MILITARY MEDICAL RESEARCH NEEDS AND OPPORTUNITIES Karl E. Friedl, PhD, COL (US Army, retired)
A hiatus exists between the inventor who knows what they could invent, if they only knew what was wanted, and the soldiers who know, or ought to know, what they want and would ask for it if they only knew how much science could do for them. - Winston S. Churchill (1929)
WHAT ARE THE DOD MEDICAL RESEARCH PRIORITIES? (WHERE DO THEY COME FROM?) National strategic plans (e.g., Quadrennial Review) Secretary of Defense & other authoritative sources in the DoD and Services Armed Services Biomedical Research Evaluation and Management Near-term problems identified by field commanders & COCOMs
CORE MEDICAL R&T RESPONDS TO THREATS TO SOLDIER HEALTH AND PERFORMANCE Endemic Disease Threats Parasitic Diseases Bacterial Diseases Viral Diseases Chemical/Biological Warfare Threats Bacterial Threats Viral Threats Toxin Threats Nerve Agents Vesicant Agents Blood Agents Environmental Hazards Heat and Cold Altitude Toxic Industrial Chemicals & Materials Inadequate Medical C4ISR Systems Hazards Laser Blast Biomechanical Insults and Stresses Noise Operational Stressors Sleep Deprivation Traumatic Stress and Situational Stressors Physical Work Load Cognitive Burden & Operational Complexity Combat Injuries Hemorrhage Head Trauma Blast Injury
TAKING CARE OF INJURED SOLDIERS HAS BEEN A HIGH PRIORITY Apart from the war, this department and I have no higher priority than to ensure wounded servicemembers have the best care and facilities and ample assistance navigating the next step in their lives. That is what we intend to give them. Secretary Gates, 2007 Recognize the critical and permanent nature of wounded, ill and injured, traumatic brain injury, and psychological health programs. This means institutionalizing and properly funding these efforts in the base budget and increasing overall spending by $300 million. The department will spend over $47 billion on healthcare in FY10. Secretary Gates, 2009
Congressional Special Interest Programs: Neurobiology > $1B
LIMB LOSS ENDURING CHALLENGES: OLD MEDICAL THREATS, NEW SCIENCE SHELL SHOCK HEMORRHAGE
DOD BLAST INJURY RESEARCH EXTENDS BACK TO WORLD WAR II Nuclear & conventional explosions Los Alamos & Albuquerque Cave blasts Armored Med Res Lab
New Science and Technology Options: Modernization of Military Medical R&D Prevention (Mitigate Risk) Acute Treatment (Mitigate Injury) Reset (Mitigate Disability) Systems Biology Methods Personalized Medicine Diagnostics Regenerative Medicine Laying the tracks for the train Advanced Training Technologies & Neuroplasticity Individual Resilience Provider Training Individual Retraining Computational Bioengineering, Biomaterials & Nanotechnologies Biomedical Standards Wound Care Advanced Prosthetics Electronic Health Record Outcomes Research Injury Surveillance Optimized Interventions Return-to-Duty Standards
Problem Trends and Low level Persistent Conflict
Services MEDICAL RESEARCH AND RELATED PROGRAMS IN THE DOD ARO USAMRMC Other Agencies ONR ONR NMRC DARPA (e.g., DSO) DTRA (e.g., TMTI) SOCOM (e.g., BISC) AFOSR AFRL AFMOA VA-DoD sharing (e.g., JIF)
DoD Problem-solving Focus: Use-inspired Medical Research Understanding underlying science creates rule base to help solve future problems Low Emphasis on Applications Low Emphasis on Fundamental Understanding High Emphasis on Basic Science Revolutionary Pure basic research (Bohr) High Emphasis on Applications Evolutionary Pure applied research (Edison) Use-inspired basic research (Pasteur)
TECHNOLOGY READINESS LEVELS (TRLS) Source: http://as.nasa.gov/aboutus/trlintroduction.html
BUREAUCRATIC READINESS LEVELS (BRL) Users don t want it/don t know how to use it (no CONOPS; no voice for user pull ) We ve never done it that way before (disruptive to current processes) It will never fly (SWaP, affordability..) (lack of vision; no sense of urgency) Important but it has never been done before (no protected incubator; zero risk mentality) Not our job/no requirement for this research (lack of commitment; lack of agility) Ideas and data cannot be shared! (secrecy, stovepipes, meeting restrictions)
Users don t want it/don t know how to use it (no CONOPS; no voice for user pull ) We ve never done it that way before (disruptive to current processes) It will never fly (SWaP, affordability..) (lack of vision; no sense of urgency) SOLUTIONS Facilitate translation of research findings and talk about science! Develop resourced centers and protected research incubators Important but it has never been done before (no protected incubator; zero risk mentality) Not our job/no requirement for this research (lack of commitment; lack of agility) Convene meetings and facilitate idea generation and collaboration Ideas and data cannot be shared! (secrecy, stovepipes, meeting restrictions)
CONVERGENCE SCIENCE: SHARP & LANGER
CONVERGENCE SCIENCE Trafficking of single groups of 5-HT1A receptors in distinct endosomal pathways measured by QDs Fichter and Vu, Oregon Health and Science University Flajolet and Greengard, The Rockefeller University The current model of GPCR recycling includes a short (blue arrows) and a long (black arrows) recycling pathway Fichter K M et al. PNAS 2010;107:18658-18663 2010 by National Academy of Sciences
DEVELOP THE CONCEPT AND SMART ENGINEERS WILL ALWAYS FIGURE OUT HOW TO REDUCE SWaP 2009 LTC Sloane Guy performed surgery in Iraq with a head-mounted camera and other cameras that could be maneuvered by remote medical consultants 1996 COL Fred Goeringer mobile satellite station beaming images from the satellite dish from a mobile surgical center Surgical telementoring
ADVANCED PHASE SYSTEM-ON-A-CHIP PERFORMANCE MONITORING SYSTEM NSF ASSIST program Veena Misra Credit: NSF, ASSIST program
VIRTUAL HOUSE CALLS THEN AND NOW Radio Doctor Concept 1924 Dr. E. Ray Dorsey conducting teleconsultation with a Parkinson s patient in the patient s home
TELE-BEHAVIORAL HEALTH: PROVE THAT USERS WANT THE DISRUPTIVE TECHNOLOGY Improve access to BH providers for soldiers, minimize travel, extend reach of BH far forward to deployed locations Patient to Provider TBH session MC4 laptops using CENTRIXS network Over 10,000 theater teleconsultations since 2004 70% of soldiers would not have sought behavioral health care if tele-behavioral health was not available BH became the primary means of delivering BH Care in Afghanistan
mcare: SECURE MOBILE APPLICATION END USER INTERFACE TO MILITARY HEALTH CARE SYSTEM Needed a system to allow members of the CBWTU care team to connect with Warriorsin-Transition throughout their outpatient recovery process through a device they already own and are familiar using -- their personal cell phone
Why can t a soldier receive telebehavioral health services in the privacy of their own home? timeliness/urgency stigma travel distance H.R. 1832, the STEP Act of 2011 Servicemembers Telemedicine & E-Health Portability Act
MONITORING EMOTIONAL STATUS VIRTUAL HUMANS AS BEHAVIORAL HEALTH COACHES http://ict.usc.edu/prototypes/simsensei/ Louis-Philippe Morency Albert "Skip" Rizzo Institute of Creative Technologies University of Southern California
HOW DO YOU REVIEW AND FUND SOMETHING THAT HAS NEVER BEEN TRIED BEFORE? Triboluminescence, UCLA/Tribogenics Nature 2008;455:1089-92 Biospleen, Wyss Institute Nature Med 2014;20:1211-16 Pathogen Reduction, Caridian Transf Apheresis Sci 2006; 35 (1): 5-17
ADVANCES IN PERSONAL PROTECTIVE EQUIPMENT HAVE CHANGED THE DISTRIBUTION OF INJURIES SHELL SHOCK BODY ARMOR PROTECTION
IT HELPS TO BE A LEADERSHIP PRIORITY NEW CONCEPT: Restore functionality and continue the mission CPT Dan Luckett leading soldiers on patrol in Afghanistan
IN THE PUBLIC PERCEPTION, COOL TECHNOLOGY IS A LEVER Neurorehabilitation Cognitive Behavioral Therapy Social Support
TALK ABOUT SCIENCE: SF VAMC & UC SAN FRANCISCO What have we done for the veteran lately? Bob Obana