Tracey Koehlmoos: CARE-ing for wounded warriors

traceykoehlmoosFrom 4-6 December 2014, I had the good fortune to attend the 5th Annual Comprehensive Advanced Restorative Effort (C.A.R.E.) Summit at the Naval Medical Center, San Diego (NMCSD). I travelled to California and attended with representatives from the Medical Officer of the Marine Corps and the Navy Bureau of Medicine, and healthcare representatives of the Marine Corps’ Wounded Warrior Regiment.

The summit was hosted and organized by the CARE Program team, some of whom I had met during their previous visits to Washington, DC, including CARE founder Captain (Dr) Craig Salt, US Navy and program director, and Commander (Dr.) Pete Shumaker, US Navy.

For those unfamiliar with the CARE Program, from its foundation it sought to specifically address the complex emotional, functional, and aesthetic recovery issues of catastrophically injured service members. The CARE Summit provides a platform for learning and teaching about the treatment of traumatic injuries from a multi-disciplinary and integrated services perspective. For example, recent advances in laser technology have the potential to provide unprecedented functional and cosmetic improvements to patients. However, the challenge remains as to how best and most rapidly disseminate that information across a series of complex and diverse medical systems, so that the wounded receive the best from the state of the science.

Keynote speakers and visiting faculty constituted the best in cutting edge research and academia, voluntary service organizations, military health research representatives, the private sector, and Navy health leadership, as well as the Department of Veterans Affairs (VA). Presentations came from a variety of luminaries, and the same pioneers presented hands on demonstrations. Imagine attending a cadaver lab with Harvard face transplant surgeon Bohdan Pomahac.

From the beginning, the summit grounded itself in the line by having two Marines and one set of Marine parents discuss their experiences, from the dirt road in Afghanistan, through urgent and recovery care in the military health system, and on the transition to post-service life and the Veterans Administration.

One of the most extreme wounded from the wars in Iraq and Afghanistan, Staff Sergeant (retired) Jason Ross, whose encounter with an improvised explosive device (IED) in Sangin resulted in the loss of his body from the pelvis down, shared his story—his struggles, his successes, and his aspirations. His parents also spoke about the caregiver experience and candidly stated, “This is not what we had planned for the rest of our lives.” While reporting to have been satisfied with the level of support that the family and SSgt Ross received from the military health system—and especially the Marine Corps’ Wounded Warrior Regiment—they expressed concerns about their recent transition to care management by the VA.

In life, I think it is important to avoid behaving like a star struck fan-girl, but it is worth noting that Gary Sinise attended and spoke at the summit. He is famous for his portrayal of dual amputee Lt Dan in the movie Forrest Gump. This decade of war has resulted in Gary Sinise being a champion for wounded warriors.

He developed the Gary Sinise Foundation, which seeks to serve defenders, veterans, first responders, and their families by creating and/or supporting unique programs, which are designed to entertain, educate, and strengthen and build communities. One tangible way in which the foundation engages with individuals and communities is through the building of accessible homes for wounded warriors—SSgt Ross and his family will receive one such home.

The summit’s focus was on cutting edge wounded warrior care, with a primary focus on surgical and reconstructive procedures and on the benefits of integrated case management. The first day focused on complex allotransplant (i.e., face, hand) and advanced reconstructive surgery. Some of the guest speakers I had met previously, such as Andrew Lee from Johns Hopkins University and Tony Atala from Wake Forest.

The second day started with an overview of traumatic brain injury (TBI) at the neurobiological level, and transitioned to the importance of lasers and other emerging technologies for scar care. This day featured presentations and demonstrations by David Hovda from UCLA, Rory Cooper from the University of Pittsburg, and Jill Waibel from the University of Miami.

The third day started with rehabilitation after extremity injury/loss, and transitioned to an overview of care and research systems that benefit wounded warriors. This was the most “health systems and research systems” day of the conference, and I appreciated that the conference organizers took the multidisciplinary and complex nature of wounded warrior care from the cellular to health systems and policy levels.

While bold in scope, I was left wanting more from the summit and from its participants. Perhaps it was the three day limit? Maybe there will be more time next year. I thought that it would have been helpful to the military providers present if there had been the inclusion of actionable or translatable best practices that could be rolled out into primary care, especially in support of wounded warriors both in the military health system and the VA system. There was a lack of discussion about the cost and best practices for sustaining care for aging wounded warriors/veterans with complex traumatic injuries.

While TBI and post-traumatic stress disorder are the signature injuries of the wars in Iraq and Afghanistan, there was scant attention given to the treatment and management of these conditions, particularly in support of those severely wounded. Again, perhaps this is a topic for another summit, but it is worth noting that there are no long term studies on the psychological impact of genital-urinary injuries. Furthermore, there would be value in exploring how best to support and smooth the transition from the military health system to the VA, with an emphasis on the support networks available to wounded warriors and their caregivers on the VA side.

To me, the best learning opportunity of the conference came from the presentation of SSgt Ross and his parents. The family’s candor brilliantly framed the complex medical interventions and health and research systems issues presented throughout the three days of the conference, as well as highlighting gaps in services, particularly in relation to their still fresh experience with the transition to the VA.

For me, 2014 has been a tremendously wild year, yet the Rosses refreshed, focused, and motivated me to continue to strive to bring the best of health services to Marines and their families, and to drive the research agenda for improving their lives.

Tracey Pérez Koehlmoos is the special assistant to the assistant commandant of the Marine Corps, and senior program liaison for community health integration for the US Marine Corps.

The opinions expressed in this article are her own and in no way reflect the opinions of the US Marine Corps, the Department of Defense, or any other agency.

Competing interests: The author has no competing interests to declare.