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Association of Military Surgeons of the United States Annual Meeting

Location: San Antonio, TX

Dr. Petzel -- thank you for that kind introduction and for your leadership of VA's healthcare administration. Your tenure as president of AMSUS has been an important engagement for VA, and I thank you for your leadership here, as well. Let me further acknowledge:

* Admiral Regina Benjamin, Surgeon General of the United States;

* Dr. Jon Woodson, Assistant Secretary of Defense for Health Affairs;

* Dr. Alex Garza, Assistant Secretary of Homeland Security for Health Affairs;

* Our Military Surgeons General: Admiral Raffaelli, U.K.; Admiral Shirtley, Australia; General Uwabe, Japan; Commodore Jung, Canada;

* Generals Schoomaker and Green, and Admiral Nathan, representing our U.S. Military services;

* Dr. Chip Rice, President of USUHS;

* General Anderson, AMSUS Executive Director;

* Generals Byron Hepburn and Ted Wong, other flag and general officers, active and retired;

* Fellow Veterans, VA colleagues, other distinguished guests, ladies and gentlemen:

I am honored to be here in San Antonio--home of U.S. Army medicine; home of Wilford Hall, the U.S. Air Force's largest medical center; and home of VA's South Texas Veterans Healthcare System with its new polytrauma rehabilitation center.

You know, far better than I, how much military medicine has evolved since World War II. In my own time in uniform, I witnessed dramatic improvements not only in personal protection--steel helmets to kevlar, flak vests to chicken plates to 2nd Chance undergarments to Ranger body armor--but also in handling trauma--combat lifesavers; "golden hour" medevac tactics, techniques and procedures; world-class surgical suites postured well-forward in the combat zone, complemented by strategic airlift to quickly and safely evacuate the seriously ill and injured from the war zone to our best hospitals back here in the continental United States--a tribute to all of you in military medicine and the joint doctrine you have developed.

As we know, casualties, today, survive catastrophic injuries that would have been lethal just a few years ago. In Korea and Vietnam, our ratio of combat deaths to surviving wounded was roughly 1:3. In the first two years in Iraq, it was approximately 1:13. A Veteran who was heavily tested during World War II attests that no double amputees in his regiment survived combat.

Today, that is not the case. Of the 42,000 amputees in VA's system, we currently care for more than 1,300 amputees from the wars in Iraq and Afghanistan--single, double, triple, and even three quadruple amputees. Importantly, these injuries are all compound, complex cases with multiple treatment regimens--physical, mental, visual, spiritual. More of our wounded are surviving--thanks to your skills, dedication, and training. Some are the long-term, permanently disabled, whose devastating injuries will exacerbate as these Veterans age.

VA is in the battle to, first, bring these patients all the way home, and second, to enhance quality of life, well-being, and functionality in spite of the frictions of aging. VA's relationship with our patients, yours and ours, begins with transitioning out of the military and continues until they are finally laid to rest in one of our 131 VA cemeteries or in another cemetery of their choice.

VA has a long history in prosthetic technologies. Following your recent trailblazing work in this area, as Afghanistan and Iraq shaped up to be the long-term commitment they have become, we are now also investing heavily in research, development, and acquisition of space age, light weight, highly functional prosthetic devices. We are also looking longer term as these 20-year-old amputees age to 40-, 60-, and even 80-year-olds. Their challenges will not be the same, but the desire for functionality and reasonable independence will remain constant.

And when the last combatant returns from Afghanistan and your patient load begins to decline, I believe it essential that we continue, even enhance, our collaboration, so that readiness, yours and ours, for the next conflict is assured.

VA is simultaneously investing heavily in the treatment of TBI (traumatic brain injury) and PTSD (post-traumatic stress disorder)--commonly called the signature wounds of war, especially the ongoing conflicts. Just last month, I visited San Antonio to open the fifth of VA's five polytrauma rehabilitation centers, now ringing the country--from Tampa, Florida, to Richmond, Virginia, to Minneapolis, Minnesota, to Palo Alto, California, and now here in San Antonio.

These are our five Tier One facilities in a three-tier system for treating these injuries. From Tier One, patients have the choice of going to one of our 22 Tier Two facilities; then, as their conditions permit, to one of our 86 tier three polytrauma treatment program sites--flowing polytrauma patients ever closer to home, wherever that will finally be.

We've made some enormous advances in treating some of our most serious TBI's--those arriving at our polytrauma centers comatose, with injuries that only a few years ago were thought to be hopelessly irreversible. Through comprehensive treatment and innovative experimentation, nearly 70 percent of these comatose patients have been brought back to consciousness--a rate far exceeding the national norm.

The term "polytrauma" did not exist before Iraq and Afghanistan. Our polytrauma centers address the growing number of complex and devastating, long-term care requirements coming out of both theaters. They add tremendous capabilities to our healthcare system of 152 medical centers, which are already affiliated with 104 of the top civilian medical schools in the country. Furthermore, each medical center serves as a healthcare flagship for some number of our 807 community-based outpatient clinics, our mobile clinics that reach out even further to remotely located Veterans, and an on-call series of outreach clinics that activate as needed. Additionally, the mental health programs within this medical system are augmented by 288 independent Vet Centers and more than 750 vocation and rehabilitation counselors, who provide readjustment, independent living, and employment counseling for combat Veterans and their families. This constellation of care is broad and deep with significant capabilities to handle a wide range of healthcare needs from the seriously injured 20-year-old to the 80-year-old dementia patient.

Even with all this capability, our challenge remains anticipation--knowing what our requirements will be, where, and when. In this aspect, we lack agility because we often lack, in your jargon, "actionable intelligence." Very little of what we do in VA originates in VA. Much of what we work on originates in DoD. VA and DoD are continuums of one another, with our patients as the threads that should knit our doctrines, our concepts, our systems, our investments, and our collaboration together. There should be no gaps between us, where patients are concerned.

For our most seriously ill and injured patients, I think that has been achieved. The numbers are small enough, and the seriousness of their cases keep them highly visible. DVBIC, the defense and Veterans brain injury center has fostered important collaboration. We can and must be more aggressive in our collaboration, teaming, resource alignments, and cross-pollination of healthcare professionals, so that DVBIC is not the exception, but the rule.

In January 2009, I inherited a congressionally enhanced VA budget of $99.8 billion--larger than any army budget I had during my tenure as chief of staff. The following year, president Obama increased that budget by 16 percent, to $115 billion--VA's largest single-year increase in over 30 years. The 2011 budget grew to $126.6 billion, and the president's 2012 budget request for VA, currently before congress, is for $132.2 billion.

The healthcare portion of those budgets grew from $41.2 billion in 2009 to $44.5 billion in 2010 to $48 billion in 2011, and dr. Petzel, because we have been granted something called advance appropriations, is already executing his $50.9 billion 2012 budget, while other VA administrations are incrementally funded under continuing resolutions guidance. About 85% of VA's discretionary dollars fall under randy Petzel's healthcare administration.

Few organizations have had this kind of presidential support, but every bit of it has been needed to address both the increasing Veteran healthcare issues growing out of Iraq and Afghanistan and to correct longstanding issues that have plagued our ability to treat and care for the 8.5 million Veterans who are currently enrolled in VA healthcare.

We have been able to correct some longstanding issues from past wars by adding three additional diseases to the list of presumptives for Agent Orange, nine diseases for Gulf War illness, and verifiable PTSD for all generations of combat Veterans, making it easier for them all to file claims and receive the compensations they earned. We owed it to our Vietnam, Gulf War, and combat Veterans at large to police up the battlefield.

We have also made progress towards our mid-term goals of increasing Veterans' access to VA services and benefits, and eliminating the backlog in disability claims and ending Veterans' homelessness in 2015.

Access: in the last two-and-a-half years, we have added nearly 800,000 Veterans to VA's healthcare rolls--a 10 percent increase. We have built more than 30 new community-based outpatient clinics, are building five new hospitals, and have invested heavily both in mental health and telehealth connectivity linking our Veterans, wherever they reside, to our VA services. We have also improved outreach to women Veterans, adding 144 women's program coordinators at our key medical centers and women Veterans' benefits coordinators at our 56 regional offices--but we still have more to do.

Homelessness: I'm sure some of you have wondered why "homelessness?" First, because it's the right thing to do--no one who has fought for this country should be homeless in it. And second, because the homeless Veteran reveals the gaps in VA's system. To meet our goal of ending this national embarrassment in 2015, we have to bring to bear all of our capabilities--primary medical and dental care, mental health, substance abuse treatment, vocational rehabilitation and employment, education, case management, housing--and persistence in shifting our main effort from rescue to prevention.

Claims backlog: VA has long been a leader in healthcare informatics based on our very successful vista electronic health record, but inexplicably, we have never automated our claims process. Over time, perhaps beginning as early as 1990, a lack of timeliness in claims processing has steadily grown into a massive backlog. We have, now, focused all our IT energies onto disability claims processing.

We have some confidence that we will be able to do this quickly with high quality outcomes. It's taken us about two years, from a cold start, to automate our new 9/11GI Bill applications processes. Today, we have over 410,000 Veterans and family members enrolled in college, using the automation tools that we specifically developed to process their applications. Because of these successes, we are confident that we can begin automating disability claims processing next may and begin reducing this backlog, which has frustrated Veterans for far too long.

In January 2009, VA was fielding only about 30 percent of its IT projects, investing billions with little to show for it. Today, execution is up to 89 percent--perhaps best in the country, public or private. For this reason, our confidence in our ability to automate disability claims processing is high. Our next big test comes in the summer of 2012, and we aim to win that one, as well.

In all that we do, trust and collaboration between DoD and VA are critical--for service members, for Veterans, and for our nation. We have worked closely with the Army and the Marine Corps to simplify the out-processing of wounded, ill, and injured servicemembers. The new system is called IDES--the Integrated Disability Evaluation System. Secretary Panetta and I personally review and impose process improvements on IDES so that the system is more transparent, more consistent, and more efficient in transitioning the great youngsters who have worn your uniforms and served us all.

A single, common, DoD-VA electronic health record would greatly enhance this process. Defense Secretary Gates and I committed both departments to creating one in January 2009, and three months later, in April 2009, the President added authority to that commitment by directing us to create a Virtual Lifetime Electronic Record, within which an electronic health record would be the key platform.

President Obama's directive was clear. So Secretaries Gates, Shinseki, and now Panetta have committed to creating a single, common, joint platform for an electronic health record that is open in architecture and non-proprietary in design. We call this effort the I-EHR--integrated electronic health record. It's an ambitious goal, but we are confident that it's achievable. This isn't about VA or DoD. This is about what's best for every servicemember who one day becomes a Veteran.

There's also enormous, potential good for the country. I-EHR could serve as a model for a national electronic health record. It must enable the free flow of crucial medical information between DoD, VA, and other care providers and stakeholders who could be granted access to selected data on a controlled basis.

It is estimated that about 80,000 Veterans remain homeless in this country every night. I have never been able to solve a problem I could not see, so an estimate masks, for me, the full scope of the problem. When I say homeless, most imagine a heavily draped figure sleeping on a steam grate in the dead of winter, and this is true--it is the most visible aspect of homelessness. But there is a much larger population "at risk" of homelessness who are one paycheck, one missed mortgage payment, one more missed utility bill, or one more crisis away from the streets.

DoD and VA collaboration could produce some significant outcomes here. It would be helpful, as service members transition out of the military, to try to identify those with potential risk factors associated with homelessness. A good transition assistance program becomes crucial to this effort.

Too many Veterans carrying the burdens of PTSD or TBI, compounded by limited financial literacy and atypical behaviors, begin a downward spiral towards isolation, depression, substance abuse, joblessness, failed relationships, homelessness--and sometimes suicide. It usually doesn't happen overnight--it's a long, slow slide. But it begins somewhere, and it would be shortsighted for any of us to presume that these conditions only ensue after the uniform comes off. We need to go from reactive to proactive care here--"actionable medical intelligence" would go a long ways towards enabling VA to be proactive. Electronic records that do not link make shared intell almost impossible. We have committed to ending Veterans homelessness in 2015, and we need your help to achieve that goal.

Finally, let me touch on an undiscussable. It concerns prescribed medications--specifically, those powerful drugs which are used to treat pain. Are we courageous enough to ask ourselves whether we overmedicate those who struggle with physical or psychological pain? Are we courageous enough to investigate whether solving problems in the short term with medication contributes to longer-term problems --and perhaps to that downward spiral which, for some, results in homelessness or even more serious consequences? If substance abuse is one of the common issues of homelessness--and it is--do we contribute, in some way, to the problem with our medication practices? This is a question VA and DoD should continue addressing together. I am not a clinician, so I ask this question without taking a side. However we come down on this, it will take courage, and DoD-VA collaboration will be crucial.

On 11 October 2004, Lance Corporal Kyle Anderson, 3rd Battalion, 5th Marines, was just completing a patrol outside Fallujah, when an RPG struck his humvee. Shrapnel penetrated his Kevlar, tearing into the left side of his brain.

Corporal Anderson was medevaced to Baghdad, where he underwent two surgeries; then was airlifted to Germany for a third surgery; before evacuation to Bethesda naval hospital and onward movement to VA's polytrauma center in Minneapolis, where he remained in a coma for weeks. When he was finally awakened, all he could do to communicate was to smile or cry.

Kyle had been a high-school state wrestling champ, but after his injury he couldn't walk, talk, or even swallow. He had to re-learn everything. His progress was agonizingly slow, but in time he learned to communicate through hand signals--thumbs up or thumbs down. Then his grunts slowly became words. Through sheer determination, on his part, mirrored by the unwavering love of those who cared for him, he slowly regained his ability to speak, eat, dress, and get around.

Today, after 2,000 rehab appointments and two more surgeries, Kyle lives at home with his father and brother in a suburb of St. Paul. He's still partially paralyzed, but works part-time as a housekeeping assistant at the Minneapolis VA. He enjoys many things most 26-year-olds do--working out, going to movies, watching wrestling matches at his old high school. He's been hunting with his father in South Africa, and he's making a film to tell his story.

Kyle's father, his full-time caregiver, says, "That [military] neurosurgeon who saved my son's life in Baghdad performed a miracle. Then the people at VA [Minneapolis polytrauma center] performed a miracle of their own."

To be fair, Kyle Anderson and his father Tim performed their own miracle--showing us what courage, determination, and teamwork really mean. Young Americans like Lance Corporal Anderson deserve nothing but our unwavering support. They fought to survive. They deserve our very best efforts to bring them all the way home. VA will be there to deliver on Abraham Lincoln's promise to care for those who have "borne the battle."

God bless our men and women in uniform, God bless our Veterans, and may God continue to bless this wonderful country of ours.

Thank you.

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