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Staying Power: Seriously Wounded Warriors Return to the Fight

Army's Wounded Care Program Transformed for Future, General Says
By Fred W. Baker III
American Forces Press Service

Army Brig. Gen. Gary Cheek
Army Brig. Gen. Gary Cheek

Brig. Gen. Gary Cheek, the Army's assistant surgeon general for warrior care and transition, recently spoke with American Forces Press Service about the Army's transformed wounded warrior care program. What follows is a question-and-answer session from that interview.

WASHINGTON, Nov. 1, 2008Q. It has been a little more than a year since the first wounded warrior brigade was stood up at Walter Reed Army Medical Center. Tell me how you think the model is doing and, overall, how you think the Army is doing in taking care of wounded warriors.

A. It is a tremendous program. We have literally completely transformed our rehabilitative care … as we transition the soldier from inpatient care to either going back to the Army or civilian life.

To some degree we've never really fully had what I would call a rehabilitative capability in the Army on the scale of what we're doing now. Once we became engaged in the two wars now, when we started to look for those rehabilitative capabilities, they really didn't exist. I don't know that we have it exactly the way we want it yet, but I think we're at a point of irreversible momentum to where we will get these things really up, designed, functioning with the policies in place to make them a terrific system.

Q. So, do you think the triad of care and the warrior transition unit models are working for the Army?

A. Really when you look at what was going on at Walter Reed [before February 2007 when the Washington Post news articles exposed a breakdown in wounded warrior care there] it was really just a microcosm of the entire Army and our systems. I don't want to point too sharp a stick at it … but it was not a system that we needed to properly take care of soldiers.

We were hit pretty hard about the facilities. But that's really only a small part of it. We had really no leadership structure. We were actually using an NCO that was in charge of those soldiers who was himself a cancer patient. We had no structure, no military discipline, no requirements for formation. We had soldiers that were not wearing uniforms, not getting hair cuts, growing beards, and really left to their own devices.

If you were a soldier trying to work the system and hang out there as long as you want, that was great. If you were a soldier who wanted to get better and get back to his unit, it was frustrating. It was difficult.

We didn't take good care of the families. We weren't watching out for the soldiers. We did not have the traditional military structure and leadership that soldiers are accustomed to. We also really didn't know what was going on. We weren't really checking and measuring how we were doing.

And that has completely changed. Now, by contrast, we have the 35 warrior transition units. We did consider going back to the rehab center concept … but the reason we didn't want to do that is because we felt that to properly rehabilitate a soldier, it's best to have him close to his home, his family, his comrades. We wanted a system that was more adaptable.

We stood up the military unit with the familiar things like company commanders, and first sergeants and squad leaders and platoon sergeants and added to that some medical management capability with a nurse case manager and primary care physician.

All in all, I think we are off to a tremendous start to this program and we continue to adjust and revise.

Q. Do you think that that discipline helps them re-associate with the Army and focuses their intent on healing?

A. Absolutely. These are soldiers. And for a soldier, the things like the Uniform Code of Military Justice, the standards, the customs and the courtesies all apply. That leadership has to take into account the conditions … unique to that soldier. Of course they will use judgment when dealing with those soldiers. We want to have discipline. We don't want it to be overly harsh. We want it to be appropriate.

The discipline I think is key and it is a big part of their rehabilitation and healing. That same discipline is also going to be pushing them to follow the instructions of their providers, their therapists and making their appointments.

Q. You've had some difficulty with the staffing the transition units. I know there are some initiatives to get that up to 100 percent. How is that going?

A. Is important for us to have the cadre right and the ratios should be at 100 percent and that's what we're moving toward. But I think there are some key misperceptions. The first one is, yes we have over 12,000 soldiers in this program … but it is not 12,000 catastrophically wounded soldiers from theater. About one-third were evacuated from theater … the other 66 percent really have come from our units … a soldier in a car accident, a soldier who has cancer, a soldier with a sports injury, a soldier injured in training. Seventy-five percent of those 12,000 are combat veterans. We have a moral obligation to take care of all of them and that's what we'll do.

But the important thing is the cadre that looks after those soldiers is more to manage their care. It's not that they're being denied medical care. It's not that they're not being taken care of or supervised. They are.

The methods we were using to staff those cadres … were just not agile enough to keep up with the growth. We've changed the way we're doing that. We have mandated to stay up with these ratios based on the population. We have brought in our commanders at the major command level … all around the world, all of our installation commanders … and we really came to a common azimuth that we're all responsible for this and we're going to keep this straight.

The main thing I would say is that even when the cadre's strengths were below the ratios we had set, I do not believe that had a major impact on the care provided to those soldiers.

As every day passes, the warrior transition units and the services, the medical care, the discipline, all the things we provide will get better and stronger with time.

Q. What was the rationale behind bringing in all wounded, ill and injured soldiers into the program, because it would seem to create more of an issue with barracks and staffing?

A. I suppose we could consider a special program for only our wounded soldiers, but then when I have a soldier who has three combat tours and he's injured in a motorcycle accident, he's not eligible. Do we not have an obligation to take care of him?

It is really about the severity of the wound, the illness or the injury. How bad is the medical condition of that soldier? That's what gains entry into this system.

We're going to tighten our criteria a bit. We have a significant number of soldiers in our warrior transition units that have a long-term problem, but with rather routine rehabilitative needs. In the future, we will more than likely keep that soldier in his unit and use traditional leadership to supervise him and the medical care provided to do that. We want to make our warrior transition units focus on those that need that intense managed care.

In the end, …we didn't stand them up to ride focused, intense management of soldiers with fairly simple issues that don't require that. As the pendulum swings, we're going to bring it back but we're going to bring it back very carefully.

Q. How is your access to senior Army leadership and what is the priority for wounded warrior care?

A. I would say our support from the senior leaders of the Army is enormous. I easily have direct access to any of them should I need to bring up an issue. Typically it works the other way around. They typically call me and I go there quite often.

Q. Is the Army able to change its policies and procedures fast enough to accommodate the needs of wounded warriors?

A. I would say yes, but I would also say we have to be very careful. You want to be very wary of a knee-jerk reaction.

We are pretty agile, but we have to be very careful I think because the second- and third-order effects of making policy changes sometimes are not apparent. Our decision, for example, to bring a lot of our medical evaluation board soldiers into the WTUs had that beneficial effect for deploying units in that it removed them from their books and allowed them to get more personnel. And to some degree it brought these soldiers together where we could help expedite their board process …. The second-order effects were we had this explosion in our population and we had this great challenge of getting our cadre up to strength. And when we finally stepped back and looked at this population, we determined that … this was designed to provide focused managed care and a lot of soldiers we brought in don't need that.