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Military Engagement

What began in 2007 as a limited program to provide reconstructive surgical care to some of the most severely injured combat veterans of Iraq and Afghanistan has evolved into a much deeper relationship with the Pentagon.

Paper Sculpture - Operation MendBy Lyndon Stambler

Paper Sculpture by Sally Vitsky

Ronald A. Katz and his wife Maddie were at home watching CNN one evening in 2006, when they heard Lou Dobbs speaking with a young U.S. Marine, who was maimed nearly two years earlier by a roadside bomb in Iraq. The explosion flipped the 26-ton amphibious-assault vehicle in which Cpl. Aaron Mankin was riding 10 feet into the air, killing four Marines and injuring 11 others. Mankin was on fire. He dove out of the wreckage, rolling in the dirt to try to put out the flames. His nose, ears and lips were burned away and the skin over much of his upper body was seared. His airway and lungs also were badly damaged by the heat and smoke, and he lost the thumb and index finger of his right hand. After Mankin was airlifted back to the states within 48 hours, surgeons at Brooke Army Medical Center in San Antonio, Texas, performed 40 lifesaving operations. But Mankin’s face remained grossly disfigured.

“I have to fix the beautiful part,” Mankin said in a scarred, raspy voice to Dobbs.

The Katzes were riveted as they watched the interview. “We have to do something about this,” said Maddie, who died in 2009, to her husband. Katz, an inventor and founder of a technology-licensing company, was in a position to do just that. As a member of the executive board of Ronald Reagan UCLA Medical Center, he had a pipeline to some of the best reconstructive plastic surgeons in the country.

Then he took his case to the U.S. military and started speaking with doctors at Brooke to convince them to let UCLA extend its expertise to the treatment of the nation’s wounded warriors. In September 2007, after months of meetings and negotiations, UCLA surgeons performed the first of 29 operations on Mankin to restore his features. Thus began Operation Mend, a unique partnership between UCLA and the military that has strengthened and grown into something much larger than when it began.

Dr. Christopher Crisera  

Top: Dr. Christopher Crisera
examines an Operation
Mend patient.

Bottom: Ronald A. Katz
(second from left) holds
the U.S. Army’s Strength of
the Nation award following
presentation in 2010 by Army
Chief of Staff Gen. George W.
Casey Jr. (left), Secretary of
the Army John McHugh
and Sgt. Maj. of the Army
Kenneth O. Preston.

Opposite Page: (From
left) U.S. Army Gen. Peter
W. Chiarelli and U.S. Marine
Corps Gen. James F. Amos
talk with Cpl. Aaron Mankin
in 2008.

Photos: (Dr. Crisera) Courtesy of Operation Mend; (Katz) J. Elise Van Pool/U.S. Army News Service; (Gen. Chiarelli) Reed Hutchinson

 

That military engagement now is part of a broader campuswide effort, the UCLA Veterans Initiative, launched last year. “We can never repay our veterans for the sacrifices they have made for our country, but we can come together as a community to better understand both the challenges and the great opportunities encountered by the growing population of veterans across the nation,” Chancellor Gene D. Block said when he announced the initiative.

KATZ LOOKED PLEASED DURING THE FIRST MEETING of the Ronald A. Katz Center for Military Collaborative Medicine in June 2013 at Ronald Reagan UCLA Medical Center. The gathering brought together UCLA doctors, administrators and a retired U.S. Army four-star general, Peter W. Chiarelli, who is the new center’s executive advisor. By day’s end, the group had heard research proposals regarding scar reduction, neurobionic devices, bioengineering and entrepreneurship.

But Katz’s priority this day concerned continuous electroencephalogram (cEEG) monitoring equipment. UCLA neurologist Paul M. Vespa, MD (FEL ’96), director of the Brain Injury Program and Neurocritical Care Unit at Ronald Reagan UCLA Medical Center, has been collaborating with military doctors and commanders to install such equipment within military critical-care units that treat wounded fighting men and women. With so many of America’s combat veterans suffering from traumatic brain injuries (TBIs), the equipment would allow UCLA doctors to continuously monitor brain activity of patients from afar and advise their military counterparts when to administer anti-seizure medicine.

At the meeting, Gen. Chiarelli, who served for nearly four years as vice chief of staff of the U.S. Army, offered to help to get the cEEG installed quickly. “Send me exactly what you need. I’ll contact medical colleagues in the Army and see what needs to be done,” he said.

Now, UCLA’s expanding relationship with the military, as exemplified by the new center, has brought Dr. Vespa’s dream to fruition. The machinery was installed this fall at Landstuhl Regional Medical Center in Germany, the largest U.S. military medical facility outside of the United States, where severely wounded service members are airlifted for treatment.

Said Katz, “This is a good project to identify with the center.”

The Katz Center is a hub at UCLA to convert the difficult lessons of war into medical advances. Kodi Azari, MD (FEL ’04), co-medical director of Operation Mend and chief of reconstructive transplantation, sees the center as a clearinghouse for military and UCLA investigators conducting research on such issues as composite-tissue transplantation and stem cells to deal with soft tissue and bony injuries, genital reconstruction, the mechanism of brain injury and building resilience within war-weary families. In addition, the center will help spread the word about clinical offerings for combat veterans, enhance the use of telemedicine to maintain contact with patients and providers, help the military with skills like hospital administration and even export the collaboration model to other settings.

THE WARS IN IRAQ AND AFGHANISTAN have created unique medical challenges. Improvised explosive devices, like the one that blew up Mankin’s vehicle, have injured and mutilated thousands. Meanwhile, the survival rate has soared, thanks to advances in battlefield lifesaving techniques that include use of tourniquets, anti-coagulants and lightning-quick evacuations.

“The military has made tremendous strides, but the problems are so great we can’t handle them alone,” Gen. Chiarelli says. “Traumatic brain injury and post-traumatic stress (PTS) are the most prolific wounds coming out of these wars. They have overwhelmed the military and the Veterans Administration.”

Add to that a historically high suicide rate among service members, caused, in part, by stress from multiple deployments. “We all agree getting people the help they need lowers the risk of suicide,” Gen. Chiarelli says. “By filling in these gaps, we’ll make a dent in this problem. It’s not just to help the military, but to help society.”

UCLA already has helped to fill some of those gaps. “This is one of the most important public-health issues of our generation,” says Nathanson Family Professor of Psychiatry Patricia Lester, MD (FEL ’00). “Research addressing suicide, PTS and TBI and focused on prevention of psychological-health problems will have enormous benefits for the military and civilian populations as well.”

  U.S. Army Gen. Peter W. Chiarelli and U.S. Marine Corps Gen. James F. Amos talk with Cpl. Aaron Mankin in 2008
  (From left) U.S. Army Gen. Peter W. Chiarelli and U.S. Marine Corps Gen. James F. Amos talk with Cpl. Aaron Mankin in 2008.

Many families are under stress from the long wars, fought by less than 1 percent of the population. Statistics about the consequences of combat tend to vary, depending on which sources are consulted; however, one report, released in May 2013, aggregated data from a variety of government and private sources to perhaps draw a more complete picture. According to the report, Serving Those Who Served: A Wise Giver’s Guide to Assisting Veterans and Military Families, published by The Philanthropy Roundtable, nearly 51,000 soldiers had been wounded in action in Iraq and Afghanistan through early 2013. In addition, more than 420,000 service members and veterans have been diagnosed with PTS or depression, and more than 220,000 experienced a TBI during deployment. “This is something we all should care very much about. As a national community, we all have an obligation to support these men and women and their families,” says Dr. Lester, who also is co-director of the Welcome Back Veterans Family Resilience Center, a network of six medical centers funded by Major League Baseball and the McCormick Foundation to enhance the care of returning service members.

  Operation Mend

GEN. CHIARELLI WAS INSTRUMENTAL in helping to sustain Operation Mend. He had just been appointed vice chief of staff of the Army, in 2008, when another military leader, Gen. James F. Amos, the then-vice commandant of the Marine Corps, and now commandant, walked into his office at the Pentagon. Gen. Amos, who had met with Katz during discussions to initiate the first phase of Operation Mend, told Gen. Chiarelli that there were some obstacles to referring cases to UCLA.

“I dug into it and found out, yes, there was an issue,” Gen. Chiarelli recalls. “As much as our doctors said they were willing to refer patients, it was clear that wasn’t always the case. All doctors are proud, and it is not always easy for military doctors, or their civilian counterparts, to recommend that patients go elsewhere for care.”

It took several months, but Gen. Chiarelli was able to work out a formal understanding between Brooke and UCLA that allowed the program to move forward. “I appealed to the fact that many of them were parents,” Gen. Chiarelli says. “‘Shouldn’t we give these kids the opportunity to choose where they want to go to get this reconstructive surgery?’ I would ask them. That resonated with them.”

Another extremely critical element that helped to allay the military’s concerns was the Buddy Family Program, created by Katz’s daughter-in-law, Dana Katz. The program continues today to provide a support network for Operation Mend patients. Buddy Family volunteers meet the patients when they arrive at UCLA, help them and their families to settle into the Tiverton House on campus, take them on outings and generally try to make the experience of being in a strange place more comfortable and positive. Strong bonds have been built through the Buddy Family Program.

Operation Mend Stats  

Similarly, UCLA’s bonds with the military also gradually strengthened. “Everyone learned to play nicely together,” says Melanie Gideon, program manager for Operation Mend. “If you strip away the politics and the bureaucracy, you recognize that these men and women are injured human beings, who have put their lives on the line for this country. We should do whatever we can to help them.”

Plastic surgeon and Operation Mend executive co-medical director Christopher Crisera, MD (RES ’04, FEL ’05), realized how far along things had evolved when, in June, Rear Adm. C. Forrest Faison III, commander of Naval Medical Center San Diego, invited a team of UCLA doctors to identify areas of potential collaboration. “Now they’re looking to work with us,” Dr. Crisera says. “That was an exciting development.”

What began as a program to provide reconstructive plastic surgery now has branched out to include hand surgeries, orthopaedics and TBI assessments. It continues to expand to include other specialties like ophthalmology, head and neck surgery and psychological care to address these complex physical and emotional wounds. Other departments also pitched in; David Hovda, PhD (FEL ’87), professor of neurosurgery, engaged a team to pursue TBI assessments. “There’s been a convergence of teams working together in an interdisciplinary way,” Dr. Lester says.

THE RELATIONSHIP BETWEEN UCLA AND THE MILITARY actually began prior to Operation Mend. In 2004, military officials realized the wars would be longer than they expected. Families were ill-prepared to deal with the stress. The following year, Dr. Lester and a colleague, William Saltzman, PhD, associate director of UCLA’s Nathanson Family Resilience Center, began traveling to Camp Pendleton , near Oceanside, California, weekly to help Marines and their families cope. Then, in 2008, the Navy Bureau of Medicine and Surgery contracted with UCLA to implement Families OverComing Under Stress (FOCUS) at seven Marine and Navy Seal sites. The program now operates at 22 sites, from Okinawa to North Carolina, and includes the Army and Air Force as well as the Navy and Marines.

“We had a lot of challenges,” Dr. Lester recalls, including the need to build trust among military families skeptical of civilian outsiders. To date, the FOCUS project has delivered services to more than 400,000 people. Dr. Lester, whose team has collected data and anecdotes on thousands of interactions with families, spoke of an Okinawa-based family whose daughter’s bedtime ritual was disrupted when her father first deployed. Before his next deployment, he and his wife planned together how to support their daughter’s routines in his absence. “He could leave with a greater sense of confidence that his family was going to be able to cope with the challenges ahead,” Dr. Lester says.

  Focus Program, Operation Mend

Several years ago, when Operation Mend realized it needed to broaden its psychological-health services, Dr. Lester’s team worked with Operation Mend to create the Operation Mend FOCUS Family Resilience Program. Led by psychologist Jo Sornborger, PsyD, this team provides family centered resilience services to both patients and family members.New media also is being pressed into service. FOCUS World (focusworld.org), for example, is a virtual world for children and families. Participants get an avatar and arrive at a virtual home via spaceship, where they learn stress-reduction and techniques. Operation Mend FOCUS also developed an app, FOCUS on the Go!, to help families build resiliency.

ON ANOTHER FRONT, DR. HOVDA, director of UCLA’s Brain Injury Research Center, has led the way in shaping how the military views brain injuries. In March 2009, Dr. Hovda traveled to Washington, DC, to brief Gen. Chiarelli and Gen. Amos on TBI. He explained to the military leaders why soldiers suffering concussions should rest to prevent further injury. Alarmed by Dr. Hovda’s revelations, the generals asked him to brief military doctors. The next day, at the Pentagon, Dr. Hovda repeated the revelations for 15 military neurologists and psychiatrists. “The reason people have symptoms after they get hit in the head is because the blow produces an ionic and metabolic cascade that you can visualize using MRI,” he said. “The cells become dysfunctional and vulnerable, which is why it’s important that people not be exposed to another injury.”

Like many of their civilian counterparts, these military physicians did not all agree with Dr. Hovda’s conclusions. Gen. Amos and Gen. Chiarelli asked Dr. Hovda to assemble two blue-ribbon symposia on TBI and PTS to further assess the issue. The result was a 2010 directive from the Joint Chiefs of Staff: Any service member suffering a concussion must be pulled out of action and allowed to rest. Admiral Mike Mullen, the former chairman of the Joint Chiefs of Staff, asked Dr. Hovda to help set up MRI scanners and prepare military labs in Afghanistan to diagnose TBI. Dr. Hovda felt it would be better to send a clinician, so UCLA neurologist Christopher Giza, MD (RES ’94, FEL ’96, ’00), joined a three-member team to set up the scanners and lab-testing protocols. Shortly thereafter, President Obama nominated Dr. Hovda to serve on the Defense Health Board, advising the secretary of defense.

  By The Numbers, Operation Mend

For his efforts on behalf of America’s servicemen and servicewomen, Dr. Hovda received the Army’s Strength of the Nation Award in 2011. Katz had received the prestigious award a year earlier. “Ron and Dave define what a patriot is,” Gen. Chiarelli says.During the award festivities in 2011, Dr. Hovda was moved to tears when a 6-foot, 4-inch soldier, who had lost a leg in combat, bent down and hugged him, saying, “It’s because of you that I’ll never give up.”

And as the war in Afghanistan now winds down, UCLA doctors hope to continue to heal the wounded and to prepare for future battles. That preparation includes training future doctors. Some UCLA medical students can now receive their continuity training at the VA Greater Los Angeles Healthcare System. The program, in its second year, is hosting 16 third-year students, including two veterans, through rotations in inpatient and ambulatory medicine, psychiatry and neurology. “It’s actually the only site that has preceptors from psychiatry as well as internal medicine,” says Gregory A. Brent, MD (RES ’85), chair of medicine at the VA Greater Los Angeles Healthcare System and a professor of medicine and physiology at UCLA. “That fact reflects the value that we place on integrating those aspects of care
for the veteran patients.”

Such training will be as important in peacetime as in war. The problem is even more profound in the general population. Each year, 3.4-million Americans suffer from TBI.

It is a fact that circles back to that first meeting of the Ronald A. Katz Center for Military Collaborative Medicine this past June. Neil A. Martin, MD, chair of neurosurgery at UCLA, cited a study by Professor of Psychiatry and Biobehavioral Sciences Gary Small, MD (FEL ’83), of five NFL players showing that concussions can alter the brain tau protein, indicating when players should be pulled out of action to rest. “We’d like to bring as much of this work (on civilian populations) as possible to the Operation Mend population,” Dr. Martin said.

Katz and Gen. Chiarelli both agreed. The spirit of cooperation, they say, is a sign that America has learned important lessons in the post-Vietnam era. Dr. Azari, for his part, will never forget walking on a street in New York City with Mankin. Passersby stopped the young Marine, who was wearing his Dress Blue uniform, and asked to take his picture. “This is a real American hero,” they said to their children.

For Gen. Chiarelli, who has been a champion of those suffering the “invisible wounds of war,” it is crucial to treat these veterans of Iraq and Afghanistan better than the country did those from the nation’s most-recent past conflict, Vietnam. “These are lifetime problems that they come home with, lifetime issues,” the general says. “And I promise you, whether there are wars going on or not, we’ve got a backlog that’s big enough to keep everyone busy for the foreseeable future.”

Lyndon Stambler is a freelance writer and teaches journalism at Santa Monica College.

For more information about veterans’ services at UCLA, go to: www.veterans.ucla.edu

To learn more about Operation Mend and to read about more of the program’s wounded warriors, go to: operationmend.ucla.edu

 

 





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