Compassionate Care in Practice: Illness Experience and Post-Traumatic Recovery

Eric B. Schoomaker, MD, PhD Uniformed Services University of the Health Sciences

Bethesda, MD

“Department of Defense: Integrative Strategies for Recovery”

Principal Topics

• How can institutions innovatively respond to the

overwhelming needs of veterans returning from war: The

Walter Reed Army Medical Center experience.

• How can we develop innovative models of care: The

Warrior Transition Unit experience.

• How can we incorporate compassion and innovation in

healthcare leadership: The USUHS experience.

There are no financial conflicts of interest.

The opinions expressed represent solely the

views of the presenter and do not reflect official

policy of the DoD or USUHS.

"Americans should not expect one

battle, but a lengthy campaign,

unlike any other we have ever

seen.” President George W. Bush

Address to a Joint Session of Congress September 20, 2001

“…the long war” GEN John Abizaid

* May 2008 DoD Data **3 June 2010 DoD Data

% Su

rvivability O

ver Tim

e

[Wounds Not Mortal / (Battle Deaths + Wounds Not Mortal)] * 100

69.7% 75.4%

86.5% 89.9%

Improved Survival Over Time

Improvements in

Warrior Care

• Improvements on the battlefield

– Better trained medics

– Improved equipment

– Far forward emergency & surgical care

• Improvements in evacuation

• Improvements in recovery &

rehabilitation

Rising Musculoskeletal & Mental

Disorders—Ambulatory Visits

OIF Mental Health Advisory

Team:

Dwell-Time is Critical

Page 7

Rising Hospitalizations for

Mental Disorders

(JAN-SEP ONLY)

Increasing Combat TBI Cases

2000

9000

10000 10,963

20,199 27,507

20000

6,282

(27%)

7,135

(26%)

4,133

(20%)

2007 2008 2009 DoD Baseline DoD OIF/OEF DoD OIF/OEF DoD OIF/OEF

DoD Total

Data Source: AFHSC

Deployed Forces

23,002

OVERALL TBI CASES HAVE MORE THAN

DOUBLED

PTSD

N=232

68.2% 2.9% 16.5%

42.1%

6.8%

5.3%

10.3%

12.6%

TBI

N=227

66.8%

Chronic Pain

N=277

81.5%

The intersection of mind & body

Lew, Otis, Tun et al., (2009). Prevalence of Chronic Pain, Post-traumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD.

Slide 10

Prevalence of Chronic Pain, PTSD and TBI in

a sample of 340 OEF/OIF veterans with

polytrauma

Trauma Spectrum Response

Depression

Somatic dysfunction

(sleep, appetite, sex,

energy)

Anxiety

Pain

TBI

PTSD

Substance dependence,

abuse and tolerance

TRAUMA SPECTRUM DISORDER

“Forty Days of Winter:

Walter Reed, the Wounded and

the Washington Post” February - March 2007

February 15, 2007 – Washington Post

reporters met with the WRAMC Commanding

General and Staff

February 18, 2007 - Sunday

First Washington Post Article

Media Storm

Changes in leadership…

March 5 - Monday

House Committee on Oversight and Government Reform

Hearings at Walter Reed

My Personal Low Point

North Atlantic Regional Medical Command

At Walter Reed: The Perfect Storm

Combined effects of:

• Unprecedented Battlefield Survival

• Medical Regulating Challenges

• Limited Primary Care Capacity

• BRAC

• A-76 Workforce Privatization

• Long-standing PDES concerns

• Fragmented wounded warrior C2

• Others…

“To stay a Soldier…”

Commanding General’s Intent

•Walter Reed provides a continuum of integrated care and services

• from point of injury to return to duty or

• transition to active citizenship.

•Warriors and their Families should receive a quality of care and services that is

commensurate with the sacrifice they provide to the Nation.

End State:

•Warrior Transition Units are established with the Triad of support consisting of:

• primary care manager (PCM),

• case manager (CM)

• squad leader (SL)

•Streamline the issues affecting Family care and disposition.

•Soldier and Family Assistance Centers are established at our supported

installations as entry points for Warriors in Transition.

•The Army & American people have a restored sense of confidence in the Army

Medical Department.

4

“I am a Warrior in Transition. My job is to heal as I transition back to duty

or continue serving the nation as a Veteran in my community. This is not a status, but a mission.

I will succeed in this mission because I AM A WARRIOR AND I AM ARMY STRONG.”

Mission of the Warrior in

Transition: to Heal

15 AUG 07 24

Administrative Services

& Benefits

Clinical Services &

Leadership

Legend: SFAC: Soldier Family Assistance Center PCM: Primary Care Manager RNCM: Registered Nurse Case Manager SQD LDR: Squad Leader

WELCOME TO

RN

CM

• RTD

• VA

• Citizen

Total Continuum of Warrior Care

+ =

SFAC

“I am a Warrior in Transition. My job is to heal as I transition back to duty or continue serving the nation as a Veteran in my community. This is not a status, but a mission. I will succeed in this mission because I AM A WARRIOR AND I AM ARMY STRONG. “

Warriors in Transition Support Team

THE SOLDIER FAMILY

ASSISTANCE CENTER

Prescription Opioids

An Epidemic in Opioid Problems in the US

– Provide recommendations for a DoD

comprehensive pain management strategy that is

holistic, multidisciplinary, and multimodal in its

approach, utilizes state of the art/science modalities

and technologies, and provides optimal quality of life

for Soldiers and other patients with acute and

chronic pain. Army Pain Management Task Force Charter; signed 21 Aug 2009

Pain Management Task Force

– Relieving Pain in America: A Blueprint for

Transforming Prevention, Care, Education and

Research Institute of Medicine; June 2011

Comprehensive Pain Management

Evidence-Based Complementary and Alternative Therapeutic Modes

Acupuncture Biofeedback Yoga Meditation

Standardizes Pain Management Services at echelons of care across our Medical Treatment Facilities: Team-Based Provides optimal quality of life for Soldiers and patients with acute and chronic pain

Defense and Veterans Pain Rating Scale

(DVPRS)

• Goal: Standardized Pain Assessment Tool

• A common language DoD and VHA pain assessment

tool with visual cues and a common set of

measurement questions—linked to function.

PASTOR/PROMIS: Patient Reported Outcomes

• Center for Disease Control and Prevention: (Health People 2020 will include PROMIS Global Measure)

• Bravewell Collaborative Integrative Medicine Outcomes Study (PRIMIER)

• Defense & Veterans Center for Integrated Pain Management (DVCIPM) Research

– Pain Management

– Rx Med Abuse

– Interdisciplinary Care

RESEARCH * OUTCOMES REGISTRY * CLINICAL DECISION TOOL

Auricular Acupuncture or

“Battlefield Acupuncture”

Mind-Body Medicine with

Guided Imagery

Special Pain Medicine Supplement on Active Self-Care

Complementary & Integrative Therapies for Chronic Pain

Examples of Holistic Care Ready for

Integration

Stars and Stripes January, 2011

Mind-body stress

management

Nutrition for optimal human

performance

Integrated “Family and

Team Care” approaches

Individual and Enterprise

Total Fitness Metrics

Acupuncture, yoga, music

therapy and exercise for

the TSR

“Compassion is not a relationship between the healer

and the wounded. It's a relationship between equals. Only

when we know our own darkness well can we be present

with the darkness of others. Compassion becomes real

when we recognize our shared humanity.” Pema Chödrön, The Places That Scare You: A Guide to

Fearlessness in Difficult Times

USUHS Medical Education:

Compassion and Innovation in Leadership

• Experiential

• Self-reflective: behaviors, cognitions and

emotions

• Values-based: personal, professional and

cultural

• Context is essential: situational and

interpersonal

• 4-C’s:

• Character

• Competencies

• Context

• Communication

USAFA PITO Leadership Model

• Leadership Focus

Areas:

– Personal

– Interpersonal

– Teams

– Organization

Leadership Focus Levels

MEM 101 Pre-Clerkship

Fundamentals of Military Medical Practice

Clerkships

Emergency Medicine

MEM 201 BBB & Post-Clerkship Advanced Military Medical Practice

Organizational

Team

Interpersonal

Personal

Military and Emergency Medicine Leadership Curriculum

Military M

edical

Practice

Learnin

g A

ctivities

MFP

10

1

MFP

10

2

Sum

mer O

peratio

nal Exp

erience

Eme

rgen

cy Me

dicin

e

4th Ye

ar Cle

rkship

MFP

20

1

Lead

ersh

ip C

apsto

ne (O

ptio

nal)

MFP

20

2 “B

ush

maste

r”

Military C

on

tingen

cy Me

dicin

e

LEADERSHIP GROWTH AND DEVELOPMENT

An

tietam M

edical Staff W

alk

Eme

rgen

cy Me

dicin

e Se

lective

(Op

tion

al)

Use of Films

Teaching Our Own

Take Away Messages

• Maintaining and restoring the health of Warriors and their Families of

all eras is paramount for the military, the military health system and

the nation.

• It is team-based, multi-disciplinary and rests on honoring the service

and commitment of each Service Member.

• Lessons abound in how we can improve health & well-being and

restore health & function. Compassion is an essential element.

• Management of chronic pain is a complex, individual experience often

with comorbid elements for which care must be patient-centered and

individualized.

• Leadership in military health & healthcare is an inherent feature of

service in uniform and must be taught carefully and deliberately.

Thank you! Questions?