In order to understand healthcare in the military, a person first has to understand the accepted mentality of a soldier. The mission is always the top priority. A commander’s job is to lead his or her troops to ensure the mission is completed. There is no room for failure. It is called “zero tolerance.” If a commander fails in his or her mission, then they have failed as a commander and are relieved from said command. As such, a commander will do whatever it takes to be successful. The loss of life, limbs, or eyesight is a factor that weighs in when the commander is planning a mission, but those are considered to be acceptable losses. The health and life of a soldier is secondary to whatever the mission is, which is why soldiers die in combat. Wars could not be fought and won if we did not have this command structure. The purpose of healthcare in the military, therefore, is to make sure that everyone is well enough to do his or her job on the battlefield. Medics fight along with infantry units and provide lifesaving care as the infantry forces are injured. Even in peacetime, commanders have certain missions, and soldiers are going to get sick, injured, or even killed from those missions. It is a risk every command must take. That a soldier dies during a training mission is sad and deplorable, but accidents do happen. What is not written in any regulation that I have ever read, but occurs, is how the medical command will downplay the seriousness of a soldier’s injury or illness.
I have heard about a military medical commander who would not authorize soldiers to have sleep-study tests done. The medical command is afraid of the consequences of having that sleep study done; for example, if a soldier is diagnosed as having sleep apnea, then he or she can claim it for service-connected disability. So, on one hand, military healthcare wants to take care of soldiers, but on the other hand, they are reluctant for soldiers to be evaluated for certain conditions. Another example is post-traumatic stress disorder (PTSD). I have listened to recordings of military healthcare providers tell combat veterans that they cannot diagnose them as having PTSD; instead, the healthcare providers will use another term such as “anxiety disorder.” Again, PTSD means that a soldier can apply for service-connected disability for that condition once they get out of the military.
It goes without saying that some soldiers tend to over exaggerate their conditions. This is purely speculative on my part, but as a medical provider in my own right, I have had people complain of something, but when I do my physical exam and history, the facts do not add up. It is harder, though, when it comes to something like PTSD. A medical provider cannot see PTSD like they can see swollen tonsils or a skin rash. A medical provider cannot feel PTSD like they can when feeling for an abdominal mass. A medical provider cannot hear PTSD directly, like listening to watery lungs when a patient has congestive heart failure. In my experience, the Army has been known to frown on soldiers who seek treatment and some soldiers are sometimes humiliated by leaders of their unit when they want to seek medical care. “Sick call” is the term used by the Army to collect the sick and injured and provide medical care. A soldier who is sick or injured must obtain permission from his or her first line leader to go on sick call; there is no privacy involved. However, most soldiers do not know they are not obligated to tell their leader what is wrong. The first thing the leader often asks is “what is wrong?” The first line leader is obligated to notify the platoon sergeant or the next person in the chain of command. This is where the sick or injured soldier might start to get harassed about being sick or injured. This line of questioning continues up to the chain of command to the company first sergeant. The soldier might then be ridiculed by the company first sergeant if he or she does not believe that the soldier needs to go on sick call.
I remember how it worked; we would show up for PT at 0630 in the morning. This would be the first formation of the unit. The person conducting the physical training would call out anyone who had a profile or anyone who wanted to go on sick call to step out of formation. Other soldiers would see those who got out of the formation, and that too could be humiliating. Bear in mind that not every unit is like that, and in defense of first sergeants, they have to look out for the health and welfare of their soldiers. If that means that they have to be an asshole, then they have to be an asshole. Some soldiers do abuse sick call to get out of doing duty and physical training. I have seen this as a medic doing morning sick call. A soldier can be charged with malingering, which is considered to be an offense in the military. The term “sick call ranger” is used to describe a soldier who goes on sick call all the time.
For the most part, the Army has physical standards that must be met in order to join and stay in the military. However, let’s say a highly qualified orthopedic surgeon wants to join the Army, but he does not meet the physical requirements; magic happens and those physical requirements are waived since the Army needs as many orthopedic surgeons as it can get. The Army medical command has several different corps. The Medical Corps consists of doctors, and the Army needs as many doctors as it can get.
The Medical Specialty Corps consists of occupations such as physician assistants, occupational therapists, and physical therapists. Members of this Corps are more expendable than the Medical Corps. The physician assistant typically works as the senior medical provider for battalion-level combat arms units. The Army uses physician assistants for both primary and specialty care. The Army even has a physician assistant program, and many enlisted soldiers get accepted into this program. The next corps is the Nursing Corps, consisting of registered nurses. This includes clinical nurse specialists, nurse practitioners, and certified registered nurse anesthetists.
The next commissioned corps is the Medical Service Corps – the medical administrators. They can lead medical platoons, but they are not considered medical providers. On the enlisted side there are just as many different military occupational specialties as there are on the officer side. The most common is the medic. Today, the Army calls the medic the “Healthcare Specialist.” The medic is the person who goes into the field of battle and saves lives. The medic can work anywhere in the military. I worked as a medic both in the active Army and in the Army National Guard. The Army also has civilians who work in the medical field, called Army civilians. They are not members of the military, but they work for the military doing a specific job. They work hand-in-hand with the military at Army hospitals and, to a lesser extent, troop medical clinics. They are government workers who can work for a given length of time and then retire as federal employees like anybody else who is a federal employee.
The Army has its own medical facilities on posts. They can vary depending on the size of the post. Army community hospitals are much like any other hospital located in a small town. The hospitals have primary and specialty clinics and inpatient wards like the civilian counterparts. The Army community consists of soldiers and family members who use the hospital system. Military retirees are entitled to use the hospitals, but on a space available basis. This was a benefit earned by military retirees, who were told if they do their 20 years or more, they would be entitled to free military healthcare for the rest of their lives. However, this benefit has eroded now to the space available and is not entirely free anymore.
Some units conduct their own sick call outside of a hospital in aid stations or troop medical clinics. The aid station is typically run at the battalion level with either a physician assistant or a doctor as the medical provider, however it is not uncommon for the aid station to be manned only by experienced medics; they can treat common illness and injury. This sick call is conducted typically within the unit’s own area, normally close to the barracks. An illness or injury that is beyond the scope of the aid station is often referred to the troop medical clinic, where soldiers can usually be seen by at least a physician assistant. I had to go to the troop medical clinic when I injured my ankle on a training mission at Fort Knox. The clinic ran the sick call for the basic training soldiers; the trainees were herded in a line, sick or not, and as the line moved, each soldier had to come to attention, take a step forward, go back to the position of attention and then go to the position of parade rest. I had never seen soldiers lined up in formation to go on sick call at any other point in my military career. Typically medical clinics are a little more relaxed, but this was a clinic that treated soldiers who were still in basic training and so discipline was tighter.
Aviation medicine is a part of medical care associated with flying. My active Army unit was both an aviation and airborne unit. Initially, my unit worked within the aviation clinic, but as the unit grew, we got our own section of the troop medical clinic to do our job.
My active duty medical section was unique. We conducted our own sick call at the clinic and we treated only the members of our unit. However, on occasion, we treated family members. On the chance the whole medical section was out on a training mission, the aviation clinic handled our patients.
In places such as Afghanistan or Iraq, the Army has combat hospitals. They are often integrated with other branches of service, and in some instances people from different countries all work at these hospitals. The combat hospital is where the wounded go for surgery or severe illness. If the combat hospital cannot meet the needs of the wounded, then they are flown to a major Army hospital in Germany or flown back to the United States. Combat hospitals are located within relatively safe areas with a lot of security and access to an airfield. The wounded coming in from battle and the wounded shipping out are treated there.
Underneath the combat hospital is something called the Forward Area Surgical Team, or FAST. The surgical team can quickly set up an operating room in the combat zone: this has saved many lives. I have seen a FAST in operation before; they are good at what they do and very motivated. Members of a FAST do not have the luxury of living on a secured base like that of a combat hospital. Every combat unit and combat support unit I have known has its own medical assets to meet the basic healthcare needs of the soldiers assigned to that unit in combat. During my tour in Afghanistan, I was assigned to the headquarters company of an infantry brigade. I was not assigned specifically to one of the infantry battalions. The majority of our brigade was located at Camp Phoenix, where there was an overabundance of medical personnel in the camp. The major job of the medics for the brigade headquarters was to go out on protective service missions. I was the medic when bodyguards went on missions. As the mission of the unit expanded, medics were dispersed across the country, supporting both American and Afghan infantry units, so we had become infantry medics.
After we returned from Desert Storm, some people in our unit did get sick, but the trends of what they specifically had were not recorded at our level. The unit had suspected early on that soldiers might suffer from chronic illness because of the burning oil wells in Kuwait. Others attributed Gulf War Syndrome to the nerve agent antidote pills that we were ordered to take called pyridostigmine bromide. Others believed that the illness was caused by exposure to nerve agents themselves, specifically a nerve agent called sarin. Some authorities believed that it was caused by using too much insect repellent. Depleted uranium was thought to be a culprit for this mysterious condition, another one of the many theories surrounding Gulf War Syndrome.
Many people believed that Gulf War Syndrome was something completely made up. These are the same people who believe conditions like fibromyalgia and chronic fatigue syndrome are “pretend.” I can only speak for myself in regards to Gulf War Syndrome. My unit was within the established boundaries of a place called Kamisiyah. There was an Iraqi weapons depot there that was being destroyed after the hostilities ended, however it was believed that the nerve agent got into the air during the demolition and spread throughout the region. Several years later, in 1997, I received a letter from the Department of Defense explaining that I was exposed to the nerve agents from the Kamisiyah demolitions. I had started to develop fairly vague symptoms such as a rash on my body called petchia, fatigue, respiratory disorders, and difficulty sleeping; I believe that Gulf War Syndrome is real and that all I experienced was a product of it.
The soldiers in Vietnam used a defoliant called Agent Orange. Twenty years after the war ended the military admitted this defoliant was toxic to the people who were exposed to it. The cynical side of me says it was known all the time, and this information was held until the majority of soldiers exposed to this agent died. In some ways, I feel that way about Gulf War Syndrome. I find it odd that after 20 years, only now more specific information about Gulf War Syndrome is being released to the public.
Both veterans and military hospitals are government-run establishments, but there are some fundamental differences. The veteran hospitals are run completely by civilians, and the veteran hospitals fall under the authority of the Veterans Affairs (VA). Each hospital system is under a different executive level branch of government, but the public often confuses veteran hospitals with military hospitals.
There are over 150 VA hospitals across the United States. They are like any other hospital in a city, providing the same services, except they are there exclusively to take care of veterans. Many of these hospitals are affiliated with local medical schools, which have doctors-in-training rotate through the VA. The VA also has medical students who do their clinical rotations at these facilities. Nursing schools also use the VA hospitals to teach students how to become nurses. The VA has smaller medical clinics that are affiliated with larger VA hospitals. These clinics are located in smaller towns with a large veteran population. They provide the same services found in an outpatient, full-service medical clinic. These clinics are not open 24 hours like the hospitals are, though, and they do not always have medical students doing clinical rotations through them. Even smaller within the VA is something called a community-based outpatient clinic (CBOC). Think of several doctors all working in a primary care practice. Some of the CBOCs have a limited pharmacy. The CBOCs are not just staffed with doctors, but they also use nurse practitioners and physician assistants to provide medical care to veterans.
I believe that the military under uses nurse practitioners and over uses physician assistants. The physician assistants are assigned to any type of unit the Army has. I have never seen a nurse practitioner assigned to an infantry brigade as a mid-level medical provider. This is in contrast to what is happening outside of the military. Nurse practitioners and physician assistants can both do the same job in a civilian clinic, emergency room, or in surgery. I believe the reason for this preference for the physician assistant is that the military has a great physician assistant school. Typically, enlisted Army medics take the classes they need, and some get accepted into the physician assistant program. The majority of physician assistants in the Army graduate from this program. I have not heard of any Army medics applying for nursing school, then going to nurse practitioner school to become an NP in the Army. Another reason, and this is my own opinion, is that nursing is considered feminine, and physician assistants are associated with masculinity. I am a nurse practitioner myself, so I dispel that myth, but I have not worked as the senior medical provider in an infantry battalion either.
“To Conserve the Fighting Strength” is a catchphrase that the Medical Corp is known for as a whole. It is written on every regimental crest that an Army medic wears on his or her dress uniform. The Army is a ground-fighting unit; the mission of Army medicine is to keep up that strength. Ultimately, I believe that the Army does a good job taking care of the soldiers both during peacetime and in combat. Some soldiers fall through the cracks, though. Some of the policies are considered harsh. I remember watching the movie MASH. In the movie, the Army surgeons were working on wounded soldiers and the surgeons would ask the assistants the rank of the soldier. Depending on how high or low the rank, the surgeon provided better care the higher the rank. MASH took place during the Korean War in the early 1950s so it might have been reflective of the time. I have never worked in a surgical hospital, but I would like to think that this does not happen today. I would find it barbaric if an Army surgeon were less reluctant to save the limb of an enlisted man and more willing to try to save the limb of a wounded officer. I would like to believe that the surgeon disregards rank when deciding medical care.
AIRBORNE (Sung to the Church Hymn “Amen”)
Airborne
Airborne
Airborne
Airborne
Airborne
Sing it louder
Airborne
Airborne
Airborne