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Fri Mar 2 01:56:40 GMT 2007

This post is medical, surgical, and health care delivery.  This  post is 
trauma and Critical Care.   Just bear with me.   I  am sick at heart with what I 
am discovering even as I am typing.  I have  been sick at heart at what I have 
been reading the past week and some of the  piety, denial, finger pointing, 
and excuses that I have read.   My  post here will address Walter Reed Army 
Medical Center in Washington DC and the  news of the past week.   Anyone not 
interested can just delete right  now and spare yourself of my particular 
assessment and  reactions.    I respect that each of you may have encountered  similar 
circumstances and that each will have their own views and  reactions.   What 
follows are mine alone.   

First, I am very proud of the Military Medicine and its commitment to the  
pursuit of excellence and application of new knowledge, especially to those in  
our young fighting force who give their all to defend freedom and our way of  
life.   The chain of survival from the time of wounding (assistance  from 
medic and buddy lifesaver) to the FSC to the Field Hospital to Landsduhl ,  
Germany, to Walter Reed, to secondary hospitals to rehabilitation hospitals  offers 
the best chance of survival and return as a functional member in society  than 
at any other time in the history of military or civilian trauma care.   EVER, 
ANYWHERE.  We ALL must take great pride in that singular and  documental 
FACT.  PERIOD,  and this could and should be the end of the  story.    
However............................

Beginning over 15 years ago there were concerns regarding military  hospitals 
and their governance and interaction.  Several were closed,  others should 
have been downsized, others should have been expanded.    Most should have been 
integrated with the civilian trauma centers, especially  our county hospital 
system across the country.   However, every  decision became very politicized.  
 WRONG decisions at the  CONGRESSIONAL, GAO, and Executive levels were made 
as far back as 10 years  ago.  Then came the BRAC commission that made even 
other damaging  recommendations.  NO real outside checks and balances were 
imposed and  MAJOR structural changes were made in locations and buildings, often 
very very  politicized, and NOT what was in the best interest of the wounded or 
sick  soldier.    It was strongly recommended that with the closure of  DC 
General Hospital, Walter Reed become the Trauma Center for ALL three services  
and be located in its current location for ALL of Washington DC.   Ironically, 
Walter Reed, and the politicized generals and congresspeople decided  AGAINST 
Walter Reed being a Trauma Center.   Thus, on 9/11 many of the  most severe 
injuries from the Pentagon were not taken to the three EXCELLENT  trauma centers 
in the greater Washington DC area.   

Decisions were made to RELOCATE and RENAME Walter Reed Hospital and this  was 
led by the BRAC Commission.   Deliberate decisions were made at  the HIGHEST 
level and by both civilians on both sides of the political aisle and  by 
military brass about NOT putting much money into buildings which would soon  be 
replaced.   BAD DECISIONS, economically and politically  motivated.    Some of 
the logic regarding the location,  structure, function, and governance of the 
NEW Walter Reed Hospital to be  located in Bethesda could be severely criticized 
when looking at the hard data  about distribution, needs, function of 
military medicine.    BRAC  prevailed and renovations of Walter Reed suffered just 
what many of our own  hospitals suffer.   We have a doctor problem and difficult 
quality  patient care, because of decisions made by persons at a higher  
lever.   In the public, governmental, HMO, and military medical care,  honest 
budgets to pay for what is needed for the patients known to exist almost  never 
occurs.   Example after example exists all across the United  States.  

Now fast forward to this week.   Reporters expose what has been  known for at 
least 5 years or longer, including known by the current surgeon  general who 
was today named to be interim Chief of Walter Reed after the firing  of the 
existing Commanding General of Walter Reed.    The  guilty party is NOT the 
commanding general who was fired, but those who sat on  the BRAC commission, those 
who refused to fund needed renovations over the past  10 years, those who 
decided to move Walter Reed in favor of a NEW building in a  NEW location.      
The laboring doctors and nurses  within the hospital knew of the problems for 
years.   The last several  chiefs of surgery knew of the politics and the 
problems.   The past 3  surgeon generals of the Army knew of the problems and the 
politics.    Deliberate decisions were made to maintain the status quo.  

So after the press showed rat droppings and leaking roofs, and complaining  
soldiers just back from Iraq, someone had to be come the sacrificial  lamb.   
FIRE the Commanding General.   How many times have  you seen this in civilian 
and in county hospital across the country.    This is in hopes that no one 
REOPENS the needed analysis of the BRAC  Commission.   This in hopes that no one 
REOPENS the decades long  debate about renovations in military medicine to 
create a Uniformed Services  Health System, much like the unified medical training 
FOR ALL SERVICES now in  existence at the Uniformed Services University for 
the Health  Sciences.   A grand example of cooperation for a needed  mission.   

As a civilian observer, I am very proud to have observed what the laboring  
doctors and nurses and technicians in the trenches have done for our wounded  
servicewomen and servicemen.   I have been saddened at many of the  politicized 
military medical decisions often made by civilians with a conflict  of 
interest at the Congressional, GAO, Civil Service, and Executive Branch  Levels.  I 
have been seeing such occur for the past 30 years.    Fortunately, using 
tenacity, medical tape, interaction with the civilian trauma  center advances, and 
putting up with the recurrent red tape, fantastic medical  care has been 
rendered.    

If I were to FIRE someone,  IF I were to question anything after this  week, 
I would do a root cause analysis and I would start with the Bell  Commission 
and the BRAC report.    I personally would throw it  OUT and start all over 
with a blue ribbon mixed civilian, military, and business  community personnel 
and do for Military Medicine what the Flexner Report did for  Medical Education 
almost 100 years ago.   

The answers are NOT TriCare.  The answers are not to close military  
hospital.   The answers are NOT to fire the Commanding General of  Walter Reed who 
inherited a mess of a building and no real resources to fix the  problems.  The 
answers are not to point fingers to those in the trenches,  but to look for the 
real culprits who put this problem into motion over the past  several 
decades.    

Congress will hear next week hearings on the Military TOP DOC to be  
Assistant Secretary of Defense for Health Affairs.   This position  should be elevated 
to Deputy Secretary of Defense for Health  Affairs.   In the Pentagon at the 
Joint Chiefs of Staff Level, there  should be a 4 star DOCTOR General who is 
OVER all surgeon generals and have  HIGHEST LEVEL POLICY making power.     Such 
has not been  present for DECADES.    We suffered in some of the deployment  
assignments due to the old structure, but that is beyond the scope of this  
post.   

Doctors are not just technicians without planning, process, and policy  brain 
capabilities.   They often have tremendous insight to help the  politicians 
and the line officers in the military and in civilian health care  delivery 
alike.  

In both civilian and military health care delivery we are in the midst of a  
perfect storm- leading to quality health care falling apart and for a lot  of 
reasons (Every Trauma Program Director can tell tales of woe concerning  
insurance companies, reluctance to take trauma call, etc. etc. ).    The root cause 
is not at the trench level it is at much higher levels where the  concepts 
and the foundation is FAULTED.   This example today with  Walter Reed Army 
Medical Center Commanding Generals Firing is just a symptom of  a much more serious 
disease.   

Kenneth L. Mattox, MD
Houston
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