Introduction

Chairman Michaud, Congressman Brown, distinguished Members of the Subcommittee, thank you for the opportunity to appear here to talk to you about the Department of Defense’s (DoD) medical care for physical injuries in combat.  On behalf of DoD, I want to take this opportunity to thank you for your continued support and demonstrated commitment to our servicemembers, veterans, and their families.  Today, I will describe some of the aspects of DoD medical care for severely injured servicemembers who have returned from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). 

On October 16, 2009, Secretary of Defense Gates stated “Beyond waging the wars we are in, treatment of our wounded, their continuing care, and eventual reintegration into everyday life is my highest priority.  I consider this a solemn pact between those who have risked and suffered and the nation that owes them its eternal gratitude.”  We who work in military medicine completely agree with Secretary Gates.

Prevalence of Injuries in OIF and OEF

Over the last nine years, a new era of combat has emerged in which our servicemembers are constantly challenged by the demands of a high operational tempo.  More than 2.1 million servicemembers have deployed to OEF and OIF from October 2001 to May 30, 2010.   Of those, 31,882 were wounded in action in OIF, and 6,773 were wounded in action in OEF.   A total of 61,874 servicemembers have been transported out of Iraq and Afghanistan to receive medical care.  Of those who were transported, 18% were for battle injuries, 21% were for non-battle injuries (such as motor vehicle injuries), and 61% were for diseases. 

DoD Care for Polytrauma

Severely injured servicemembers often require prolonged and intensive medical treatment and rehabilitative care.  DoD has addressed this challenge by establishing specialty centers of excellence.  DoD also has strengthened its partnership with the Department of Veterans Affairs, including with the four Polytrauma Rehabilitation Centers.  Servicemembers who sustain severe injuries require complex, well-integrated care from a variety of medical specialties, which DoD provides at centers that specialize in providing care for combat trauma.

Key components of DoD health care for severely injured servicemembers include three DoD amputee care centers, the Brooke Army Medical Center Burn Center, and the Defense and Veterans Brain Injury Center.  DoD has established three major centers that specialize in the treatment and rehabilitation of combat injuries.  The Military Advanced Training Center at Walter Reed Army Medical Center opened in 2007 to provide optimal amputation care and prosthetics.  The Center for the Intrepid at Brooke Army Medical Center opened in January 2007 in San Antonio to provide state-of-the-art rehabilitation for servicemembers with amputations or severe burns.  The Comprehensive Combat and Complex Casualty Care Center at the Naval Medical Center San Diego has a similar mission; and its mission and infrastructure were expanded in 2007.  Each of these three trauma care centers provides orthopedic surgery, reconstructive plastic surgery, amputee care and prosthetics, and care for traumatic brain injuries (TBI) and post-traumatic stress disorder.

DoD has long been a leader in research on improved treatments for traumatic injuries.  The U.S. Army Institute of Surgical Research (USAISR) is located at the Brooke Army Medical Center in Texas.  USAISR is dedicated to both laboratory and clinical trauma research.  Its mission is to discover new treatments for combat casualty care for injured servicemembers across the full spectrum of military operations.  In addition, USAISR is involved in providing state-of-the-art trauma, burn, and critical care to servicemembers around the world and to civilians in the local community.  Brooke Army Medical Center has a world class burn care center, and it is considered one of the world’s leaders in burn care research.

The Defense and Veterans Brain Injury Center (DVBIC) was established in 1992 to provide state-of-the-art care for servicemembers who were diagnosed with traumatic brain injuries (TBIs).  TBI is often part of the spectrum of polytrauma, which includes spinal cord injuries, amputations, and visual and hearing impairment.  DVBIC serves servicemembers and veterans with TBI and their families, through state-of-the-art medical care, and through innovative clinical research and educational programs.  DVBIC has established several specialized centers, including centers at the Walter Reed Army Medical Center, Naval Medical Center San Diego, and San Antonio Military Medical Center.   For polytrauma patients who have sustained a TBI, DVBIC is part of the comprehensive medical team, coordinating and contributing to multidisciplinary treatment.  Through a network of TBI Regional Care Coordinators, DVBIC also assists in coordinating servicemember transitions as they move among different systems of care, including between military medical treatment facilities, Department of Veterans Affairs (VA) Polytrauma Centers, and local community care.

DoD has established three Centers of Excellence focused on hearing impairment, vision impairment, and extremity injuries and amputations.  These centers collaborate to the maximum extent practicable with VA, institutions of higher education, and other appropriate public and private entities (U.S. and international) to carry out their responsibilities.   In addition, they are working together to create registries that will enable them to document injuries and follow treatments of servicemembers suffering eye, ear, or extremity injuries.  These centers augment the work of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE), which was established in 2007.  The DCoE offers a central coordinating point for activities related to traumatic brain injuries and psychological health.  DCoE focuses on the full continuum of medical care and prevention to enhance coordination among the Services, Federal agencies, and civilian medical organizations. 

DoD Extremity and Amputation Center of Excellence

The DoD Extremity and Amputation Center of Excellence (EACE) was approved for establishment in May 2010 pending final agreements with VA, but it has been working since early 2009 to serve as the lead organization for identifying policy issues, providing direction and oversight of a multidisciplinary network for care, and research on traumatic amputations and extremity injuries.  The EACE will promote excellence in the research, diagnosis, treatment, and rehabilitation of traumatic injuries; and its vision is to assist servicemembers as they return to the highest possible levels of physical and psychological functioning.  The EACE will oversee medical care from the time of injury through definitive care and rehabilitation to reduce disability and optimize the quality of life of servicemembers and veterans.  EACE services will include rehabilitation, in collaboration with the VA.  EACE will include several affiliated regional centers, including the three DoD amputee centers, and the VA Polytrauma Rehabilitation Centers.

DoD Vision Center of Excellence

The DoD Vision Center of Excellence (VCE) was formally established in May 2010 with the Navy as the Lead Component, but it has been working since 2008 to provide leadership in the prevention, diagnosis, treatment, and rehabilitation of eye injuries. 

VA has provided the deputy director for this center.  The VCE will provide clinical support for the full scope of military eye care, treatment, and research; and it will provide clinical education programs on eye injuries in servicemembers for both the DoD and VA.  Servicemembers can experience vision problems through a variety of mechanisms: trauma from explosions and projectiles, vision abnormalities secondary to TBI, and eye injuries from chemical hazards, biological hazards, or extreme environmental conditions.  The VCE is working with VA to coordinate transition of medical care.  For example, a collaborative process has been developed at Walter Reed Army Medical Center for servicemembers to receive blind rehabilitation care from VA while they are still receiving DoD care.  The VCE is involved in several innovative research projects, including evaluating treatments for blast and burn injuries to eye structures and treatments for TBI-associated visual problems.  The VCE is planning to establish four Regional Clinical Centers for Ocular Disease and Trauma at military medical centers that have ophthalmology residency training programs.  The VCE recently added two VA staff members with expertise in Blind Rehabilitation and Low Vision Research; they will work closely with the VA Blind Rehabilitation Centers and Polytrauma Centers in tracking and caring for patients with eye and vision injuries across the DoD and VA continuum of care.  In addition, there are several research centers in DoD and VA that are collaborating with the VCE.    

DoD Hearing Center of Excellence

The Hearing Center of Excellence (HCE) also was established in May 2010, but has been working since early 2009 to promote excellence in the prevention, diagnosis, treatment, and rehabilitation of hearing loss and injuries of the vestibular system in servicemembers and veterans.  The Air Force is the Lead Component for this center.  The scope of the HCE includes hearing loss, tinnitus, and problems with balance and equilibrium, which could be due to injuries from blasts, blunt trauma, barotrauma, and high noise levels.  Hearing loss is very frequent in veterans, and hearing loss and tinnitus are the top two diseases in terms of VA disability compensation.  In addition, vertigo and dizziness are common symptoms in patients with TBI.  There is close collaboration with affiliated Regional Centers for Otologic Disease and Trauma at several military and VA hospitals, including Walter Reed Army Medical Center, Naval Medical Center San Diego, and Madigan Army Medical Center in Tacoma, WA.  In addition, there are several research centers in DoD and VA that are collaborating with the HCE.

DoD Program on Spinal Cord Injuries

DoD is conducting a robust research program on spinal cord injuries that includes laboratory research on repair and regeneration of damaged spinal cords and clinical research to improve rehabilitation therapies.  The program focuses on innovative projects that have the potential to make a significant impact on improving the function, wellness, and overall quality of life for servicemembers.  The scientific areas include neuroprotection and repair, and rehabilitation and complications of chronic spinal cord injuries.

DoD Support Programs for Severely Injured Servicemembers and Their Families

DoD has developed many support resources to assist injured servicemembers, veterans, and their families.  One important resource is the Recovery Coordination Program, which was established in 2008, to ensure that wounded, ill, or injured servicemembers receive the non-medical support they need to successfully navigate the road to recovery.  A servicemember who has a serious injury would be eligible for a Recovery Care Coordinator (RCC), if the servicemember would not return to duty within a specified time determined by the Military Wounded Warrior Program or if the servicemember might be medically separated.  The RCC works for one of the programs in any of the four Services, including the Army Reserve, as well as the Special Operations Command Care Coalition.  The RCC develops a recovery plan, evaluates its effectiveness, and adjusts it as transitions occur.  The RCC makes sure the plan meets the servicemember's and the family's goals, and works with the individual’s Commander to coordinate the services included in the plan.  Currently, there are 130 RCCs in 55 locations nationwide.   

DoD provides outreach to servicemembers and families to promote awareness of the available resources.  We conduct outreach to encourage servicemembers and families to seek help from these programs, when needed, and to ensure the most complete recovery possible.  One of the most important support resources is Military One Source, which provides assistance to servicemembers and their families to evaluate their needs, and coordinate referrals to other programs to provide the appropriate services.   Military One Source is a central coordination point to ensure accessibility to the many available resources for servicemembers and their families. 

Four service-specific programs provide assistance: the Army Wounded Warrior Program, Marine Wounded Warrior Regiment, Air Force Wounded Warrior, and Navy Safe Harbor.  The wounded warrior programs assist and advocate for severely wounded, ill, and injured servicemembers, veterans, and their families, wherever they are located.  The four Service-specific programs provide counseling, employment assistance, family support, and other services needed to transition to home and the community.  These services are provided as long as severely injured servicemembers and their families require support.   

Transition from DoD Care to VA Care for Severely Injured Servicemembers

DoD and VA are working together to improve their coordination of medical care for servicemembers and veterans, including those who were severely injured in OIF and OEF.  The key objectives of our coordinated transition efforts include: ensuring continuity of medical care from DoD to VA health care providers; and providing clear and comprehensive information about available support programs to servicemembers and their families.

DoD takes advantage of the four VA Polytrauma Rehabilitation Centers (Tampa, Minneapolis, Richmond, and Palo Alto) to meet the needs of active-duty servicemembers who have experienced multiple, severe injuries, including TBI.  DoD has a longstanding relationship with VA to ensure continuity of care, and DoD refers injured servicemembers to VA for long-term rehabilitation.  From March 2003 to June 2010, more than 500 active-duty servicemembers who were injured in theater were treated in the four VA Polytrauma Rehabilitation Centers.  In addition, 21 VA Polytrauma Network Sites nationwide provide continuing long-term care to these injured veterans

In August 2003, DoD incorporated a VA Liaison Program at Walter Reed Army Medical Center to provide case management for combat veterans.  When severely injured servicemembers need long-term medical care, VA liaison personnel work with them to coordinate VA services.  This joint program has expanded to 12 more military hospitals.  At these 13 hospitals, 27 VA nurses and social workers provide the linkage to follow-up care at VA facilities near the servicemembers’ homes.  As of June 2010, this program had made more than 10,000 patient referrals to VA to ensure continuity of care.

Conclusion

DoD is providing comprehensive, state-of-the-art care for severely injured servicemembers in collaboration with our partners at VA.  We are committed to continued and more expansive collaboration and coordination with VA because we believe it is essential to our ability to provide servicemembers, veterans, and their families with consistently superior medical care and support services as well as continuity of care in the most comprehensive way. 

Thank you for the opportunity to address this vital issue.  I will be pleased to respond to any questions you may have and to participate in an ongoing dialogue to better serve our current and former servicemembers.