. Army in recent years. To address this issue, the 3rd Infantry Division created councils of experts to address the size of its medically nondeployable population. Our results demonstrate success in effectively reducing the subpopulation of Soldiers who have been medically nondeployable for long periods of time by enforcing their return to duty or medical retirement. This study also demonstrates that council-based management affects the composition of the medically-not-ready population. Traditional approaches allow a minority subpopulation of Soldiers with poor prognoses to dwell within the nondeployable population for long periods of time (6-18+ months), whereas the healthier majority recovers within the first 6 months. This creates a dynamic in which remaining in the population for longer time periods increases the probability of being medically retired. Our study demonstrates that councils consistently and actively shape the character of the group such that those remaining in the medically-not-ready population for longer periods of time do not have an increased risk of medical retirement. Soldier Medical Readiness Councils have already been adopted by the Army. This article provides evidence to support their efficacy.
Background: In 2009, suicide accounted for 36 897 deaths in the United States. Purpose: To review... more Background: In 2009, suicide accounted for 36 897 deaths in the United States. Purpose: To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care. Data Sources: Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012). Study Selection: Fair-or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings. Data Extraction: One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality. Data Synthesis: Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths. Limitation: Treatment evidence was derived from high-risk rather than screening-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited. Conclusion: Primary care-feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven.
: An 18-year-old male recruit underwent a physical examination to assess fitness for enrollment i... more : An 18-year-old male recruit underwent a physical examination to assess fitness for enrollment into the Naval Academy. There was no health complaint. His medical history was significant for a pectus excavatum. His surgical history was notable only for a cosmetic repair of the pectus at age 14. Review of systems included an ability to participate in athletics without limitation. His admission physical exam documented only ?a left chest wall 6 cm scar consistent with surgical history.? The screening chest x-ray is presented below (Fig 1A). Technical limitations impeded a thorough echocardiographic evaluation and a cardiac magnetic resonance imaging (MRI) study was performed to determine whether the condition represented dextroposition, true mirror-image dextrocardia, or a more sinister culprit such as corrected transposition of the great arteries (Fig. 1B, coronal; Figs. 1C, 1D and 1E, axial cranial to caudal).
Introduction Since 2009, the Military Health System (MHS) has represented its mission as that of ... more Introduction Since 2009, the Military Health System (MHS) has represented its mission as that of attaining the Quadruple Aim (QUAD AIM): increased readiness, better health, better care, and low per capita costs. The journey to reach the four goals is challenging and ongoing. Leaders in the MHS’s Central Texas Market (CTM) sought to understand and overcome the root-cause obstacles that interfered with achieving the QUAD AIM. This process required a self-critical and thoroughly objective review of the behavioral economics of the system. We hypothesized that two corporate behaviors fed upon each other to create a vicious downward spiral. First, as a socialized (salary-based) system, the enterprise has a built-in incentive that covertly competes with the attainment of the QUAD AIM. Because additional work does not result in any material gain for its workers, the system regulates to a comfortable flow. Second, centralized leaders defer important management controls to tactical teammates ...
: Perhaps the greatest modern medical policymaker was Major General (MG) Spurgeon Neel. Serving f... more : Perhaps the greatest modern medical policymaker was Major General (MG) Spurgeon Neel. Serving from 1943 to 1977, Neel is best known as the Father of DUST OFF or the Father of Aviation Medicine for his pioneering role in the creation of the doctrine of helicopter medical evacuation. One of Neel's greatest strengths was his power of evidenced-based persuasion. He published more than 33 articles in the fields of flight, operational, and military medicine. He was passionate about his causes to be sure. Nonetheless, his support for them was based on rational analysis. Diverging from common mental models, the ideas contained in his writings included a supported set of instructions for an improved future. Most importantly, as a champion of change, MG Neel possessed the leadership skills to convince the establishment that his visions were incontrovertible. Almost all of Neel's policies have withstood the test of time. One has become distorted. In 1973, Neel described the concept o...
INTRODUCTION For the past 16 years, Military Health System primary care providers have been incen... more INTRODUCTION For the past 16 years, Military Health System primary care providers have been incentivized to pursue work in a fee-for-service (FFS) model. The system values documentation of productivity to earn as many relative value units as possible. The result is densely packed clinic schedules that often lack the space or flexibility to accommodate patients when sick. Leakage ensues. Furthermore, prevention and patient experience are not directly incentivized. METHODS The Central Texas Market's Accountable Care Organization reformed incentives in its #5 FFS-designed community-based medical homes to value outcomes over productivity. The resulting quality, urgent, internet, and phone care (QUiC) clinics are value-based and, therefore, better structured to achieve the Quad aim (better care, better health/readiness, and low cost). Forsaking deeply ingrained FFS practices, QUiC clinics funnel all routine (information-sharing) appointments into efficient internet or phone appointme...
An 18-year-old male recruit underwent a physical examination to assess fitness for enrollment int... more An 18-year-old male recruit underwent a physical examination to assess fitness for enrollment into the Naval Academy. There was no health complaint. His medical history was significant for a pectus excavatum. His surgical history was notable only for a cosmetic repair of the pectus at age 14. Review of systems included an ability to participate in athletics without limitation. His admission physical exam documented only "a left chest wall 6 cm scar consistent with surgical history." The screening chest x-ray is presented below (Fig 1A). Technical limitations impeded a thorough echocardiographic evaluation and a cardiac magnetic resonance imaging (MRI) study was performed to determine whether the condition represented dextroposition, true mirror-image dextrocardia, or a more sinister culprit such as corrected transposition of the great arteries (Fig. 1B, coronal; Figs. 1C, 1D and 1E, axial cranial to caudal). Imaging Findings The PA radiograph (Fig. 1A) demonstrates a right-sided heart. Cardiac MRI images further define the internal cardiac anatomy. On a coronal bright blood MRI image (Fig. 1B; LA = left atrium; LPA = left pulmonary artery; Ao = aorta), the pulmonary veins (arrow) are seen entering into the leftsided atrial chamber (i.e. left atrium). This confirms the usual atrial position. On axial black blood MRI images (Figs. 1C thru 1E, cranial to caudal), the moderator band (arrow, Figs. 1D and 1E; RV = right ventricle; LV = left ventricle), a structure unique to the right ventricle, is visualized in the right-most ventricle in Fig. 1C, confirming a normal d-loop ventricular development and orientation. On a more cranial axial cardiac MRI image (Fig. 1C), the aorta
BACKGROUND The COVID-19 pandemic creates unique challenges for healthcare systems. While mass cas... more BACKGROUND The COVID-19 pandemic creates unique challenges for healthcare systems. While mass casualty protocols and plans exist for trauma-induced large-scale resource utilization events, contagious infectious disease mass casualty events do not have such rigorous procedures established. COVID-19 forces Emergency Departments (EDs) to simultaneously treat seriously ill patients and evaluate large influxes of 'worried well'-while maintaining both staff and patient safety. METHODS The objectives of this project are to create an avenue to evaluate large surges of patients while minimizing hospital-acquired infections. After identifying areas for improvement and anticipating potential failures, we devised eight healthcare delivery innovations to address those areas and meet our objectives: (1) Parallel ED Lanes (2) Universal Respiratory Precautions (3) Respiratory Drive Through (RDT) (4) Medical Company (5) Provider Triage (6) ED Quarterback Patient Liaison (EDQB) (7) Virtual Re...
[ILLUSTRATION OMITTED] Leader development is achieved through the lifelong synthesis of knowledge... more [ILLUSTRATION OMITTED] Leader development is achieved through the lifelong synthesis of knowledge, skills, and experiences gained through institutional training and education, organizational training, operational experience, and self-development. --FM 6-22, Army Leadership, October 2006 (1) THE ARMY POSSESSES a corps of noncommissioned officers (NCOs) unparalleled among the world's militaries. Noncomissioned officers assigned to maneuver units deserve praise for their ability to adapt, with agility, to the roles of Soldier, leader, and trainer. Because of the wars in Iraq and Afghanistan, NCOs have become master communicators, diplomats, strategists, and mediators; however, NCO growth and mastery in technical areas may be overlooked. In specialties such as communications, engineering, and computer science, NCOs have transformed the U.S. land force into an entity for which the word "army" seems simple and antiquated. Due to their dedication and ability to learn, the men and women who deploy in support of U.S. national security represent a team of multidimensional experts. A good example is combat casualty management. The case fatality rates for the wars in Iraq and Afghanistan are the lowest on record. Experts credit two items for this development: body armor and battlefield first aid. Arguably, the more dynamic and ethereal component of this two-armed success is medical care. Unfortunately, reducing its actions to the term "first aid" depersonalizes heroic deeds performed by Soldiers within a frightening kinetic environment. The "medic," or Military Occupational Specialty (MOS) 91W, is one of many unsung heroes of the wars in Iraq and Afghanistan. Using the combat medic as a case study, I will evaluate technical professionalism in the Army as a micro-revolution in military affairs. To describe the transformation of the combat medic during the first decade of the new millennium, one must trace the roots of change to decades past. In the 1980s, careful analysis of the lessons of the Vietnam War set in motion a chain of events that led to the creation of the modern U.S. medic. During the 1990s, the lessons learned from Vietnam gradually became part of reformed medical training. When war broke out in Afghanistan in 2001 and Iraq in 2003, the U.S. military found itself at a crossroads of medical doctrine. Without hesitation, the Army attacked the challenge and instituted a fundamentally new model of battlefield first aid. [ILLUSTRATION OMITTED] The medical NCO was influential in every chapter of this growth in medical professionalism. Medical NCOs first provided proof of concept. Thereafter, the Army entrusted them with the vital task of teaching, training, and mentoring a new breed of combat medic. The Army Medical Department Center and School in San Antonio, Texas, delegated the details of institutional change to the medical NCO. When the luxury of time dissipated with the onset of combat operations in 2001, the medical NCO provided a "hip-pocket" training bridge from old doctrine to innovative practice on the battlefield. The stakes were high, and there was no guarantee of success. At each step, the Army placed more expectations upon the medical NCO. The lower case fatality rates in Iraq and Afghanistan are a testament to the degree in which NCOs have met these expectations. The achievement of this standard reflects a model of organizational leader development. NCOs continually supported, reinforced, and expanded good ideas with professional and technical competency. Understanding Soldier Combat Medical Needs Today's combat medic owes much of his success to the pioneering work of Dr. (Colonel) Ronald F. Bellamy. Using theoretical models and data on wounds and munitions effectiveness in Vietnam, Dr. Bellamy sought to understand how Soldiers died on the modern battlefield. (2) In his 1984 article, "The Causes of Death in Conventional Land Warfare: Implications for Combat Casualty Care Research," Bellamy reached two important conclusions: first, that 90 percent of Soldiers killed in action suffered unsurvivable, catastrophic deaths while only 10 percent had injuries that were potentially survivable; and second, that 98 percent of patients who reached medical aid stations while still alive, ultimately survived. …
Uploads
Papers by Richard Malish