A Canadian soldier named Luc Pesant was in Haiti on a peacekeeping assignment in 1996. One day, he was shot eight times by persons unknown. Three bullets produced potentially fatal wounds. One pierced Pesant's hepatic artery, which runs between the liver and heart. The severing of a hepatic artery leads to death in 60 percent of cases, even if top-notch care is available.
Pesant managed to reach a US Navy resuscitation team. They sewed up the artery and stitched his other wounds. Before long, the Navy team called the US Air Force for help.
The Air Force prepared and launched a medical team from Wilford Hall Medical Center, Lackland AFB, Texas. A mere 12 hours after the shooting, it was in Haiti and at work on Pesant. The Navy team had already used up every unit of Pesant's blood type for hundreds of miles around. In fact, the fluids pumped into his body had caused the wounded peacekeeper to gain 100 pounds in weight. None of his systems were functioning properly.
Air Force doctors figured Pesant would be dead in two hours, meaning they could not hope to get him back to Texas for treatment. Instead they loaded him on their C-21 medevac aircraft and took off for Jackson Memorial Hospital in Miami, an hour's flying time away.
"That's the world we live in," said Lt. Gen. Paul K. Carlton Jr., the new surgeon general of the Air Force. "A Canadian peacekeeper on a UN mission in Haiti shot by unknown assailants, resuscitated by a Navy team, transported by an Air Force team, definitive care given by a level-one trauma center in the United States of America. That's our complexity."
The story of Pesant is just one example of how the context of Air Force medicine has changed dramatically over the past decade as demands, resources, and partners have changed with lightning speed. Today, the air transportable hospitals of the Persian Gulf era look outdated, cumbersome, and inflexible. In the era of Tricare and constricted budgets, some Air Force medical infrastructure looks too expensive to survive.
In recent years Air Force officials have done much to make their medical service more efficient and effective. More work lies ahead, said the service's new top doctor.
"We have to recognize that the world around us has changed," said Carlton. "The question then becomes, how do we change and optimize those things that we've done before and do differently those things that perhaps we need to do differently?"
Air Force medical personnel need to feel an urgency about change, Carlton said in an interview at his office at Bolling AFB, D.C. For various reasons, the military medical system has "disenfranchised" a large number of people, he said. Right-sizing, plus optimum use of resources, could make room for them to be brought back within the system.
"The bottom line is, we can take care of an awful lot more people within the primary care organization that we have," said Carlton. "Where we can't do the direct care, we can partner."
The Air Force mission has changed radically in the last 10 to 15 years. Once, the service was focused almost entirely on the Cold War and the Soviet Union's military forces in Europe and the Far East. Now, it has a multipart readiness mission. That has had a particularly profound effect on Air Force medicine, which is a part of almost every operation the service undertakes these days. As Carlton said, "We do evacuations, we do humanitarian relief operations, we do natural disasters."
In the future, reported Carlton, Air Force medicine will operate from two basic platforms. One is the deployable readiness platform, and the other is the health care clinic.
Carlton has only been in his new post a short while, but he is already hard at work on the readiness side of this equation. Gulf War-era air transportable hospitals were fine for their time, but in today's world they are just too heavy. It takes a long time to fly the unit into a foreign area and construct a fully functioning health care infrastructure.
A new concept-the so-called expeditionary medical support equipment-will be lighter and faster, enabling Air Force doctors to care for their patients from the first aircraft in to the last one out. "Expeditionary medical support is our ticket on the first plane into the future," said Carlton.
The new approach is modular. The basic unit of the expeditionary medical support Air Force theater hospital can be carried on only three pallets and brings with it 25 personnel. It contains four holding beds and can provide the basis for critical care, trauma resuscitation, heart attack revivals-the full spectrum of combat medicine. Plug-in units keep building the basic expeditionary medical support up to a 500-bed hospital.
"We're going to buy eight of these this year," said Carlton. "The demand is tremendous. We've already used this in Kosovo very successfully."
In today's fast moving deployment situations, the size of the logistics footprint is critical. USAF's new expeditionary medical support unit takes up about 60 percent fewer pallets than the transportable equipment that it replaces. Small teams of doctors and support personnel will arrive even before the first pallet rolls off a C-17. Those on the first airplane on the ground, in any situation, will have to worry about food, water, and sanitation, noted Carlton. So the flight could carry a public health officer and military flight surgeon-with backpacks, no pallets. In the second phase, a five-member surgical team would come in with the crew chiefs. "The third phase is the first time we see a pallet," said Carlton.
All this will take place in a joint environment. Air Force medical teams have been practicing their plug-and-play approach with personnel from the other services for some time.
As in the story of the Canadian peacekeeper, most future deployments will also entail practicing medicine with-and for-personnel of other countries. Some nations, such as Chile and the UK, work well with USAF medical personnel today. Others, such as Japan, are studying USAF's sophisticated air evacuation techniques.
The coalition environment is a "challenging" one, said Carlton.
When it comes to the health of the individual member of the Air Force, the medical side of the service is currently focused on learning from an approach its line brethren perfected back in the 1950s.
Forty years ago, service leaders instituted three-level maintenance for its aircraft. Primary prevention kept airplanes healthy. Back-shop maintenance fixed small things that broke. Depot-level maintenance remanufactured aircraft on a rotating basis. The Air Force has translated this approach to the field of medicine, said Carlton.
Preventive care, such as immunizations, can keep people healthy. Back-shop care is done at the base clinic, which patches up small injuries and keeps an eye out for chronic conditions. The medical center is the depot of health care. It cures diseases and does serious operations.
Carlton noted that his son is an F-16 pilot, and, after every flight, his son's crew chief takes a sample of oil from the airplane. That oil is put through a spectral analysis, which examines the levels of minute metal particles. Engines are designed so that the No. 1 rod shaft bearing is made out of tungsten. The No. 2 rod shaft bearing is made out of something else. High levels of tungsten in the oil sample are an indication that the No. 1 rod shaft bearing may be close to failure. It's pulled and replaced.
"That's the level of sophistication we're at," said Carlton. "Can't we do the same with our humans?"
Carlton added, "That's what we practice now. It's not surgery, it's not medicine, it's not nursing. It's health."
Optimum Medical Care
Carlton said another major goal is to optimize the Air Force Medical Service-make it more efficient and effective-so that it can take care of many more people than is now the case.
Major growth is quite possible. Right now the AFMS has an enrollment of about 960,000 people, yet officials figure that 2.32 million people are eligible for their services.
The goal is to have one primary care provider for every 1,500 enrolled persons. Each provider should be able to see 25 patients a day and should be helped by 3.5 support personnel and have access to two exam rooms.
Some Air Force facilities have already surpassed this efficiency level.
"Scott Air Force Base [Ill.] laughs at [the ratio of] 1,500-to-1," said Carlton. "The last time I was there, they were at 1,900-to-1, and they still had open appointments."
Carlton reports establishment of the principle of primary care model blocks. A block will have four primary care providers, two nurses, eight medical technicians, and four administrators. It will be able to take care of 6,000 people.
"And then it's a very simple building block," said Carlton. "As you go from 6,000 to 12,000 to 18,000 [people], you add [primary care model] blocks. And it makes us look at the support staff and say, 'Is it value added?' and then [we] eliminate the nonvalue added."
Carlton cites Aviano AB, Italy, as an example of efficient support staff management. Aviano has instituted a nurse triage system, in which nurses answer patient phone calls and provide simple advice, if necessary. They schedule office visits only for those patients whose conditions truly require a meeting with a physician.
For example: Someone whose child has a 101-degree fever might be told by the nurse to undertake certain basic steps and to call again in 24 hours if the fever does not break. Someone whose child has a 101-degree fever plus trouble swallowing-a red-flag symptom-would be told to come in for a visit.
Scott AFB has a similar system. A recent survey of patients handled by nurse triage found that all of them received good advice. Ninety percent were happy with their experience. Ten percent said they had expected to see a health care provider.
Referring to that 10 percent whose expectations were not met, Carlton said, "That's an education opportunity. We want to make it easier. We want to provide excellent service, but there is a transition that has to occur in all of our minds."
Cost control is important. The world of medicine has changed. The customary fee for a primary care visit used to be around $140. But in today's competitive world, $35 is the norm, said Carlton.
New Types of Clinics
One promising cost-cutting move: establishment of nurse-run clinics to handle the treatment of diabetics, asthmatics, and others with chronic conditions. These clinics focus heavily on preventive moves. For example, a clinic in Little Rock, Ark., warns asthmatics when air-quality levels are unhealthy. As a result, it has presided over a 92 percent reduction in hospital admissions for asthma.
The nurse corps itself could see changes. All Air Force nurses are officers-which many consider an expensive approach to meeting the need. Having a multilevel nurse career field, with nurse assistants, licensed vocational nurses, and then registered nurses, could allow some personnel positions to be moved to the enlisted ranks or even to the civilian side.
"The US Army did that in the early '90s," said Carlton. "They transferred half their officer corps, on the nurse side, into the civilian side. And they're very pleased with it."
Increased partnering with civilian institutions is another promising approach to optimization, said the surgeon general. It could turn out to be a two-way street. For example, the Air Force is associated with two graduate medical institutions in the San Antonio area. Both are in financial trouble because they have a high percentage of patients who cannot pay for services. If they agree to waive the required 20 percent co-payment for Air Force patients, said Carlton, he can agree to send them a steady stream of paying patients.
That, he said, could help get more 65-and-over retirees back into the Air Force system.
"If they'll accept the 80 percent [payment], I would tell retired Major Flynn, age 68, that I could do his hip at Wilford Hall with a 19-week waiting time; I could do him at the university next week; or I could do it at Santa Rosa [Hospital] tomorrow."
That would be a step in the right direction, as far as retirees are concerned, according to Carlton. The solution, he said, is to simply be a competing partner with Medicare.
"If we provide the better service, then Major Flynn would say, 'I'll go with you,' " said Carlton. "If somebody else provides the better service, then that's fine. ... I'm not sure our Medicare partners are ready for that right now."
On the question of what 65-and-over retirees deserve from Air Force medicine, the medical service chief said he has no question that a major health care promise was made when these retirees first joined the force. He also said, "I don't have any question that we haven't got the funds right now to fulfill that promise."
The Air Force part now is to make sure that it is giving the best primary care that it can, effectively and efficiently. Then partnering is the way to go for things the AFMS can't do, for whatever reason, according to Carlton.
Of all the demonstration programs currently testing different approaches for providing care to Medicareeligible military retirees, MacDill 65 is the one Carlton likes best. MacDill 65 is a subvention program that cares for up to 2,000 enrollees in the Tampa, Fla., region.
"We have actively said to our [65-and-over] population, 'We value you ... and let us do excellent primary care with you,' " said Carlton. " 'And if you need something more than primary care, then the Medicare piece will cover you-in the superb facilities that we'll keep track of downtown, making sure that they do a good job.' "
Senior Prime Disappointment
He said the Tricare Senior Prime demonstration has not gone as well as it could, from the Air Force point of view. The service did not win discussions about how this test of Medicare Subvention would be implemented. The way that details have worked out means that the Air Force, in essence, gets no reimbursement for the care it provides under the test.
"The details haven't worked out for us because no money's coming," said Carlton. "That detail is fairly important."
Implementation of Tricare itself shapes up as a long-running effort. Carlton freely admits that the military has not done as good a job as it could have in Tricare activities. "As we've learned how to do things, what you've seen from the West Coast to the East Coast is the number of concerns peak and then start coming down as we have a mature program," he said. "When somebody's having trouble, we've failed. It's that simple," Carlton continued.
Military officials thought they would have better Tricare contracts and systems in place by now. They thought that the system would have learned permanent lessons from its stumbles in the early years. The learning process is indeed under way, said Carlton, but it is progressing more slowly than anticipated.
"We're learning to partner with our [contractors] much better than before, and we're getting over the idea that we're in competition with them," said Carlton.
The ideal situation would be that Tricare, five years from now, would have fewer contracts and fewer regions, to eliminate the variations in service that currently bedevil Air Force personnel. "We have to make it simpler," said Carlton. "We have to make it user-friendly. We have to take the hassle out."
That is because, in all its endeavors, the Air Force Medical Service should strive to do more than just meet a customer's basic expectations. Carlton has a different standard. "How do you delight that customer?" he said.
This joint statement by F. Whitten Peters, Secretary of the Air Force, and Gen. Michael E. Ryan, Air Force Chief of Staff, was contained in the Air Force posture statement, presented in February to the Senate and House Armed Services Committees.
"Perhaps the biggest quality-of-life issue facing the Air Force today and in the coming years is medical care. Access to quality health care is crucial to the quality of life of our airmen (active duty and retirees) and their families and greatly affects our recruiting and retention efforts and, ultimately, our readiness.
"Tricare, the DoD program to ensure health care at a reasonable cost, is designed to provide a quality health care benefit, improve beneficiary access, preserve choices for our beneficiaries, and contain costs, all while providing a structure to support the military medical forces needed to deter and fight the nation's wars. Tricare was fully implemented as of June 1998 and is a good start to providing quality health care.
"However, there have been problems, such as access to care, claims processing, reimbursement levels, and Tricare management requires constant attention. Several of these issues have been resolved, and the rest are being worked aggressively. Our latest Air Force Inspection Agency audit concluded customer satisfaction with Tricare is increasing.
"The Air Force Medical Service initiated bold re-engineering efforts to increase access to Military Treatment Facility medical care and provide a much stronger emphasis on preventive services. The goal is to enable all Tricare Prime beneficiaries to be assigned to an MTF Primary Care Manager by name, as well as to be guaranteed access for acute, routine, and preventive appointments.
"At the direction of the Secretary and the Chief of Staff, the Air Force Surgeon General developed a campaign plan to ensure line commanders understand Tricare and know how to help subordinates with problems. Preliminary results from this program, Operation Command Champion, have been very encouraging.
"Also, numerous demonstration projects to improve the quality of Tricare are under way, especially for retirees and Medicare-eligible beneficiaries. For example, a Medicare Subvention program called Tricare Senior Prime is currently active at five Air Force locations; the MacDill 65 subvention program cares for up to 2,000 enrollees in the Tampa, Fla., region; and the Federal Employees Health Benefits Program 65 test, a nationwide program at eight selected locations, is slated to begin in spring 2000.
"We are now working Tricare and health care issues through the Joint Chiefs of Staff and the Defense Medical Oversight Committee, which has been formed to ensure optimum service participation in the health care agenda and improve health care for active and retired members."
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