Physician Airman

Published Nov. 6, 2007

WASHINGTON -- This interview with Air Force Surgeon General Lt. Gen. (Dr.) James G. Roudebush was published in the Sept. 16, 2007 edition of Military Medical Technology magazine. The interview was conducted by MMT Editor Jeff McKaughan and is republished here with MMT's permission.

Q: Good afternoon general. As a starting point can you give me a quick tour around Air Force medicine--how big is it, how many facilities, number of people and the budget you have to work with?

A: The Air Force Medical Service [AFMS] operates with an approximate $7.7 billion annual budget. Our authorized end strength is 39,600 Air Force medics. And please note that when I say medics, I am referring to all Air Force medical personnel...officer, enlisted and civilian. We operate 75 military treatment facilities [MTFs]-- 57 clinics, one ambulatory surgery center, 13 hospitals, and four medical centers across the globe.

Q: Has there been a noticeable trend with any of those key parameters--up or down--over the past few years?

A: We have been busy transforming our infrastructure to match changes in population and Air Force missions while ensuring the best quality of care for our beneficiaries. From 1988 to 2013, we have reduced the number of facilities 43 percent, and converted many of our bedded facilities to clinics. This is in large part due to changes in medicine that have driven more outpatient care and higher acuity inpatients. Our small hospitals, similar to rural hospitals around the country, could not expand to meet the needs of higher acuity inpatients. Although our physical footprint has changed, we continue to deliver impeccable care to deployed forces and state-of-art care at home.

Air Force medicine is a highly adaptive capability, a key part of Air Force expeditionary capabilities and culture. Our proactive and visionary work contributes heavily to a healthy fit force that is leveraged and designed, in fact, to prevent casualties. But, when there are casualties, we are there with world-class care.

We provide the same quality of care--and access to care--for all of our nearly three million beneficiaries. Our health care and health service support worldwide ensures total force personnel are healthy and fit before they deploy, while deployed, and when they return home. This is our hallmark, and the result is the lowest disease, non-battle injury and died-of-wounds rates in history of war.

Q: Air Force medicine is structured differently than the medical services in the Army and Navy. Can you tell me a little bit about that and the reasons behind why it became that way and why it stays so?

A: The Air Force mission is doctrinally different than the Army, Navy or Marines. We fight from our bases and build new bases [airfields] when needed. Air Force medics are funded and fielded differently than our Army and Navy counterparts. The AFMS does not have a separate line funded operational medical capability. Our facilities are funded through the Defense Health Program but all medical capabilities are under direct operational control of Air Force line commanders at each base.

This close alignment has enabled remarkable transformation. We've transformed from a heavy, forward-based medical force to a light, lean, modular, targeted capability. We are innovators in modular capability and are routinely first tasked and first in place for contingencies due to our modular capabilities and close linkage to airlift. We can go in light because we are always connected via air evacuation to medical facilities worldwide. Our close ties to the Air Force line keeps us highly agile.

Ensuring a fit and healthy force, preventing casualties, restoring health, sustaining human performance and supporting the joint warfight is our mission and our mantra. Our local wing [base] commanders are responsible for their airmen's health; and our medical group commanders have a direct responsibility to the wing commander for the health of each and every airman and their families.

Q: How has aeromedical evacuation changed in recent years? Has the ability to provide a deeper level of care in-flight been improved either through better training, better procedures, better technologies--or a combination of factors?

A: Our medical teams operate closer to the front lines than ever before, enabling us to provide warfighters advanced medical care within minutes. Without question, every day, Air Force medics, working interoperably and interdependently with our sister service and coalition partners, save the lives of soldiers, sailors, Marines, airmen and civilians...Coalition, Afghani and Iraqi...friend and foe alike. Underpinning this world-class health care for our joint warfighters is our system of en route care. We ensure joint warfighters receive seamless care through the continuum of care from first battle damage surgery to definitive care and recovery back in the United States. En route care relies on our unique capabilities in expeditionary medical support and aeromedical evacuation [AE].

Aeromedical evacuation is distinctly Air Force, and a critical component of the Air Force's global reach capability in support of joint operations. We safely care for and transport even the most severely injured patients to definitive care.

Our expeditionary medical system and AE system combine to achieve an average patient movement time of three days from the battlefield to stateside care. This is remarkable when compared to the 14 days required during the 1991 Persian Gulf War or the average 21 days it took in Vietnam.

Our modern AE teams--which include active duty, Guard, and Reserve forces--coupled with our innovative critical care air transport team [CCATT], operate flying intensive care units in the back of virtually any airlift platform. This success resulted from our shift to designated, versus dedicated, aircraft and training universally qualified AE crew members able to execute their AE mission on any airlift aircraft. This transformation of AE has been repeatedly proven in the global war on terrorism, as evidenced by the safe and rapid transfer of more than 44,000 Operation Enduring Freedom and Operation Iraqi Freedom patients from overseas theaters of operation to stateside hospitals.

Q: How effective is the in-flight patient tracking system in monitoring the status and location of those in your care?

A: Our global patient tracking system is Web-based and is referred to as TRAC2ES [TRANSCOM Regulating and Command & Control Evacuation System]. TRAC2ES provides us a patient's location at all points of care and information on the patient's condition, as well as treatment notes and medications. This information is updated when the patient is received at each facility en route. Additionally, we document in TRAC2ES the specific medical equipment required to support each patient.

The Joint Patient Tracking Application [JPTA] is another Web-based program that has been successful in the joint medical treatment facility environment. JPTA linked with TRAC2ES provides updates at each en route stop. Commanders and medics have excellent visibility on casualties throughout movement. These systems are not linked real time yet but are now programmed to be fully integrated into AHLTA, the DoD electronic health record system.

Our Air Mobility Command and U.S. Transportation Command SG staffs are working collaboratively to develop and enhance in-flight patient status tracking and documentation systems. Additionally, we are working to establish direct in-flight AE medical crew communications with ground medical facility specialists to relay real-time patient status information.

Q: What are some of the challenges Air Force Medicine faces with the deployed hospitals at Balad, Bagram as well as other locations around Iraq and Afghanistan?

A: The AFMS has been deeply involved in establishing the most effective joint casualty care and management system in military history. Whether stabilizing a casualty, preparing a casualty for transport, providing continual care at stops along the way, or moving the patient in our AE system; what matters is providing the best care possible to every injured or ill warfighter at every point in the care continuum. Everything medical in theater is designed to support moving casualties from the point of injury to the right level of care, at the right place, in the least amount of time. To that end, we believe it is critically important to work closely with our sister service medics in leveraging our joint capabilities. Working to improve our common "enabling" platforms--such as logistics, information management, information technology, and medical research and development--will serve to make our medics better prepared to support the joint warfighters.

Delivering this remarkable medical care across the spectrum of missions takes trained, clinically current physicians, nurses and technicians. The AFMS concentrates on joint medical education programs and has developed clinical training platforms providing surgical and trauma care experience. Our readiness platforms, including training arrangement with Baltimore Shock Trauma, Cincinnati-Center of Sustainment of Trauma and Readiness Skills [C-STARS], and St. Louis C-STARS, ensure our Air Force medics are the best trained in history.

Other challenges that we've worked include the successful transition of our theater hospitals from expansive tent structures to more enduring modular facilities, the ongoing review and replacement of our medical equipment and technology, and working the right mix of clinical specialty support for the casualty care needs of each location.

Q: What are some of the tools or technologies that you would like to see better options for or more advanced development of? For example, how involved is your team in IT services both for medical purposes as well as information management in general?

A: Air Force medical modernization teams are highly focused in IT services and products which enable expeditionary medical care. Our teams have successfully installed and deployed the first electronic medical record in-theater for our warfighters. Forward locations such as Bagram, Afghanistan, Baghdad International Airport, and Balad are entering patient data on local computers. The patient's information is then transferred to our centralized medical database repository. This repository allows patient information to be accessible to medical providers regardless where the patient may be...Balad to Wilford Hall. Soon, those records will be visible within the Department of Veterans Affairs systems.

The AFMS has invested in an innovative informatics production strategy that involves secure connectivity/centralized data pulls from all our medical treatment facilities. This model enables the creation of master data tables on a .mil storage array upon which thin client applications can be designed and made securely available to all consumers of information with a need to know across the AFMS. This highly economical construct allows AFMS to provide the best available analytic and informatics techniques to every front-line technician and manager in our organization who has secure access to the worldwide web. The AFMS portfolio of informatics tools saves countless hours of local-level analysis, and ensures consistent, uniform information availability for critical process support. This capability (and associated web applications) was recognized as the winner of the 2007 Microsoft Health Utilization Group's Innovation Award for Performance Reporting.

Epidemic outbreak surveillance is a dual use system-of-systems designed to combine advanced human in-vitro infectious disease diagnostics and an IM/IT infrastructure to perform infectious disease surveillance in near real-time [less than four hours].
When fielded it will: 1) rapidly detect and identify a wide range of pathogens and biological threat agents; 2) bridge the gap between human in-vitro diagnostics and surveillance; 3) deliver enhanced situational awareness and decision support tools to key personnel; 4) and provide decision-quality information to commanders, public health, and health care providers in near real-time.

Finally, the stability and dependability of expeditionary computer networks continues to be a challenge. Today our teams struggle with bandwidth constraints and sporadic dropping of network connectivity in-theater. We look forward to new network technologies with increased capacity, while maintaining security and stability. We feel that developers must be proactive in building security into their products. Regulatory compliance is a baseline start, but they must also build real-time or near-real-time virus/patch management into their products. These solutions will enable our IT teams to facilitate outstanding quality of care for our servicemen. We are making huge strides in medical IM/IT arena, but we continually work towards the best solutions for our warrior medics and the patients they serve.

Q: Can you talk at all about the controlled use of pharmaceuticals in the cockpit to increase pilot alertness on all missions but especially those of long duration?

A: Our Air Force fatigue countermeasures program is a comprehensive array of actions designed to anticipate, avoid, and mitigate the effects of long duration missions, poor sleep due to combat operations, and rapid shift in time zones (circadian desynchrony). The use of medication as a fatigue countermeasure is one of the tools available in this comprehensive program and has been used safely and successfully in USAF fighter/bomber combat operations.

It is important to note that the use of medications is considered for use only when all other fatigue countermeasures have been exhausted and is a completely voluntary option. The medications selected are carefully screened for side effects and the pilots undergo ground testing before operational use. The medications are issued, if requested by the pilots, and then taken on the ground to enhance sleep or in the air to sustain alertness. The program is carefully monitored by line commanders and medical personnel, and our experience to date has shown minor side effects in less than 1 in 5,000 doses. Testing is also currently underway for long duration cargo/transport operations and the initial results are promising.

Q: In relation to deployments four years ago, are you experiencing the same problem getting airmen and women ready to deploy and not be ready for health reasons. Do you have programs to promote healthy choices and better fitness?

A: We have improved our program to rapidly assess a member's medical condition, and provide that data to commanders to allow them to make decisions as early as possible. While we found that the medical conditions that preclude deployment have not changed, we note that early identification, prompt attention and, if possible, resolution of these medical conditions have allowed airmen maximum planning time in order to get themselves and their families prepared for deployments. We realized that any medical condition identified at the last minute before deployment leads to a short notice tasking for some other airman to fill, and disrupts two lives as well as operations for the commanders. We hope to resolve this with our new duty limiting condition program. This program includes a new Air Force Instruction, a simplified electronic process, and increased visibility/concurrence by commanders. We began deploying this program within the USAF in July 2007 with positive feedback at the MTF and wing levels.
Also, returning deployed airmen had previously reported how physically taxing their deployments were. The start-up of the new AF fitness program in 2004 helped deployed airmen perform their tasks at an optimal level and positioned them to better cope with the stressors of their austere deployment environments. Our health and wellness centers promote and provide services to help airmen make healthier food choices, discontinue or discourage initiating tobacco use, and develop and maintain an active lifestyle through the fitness program.

Q: The increasing use of unmanned systems has created a new breed of pilots. Have you seen any medical conditions brought on by those job skills--high use of computer monitors, handheld controls, etc.?

A: The unmanned aerial systems [UAS] environment has not produced any unique medical issues associated with remote control aircraft operations. The UAS program has actually presented an occupational environment that is free from many of the medical issues involved with flight such as altitude, G forces and hypoxia. USAF Aerospace Medicine experts are working closely with our sister services and the FAA to maximize safety in operations.

Q: Is there anything else you would like to add?

A: Air Force medics have a lot to be proud of...their talent and dedication ensures that an incredible 97 percent of casualties seen in our deployed hospitals will survive today. More than 44,000 patients have been safely evacuated by airmen since the outset of Operation Enduring Freedom and Operation Iraqi Freedom. Compassionate care was provided to over 1.5 million people during humanitarian missions over the last six years. We continue to provide the best care America can offer to over three million patients annually. I'm very proud of Air Force medics and appreciate your letting me share our story with your readers.

USAF. (U.S. Air Force Graphic by Rosario "Charo" Gutierrez)